iEHR, VLER, and The ESB

1. iEHR, VLER, and The ESB Joe Paiva Paul Tibbits, MD Dec 2011 V3

2. Agenda • iEHR • VLER (ESB; Data Access) • Common Information Interoperability Framework • XML • Management: Service Aware Integration Framework CIO Conference: iEHR, VLER, ESB v3

3. iEHR Vision DoD and VA are committed to full and seamless electronic exchange and record portability of healthcare information in secure and private format, wherever needed, to ensure highest quality and effective delivery of healthcare services. DoD-VA Integrated EHR Way Forward Update for DEPSECDEF, DEPSECVA and VCJCS” briefing, 12 February 2011. CIO Conference: iEHR, VLER, ESB v3

4. Achieving The Vision Common Information Interoperability Framework (CIIF) Crafting Usability CIO Conference: iEHR, VLER, ESB v3

5. Achieving the Vision Presentation Layer Implementation at North Chicago to be complete Q1 FY12 OSEHRA in place ESB Purchase decision in progress Notional architecture for joint operations completed Work continues on Common Information Model CIO Conference: iEHR, VLER, ESB v3

6. Crafting iEHR Usability • iEHR usability will be achieved by designing system so that users’ interactions are simple and efficient while allowing them to accomplishing their goals • Enable clinician to view single integrated medical record • Unify what providers, employees and patients see • Eliminate need for provider to search and find data within disparate legacy systems • Minimize number of clicks • Design with mobile devices in mind • Future iEHR Presentation Layer will be integrated and interactive, allowing clinicians to think and discover • Show relationships among data graphically • Allow users to act on data and explore ideas through dynamic coordinated displays • Infrastructure, capability planning and continuity of operations CIO Conference: iEHR, VLER, ESB v3

7. AC VA Loan RC Retire GI Bill VLER Goal: Proactive Service Delivery Federal DoD Benefits State & Local Empowered Veterans Oath to Final Benefit eBenefits Empowered Veterans & Servicemembers With Access & Control VA Benefits DoD Personnel VLER better enables VA and its partners to proactively provide full continuum of services and benefits Veterans have earned via Veteran-centric processes made possible by effective and efficient standards-based information sharing DoD Health Private Partners 2 VA Health iEHR

8. Mission VLER is multifaceted business and technology initiative that includes portfolio of health, benefits, personnel, and administrative information sharing capabilities Its mission is to enable VA and its partners to proactively provide full continuum of services and benefits to Veterans through Veteran-centric processes and effective, efficient, standards-based information sharing

9. VLER Priorities Empower Veterans Eliminate Barriers to Information Sharing Exploit Information Sharing to Realize VLER

10. Who Is The VLER Community? Private Health Care Providers State organizations Inside the DoD & VA External to the DoD and VA Education Institutions MHS OSD P&R VHA NCA VBA VLER “will ultimately contain administrative and medical information from the day an individual enters military service throughout their military career and after they leave the military.” -President Barack Obama Lending Institutions CIO Conference: iEHR, VLER, ESB v3

11. Enterprise Architecture View of VLER Veteran VLER integrates Veteran Servicing Systems With the support of VA Operations and Systems Veteran Servicing Systems Benefits Domain Cemetery Domain Health Domain VRM Benefits and Services business processes Health Compensation Pension Education Insurance Memorials Burials VR&E Loan Guaranty Homelessness VBMS New Models Access GI Bill Mental Health Data About Veterans Data About VA Operations R&D System of Veteran Servicing Systems = VLER HI VLER SCIP HCIP Prep VA operations business processes STDP HCE Financial Management Human Resources Management Material Management IT Management Cyber Security & Privacy Corporate Management CIO Conference: iEHR, VLER, ESB v3 VA Operational Systems IOM

12. INTEGRATED EHR SOLUTION EHR SERVICES PLATFORM (ESP) EHR ISLocator Information Access & Longitudinal Record Services (LRS) Population HealthData &Services EHRData &Services RegistriesData &Services Population HealthData &Services EHR Information Services (EHR IS) Point of ServiceApplications Personal Health Record Systems EHR Viewers Technical Vision: EHR Service Platform (ESP) CIO Conference: iEHR, VLER, ESB v3 See notes page

