HIE, Interoperability, and NHIN
CSE
5810
Prof. Steven A. Demurjian, Sr.
Computer Science & Engineering Department
The University of Connecticut
371 Fairfield Road, Box U-255
Storrs, CT 06269-2155
steve@engr.uconn.edu
http://www.engr.uconn.edu/~steve
(860) 486 - 4818
Copyright © 2014 by S. Demurjian, Storrs, CT.
SWEA1
Objective of Presentation
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CSE
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Health Information Change a Growing Concern
Many Efforts are Ongoing/In Progress
 Standards a Concern to Address Data Exchange
 Many Efforts in Play
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

NHIN (www.nist.gov/healthcare/testing/nhin.cfm)
CONNECT www.connectopensource.org/
DIRECT (wiki.directproject.org)
Biosurviellance
We’ll Review Many Efforts by “Leveraging” Existing
Materials and Progress
See set of PPTs on web page:
SWEA2
Towards a Nationwide Health
Information Network (NHIN)
Where Should We Be in 2014

Building a NHIN



NHIN-2004
NHIN-2005-2006
NHIN-2007
US National HIT Strategic Plan
On July 21, 2004 the Department of Health and
Human Services (DHHS) announced the decade
of health information technology for “delivering
consumer–centric and information-rich health
care.”
The vision is to build a National* Health
Information Network (NHIN) of regional health
information exchanges formed by health care
providers who will utilize electronic health record
systems.
* Original term “National” has been changed on “Nationwide” in January 2006
Thompson TG and Brailer DJ. The Decade of Heath Information Technology to Deliver Consumer-centric
and Information-rich Health Care. Framework for Strategic Action. US DHHS, July 21, 2004.
DHHS’ Framework for Health Information Technology:
Building a NHIN
NHIN will be based on:
Electronic Health Record Systems (EHRS) that will
enable
Regional Health Information Exchanges (RHIEs)
organized via
Regional Health Information Organizations
(RHIOs)
Thompson TG and Brailer DJ. The Decade of Heath Information Technology to Deliver Consumer-centric
and Information-rich Health Care. Framework for Strategic Action. US DHHS, July 21, 2004.
President’s Strategic Framework for HIT
US Nationwide Health Information Network
Provider Record Laboratory Results Specialist Record
Records
Returned
Requests
for Records
Another
RHIO
Authorized
RHIO
Inquiry
Patient data
to other
RHIO
Index of
where patients Temporary Aggregate
have records
Patient History
RHIO
Source: Jennie Harvell. The Decade of Health Information Technology – Framework for
Strategic Actions. MMIS Conference, September 2004
US Health Information Network - 2014
Source: Dr. Peter Elkin, Mayo Clinic, MN
Source: Dr. Peter Elkin, Mayo Clinic, MN, 2006
RHIOs as NHIN Components
Nationwide Health Information Network (NHIN)
Emerging data shows the value that
standardized health information exchange
will provide to all stakeholders:
Healthcare purchasers and payers
Hospitals and other healthcare providers
Laboratories
Practicing clinicians
Public health
Source: John Glaser, Janet Marchibroda, Jim Schuping. CCBH. Washington, D.C. December 6-7, 2004
URL: www.ehealthinitiative.com
Building a NHIN
On November 15, 2004 Office of National Coordinator for
Health Information Technology (ONC), Department of
Health and Human Services (DHHS), released
THE REQUEST FOR INFORMATION (RFI)
on the Development and Adoption of a “National”
Health Information Network
Over 500 responses from various healthcare
stakeholders has been submitted.
URL: http://www.dhhs.gov
PHDSC
Model:
PHDSC
Model
for Electronic Health Record-based Data Exchange
RHIO
EHR-PH
Info
Exchange
NHIN Development Process
In October 2005 DHHS Office of National
Coordinator (ONC) awarded several
NHIN contracts ($65M) as follows:




Standards Harmonization
EHR Certification
NHIN Architecture Prototypes
Health Information Security and Privacy
URL: http://www.hhs.gov/healthit/ahic.html
DHHS NHIN Contracts
Standards Harmonization - Harmonize the health care and
technology standards used in health information
interchange to address gaps and conflicts in current
standards
 EHR Certification - Set forth certification criteria for the
many electronic health care record products and
technologies currently available on the market
 NHIN Prototypes - Develop and evaluate prototypes for
the network architecture to assess the feasibility of
developing a national health information network prototype
 Privacy - Address privacy and security policy questions
affecting the exchange of health information.
Work resulting from each of these projects will be used by
HHS to develop and refine the business case for
establishing the network.

