Standardisierung von EPAs

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1 Integrating the Healthcare Enterprise Standardisierung von EPAs -IHE- Andreas Kassner VHitG e.v. IHE-Deutschland vendor co-chair chair Interoperabilität ganz einfach

2 IHE : Integrating the Healthcare Enterprise Professional Societies Sponsorship Healthcare Providers & Vendors Healthcare IT Standards HL7, DICOM, etc. Allgemeine IT Standards Internet, ISO, etc. IHE Prozess Interoperable Healthcare IT Solution Specifications Interoperable Healthcare IT IHE Integration Solution Profile Specifications Interoperable Healthcare IT IHE Integration Solution Profile Specifications Interoperable Healthcare IT IHE Integration Solution Profile Specifications IHE Integration Profile IHE-EUR EUR Länder und Teilnehmer Denmark France Germany Israel Italy Netherlands Norway Spain Sweden United Kingdom Users, HC Authorities, Vendors: Users Amphia Antonius Mesos Amsterdam MC AZ Maastricht Ned. Ver. Radiologie Ned. VerLeeuwarden UMC Nijmegen UMC Groningen. Kl. Chemie Ned. Ver. Microbiologie MC Vumc 40% nationale Lösungsanbieter 60% multi-nationale Hersteller Beispiel: : IHE-Netherlands Vendors Government / Associations Agfa Forcare Chipsoft D&A Medical GE Healthcare Getronics H2W IBM ICT Healthcare Initiate Systems isoft Leones Medical Phit Nucletron Oldelft Benelux Philips RVC Sectra Siemens Verdonk, Klooster & Associates Welch Allyn Cardio Control APC Platform NICTIZ HL7 Nederland OIZ TNO

3 Evolution der IHE Domänen IHE Globale Entwicklung Integrationsprofile Lösung für Real-World Bedarf & Probleme: Innerhalb Medizinischer Einrichtungen: o Radiologie o Kardiologie o Labor o... Einrichtungsübergreifend XDS o RHIOs (Regional Healthcare Information Organizations) o EHR Enablers Radiology (18) Patient Care Coordination (5) Radiation Oncology (1) Laboratory (6) Cardiology (7) IT Infrastructure for Healthcare (17) Veterinarian Endoscopy (1) Eye Care / (3) Ophthalmology Pharmacy Pathology (1) Patient Care Devices (1) Year 1 (1999) Year 2 (2000) Year 3 (2001) Year 4 (2002) Year 5 (2003) Year 6 (2004) Year 7 (2005) Year 8 (2006) Was ist IHE IT Infrastructure? Electronic Health Record Radiology Cardiology 14 Integration Profiles Laboratory 5 Integration Profiles Future Domains Pathology IHE IT Infrastructure 13 Integration Profiles Eye Care Oncology 4 Integration Profiles Patient Care Coordination 1 Integration Profile Patient Care Devices

4 IHE XDS in regionalen und national Projekten Canada Infoway MA-Share MA France DMP Austria HITSP Interop Specifications Philadelphia HIE THINC- New York NCHICA N. Carolina Denmark (Funen) Italy (Veneto) Spain (Aragon) Italy (Conto Corrente Salute) CHINA-MoH Lab results sharing Profil XDS (Dokumentenaustausch( Dokumentenaustausch) Typischerweise besucht ein Patient in vielen Besuchen eine Reihe von Einrichtungen Acute Care (Inpatient) Long Term Care Other Specialized Care (incl. Diagnostics Services) GPs and Clinics (Ambulatory) Continuity of Care: Patient Longitudinal Record Fallbezogen!

5 Was ist IHE IT Infrastructure? Emergency Referrals Patient Created Summaries Format of the Content ECG Format and Report associated of the coded vocabulary Content Lab and Results associated coded vocabulary Format of the Content Scanned and associated Content s coded vocabulary Format of the Content Format Imaging and associated of the Information coded vocabulary Content Medical Summary Format of the Content and (Meds, associated Allergies, coded Pbs) vocabulary Format of the Content and associated coded vocabulary Cross-Enterprise Sharing Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Cross-enterprise Point-to-Point Interchange Media-CD/USB & push Patient Consent Digital Signature Attesting true-copy and origin Notice of Availability Know about new information Support for RHIOs Patient Demographics Query Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Audit Trail & Node Authentication Centralized privacy audit trail and node to node authentication to create a secured domain. Consistent Time Coordinate time across networked systems XDS Szenario PDQ Query to Acquire XAD Patient ID PDQ Query to Acquire XAD Patient ID Patient Demographics Supplier PMS Physician Office ED Application Repository Registry PACS PACS Community Clinic Lab Info. System Record Audit Event Query (using Patient ID) Maintain Time Retrieve Maintain Time Audit record repository ATNA Register (using Patient ID) Time server CT XDS Clinical Affinity Domain Maintain Time Record Audit Event Repository EHR System Provide & Register Teaching Hospital

