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Infrastructure—Patient Index and Demographics Implementation Strategies

Infrastructure—Patient Index and Demographics Implementation Strategies. Yongjian Bao GE Healthcare May 16, 2007. Why Patient Identity Management. Establishing Reliable Patient Identity is a Critical Infrastructure Component in Health IT Bind clinical data to its subject of care

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Infrastructure—Patient Index and Demographics Implementation Strategies

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  1. Infrastructure—Patient Index and Demographics Implementation Strategies Yongjian Bao GE Healthcare May 16, 2007

  2. Why Patient Identity Management • Establishing Reliable Patient Identity is a Critical Infrastructure Component in Health IT • Bind clinical data to its subject of care • Identity Life-Cycle Management is the Key to Accurate Identification of Patient • Ensure consistent patient data across all clinical domains and applications • EHR Drives Need for Patient Identity Process Cross Health Enterprises • Collect and access to Longitudinal EHR data

  3. EHR Drives Needs for Patient Identity Management inter- and intra-Enterprise Patient Registration Access Info in EHR US Exam System Access Info in EHR Physician Office Patient Registration Document Repository Provide Info to EHR EHR Provide Info to EHR PACS Provide Info to EHR Access Info in EHR Lab Info. System Community Clinic Patient Registration ED Application PACS EHR System Document Repository Reliable, Accurate Patient Identity is the Key to Integrate Clinical Applications Teaching Hospital

  4. Patient Identity Problems • Establish Patient Identity • Manage Patient Identity Life-Cycle • Update / add new attributes, link / merge, end of life, etc. • Patient Identification at Point of Care • Find Detailed Demographics Information • Locate Patient Record in Other Institutions Solution: IHE Patient Identity Integration Profiles

  5. Patient Identity Model

  6. Patient Identity Model Patient Identity Record Identifying traits Other data items Patient ID: A Symbol to Uniquely Identify each Record Patient ID Domain: A Namespace issuing unique Patient ID Namespace ID Unique ID / Unique ID Type Identification: A Process to Bind a Patient ID to a Record Patient ID Domain Patient ID Patient Identifying Traits Patient identity Record Patient Identifying Traits Patient Identifying Traits Additional Patient Data Items Additional Patient Data Items Additional Patient Data Items Patient Identity Model

  7. Patient Identity Source Patient Identity Source: a Collection of Records Created from a Patient Identity Model Identified in the Same Domain(s) Administered under the Same Policy A Patient Identity Source Decides Its Own Identifier Domain(s) and Administration Policy Different Organizations Often Have Their Own Patient Registries, and therefore Different Patient Identity Sources MAIN HOSPITAL 29764 Patient identity Record James A. Massie 1956-01-29 Male 171 Zoberlein, Ishpeming MI 49849 76363 91432 63537 Patient identity Record I6381209 Asian CFR James Addison Patient identity Record Alice Smith 1974-03-21 Female 123 South Street, New York NY 10021 Patient identity Record Mary Jones 1967-09-14 Female 1634 J St, Apt. 214, Davis CA 95616 John Smith 1963-04-23 Male N2378 South St.. Madison WI 53711 I87745833 African American AMT Carl Anderson I53874747 American Indian AME Dr. John Griffin I8944747 White ABC Ellen Massie Patient Identity Source

  8. Patient Identity in Multiple Sources 29764 AL-6625 29764 US Exam System ED Application Physician Office 62627 PACS Document Repository EHR System Document Repository PACS Lab Info. System Community Clinic Teaching Hospital

  9. Enterprise MPI Enterprise MPI US Exam System ED Application Physician Office PACS Document Repository EHR System Document Repository PACS Lab Info. System Community Clinic Teaching Hospital EMPI Patient Identification Domain

  10. IHE Patient Administration Management (PAM) Integration Profile

  11. Patient Administration Management Integration Profile: Abstract Patient Encounter Consumer Patient Encounter Source ITI-31: Patient Encounter Management Patient Demographics Consumer ITI-30: Patient Identity Feed Patient Demographics Source • Patient Identity and Patient Encounter Management for All Clinical Domains • Source – Consumer notification messaging model … both in- and outpatient settings • Identity life-cycle management … creation, update, merge / link • Encounter - movement model … historical events tracking and updating • Designed with HL7 2.5 Standard Conformance Profile Structure • Static Constraints on message, segment, and data type levels • Dynamic Constraints on event level • Message control and acknowledgement definition … robust error reporting by leveraging HL7 2.5 • OptionPackages • Support a wide range of applicationneeds