FHA Presentation to HIMSS National
Capital Area Chapter
January 15, 2009
Vish Sankaran
Program Director
Federal Health Architecture
Phase 1
2004 – 2008
Foundation for Health Information Exchange Established
In April, 2004
•
•
Executive Order 13335: Office of the national
coordinator created
Executive Order 13410: Federal federal agencies
required to implement HHS Secretary recognized
standards and cost & quality transparency
In the last four years, ONC worked with Federal,
States and private sector to:
•
•
•
•
Harmonize interoperable standards
Create Health IT certification for functionality,
security, and interoperability
Launch the Nationwide Health Information Network
Address Policy variations
The Tipping Point for Phase 2 is now at hand
16
President-elect Obama’s Commitment
to Electronic Health Systems
The goal is not to move from
“paper silos” to “electronic silos”
The goal is an electronic health
system that supports and requires
the movement of interoperable
health information supporting:
In a January 9, 2009 speech at
George Mason University
"To improve the quality of our
healthcare while lowering
its cost, we will make the immediate
investments necessary to ensure that,
within five years, all of America’s
medical records are computerized.”
•Continuity of Care
•Population Needs (pandemics
and other disasters)
•Bench to Bedside Research
•Disability Determination
17
FHA Mission
“Secure Exchange of Interoperable Health Information”
Working together to provide the tools and solutions to support the
development and exchange of interoperable health information
within the federal government and with the tribal, state, local and
private sector, thereby, enabling better care, increased efficiency,
and improved access to care for American citizens.
Effective Government
18
Agency Concept of Operations
1
Business
Priorities
2
Architect
Solutions
3
Plan
Investments
4
Implement
Solutions
5
Measure
Progress
FHA can provide guidance / support in any phase of your operations.
19
2009 Vision
Agencies Collaborate to Reform Healthcare through IT
Reform HealthCare
VISION
Improve
Quality
GOALS
Increase
Access
Reduce
Costs
POPULATIONS…
Elderly
Veterans
Military
Native Americans
Disabled
Children
Underserved
STAKEHOLDERS
State, Local, Private
State Agencies
Local Agencies
Providers
Health IT Vendors
Payers
Others…..
COLLABORATION
Federal Programs
PROCESS
Solutions
RESULT
Business
Needs
Architect
Investment
Implement
Improved Performance
20
The Nationwide Health Information Network
Health Bank or
PHR Support Organization
State and
Local Gov
Community
Health
Centers
SSA
Community #1
VA
Common “Dial Tone” & Chain of trust
DoD
Labs
FDA
CDC
Integrated
Delivery
System
Pharmacies
Community #2
The Internet
Standards, Specifications and Agreements
for Secure Connections
21
CONNECT: Tools for Information Exchange
FHA’s CONNECT Initiative provides three related tools to
enable organizations to connect to the NHIN:
– The Gateway, which implements the core services defined by
the NHIN
– Enterprise Service Components, which provide robust tools
for indexing patient identities, maintaining patient health
documents, implementing business rules for authorizing the
release of medical information and more
– The Software Development Kit (SDK), which enables
developers to customize the Gateway and add or replace
enterprise service components
22
CONNECT 2008 Progress
2008
March 2008
CONNECT
development
started
Sep 2008
3 agencies
demonstrated
HIE with
private sector
2009
Dec 2008
6 agencies
demonstrated
HIE with
private sector
2009
Plan to include
all health
agencies by
end of year
Collaboration you can be proud of!
23
CONNECT Roadmap: 2008-2011
2008
• Participate in NHIN Trial Implementations
• Develop first release of the Federal NHIN Gateway
• Demonstrate value of connecting to the NHIN for agencies
2009
• Move selected agencies into production using NHIN
• Use of NHIN to solve agency needs and improve performance
• Distribute Gateway software to facilitate NHIN solution
development by marketplace
2010
• Expand the set of agency programs using the NHIN
• Begin the process of transitioning to gateway software
provided by the marketplace
2011
• Complete process of transitioning to gateway software provided
by the marketplace
• Support every agency that performs health-related information
exchanges using the NHIN
24
Private sector and Government Must Care
Data flow in our health care systems is a must for the coming years
• Government – Ensure interoperability is in agency business and strategic plans.
• Systems integrators: Support the federal, state, private providers and public health
agencies transformation towards interoperability. Leverage the CONNECT tools as a
means to integrate existing health information systems.
• Product vendors: Create unique HIE solutions for the health marketplace by adding
value on the CONNECT solution, or create your own products that provide NHIN
services.
For this transformation to succeed, all of us must participate
25
What is Direct?

