IHE Profiles and CDA

HL7 UK 2007HL7 UK 2007Keith W. BooneKeith W. BooneInteroperability Architect, GE HealthcareInteroperability Architect, GE Healthcare

Co-chair, IHE Patient Care Coordination TC Co-chair, IHE Patient Care Coordination TC

Co-chair, HL7 Structured DocumentsCo-chair, HL7 Structured Documents

Member, ANSI/HITSP CE, CD and PH TCsMember, ANSI/HITSP CE, CD and PH TCs

Member, ASTMMember, ASTM

Agenda

• IHE Profiles

• Templates

• IHE CDA Based Templates

• IHE Privacy and Security Framework

• Basic Patient Privacy Consents

IHE Actor and Transaction Diagrams

DisplayInformation

Source

Request Specific Information for Display [ITI-11]

Request Document for Display [ITI-12]

• Actors– Analogous to HL7 Application Roles– A UML "Interface"

• Transactions– A sequence of one or more standards

based interactions– Somewhat analogous to HL7 Interactions

Cross Enterprise Document Sharing - XDS

DocumentSource

DocumentRepository

DocumentRegistry

Provider and RegisterDocument Set [ITI-15]

Register Document Set [ITI-14]

DocumentConsumer

Query Registry[ITI-16]

Retrieve Document[ITI-17]

Patient IdentitySource

Patient IdentityFeed [ITI-8]

[ITI-8] HL7 V2 ADT

[ITI-14, 15, 16] ebRIM (Registry Information Model)ebRS (Registry Services)

[ITI-17] HTTP

Cross Enterprise Document SharingMetadata

Who What Where WhenDocument Patient

Identifiers, Name, Address, Gender, Date of Birth

AuthorInstitution, Person, Role, Specialty

Legal Authenticator

Service EventConfidentialityDocument

TypeClassFormatLanguageTitleURI

Healthcare Facility

Practice Setting

Service start Service endCreation

Folder Owner Code(s)Description

Update

Submission Set

Patient IdentifierAuthor

Institution, Person, Role, Specialty

Content Source Submitted

Searchable Metadata, Searchable Metadata, Stored MetadataStored Metadata

Consistent Time - CT

Time Client Time ServerMaintain Time [ITI-1]

[ITI-1] RFC-1305 (NTP), RFC-2030 (SNTP)

Audit Trails and Node Authentication - ATNA

Time Server

Secure NodeAudit

Repository

Maintain Time [ITI-1]

Record Audit Event [ITI-20]

Authenticate Node [ITI-19]

[ITI-1] RFC-1305 (NTP), RFC-2030 (SNTP)

[ITI-19] RFC-2246 (TLS), X.509

[ITI-20] RFC-3164 (Syslog), RFC-3881

Patient Identity Cross Referencing - PIX

Patient IdentitySource

Patient IdentityCross

ReferenceManager

Patient IdentifyCross

ReferenceConsumer

Patient Identity Feed [ITI-8]

PIX Update Notification [ITI-10]

PIX Query [ITI-9]

[ITI-8] HL7 V2.3.1 ADT or HL7 V3 Patient Administration

[ITI-9] HL7 V2.5 Query or HL7 V3 Patient Administration

[ITI-10] HL7 V2.5 ADT or HL7 V3 Patient Administration

Patient Demograpics Query - PDQ

PatientDemographics

Supplier

PatientDemographics

Consumer

Patient Demographics Query [ITI-21]

Patient Demographics and Visit Query [ITI-22]

[ITI-20,21] HL7 V2.5 ADT or HL7 V3 Patient Administration

Request Form for Data Capture - RFD

Form Archiver

Form Reciever

Form Filler ArchiveForm

Submit Form

Form Manager Retrieve Form

XForms 1.0, WSDL, XML

Query for Existing Data - QED

Diagnostic DataRepository

Clinical DataConsumer

ImmunizationsData

Repository

Vital Signs DataRepository

Problems andAllergies Data

Repository

MedicationsData

Repository

ProfessionalServices Data

Repository

QueryVital Signs

[PCC-1]

Query Medications[PCC-2]

QueryImmunizations

[PCC-3]

QueryDiagnostic Data

[PCC-4]

QueryProfessional

Services[PCC-6]

QueryProblems

and Allergies[PCC-1]

HL7 V3 Care Record, Care Record QueryASTM/HL7 Continuity of Care Document

Putting it Together

EHR

RegistrationSystem

AuditSystem

eMPI

TimeServer

eMPI

HIE

AuditSystem

CDA Templates

• What is a Template?