6 Akteure und Transaktionen - XDS Patient Identity Patient Identity Feed Registry Query s Register Set Provide&Register Set Repository Retrieve IHE-XDS Zentralisierte Architektur Patient Identity Patient Identity Feed Provide&Register Set Registry Repository Query s Retrieve

7 IHE-XDS Dezentralisierte Architektur Patient Identity Patient Identity Feed Register Set Registry Query s Repository Repository Repository Repository Retrieve IHE-XDS Gemischte Architektur Provide & Register Set Repository Repository Repository Repository Register Set Patient Identity Patient Identity Feed Registry Repository Query s Retrieve

8 Registry Metadata Basierend auf HL7 CDA R1 (ANSI) ; HL7 CDA R2 (Draft) ; EHR ENV (CEN-Draft) Patient ID Service Start and Stop Time Creation Time Class Code and Display Name Practice Setting Code and Display Name Healthcare Facility Type Code and Display Name Available Status (Available, Deprecated) Unique ID... Die komplette Liste enthält 33 Attribute, plus freie Definitionen RegistryPackage Klassendiagramm ExtrinsicObject XDSSubmissionSet authorinstitution authorperson authorrole authorspecialty comments contenttypecode patientid sourceid submissiontime uniqueid + XDSFolder codelist comments lastupdatetime patientid uniqueid * + + XDSEntry authorinstitution authorperson authorrole authorspecialty availabilitystatus classcode confidentialitycode creationtime entryuuid eventcodelist formatcode hash healthcarefacilitytypecode languagecode legalauthenticator mimetype parentid patientid practicesettingcode servicestarttime servicestoptime size sourcepatientid sourcepatientinfo title typecode uniqueid URI Einige allgemeine Attribute: author patient document source encounter Andere enthalten logische / technische Informationen title type of document eventcodelist classcode availabilitycode confidentialitycode formatcode language MIME Type size vgl. HL7 CDA

9 Relationships von HL7 APND (append) Aktuelles Dokument ist eine Erweiterung zu Elterndokument RPLC (replace) Aktuelles Dokument ersetzt das Elterndokument XFRM (transform) Aktuelles Dokument ist eine Transformation des Elterndokuments XFRM_RPLC (transform with replace) Aktuelles Dokument ist beides, Transformation und Ersatz eines Elterndokuments 1 parent * parentid current Repository and Registry Example of Submission Request Registry Submission Request Submission Set 1 Folder A Entry Entry Repositories

10 Cross-Enterprise Sharing (XDS) Standards XDS Infrastructure Standards OASIS/ebXML Registry Information Model v2.0 Basis of XDS Registry Information Model Registry Services Specifications v2.0 Registry Services Messaging Services Specifications v2.0 Offline protocols ISO/IEC 9075 Database Language SQL Registry Query Language SOAP with Attachments Protocol for communication with XDS Registries and Repositories SHA-1 [FIPS 180-1] Hashes Internet Standards HTTP Protocol for Retrieve Online SOAP bindings SMTP Offline ebms bindings IETF Language Identifiers MIME Type codes PDF, JPEG, HTML XDS Content UTF-8 Encoding of Registry Attributes

11 Cross-Enterprise Sharing (XDS) Standards XDS Infrastructure Standards (cont) HL7 Version Messages for Patient Identity Management HL7 Version 2.5 Datatypes for XDS Registry Attribute values HL7 CDA Release 1 XDS concept definition of XDS Entry Attributes DICOM, ASTM CCR, HL7 CDA Release 2, CEN EHRcom s of XDS Entry Attributes Cross Community Discovery Build an index of patient data locations Several identifying communities Controlled by attributes (1) Community Attribute Search Engine (1) XDS Community A XDS Community B RLS/PIX+ XDS Registry (7) Cross Community Bridge (3) (4) Cross Community Bridge (5) PDQ Server XDS Repository (2) (8) Cross Community Searcher (6) XDS Registry XDS Repository

12 Akteurmodell (efa( v1.1) Patient Identity Feed Identity Management Case Registry TokenService»Case«Patient Care Coordination Adressiert die Integration von Leistungserbringern über Einrichtungsgrenzen, klinische Fragestellung und Zeit Berücksichtigt allgemeine und spezielle medizinische Aspekte, ebenso wie technische Infrastruktur Bildet Workflow und Informationsaustausch ab in kooperativen Netzen In 2005 begonnen, heute 5 Profile

13 PCC Profiles Integration Content Basic Patient Privacy Consent Preprocedure History and Physical Medical Summaries Emergency Department Report Query for Dynamic Clinical Data Antenatal Care Summary ED Referral Care Assessments Exchanging PHR Content Lab Report PCC TF as Library of Templates s Sections Entries Parts Referral Problems Problem Severity XPHR Vitals Vital LAB Result Obs

