IHE IT Infrastructure Domain Update

1. IHE IT Infrastructure Domain Update Didi Davis, Co-Chair ITI Planning Committee, Director IT Product Strategies Eclipsys Corporation

2. Connecting standards to care • Care providers work with vendors to coordinate the implementation of standards to meet their needs • Care providers identify the key interoperability problems they face • Drive industry to develop and make available standards-based solutions • Implementers follow common guidelines in purchasing and integrating systems that deliver these solutions What is the effective way to establish those “standards” for how to implement standards ?

3. An Infrastructure Component Is… • An infrastructure component… • Represents a common IT function or service that is used as a building block for a variety of use cases • May be imbedded in an application, but is often deployed as a shared resource within a RHIO or Health Information Exchange • Is a necessary ingredient, but is rarely visible to the end user

4. IHE 2006 – Nine Active Domains Over 100 vendors involved world-wide,5 Technical Frameworks 37 Integration Profiles, Testing at Connectathons Demonstrations at major conferences world-wide

5. IHE IT InfrastructureWhat We Have Done 2003-2005 • EHR Profiles • Retrieve Information for Display (RID) • Patient Identifier Cross-Referencing (PIX) • Patient Synchronized Applications (PSA) • Cross-Enterprise Document Sharing (XDS) • Patient Demographics Query (PDQ) • Notification of Document Availability (NAV) • Patient Administration Management (PAM) • Security & Privacy Profiles • Enterprise User Authentication (EUA) • Consistent Time (CT) • Audit Trail and Node Authentication (ATNA) • Personnel White Pages (PWP) • Cross-Enterprise User Authentication (XUA) • Document Digital Signature (DSG)

6. IHE IT InfrastructureWhat We Are Doing 2006 and beyond • Roadmap Published for 3+ Years • Get updated information on profiles descriptions • EHR Profiles • Templates, Federated XDS, Composite Documents, Scheduling, Workflow • Security & Privacy Profiles • RBAC, Mobile, Anonymization, Pseudoanonymization • Common Data Sources Profiles • Master Files, Service Discovery, Configuration Management, SNMP MIBs

7. Introduced at HIMSS in 2005 : IHE-XDS Community or sub-network Hospital Record Reference to records Clinic Record Specialist Record 3-Records Returned 4-Patient data presented to Physician Aggregate Patient Info Index of patients records (Document-level) Clinical IT System Sharing System 2-Reference to Records for Inquiry Clinical Encounter Repository ofDocuments Repository ofDocuments

8. Health Information Exchanges Interoperability: Cross-enterprise Document Sharing • Cross-Enterprise Document Sharing minimizes clinical data management by the infrastructure. Transparency = Ease of Evolution • Patients have guaranteed portability and providers may share information without concerns of aggregation errors.Digital Documents = Patients and providers empowerment • Supports both centralized and decentralized repository architectures. Ease of federation nationally. Flexible privacy,Flexibility of configurations • Workflows addressed in a second step in a much simpler manner.Point-to-Point messages best suited for workflows mgt

9. Cross-Enterprise Document Sharing (XDS) Standards Used HealthcareContent Standards HL7 CDA, CEN EHRcomHL7, ASTM CCRDICOM … • Implemented world-wide by more than 30 vendors/open source. Final text published August 2005. • Adopted in several national & regional projects (Italy, France, Canada, Austria, USA, etc.) • IHE XDS: 15800 “Google” references (Jan’ 06) Electronic BusinessStandards ebXML Registry, SOAP … Internet Standards HTML, HTTP,ISO, PDF, JPEG …

10. Medical Summaries (HL7 CDA/CRS+V3) • Imaging (DICOM) • ECG Reports (PDF+) • Next lab, nursing, etc. Cross-Enterprise Document Sharing (XDS) Standards Used Two “categories” of standards used XDS Doc Content XDS Infrastructure (Document sources, consumers,registries, repostories)

11. IHE Cross-Enterprise Sharing Documents

12. Why is IHE-XDS a breakthrough ? • It based on an International Standards; ebXML registry: OASIS and ISO standard, Web Service/Soap/XML. • Sharing of digital documents as “attested by the source”, meets the most urgent needs. A proven healthcare community data-sharing paradigm (Message feeding a central web server hinders use of EHRs). • Efficient to support all types of Health IT Systems (IDNs, Hospitals, Ambulatory, Pharmacy, Diagnostics Centers, etc.) and all types of information (summaries, meds, images, lab reports, ECGs, etc.), structured and unstructured. • Meets both the needs of point-to-point push communication and on-demand pull in a variety of centralized or distributed architectures. Offer a consistent, standards-based and functional record sharing for EHRs, PHRs & other IT Systems

