Organizing IHE Integration Profiles related to the Electronic Health Record Initial Thoughts

1. Organizing IHE Integration Profiles related to the Electronic Health Record Initial Thoughts IHE ITI Tech Committee - December 2003 V6

2. IHE Integration Profiles Focused on the EHR • An IHE Integration Profile organizes a set of coordinated, standards-based transactions between a subset of the functional components of healthcare enterprises in order to address a specific clinical or infrastructure need. • IHE develops such solutions for IT systems integration in a stepwise and pragmatic manner, focusing on the most common integration challenges. • IHE has developed close to 20 Integration Profiles focuses on Radiology, Laboratory, IT Infrastructure (MPI, Security, etc.) and is now expanding to Cardiology. This is an intra-enterprise, bottom-up approach. • In this proposal, IHE explains how it intends to approach the longitudinal dimension of the EHR with a distributed, cross-enterprise, document centric, top-down point of view. • The strategy is to progressively bridge the two approaches as new integration profiles are developed. • Feedback on this approach and expanding collaborations are sought. V6

3. Continuity of Care: Patient Longitudinal Record Across Encounters Nursing Homes Acute Care (Inpatient) Other Specialized Careor Diagnostics Services A typical patient goes through a sequence of encounters in different Care Setting (incl. Diagnostics Services). GPs and Clinics (Outpatient) V6

4. Integration : Feeding & Accessing the Longitudinal Health Record Information EHR-LR Acute Care (Inpatient) Nursing Homes Other Specialized Careor Diagnostics Services GPs and Clinics (Outpatient) The EHR-LR (Longitudinal Record) brings together patient encounter information managed by multiple care delivery systems V6

5. EHR-LR EHR-LR EHR-LR Read Create Update Read Identification Decide to Assess demand For care End ofEncounter Define an action plan Selection of informations Actions to order EHR-CR Define healthcare Objective Two types of Integration : Health Record as used during care delivery Health Record as used across-encounters Care Delivery Process EHR-CR : EHR information supporting immediate care delivery EHR-LR : EHR information supporting long term care delivery V6

6. EHR-LR Actors: Directory & Repository Actors EHR-LR Directory EHR-LR Documents Repository Custodian for an unspecified time of Documents recorded from patient encounters. EHR-LR Documents Repository Custodian for an unspecified time of Documents recorded from patient encounters. EHR-LR Virtual Documents Repository Custodian for an unspecified time of Documents recorded from local patient encounters. EHR-CR EHR-CR V6

7. Key Statements : EHR-LR Fundamentals • The EHR-LR (Longitudinal Record) brings together patient encounter information managed by multiple care delivery systems, ranging from EHR-CR (Care-delivery Record) in a large hospital network all the way down to a single practice management system. • EHR-LR will be cross-enterprise and may include one or more clinical domain and will be typically collected over a large period of time. • EHR-LR includes repositories of encounter data that contribute to the patient’s longitudinal healthcare record. EHR-LR data will be stored in multiple repositories (depts., sites, domains). • Encounter data includes some information/state/workflow info that may not end up in the EHR-LR. V6

8. Key Statements: What is in the EHR-LR ? • The EHR-LR data is made of discrete, persistent, clinical documents accessed by a unique identifier. It may also contain other dynamic objects (e.g. prescription status, allergy lists, etc.) which are not addressed at this time. • EHR-LR data will follow relevant clinical domain standards defined by field experts. Their content and codification will evolve according to the clinical needs. • At the end of an encounter, new document(s) are published to the EHR-LR. These new EHR-LR documents will either be kept in the EHR-CR where they are created or pushed to a separate EHR-LR repository. • Conversion between EHR-CR internal data formats and the standard EHR-LR document is the responsibility of the EHR-CR. V6

