September, 2005What IHE Delivers 1 Displayable Reports (DRPT) ACCA IHE Workshop 2007 Harry Solomon,...

1September, 2005 What IHE Delivers

Displayable Reports Displayable Reports (DRPT)(DRPT)

ACCA IHE Workshop 2007ACCA IHE Workshop 2007

Harry Solomon, GE HealthcareHarry Solomon, GE Healthcare

IHE-Cardiology Technical & Planning CommitteesIHE-Cardiology Technical & Planning Committees

2

Typical Cardiology ReportsTypical Cardiology Reports

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Typical Report Supported by EMRTypical Report Supported by EMRHistory:35 yo white female with a history of inappropriate sinus tachycardia presents for sinus node modification. Mrs. Edmonds has had a history of a rapid heart rate for the past three to four years which is usally initiated by activity/exercise. These episodes of rapid heart rate have occassionally been associated with presyncope/dizzy spells. The patient has not suffered any injuries from these episodes. She has previously been evaluated by Dr. Schutzman with the Care Group - who has attempted control of her heart rate with multiple medical regiments including beta-blockers and calcium channel blockers. The patient could not tolerate either of the classes of medications. The patient had a normal ECHO and an unremarkable Holter Monitor. She subsequently had a an Event Monitor which showed several episodes of sinus tachycardia up to rate of 150 bpm. She then underwent a Tilt Table Test on October 3, 2006 to differentiate between inappropriate sinus tachycardia and postural tachycardia syndrome. Her Tilt was postive for NCS without any evidence of POTS. Past medical history significant for gallbladder and thyroid surgery - not on synthroid currently. Informed consent detailing risks and benefits of the procedure was obtained from the patient and witnessed on the day of the procedure.Physical:Normal cardiovascular exam, without evidence of congestive heart failure. Normal jugular venous pressure and carotids, regular rhythm with no murmur, no gallop. Normal symmetrical pulses, no edema. Lab Data:No significant abnormalities.Procedure:After prepping and draping and effecting local anesthesia with lidocaine, catheters were inserted as follows:A 5F quadripolar catheter was advanced from the left femoral vein (TriPort) to the high right atrium.A 6F deflectable quadripolar catheter was advance from the left femoral vein (TriPort) to the A-V junction (His bundle).A 5F quadripolar catheter was advanced from the left femoral vein (TriPort) to the right ventricular apex.A 7F deflectable decapolar catheter was placed from the right femoral vein to the coronary sinus.A 7F EPT ablation catheter was advanced from the right femoral vein for mapping and ablation.A 4F sheath was placed into the left femoral artery for blood pressure monitoring.Twelve surface ECG leads and intracardiac electrograms from the above locations were recorded during the study.Medications administered:propofol, total 1341 mg IVfentanyl, total 100 mcg IVpromethazine, total 25 mg IVisoproterenol, up to 2.5 mcg/min infusionAt the end of the study, the catheters were removed and hemostasis achieved using direct pressure.Results:The spontaneous rhythm was sinus with ventricular cycle length 968 ms. The P wave duration was 79 ms (nl <100), with no atrial abnormality; the PR interval was 151 ms (nl 120-200); the QRS duration was 71 ms (nl, 80-120), showing no conduction disturbance with an axis of 45° and QT interval 368 ms (nl, 390-440); the corrected QT [Bazett’s formula] was 374 ms. There was no evidence of a previous MI or delta waves.

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How do we cross the chasm between the How do we cross the chasm between the graphically rich cardiology reports and graphically rich cardiology reports and

the limited capabilities of EMR systems?the limited capabilities of EMR systems?

How do we bring electronic reports to How do we bring electronic reports to environments that do not yet support environments that do not yet support

them at all?them at all?