14 Emergency Department Referral Abstract Define a referral format for "heads-up" call Supports Medical Summary Content Special Needs of Emergency Department Expected Time of Arrival Mode of Arrival Disposition/Orders Emergency Department Referral Use Case 1. The patient undergoes assessments by a triage nurse, is assigned a triage category (i.e. emergent, urgent, non-urgent). 2. The patient is then registered and demographic data is obtained. 3. The patient undergoes additional assessments by a primary RN, 4. The patient is seen by an ED physician who performs a history and physical, orders various diagnostic tests, determines a course of therapy, orders medications to be administered in the ED and performs procedures on the patient. 5. Upon completion of ED care, the patient is either admitted to the hospital, discharged from the ED, or transferred to another facility.

15 Exchange of PHR Content Abstract Hilft beim Austausch von Dokumenten zwischen PHR und EHR Systemen Unterstützt verschiedenste Mechanismen zur Übersetzung/Übermittlung Beinhaltet PHR Update Basic Patient Privacy Consents (BPPC) Konzepte zur: Abstract Patientenzustimmung(en) Indentifizierung von Policies unter denen ein Dokument Authorisiert veröffentlicht werden soll Zwingt zur Einhaltung des Datenschutzes und der Patientenzustimmung

16 Antepartum Summary Pregnant diabetic patient is seen by obstetrician in office for initial visit. Ultrasound performed to determine gestational age. Patient sent for perinatology consult as a high risk patient. Patient returns to perinatologist biweekly for blood testing and ultrasounds when necessary in addition to regular ob visits. Perinatologist reports back to obstetrician after each visit. Patient arrives at labor and delivery at the hospital. Obstetrician delivers by Cesarean Section after anesthesia. Obstetrician provides postpartum care. Functional Status Assessment The Institute of Medicine has determined that a high risk for errors occurs during the transfer of care. The Functional Status Assessment Profile (FSA) supports the handoff of assessment information between practitioners during transfers of care, cross-enterprise or intra-enterprise. Transfer of physician documentation provides medical assessment, diagnosis and treatment information. Transfer of nursing documentation provides assessment and treatment of human response (psychosocial, physiologic, emotional and spiritual) of patient/family to changing conditions.

17 Key Technical Properties Considerations for scales Scales chosen are evidence based with strong reliability and validity. Widely accepted cross-enterprise or required/recommended by accrediting agencies Content Scales Numeric Rating Scale (NRS-11) for Pain Braden Scale for Predicting Pressure Sore Risk Geriatric Depression Scale (GDS) Minimum Data Set Section G Query for Existing Data Profile Exchange of information between Data Repositories and Clinical Data s for: 1. Drug Safety 2. Public Health, Biosurveillance and Disease Registries 3. Identifying Qualifying Patients 1. Clinical Trials 2. Disease Management 4. Quality Reporting 5. Claims Submission

18 Actors and Transactions [PCC-1] Query Vital Signs [PCC-5] Query Problems and Allergies [PCC-2] Query Medications [PCC-4] Query Diagnostic Data [PCC-3] Query Immunizations Beispiel Use Case - PAM

19 Herangehensweisen Elektronische Patientenakten Quelle: Kees Smedema... demnächst in IT Infrastructure Next step 2007 XDS Federation PIX and PDQ using HL7 v3 Web Services Transport for IHE Transactions XUA Cross-Enterprise User Authentication Risk Management Planning White Paper Candidates 2008 Scheduling ( PCC) Wide-area patient acess Mobile applications Candidates 2009 Remote service access Anonymization Pseudonymisierung Patient-controlled access

20 IHE Connectathon Offene Einladung an die Software Entwickler Community Es werden moderne Testtools (MESA) genutzt Konformanztest organisiert und überwacht durch die neutrale Prüfer von IHE Tausende systemübergreifende Tests durchgeführt IHE-EUR EUR Connectathon Domains Integration profil Actors Com panies System s Participants Der jährliche IHE Prozess Develop technical specifications Identify available standards (e.g. HL7, DICOM, IETF, OASIS) Testing at Connectathons IHE Demonstrations Products with IHE Use Case Requirements Timely access to information Easy to integrate products

21 Ressourcen XDS Open : Vielen Dank für Ihre Aufmerksamkeit Andreas Kassner

22 Use Case: Multiple primary residences Use Case: Between two XDS Affinity Domains Use Case: Patient Move Use Case: Vacationer Vacationer: A patient Use Case: Mergers, aquisitions, divestitures. A large healthcare corporation, Bigco, acquires a small local hospital, Smallco. Divestitures A healthcare facility splits into two new organizations: Newco1 and Newco2. Use Case: Transitory Alliances A medical facility and a research facility form a short term alliance for a research project. Use Case: Surveillance, CDC pseudonimized Use Case: PHR Services Use Case: Remote Consulting.

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