Transcript Putting Our Principles to the Test

Technical Overview of the Common Framework
HIT Symposium at MIT
J. Marc Overhage, MD, PhD
Regenstrief Institute
Indiana University School of Medicine
Indiana Health Information Exchange
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Common Framework
Connecting for Health principles
– Builds on existing systems
(“incremental”) and creates
early value for doctors and
patients
– Designed to safeguard
privacy – imposed the
requirements and then
designed the solution
– Consists of an interoperable,
open standards-based
“network of networks” built
on the Internet
– Leverages both “bottom-up”
and “top-down” strategies
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Architecture is Federated and Decentralized:
Once records are located, the health
information flows peer-to-peer – with
patient’s authorization
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The architecture supports point of care
information sharing and population-based
reporting
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The Connecting for Health Model
for Health Information Sharing
• Sharing occurs via a network of networks
(National Health Information Network) — not a
completely new architecture
• The nationwide “network” is made up of smaller
community networks or SNOs (Sub Network
Organizations)
• Each SNO has an RLS (Record Locator Service)
to locate patient records
• SNOs are interconnected through ISBs (InterSNO Bridges)
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NHIN: Network of Networks
• National Health Information Network, not National
Health Information Database
• Bad Tradeoff: 1000x Searches for 0.1 to 0.01
increase
• No “Top Level” Query
–Privacy
–Security
–Patient Trust
–Source of Truth
–Data Cleanliness
• Queries Must Be Targeted/No Fishing
• Built On Lines of Actual Human Trust
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What is a SNO?
• A group of entities (regional or non-regional)
that agree to share information with each other
• Implements the Common Framework
• Provides an ISB for all external traffic
• Runs an RLS internally
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What is a Record Locator Service
(RLS)?
• Like a phone book
listing locations of
information
• Contains no clinical
information
• Only authorized
participants can access
it
• Obtaining the actual
clinical record is a
separate
transaction not involving
RLS
RLS
Care Delivery
Organization 1
SNO
(Secure Reliable
Internet)
Public Health
Organization
Care Delivery
Organization 2
Payer or Other
Organization
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What is a Inter-SNO Bridge (ISB)?
• Software that
provides the
interfaces that
define a SNO
• Provides essential
services
SNO 2
RLS
ISB
RLS
RLS
ISB
SNO 1
NHIN
ISB
SNO 3
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How Multiple SNOs Connect to Form NHIN
• A SNO queries other SNOs when it knows:
–An institution where the patient received care
–A region where the patient received care
• Same query formatted for all remote SNOs
• Only need location of
ISBs
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Three Standard Interfaces Required
• Publish local record locations to RLS (Pink)
• Query institution+MRN from RLS (Orange)
• Retrieve clinical data directly from sources (Green)
1. Request
Record Locations
for Patient
2. Return Index to
location of patient
records
Healthcare
Practitioner
Patient
Index
[RLS]
0. Publish Index to
location of patient
medical records
3. Request Patient
Medical Records
Clinical Data
Source
4. Provide Patient
Medical Records
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Location: Namespaces
Problem of Global Uniqueness
Globally Unique Institutions IDs +
Locally Unique Record Numbers =
Globally Unique Record IDs
Examples:
[email protected]
HHS.gov/help.html
GeneralHospital/MRN:457398457
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Disambiguation:
Probabilistic Match on Demographics
• Assume No National Health ID
• Use Only Demographics / No Clinical Data
• Use common set of patient demographics
– Name/DOB/Gender/Zip/SSN/etc
• Pluggable Matching Algorithm
• Optimized To Minimize False Positives
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Patient Match
• Incoming PID Fields Matched Against DB
• Algorithm Tuned to Local Conditions
• False Positives Tuned to < 1 in 100,000
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Underlying Technologies
•
•
•
•
•
•
TCP/IP
SOAP
Web Services
HL7/NCPDP messaging standards
LOINC codes
NDC codes
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Security / Confidentiality
• Server-to-server (ISB-to-ISB)
authentication via X.509 certificates
• Communication protected by SSL/TLS
• Federated identity based on single
token authentication in edge systems
• Role based/level based access control
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What did we learn from the
prototype work?
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Authentication
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Patient demographic entry
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Query options
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Viewer results display
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Viewer results display -- more
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Prototype SNOs reflect the realities of
existing market and health IT variation
IHIE
MA-SHARE
Mendocino HRE
Market
Mixed urban and rural;
dominant academic
anchor (IU)
Urban mix of academic,
community and
commercial influences
Rural and underserved
community medicine and
health centers
RHIO-related
history
35+ years
25+ years
7 years
Technology
partner
Regenstrief
(academic not-for-profit)
CSC
(large commercial)
Browsersoft
(small commercial)
Development
preference
J2EE
Microsoft .NET
Mixed Open Source
Overall
architecture
Central data repository
with standardized data
Federated, with shared
Record Locator Service
Brokered through mirrored
data at central HRE
Standards
Significant investment in
HL7 2.x
Implementing HL7 3.0;
investigating XDS
“Bi-lingual”
(HL7 2.x and 3.0)
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Prototype Approaches
Supported by Browsersoft, Inc.
(OpenHRE)
IHIE / INPC (at Regenstrief)
Clinical Data
Record Exchange Service (RES)
Mirrored
Clinical Data
RLS
HL7
Update
Services
MPI / RLS
Service
InterSNO
Bridge
INPC Disburser /
Aggregator (serving
as InterSNO Bridge)
Auth / Access Control
Service (AACS)
Indiana
• Developed Disburser / Aggregator for ISB
• Adapted existing MPI for RLS
• Source systems send data to hosted HL7
Hosted by CSC
Update Services for transformation and
RLS
Communityhosting in standard
form
level
registries
g
CDX Gateway (serving as
InterSNO Bridge)
Registries,
Audit, etc.
Mendocino
• Developed RLS
and ISB
• Source systems
send data to
HRE for hosting
in native form
with on demand
transformation
Consolidated
Tribal Health
UVPMCG
= New “NHIN” functionality
Ukiah Valley
Medical Ctr.
Clarian
Community
Hospitals
Indiana
DPH
Indiana
Medicaid
IN Cancer
Registry
IU Medical
Group
St. Francis
St. Vincent
Wishard
AEGIS
(public
health)
Beth Israel
Deaconess
Boston
Medical Ctr.
Massachusetts
• Adapted its CDX Gateway as
front-end to the RLS and ISB
• Distributed CDX Gateways
fetch source data on demand
from participant sites
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What Common Framework
technical resources are available?
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Types of Technical Resources
Background Information
• On the Technical Architecture and Design Overall (T1)
• On Data Quality (T5)
• On the RLS (from the MA prototype site) (T6)
Implementation Guides
• NHIN Message Implementation Guide including Record Locator Service/Inter-SNO
Bridge (T2)
• Standards Guides
– Medication History: Adapted NCPDP SCRIPT (T3)
– Laboratory Results: ELINCS 2.0, with modifications (T4)
Example Code/Interfaces
• Test Interfaces: CA, IN, MA www.connectingforhealth.org (under T2)
• Code base: CA, IN, MA www.connectingforhealth.org (under T2)
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