September, 2005What IHE Delivers Content Integration Profiles Ana ESTELRICH, GIP-DMP, FRANCE Charles...

September, 2005 What IHE Delivers

Content Integration Content Integration ProfilesProfiles

Ana ESTELRICH, GIP-DMP, FRANCEAna ESTELRICH, GIP-DMP, FRANCE

Charles PARISOT, GECharles PARISOT, GE

Grateful thanks to Charles Parisot, Keith Boone, Lori Forquet, Liora Alschuler, Larry McKnight, René Spronk, Thom Kuhn, Todd Rothenhaus, John Donnelly whose work contributed to the creation of this presentation

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Content Integration ProfileContent Integration Profile

IHE-XDS is neutral regarding contentIHE-XDS is neutral regarding content

Will exchange any type of document as an Will exchange any type of document as an opaque octet of informationopaque octet of information

Content Profiles address clinical informationContent Profiles address clinical information

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Content Integration ProfilesSupport profiles addressing integration issues that combine providers, patient problems or time.

Deal with general clinical care aspects rather than technology infrastructure.

Address workflows and information sharing needs that are common to multiple specialty areas.

Started in 2005 and now supports 9 Content Profiles

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A content profile is…A sharable information component that can be exchanged… within an HIE or RHIO (XDS) via Media or USB Device (XDM) via Reliable Messages Point to Point (XDR)

Document content using standards CDA Release 2.0 HL7 Care Record Summary ASTM/HL7 Continuity of Care Document

More complex documents have a library of reusable parts

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Content profiles – full picture

BPPCBPPC

XDS-XDS-SDSD


Cross-sharing of scanned Cross-sharing of scanned documentsdocumentsXDS-SD XDS-SD

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XDS-SDXDS-SD

Most basic exchangeMost basic exchange of documents of documents

CDA headerCDA header

pdfpdf or or texttext content content

CDA (Clinical Document Architecture) header needed CDA (Clinical Document Architecture) header needed to preserve the document’s integrity and its context of to preserve the document’s integrity and its context of creationcreation

The XDS-SD profile specifies the minimum The XDS-SD profile specifies the minimum requirements needed as a CDA header, but it is not requirements needed as a CDA header, but it is not restricted only to that.restricted only to that.

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Creation of a Creation of a pdfpdf or or texttext document document within the XDS-SD within the XDS-SD contextcontext

A PDF/A or text document is created by the application or by scanning a paper document (pdf ou txt)

The application will also generate a CDA R2 for the document pdf ou text created

The document is stable on its own, and it is able to be queried and imported by a Document Consumer

The document is wrapped by the CDA header, keeping its authentic context of creation. It can be used

clinically

The XDS metadata are generated based on the data present in the CDA header

The document thus created is sent to the Respository via transaction ITI-15 - Provide and Register

Document Set

The document is complete

The Repository saves the document and registers the XDS metadata with the Registry

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The specification for the XDS-SDThe specification for the XDS-SD

The specification for the construction of XDS-SD type of The specification for the construction of XDS-SD type of documents are found on:documents are found on:

http://www.ihe.net/Technical_Framework/upload/http://www.ihe.net/Technical_Framework/upload/IHE_ITI_TF_Supplement_XDS_Scanned_Docs_TI_2007_08_20.pdfIHE_ITI_TF_Supplement_XDS_Scanned_Docs_TI_2007_08_20.pdf


Patient Care Patient Care Coordination Coordination

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PCC Content Profiles - ReminderKey Technical Properties

Human readableHuman readable

Machine processableMachine processable

Digital Signature enabledDigital Signature enabled

Can be shared multiple waysCan be shared multiple ways RHIO or HIE (XDS)RHIO or HIE (XDS) CD or USB Media (XDM)CD or USB Media (XDM) Point to Point (XDR)Point to Point (XDR)


Medical Summary Profiles Medical Summary Profiles

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What's in a Medical Summary?What's in a Medical Summary?

Intended AudienceIntended Audience

Pro

blem

Sco

peP

robl

em S

cope

Broad

Focused

Focused

Broad

EpisodeCareCollaborative

Care

PermanentCare

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Medical Summary – Use CaseMedical Summary – Use CaseEpisode CareEpisode Care Purpose: summarize an Purpose: summarize an episodeepisode Author participation in care continues (generally)Author participation in care continues (generally) Scope: Scope: problems involved in episodeproblems involved in episode ExEx: Admit H&P (History and Physical), : Admit H&P (History and Physical), Discharge SummaryDischarge Summary, ,

Procedure NoteProcedure Note

Collaborative CareCollaborative Care Purpose: Purpose: request helprequest help in Patient Management in Patient Management Broad Audience is a side effectBroad Audience is a side effect Scope: focus on a problemScope: focus on a problem ExEx: : ReferralReferral, admit to long term care, admit to long term care