• How can it be expressed?

• What can I do with it?

What is a Template?

A template is an expression of a set of constraints on the RIM that is used to apply additional constraints to a portion of an instance of data which is expressed in terms of some other Static Model.

HL7 Specification and Use of Reusable Constraint Templates

Expression of Templates

• Formal Written Definition– In human readable form

• Explicit or Implicit HL7 Static Model– Application results in a Static Model

• Implementation Specific Representations– Static Model– W3C Schema– ISO Schematron

Features of a Template

• Has an Identity• Can Require, Prohibit, or Suggest (constrain)

– RIM Attributes– Relationships– Other Templates– Specify Cardinality– Conditional and Co-relationships

• Can Inherit from other Templates

IHE Patient Care Coordination Templates

• Are Content Profiles or Modules• Have a formal Written Definition• Result in an Implicit HL7 Static Model• Use ISO Schematron for Implementation• Inherit from ASTM/HL7 CCD when possible• Provide Constraints on

– Documents– Sections– Entries

Document Level Templates

• Template ID• Summary Description• Format Code for use with XDS• Standards Used• Data Element Table (needs Definitions)• Specification

– Sections– (Header) Entries

• Conformance• Sample XML (abbreviated)• Schematron

Document Template Specification

IHE PCC Document Templates (12)

• Medical Documents Specification • Medical Summary Specification • Referral Summary Specification • Discharge Summary Specification • PHR Extract Specification • PHR Update Specification • Emergency Department Referral Specification • Antepartum Summary • Triage Note • Nursing Note • Composite Triage and Nursing Note • ED Physician Note

Section Level Template

• Template ID• Parent Template(s)• Summary Description• LOINC Code• Required and Optional Sub-sections• Required and Optional Entry Templates • Sample XML (abbreviated)• Schematron

Section Template Example

IHE PCC Section Templates (71)

• Reasons for Care (4)• Other Condition Histories (12)• Medications (5)• Physical Exams (28)• Relevant Studies (5)• Plans of Care (7)• Procedures Performed (3)• Impressions (3)• Administrative and Other Information (4)

Reasons for Care

The sections described below describe various reasons why healthcare is being provided to the patient.

Reason for Referral

Coded Reason for Referral

Chief Complaint

Hospital Admission Diagnosis

Other Condition Histories

History of Present Illness Hospital Course Active Problems Discharge Diagnosis Resolved Problems Encounter Histories History of Outpatient Visits History of Inpatient Visits List of Surgeries Coded List of Surgeries Allergies and Other Adverse Reactions Family Medical History Coded Family Medical History Social History

The sections defined below provide historical information about the patient's conditions.

Functional StatusCoded Functional StatusPain Scale Assessment Braden Score Assessment Geriatric Depression Scale Physical Function Review of Systems Hazardous Working Conditions Pregnancy History Estimated Delivery Date Section Medical Devices Foreign Travel History of Tobacco Use Current Alcohol/Substance Abuse

Medications

This section contains section content modules that describe activities surrounding the use of medication.

Medications

Admission Medication History

Medications Administered

Hospital Discharge Medications

Immunizations

Physical Exams

Physical Exam Physical Exam (with subsections) Hospital Discharge Physical Exam Vital Signs Coded Vital Signs General Appearance Visible Implanted Medical Devices Integumentary System Head Eyes Ears, Nose, Mouth and Throat Ears Nose Mouth, Throat, and Teeth

Neck Endocrine System Thorax and Lungs Chest Wall Breasts Heart Respiratory System Abdomen Lymphatic System Vessels Musculoskeletal System Neurologic System Genitalia Rectum

Relevant Studies

Results

Coded Results

Hospital Studies Summary

Coded Hospital Studies Summary

Consultations

Plans of Care

This section provides content modules for sections that describe the plan of care intended for the patient.

