organizing ihe integration profiles related to the electronic

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Organizing IHE Integration Profilesrelated to the Electronic Health Record

Initial Thoughts

IHE ITI Tech Committee - December 2003

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IHE Integration Profiles Focused on the EHRIHE 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.

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Acute Care (Inpatient)

GPs and Clinics (Outpatient)

Nursing Homes

Other Specialized Careor Diagnostics Services

Continuity of Care: Patient Longitudinal Record Across Encounters

A typical patient goes through a sequence of encounters in different Care Setting (incl. Diagnostics Services).

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Nursing Homes


Integration : Feeding & Accessing the Longitudinal Health Record Information

EHR-LR

The EHR-LR (Longitudinal Record) brings together patient encounter information managed by multiple care delivery systems

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Care Delivery Process

Selection of informations

Decide toAssess demand For care

Actions to order

Define an action plan

Identification End ofEncounter

Define healthcareObjective

EHR-CREHR-CR : EHR information supporting immediate care deliveryEHR-LREHR-LR : EHR information supporting long term care delivery

Two types of Integration : Health Record as used during care delivery Health Record as used across-encounters

EHR-CR

Read

EHR-LR EHR-LR

Read

EHR-LR

CreateUpdate

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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-LR Directory

EHR-LR Actors: Directory & Repository Actors


Custodian for an unspecified time of Documents recorded from patient encounters.EH

R-C

R

EH

R-C

R

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Key Statements : EHR-LR FundamentalsEHR-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.

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Key Statements: What is in the EHR-LR ? 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.

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Key Statements : IHE ConstraintsIHE 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.

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Key Statements : Accessing EHR-LRAccessing 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 been registered.

• 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.

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Key Statements : Deploying IHE EHR-LR ProfilesDeploying IHE EHR-LR Profiles• EHR-LR will likely be initially focused on certain specialties

(cardiology, oncology, etc), disease, or on key information for continuity of care (CCR summaries only) and expand progressively.

Now includes disease.

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EHR-LR= The Longitudinal Record of a person’s healthEHR-CR= Care-delivery Record

Integration Profiles : Current Profiles vs “EHR-LR Profiles

EHR-LR

EHR-CR

EHR-CR

EHR-CR

EHR-CR

Nursing Homes


IHEIntegration Profile

(e.g. IT Infrastructure


(e.g. Lab, Cardio, etc)














Patient Access


Domain SpecificDoc Content





IHEIntegration ProfileX-Enterprise Security, MPI

LR Register, Retrieve.

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EHR-LR Integration Profiles : Infrastructure(s) + Content(s)

EHR-LR Security, MPILR Register, Retrieve. Integration Profile(s)

Cath Report Integration

Profile

Tumor Report Integration

Profile

Radiology Report Integration

Profile

In PatientIn PatientOutpatientOutpatientLinkLink

CardiologyCardiologySpecialist toSpecialist toAcuteAcute

OncologyOncologySpecialist toSpecialist toAcuteAcute

Etc….Etc….

. . . .

. . . .

EHR-LR Security, MPILR Register, Retrieve. Integration Profile(s)

EHR-LR Security, PIXLR Register, Retrieve. Integration Profile(s)

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Some examples applying this EHR ConceptSome 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).

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EHR-LR Patient/Encounter Level Directory

EHR-LR Encounter/Documents Level Directory

Example : GP Office in multiple IDNswith an EHR-LR ASP

One Directory by IDN.Holds a reference to all encountersknown by the IDN, including thosefrom the GP

This Encounter Directory manages allencounters form the GP. It is an EHR-LRASP. This ASP system is also theprimary EHR-CR or all documentscreated by the GP’s encounters.EHR-LR Documents Repository


GP Practice Clinical Record Entry Document Creator and Consumer

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Example : Cardiologist Practices and Inpatient

IDN and associated Cardiologists establisha Central Directory.Holds a reference to all encountersknown by the IDN and Cardiologist

This Encounter Directory manages allencounters form the Cardiologists.It is an EHR-LR with all documentscreated by Cardiology encounters.


Cardiologist Practice Clinical Record Document Creator and Consumer


CardiologyInpatient Clinical Record Document Creator and Consumer

CardiologyInpatient Clinical Record Document Creator and Consumer



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EHR-LR Patient Level Directory



Example : Regional or Country-Wide (e.g. NHII)

One such Patient Directory by region.Shadows copies. Knows all lower leveldirectories where encounters are identified.

One such P/E Directory by region.Holds a reference to all encountersmade in the region.

One such E/D Directory by EncounterCustodian used by the health deliveryentity where the encounter happen

One or more document repository by document custodians used by the health delivery entity where the encounter happen or external.EHR-LR Documents Repository






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EHR-LR Patient Directory


EHR-LR Documents Virtual Repository

Custodian for an unspecified time of Documents recorded from local patient encounters.

EHR-LR Encounter Directory

EHR-LR Use Cases: Actors & Transactions Concepts D

ocu

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Do

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Do

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EHR-LR Encounter Directory



Registerand Provide Doc

Register Doc

RetrieveDoc

QueryDoc List

EHR-CR

EH

R-C

R

Not all transactions necessary to ensure management of a distributed and dynamic EHR-LR are depicted in this illustration.

EHR-LR

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IHE Integration Profiles Focused on the EHRIHE 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.

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Draft IHE IT Infrastructure RoadmapDraft IHE IT Infrastructure Roadmap

In support of the IHE Integration ProfilesIn support of the IHE Integration Profilesfocused on the EHRfocused on the EHR

Draft for Comments – 11/03To be finalized January 2004.

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IHE IT Infrastructure Roadmap – HIMSS 2004 (1)IHE IT Infrastructure Roadmap – HIMSS 2004 (1)

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

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IHE IT Infrastructure Roadmap - Next Stage (2)IHE IT Infrastructure Roadmap - Next Stage (2) 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

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IHE IT Infrastructure Roadmap – Stage 3 IHE IT Infrastructure Roadmap – Stage 3 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

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IHE IT Infrastructure Roadmap – Stage 4IHE IT Infrastructure Roadmap – Stage 4


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

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IHE IT Infrastructure Roadmap – Stage 5IHE IT Infrastructure Roadmap – Stage 5


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

organizing ihe integration profiles related to the electronic

Documents

ehrlr ehrlr

ehrcr ehrcr

ehrlr directory ehrlr

ehrlr fundamentals

ehrlr longitudinal record

ehr information

immediate care delivery

ehrcr caredelivery record