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DRPT PremisesDRPT Premises

PDF is a prevalent output format for PDF is a prevalent output format for reporting applicationsreporting applications

Design must support independent Design must support independent reporting appsreporting apps

We can control (more or less) what We can control (more or less) what happens in the departmenthappens in the department

Provide a variety of mechanisms for Provide a variety of mechanisms for integration to systems outside the integration to systems outside the department (since we can’t control them)department (since we can’t control them)

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Displayable Reports ProfileDisplayable Reports ProfileTransaction DiagramTransaction Diagram

Encapsulated Report

Report Repository

ReportManager

Enterprise Report

Repository

Encapsulated Report QueryEncapsulated Report Retrieve

Report Reader

Report Creator

Encapsulated Report

Storage Commitment

Retrieve Document for Display

InformationSource

Report Reference

Web DisplayPatient

Demographics Source

Patient Identity Feed Patient Demographics

Consumer

Dept Scheduler /Order Filler

Encapsulated Report or

Report Completion Notify

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Displayable Reports ProfileDisplayable Reports ProfileActorsActors

Report CreatorReport Creator – A system that generates and transmits – A system that generates and transmits clinical reports clinical reports (the reporting app)(the reporting app). .

Report ManagerReport Manager – A system that manages the status of – A system that manages the status of reporting, and distributes reports to report repositories reporting, and distributes reports to report repositories (the (the department info system)department info system). .

Report RepositoryReport Repository – A departmental system that receives – A departmental system that receives reports and stores them for long-term access reports and stores them for long-term access (may leverage the (may leverage the PACSPACS..

Enterprise Report RepositoryEnterprise Report Repository – A system that receives – A system that receives reports and/or references (pointers) to reports, and stores them reports and/or references (pointers) to reports, and stores them for access throughout the healthcare enterprise for access throughout the healthcare enterprise (the EMR)(the EMR). .

Report ReaderReport Reader – A system that can query/retrieve and view – A system that can query/retrieve and view reports encoded as DICOM objects reports encoded as DICOM objects (an imaging workstation)(an imaging workstation)..

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Displayable Reports ProfileDisplayable Reports ProfileStandards UsedStandards Used

Encapsulated Report

Report Repository

ReportManager

Enterprise Report

Repository

Encapsulated Report QueryEncapsulated Report Retrieve

Report Reader

Report Creator

Encapsulated Report

Storage Commitment

Retrieve Document for Display

InformationSource

Report Reference

Web DisplayPatient

Demographics Source

Patient Identity Feed Patient Demographics

Consumer

Dept Scheduler /Order Filler

Encapsulated Report or

Report Completion Notif

MSH|^~\$|… PID|1|0123456‑1||R… OBR|1|X89‑1501^…OBX|1|ED|11528-7^LN…


HL7


MSH|^~\$|… PID|1|0123456‑1||R… OBR|1|X89‑1501^…OBX|1|RP|11528-7^LN…

http://serv.hosp.org/app?requestType=DOCUMENT&documentUID=”1.2.3”&preferredContentType=”application/pdf”

HL7

(0008,0005) IR_100(0008,0012) 20061113(0008,0013) 1109(0008,0016) 1.2.8401008.…

DICOM HTTP

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Profile StatusProfile Status

Demonstrated in 2006Demonstrated in 2006

Currently being reworked to use most Currently being reworked to use most recent HL7 message definitionsrecent HL7 message definitions

Re-release for trial implementation in June Re-release for trial implementation in June 20072007

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Implications for RFPsImplications for RFPs

Reporting apps – Reporting apps –

Department info systems –Department info systems –

Cardiology PACS –Cardiology PACS –

Imaging workstations –Imaging workstations –

EMR and clinical workstations – EMR and clinical workstations –


IHE for Regional Health IHE for Regional Health Information Networks –Information Networks –

XDS and Related ProfilesXDS and Related Profiles




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Acute Care (Inpatient)

PCPs and Clinics (Ambulatory)

Long Term Care

Other Specialized Careor Diagnostics Services

Regional Health Information Organization

(RHIO)

The Enterprise Silo ProblemThe Enterprise Silo Problem

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RHIOs – an emerging trendRHIOs – an emerging trend

85+% of healthcare encounters in local home area85+% of healthcare encounters in local home area

Regional markets often limited to 2-5 major IDNs, Regional markets often limited to 2-5 major IDNs, facilitating agreement among all playersfacilitating agreement among all players

Social factors favor regional business agreements Social factors favor regional business agreements

Regional markets may be assisted by state Regional markets may be assisted by state initiativesinitiatives

Regional Health Information Organizations (RHIOs) Regional Health Information Organizations (RHIOs) recognized as the preferred model for EHR data recognized as the preferred model for EHR data

sharing by US Dept. of Health and Human Servicessharing by US Dept. of Health and Human Services

