MATHUR-1

CSE5810

A Study of Health Information Exchange and A Study of Health Information Exchange and Interoperability System SolutionsInteroperability System Solutions

Anubhav MathurMasters in Computer Science

Computer Science & Engineering DepartmentUniversity of Connecticut

anubhav.mathur@engr.uconn.eduhttp://www.engr.uconn.edu/~anm13020

(908) 210 - 1660

MATHUR-2

CSE5810

OverviewOverview What Is HIE?What Is HIE? Key forms of HIEKey forms of HIE What is InteroperabilityWhat is Interoperability Aspects of InteroperabilityAspects of Interoperability Current StateCurrent State ProblemsProblems InitiativesInitiatives SolutionsSolutions Core IssuesCore Issues Future ScopeFuture Scope ReferencesReferences

MATHUR-3

CSE5810

What Is HIE?What Is HIE? Secure access of patient’s vital medical information Secure access of patient’s vital medical information

electronicallyelectronically Stakeholders: Doctors,Stakeholders: Doctors,

Nurses, Pharmacists, Other health care providers Patients!

Advantages: Advantages: Improving the speed, Quality, Safety Cost of patient care.

Example: DIRECT Messaging SystemExample: DIRECT Messaging System

MATHUR-4

CSE5810

Key forms of health information exchangeKey forms of health information exchange Directed Exchange – ability to send and receive secure Directed Exchange – ability to send and receive secure

information electronically between care providers to information electronically between care providers to support coordinated caresupport coordinated care

Query-based Exchange – ability for providers to find Query-based Exchange – ability for providers to find and/or request information on a patient from other and/or request information on a patient from other providers, often used for unplanned careproviders, often used for unplanned care

Consumer Mediated Exchange – ability for patients to Consumer Mediated Exchange – ability for patients to aggregate and control the use of their health aggregate and control the use of their health information among providers information among providers 

The foundation of standards, policies and technology The foundation of standards, policies and technology required to initiate all three forms of health required to initiate all three forms of health information exchange are complete, tested, and information exchange are complete, tested, and available today. available today.

MATHUR-5

CSE5810

InteroperabilityInteroperability What is Interoperability?What is Interoperability?

Ability of two or more systems or components to use the exchanged information.

Fundamental Building Blocks:Fundamental Building Blocks:1. Meaning through the use of standardized

healthcare vocabularies,2. Structure by leveraging standards in HL73. Transport using secure email protocols,4. Security through National Institute of Standards

and Technology (NIST)-adopted encryption standards, and services through open, and accessible application programming interfaces (APIs).

MATHUR-6

CSE5810

Aspects of InteroperabilityAspects of Interoperability TransportTransport

More than one transport standards

Standardization of dataStandardization of data Vocabularies Terminologies

Standards for structureStandards for structure

People

Information Technology

Informatics

Image Title

MATHUR-7

CSE5810

Benefits of InteroperabilityBenefits of Interoperability For health professionals:

Improve access to health record data and health information anytime, anywhere.

For patients: Improve quality and safety of care by improving

data exchange, the quality of data flow and access to information by health professionals thereby potentially reducing errors.

For health managers: Improve data collection and facilitate statistical

and economic analysis.

MATHUR-8

CSE5810

Benefits of InteroperabilityBenefits of Interoperability For health researchers:

Improve and increase the availability of medical data.

For the healthcare technology industry: Improve access to the healthcare market for more

companies (SMEs in particular who may be limited in their ability to provide technologies which can integrate with an organisation's legacy systems).

MATHUR-9

CSE5810

Current stateCurrent state Developments in the past 3-4 years in standards and Developments in the past 3-4 years in standards and

technology.technology. Development of HIEs and HIXsDevelopment of HIEs and HIXs Transfer of financial information using X.12 Transfer of financial information using X.12

standards.standards. Standards-based representation of information (CDA, Standards-based representation of information (CDA,

CCD, CCDA) CCD, CCDA) Communication Communication

IHE XDS Direct Project PHINMS eHealth Exchange

MATHUR-10

CSE5810

ProblemsProblems Not a “one-size-fits-all” solution.Not a “one-size-fits-all” solution.