13. EHR IS Enabled PHR System EHR IS Enabled Legacy System EHR IS INTEGRATED EHR SOLUTION EHR SERVICES PLATFORM (ESP) EHR ISLocator Information Access & Longitudinal Record Services (LRS) ESP Based System Population HealthData &Services EHRData &Services RegistriesData &Services EHR Information Services (EHR IS) Point of ServiceApplications Personal Health Record Systems EHR Viewers Key Concepts: Federated EHR Services Architecture Population HealthData &Services Tier 3 Plug-&-Play Data Stores EAI IP Data Access Virtualization Layer Tier 2 EHR Information Services Application Virtualization Layer EHR IP EHR IP EHR IP Tier 1 Plug-&-Play Applications IP is SOA Interoperability Profile aka Service Interface EAI is Enterprise Application Integration CIO Conference: iEHR, VLER, ESB v3 See notes page

14. INTEGRATED EHR SOLUTION LEGACY EHR SYSTEM EHR SERVICES PLATFORM (ESP) EHR-IS ENABLED LEGACY INFRASTRUCTURE Information Access & Longitudinal Record Services (LRS) Information Access & Longitudinal Record Services (LRS) DataWarehouse Data & Services DataWarehouse Data & Services Population HealthData &Services EHRData &Services RegistriesData &Services EHRData &Services EHR Information Services (EHR IS) EHR Information Services (EHR IS) Legacy Point of ServiceApplication Personal Health Record System Point of ServiceApplication EHR Viewer Personal Health Record Systems Legacy Transition Strategy Legacy EAI IP EHR-IS Bi-Directional Information Exchange EHR-IS EAI IP EAI IP EHR IP EHR IP EHR IP EAI is Enterprise Application Integration IP is SOA Interoperability Profile aka Service Interface EHR-IS enabled legacy systems allow users to transition at a convenient time and then legacy systems can be shut down. CIO Conference: iEHR, VLER, ESB v3 14

15. Information Access & Longitudinal Record Services (LRS) Common Information Interoperability Framework (CIIF) and Common Services Secure Communications Bus EHR SERVICES PLATFORM (ESP) ORGANISATIONAL INFOSTRUCTURE Population Health Data& Services EHR Data& Services Data Warehouse & Services Registries Data& Services OutbreakManagement PHSReporting SharedHealth Record DrugInformation DiagnosticImaging Laboratory HealthInformation ClientRegistry ProviderRegistry BusinessRules EHRIndex MessageStructures NormalizationRules LocationRegistry TerminologyRegistry Security MgmtRules/Data Privacy Mgmt Rules/Data Configuration Rules/Data EHR IS Public HealthServices PharmacySystem RadiologyCenterPACS/RIS Lab System(LIS) Hospital, LTC,CCC, EPR PhysicianOffice EMR EHR Viewer Public Health Provider Pharmacist Radiologist Lab Clinician Physician/Provider Physician/Provider Physician/Provider POINT OF SERVICE APPLICATIONS EHR Information Services (EHR IS) Within EHR Services Platform (ESP) IP is SOA Interoperability Profile aka Service Interface EAI is Enterprise Application Integration EAI IP EAI IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP CIO Conference: iEHR, VLER, ESB v3 See notes page