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IHE’s approach for RHIOsIHE’s approach for RHIOs

Common technical specification for local, regional, Common technical specification for local, regional, disease-specific, or national health information exchangedisease-specific, or national health information exchange

Enable document-based search and exchange between Enable document-based search and exchange between EHR systems, ancillary IT systems (lab, pharmacy, payers), EHR systems, ancillary IT systems (lab, pharmacy, payers), and personal health record systemsand personal health record systems

Incrementally build on (do not replace) existing healthcare Incrementally build on (do not replace) existing healthcare business models, including models of “data business models, including models of “data custodianship” custodianship”

Avoid the pitfalls of “rampant featurism” – keep it simpleAvoid the pitfalls of “rampant featurism” – keep it simple

IHE Cross-Enterprise Document Sharing (XDS) IHE Cross-Enterprise Document Sharing (XDS) introduced in 2005introduced in 2005

Adopted as primary foundation for HITSP Adopted as primary foundation for HITSP Interoperability Specifications in 2006Interoperability Specifications in 2006

16Clinical Encounter

Clinical IT System Index of patients records(Document-level)

Aggregate Patient Info

4-Patient data 4-Patient data presented to presented to

PhysicianPhysician

Sharing SystemSharing System

Clinic Record Specialist Record

Hospital Record

2-Reference2-Referenceto Records to Records for Inquiryfor Inquiry

3-Records3-RecordsReturnedReturned

1-Reference1-Referenceto recordsto records

Repository ofDocuments

Repository ofDocuments

XDS – How it worksXDS – How it works

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IHE-XDS family of profilesIHE-XDS family of profiles

Security and privacySecurity and privacy

Patient identification managementPatient identification management

Notification of document availabilityNotification of document availability

Multi-point sharing (RHIO) and direct point-to-point Multi-point sharing (RHIO) and direct point-to-point exchange modelsexchange models

Rich Document Content for end-to-end application Rich Document Content for end-to-end application interoperability interoperability Specific structured document templatesSpecific structured document templates

IHE-XDS + related IHE profiles IHE-XDS + related IHE profiles provide a complete interoperability solutionprovide a complete interoperability solution

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XD* Content ProfilesXD* Content Profiles

Medical Summary Medical Summary – encounter notes, discharge – encounter notes, discharge summarysummary

Imaging Imaging – exchange of image links– exchange of image links

Emergency Department ReferralEmergency Department Referral

Pre-procedure History and PhysicalPre-procedure History and Physical

Scanned DocumentsScanned Documents

Personal Health RecordsPersonal Health Records

Basic Patient Privacy ConsentsBasic Patient Privacy Consents

Laboratory ReportsLaboratory Reports

All from Patient Care Coordination Domain, except All from Patient Care Coordination Domain, except Imaging (Radiology) and Laboratory (Laboratory Domain)Imaging (Radiology) and Laboratory (Laboratory Domain)

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Structured Content with Coded Entries

Reason for Referral Vital Signs

Studies

Social History

Care Plan

XDS-MS Medical SummaryXDS-MS Medical SummaryStructured and Coded Header

Patient, Author, Authenticator, Institution,Time of Service, etc.

Header always structured and coded

Title-coded sections with non-structured non-coded content (text, lists, tables). Simple Viewing (XML Style sheet)

Level 1Level 1

Level 2Level 2

Text StructureEntry

Text Structure Entry

Meds, Problems and Allergies required as highly structured text. Text easy to import/parse

Text StructureEntry

Level 3Level 3

Meds, Problems andAllergies have a required fine-grain structure with optional coding. Coding Scheme not standardized, but explicitly identified.

Coded Section Entry

Coded Section Entry

Coded Section Entry

Level 3Level 3

XDS-MS enables both semantic XDS-MS enables both semantic interoperability and simple viewing !interoperability and simple viewing !

Medications

Allergies

Problems

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Use of XDS infrastructure to access Use of XDS infrastructure to access Images and Imaging Reports (XDS-I) Images and Imaging Reports (XDS-I)

HospitalHospital

Imaging CenterImaging CenterPhysician PracticePhysician Practice

PACS Y

PACS Z

PACS -to-PACS -to-PACSPACS

PACS -to-PACS -to-OfficeOffice

Same XDS InfrastructureSame XDS Infrastructure for medical summaries for medical summaries and imaging information !and imaging information !