Home-grown and legacy applications, providing Home-grown and legacy applications, providing functionality across patient and infrastructure functionality across patient and infrastructure management, clinical care, administrative and management, clinical care, administrative and financial domains. financial domains.

Pre-date the introduction of standards for information Pre-date the introduction of standards for information sharing. sharing.

Closed in natureClosed in nature

MATHUR-11

CSE5810

ProblemsProblems Reluctance to change from traditional paper-based Reluctance to change from traditional paper-based

systems to electronic systems.systems to electronic systems.

Lack of specificity of healthcare standards and Lack of specificity of healthcare standards and information sharing protocols information sharing protocols

Numerous incompatible terminologies and ontologies Numerous incompatible terminologies and ontologies involved. involved.

Semantic interoperability major challenge.Semantic interoperability major challenge.

Amplification at the state or national level or when Amplification at the state or national level or when health systems attempt to manage a population’s health systems attempt to manage a population’s wellness and develop mechanisms to exchange wellness and develop mechanisms to exchange population-level data.population-level data.

MATHUR-12

CSE5810

Current initiativesCurrent initiatives Government standardization initiatives:Government standardization initiatives:

Office of Science & Technology (OST). Office of the National Coordinator for Health

Information Technology’s (ONC) Enable the health IT community to convene and Enable the health IT community to convene and

rapidly prioritize health IT challenges.rapidly prioritize health IT challenges.

Develop and harmonize standards, specifications and Develop and harmonize standards, specifications and implementation guidance to solve those challenges. implementation guidance to solve those challenges.

Curate the set of standards and specifications that Curate the set of standards and specifications that support interoperability and ensuring that they can be support interoperability and ensuring that they can be assembled into solutions for a variety of health assembled into solutions for a variety of health information exchange scenarios.information exchange scenarios.

MATHUR-13

CSE5810

Current initiativesCurrent initiatives

HITECH Act.HITECH Act.

Promoting the adoption and uptake of health information technology

Ensure technical standards and specifications are in place to support this technology

Critical to the development and success of a fully Critical to the development and success of a fully functional nationwide health IT ecosystem.functional nationwide health IT ecosystem.

MATHUR-14

CSE5810

SolutionsSolutionsFor HIEFor HIE

MATHUR-15

CSE5810

CONNECTCONNECT Open source software solution developed by over 20 Open source software solution developed by over 20

federal agencies that organizations can use to securely federal agencies that organizations can use to securely link their existing health IT systems into the NwHIN. link their existing health IT systems into the NwHIN.

MATHUR-16

CSE5810

AdvantagesAdvantages Open source and free for download. This improves Open source and free for download. This improves

adaptability among various HIEsadaptability among various HIEs Coordinates care across public and private care Coordinates care across public and private care

sectors. Providers will have access to medical records sectors. Providers will have access to medical records throughout the continuum of care, regardless of throughout the continuum of care, regardless of whether the treatment facilities are in the government whether the treatment facilities are in the government or private sectoror private sector

Speeds the dissemination of clinical and scientific Speeds the dissemination of clinical and scientific research results to government, industry and the research results to government, industry and the scientific community to benefit population healthscientific community to benefit population health

Improves regulation of pharmaceutical products and Improves regulation of pharmaceutical products and medical devices through faster, more comprehensive medical devices through faster, more comprehensive and more accurate detection of adverse drug eventsand more accurate detection of adverse drug events

MATHUR-17

CSE5810

NwHIN Exchange:NwHIN Exchange: The NwHIN Exchange is a collection of standards, The NwHIN Exchange is a collection of standards,

protocols, legal agreements, specifications and protocols, legal agreements, specifications and services that enables the secure exchange of health services that enables the secure exchange of health information over the internet.information over the internet.

