A Study of Health Information Exchange and Interoperability System Solutions

1. A Study of Health Information Exchange and Interoperability System Solutions Anubhav Mathur Masters in Computer Science Computer Science & Engineering Department University of Connecticut anubhav.mathur@engr.uconn.edu http://www.engr.uconn.edu/~anm13020 (908) 210 - 1660

2. Overview • What Is HIE? • Key forms of HIE • What is Interoperability • Aspects of Interoperability • Current State • Problems • Initiatives • Solutions • Core Issues • Future Scope • References

3. What Is HIE? • Secure access of patient’s vital medical information electronically • Stakeholders: Doctors, • Nurses, Pharmacists, • Other health care providers • Patients! • Advantages: • Improving the speed, • Quality, • Safety • Cost of patient care. • Example: DIRECT Messaging System

4. Key forms of health information exchange • Directed Exchange – ability to send and receive secure information electronically between care providers to support coordinated care • Query-based Exchange – ability for providers to find and/or request information on a patient from other providers, often used for unplanned care • Consumer Mediated Exchange – ability for patients to aggregate and control the use of their health information among providers  • The foundation of standards, policies and technology required to initiate all three forms of health information exchange are complete, tested, and available today.

5. Interoperability • What is Interoperability? • Ability of two or more systems or components to use the exchanged information. • Fundamental Building Blocks: • Meaning through the use of standardized healthcare vocabularies, • Structure by leveraging standards in HL7 • Transport using secure email protocols, • Security through National Institute of Standards and Technology (NIST)-adopted encryption standards, and services through open, and accessible application programming interfaces (APIs).

6. Aspects of Interoperability Informatics People Information Technology Image Title • Transport • More than one transport standards • Standardization of data • Vocabularies • Terminologies • Standards for structure

7. Benefits of Interoperability • For health professionals: • Improve access to health record data and health information anytime, anywhere. • For patients: • Improve quality and safety of care by improving data exchange, the quality of data flow and access to information by health professionals thereby potentially reducing errors. • For health managers: • Improve data collection and facilitate statistical and economic analysis.

8. Benefits of Interoperability • For health researchers: • Improve and increase the availability of medical data. • For the healthcare technology industry: • Improve access to the healthcare market for more companies (SMEs in particular who may be limited in their ability to provide technologies which can integrate with an organisation's legacy systems).

9. Current state • Developments in the past 3-4 years in standards and technology. • Development of HIEs and HIXs • Transfer of financial information using X.12 standards. • Standards-based representation of information (CDA, CCD, CCDA) • Communication • IHE • XDS • Direct Project • PHINMS • eHealth Exchange

10. Problems • Not a “one-size-fits-all” solution. • Home-grown and legacy applications, providing functionality across patient and infrastructure management, clinical care, administrative and financial domains. • Pre-date the introduction of standards for information sharing. • Closed in nature

11. Problems • Reluctance to change from traditional paper-based systems to electronic systems. • Lack of specificity of healthcare standards and information sharing protocols • Numerous incompatible terminologies and ontologies involved. • Semantic interoperability major challenge. • Amplification at the state or national level or when health systems attempt to manage a population’s wellness and develop mechanisms to exchange population-level data.

12. Current initiatives • Government standardization initiatives: • Office of Science & Technology (OST). • Office of the National Coordinator for Health Information Technology’s (ONC) • Enable the health IT community to convene and rapidly prioritize health IT challenges. • Develop and harmonize standards, specifications and implementation guidance to solve those challenges. • Curate the set of standards and specifications that support interoperability and ensuring that they can be assembled into solutions for a variety of health information exchange scenarios.

13. Current initiatives • HITECH Act. • Promoting the adoption and uptake of health information technology • Ensure technical standards and specifications are in place to support this technology • Critical to the development and success of a fully functional nationwide health IT ecosystem.

14. Solutions For HIE

15. CONNECT • Open source software solution developed by over 20 federal agencies that organizations can use to securely link their existing health IT systems into the NwHIN.

16. Advantages • Open source and free for download. This improves adaptability among various HIEs • Coordinates care across public and private care sectors. Providers will have access to medical records throughout the continuum of care, regardless of whether the treatment facilities are in the government or private sector • Speeds the dissemination of clinical and scientific research results to government, industry and the scientific community to benefit population health • Improves regulation of pharmaceutical products and medical devices through faster, more comprehensive and more accurate detection of adverse drug events

17. NwHIN Exchange: • The NwHIN Exchange is a collection of standards, protocols, legal agreements, specifications and services that enables the secure exchange of health information over the internet.

18. NwHIN Exchange • Advantages: • The NwHIN Exchange has methods to perform universal patient lookup, document discovery and retrieval, and exchange between organizations and federal agencies (VA, DOD, CDC, SSA, plus 22 others). The organizations entering into an exchange with those federal agencies are typically sizable HIOs, HIEs or large IDNs.

19. NwHIN Exchange • Disadvantages: • Participation currently limited to federal health agencies and healthcare organizations under ONC contract and other recipients of federal grants. • Most individual providers/small practices have limited technical resources. • Since many providers will not be able to participate in the NwHIN Exchange, they still need a model to help them reach Stage 1 Meaningful Use (MU) requirements. • Development geared toward large HIOs/IDNs before the HITECH Act/Meaningful Use criteria existed. In order to provide a simpler option to help providers meet basic MU requirements.