16. HL7 Service Aware Interoperability Framework (SAIF)Enterprise Compliance and Conformance Framework (ECCF) ECCF Enterprise Dimension “Why” - Policy Information Dimension “What” - Content Computational Dimension “How” - Behavior Engineering Dimension “Where” - Implementation Technical Dimension “Where” - Deployments Conceptual Perspective • Inventory of • User Cases, Contracts • Capabilities • Business Mission, Vision, Scope • Inventory of • Domain Entities • Activities • Associations • Information Requirements • Information Models • Conceptual • Domain • Inventory of • Functions-services • Requirements • Accountability, Roles • Functional Requirements, Profiles, Behaviors, Interactions • Interfaces, Contracts • Inventory of • SW Platforms, Layers • SW Environments • SW Components • SW Services • Technical Requirements • Enterprise Service Bus • Key Performance Parameters • Inventory of • HW Platforms • HW Environments • Network Devices • Communication Devices • Technical Requirements Logical Perspective • Business Policies • Governance • Implementation Guides • Design Constraints • Organization Contracts • Information Models • Terminologies • Value Sets • Content Specifications • Specifications • Use Cases, Interactions • Components, Interfaces • Collaboration Participations • Collaboration Types & Roles • Function Types • Interface Types • Service Contracts • Models, Capabilities, Features and Versions for • SW Environments • SW Capabilities • SW Libraries • SW Services • SW Transports • Models, Capabilities, Features and Versions for • HW Platforms • HW Environments • Network Devices • Communication Devices • Implementable Perspective • Business Nodes • Business Rules • Business Procedures • Business Workflows • Technology Specific Standards • Schemas for • Databases • Messages • Documents • Services • Transformations • Automation Units • Technical Interfaces • Technical Operations • Orchestration Scripts • SW Specifications for • Applications • GUIs • Components • SW Deployment Topologies • HW Deployment Specifications • HW Execution Context • HW Application Bindings • HW Deployment Topology • HW Platform Bindings Five (5) Categories: Capability | Mission | Business Process | Infrastructure/Enterprise Architecture | Interoperability 16 CIO Conference: iEHR, VLER, ESB v3

17. Open Source Principles: iEHR • VA will use OSEHRA EHR product as its EHR • All VA SW development will be focused on OSEHRA product • VA staff will contribute code, on frequent release schedule, using VA Contribution Agreement • VA employees and contractors may choose to contribute code on their own time and do so using Individual Contribution Agreement • VA will establish a governance process with OSEHRA to determine what parts of contributed software constitute “gold” release • VA will develop a test/release process to accept OSEHRA product into VA production environment CIO Conference: iEHR, VLER, ESB v3

18. Open Source Approach • iEHR software development will be focused on Open Source Electronic Health Record Agent (OSEHRA) product with contributions from open source community • iEHR will implement governance process with OSEHRA to determine what parts of contributed software constitute “gold” release • iEHR team will develop processes to integrate OSEHRA products into iEHR operational environment Http://www.OSEHRA.org Open Source approach will encourage innovation, flexibility, interoperability, and discipline CIO Conference: iEHR, VLER, ESB v3

19. ERH Services Platform (ESP) enabled system (conceptual view) 19 CIO Conference: iEHR, VLER, ESB v3 19 See notes page

20. What Is Common Information Interoperability Framework? From CIIF Working Group Presentation 10/7/11 Common Information Interoperability Framework(CIIF) Information Interoperability The CIIF enables real-time semantic harmonization CIO Conference: iEHR, VLER, ESB v3

21. CIIF Goals • Enable open source medical record development community by developing common health services framework and standards in open source environment • Enable interoperability across healthcare enterprise, including VA, DoD, providers and patients • Enable new capabilities to be constructed more quickly with less risk, higher quality, and improved data access • Facilitate rapid integration of new capabilities through use of common data models and standards, all in open source environment • Apply standard interfaces and protocols for iEHR data, network, and systems access Enable interoperability among trading partners while allowing opportunity and time to modernize their own legacy systems CIO Conference: iEHR, VLER, ESB v3

22. From iEHR Data Layer Engineering Lockdown June 29. 2011 CIIF Concept Common Information Interoperability Framework CIO Conference: iEHR, VLER, ESB v3

23. CIIF Approach • Ensure harmonization of healthcare data across enterprise • Build common vocabulary • Build conceptual models • Make data available through common services on ESB • Mediate connection with NwHIN • Transform data at system boundary (in motion) • Support data center consolidation • Co-location vs. virtualization • Support iEHR capability releases • Employ pilots to explore viability of interoperability solutions • Demonstrate interoperability solutions in pilots • Apply models and lessons learned on pilots to drive requirements and service specifications across enterprise • Apply common guidance and standards across enterprise CIO Conference: iEHR, VLER, ESB v3

24. CIIF In Context Tier 1 Front End Systems Presentation/Business Rules Applications/Business Services Virtualization Layer of Federated Standards-Based Services Tier 2 EHR IS C/ESB Broker External Gateway Metadata Services Service Registry Security Controls Performance Caches CIIF Design-Time Workbench of Model Driven Health Tools (MDHTs) Common Services Dynamic Translation Services MDR Metadata Services Secure Standards-Based Information Exchanges Virtualization Layer of Federated Standards-Based Services Information Model Terminology Model Tier 3 Back End Systems Common Data Federated/Virtual Data Legacy Data Information Exchange Specs Translation Model MDR Data Stores Data Services Data Caches CIO Conference: iEHR, VLER, ESB v3