CSE
5810

Allow individuals, providers and organizations to share
information with best practices that have trust and
privacy considerations
Health Information Service Provider (HISP)
 Manage security/transport for directed exchange
 Organizational model that performs HISP functions
 Works to send/receive to organization or individual
 Legal Business Associate Agreements with HIPAA
 Includes all data collection, use, retention, and
disclosure policies
26
SWEA26
One Possible Architecture
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5810
Clinic1
X.509
Clinic2
Hart. Hosp.
MD-Psych
HISP2
Clinic3
HISP1
Hart. Hosp.
MD-Reg
St. Francis
MD-Pysch
Hart. Hosp.
Admin
HISP3
Hart. Hosp.
RNs
Clinic4
HISP4
HIE
MD Access
Clinic5
Overview of HISP and HIE.
Trustee
Key Crowd Authentication
Process (see Figure 5)
Prover
St. Francis
RNs
(issued by
EHR
Asylum Hill)
St. Francis
MD-Reg
UCHC
Res-Genomic
UCHC
Res-DID
X.509
Asylum Hill
Staff
Asylum Hill
MD
Examine MD Certs to
Determine if MD can join Hart.
Hosp. MD-Reg Crowd
MD
(issued by
EHR St.
Francis)
X.509
Request Access
To Hart. Hosp.
(issued by
CRDW
UCHC)
MD Certificates
Key
Crowd
Verifier
Figure 1 HISP and HIE, MD Certificates, and Key Crowd Authentication Process.
SWEA27
Biosurveillance Use Case
Transmit essential ambulatory care and
emergency department visit, resource
utilization, and lab result data from
electronically enabled health care delivery
and public health systems in standardized
and anonymized format to authorized
Public Health Agencies with less than one
day lag time.
Source: HITSP Meeting, Arlington VA, September 20, 2006
AHIC Biosurveillance Use Case
Event Detection
Neighboring
Jurisdictions
Hospital
State Public Health
Surveillance System
4- Report/retrieve of symptoms,diagnosis
& medication prescription data from EHRS
Ambulatory
Care
9 – Order
test
13 – Report on the positive case
electronically & by phone
4 – Data mining
of EMR notes
7 – Notify on
increased number
of cases &
recommend to
order specific tests
11 – Report
test result
electronically
& by phone
Local
Public Health
Surveillance
System
DHHS
Media
Laboratory
Pharmacy
Response
Team
P
U
B
L
I
C
Biosurveillance
AHIC-ONC BIO Consolidated Use Case
Patient-level data to Public Health
Message-based Submission
HITSP
Biosurveillance – Patient-level and Resource Utilization Interoperability Specification
Transaction Package
Consumer/Patient Id X-ref
Transaction
Pseudonymize
Message-based
Scenario
Component
Encounter Msg
Lab Report Message
Radiology Msg
Terminology
Standards
HCPCS HL7 V3
CPT HL7 V2.5
CCC SNOMED-CT
ICD 9/10 LOINC
NCCLS
UCUM
UB-92
URL
FIPS 5-2
HAVE
Base
Std
HL7V2.5
ADT^xxx
Base
Std
HL7V2.5
ORU^R01
IHE
XDS
IHE
PIX
PDQ
Component
Component
Component
Base
Std
HL7
QBP^Q23
RSP^K23
Anonymize
Component
Lab Terminology
Base
Std
LOINC
SNOMEDCT
Base
Std
ISO
DTS/
25237
HIPAA
DICOM
Base
Std
ISO 15000
ebRS 2.1/3.0
Base
Std
HL7 V2.5
Biosurveillance
AHIC-ONC BIO Consolidated Use Case
Patient-Level Data to Public Health
Document-based Submission
HITSP
Biosurveillance – Patient-level and Resource Utilization Interoperability Specification
Transaction Package
Consumer/Patient Id X-ref
Transaction Package
Manage Sharing of
Docs
Document-based
Scenario
Transaction
Notif of Doc Availability
IHE
XDS-I
Base
Std
HL7
QBP^Q23
RSP^K23
Transaction
Pseudonymize
IHE
NAV
IHE
XDS
IHE
PIX
PDQ
Component
Lab Report Document
Component
Anonymize
Component
Lab Terminology
Base
Std
DICOM
Base
Std
LOINC
SNOMEDCT
IHE
XDS-MS
Base
Std
HL7
CDA r2
IHE
XDS-LAB
Terminology
Standards
HCPCS HL7 V3
CPT HL7 V2.5
CCC SNOMED-CT
ICD 9/10 LOINC
NCCLS
UCUM
UB-92
URL
FIPS 5-2
HAVE
Base
Std
ISO
DTS/
25237
HIPAA
DICOM
Base
Std
ISO 15000
ebRS 2.1/3.0
Base
Std
HL7 V2.5
Event Detection
EHRS
Neighboring
Jurisdictions
Hospital State Public Health
Surveillance System
1- Report/retrieve symptoms, diagnosis &
medication prescription data from EMRs
Ambulatory
Care
4 – Order
pathogen
test
2 – Data mining
of EMR notes
3 – Notify on
