Israel Association for Medical Information Tel-Aviv May 17, 2006

1. The fundamentals of IHEIntegrating Enterprises and building standards-based regional and national health information networks Israel Association for Medical Information Tel-Aviv May 17, 2006 Charles ParisotGE Healthcare – IHE IT Infrastructure Technical Co-chair

2. Standards are critical but alone are not enough • Standards offer generality, ambiguity and alternatives • Standard Implementation Guides are focused on a single standard • Increasing complexity IHE provides a standard process for implementing multiple standards!

3. 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 IHE, effective way to establish those “standards” for how to implement standards

4. What is Integrating the Healthcare Enterprise? • IHE provides a common framework for passing health information seamlessly: • within the healthcare enterprise • across multiple healthcare enterprises • for local, regional & nationalhealth information networks • IHE is sponsored by healthcare professional associations: HIMSS, RSNA, ACC, ACCE, ESC, SFR, BIR, GMSIH, etc. • IHE drives standards adoption to address specific clinical needs

5. IHE Maturity and Acceptance • More than 40 user organizations & close to 200 healthcare vendors worldwide have contributed to IHE • Delivery of ready-to-integrate products to benefit healthcare enterprises of all sizes • In clinical use today in enterprises and regional networks • IHE scope, today and in the future • radiology, cardiology, laboratory, oncology, eye care, devices • enterprise healthcare IT infrastructures • cross-enterprise healthcare IT infrastructures • RHIO’s and NHIN

6. Testing at Connectathons IHE Demonstrations Develop technical specifications Products with IHE Identify available standards (e.g. HL7, DICOM, IETF, OASIS) Document Use Case Requirements Easy to integrate products Timely access to information Proven Standards Adoption Process

7. IHE Connectathon

8. Achievements and Expanding Scope Close to 200 vendors involved world-wide,5 Technical Frameworks 48 Integration Profiles, Testing at Connectathons Demonstrations at major conferences world-wide

9. IHE (International) Strategic Development Committee SponsorsCo-Chairs reports supervises Global IHE North America IHE Europe IHE Asia/Oceania Regional &NationalDeployment Interoperability Delegates National Extensions IHE Organizational Structure IHE Domain-related Planning Committee and Technical Committee Global Development:Radiology,IT Infrastructure,Cardiology,Lab, etc. contribute Participants

10. What is IHE NOT? • Not a standard, although it leverages them • A vendor initiative, although they participate • Not a certifying authority, although IHE provides compliance testing • Not simply a demonstration project • Demos are only one means to the end: Adoption • Backed up by documentation, tools, testing, and publication of Technical Frameworks and Product Integration Statements. IHE, critical for standardizing interoperability

11. IHE Model • Actors in precisely defined roles • Abstracts a specific function of information system • …Executing precisely defined transactions • Using existing standards • ……To solve real world interoperability problems • Specifying Integration Profiles

12. An Integration Profile : • A Set of Actors • Exchanging Transactions Use casesProcess Flows Actors Transactions • For each transaction: • Std referenced • Options specified • Mapping required IHE Technical FrameworksImplementation Guide for each Integration Profile

13. EnterpriseIT Infrastructure eMPI User Auth RIS CIS LIS -Radiation Therapy -Patient Care Devices -Pathology -Eye Care PACS Img Acq Cath ECG Auto Mgr Analyzer Cardiology Laboratory Radiology IHE Solutions within the Enterprise EMR - HIS

14. Cardiology Integration Profiles Cardiac Catheterization Lab Workflow Echocardiography Lab Workflow Retrieve ECG for Display Displayable Reports Cath and Echo Evidence Documents eMPI User Auth IHE Solutions within the Enterprise Cardiology EMR - HIS EnterpriseIT Infrastructure RIS CIS LIS -Radiation Therapy -Patient Care Devices -Pathology -Eye Care PACS Img Acq Cath ECG Auto Mgr Analyzer Cardiology Laboratory Radiology

15. Laboratory Integration Profiles Laboratory Scheduled Workflow Laboratory Information Reconciliation Laboratory Point Of Care Testing Laboratory Device Automation Laboratory Code Set Distribution eMPI User Auth IHE Solutions within the Enterprise Laboratory EMR - HIS EnterpriseIT Infrastructure RIS CIS LIS -Radiation Therapy -Patient Care Devices -Pathology -Eye Care PACS Img Acq Cath ECG Auto Mgr Analyzer Cardiology Laboratory Radiology