25. Health Data Standards Overview NwHIN • Health Data standards support interoperability across heterogeneous systems • Health data standards are an essential part of the iEHR target architecture, transition strategy, and data migration Clinical Document Standards(Ex:HTML, XML, GIF) Health Security Standards(Ex:TLS, PKI) Clinical Vocabularies(Ex:RxNorm, LOINC) Health Message Standards(Ex:HL7 RIM) Transport Standards(Ex:FTP, SMTP) Computer System Computer System Data Repository CIIF Data Repository Data in Motion CIO Conference: iEHR, VLER, ESB v3

26. Data Strategy Considerations • Data access and interoperability • Data mediation, transformation and integration • Metadata approach • Security and privacy • Performance and measurement • Meaningful Use • Quality • Continuity of Operations (COOP) • Infrastructure CIO Conference: iEHR, VLER, ESB v3

27. Development Concept

28. How Is Metadata Managed In CIIF? • Use model-based XML tagging • CIIF data transformation rules based on information models and terminologies from NwHIN standards, extended as necessary to support comprehensive health care delivery • All NwHIN trading partners will use NwHIN standards for information interoperability CIO Conference: iEHR, VLER, ESB v3

29. Have Data Quality Metrics Been Established? • Meaningful Use • XML tags will set constraints of allowable values to enforce data quality at point of data • Transport when connecting to CIIF • Through NwHIN • Through direct connection • Creation when standard data model and terminologies are instantiated natively in new data stores going forward CIO Conference: iEHR, VLER, ESB v3

30. How Does CIIF Handle Data Integration? Or Is It ESB? • CIIF = runtime data access service for semantic mediation of data in motion • CIIF instantiated as runtime service on DoD-VA ESB • VLER program acquires/delivers ESB CIO Conference: iEHR, VLER, ESB v3

31. Does CIIF Facilitate Federated Queries? • Yes • CIIF enables clinically-relevant information interoperability and clinical decision support by preserving semantic intent among data creators (and senders) and data readers (and recipients) • CIIF does not address or require harmonization of disparate business processes CIO Conference: iEHR, VLER, ESB v3

32. How Does CIIF Promote Data Virtualization? • CIIF enables exchange of data with semantic coherence irrespective of native storage format • CIIF transforms existing and future data stores into virtual (logical) record on the fly • DoD-VA • Both agencies will move to (logically) single record storage capability going forward • NwHIN • Each trading partner exercises judgment to store or not store views created on the fly using data from another trading partner CIO Conference: iEHR, VLER, ESB v3

33. When Will CIIF Terminology Models Be Developed? • CIIF terminology • Model will be entirely based on national standards • Development will be limited to extensions of NwHIN standards in only those instances where national standards are not sufficiently robust for clinical health care delivery • Development (extensions) will start in FY12 CIO Conference: iEHR, VLER, ESB v3

34. Will DoD/VA VLER  Be Interoperable With Civilian Networks Used By TRICARE And VA? • Yes • VLER (and iEHR and CIIF) will be interoperable with all trading partners who connect to the NwHIN CIO Conference: iEHR, VLER, ESB v3

35. What System Engineering Standard Will Be Used To Develop Interface Requirements Specification & Interface Design Document For CIIF? HHS/HITSP specified RESTful or SOAP-based web services calls supported by web service security standards. Payloads are XML-based and conform to HL7 and NIEM content and styles. CIO Conference: iEHR, VLER, ESB v3

36. XML Key Points • Set of standard XML schemas for information to be exchanged and consumed within VLER community has repercussions throughout DoD and VA • Business community leads in: • Determining what XML schemas are needed • Defining needed information content within each XML schema • Technical community leads in: • Establishing uniform XML schema style for all XML schemas CIO Conference: iEHR, VLER, ESB v3

