The information contained in this presentation is based on proposed and working documents.

1. Health Information Exchange Interoperability Minnesota Department of Health December 2008 The information contained in this presentation is based on proposed and working documents.

2. Proposed Working Definition of Interoperability in Minnesota 1. Background • Variety of definitions for electronic health record (EHR) interoperability used nationally • Proposed Minnesota definition draws from this work • Minnesota definition adapted in part from: • HL7 white paper “Coming to Terms: Scoping Interoperability for Health Care” (HL7–2007) • e-Health Initiative definition (ehealthinitiative.org, 2004) • Supports statewide mandate that all health care providers adopt interoperable EHRs by 2015 • Focuses on electronic exchange; health information exchange can be electronic or non-electronic

3. Proposed Working Definition of Interoperability in Minnesota (continued) 2. Principles • Includes key conceptual components of HL7 white paper and national e-Health Initiative definition • Sufficient specificity to be useful • Sufficiently dynamic to allow for necessary updating • Logical and understandable in context of Minnesota e-health environment • Supports Minnesota needs related to 2015 mandate

4. Proposed Working Definition of Interoperability in Minnesota (continued) 3. Working Definition Interoperability of Electronic Health Records (EHR) in Minnesota means the ability of two or more EHR systems or components of EHR systems* to exchange information electronically, securely, accurately and verifiably, when and where needed; comprised of “technical”, “semantic” and “process” interoperability; the information includes transactions and standards as defined by the Commissioner of Health and currently includes the following transactions indicated below: • Electronic Prescribing / Medication Management • Immunization Information Exchange • Laboratory Results Reporting Anticipated transactions for 2008-09 include: • Exchange of clinical summaries • Public Health Surveillance and Case Reporting * Electronic health record systems includes ancillary health information systems such as laboratory, pharmacy and radiology as identified in Appendix B of statewide implementation plan. http://www.health.state.mn.us/ehealth/ehrplan2008.pdf Adapted in part from: HL7 white paper “Coming to Terms: Scoping Interoperability for Health Care” (HL7–2007), e-Health Initiative definition (ehealthinitiative.org, 2004)

5. Types of Interoperability • Technical interoperability • Neutralizes effects of distance • E.g., hardware, software, networks • Semantic interoperability • Communicates meaning • E.g., data content terminologies (e.g., ICD-10, SNOMED, LOINC) • Process interoperability • Coordinates work processes • E.g., work flow, user roles These three types of interoperability are all required for consistent and timely exchange of health information among partners Adapted in part from: HL7 white paper “Coming to Terms: Scoping Interoperability for Health Care” (HL7–2007)

6. Visual Depiction of Types of Interoperability Technical interoperability:hardware, software, networks Semantic interoperability: Data content terminologies Process interoperability: People interacting with systems, workflow, user roles etc., Process interoperability: People interacting with systems, workflow, user roles etc.,

7. Examples: Interoperability in Context of Electronic Prescribing • Technical interoperability • Appropriate hardware, software, and networks for routing prescriptions electronically • Pharmacy information system that can integrate an electronic prescription without data re-entry • Certification of electronic prescribing systems • Certification of prescriber systems (EHRs) offered by CCHIT; certification of hand held e-Rx systems to be offered in near future by CCHIT • Certification of networks offered by SureScripts-RxHub • Semantic interoperability • Usage of appropriate drug database • Ability of pharmacy application to read and interpret correctly the prescription sent by the electronic prescribing application (use of common terminology and vocabulary) • Process interoperability • User interface guidelines • Similar work/process flows in various electronic prescribing application • Options and drop-downs should be similar • Electronic prescribing process guidelines • Guidelines on when a pharmacy application detects an error in prescription • Guidelines on when a pharmacy application rejects an electronic prescription

8. Failure of Interoperability Examples Three examples relating to an imaginary school bus accident: • Technical interoperability failure An Emergency Department physician receives an electronic message from the primary care physician of a critically injured student stating that the student has no allergies to drugs. However, an electronic bit was inadvertently flipped during transmission; the patient dies from an allergic reaction to the drug • Semantic interoperability failure: An Emergency Department physician sends an electronic message to an overseas physician asking whether there were any warnings about a visiting student’s health. The foreign doctor sends the message code "N/A" that asserts that the information regarding allergies was never gathered. The ED physician interprets the response as "Negative for Allergies" and gives an antibiotic drug; the patient dies from an allergic reaction to the drug • Process interoperability failure: The injured school children arrive at an Emergency Department (ED). The provider uses several different EHRs and assumes that all the systems provide alerts for allergy. This particular ED system does not have alerts implemented and thus the provider is not aware of this different process. A drug is prescribed with potential allergic reaction to an injured child. Adapted in part from: HL7 white paper “Coming to Terms: Scoping Interoperability for Health Care” (HL7–2007)

9. Proposed Minnesota Roadmap for Standards and Interoperability