Johns Hopkins SchooI of Medicine Division of Health Sciences Informatics March 23, 2007

1. Johns Hopkins SchooI of MedicineDivision of Health Sciences Informatics March 23, 2007 Nationwide Health Information Network Update Anna O. Orlova, PhD aorlova@jhsph.edu Public Health Data Standards Consortium & Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, USA

2. Towards a Nationwide Health Information Network (NHIN) Where Should We Be in 2014 • Building a NHIN • NHIN-2004 • NHIN-2005-2006 • NHIN-2007

3. US National HIT Strategic Plan On July 21, 2004 the Department of Health and Human Services (DHHS) announced the decade of health information technology for “delivering consumer–centric and information-rich health care.” The vision is to build a National* Health Information Network (NHIN) of regional health information exchanges formed by health care providers who will utilize electronic health record systems. * Original term “National” has been changed on “Nationwide” in January 2006 Thompson TG and Brailer DJ. The Decade of Heath Information Technology to Deliver Consumer-centric and Information-rich Health Care. Framework for Strategic Action. US DHHS, July 21, 2004.

4. DHHS’ Framework for Health Information Technology: Building a NHIN NHIN will be based on: • Electronic Health Record Systems (EHRS) that will enable • Regional Health Information Exchanges (RHIEs) organized via • Regional Health Information Organizations (RHIOs) Thompson TG and Brailer DJ. The Decade of Heath Information Technology to Deliver Consumer-centric and Information-rich Health Care. Framework for Strategic Action. US DHHS, July 21, 2004.

5. President’s Strategic Framework for HIT

6. Provider Record Records Returned Laboratory Results Specialist Record Requests for Records Temporary Aggregate Patient History Index of where patients have records Authorized RHIO Inquiry Another RHIO RHIO Patient data to other RHIO US Nationwide Health Information Network Source: Jennie Harvell. The Decade of Health Information Technology – Framework for Strategic Actions. MMIS Conference, September 2004

7. US Health Information Network - 2014 Source: Dr. Peter Elkin, Mayo Clinic, MN

8. Source: Dr. Peter Elkin, Mayo Clinic, MN, 2006 RHIOs as NHIN Components

9. Nationwide Health Information Network (NHIN) Emerging data shows the value that standardized health information exchange will provide to all stakeholders: • Healthcare purchasers and payers • Hospitals and other healthcare providers • Laboratories • Practicing clinicians • Public health Source: John Glaser, Janet Marchibroda, Jim Schuping. CCBH. Washington, D.C. December 6-7, 2004 URL: www.ehealthinitiative.com

10. Building a NHIN

11. Building a NHIN On November 15, 2004 Office of National Coordinator for Health Information Technology (ONC), Department of Health and Human Services (DHHS), released THE REQUEST FOR INFORMATION (RFI) on the Development and Adoption of a “National” Health Information Network Over 500 responses from various healthcare stakeholders has been submitted. URL: http://www.dhhs.gov

12. Public Health Data Standards Consortium PHDSC RESPONSE TO THE RFI on the Development and Adoption of a “National” Health Information Network was submitted to DHHS on January 18, 2005 URL: http://phdatastandards.info or http://www.phdsc.org

13. PHDSC Model: PHDSC Model for Electronic Health Record-based Data Exchange RHIO EHR-PH Info Exchange

14. NHIN Development Process In October 2005 DHHS Office of National Coordinator (ONC) awarded several NHIN contracts ($65M) as follows: • Standards Harmonization • EHR Certification • NHIN Architecture Prototypes • Health Information Security and Privacy URL: http://www.hhs.gov/healthit/ahic.html

15. DHHS NHIN Contracts • Standards Harmonization - Harmonize the health care and technology standards used in health information interchange to address gaps and conflicts in current standards • EHR Certification - Set forth certification criteria for the many electronic health care record products and technologies currently available on the market • NHIN Prototypes - Develop and evaluate prototypes for the network architecture to assess the feasibility of developing a national health information network prototype • Privacy - Address privacy and security policy questions affecting the exchange of health information. Work resulting from each of these projects will be used by HHS to develop and refine the business case for establishing the network.