  12. Patient Administration Management: Patient Identity Feed Transaction (ITI-30) Actor Requirements Patient demographics source – Required Patient demographics consumer – Required Patient Identity Management Patient Identifying Traits Messages to notify patient identity life-cycle events: Creation / Update / Duplicates Resolution Base Set of Messages + 2 Options Patient identifying traits defined in base messages Two ways to handle patient identity duplicates At least one of them must be supported … it can be defined in national extensions PID-3 Patient Identifier List R PID-5 Patient Name R PID-7 Date / Time of Birth CE PID-8 Administrative Sex CE PID-11 Patient Address CE PID-31 Identifier Unknown Indicator CE PID-32 Identifier Reliability Code CE PID-35 Species Code CE PID-36 Breed Code CE Patient Identifying Traits in PID Segment Merge Two Patients (A40/A39) Link Patient Information (A24/A24) Unlink Patient Information (A37/A37) Create New Patient (A28/A05) Update Patient Information (A31/A05) Change Patient Identifier List (A47/A30)

  13. IHE Patient Identifier Cross-Referencing (PIX) Integration Profile

  14. Patient Identifier Cross-Referencing Integration Profile: Abstract Patient Identifier Cross-Referencing Manager Patient Identity Source ITI-8: Patient Identity Feed ITI-9 ITI-10 Patient Identifier Cross-Referencing Consumer ITI-9: PIX Query ITI-10: PIX Update Notification • Cross-Mapping of Patient Identity Records of the Same Patient from Different Domains • Specify identifying traits, but leave matching design open for implementation • Specify consumer behaviors on receiving PIX query responses • PIX Domain … the Scope Supported in PIX Manager • Not a real id domain, but a set of cross-mapped id domains • PIX Manager provides only ID-cross-mapping services … no identity details • HL7 Messages to Access PIX Services • PIX Query: Look-up identifiers in other domains • PIX Update Notification: Subscription service to receive cross-mapped identifiers and their changes • HL7 2.5 versionsupported since2003 … HL7 V3 support in trial implementationphase

  15. Patient Identifier Cross-Referencing : Patient Identity Feed Transaction (ITI-8) Patient Identifying Traits PID-3 Patient Identifier List R PID-5 Patient Name R PID-6 PID-7 Date / Time of Birth Mother’s Maiden Name R+ R+ PID-8 Administrative Sex R+ PID-11 Patient Address R2 PID-13 Phone Number - Home R2 PID-14 Phone Number - Work R2 PID-16 SSN Number - Patient R2 PID-25 Driver’s License Number R2 PIX Manager Document Registry PIX Manager PIX Manager • Implementation Considerations: • Send Patient Identifier in PID-3, always with Patient Identifier Domain information (PID-3.4) • If the Identity Source supports multiple Patient Identifiers, list all of them in PID-3 • Use ISO OID to identify Patient Identifier Domain if possible … if the identity feed is to Document Registry, this is required. • Send detailed demographics … all of the traits IHE required for PIX Manager and more • Actor Requirements • Patient identity source – Required • Patient identifier cross-referencing manager – Required • Feed Patient Identity records from different sources to PIX Manager for cross-referencing • HL7 Standard: Version 2.3.1 and Higher HL7 V3 Support of ITI-8 Trial Implementation Supplement Since 2006 Patient Identity Source Patient Identity Source ADT^A01 ADT^A04 ADT^A05 ADT^A08 ADT^A40 Run Patient ID X-Ref Process Trigger PIX Notification if Any Change in Patient ID X-Ref Relationship within PIX Manager ACK^Axx