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IHE-XDS Infrastructure ComponentsIHE-XDS Infrastructure ComponentsAudit Record Repository (ATNA)Audit Record Repository (ATNA) – – Receive audit records from other Receive audit records from other actors and securely store for audit purposes. ATNA also authenticates actors and securely store for audit purposes. ATNA also authenticates peer-nodes and encrypt communications.peer-nodes and encrypt communications.

Time Server (CT)Time Server (CT) – – Provides consistent definition of date/time enabling Provides consistent definition of date/time enabling time synchronization across multiple systems. Enables events time synchronization across multiple systems. Enables events associated with patients to be sorted reliably in chronological order.associated with patients to be sorted reliably in chronological order.

Document Registry (XDS)Document Registry (XDS) – – Queryable index of metadata and Queryable index of metadata and references to all documents shared within a connected community references to all documents shared within a connected community (XDS Affinity Domain)(XDS Affinity Domain)

Document Repository (XDS)Document Repository (XDS) – – Supports storage and retrieval of Supports storage and retrieval of clinical information (as documents). May be centralized or distributed.clinical information (as documents). May be centralized or distributed.

Patient Identifier Cross Reference Manager (PIX)Patient Identifier Cross Reference Manager (PIX) – – Reconciles Reconciles information on patients from multiple domains to a single, cross information on patients from multiple domains to a single, cross referenced set of ids for each given patient.referenced set of ids for each given patient.

Patient Demographics Supplier (PDQ)Patient Demographics Supplier (PDQ) – – Returns demographic Returns demographic information and identifiers for patients based on specified demographic information and identifiers for patients based on specified demographic criteria.criteria.

25XDS Affinity Domain (NHIN sub-network)

Community Clinic

Lab Info. System

PACS

Teaching Hospital

PACS

ED Application

EHR System

Physician Office

EHR System

XDS Scenario with use of ATNA & CTXDS Scenario with use of ATNA & CT

PMS

Retrieve DocumentRetrieve Document

Register DocumentRegister DocumentQuery DocumentQuery Document

XDS Document Registry

ATNA Audit record repository CT Time server

Record AuditRecord AuditEventEvent

MaintainMaintainTimeTime

MaintainMaintainTimeTimeRecord AuditRecord Audit

EventEvent

Maintain TimeMaintain TimeProvide & Register Docs

Record AuditRecord AuditEventEvent

XDS Document Repository

XDSDocumen

t Reposito

rySecured MessagingSecured Messaging

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Basic Patient Privacy ConsentsBasic Patient Privacy Consents

An XDS Affinity Domain can An XDS Affinity Domain can Develop privacy policies, Develop privacy policies, Implement them with role-based or other access control Implement them with role-based or other access control

mechanisms supported by EHR systems.mechanisms supported by EHR systems.

A patient canA patient can Be made aware of an institutions privacy policies. Be made aware of an institutions privacy policies. Have an opportunity to selectively control access to their Have an opportunity to selectively control access to their

healthcare information.healthcare information.

The BPPC documentThe BPPC document Records the patient privacy consent(s), Records the patient privacy consent(s), Is human readable and machine processable,Is human readable and machine processable, Can capture scanned signatures and digital signatures,Can capture scanned signatures and digital signatures, Is exchanged using XDS mechanisms. Is exchanged using XDS mechanisms.

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Implications for RFPsImplications for RFPs

Department info systems –Department info systems –

Cardiology PACS –Cardiology PACS –

EMR and clinical workstations – EMR and clinical workstations –


The US Federal Landscape The US Federal Landscape for for HHealth ealth IInformation nformation

TTechnologyechnologyONCONCHITHIT, , HITHITSP, CCSP, CCHITHIT




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The current initiativeThe current initiative

Executive Order 13,335 (2004)Executive Order 13,335 (2004)

Most Americans to have an EHR by 2014Most Americans to have an EHR by 2014 Establish DHHS Office of National Coordinator for Health ITEstablish DHHS Office of National Coordinator for Health IT

American Health Information Community (2005)American Health Information Community (2005)