    

MATHUR-18

CSE5810

NwHIN ExchangeNwHIN Exchange

Advantages:Advantages:

The NwHIN Exchange has methods to perform The NwHIN Exchange has methods to perform universal patient lookup, document discovery and universal patient lookup, document discovery and retrieval, and exchange between organizations and retrieval, and exchange between organizations and federal agencies (VA, DOD, CDC, SSA, plus 22 federal agencies (VA, DOD, CDC, SSA, plus 22 others). The organizations entering into an exchange others). The organizations entering into an exchange with those federal agencies are typically sizable HIOs, with those federal agencies are typically sizable HIOs, HIEs or large IDNs.HIEs or large IDNs.

MATHUR-19

CSE5810

NwHIN ExchangeNwHIN Exchange

Disadvantages:Disadvantages: Participation currently limited to federal health agencies Participation currently limited to federal health agencies

and healthcare organizations under ONC contract and and healthcare organizations under ONC contract and other recipients of federal grants.other recipients of federal grants.

Most individual providers/small practices have limited Most individual providers/small practices have limited technical resources. technical resources.

Since many providers will not be able to participate in Since many providers will not be able to participate in the NwHIN Exchange, they still need a model to help the NwHIN Exchange, they still need a model to help them reach Stage 1 Meaningful Use (MU) requirements. them reach Stage 1 Meaningful Use (MU) requirements.

Development geared toward large HIOs/IDNs before Development geared toward large HIOs/IDNs before the HITECH Act/Meaningful Use criteria existed. In the HITECH Act/Meaningful Use criteria existed. In order to provide a simpler option to help providers meet order to provide a simpler option to help providers meet basic MU requirements.basic MU requirements.

MATHUR-20

CSE5810

NwHIN DIRECTNwHIN DIRECT

The set of standards, policies and services that enable The set of standards, policies and services that enable simple, secure transport of health information between simple, secure transport of health information between authorized care providers. authorized care providers.

NwHIN Direct enables standards-based health NwHIN Direct enables standards-based health information exchange in support of core Stage 1 MU information exchange in support of core Stage 1 MU measures, including communication of summary care measures, including communication of summary care records, referrals, discharge summaries and other records, referrals, discharge summaries and other clinical documents in support of continuity of care and clinical documents in support of continuity of care and medication reconciliation, and communication of medication reconciliation, and communication of laboratory results to providers.”laboratory results to providers.”

MATHUR-21

CSE5810

HISPHISP Used by the DIRECT project, to describe the Used by the DIRECT project, to describe the

management of security and transport for directed management of security and transport for directed exchange and an organizational model exchange and an organizational model

Performs HISP functions on behalf of the sending or Performs HISP functions on behalf of the sending or receiving organization or individual. receiving organization or individual.

Separate business organization from the sending and Separate business organization from the sending and receiving organization required to have contractually receiving organization required to have contractually binding legal Business Associate Agreements (BAAs) binding legal Business Associate Agreements (BAAs) with HIPAA Covered Entities with the sender or with HIPAA Covered Entities with the sender or receiver of directed exchange of Personally receiver of directed exchange of Personally Identifiable Information.Identifiable Information.

Must include all data collection, use, retention, and Must include all data collection, use, retention, and disclosure policies (including rights reserved but not disclosure policies (including rights reserved but not exercised) in other service agreements.exercised) in other service agreements.

MATHUR-22

CSE5810

DIRECTDIRECT Advantages:Advantages:

DIRECT is based on Open source software, therefore DIRECT is based on Open source software, therefore it promotes community participation in the it promotes community participation in the development and maintenance of the system .development and maintenance of the system .

It offers customizability and adaptabilityIt offers customizability and adaptability

Security is implemented a thorough vetting system to Security is implemented a thorough vetting system to ensure all providers who use the system are actually ensure all providers who use the system are actually who they say they are.who they say they are.