  16. Patient Identifier Cross-Referencing : PIX Query Transaction (ITI-9) • Implementation Considerations: • Specify one patient identifier with domain information (QPD-3) as search key, to look up identifiers of the same patient in other domains – “Domains Returned” • Specify Domains Returned in QPD-4 • Use ISO OID to specify all patient identifier domain if possible • If Domains Returned are not specified, the PIX Manager returns patient identifiers in all domains it knows, which are cross-linked to the identifier in PIX query request. • PIX query response may include multiple identifiers in one domain … you SHALL use or ignore them all • Actor Requirements • Patient identifier Cross-referencing consumer – Required • Patient identifier cross-referencing manager – Required • Look-up Patient Identifier from one domain to other domains • Query Name: QPD-1=“IHE PIX Query” • HL7 Immediate Query Mode is Required • HL7 Standard: Version 2.5 HL7 V3 Support of ITI-9 Trial Implementation Supplement Since 2006 Patient Identifier Cross-Referencing Consumer Patient Identifier Cross-Referencing Manager QBP^Q23 MSH|^~\&|CLINREG|WESTCLIN|HOSPMPI|HOSP|20050801073005-0600||QBP^Q23^QBP_Q21|8699|P|2.5 QPD|Q23^Get Corresponding IDs^HL70471|111069|112234^^^METRO HOSPITAL|^^^WEST CLINIC~^^^SOUTH LAB RCP||I| Process PIX Query Request MSH|^~\&|HOSPMPI|HOSP|CLINREG|WESTCLIN|20050801073008-0600||RSP^K23^RSP_K23|1|P|2.5| MSA|AA|8699| QAK|111069|OK|Q23^Get Corresponding IDs^HL70471|1| QPD|Q23^Get Corresponding IDs^HL70471|111069|112234^^^METRO HOSPITAL|^^^WEST CLINIC~^^^SOUTH LAB| PID|||56321A^^^WEST CLINIC~66532^^^SOUTH LAB||~^^^^^^S| RSP^K23

  17. Patient Identifier Cross-Referencing : PIX Update Notification Transaction (ITI-10) • Implementation Considerations: • Notification transaction is initiated from the PIX Manager to PIX Consumer • Provide a method for PIX Consumer to subscribe the notification • Domain(s) of interest • Network address to send the notification • The PIX notification service is useful for a PIX Consumer which maintains a local cache of patient identifier cross-referencing relationship to avoid frequent PIX queries. • Notification may include multiple identifiers in one domain … you SHALLL use or ignore them all • Actor Requirements • Patient identifier cross-referencing consumer – Optional • Patient identifier cross-referencing manager – Required • Enable PIX Consumer locally cache (a portion of) x-ref’ed identifiers, mirrored from the PIX Manager • HL7 Standard: Version 2.5 HL7 V3 Support of ITI-10 Trial Implementation Supplement Since 2006 Patient Identifier Cross-Referencing Consumer Patient Identifier Cross-Referencing Manager Any Process Resulting in Change in Patient ID X-Ref Relationship ADT^A31 MSH|^~\&|HOSPMPI|HOSP|CLINREG|WESTCLIN|20050801073005-0600||ADT^A31^ADT_A05|8703|P|2.5| EVN|A31|200508010700||||200508010700 PID|||56321A^^^WEST CLINIC~66532^^^SOUTH LAB||~^^^^^^S| ACK^A31

  18. PIX Process Flow: Overview Patient ID Domain A PIX Manager Patient ID Feed Patient ID Feed L-716 14355 14355 A87631 Patient ID X-Ref Query Patient ID X-Ref Query Patient Registration US Exam System L-716 Patient ID Domain C Patient ID Feed Patient ID Feed A87631 Patient ID X-Ref Notification Patient ID X-Ref Notification Patient Registration 35424 35424 EHR System PIX Domain Patient ID Domain B Patient Registration Clinical Information System Patient ID Domain D Patient Registration PACS

  19. PIX Process Flow: Query and Notification Examples Patient ID Domain A PIX Manager L-716 14355 14355 A87631 Patient Registration US Exam System L-716 Patient ID Domain C A87631 Patient Registration 35424 35424 EHR System S1763 14355 98532 Y-456 L-716 D-776 DF-45 A74630 A87631 35424 63452 23511 PIX Domain Patient ID Domain B A: S1763 B: ? D: ? Patient Registration A: S1763 B: Y-456 D: A74630 Clinical Information System PIX Query Patient ID Domain D A: 98532 B: DF-45 C: 23511 Patient Registration PIX Notification PACS

  20. PIX and MPI: Combined Use in Typical IHE View A87631 L-716 Patient ID Domain A Patient ID Domain B Patient ID Feed Patient ID Feed L-716 14355 14355 Patient Registration Patient Registration US Exam System Clinical Information System Patient ID Domain C Patient ID Feed Patient ID Feed Patient ID Feed A87631 Patient Registration 35424 35424 35424 Master Patient Index (MPI) EHR System M8354673993 M8354673993 Patient ID Domain MPI PIX Domain PIX Manager A87631 Patient ID Domain D Patient Registration PACS

  21. PIX and MPI: MPI Joins in PIX as One Domain A87631 L-716 Patient ID Domain A PIX Manager Patient ID Feed Patient ID Feed L-716 14355 14355 14355 A87631 Patient Registration US Exam System L-716 Patient ID Domain C Patient ID Feed Patient ID Feed Patient ID Feed A87631 Patient Registration 35424 35424 35424 Master Patient Index (MPI) EHR System M8354673993 M8354673993 Patient ID Domain MPI PIX Domain Patient ID Domain B Patient Registration Clinical Information System Patient ID Domain D Patient Registration PACS