16. The Certification Commission for Healthcare Information Technology (CCHIT) Healthcare Information Technology Standards Panel (HITSP) American Health Information Community (Community) The Health Information Security and Privacy Collaboration (HISPC) Nationwide Health Information Network (NHIN) Architecture Projects A public-private “Community” was established to serve as the focal point for America’s health information concerns and drive opportunities for increasing interoperability The Community is a federally-chartered commission that provides input and recommendations to DHHS on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected in a smooth, market-led way.

17. NHIN Development Process The Community is chartered for two years, with the option to renew and duration of no more than five years. The DHHS intends for the Community to be succeeded within five years by a private-sector health information community initiative that, among other things, would set additional needed standards, certify new health information technology, and provide long-term governance for health care transformation. * AHIC URL: www.hhs.gov/healthit/ahiccharter.pdf

18. The Certification Commission for Healthcare Information Technology (CCHIT) Healthcare Information Technology Standards Panel (HITSP) American Health Information Community (Community) The Health Information Security and Privacy Collaboration (HISPC) Nationwide Health Information Network (NHIN) Architecture Projects A public-private “Community” was established to serve as the focal point for America’s health information concerns and drive opportunities for increasing interoperability

19. Discussion Document Standards Harmonization Technical Committees Update Report to the Healthcare Information Technology Standards Panel HITSP includes 206 member organizations: 17 SDOs (8%) 161 Non-SDOs (79%) 18 Govt. bodies (8%) 10 Consumer groups (5%) Contract HHSP23320054103EC Arlington, VA September 20, 2006

20. HITSP Standards Categories • Data Standards (vocabularies and terminologies) • Information Content Standards (RIMs) • Information Exchange Standards • Identifiers Standards • Privacy and Security Standards • Functional Standards • Other HITSP definition

21. HITSP Framework for Interoperability Specification Development • HITSP receives Use Cases and Harmonization Requests from external sources, such as Community and ONC. • The Use Case or Request defines scenarios, business actors, and business and functional/interoperability requirements. • HITSP develops Interoperability Specifications supporting the Use Cases: technical actors, transactions, content and terminology. Source: HITSP Meeting, Arlington VA, September 20, 2006

22. HITSP Framework for Interoperability Specification Development • HITSP identifies constructs which are logical groupings of base standards that work together, such as message and terminology. • These constructs can be reused like building blocks. • While reuse is a HITSP goal, it is established in the context of a use case and its functional/interoperability requirements. • HITSP constructs are version controlled and, if reused, will be uniquely identified. Source: HITSP Meeting, Arlington VA, September 20, 2006

23. The standards harmonization process is a seriesof steps taken by industry stakeholders Harmonization Process Steps ReceiveRequest I Harmonization Request II RequirementsAnalysis III Identificationof CandidateStandards IV Gaps,Duplicationsand Overlaps Resolution V Standards Selection VI ConstructionofInteroperabilitySpecification VII InspectionTest VIIIInteroperabilitySpecificationReleaseandDissemination IXProgram Management BeginSupport Source: HITSP Meeting, Arlington VA, September 20, 2006

24. HITSPFramework Source: HITSP Meeting, Arlington VA, September 20, 2006

25. Standard Harmonization Process The Community identified 3 breakthrough areas for the NHIN development process in 2006: • Biosurveillance • Consumer Empowerment • Electronic Health Record * AHIC URL: www.hhs.gov/healthit/ahiccharter.pdf

26. Consumer Empowerment Use Case Allow consumers to establish and manage permissions access rights and informed consent for authorized and secure exchange, viewing, and querying of their linked patient registration summaries and medication histories between designated caregivers and other health professionals.  Source: HITSP Meeting, Arlington VA, September 20, 2006

27. Electronic Health Record Use Case Allow ordering clinicians to electronically access laboratory results, and allow non-ordering authorized clinicians to electronically access historical and other laboratory results for clinical care. Source: HITSP Meeting, Arlington VA, September 20, 2006