16. IT Infrastructure Integration Profiles Patient Administration Management Patient Demographics Query Patient Identifier Cross-referencing Retrieve Information for Display Enterprise User Authentication Consistent Time Patient Synchronized Applications Audit Trail and Node Authentication Personnel White Pages eMPI User Auth IHE Solutions within the EnterpriseIT Infrastructure (Enterprise) EMR - HIS EnterpriseIT Infrastructure RIS CIS LIS -Radiation Therapy -Patient Care Devices -Pathology -Eye Care PACS Img Acq Cath ECG Auto Mgr Analyzer Cardiology Laboratory Radiology

17. Radiology Integration Profiles Radiology Scheduled Workflow Patient Information Reconciliation Access to Radiology Information Portable Data for Imaging Consistent Presentation of Images Key Image Note Presentation of Grouped Procedures Evidence Documents Audit trail and Node Authentication (Rad option) Teaching Files and Clinical Trials Export Post-processing Workflow Reporting Workflow Charge Posting Simple Image and Numeric Reports eMPI User Auth IHE Solutions within the Enterprise Radiology EMR - HIS EnterpriseIT Infrastructure RIS CIS LIS -Radiation Therapy -Patient Care Devices -Pathology -Eye Care PACS Img Acq Cath ECG Auto Mgr Analyzer Cardiology Laboratory Radiology How to use IHE ? IHE Radiology Handbook

18. IHE Scheduled Workflow (SWF) and Patient Information Reconciliation (PIR) SWF = Fulfilling a request for imaging service with maximum efficiency? • How do I avoid reentering information on modalities? • How do I avoid entering in my RIS what my modality already knows ? • How do I ensure that in all cases no study is lost, remains unread, or read incomplete. • How do I ensure that all necessary information is automatically on my PACS and RIS? PIR = Fulfilling a request for imaging service in the absence of key information? • How do I deal with trauma and “non-registered patients”? • What if the ADT/ Patient Registration is down? • What if the Order Placer is down?

19. Scheduled Workflow Profile report Registration Film Lightbox Image Manager & Archive Orders Filled Film Folder Diagnostic Workstation Film Report Repository Orders Placed AcquisitionModality acquisitioncompleted acquisitionin-progress imagesprinted Modality acquisitioncompleted

20. IHE for Regional or National EHRSharing Health Recordsacross different care settings

21. Sharing and Accessing Electronic Health Records • IHE offers interoperability for local, regional, specific, or national health information exchange • Goal is to enable exchange between providers’s EHR systems and ancillary IT systems (Lab, Pharma, Payers) and personal health record systems. • Objective is to empower the consumer in having “shared EHR information” between all of its potential healthcare providers (if authorized) and self. • IHE goal is not: • To create a “perfect health record”, the truth about a patient health. • To create an other “health record”, next to the one(s) managed by the provider and the consumer.

22. 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 Introduced at HIMSS in 2005 : IHE-XDS Community or sub-network Repository ofDocuments Repository ofDocuments

23. Health Information Exchanges Interoperability: Cross-enterprise Digital 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

24. Cross-Enterprise Document Sharing (XDS) Standards Used HealthcareContent Standards HL7 CDA, CEN EHRcomHL7, DICOM … • 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, based on ISO 15000 standard:15800 “Google” references (Jan’ 06)  38900 (April’ 06) Electronic BusinessStandards ebXML Registry, SOAP … Internet Standards HTML, HTTP,ISO, PDF, JPEG …

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

26. IHE-XDS is part of a family of profiles • Regional, national, local or disease centric networks need a consistent set of Integration Profiles • Nine Integration Profiles completed and tested, plus seven in development = Standards-based interoperability building blocks for • Rich Document Content for end-to-end application interoperability. Available is a structured medical summary (incl meds, allergies, pbs) and imaging information (incl. Images and reports). More in development. • Patient identification management • Security and privacy • Basic workflow (Notif of doc availbility) IHE-XDS + related IHE Integration profiles provide a complete interoperability solution

27. Scanned Documents Lab Results Document Content ECG Report Document Patient Created Summaries Emergency Referrals Cross-enterprise User Authentication Format of the Document Content and associated coded vocabulary 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 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 IHE Integration Profiles for Health Info NetsWhat is available and has been added in 2005 and is for 2006