37. XML Schemas: Need for Enterprise Approach • Programmable web has been driven by HTTP, HTML and XML • As VA modernizes, XML will form basis for sharing structured, tagged data, between computational entities • Veteran-centric vision requires more structured data to meet computational needs • Increased interoperability demands require consistency in structured data • XML schemas (i.e. XSDs) is technology that allows elements, attributes, data types, and syntax in XML payloads to be validated • Eventually there will be hundreds of XML schemas within VA and DoD • Left uncoordinated, project teams will develop schemas that might meet point-to-point needs but will make large-scale interoperability impossible • Coordinated XML schema development concept, and plan to achieve it is needed CIO Conference: iEHR, VLER, ESB v3

38. XML Schemas: Value Proposition • A common XML Schema style and standards: • Provides improved cohesion and interoperability • Reduces the number of “point-to-point” negotiations • Makes XML schema development by (or for) multiple development teams possible • Alternative is chaotic and ad hoc development • An identified and baselined set of XML schemas that constitute the Virtual Lifetime Electronic Record provides a framework for: • An improved vision for VLER • VA-wide development to better connect with the VLER major initiative • Assigning XML schema development responsibilities • Developing schedules and monitoring progress • A clear enterprise-wide method of developing and governing XML schemas: • Makes clear the role of project teams and supporting organizations • Provides the least costly and fasted approach to achieving wide scale adoption of a cohesive set of implementable XML schemas CIO Conference: iEHR, VLER, ESB v3

39. Ongoing XML Schema Activities • XML Schema Lockdown • Held Oct 4-6, 2011 at Washington, DC • Focus: (1) Needed XML schemas and a structure for organizing them; (2) XML Schema Style; (3) Enterprise-wide XML schema development approach; and (4) Go forward plan • XML Schema Working IPT (WIPT) • Created to better prepare for XML Schema Lockdown • Composed of personnel from (1) VBA, VHA, NCA, and (2) business and technical • VLER Data Access Service (DAS) • Will provide consumers of VLER common mechanism for discovering and accessing documents and representations within any person’s VLER • Vision is for these documents and representations to be structured data of a common style • Aggregates content from multiple producers of similar data into standard sets of web feed collections • Under development as part of VLER MI portfolio • DoD is engaged via Information Sharing Initiative (ISI) • HAIG • NIEM has been positioned to members of HAIG (VA and DoD) as standard for developing VLER-related XML schemas CIO Conference: iEHR, VLER, ESB v3

40. XML Schema Basics • What is XML? • XML stands for Extensible Markup Language • XML is a markup language like HTML, but does not replace HTML • XML tags are not predefined – one must define one’s own tags or use an existing set • XML was designed to structure, describe, and carry data, not to display data • XML Technologies • Schema: Describes the structure of an XML document and defines the building blocks • XPATH: Extensible Path Language (XPATH) is used to extract data from an XML file • XQUERY: Used to perform query functions on XML data, similar to SQL for databases • XSLT: Extensible style sheet language transformations (XSLT) is a styling language that can transform XML to another file type (including HTML, PDF, MS Word, etc) CIO Conference: iEHR, VLER, ESB v3

41. XML Schema Basics (cont’d) • What is XML Schema? • An XML Schema describes the structure of an XML document • Also referred to as an XML Schema Document (XSD) • Describes the valid format of a an XML data-set • What elements are and are not allowed at any point • What the attributes of an element may be • What type of data is allowed • The number of occurrences of elements, etc • What is the relationship of an XML Schema and an XML document? • An XML document usually specifies its associated schema • An XML document with this association must follow the structure defined in the schema • The XML document is an instance of the schema • Can validate XML documents as compliant with the XML schema during test and run time CIO Conference: iEHR, VLER, ESB v3

42. XML Schema Basics (cont’d) • What’s the benefits of having a schema? • Schemas allow us to better define, restrict, and convert specific data types • Schemas allow us to validate our data and ensure that it conforms to the schema specifications • Schemas encourage standardization • Schemas can be reused • Multiple schemas can be referenced in a single XML document • Schemas are easily customizable and written in XML CIO Conference: iEHR, VLER, ESB v3