Permanent Care:Permanent Care: Purpose is Transfer CarePurpose is Transfer Care Author participation in care does not continueAuthor participation in care does not continue Scope: all aspects of careScope: all aspects of care ExEx: discharge from military, patient relocation: discharge from military, patient relocation

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Medical Summary - ScopeMedical Summary - Scope

Define a medical summary format for clinical Define a medical summary format for clinical documents containing at a minimum that documents containing at a minimum that provides essential information to the HCP:provides essential information to the HCP:

ProblemsProblems AllergiesAllergies MedicationsMedications Pointers to other materialPointers to other material

Medical Medical SummariesSummaries

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Value PropositionValue Proposition

A common mechanism for transfer of encoded A common mechanism for transfer of encoded clinical data embedded in documentsclinical data embedded in documents

To be used in millions of care coordination To be used in millions of care coordination across settings everydayacross settings everyday Inpatient to Primary Care Provider (Discharge)Inpatient to Primary Care Provider (Discharge) Primary Care Provider to Specialist (Referral)Primary Care Provider to Specialist (Referral)


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Key Technical PropertiesKey Technical PropertiesDocument Transfer (Integration Profile)Document Transfer (Integration Profile) XDS/XDM/XDR for document sharing.XDS/XDM/XDR for document sharing. NAV for notification.NAV for notification. XDS Folders to support organization.XDS Folders to support organization. XDS Submission Sets to support packaging.XDS Submission Sets to support packaging.

Document Content (Content Profile) - StandardsDocument Content (Content Profile) - Standards CDA Release 2.0CDA Release 2.0 Continuity of Care Document Implementation (CCD) GuideContinuity of Care Document Implementation (CCD) Guide Key Medical Terminologies subject to national extensions Key Medical Terminologies subject to national extensions

• Medication, Problems, Allergies, etc. Medication, Problems, Allergies, etc.



EmergencyDepartment Encounter

Summary

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Use CaseThe patient undergoes assessments by a triage nurse, is assigned a triage category (i.e. emergent, urgent, nonurgent) –

* may or may not happen like that in all countries

The patient is then registered and demographic data is obtained.

The patient undergoes additional assessments by a primary RN*

The patient is seen by an ED physician who performs a history and physical, orders various diagnostic tests, determines a course of therapy, orders medications to be administered in the ED and performs procedures on the patient.

Upon completion of ED care, the patient is either admitted to the hospital, discharged from the ED, or transferred to another facility.

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ScopeScope

Emergency Department Information Systems (EDIS)

Inpatient EHR Systems

Ambulatory EHR Systems

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Value Proposition

In US alone there were 110 million emergency department visits in 2004

ED visits account for as much as 40% of hospital admissions

The ED Chart is the most common medical summary in use today

This profile supports sharing of the clinical information in the ED chart with inpatient care providers and the patient's primary care physician.


Emergency Department Emergency Department ReferralReferral

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Use CaseUse Case

Health care provider determines that a patient needs to go to the ED

Provider creates an ED referral package using his or her HER

Upon arrival, the ED provider identifies the patient as a referral

The posted referral package is imported into the Emergency Department Information System (EDIS)

ED ReferralED Referral

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Value PropositionValue PropositionProvide access to critical health information in ED information Provide access to critical health information in ED information systems in a standard mannersystems in a standard manner

Nearly 5000 EDs in USNearly 5000 EDs in US

Significant percentage of ED visits are referralsSignificant percentage of ED visits are referrals

Shortage of critical health data for emergency department patientsShortage of critical health data for emergency department patients

Need to improve communication of intended patient care plans to ED Need to improve communication of intended patient care plans to ED providers and ensure that no pertinent data is lostproviders and ensure that no pertinent data is lost

Streamline workflow by obviating telephone calls between busy Streamline workflow by obviating telephone calls between busy cliniciansclinicians


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ScopeScope

EHR system capable of creating a care record EHR system capable of creating a care record summary would be capable of creating a referral summary would be capable of creating a referral package for a receiving systempackage for a receiving system

The emergency department information systems The emergency department information systems (EDIS) will need to retrieve and read and display (EDIS) will need to retrieve and read and display this data.this data.


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Profile contents based on CDAProfile contents based on CDA

Interoperability Human

• The “paper world” with documents, forms...

Application• Storage, management of clinical data• Context driven analysis• Reusability

Stepwise approach to application interoperabilityapplication interoperability Immediate human interoperability (compliant users) Incremental interoperability between machines – very much

sought-after by clinicians

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12 steps to semantic interoperability

Liora Alschuler 2007

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Clinical Document ArchitectureClinical Document Architecture

René SpronkRené Spronk

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CDA StructureCDA Structure


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Section LevelsSection Levels


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CDA - Three LevelsCDA - Three Levels


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Why CDA? Why CDA? Content integration profiles and templatesContent integration profiles and templates

What is a template?What is a template?