28. 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

29. Level 3 Text Structure Med, Problems and Allergies Entry required as highly structured Coded Section Coded Section Coded Section text. Text easy to import/parse Entry Entry Entry Level 3 Text Structure Entry Med Problems a nd Allergies have a required fine - grain structure with optional coding.  Procesable health data import Text Structure Entry XDS-MS Medical Summary (HL7 CDA) Level 1 Structured and Coded Header Patient, A uthor, Authenticator, Institution, Header always structured and coded Time of Service, etc. Level 2 S t r u c t u r e d C o n t e n t w i t h c o d e d s e c t i o n s : S t r u c t u r e d C o n t e n t w i t h c o d e d s e c t i o n s : Title - coded sections with non - structured · Reason for Referral nor coded content (text, lists, tables). · · Vital Signs  Simple Viewing (XML Style sheet) · · M e d i c a t i o n M e d i c a t i o n · Studies · · A l l e r g i e s A l l e r g i e s · Social History · · P r o b l e m s P r o b l e m s XDS-MS enables both semantical interoperability and simple viewing ! · Care Plan

30. 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 !

31. HIMSS Feb 2006 Interoperability Showcase

32. Successful showcase - Over 3000 visitors • Real-world implementations. Effective IHE interoperability • 36 vendor products: EHR & Ancillary IT systems, PHR systems, Registries, Repositories, MPIs, etc. • 4 Federal entities or grantees (VA, DoD, NIST, CDC/UW) • All implementations passed IHE Connectathon tests • Scenario focused on health information exchange: • Within the enterprise (Cardiology, Radiology, etc.) • Across inpatient and physician offices care settings in a RHIO for health status information (meds, allergies, pbs, etc.), reports, images, legacy docs • Empowered with your own health record: • Show-wide record submission and access (11 vendor booths) • “HIMSS RHIO” Infrastructure: secured access & communications, distributed repositories, document registries, patient Id X-referencing

33. Implementer Level Allscripts Canon CapMed Cardiac Science CGI-AMS CompassCare CPSI Dictaphone DR Systems Eastman Kodak Eclipsys Epic Systems HIPAAT HX Technologies INFINITT Technology Kryptiq McKesson MedAccess Plus Medical Informatics MediNotes MNI National Institute of Sci & Tech NextGen Healthcare Philips Medical ScImage Witt Biomedical DMP–French Natl. Personal EHR Health Level 7 HTP IEEE Midmark Diagostics Group HIMSS RHIO Federation Liberty Alliance Univ. of Washington Supporter Level: Acuo Bond Carefx Clearcube Organizational participant: American Coll. of Clinical Eng. Catholic Healthcare West US Dept of Defense US Dept of Veterans Affairs Dairyland EMC Identrus Intel Mediserve Medkey Motion Comp. Picis Pulse Sentillion HIMSS IHE Interoperability ShowcaseFebruary 2006 Participants Leadership Level Blue Ware Cerner GE Healthcare +IDX IBM Initiate Systems InterSystems MiSys Healthcare Quovadx Siemens

34. Endorsements • National & Regional Projects • Italy • Canada • Austria • France • Japan • USA (NHIN prototypes and RHIOs) • Vendors • US EHR Vendor Association (95% market): Interoperability Roadmap: www.himssehrva.org • Europe: COCIR

36. Participating and Contributing Vendors (America) Epic Systems Corp. ETIAM Fujifilm GE Healthcare Heartlab HIPAAT Inc. Hitachi Medical Corp. Hologic Hx Technologies IDX Systems Corporation Imco Technologies INFINITT Initiate Systems Inc. InSiteOne Intelerad Medical Systems IBM Intersystems Corporation Konica Minolta Kryptic Marotech, Inc. McKesson MedAccessPlus Health MedCommons Inc Medcon Medical Informatics Eng. Medical Manager Health Mediface Co. Medinotes Medis Medical Imaging Merge eFilm Misys MNI Medicos Mortara NextGen Novell Open Text Corp. Philips Medical Systems Procom Technology Prosolv Cardiovascular QRS Diagnostics Quovadx RADinfo Systems Raining Data RASNA Imaging Systems ScImage Inc. Sectra Imtec Sentillion Shimadzu Corp Siemens Medical Solutns’ Softmedical Stentor, Inc St. Jude Medical StorCOMM, Inc Swissray International, Inc Tiani-Spirit Toshiba Medical Systems T-Systems UltraVisual Medical Syst. Vital Images, Inc. Voxar Limited WebMD Practice Services Witt Biomedical Corp. XIMIS Agfa HealthCare Algotec Allscripts Healthcare Berdy Blueware Camtronics Canon Medical Systems CapMed Cardiac Science Corp. Carefx Cedara Software Corp. Cerner Corporation CGI-AMS CSIST Dictaphone DR Systems Dynamic Imaging Eastman Kodak Company EBM Technologies Eclipsys Emageon In yellow, companies with IHE Committees Chairs (Spring 2006)