43. Virtual Lifetime Electronic Record A Consuming Community Virtual Lifetime Electronic Record can be expressed as hierarchy of collections that leverage web technologies “A place for everything, everything in its place.” • Benjamin Franklin Person Identity Health Benefits Personnel Admin • Audits • Encounter Log • Life Event Docs • Power Of Attorney • Birth Certificates • Other Insurance • Etc • Health Services • Behavioral Health • Primary Care • Extended Care • Laboratory • Radiology • Rehabilitation • Specialty Health • Dental • Pharmacy • Nutrition and Food • Clinical Documentation • Research Studies • Health Admin Info • Pension • Compensation • Education • Home Loan • Insurance • Vocational Rehab and Employment • Special Adaptive Housing • Vehicle Modifications • Eligibility • Payments • Integrated Care • Cemetery • Person Demographics • Service History • Dependents • Epidemiological Occupations • Financial Profile • Military Disability • Education Profile • Life Event History CIO Conference: iEHR, VLER, ESB v3

44. What’s In VLER Collection? • Collections contain a specific viewpoint into a veteran’s or service member’s lifetime electronic record • Similar to pre-defined queries • Data within a particular collection may be included in another collection as well (because it’s pertinent to the viewpoint); however, all data is to be “fresh” when made available to a Consumer • Each collection should serve particular business needs • Collection Example • https://vler.va.gov/das/v1/vaOID/ICN/health/clinicalAssessments/conditions • Where: • Consumer Community = https://vler.va.gov/das/v1 • Person ID = aOID/ICN • Collection Path = health/clinicalAssessments/conditions • Containing all reported Conditions (i.e. Problem List) of a veteran/service member • Each entry is a structured XML representation, One XML schema per collection CIO Conference: iEHR, VLER, ESB v3

45. Collection Hierarchy Considerations • Robust, stable collection hierarchy is needed • Hierarchy is business driven • Technology solution must have an ability to institute some changes over time • Baseline collection hierarchy now provides: • Improved vision for VLER • Baseline for VA-wide development to connect with the VLER major initiative • Framework to assign XML schema development • Framework to develop schedules and major progress CIO Conference: iEHR, VLER, ESB v3

46. XML Schema Style Considerations • A DoD+VA-wide XML schema style is needed • Improved cohesion and interoperability • Makes XML schema development by (or for) multiple development teams possible • Alternative is chaotic and ad hoc development • A baseline set of XML schema style standards must: • Span Health, Benefits, Memorial, and Personnel needs • Support “concrete” schemas: remove ambiguity of interpretation • Address • Naming and design conventions • Packaging • Integration of code sets • Reuse of global elements and complex types • Use of subsets • Distribution CIO Conference: iEHR, VLER, ESB v3

47. What Is NIEM? • A National Standard that facilitates information sharing: • Across organizational and jurisdictional boundaries • At all levels of government • A Data Model providing: • Agreed-upon terms, definitions, and formats for various business concepts • Agreed-upon rules for how those concepts fit together • Independence from how information is stored in individual agency systems • A Structured Approach for: • Development tools, processes, and methodologies CIO Conference: iEHR, VLER, ESB v3

48. What NIEM Is Not… • Database schema • Just data dictionary • Only applicable to Federal government • Includes many other communities at all levels of government • Programming language • Replacement for interagency agreements • NIEM is technical solution, but policy and business issues must also be worked out CIO Conference: iEHR, VLER, ESB v3

49. Key NIEM Definitions • Domain • For purposes of NIEM, a domain refers to a business enterprise broadly reflecting the agencies, units of government, operational functions, services, and information systems which are more or less organized or affiliated to meet common objectives. • Community of Interest • Communities of interest (COIs) are collectives of people (e.g., committees, working groups or technical subcommittees) who authoritatively represent their respective domains. Generally COIs are formally constituted through an organizational charter, memoranda of understanding (MOU), articles of incorporation, or the Federal Advisory Committee Act (FACA) • A COI may have an interest in one or more domains, because domains can overlap. COIs can reuse data components and IEPDs from any domain and can offer content into various domains. Additionally, multiple COIs can coordinate to develop new domain content. • IEPD (MPD) • An IEPD (MPD), or Information Exchange Package Documentation (or Message Package Documentation), is a specification for a data exchange and defines a particular data exchange. CIO Conference: iEHR, VLER, ESB v3

50. NIEM from 50,000 feet All NIEM Domains leverage NIEM-core NIEM Core CIO Conference: iEHR, VLER, ESB v3