28. Biosurveillance Use Case Transmit essential ambulatory care and emergency department visit, resource utilization, and lab result data from electronically enabled health care delivery and public health systems in standardized and anonymized format to authorized Public Health Agencies with less than one day lag time. Source: HITSP Meeting, Arlington VA, September 20, 2006

29. Event Detection NeighboringJurisdictions EHRS Hospital State Public HealthSurveillance System 1- Report/retrieve symptoms, diagnosis & medication prescription data from EMRs 7 – Report on the positive case electronically & by phone 2 – Data mining of EMR notes Ambulatory Care 3 – Notify on increased number of cases & recommend to order pathogen test 4 – Order pathogen test DHHS LocalPublic HealthSurveillance System 5 – Report test results P U B L I C 6 – Report positive test result electronically & by phone Media Laboratory Response Team Pharmacy

30. Biosurveillance Technical Committee Recommendations

31. AHIC-ONC BIO Consolidated Use Case Transaction Package Consumer/Patient Id X-ref Component Lab Report Message Component Radiology Msg Component Lab Terminology Component Encounter Msg Component Anonymize Base Std HL7V2.5 ADT^xxx Biosurveillance Patient-level data to Public Health Message-based Submission HITSP Biosurveillance – Patient-level and Resource Utilization Interoperability Specification Base Std HL7QBP^Q23 RSP^K23 Transaction Pseudonymize IHEXDS IHEPIXPDQ Message-based Scenario Terminology Standards Base Std ISO DTS/ 25237 Base Std ISO 15000ebRS 2.1/3.0 Base Std HL7 V2.5 Base Std HL7V2.5 ORU^R01 Base Std LOINC HCPCS HL7 V3 CPT HL7 V2.5 HIPAA SNOMED-CT CCC DICOM ICD 9/10 LOINC SNOMED-CT NCCLS UCUM UB-92 URL FIPS 5-2 HAVE

32. AHIC-ONC BIO Consolidated Use Case Transaction Package Consumer/Patient Id X-ref Component Lab Report Document Component Lab Terminology Component Anonymize Biosurveillance Patient-Level Data to Public Health Document-based Submission HITSP Biosurveillance – Patient-level and Resource Utilization Interoperability Specification Transaction Package Manage Sharing of Docs Document-based Scenario Transaction Notif of Doc Availability Base Std HL7QBP^Q23 RSP^K23 Transaction Pseudonymize IHEXDS IHEPIXPDQ IHE XDS-I IHE NAV IHE XDS-MS IHE XDS-LAB Terminology Standards Base Std HL7CDA r2 Base Std ISO DTS/ 25237 Base Std ISO 15000ebRS 2.1/3.0 Base Std HL7 V2.5 Base Std DICOM Base Std LOINC HCPCS HL7 V3 CPT HL7 V2.5 SNOMED-CT CCC HIPAA ICD 9/10 LOINC SNOMED-CT DICOM NCCLS UCUM UB-92 URL FIPS 5-2 HAVE

33. The Certification Commission for Healthcare Information Technology (CCHIT) Healthcare Information Technology Standards Panel (HITSP) American Health Information Community (Community) The Health Information Security and Privacy Collaboration (HISPC) Nationwide Health Information Network (NHIN) Architecture Projects A public-private “Community” was established to serve as the focal point for America’s health information concerns and drive opportunities for increasing interoperability

34. Health Information Security and PrivacyCollaborative (HISPC) RTI International coordinates assessment of health information exchange among states In May 2006, RTI established the National Health Information Security and Privacy Collaboration (HISPC) by announcing the 34 states and U.S. territories who signed agreements to join this project. The project is a national collaboration created to address privacy and security policy questions affecting the exchange of health information. The project is being managed by RTI in cooperation with the National Governors Association under a contract from the Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality. RTI's project team includes multidisciplinary experts in privacy and security law and in health care management together with state and territorial governments. URL: http://www.rti.org/page.cfm?nav=7&objectid=6D0A81F4-6A6D-44A5-BD5E14B2A7077ED6

