Integrating the Healthcare Enterprise Organizing IHE Integration Profiles related to the Electronic...

Integrating the Healthcare EnterpriseIntegrating the Healthcare Enterprise

Organizing IHE Integration Profilesrelated to the Electronic Health Record

Initial Thoughts

Summary for the IHE International MeetingRSNA, November 2003

C. Parisot, GE

IHE IT InfrastructureIHE IT Infrastructure5 Integration Profiles5 Integration Profiles

Enterprise User Authentication

Provide users a single nameand

centralized authentication process

across all systems

Enterprise User Authentication

Provide users a single nameand

centralized authentication process

across all systems

Retrieve Information for Display

Access a patient’s clinical information and documents in a

format ready to be presentedto the requesting user

Retrieve Information for Display

Access a patient’s clinical information and documents in a

format ready to be presentedto the requesting user

Patient Identifier Cross-referencing

for MPI

Map patient identifiers across independent

identification domains

Patient Identifier Cross-referencing

for MPI

Map patient identifiers across independent

identification domains

Synchronize multiple applications on a desktop to the same patient

Patient Synchronized Applications

Synchronize multiple applications on a desktop to the same patient

Patient Synchronized Applications

Consistent Time

Coordinate time across networked

systems

Consistent Time

Coordinate time across networked

systems

New at HIMSS in 2004New at HIMSS in 2004 In 2002 and 2003, IHE and HL7 have held separate

demonstration– HL7 demos were « throw away »– IHE demos were « radiology centric »

IHE is now in Healthcare IT - 5 new profiles to be showcased at HIMSS 2004

HL7 and IHE have decided this year to combine their demos and convey a 2 tier message:– HL7 broad in scope but leaves choices for interoperability– IHE Profiles are narrow in scope but high interoperability

IHE Integration Profiles Focused on the EHRIHE Integration Profiles Focused on the EHRShaping a strategy and plan for the next three yearsShaping a strategy and plan for the next three years

• IHE has developed close to 20 Integration Profiles focuses on Radiology, Laboratory, IT Infrastructure (MPI, Security, etc.) and is now expanding to Cardiology. This is an intra-enterprise, bottom-up approach.

• In this proposal, IHE explains how it intends to approach the longitudinal dimension of the EHR with a distributed, cross-enterprise, document centric, top-down point of view.

• The strategy is to progressively bridge the two approaches as new integration profiles are developed.

Feedback on this approach and expanding collaborations are sought.

Acute Care (Inpatient)Acute Care (Inpatient)

EHR-LR= The Longitudinal Record of a person’s healthEHR-CR= Care-delivery Record

Integration Profiles : Intra Enterprise vs Cross-Enterprise

EHR-LR

EHR-CR

EHR-CR

EHR-CR

EHR-CR

IHEIntegration Profile

(e.g. IT Infrastructure


(e.g. Lab, Cardio, etc)









Nursing HomesNursing Homes



Other Specialized CareOther Specialized Careor Diagnostics Servicesor Diagnostics Services




(e.g. Cross-enterprise Security, LR Management, etc.


(e.g. Cross-enterprise Security, LR Management, etc.

GPs and Clinics (Outpatient)GPs and Clinics (Outpatient)

Patient AccessPatient Access

EHR-LR Documents Virtual Repository

Custodian for an unspecified time of Documents recorded from local patient encounters.

EHR-LR Use Cases: Directory Concept, Core Actors D

ocu

men

t C

reat

or

Do

cum

ent

Cre

ato

r

EHR-LR Directory

EHR-LR Directory

EHR-LR Encounter/Documents Directory

EHR-LR Directory

EHR-LR DirectoryEHR-LR Directory

EHR-LR Encounter/Documents Directory

Register Doc

Registerand Provide Doc

Do

cum

ent

Co

ns

um

er

Do

cum

ent

Co

ns

um

er

RetrieveDoc

QueryDoc List

EHR-CR

EH

R-

CR

EHR-LR Documents Repository

Custodian for an unspecified time of Documents recorded from patient encounters.

EHR-LR Documents Repository

Custodian for an unspecified time of Documents recorded from patient encounters.