increased number
of cases &
recommend to
order pathogen test
5 – Report
test results
7 – Report on the positive case
electronically & by phone
Local
Public Health
Surveillance
System
DHHS
6 – Report
positive
test result
electronically
& by phone
Media
Laboratory
Pharmacy
Response
Team
P
U
B
L
I
C
Event
Monitoring
Neighboring
Jurisdictions
EHRS
3 - Monitor ER
visits &
hospitalizations
data from EMRs
1 – Send
health alert
Ambulatory
Care
4 – Order
pathogen
test
2 - Monitor newly
diagnosed cases
& vaccination
data from EMRs
State Public Health
Surveillance System
9 – Send updates
on the event
6 – Send order to
activate emergency
vaccination
Local
Public Health
Surveillance
System
5 – Report
test results
7 – Order/
Supply
vaccine
Lab
Hospital
8 – Monitor
vaccine
supplies
Pharmacy
10 – Send
health alert
to the public
DHHS
Media
Response
Team
P
U
B
L
I
C
Event
Management
Neighboring
Jurisdictions
EHRS
3 - Monitor ER
visits,
hospitalizations
data from EMRs
& utilization data
1 – Send
Outbreak updates
Ambulatory
Care
4 – Order
pathogen
test
2 - Monitor newly
diagnosed cases
& vaccination
data from EMRs
State Public Health
Surveillance System
9 – Send outbreak
updates
6 – Send Rapid Flu
Test Kits
10 – Send
outbreak
updates
to the public
Local
Public Health
Surveillance
System
5 – Report
test results
DHHS
9 – Activate
coordinated
response
7 – Deliver
vaccine
Lab
Hospital
8 – Monitor
vaccine
supplies
Pharmacy
Media
Response
Team
P
U
B
L
I
C
Cardiovascular
Disease (CVD)
Surveillance
Payor
Hospital
EHRS
1 – Conduct
Routine Check-ups
4 – Prescribe
Medication and
Treatment Plan
Ambulatory
Care
9 - Monitor ER visits,
hospitalizations data
from EMRs &
utilization data
11 – Send reports
12– Conduct
Surveys
(BRFSS)
5 – Monitor
Treatment
2 – Order
cholesterol
test
3 – Report
test results
7 – Report
Data to
Schools
State Public Health
Surveillance System
Local CVD
Surveillance
System
10 – Conduct
Health
Education
DHHS
6 – Fill
Prescription
8– Coordinate
Care
Media
Laboratory
Pharmacy
School
P
U
B
L
I
C
Hospital
Asthma
Surveillance
Payor
EHRS
1 – Conduct
Routine Check-ups
4 – Prescribe
Medication and
Treatment Plan
Ambulatory
Care
9 - Monitor ER visits,
hospitalizations data
from EMRs &
utilization data
11 – Send reports
5 – Monitor
Treatment
2 – Order
allergen
test
3 – Report
test results
7 – Report
Data to
Schools
State Public Health
Surveillance System
12– Conduct
Surveys
(BRFSS)
Local Asthma
Surveillance
System
10 – Conduct
Health
Education
DHHS
6 – Fill
Prescription
8– Coordinate
Care
Media
Laboratory
Pharmacy
School
P
U
B
L
I
C
EHR-PH System Prototype for Interoperability
Public
Health Surveillance
Clinical Care in 21st Century Health Care
System
Hospital of Birth
State Health Department
ADTBirth Record
HL7 2.4
Newborn
Screening
Test
Hearing
Screening
Test
Immunization
Administration
HL7 3.0
HL7 3.0
Newborn
Screening
Registry
HL7 3.0
EHR-PH
Info Exchange
HL7 3.0
HL7 2.4
Immunization
Registry
HL7 2.4
HL7 3.0
HL7 2.4
J2EE
External
Laboratory
Hearing
Screening
Registry
HTB
J2EE
Communicable
Disease
Registry
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Healthcare
Transaction
Viewer
HTB – Health Transaction Base
Source: Orlova, et al. HIMSS 2005,Dallas TX, February 13-17, 2005 and AMIA, Washington DC, November, 2005
EHR-PH
System
Prototype
forforInteroperability
EHR-PH
System
Prototype
Interoperability
Health Surveillance
Clinical
Care in 21stHealth
in 21st
Century
CenturyCare
HealthSystem
CarePublic
System
Our Prototype
 Shows how interoperability between healthcare
systems can be achieved with a standards-based
infrastructure
 Is built upon existing systems in clinical care and
public health programs
 Enables electronic data reporting from a clinical
setting to multiple public health systems
 Enables translation of customized standards into
HL7 3.0 messaging standard
 Links clinical and public health systems to provide
a continues view of the patient record across the
systems involved