Make policy recommendations to HHS SecretaryMake policy recommendations to HHS Secretary Identify ‘early breakthrough’ priorities:Identify ‘early breakthrough’ priorities:

• Initial set: Biosurveillance, Consumer Empowerment, EHRs, Chronic DiseaseInitial set: Biosurveillance, Consumer Empowerment, EHRs, Chronic Disease

ONCHIT contracts in four programmatic areas (2005)ONCHIT contracts in four programmatic areas (2005)

Standards harmonization (HITSP)Standards harmonization (HITSP) Security and privacy policy (HISPC)Security and privacy policy (HISPC) System certification (CCHIT)System certification (CCHIT) Prototype National Health Information Networks (NHIN)Prototype National Health Information Networks (NHIN)

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American Health Information CommunityAmerican Health Information Community

Healthcare Information Technology

Standards Panel (HITSP)

Nationwide Health

Information Network

Architecture Projects (NHIN)

The Health Information Security and

Privacy Collaboration

(HISPC)

The Certification Commission for

Healthcare Information Technology

(CCHIT)American

Health Information Community

The Community is a federally-chartered commission that

provides input and recommendations to HHS on how to make health records

digital and interoperable, and how to assure that the privacy and security of those records

are protected, in a smooth, market-led way.

The public-private Community serves as the focal point for US

health information concerns and drives opportunities for increasing interoperability.

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Federal HIT ProjectsFederal HIT Projects

HITSP delivers first set of Interoperability Specifications HITSP delivers first set of Interoperability Specifications (2006)(2006) Based on three AHIC breakthrough prioritiesBased on three AHIC breakthrough priorities Using IHE Profiles for 80% of technical contentUsing IHE Profiles for 80% of technical content

CCHIT completes first round of certifications (2006)CCHIT completes first round of certifications (2006) Ambulatory EMR systemsAmbulatory EMR systems

Four NHIN contractors begin implementation of 12 Four NHIN contractors begin implementation of 12 prototype RHIOsprototype RHIOs 9 of 12 are based on IHE Profiles9 of 12 are based on IHE Profiles

HISPC to deliver report (April 2007)HISPC to deliver report (April 2007) Recommendations on security and privacy regulations (federal and Recommendations on security and privacy regulations (federal and

state)state)

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HITSP Technical Committees Focus on HITSP Technical Committees Focus on AHIC Breakthrough AreasAHIC Breakthrough Areas

Biosurveillance Biosurveillance -- Transmit essential ambulatory care and emergency -- Transmit essential ambulatory care and emergency department visit, utilization, and lab result data from electronically enabled department visit, utilization, and lab result data from electronically enabled health care delivery and public health systems in standardized and health care delivery and public health systems in standardized and anonymized format to authorized public health agencies with less than one anonymized format to authorized public health agencies with less than one day lag time. day lag time.

Consumer Empowerment Consumer Empowerment -- Deploy to targeted populations a pre-populated, -- Deploy to targeted populations a pre-populated, consumer-directed and secure electronic registration summary. Deploy a consumer-directed and secure electronic registration summary. Deploy a widely available pre-populated medication history linked to the registration widely available pre-populated medication history linked to the registration summary.summary.

Electronic Health RecordsElectronic Health Records -- Deploy standardized, widely available, secure -- Deploy standardized, widely available, secure solutions for accessing laboratory results and interpretations in a patient-solutions for accessing laboratory results and interpretations in a patient-centric manner for clinical care by authorized parties. centric manner for clinical care by authorized parties.

Chronic Care Chronic Care – Ensure that widespread use of secure messaging, as – Ensure that widespread use of secure messaging, as appropriate, is fostered as a means of communication between clinicians appropriate, is fostered as a means of communication between clinicians and patients about care delivery and patients about care delivery

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HITSP FrameworkUse Case / Modification Request

Interoperability Specification

Transaction1… n components or composite standards

Component1... n base standards or composite standard

Base Standard

#1

Base Standard

#2

Base Standard

#3

Transaction Package1…n transactions or composite

standards

Package (Composite)

Standard

Component (Composite)

Standard

Transaction(Composite)