13. IHE-XDS Infrastructure Components • Audit Record Repository (ATNA) – Receive audit records from other actors and securely store for audit purposes. ATNA also authenticates peer-nodes and encrypt communications. • Time Server (CT) – Provides consistent definition of date/time enabling time synchronization across multiple systems. Enables events associated with patients to be sorted reliably in chronological order. • Document Registry (XDS) – Queryable index of metadata and references to all documents shared within a connected community (XDS Affinity Domain) • Document Repository (XDS) – Supports storage and retrieval of clinical information (as documents). May be centralized or distributed. • Patient Identifier Cross Reference Manager (PIX) – Reconciles information on patients from multiple domains to a single, cross referenced set of ids for each given patient. • Patient Demographics Supplier (PDQ) – Returns demographic information and identifiers for patients based on specified demographic criteria.

14. EHR System ED Application Physician Office XDS Document Repository PACS XDSDocument Repository EHR System PACS Lab Info. System Teaching Hospital Community Clinic ATNA Audit record repository CT Time server XDS Affinity Domain (NHIN sub-network) XDS Scenario + use of ATNA & CT PMS XDS Document Registry Query Document Register Document Secured Messaging Retrieve Document Provide & Register Docs Maintain Time Maintain Time Record Audit Event Maintain Time Record Audit Event Record Audit Event

15. A87631 A87631 A87631 14355 M8354673993 M8354673993 M8354673993 M8354673993 EHR System ED Application Physician Office XDS Document Repository PACS XDS Document Repository EHR System PACS Lab Info. System L-716 L-716 L-716 Teaching Hospital Community Clinic ATNA Audit record repository CT Time server XDS Affinity Domain (NHIN sub-network) XDS Scenario + use of PIX & PDQ PDQ Query to Acquire Affinity Domain Patient ID Patient Identity Feed Patient Identity XRef Mgr Patient Identity Feed Affinity Domain Patient Identity Source Patient Identity Feed Patient Identity Feed PIX Query Document Registry PIX Query Query Document (using Pt Id) Register (using Pt ID) Provide & Register Docs Retrieve Document PACS

16. Patient Identity XRef Mgr State RHIO Cross-state IDN Cancer Treatment A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 A87631 14355 14355 14355 14355 14355 14355 14355 14355 14355 14355 14355 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 M8354673993 RegistryLocator service Patient Identity XRef Mgr Patient Identity XRef Mgr Patient Identity XRef Mgr Patient Identity XRef Mgr Patient Identity XRef Mgr Patient Identity XRef Mgr Patient Identity XRef Mgr Patient Identity XRef Mgr Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source EHR System EHR System EHR System EHR System EHR System EHR System EHR System EHR System ED Application ED Application ED Application ED Application ED Application ED Application ED Application ED Application EHR System EHR System EHR System PatientIdentityFeed PatientIdentityFeed PatientIdentityFeed PatientIdentityFeed PatientIdentityFeed PatientIdentityFeed PatientIdentityFeed PatientIdentityFeed ED Application ED Application ED Application PACS PACS PACS PACS PACS PACS PACS PACS PIX Query PIX Query PIX Query PIX Query PIX Query PIX Query PIX Query PIX Query Physician Office Physician Office Physician Office RegistryLocator service RegistryLocator service NHIN Backbone EHR System EHR System EHR System EHR System EHR System EHR System EHR System EHR System PACS PACS PACS PACS PACS PACS PACS PACS PACS PACS PACS PACS PACS PACS PACS PACS Lab Info. System Lab Info. System Lab Info. System Lab Info. System Lab Info. System Lab Info. System Lab Info. System Lab Info. System PatientIdentityFeed Document Registry XDS Document Repository PACS PACS PACS RegistryLocator service XDS Document Repository State RHIO PIX Query EHR System EHR System EHR System Sub-Network Sub-Network Sub-Network PACS PACS PACS Patient Identity XRef Mgr Patient Identity XRef Mgr PACS Lab Info. System Lab Info. System Lab Info. System L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 L-716 Affinity Domain Patient Identity Source Affinity Domain Patient Identity Source Integrated Delivery Network Teaching Hospital Teaching Hospital Teaching Hospital PatientIdentityFeed PatientIdentityFeed Document Registry Document Registry XDS Document Repository XDS Document Repository Community Clinic Community Clinic Community Clinic XDS Document Repository XDS Document Repository ATNA Audit record repository ATNA Audit record repository ATNA Audit record repository PIX Query PIX Query CT Time server CT Time server CT Time server PACS PACS XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) XDS Affinity Domain (NHIN sub-network) Federation of XDS and non-XDS DomainsLeverage Connecting for Health RLS – 2006-2007 Development Which registry holds records for a patient ? Sub-Network