9. Key Statements : IHE Constraints • The domains of EHR-LR are primarily clinical. Other information and services are needed to provide a complete view of the patient longitudinal record (e.g. demographics, security, consents – IHE has already addressed some). • The EHR-LR and EHR-CR repositories may be using different Patient Ids. The longitudinal view is provided by cross-patient identification services. • The way data is stored and managed by the EHR-CR is out of scope of the EHR-LR IHE Integration Profiles. V6

10. Key Statements : Accessing EHR-LR • EHR-LR shall provide a list of available documents for a patient. Logical directories will be used to provide such lists. • The location and filtering of documents is the responsibility of the EHR-LR and not of the consumer applications. The EHR-LR will use meta-information about the documents it tracks to provide this service. • The EHR-LR must provide with full content fidelity all clinical documents that have beenregistered. • Documents may include references to other documents such as images, waveforms, etc. • In addition, the EHR-LR may optionally provide clinical data to consumer applications based on processing, extracting, or combining the content of multiple existing documents. V6

11. Key Statements : Deploying IHE EHR-LR Profiles • EHR-LR will likely be initially focused on certain specialties (cardiology, oncology, etc) or a key information for continuity of care (CCR summaries only) and expand progressively. V6

12. IHE Integration Profile(e.g. Lab, Cardio, etc) IHE Integration Profile(e.g. Lab, Cardio, etc) IHE Integration Profile(e.g. IT Infrastructure IHE Integration Profile(e.g. IT Infrastructure IHE Integration Profile(e.g. Lab, Cardio, etc) IHE Integration Profile(e.g. Lab, Cardio, etc) IHE Integration Profile(e.g. Lab, Cardio, etc) IHE Integration Profile(e.g. IT Infrastructure IHE Integration ProfileDomain Specific Doc Content IHE Integration ProfileDomain Specific Doc Content IHE Integration ProfileDomain Specific Doc Content IHE Integration ProfileX-Enterprise Security, MPI LR Register, Retrieve. Integration Profiles : Current Profiles vs “EHR-LR Profiles EHR-LR Acute Care (Inpatient) Nursing Homes EHR-CR EHR-CR EHR-CR Other Specialized Careor Diagnostics Services Patient Access EHR-CR EHR-LR= The Longitudinal Record of a person’s health EHR-CR= Care-delivery Record GPs and Clinics (Outpatient) V6

13. In PatientOutpatient Link CardiologySpecialist toAcute OncologySpecialist toAcute Etc…. EHR-LR Security, MPILR Register, Retrieve. Integration Profile(s) EHR-LR Security, MPILR Register, Retrieve. Integration Profile(s) EHR-LR Security, PIXLR Register, Retrieve. Integration Profile(s) . . . . Cath Report Integration Profile Tumor Report Integration Profile Radiology Report Integration Profile . . . . EHR-LR Integration Profiles : Infrastructure(s) + Content(s) V6

14. Some examples applying this EHR Concept • Following are three examples where the same “EHR-LR integration concept would be applicable: • GP Office in multiple IDNs with an EHR-LR ASP: GP linkage to acute care • Cardiologist Practices and Inpatient: a domain specific longitudinal record • Region or Country-Wide: a broad cross-domain longitudinal record • These examples largely rely on the same set of core-EHR-LR IHE Integration Profiles, but used with different configurations and policies. The EHR-LR documents content would greatly vary. • These examples are not intended to be exhaustive, but attempt to demonstrate the balance that IHE is looking for a reasonably broad set of use cases that would share the same infrastructure (i.e. set of actors and transactions). V6

15. Example : GP Office in multiple IDNswith an EHR-LR ASP One Directory by IDN. Holds a reference to all encountersknown by the IDN, including those from the GP EHR-LR Patient/Encounter Level Directory EHR-LR Patient/Encounter Level Directory This Encounter Directory manages allencounters form the GP. It is an EHR-LR ASP. This ASP system is also theprimary EHR-CR or all documentscreated by the GP’s encounters. EHR-LR Encounter/Documents Level Directory EHR-LR Documents Repository GP Practice Clinical Record Entry Document Creator and Consumer V6