MATHUR-23

CSE5810

SolutionsSolutionsFor InteroperabilityFor Interoperability

ProblemProblem

MATHUR-24

CSE5810

Integrating the Healthcare EnterpriseIntegrating the Healthcare Enterprise Integrating the Healthcare Enterprise (IHE) Integrating the Healthcare Enterprise (IHE)

Initiative by the healthcare industry to improve the Initiative by the healthcare industry to improve the way computer systems share information. way computer systems share information.

Established in 1998 by a consortium of radiologists Established in 1998 by a consortium of radiologists and information technology (IT) experts.and information technology (IT) experts.

IHE integration statements are prepared and published IHE integration statements are prepared and published by a vendor to list the IHE profiles supported by a by a vendor to list the IHE profiles supported by a specific release of a specific product.specific release of a specific product.

MATHUR-25

CSE5810

Cross-enterprise Document SharingCross-enterprise Document Sharing Cross-Enterprise Document Sharing minimizes Cross-Enterprise Document Sharing minimizes

clinical/admin data management by the infrastructure. clinical/admin data management by the infrastructure. Transparency = Ease of EvolutionTransparency = Ease of Evolution

Patients/consumers have guaranteed portability and Patients/consumers have guaranteed portability and providers may share information without concerns of providers may share information without concerns of aggregation errors.aggregation errors.Digital Documents = Patients and providers Digital Documents = Patients and providers empowermentempowerment

Supports both centralized and decentralized repository Supports both centralized and decentralized repository architectures. Ease of federation nationally. Flexible architectures. Ease of federation nationally. Flexible privacy, Flexibility of configurationsprivacy, Flexibility of configurations

Has received major support world-wide: Has received major support world-wide: National & regional projects, NHIN contractors, US National & regional projects, NHIN contractors, US EHR Vendor Assoc., complements Connecting for EHR Vendor Assoc., complements Connecting for Health RLS.Health RLS.

MATHUR-26

CSE5810

Why is IHE-XDS a breakthrough ?Why is IHE-XDS a breakthrough ? Sharing of digital documents as “attested by the

source”, meets the most urgent needs. A proven healthcare community data-sharing paradigm (Message feeding to web servers hinders use of EHRs & PHRs).

Efficient to support all types of Health IT Systems (IDNs, Hospitals, Ambulatory, Pharmacy, Payers, Diagnostics Centers, etc.) and all types of information (summaries, meds, images, lab reports, ECGs, etc.), structured and unstructured.

Offer a consistent, standards-based and functional record sharing for EHRs, PHRs & other IT Systems

MATHUR-27

CSE5810

LOINCLOINC The Logical Observation Identifiers Names and The Logical Observation Identifiers Names and

Codes (LOINC) standard codes for use Codes (LOINC) standard codes for use in databases are often used in IHE profiles.in databases are often used in IHE profiles.

Applies universal code names and identifiers to medical terminology related to electronic health records. 

Assist in the electronic exchange and gathering of clinical results

Example: laboratory tests, clinical observations, outcomes management and research

MATHUR-28

CSE5810

Current StateCurrent State Currently most clinical laboratories and other Currently most clinical laboratories and other

diagnostic services use HL7 to send their results diagnostic services use HL7 to send their results electronically from their reporting systems to their electronically from their reporting systems to their care systemscare systems

Most labs, however, identify tests in these messages Most labs, however, identify tests in these messages by means of their internal code valuesby means of their internal code values

Care systems must either use the internal codes Care systems must either use the internal codes provided by laboratory or map to LOINC or local provided by laboratory or map to LOINC or local codescodes

Universal use of LOINC would solve this problem, Universal use of LOINC would solve this problem, and there is momentum to move in this directionand there is momentum to move in this direction

MATHUR-29

CSE5810

MATHUR-30

CSE5810

AdvantagesAdvantages Improved communication in integrated health delivery Improved communication in integrated health delivery

networksnetworks

Supports aggregated electronic health recordsSupports aggregated electronic health records

Permits automatic transfer to public health authorities Permits automatic transfer to public health authorities of case reports for reportable diseasesof case reports for reportable diseases

Improved transfer of payment particularly claims Improved transfer of payment particularly claims attachmentsattachments

Supports reduction of errorsSupports reduction of errors

MATHUR-31

CSE5810

DICOMDICOMThe standard for Digital Imaging and Communications The standard for Digital Imaging and Communications in Medicine.in Medicine.