37. Participating and Contributing Vendors (Europe) AGFA Healthcare AISoftw@re Medical Algotec ARES SA aycan Digitalsysteme CEGEDIM Cerner Corp. CHILI CMT Medical Tech. Conto Corrente Salute ConVis CTI Mirada Solutions Data Processing SPA DEDALUS Dianoema Eastman Kodak Co. Ebit Sanita EDL ELFIN s.r.l. Engineering Sanità ESAOTE ETIAM Ferrania Fujifilm GE Healthcare GIE Convergence-Profils Global Imaging Online GWI Research Hi. tech IASI Srl IdeoPass INFINITT INFOPATIENT INOVIT INSIEL Intersystems Corp. Invita ITZ Medicom iSoft McKesson MED2RAD MEDarchiver MEDASYS SA Medavis Medical Communications Medigration GmbH MEDIMON Ltd. MEDIWARE MEDOS AG Merge eFilm METAFORA Mevis Diagnostics Konica Minolta Omnilab Philips Medical Systems POLYMEDIS Rasna Imaging Systems RAYPAX INC. REM Rogan-Delft Sago spa Sectra Imtec AB SeeBeyond Technology Siemens Medical Soluzioni Informatiche srl Stentor Inc. St. Jude Swissray Medical AG Symphonie On Line Synapsis Synchro-Med TECHNIDATA TELEMIS S.A. Tiani-Sprit Tomtec Imaging TOREX GAP Medical Toshiba Medical Systems TSI groupe europMedica T-Systems Uni-medicine VEPRO AG VISUS Technology Transfer WAID XR PARTNER In yellow, companies with IHE Committees Chairs (Winter 2005)

38. Participating and Contributing Vendors (Asia) Taiwan INFINITT Shing Shian INQ GEN TEP Tah Ya Japan EBMJ PSP PANASONIC ALOKA KONICA MINOLTA Hitachi Medical Co. KODAK HITACHI SBS INFOCOM CLIMBMS TECHMATRIX CANON VIEWSEND Japan ITEC WINTCS NEC AGFA JMAC GEYMS AJS TOSHIBA YOKOGAWA GOODMAN FUJITSU AANDT FUJIFILM Korea AGFA Korea GE Healthcare Korea INFINITT LG CNS Marotech, Inc. Medical Standard Peoplenet Communications Samsung SDS

39. 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 ? • Join IHE Israel • Contribute to Global IHE Committees

40. Call for Tenders • Be Brief (but ineffective) ? • “The system must support DICOM” • “The system must support HL7” • Be Effective (but lengthy) ? • “The system must support the following DICOM or HL7 services according to the following 100 pages of specifications: …” • Be Both brief and effective: • Quote IHE profiles and actors: “The system must support the IHE Scheduled Workflow as the Order Filler actor.” • Request IHE Integration Statements • Version 2.1 of the SuperX CT supports IHE Scheduled Workflow, Patient Information Reconciliation and Key Image Note as an Acquisition Modality

41. IHE Integration Statements • Explicit claim by the vendor, for a specific product version • Lists profiles, actors, options • Short (1 page) & Sweet • Compare apples with apples. e.g.: The number of IHE Integration Profiles actually delivered on different PACS products varies greatly: • http://www.ihe.net/resources/ ihe_integration_statements.cfm

42. 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  IHE Israel • Help to shape IHE’s future direction As a Vendor Participant • Respond to Public Comments of Domain Supplements • Attend Educational Workshops • Participate in Connect-a-thons and Demonstrations As a Provider/Consultant Participant • Respond to Public Comments of Domain Supplements • Attend Educational Workshops • Include IHE Integration Profiles in your RFPs and Integration Projects.

43. 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