16. Example : Cardiologist Practices and Inpatient IDN and associated Cardiologists establisha Central Directory. Holds a reference to all encountersknown by the IDN and Cardiologist EHR-LR Patient/Encounter Level Directory EHR-LR Encounter/Documents Level Directory This Encounter Directory manages allencounters form the Cardiologists.It is an EHR-LR with all documentscreated by Cardiology encounters. EHR-LR Documents Repository Cardiologist Practice Clinical Record Document Creator and Consumer CardiologyInpatient Clinical Record Document Creator and Consumer Cardiologist Practice Clinical Record Document Creator and Consumer CardiologyInpatient Clinical Record Document Creator and Consumer Cardiologist Practice Clinical Record Document Creator and Consumer V6

17. Example : Regional or Country-Wide (e.g. NHII) One such Patient Directory by region. Shadows copies. Knows all lower leveldirectories where encounters are identified. EHR-LR Patient Level Directory One such P/E Directory by region. Holds a reference to all encountersmade in the region. EHR-LR Patient/Encounter Level Directory EHR-LR Patient/Encounter Level Directory One such E/D Directory by EncounterCustodian used by the health delivery entity where the encounter happen EHR-LR Encounter/Documents Level Directory EHR-LR Encounter/Documents Level Directory EHR-LR Documents Repository EHR-LR Encounter/Documents Level Directory One or more document repository by document custodians used by the health delivery entity where the encounter happen or external. EHR-LR Documents Repository EHR-LR Documents Repository V6

18. EHR-LR Use Cases: Actors & Transactions Concepts EHR-LR Patient Directory EHR-LR Patient Directory EHR-CR EHR-LR EHR-LR Patient Directory QueryDoc List EHR-LR Patient Directory EHR-LR Encounter Directory EHR-LR Encounter Directory EHR-CR Document Consumer EHR-LR Documents Repository Custodian for an unspecified time of Documents recorded from patient encounters. Register Doc EHR-LR Documents Repository Custodian for an unspecified time of Documents recorded from patient encounters. Register and Provide Doc RetrieveDoc Document Creator EHR-LR Documents Virtual Repository Custodian for an unspecified time of Documents recorded from local patient encounters. Not all transactions necessary to ensure management of a distributed and dynamic EHR-LR are depicted in this illustration. V6

19. IHE Integration Profiles Focused on the EHR • IHE proposes an approach to obtaining a longitudinal view of the EHR, with a distributed, cross-enterprise, document centric solution. • The strategy is to progressively bridge the gap between the EHR-LR Integration Profiles and the domain integration profiles as new integration profiles are developed. • Feedback on this approach and expanding collaborations are sought. • Is this a useful “brick” ? • The proposed strategy is a scoping exercise to address one of the many integration problems in the realization of the EHR vision. IHE does not claim to master and address the definition and all aspects of a complete and interoperable EHR System. • In collaboration with well established standards bodies and other EHR related initiatives world-wide (EHRCOM, CCR, HL7, etc.), IHE expects to contribute at a more cost-effective and rapid deployment. V6

20. Draft IHE IT Infrastructure Roadmap In support of the IHE Integration Profiles focused on the EHR Draft for Comments – 11/03 To be finalized January 2004. V6

21. EHR Security Common Data Profiles ·RID ·PIX ·PSA Profiles ·EUA ·CT · No content Standards & Prerequisites ·CCOW v1.4 Patient Context ·HL7 v2.3.1 ·HL7 v2.4 ·HTTP ·WSDL 1.1 ·XHTML 1.0 ·XML 1.0 Standards & Prerequisites ·CCOW v 1.4 User Context ·Kerberos ·NTP ·SNTP IHE IT Infrastructure Roadmap – HIMSS 2004 (1) V6