17. IHE Integration Profiles for Health Info NetsWhat is available and has been added in 2005 and is for 2006 Scanned Documents Lab Results Document Content ECG Report Document Patient Created Summaries Emergency Referrals Cross-enterprise User Authentication Format of the Document Content Format of the Document Content and associated coded vocabulary Format of the Document Content and associated coded vocabulary Format of the Document Content and associated coded vocabulary Format of the Document Content and associated coded vocabulary Patient Identifier Cross-referencing Authentication & Auditing: Enhanced Access Control Cross-Enterprise Document Sharing Map patient identifiers across independent identification domains Imaging Information Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Patient Demographics Query Medical Summary (Meds, Allergies, Pbs) Format of the Document Content and associated coded vocabulary Document Digital Signature Audit Trail & Node Authentication Format of the Document Content and associated coded vocabulary Attesting “true-copy and origin Centralized privacy audit trail and node to node authentication to create a secured domain. Consistent Time Notification of Document Availability Cross-enterpriseDocument Interchange Notification of a remote provider/ health enterprise Coordinate time across networked systems Media-CD/USB & e-mail push

18. Cross-Enterprise Sharing of Medical Summaries (XDS-MS) Patient Examination or Discharge Discharge or Referral Document Created Referred Physician Notification Document Registry EMR EMR Review ofMedical Summary Report Repository MedicalSummary The Cross-Enterprise Sharing of Medical Summaries Integration Profile solves the problem of transferring summary patient information between providers in different clinical settings.

19. Use of a shared XDS infrastructure to access Radiology Reports and Images (XDS-I) Between Radiology and : • Imaging specialists • Non-imaging clinicians Hospital PACS Y Radiology -to-Radiology Radiology -to-Physicians PACS Z Imaging Center Physician Practice Same XDS Infrastructure (Registry and Repositories) for medical summaries and imaging information !

20. Health Information Exchanges Interoperability: Cross-enterprise Document Sharing • Cross-Enterprise Document Sharing minimizes clinical data management by the infrastructure. Transparency = Ease of Evolution • Patients have guaranteed portability and providers may share information without concerns of aggregation errors.Documents = Patient empowerment, providers confidence • Supports both centralized and decentralized repository architectures. Ease of federation nationally. Flexibility of configurations

21. How real is IHE’s ITI Implementation? • Specification work since Nov 2003 • Under Public Comments June-July 2004 • 600 constructive comments received. • Validity of XDS approach confirmed (e.g. CfH Collaborative Response). • Stable specification IHE Technical Framework Published Aug 15th, 2004 • IHE Connectathon - January 2005 (USA) • 14 Vendors passed • HIMSS Feb 2005 - show-wide demonstration • 17 EHRs, 800 patients, 7700 documents registered, 41000 queries. • IHE Connectathon - April 2005 (Europe) • 22 Vendors registered Several Implementation Projects by health authorities in 2005 Italy: Liguria & Veneto Regions - Canada: Newfoundland – France: Trials

22. IHE IT Infrastructure – Plan for 2006 • Development Schedule: • Planning Committee decision: mid-March • Issue Public Comment version: June 2006 • Public Comment Due: July 2006 • Issue Trial Implementation version: August 2006 • IHE Connectathon: January 2007 • HIMSS Demo: February 2007 • New Profiles For 2006 • PIX/PDQ-V3 • Cross Enterprise User Authentication • XDS Federation • Scanned Document Sharing • Point to Point Media Exchange • Request Form for Display

23. What can you do? • Learn about IHE • Insist on IHE compliance in your RFPs and contract documents: • Select Integration Profiles, and Appropriate Actor(s) • Ask vendors for their products “IHE Integration Statements”. • Need more interoperability ? • Contribute to IHE Committees

24. How can I participate? As a Provider or Vendor Contributor • Offer Clinical Use Case Input to Drive IHE Profile Development • Become a member of relevant domain’s Planning or Technical Committees • Become a member of relevant Regional/National Committees • Help to shape IHE’s future direction As a Vendor Participant • Respond to Public Comments of Domain Supplements • Attend the June Educational Workshop • Participate in Connect-a-thons and Demonstrations As a Provider/Consultant Participant • Respond to Public Comments of Domain Supplements • Attend the June Educational Workshop • Attend Demonstrations and include IHE Integration Profiles in your RFPs and Integration Projects.

25. IHE Web site:www.IHE .net • Frequently AskedQuestions • Integration Profiles in Technical Frameworks: See Volume 1 of each TF for Use cases • Cardiology • IT Infrastructure • Laboratory • Patient Care Coordination • Radiology • Connectathon Result: www.ihe.net/Events/connectathon_results.cfm • Vendor Products Integration Statements • Participation in Committees & Connectathons