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A Primer on Healthcare Information Exchange
John D. Halamka MDCIO, Harvard Medical School and Beth Israel Deaconess Medical Center
The National Effort• Office of the National Coordinator
• HIT Policy Committee–Meaningful Use Workgroup–Certification Workgroup–Health Information Exchange Workgroup
• HIT Standards Committee–Clinical Operations Workgroup–Clinical Quality Workgroup–Security and Privacy Workgroup
• HITSP and CCHIT
• Nationwide Healthcare Information Network
Architectures
• Push and Pull
• Point to Point
• Decentralized Messaging - Massachusetts
• Centralized and Normalized - Indiana
The Massachusetts Approach
Built on a common
messaging gateway
framework
Placed on the network
of each participating
institution
CDXCDX Rx GatewayRx Gateway
• Pharmacy Directory• Pharmacy Directory
• Formulary Service• Formulary Service
• Drug Eligibility• Drug Eligibility
• Medication History• Medication History
• eRX Adaptors• eRX Adaptors
• Prescription Routing• Prescription Routing
• Publishing Service• Publishing Service
• Record Index Management
• Record Index Management
• Record Locator Service
• Record Locator Service
• EHR Adaptors• EHR Adaptors
• XDS Repository Adaptor• XDS Repository Adaptor
• Security• Trading Partner Registry
• Logging• Validation
• Translation• Routing
• Guaranteed Delivery
• Security• Trading Partner Registry
• Logging• Validation
• Translation• Routing
• Guaranteed Delivery
Core Gateway
Core Gateway
NEHENNEHEN
• NEHEN Express• Direct Data Entry
• Billing / PMS Adaptors• ADT Adaptors
• NEHEN Express• Direct Data Entry
• Billing / PMS Adaptors• ADT Adaptors
Hosted Portal
•Hosted by service provider (MA-SHARE)•Provides document / data storage, HTTP viewing for subscribers, and common provider index for dissemination to local gateway participants
Local Gateway Participant
•Local gateway users control integration, etc.•Can leverage infrastructure for internal integration•Interfaces can be direct or use interface engine or similar tools
Architecture Overview
Local Provider Directory
Internet / Network
Published Patient Data
EMRs and Other Enterprise Systems
Secondary Local System
E-Mail Server
CCD Standard Messages, e-mail or fax
encapsulation
Interface Engine or Portal
HIE Application Server / Gateway
Fax ServerWeb Server
Network Subscriber
•No infrastructure support requirement – just Internet connection, fax or e-mail
Summary / Results Viewer
Fax
Summary / Results Viewer
E-Mail Server
Web Server
Printer
E-mail, fax or HTTP encapsulation
Published Patient Data
Community Provider Directory
Local Gateway Participant
EMRs and Other Enterprise Systems
Secondary Local System
E-Mail Server
Interface Engine or Portal
Fax Server Web Server
Published Patient Data
HIE Application Server / Gateway
Local Provider Directory
HIE Application Server / Gateway
CCD Standard Messages, HTTP encapsulation
Summary / Results Viewer
External Networks
Patient visits PCP or specialist and establishes trusted relationship and consents
for release of data
As a result of a referral, admission, or emergency, patient registers in
hospital
Patient is discharged from hospital
Standard format discharge summary or ER report is
transmitted to HIE network
HIE service checks provider directory for routing
instructions
HIE service routes discharge summary to PCP, specialist or other interested
and trusted party (e.g., health insurance case manager)
Consents and provider routing preferences are sent
to HIE service
Patient receives care and details are noted in hospital medical record
Visit/Discharge Summary ExchangeSend / push / route hospital data to interested parties
ReferralsSend / push / route visit and other data in support of referral consultation
Patient visits PCP or specialist and establishes trusted relationship and
consents for release of data; consents and provider
routing preferences are sent to HIE service
Provider refers patient to a specialist, hospital or other provider for consultation or
service
Standard format visit summary with consultation notes transmitted to HIE
network
HIE service checks provider directory for routing instructions and sends referral request with pertinent
patient information / history, diagnosis and service requested to consulting provider; business rules
can be stored in HIE service for elements of real-time decision
support
HIE service routes visit summary to PCP, specialist or
other interested and trusted party (e.g., health insurance
case manager)
Patient visits consulting provider, receives services, and details are noted in patient chart , electronic medical record or other result is
created (e.g., at lab)
HIE service submits referral authorization request to payer for
approval and referral #
Admission NotificationSend / push / route admission notification to payers and providers
Patient visits hospital or other provider and establishes trusted
relationship and consents for release of admission notification
data
Consents, provider routing preferences, and admission
notification notice are sent to HIE service
HIE service checks provider directory for routing instructions and sends admission notification to patient’s preferred payer and
provider
Authorized payers and providers are notified of patient
hospital admission
Laboratory Results
Patient undergoes tests from his or her physician, establishes trusted relationship and consents
for release of laboratory data
Consents, lab results, and provider routing preferences
are sent to HIE service
HIE service checks provider directory for routing instructions and sends laboratory results to
patient’s preferred provider
Authorized providers can access patient’s laboratory
results
Standardized Quality DataSend / push / route visit and other data for standardized quality reporting (and other reporting)
Patient visits PCP, specialist, hospital or other provider and
establishes trusted relationship and consents for release of data
Consents, provider routing preferences and applicable data are sent to HIE service
Standard format visit summary or batch with data for determining quality metrics is sent to payer, government agency or other
quality metrics organization based on patient consent and business rules in HIE
service
Community Provider Directory
Provider organizations track and maintains internal
provider directory
Provider information from each provider organization is
sent to HIE service
HIE service consolidates organizational provider information into a single community provider
directory
Authorized HIE users can access community provider
directory
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Copyright © 2009 Indiana Health Information Exchange, Inc. www.ihie.com
Health Information Exchange – General Concept
Data Stewardship
Ind
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Copyright © 2009 Indiana Health Information Exchange, Inc. www.ihie.com
Layer I: Including Interface Engine, Community Trust, …
Layer II: Including Mapped/Normalized Data…
New Value-added
ServiceLayer III: Including Repository Services…
New Value-added
ServiceMedication Profile
Public HealthSurveillance
Clinical Messaging
Clinical Quality
Services
Ambulatory Results Review
ED Abstract and Results
ReviewNew
Value-added
Service
Inpatient Results Review
Value-added services that can be built upon the HIE investment
A layer of necessary investment
Interdependency of HIE Components
HIE assets are interdependent and, once created, can be leveraged to deliver additional services.
Summary
• Several Health Information Exchanges are operational today
• Architectures and Standards differ
• Policies and trust are very important
• Local and regional business cases drive adoption
• Loosely coupled messaging approaches and centralized repositories both work