22. EHR Security Common Data Profiles ·EHR-LR -Provide Document -Register Document -Query Document(s) -Retrieve Document ·Patient Demographics Query - enterprise Profiles ·Take-on Basic Security -Common Audit schema -Node authentication PKI ·User demographics directory -Healthcare staff -Patients? Profiles ·LDAP base -Federated -Multiple information bases: equipment, organizations, users ·Reference code sets -Distribution -Update ·SNMP MIBS? -Event reports -Equipment calibration changes -Equipment and software change management & tracking -Event trending Standards & Prerequisites ·Stage 0 IHE ITI profiles -PIX-enabled EMPI service ·CDA level 1 -ASTM E31.28 CCR encoding Standards & Prerequisites ·IHE Radiology Basic Security ·Stage 0 IHE ITI security profiles ·RFC 2798 ·ITU X.509(95) ·Stable Common Audit Message RFC Standards & Prerequisites ·LDAP ·SNMP -MIB standards / registry ·Mature/stable standards for selected code sets IHE IT Infrastructure Roadmap - Next Stage (2) V6

23. EHR Security Common Data Profiles ·EHR-LR -Solidify step 1 -Add 2 composite information sets (candidates: allergies, discharge summaries, medication lists; consult with IHE clinicians on choices) -RAD plug-in ·Patient Demographics Query - multi-enterprise Profiles ·Incorporate Kerberized standards into EUA -DICOM -HL7 v2 (v3?) -HL7 CCOW ·User PKI -Enterprise -Patients -Multi-enterprise? -Key distribution Profiles ·Masterfile Maintenance ·Additional LDAP information sources ·RID configurability directory #1 Standards & Prerequisites ·Stage 1 IHE ITI profiles ·Additional CDA templates ·PKI for user identify management Standards & Prerequisites ·Stage 1 IHE ITI security profiles ·Stable Kerberos support in: -HL7 v2.6 -CCOW -DICOM ·PKCS#10 ·ISO/TS 17090 Standards & Prerequisites ·Stage 1 IHE ITI common data profiles ·HL7 v2 Masterfile maintenance ·Mature/stable standards for selected information sources ·Suitable LDAP schema definitions IHE IT Infrastructure Roadmap – Stage 3 V6

24. EHR Security Common Data Profiles ·EHR -Lab trending -Consents -Medication list Profiles ·Add attribute certificates to PKI to support: -Basic RBAC -Consents? ·Multi-entity EUA ·Digital signatures Profiles ·Additional LDAP information sources ·RID configurability directory #2 ·Workflow management preferences? Standards & Prerequisites ·Stage 2 IHE ITI profiles ·IHE Lab profiles ·Basic RBAC Standards & Prerequisites ·Stage 2 IHE ITI security profiles ·Mature attribute certificate distribution specification/standard ·ISO/TC 215 Privilege Management Infrastructure specification Standards & Prerequisites ·Stage 2 IHE ITI common data profiles ·Mature/stable standards for selected information sources ·Suitable LDAP schema definitions IHE IT Infrastructure Roadmap – Stage 4 V6

25. EHR Security Common Data Profiles ·EHR-LR -More document types (general document templates) -More clinical domains (cardiology, nuclear medicine, pharmacy, ...) -Composite documents from multiple clinical domains. Profiles ·Remote service access ·Anonymization ·Wide-area patient access ·Mobile applications -Wireless -Patient active homecare -Mobile providers ·Location-sensitive behaviors ·Patient identification standards Profiles ·RID configurability directory #3 -"Hanging protocols" Standards & Prerequisites ·Stage 3 IHE ITI profiles ·IHE clinical domain uptake Standards & Prerequisites ·Stage 3 IHE ITI security profiles ·Stable standards for mobile access security ·Stable standards for patient identification Standards & Prerequisites ·Stage 3 IHE ITI common data profiles ·Suitable LDAP schema definitions IHE IT Infrastructure Roadmap – Stage 5 V6