Not all transactions necessary to ensure management of a distributed and dynamic EHR-LR are depicted in this illustration.

EHR-LR

IHE Integration Profiles Focused on the EHRIHE Integration Profiles Focused on the EHR • In this proposal, IHE has proposed an approach the longitudinal

dimension of the EHR, with a distributed, cross-enterprise, document centric, top-down point of view.

• 30 principles have been defined for the definition of EHR-LR IHE Integration Profiles.

Feedback on this approach and expanding collaborations are sought.

Is this a useful “brick” ?

• The proposed strategy is a scoping exercise to address one of the many integration problems in the realization of the EHR vision. IHE does not claim to master and address the definition and all aspects of a complete and interoperable EHR System.

• In collaboration with well established standards bodies and other EHR related initiatives world-wide (EHRCOM, CCR, HL7, etc.), IHE expects to contribute at a more cost-effective and rapid deployment.

Draft IHE IT Infrastructure RoadmapDraft IHE IT Infrastructure Roadmap

In support of the IHE Integration ProfilesIn support of the IHE Integration Profilesfocused on the EHRfocused on the EHR

Draft for Comments – 11/03To be finalized January 2004.

IHE IT Infrastructure Roadmap – HIMSS 2004 (1)IHE IT Infrastructure Roadmap – HIMSS 2004 (1)

EHR Security Common Data

Profiles RID PIX PSA

Profiles EUA CT

No content

Standards & Prerequisites CCOW v1.4 Patient Context HL7 v2.3.1 HL7 v2.4 HTTP WSDL 1.1 XHTML 1.0 XML 1.0

Standards & Prerequisites CCOW v 1.4 User Context Kerberos NTP SNTP

IHE IT Infrastructure Roadmap - Next step (2)IHE IT Infrastructure Roadmap - Next step (2)


Profiles EHR-LR- Provide Document- Register Document- Query Document(s)- Retrieve Document Patient Demographics Query - enterprise

Profiles Take-on Basic Security- Common Audit schema - Node authentication PKI User demographics directory- Healthcare staff- Patients?

Profiles LDAP base- Federated- Multiple information bases: equipment, organizations, users Reference code sets- Distribution- Update SNMP MIBS?- Event reports- Equipment calibration changes- Equipment and software change management & tracking- Event trending

Standards & Prerequisites Stage 0 IHE ITI profiles- PIX-enabled EMPI service CDA level 1- ASTM E31.28 CCR encoding

Standards & Prerequisites IHE Radiology Basic Security Stage 0 IHE ITI security profiles RFC 2798 ITU X.509(95) Stable Common Audit Message RFC

Standards & Prerequisites LDAP SNMP- MIB standards / registry Mature/stable standards for selected code sets

IHE IT Infrastructure Roadmap – Step 3 IHE IT Infrastructure Roadmap – Step 3


Profiles EHR-LR- Solidify step 1- Add 2 composite information sets (candidates: allergies, discharge summaries, medication lists; consult with IHE clinicians on choices)- RAD plug-in Patient Demographics Query - multi-enterprise

Profiles Incorporate Kerberized standards into EUA- DICOM- HL7 v2 (v3?)- HL7 CCOW User PKI- Enterprise- Patients- Multi-enterprise?- Key distribution

Profiles Masterfile Maintenance Additional LDAP information sources RID configurability directory #1

Standards & Prerequisites Stage 1 IHE ITI profiles Additional CDA templates PKI for user identify management

Standards & Prerequisites Stage 1 IHE ITI security profiles Stable Kerberos support in:- HL7 v2.6- CCOW- DICOM PKCS#10 ISO/TS 17090

Standards & Prerequisites Stage 1 IHE ITI common data profiles HL7 v2 Masterfile maintenance Mature/stable standards for selected information sources Suitable LDAP schema definitions

IHE IT Infrastructure Roadmap – Step 4IHE IT Infrastructure Roadmap – Step 4


Profiles EHR - Lab trending - Consents- Medication list

Profiles Add attribute certificates to PKI to support:- Basic RBAC- Consents? Multi-entity EUA Digital signatures

Profiles Additional LDAP information sources RID configurability directory #2 Workflow management preferences?