How can it be expressed?How can it be expressed?

What can I do with it?What can I do with it?

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WhatWhat is a Template?is a Template?

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

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IHE Content Integration TemplatesIHE Content Integration Templates

Are Content Profiles or ModulesAre Content Profiles or Modules

Have a formal written definitionHave a formal written definition

Result in an Implicit HL7 Static ModelResult in an Implicit HL7 Static Model

Use ISO Schematron for ImplementationUse ISO Schematron for Implementation

Inherit from ASTM/HL7 CCD when possibleInherit from ASTM/HL7 CCD when possible

Provide Constraints onProvide Constraints on DocumentsDocuments SectionsSections EntriesEntries

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Features of a TemplateFeatures of a Template

Has an IdentityHas an Identity

Can Require, Prohibit, or Suggest Can Require, Prohibit, or Suggest (constrain)(constrain) RIM AttributesRIM Attributes RelationshipsRelationships Other TemplatesOther Templates Specify CardinalitySpecify Cardinality Conditional and Co-relationshipsConditional and Co-relationships

Can Inherit from other TemplatesCan Inherit from other Templates

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Document Level TemplatesDocument Level Templates

Template IDTemplate ID

Summary DescriptionSummary Description

Format Code for use with XDSFormat Code for use with XDS

Standards UsedStandards Used

Data Element Table (needs Definitions)Data Element Table (needs Definitions)

SpecificationSpecification SectionsSections (Header) Entries(Header) Entries

ConformanceConformance

Sample XML (abbreviated)Sample XML (abbreviated)

SchematronSchematron

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Document Template SpecificationDocument Template Specification

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IHE PCC Document TemplatesIHE PCC Document Templates

Medical Summary Specification Medical Summary Specification

XDS-SD Scanned DocumentsXDS-SD Scanned Documents

Referral Summary Specification Referral Summary Specification

Discharge Summary Specification Discharge Summary Specification

PHR Extract Specification PHR Extract Specification

PHR Update Specification PHR Update Specification

Emergency Department Referral Specification Emergency Department Referral Specification

Emergency Department Encounter SummaryEmergency Department Encounter Summary

Antepartum Summary Antepartum Summary

Triage Note Triage Note

Nursing Note Nursing Note

Composite Triage and Nursing Note Composite Triage and Nursing Note

ED Physician NoteED Physician Note

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Section Level TemplateSection Level Template


Parent Template(s)Parent Template(s)


LOINC CodeLOINC Code

Required and Optional Sub-sectionsRequired and Optional Sub-sections

Required and Optional Entry Templates Required and Optional Entry Templates

Sample XML (abbreviated)Sample XML (abbreviated)

SchematronSchematron

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Section Level TemplateSection Level Template

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Section TemplatesSection Templates

Reasons for Care Reasons for Care

Other Condition Histories Other Condition Histories

Medications Medications

Physical Exams Physical Exams

Relevant Studies Relevant Studies

Plans of Care Plans of Care

Procedures Performed Procedures Performed

Impressions Impressions

Administrative and Other InformationAdministrative and Other Information

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Entry Level TemplateEntry Level Template



StandardsStandards

Parent Template(s)Parent Template(s)

SpecificationSpecification Example XML (abbreviated)Example XML (abbreviated) Line by Line SpecificationLine by Line Specification Code TablesCode Tables References to Other TemplatesReferences to Other Templates (Schematron coming)(Schematron coming)

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Entry Template ExampleEntry Template Example

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Entry Level TemplatesEntry Level TemplatesLanguage Communication Language Communication

Employer and School Contacts Employer and School Contacts

Healthcare Providers and Pharmacies Healthcare Providers and Pharmacies

Patient Contacts Patient Contacts

Authorization Authorization

Consent Service EventsConsent Service Events

Authors and Informants Authors and Informants

Linking Narrative and Coded Entries Linking Narrative and Coded Entries

Severity Severity

Problem Status Observation Problem Status Observation

Health Status Health Status

Comments Comments

Patient Medication Instructions Patient Medication Instructions

Medication Fulfillment Instructions Medication Fulfillment Instructions

External References External References

Internal References Internal References

Language Communication Language Communication








Severity Severity



Comments Comments




Internal ReferencesInternal References

Language Communication Language Communication








Severity Severity



Comments Comments




Internal References Internal References

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Navigating the wikiNavigating the wiki

http://wiki.ihe.net/index.php?title=Main_Pagehttp://wiki.ihe.net/index.php?title=Main_Page

Or type in Google “IHE wiki” – demonstration Or type in Google “IHE wiki” – demonstration by Charles Parisot, GEby Charles Parisot, GE

Schematrons for the ConnectathonSchematrons for the Connectathon

[email protected]@[email protected]@med.ge.com

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