Care Plan Assessment and Plan Discharge Disposition Discharge Diet Advance Directives Coded Advance Directives Transport Mode

Procedures Performed

• Patient Education and Consents

• Coded Patient Education and Consents

• Procedures Performed

Impressions

• ACOG Visit Summary Flowsheet Section

• Progress Note

• ED Diagnoses

Administrative and Other Information

• Payers

• Referral Source

• Mode of Arrival

• ED Disposition

Entry Level Template

• Template ID• Summary Description• Standards• Parent Template(s)• Specification

– Example XML (abbreviated)– Line by Line Specification– Code Tables– References to Other Templates– (Schematron coming)

Entry Template Example

IHE PCC Entry Templates (50)

Language Communication Employer and School Contacts Healthcare Providers and

Pharmacies Patient Contacts Authorization Consent Service EventsAuthors and Informants Linking Narrative and Coded

Entries Severity Problem Status Observation Health Status Comments Patient Medication Instructions Medication Fulfillment

Instructions External References Internal References

Concern Entry Problem Concern EntryAllergy and Intolerance

Concern Problem Entry Allergies and Intolerances Medications Immunizations Supply Entry Product Entry Simple Observations Vital Signs Organizer Vital Signs Observation Family History Organizer Family History Observation Social History Observation Pregnancy Observation Estimated Delivery Date

Observation

ACOG Visit Summary Battery Advance Directive Observation Blood Type Observation Encounters Update Entry Procedure Entry Transport Intended Encounter Disposition Coverage Entry Payer Entry Pain Score Observation Braden Score Observation Braden Score Component Geriatric Depression Score

Observation Geriatric Depression Score

Component Survey Panel Survey Observation

IHE Security and Privacy Framework

• Consistent Time – NTP• Audit Trails and Node Authentication

– Bidirectional Certificate Based Node Authentication– Encrypted Communication (AES 128)– Audit Trails (RFC 3881)

• Basic Patient Privacy Consents– CDA Based Document– Header Entries Describe

• Consent Event• Document Sensitivity

• Document Digital Signature– XADES– XML Digital Signature– X.509– ASTM E1762

• Cross Enterprise User Authentication– SAML

BPPC Consent Framework

• For a Consent, Documentation is of:– A Consent Act

• Identifiers for the Consent Policies Agreed To

• Effective Time

– Performed by the Patient– Attested to by Patient or other Authority– Document Content is Human Readable description of Policy

• Within a Document, its Sensitivity– Is specified in authorization/consent– Indicates policies applied to "this" document

Sample Consent Matrix

Sensitivity

Functional Role HIV

Sta

tus

Sex

ual H

ealt

h In

form

atio

n

Men

tal H

ealt

h In

form

atio

n

Dev

elop

men

tal D

isab

ility

In

form

atio

n

Alc

ohol

/Dru

g A

buse

In

form

atio

n

Tre

atm

ent

Res

earc

h

Emergency Treatment Provider Treatment Provider Direct Care Provider Alcohol/Drug Abuse Provider Developmental Provider Mental Health Provider Sexual Health Provider Patient or Legal Representative Payer Researcher

More information….

• IHE Wiki: http://wiki.ihe.net/index.php?title=PCC • IHE Web site: http://www.ihe.net

http://www.himss.org/IHE http://www.rsna.org/IHE

• e-Mail Listsmailto:pcctech@rsna.org?subject=subscribe mailto:pccplan@rsna.org?subject=subscribe

• Technical Frameworks• Technical Framework Supplements – Trial Implementation• Non-Technical Brochures :

– Calls for Participation– IHE Fact Sheet and FAQ– IHE Integration Profiles: Guidelines for Buyers– IHE Connect-a-thon Results– Vendor Products Integration Statements

Questions?

Questions?