Developed by the National Electrical Manufacturers Developed by the National Electrical Manufacturers Association (NEMA) in conjunction with the American Association (NEMA) in conjunction with the American College of Radiology (ACR).College of Radiology (ACR).

Covers most image formats for all of medicine.Covers most image formats for all of medicine.

Specification for messaging and communication Specification for messaging and communication between imaging machines.between imaging machines.

MATHUR-32

CSE5810

Features of DICOMFeatures of DICOM NETWORK PROTOCOLNETWORK PROTOCOL

● DICOM incorporates negotiation to permit peers to agree on the functions to be performed

MESSAGE ENCODINGMESSAGE ENCODING● DICOM defines 24 data types (V2.0 had 4)● DICOM message encoding includes JPEG compression● DICOM supports multiple character repertoires

OBJECT DATA MODELOBJECT DATA MODEL● DICOM is based on a completely specified data model ● DICOM includes a robust UID mechanism

DATA DICTIONARYDATA DICTIONARY● DICOM includes a large number of new data elements

SERVICE CLASSESSERVICE CLASSES● DICOM defines classes of service for specific applications

(e.g. image management, printing) and conformance levels

MATHUR-33

CSE5810

Core IssuesCore Issues

Without interoperability, fundamental data and information such as patient records can't easily be shared across and sometimes within enterprises.

Achieving interoperability in a domain where information technologies, where they have been deployed in routine practice, may not have been designed to support it.

Many standards to support interoperability are only just now being developed - after many HIT systems have been installed.

MATHUR-34

CSE5810

Core IssuesCore Issues

Where HIT standards do exist they may also compete, making interoperability more difficult to achieve.

A lot of computerized clinical data are stored in ageing legacy systems in proprietary formats which are difficult for other systems to access, re-represent and transfer for (re)use. (The use of proprietary formats may also lock customers into specific information systems.)

Implementation of interoperable health information systems may require a high degree of technical expertise not readily available to small organisations in particular.

MATHUR-35

CSE5810

Future WorkFuture Work The Artemis project [aims to support] "interoperability

of medical information systems through semantically enriched Web services.“

Ability to aggregate and share lifelong EHRs for Ability to aggregate and share lifelong EHRs for patients with multiple stakeholderspatients with multiple stakeholders

Potential in using combined clinical data—from Potential in using combined clinical data—from EHRs, patient health record systems (PHR) and EHRs, patient health record systems (PHR) and wireless medical sensor devices wireless medical sensor devices

Clinical research to analyze trends within patient Clinical research to analyze trends within patient populations for more effective research, and to evolve populations for more effective research, and to evolve evidence-based care protocols.evidence-based care protocols.

MATHUR-36

CSE5810

ReferencesReferences http://www.sgsmp.ch/dicom/parisot1.pdfhttp://www.sgsmp.ch/dicom/parisot1.pdf http://www.hcup-us.ahrq.gov/datainnovations/http://www.hcup-us.ahrq.gov/datainnovations/

clinicaldata/FL20LOINCIntroductionHammond.pdfclinicaldata/FL20LOINCIntroductionHammond.pdf http://dicom.nema.org/http://dicom.nema.org/ http://www.sciencedaily.com/releases/

2006/01/060103182421.htm IST Results. "Building Interoperability Into Medical

Information." ScienceDaily. ScienceDaily, 4 January 2006. <www.sciencedaily.com/releases/2006/01/060103182421.htm>.

MATHUR-37

CSE5810

Thank youThank you