20. NwHIN DIRECT • The set of standards, policies and services that enable simple, secure transport of health information between authorized care providers. • NwHIN Direct enables standards-based health information exchange in support of core Stage 1 MU measures, including communication of summary care records, referrals, discharge summaries and other clinical documents in support of continuity of care and medication reconciliation, and communication of laboratory results to providers.”

21. HISP • Used by the DIRECT project, to describe the management of security and transport for directed exchange and an organizational model • Performs HISP functions on behalf of the sending or receiving organization or individual. • Separate business organization from the sending and receiving organization required to have contractually binding legal Business Associate Agreements (BAAs) with HIPAA Covered Entities with the sender or receiver of directed exchange of Personally Identifiable Information. • Must include all data collection, use, retention, and disclosure policies (including rights reserved but not exercised) in other service agreements.

22. DIRECT • Advantages: • DIRECT is based on Open source software, therefore it promotes community participation in the development and maintenance of the system . • It offers customizability and adaptability • Security is implemented a thorough vetting system to ensure all providers who use the system are actually who they say they are.

23. Solutions For Interoperability Problem

24. Integrating the Healthcare Enterprise • Integrating the Healthcare Enterprise (IHE) • Initiative by the healthcare industry to improve the way computer systems share information. • Established in 1998 by a consortium of radiologists and information technology (IT) experts. • IHE integration statements are prepared and published by a vendor to list the IHE profiles supported by a specific release of a specific product.

25. Cross-enterprise Document Sharing • Cross-Enterprise Document Sharing minimizes clinical/admin data management by the infrastructure. Transparency = Ease of Evolution • Patients/consumers 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 • Has received major support world-wide: National & regional projects, NHIN contractors, US EHR Vendor Assoc., complements Connecting for Health RLS.

26. Why is IHE-XDS a breakthrough ? • Sharing of digital documents as “attested by the source”, meets the most urgent needs. A proven healthcare community data-sharing paradigm (Message feeding to web servers hinders use of EHRs & PHRs). • Efficient to support all types of Health IT Systems (IDNs, Hospitals, Ambulatory, Pharmacy, Payers, Diagnostics Centers, etc.) and all types of information (summaries, meds, images, lab reports, ECGs, etc.), structured and unstructured. • Offer a consistent, standards-based and functional record sharing for EHRs, PHRs & other IT Systems

27. LOINC • The Logical Observation Identifiers Names and Codes (LOINC) standard codes for use in databases are often used in IHE profiles. • Applies universal code names and identifiers to medical terminology related to electronic health records.  • Assist in the electronic exchange and gathering of clinical results • Example: laboratory tests, clinical observations, outcomes management and research

28. Current State • Currently most clinical laboratories and other diagnostic services use HL7 to send their results electronically from their reporting systems to their care systems • Most labs, however, identify tests in these messages by means of their internal code values • Care systems must either use the internal codes provided by laboratory or map to LOINC or local codes • Universal use of LOINC would solve this problem, and there is momentum to move in this direction

30. Advantages • Improved communication in integrated health delivery networks • Supports aggregated electronic health records • Permits automatic transfer to public health authorities of case reports for reportable diseases • Improved transfer of payment particularly claims attachments • Supports reduction of errors

31. DICOM • The standard for Digital Imaging and Communications in Medicine. • Developed by the National Electrical Manufacturers Association (NEMA) in conjunction with the American College of Radiology (ACR). • Covers most image formats for all of medicine. • Specification for messaging and communication between imaging machines.

32. Features of DICOM • NETWORK PROTOCOL • DICOM incorporates negotiation to permit peers to agree on the functions to be performed • MESSAGE ENCODING • DICOM defines 24 data types (V2.0 had 4) • DICOM message encoding includes JPEG compression • DICOM supports multiple character repertoires • OBJECT DATA MODEL • DICOM is based on a completely specified data model • DICOM includes a robust UID mechanism • DATA DICTIONARY • DICOM includes a large number of new data elements • SERVICE CLASSES • DICOM defines classes of service for specific applications (e.g. image management, printing) and conformance levels

33. Core Issues • Without interoperability, fundamental data and information such as patient records can't easily be shared across and sometimes within enterprises. • Achieving interoperability in a domain where information technologies, where they have been deployed in routine practice, may not have been designed to support it. • Many standards to support interoperability are only just now being developed - after many HIT systems have been installed.

34. Core Issues • Where HIT standards do exist they may also compete, making interoperability more difficult to achieve. • A lot of computerized clinical data are stored in ageing legacy systems in proprietary formats which are difficult for other systems to access, re-represent and transfer for (re)use. (The use of proprietary formats may also lock customers into specific information systems.) • Implementation of interoperable health information systems may require a high degree of technical expertise not readily available to small organisations in particular.

35. Future Work • The Artemis project [aims to support] "interoperability of medical information systems through semantically enriched Web services.“ • Ability to aggregate and share lifelong EHRs for patients with multiple stakeholders • Potential in using combined clinical data—from EHRs, patient health record systems (PHR) and wireless medical sensor devices • Clinical research to analyze trends within patient populations for more effective research, and to evolve evidence-based care protocols.

36. References • http://www.sgsmp.ch/dicom/parisot1.pdf • http://www.hcup-us.ahrq.gov/datainnovations/clinicaldata/FL20LOINCIntroductionHammond.pdf • http://dicom.nema.org/ • http://www.sciencedaily.com/releases/2006/01/060103182421.htm • IST Results. "Building Interoperability Into Medical Information." ScienceDaily. ScienceDaily, 4 January 2006. <www.sciencedaily.com/releases/2006/01/060103182421.htm>.

37. Thank you