  22. IHE Patient Demographics Query (PDQ) Integration Profile

  23. Patient Demographics Query Integration Profile: Abstract Patient Demographics Supplier ITI-22: Patient Demographics and Visit Query ITI-21: Patient Demographics Query Patient Demographics Consumer • PDQ Information Model • Query by parameter – patient identifying traits • Multiple patient information sources • Patient identifiers from other domains • Patient Identification at Point of Care • Partial identifying traits  patient pick list • Patient visit traits  patient pick list • Patient identifier  patient record details • Acquire Patient Identifier in a Different Domain … an Alternative Way to PIX • Typically used in XDS environment to acquire patient identifier in Affinity Domain • Standardized HL7 QBP Message Profile • Query response continuation protocol • HL7 2.5 version Supported since 2003 … HL7 V3 support in trial implementation phase

  24. PDQ Model: Patient Information Source and Patient Information Supplier 66473322 J-718 Patient Identity Source B 14355 Patient Identity Source A RAD-0202 Patient Demographics Supplier Patient Demographics Supplier • A PDQ request is always defined in one Source, where patient records are identified in the source’s patient identifier domain. • The Supplier may know patient identifiers from OtherDomains corresponding to its patient records. • The Supplier may support multiple Sources – the Consumer must select which source a query to be served.

  25. Specify Patient Identity Source in PDQ Request 14355 J-718 Patient Identity Source B 14355 Patient Identity Source A 14355 Physician Office System Patient Demographics Supplier Example given in HL7 2.5 … HL7 V3 since 2008 • PDQ Request: QBP^Q22 or QBP^ZV1 • MSH-5 to select Patient Identity Source • QPD-8 to specify Other Domains from which additional Patient ID are to be returned (optional), e.g., Patient ID in XDS Affinity Domain Patient Demographics Consumer

  26. Patient Demonstration Query: Patient Demographics Query Transaction (ITI-21) Patient Identifying Traits PID-3 Patient Identifier List R PID-5 Patient Name R PID-7 Date / Time of Birth R2 PID-8 Administrative Sex R2 PID-11 Patient Address R2 PID-18 Patient Account Number R2 • Implementation Considerations: • Specify search keys in QPI-3 – Patient ID or demographics traits as PID/PD1 fields. They are AND’ed • List of Sources supported by the Suplier … Specifying a unknown Source in MSH-5 causes error condition • List of Other Domains supported in each Source … Specifying a unknown domain causes error condition • Requested Patient ID in Other Domains may not be returned in PDQ response. It is not error condition. • Return detailed demographics … those required and more • IHE neither specifies nor prohibits: additional identifying traits for matching, wildcards matching, repetitions in one PID field • Actor Requirements • Patient demographics supplier – Required • Patient demographics consumer – Required • Query Name: QPD-1=“IHE PDQ Query” • HL7 Query Immediate Mode Required • HL7 Query Continuation Protocol Supported • HL7 Standard: Version 2.5 HL7 V3 Support of ITI-2 since 2008 Patient Demographics Consumer Patient Demographics Supplier QBP^Q22 Process PDQ Query Request RSP^K22

  27. PDQ: Incremental Query Response Support Patient Demographics Supplier Patient Demographics Consumer • Implementation Considerations: • Throughout all interactions in a continuation process, Query Tag (QAK-1) is used to correlate all request/response messages associated with the same query • Supplier should declare its time-out policy to terminate a query continuation • In continuation, consumer resends the original query request in a new message – new value in MSH-10 QBP^Q22 or QBP^ZV1 RCP-1=“I” – R RCP-2=n - O RSP^K22 or RSP^ZV2 DSC-1= CP If continuation requested and supplier has more record to return Loop [If RSP contains a valid CP] [If RSP contains a valid CP, and Consumer wants to receive the next block of results] Loop QBP^Q22 or QBP^ZV1 Fetch next continuation block of matched results Send original query request in a new message w/ DSC echoing CP received in RSP RSP^K22 or RSP^ZV2 DSC-1= CP If supplier has more record to return. The CP is a new one Example given in HL7 2.5 … HL7 V3 supported since 2008 [else] QCN^J01 ACK^QCN