35. Health Information Security and PrivacyCollaborative (HISPC) Review of State Findings 34 states and U.S. territories signed agreements to join HISPC project Source: Walter G. Suarez. Advancing State Approaches Towards Solutions and Implementation. Health Information Security and Privacy Collaborative. Regional Meeting, November 17, 2006 – Boston, MA

36. Health Information Security and PrivacyCollaborative (HISPC) - Scenarios

37. Nine Domains of Privacy and Security • User and entityauthentication to verify that a person or entity seeking access to electronic personal health information is who they claim to be. • Informationauthorization and access controls to allow access only to people or software programs that have been granted access rights to electronic personal health information. • Patient and provider identification to match identities across multiple information systems and locate electronic personal health information across enterprises. • Information transmission security or exchange protocols (i.e., encryption, etc.) for information that is being exchanged over an electronic communications network. • Information protections so that electronic personal health information cannot be improperly modified. • Information audits that record and monitor the activities of health information systems. • Administrative or physical security safeguards required to implement a comprehensive security platform for health IT. • State law restrictions about information types and classes, and the solutions by which electronic personal health information can be viewed and exchanged. • Information use and disclosure policies that arise as health care entities share clinical health information electronically.

38. Health Information Security and PrivacyCollaborative (HISPC) – Design Nov.- Dec. 06 March 2007

39. Review of State Findings: Variation Analysis Source: Walter G. Suarez. Health Information Security and Privacy Collaborative. Regional Meeting, Nov. 17, 2006 – Boston, MA

40. Review of State Findings Source: Walter G. Suarez. Health Information Security and Privacy Collaborative. Regional Meeting, Nov. 17, 2006 – Boston, MA

41. Review of State Findings Source: Walter G. Suarez. Health Information Security and Privacy Collaborative. Regional Meeting, Nov. 17, 2006 – Boston, MA

42. Review of State Findings Source: Walter G. Suarez. Health Information Security and Privacy Collaborative. Regional Meeting, Nov. 17, 2006 – Boston, MA

43. The Certification Commission for Healthcare Information Technology (CCHIT) Healthcare Information Technology Standards Panel (HITSP) American Health Information Community (Community) The Health Information Security and Privacy Collaboration (HISPC) Nationwide Health Information Network (NHIN) Architecture Projects A public-private “Community” was established to serve as the focal point for America’s health information concerns and drive opportunities for increasing interoperability

44. The Certification Commission for Healthcare Information Technology (CCHIT) Healthcare Information Technology Standards Panel (HITSP) American Health Information Community (Community) The Health Information Security and Privacy Collaboration (HISPC) Nationwide Health Information Network (NHIN) Architecture Projects A public-private “Community” was established to serve as the focal point for America’s health information concerns and drive opportunities for increasing interoperability

45. Role of Public Health in a NHIN NEXT STEPS

46. W W W . I H E . N E T Providers and Software Developers Working Together to Deliver Interoperable Health Information Systems in the Enterprise and Across Care Settings

47. Integrating the Healthcare Enterprise (IHE) Overview Presented by Dan Russler, M.D., IHE PCC Co-chair IHE Workshop – June 19, 2006

48. Why IHE? • 1970’s—Mainframe Era--$100,000 per interface • 1990’s—HL7 2.x--$10,000 per interface • 2000’s—IHE Implementation Profiles— Cheaper than a new phone line! How? IHE Eliminates Options Found in Published Standards

49. Who is IHE? • IHE is a joint initiative among: • American College of Cardiology (ACC) • Radiological Society of North America (RSNA) • Healthcare Information Management Systems Society (HIMSS) • GMSIH, HPRIM, JAHIS (laboratory) • American Society of Ophthalmology • American College of Physicians (ACP) • American College of Clinical Engineering (ACCE) • And many more…. • Began in 1997 in Radiology (RSNA) and IT (HIMSS) • International effort: IHE- Europe and IHE-Asia • Additional sponsors for Cardiology including ASE, ESC, ASNC, SCA&I, HRS and more

50. 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 15 Active national chapters on 4 continents