Standards & Prerequisites Stage 2 IHE ITI profiles IHE Lab profiles Basic RBAC

Standards & Prerequisites Stage 2 IHE ITI security profiles Mature attribute certificate distribution specification/standard ISO/TC 215 Privilege Management Infrastructure specification

Standards & Prerequisites Stage 2 IHE ITI common data profiles Mature/stable standards for selected information sources Suitable LDAP schema definitions

IHE IT Infrastructure Roadmap – Step 5IHE IT Infrastructure Roadmap – Step 5


Profiles EHR-LR- More document types (general document templates)- More clinical domains (cardiology, nuclear medicine, pharmacy, ...)- Composite documents from multiple clinical domains.

Profiles Remote service access Anonymization Wide-area patient access Mobile applications- Wireless- Patient active homecare- Mobile providers Location-sensitive behaviors Patient identification standards

Profiles RID configurability directory #3- "Hanging protocols"

Standards & Prerequisites Stage 3 IHE ITI profiles IHE clinical domain uptake

Standards & Prerequisites Stage 3 IHE ITI security profiles Stable standards for mobile access security Stable standards for patient identification

Standards & Prerequisites Stage 3 IHE ITI common data profiles Suitable LDAP schema definitions

Principles in support of the IHE Integration ProfilesPrinciples in support of the IHE Integration Profilesfocused on the EHRfocused on the EHR

Draft for Comments – 11/03To be finalized January 2004.

Key Statements : IHE Focuses on the EHR-LRIHE Focuses on the EHR-LR

1. The EHR-LR (Longitudinal Record) federates patient encounter information managed by “EHRs within an enterprise” (EHR-CRs). EHR CRs (Care-delivery Record) may range from a large EHR of an IDN enterprise all the way down to a single practice management system.

2. EHR-LR includes repositories of encounter data that contribute to the patient’s longitudinal healthcare record. EHR-LR data will be stored in multiple repositories (depts., sites, domains).

3. Encounter data includes some information/state/workflow info that may not end up in the EHR-LR.

Key Statements: What is in the EHR-LR ? What is in the EHR-LR ?

1. The EHR-LR data is made of discrete, persistent, logical documents which may be accessed by a unique identifier.

2. LR data is coded/formatted according to relevant clinical domain standards. The body of clinical domain standards is expected to evolve.

3. Conversion between EHR-CR data “formats” and EHR-LR document “formats” is the responsibility of the EHR-CR.

4. At the end of an encounter, new document(s) are added to the EHR-LR. These new EHR-LR docs could be stored (in any form) in the EHR-CR where they are created or pushed to a separate EHR-LR repository (in a standard format).

5. EHR-LR will likely be initially focused on certain pathologies (cardiology, oncology, etc) or a key information for continuity of care (CCR summaries only) and expand progressively.

Key Statements : IHE ConstraintsIHE Constraints

1. The domains of EHR content are primarily clinical. Other information and services are needed to provide an operational EHR-LR environment (e.g. demographics, security, consents – IHE has already addressed some).

2. Different EHR-LR and EHR-CR repositories may be using different Patient Ids.

3. The care-delivery view and form of current encounter data (EHR-CR) is out of scope of EHR-LR IHE Integration Profiles.

Key Statements : Accessing EHR-LRAccessing EHR-LR1. EHR-LR shall provide a list of available documents for a

patient. Logical directories are necessary to provide such document lists.

2. The full burden of locating and filtering documents should not be placed on the EHR-LR consumer applications. The EHR-LR needs to have some meta-information about the documents it tracks.

3. There is a need for the EHR-LR to provide a means to retrieve the clinical documents that have been registered with full content fidelity.

4. There is a also a need for the EHR-LR to provide clinical data to consumer applications based on processing, extracting, or combining the content multiple existing documents.

5. Documents may reference other documents including images, waveforms, etc.

Integrating the Healthcare Enterprise Organizing IHE Integration Profiles related to the Electronic...

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