  28. Patient Identity Solutions and Implementation Strategy

  29. Patient Identifying Traits Required in IHE Integration Profiles PAM PIX PDQ Patient Identifying Traits in PID Segment Patient Identifying Traits Patient Identifying Traits PID-3 PID-3 PID-3 Patient Identifier List Patient Identifier List Patient Identifier List R R R PID-5 PID-5 PID-5 Patient Name Patient Name Patient Name R R R PID-7 PID-6 PID-7 PID-7 Date / Time of Birth Date / Time of Birth Date / Time of Birth Mother’s Maiden Name CE R+ R2 R+ PID-8 PID-8 PID-8 Administrative Sex Administrative Sex Administrative Sex R+ CE R2 PID-11 PID-11 PID-11 Patient Address Patient Address Patient Address R2 R2 CE PID-31 PID-13 PID-18 Phone Number - Home Patient Account Number Identifier Unknown Indicator R2 R2 CE PID-32 PID-14 Phone Number - Work Identifier Reliability Code CE R2 PID-16 PID-35 SSN Number - Patient Species Code CE R2 PID-36 PID-25 Breed Code Driver’s License Number R2 CE

  30. Patient Identity Profiles Implementation: Security Considerations Patient Encounter Consumer Patient Encounter Source ITI-31 Patient Demographics Consumer Patient Demographics Source ITI-30 Patient Identifier Cross-Referencing Manager Patient Demographics Supplier Patient Identity Source ITI-8 ITI-9 ITI-10 ITI-21 ITI-22 Patient Demographics Consumer Patient Identifier Cross-Referencing Consumer ATNA Patient Record Patient Record Patient Record Query Event Query Event Patient Record

  31. Patient Identity Profiles Implementation: System Deployment Considerations ATNA Patient Encounter Consumer Patient Encounter Source Patient Record ITI-31 Patient Demographics Consumer Patient Demographics Source Patient Record ITI-30 Patient Identifier Cross-Referencing Manager Patient Demographics Supplier Patient Identity Source ITI-8 Patient Record Query Event Query Event Patient Record ITI-9 ITI-22 ITI-21 ITI-10 Patient Demographics Consumer Patient Identifier Cross-Referencing Consumer

  32. Implementation Example: Using PIX to Cross-Link Patient Identities across Different Organizations Longitudinal Record Services HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP Standards EHR IP Common Services Communication Bus CANADA INFOWAY JURISDICTIONAL INFOSTRUCTURE Ancillary Data& Services EHR Data& Services DataWarehouse Registries Data& Services OutbreakMgmt PHSReporting SharedHealth Record DrugInformation DiagnosticImaging Laboratory HealthInformation ClientRegistry ProviderRegistry LocationRegistry BusinessRules EHRIndex MessageStructures NormalizationRules TerminologyRegistry Security Mgmt Privacy Data Configuration HIAL EHR SCP Standards • Centricity PACS • IHE PIX for Client Registry • IHE XDS /I for Information Exchange • XDS Consumer • XDS Source (local repository) PIX XDS/i

  33. Implementation Example: Using PDQ to Query Patient Identities Information ISB RLS ISB CDX Gateway Aggregated Lab Results (Local and Remote) BMC XDS Domain CHC Repositories Clinical Doc Locations Document Registry Cross-Domain Bridge ISB ISB GE Centricity Query CDX Gateway RLS • BMC Physician Retrieves Lab Results • Centricity sends query to BMC CDX Gateway, which passes it to the MA-SHARE Gateway/ISB & queries RLS for location of local patient records • MA-SHARE Gateway retrieves clinical doc locations (metadata) from XDS registry • ISB Queries other RHIOs (Indiana Health Information Exchange • Aggregated query metadata displayed on EMR • Physician selects documents to view Boston MC Whittier HC South Boston HC Courtesy of

  34. IHE Patient Identity Profiles Summary • Communication Mechanism: HL7 2.x Messages • Some of these profiles are being adapted to HL7 V3 messages using Web Services (work in progress) • Standardized Patient Identifying Traits • Standardized Messages for Patient Records Life-Cycle Management Events • Standardized Query Messages to Acquire Patient Identity / Demographics Information • Defined Cross-Referencing Mechanism to Map Identities across Different Domains

  35. Further IHE Documents • IHE Web site: • http://www.IHE.net • Technical Frameworks: • ITI V3.0 • Technical Framework Supplements - Trial Implementation • July 2005: PAM Integration Profile (Revised Nov. 2006) • Non-Technical Brochures : • Calls for Participation • IHE Fact Sheet and FAQ • IHE Integration Profiles: Guidelines for Buyers • IHE Connect-a-thon Results • Vendor Products Integration Statements

  36. Questions?

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