Standard

Pot

ent ia

l for

Reu

s e in

Ot h

er C

ont e

xt

Defines and N

arrows C

ontextPolicy Makers and Industry

Base Standard

#4

HITSP

Base Standard

#6

Base Standard

#7

Base Standard

#8

Base Standard

#9

Base Standard

#5

Standards

Organizations

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IHE and HITSP IHE and HITSP Interoperability SpecificationsInteroperability Specifications

HITSP Interoperability Specifications for 3 use cases use 8 IHE profilesHITSP Interoperability Specifications for 3 use cases use 8 IHE profiles

EHR - Access to Lab resultsEHR - Access to Lab results

Historical Results: XDS + NAV + XDS-Lab + PIX + PDQHistorical Results: XDS + NAV + XDS-Lab + PIX + PDQ Lab to Ordering Provider: Lab to Ordering Provider: HL7 V2.5 msg with some differences with Lab-3 transaction HL7 V2.5 msg with some differences with Lab-3 transaction

from LSWFfrom LSWF..

Consumer EmpowermentConsumer Empowerment

Doc Sharing: XDS + PIX + PDQDoc Sharing: XDS + PIX + PDQ Reg/Med History:Reg/Med History: Not finalized but will be CDA/CCD. Not finalized but will be CDA/CCD. XPHR-TIXPHR-TI version to be aligned version to be aligned

on CCD when final is on the HITSP path.on CCD when final is on the HITSP path.

BiosurveillanceBiosurveillance

Doc Sharing track: XDS, XDS-Lab, XDS-I, XDS-MSDoc Sharing track: XDS, XDS-Lab, XDS-I, XDS-MS Anonimization: PIX + PDQ (with extensions)Anonimization: PIX + PDQ (with extensions) Capture: RFDCapture: RFD Messaging track, no use of IHE profilesMessaging track, no use of IHE profiles

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CCHIT within HHS Health IT StrategyCCHIT within HHS Health IT Strategy

StandardsHarmonization

ContractorCCHIT:

ComplianceCertificationContractor

Privacy/SecuritySolutionsContractor

Office of the National CoordinatorProject Officers

American Health Information CommunityChaired by HHS Secretary Mike Leavitt

NHINPrototype

Contractors

HarmonizedStandards

NetworkArchitecture

PrivacyPolicies

Governance and Consensus Process EngagingPublic and Private Sector Stakeholders

CertificationCriteria +

Inspection Processfor EHRs

and Networks

Strategic Direction +Breakthrough Use Cases

Accelerated adoption of robust,

interoperable, privacy-enhancing

Health IT

Accelerated adoption of robust,

interoperable, privacy-enhancing

Health IT

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Scope of Work Scope of Work Under HHS ContractUnder HHS Contract

Phase I (Oct 05 – Sep 06)Phase I (Oct 05 – Sep 06)

Develop, pilot test, and assess certification ofDevelop, pilot test, and assess certification ofEHR products for ambulatory care settingsEHR products for ambulatory care settings

Phase II (Oct 06 – Sep 07)Phase II (Oct 06 – Sep 07)

Develop, pilot test, and assess certification ofDevelop, pilot test, and assess certification ofEHR products for inpatient care settingsEHR products for inpatient care settings

Phase III (Oct 07 – Sep 08)Phase III (Oct 07 – Sep 08)

Develop, pilot test, and assess certification of Develop, pilot test, and assess certification of infrastructure or network componentsinfrastructure or network componentsthrough which EHRs interoperatethrough which EHRs interoperate

Scope Expansion (effective Oct 06)Scope Expansion (effective Oct 06)

Address Address specialized EHRspecialized EHR needs needs

This will include cardiology

As defined by HITSP Interop

Specs (80% IHE)

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Implications of CertificationImplications of Certification

Likely requirement (2009-10) for all health Likely requirement (2009-10) for all health IT purchased with federal funds to be IT purchased with federal funds to be certified by CCHIT under HITSP certified by CCHIT under HITSP Interoperability SpecsInteroperability Specs How far will that go regarding HIT used in How far will that go regarding HIT used in

treatment of CMS patients?treatment of CMS patients?

HITSP Interoperability Specs HITSP Interoperability Specs areare IHE! IHE!

September, 2005What IHE Delivers 1 Displayable Reports (DRPT) ACCA IHE Workshop 2007 Harry Solomon,...

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