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HL7 Work Group ReportSeptember 20 - 25, 2009 - Atlanta, GA USA
HL7 Project Prototype:
EHR System Design Reference Model
(EHR-SD RM)
Immunization and Adverse Event Reporting
Nancy Orvis, HL7 Project Co-ChairStephen Hufnagel PhD, HL7 Project Facilitator
September 22, 2009-D
ContentsEHR System Design Reference Model
(EHR-SD RM)
• Background– 2008 Project Results– 2009 HL7 EHR SD RM Project plan
• What Changed in 2009– ARRA (American Reinvestment and Recovery Act)– HITSP Harmonization Framework for reuse– HITSP Capabilities
• Information Exchanges Interface Standards Specifications– HITSP Service Collaborations
• EHR SD RM Model– Jan 2009 baseline project– Sep 2009 Information Model (IM) additions– 2010 EHR SD RM Model with HITSP Capabilities, IM & ARRA
• Vaccination and Adverse Event Reporting Prototype– AHIC Use Cases– EHR-S FM– HITSP Capabilities
• Next Steps 2
3
• In 2004, Executive Orders 13335 set the objective for National Electronic Healthcare Record (EHR) Interoperability by 2014
• In 2006, Executive Order 13410 mandated Federal agencies to begin transformation to Healthcare Information Technology Standards Panel (HITSP) conformant EHR interoperable systems by 2007
• We present a standards-based strategic approach for interoperability at the service level to construct semantically consistent interoperable Enterprise Architectures (EAs)
– It builds upon the functional foundation of the HL7 EHR System Functional Model (EHR-S) and the technical foundation of Thomas Erl’s Service Oriented Architecture (SOA) model to specify a standard Healthcare SOA Reference Architecture (H-SOA-RA)
– Information Exchange Requirements (IERs) are used to identify services and as the key to traceability from requirements to implementation, test and certification
Introduction
4
HL7 Project Intent
• Implement a step in HL7 roadmap– Identify gaps and overlaps in HL7’s portfolio
– Identify gaps in the EHR-S FM
– Pilot HL7 ARB SAEAF methodology
• Create H-SOA-RA Version 2
• Create Healthcare SOA EHR-SD Reference Model based on EHR System Functional Model (EHR-S FM)
• Create prototype architectural case study using HL7 HSSP Practical Guide for SOA in Healthcare “sample health” and service specifications, EHR-S FM, EHR-SD RM, AHIC Use Cases, HITSP Interoperability Specifications and NHIN services
• Demonstrate standards-based Model Driven Architecture (MDA) approach
5
• This project will mature the April 2008 H-SOA-RA version 1.0 into H-SOA-RA Version 2.0 and integrate it into an EHR-SD RM using – HL7 (SAEAF, – HITSP MEANS, and – EHR System Functional Model (EHR-S FM)
• Emphasis will be placed on maintaining AHIC, HITSP, NHIN and CCHIT conformance by maintaining IERs and Data Requirements (DRs) traceability– Mapping and analysis of the HL7 product portfolio against the EHR-S FM will be used to
integrate the reference architecture with HL7 product lines and initially mature the resulting model as a technical white papers, then an informative reference model and finally a standard reference model
• An HSSP based prototype case study architectural specification will be built to validate the effort using the AHIC-HITSP Immunization and Response Management and Public Health Case Reporting use cases
HL7 Project Scope
6
HL7 Project Schedule
• Sep 2008 – Healthcare SOA Reference Architecture (H-SOA-RA)
• Jan 2009 – harmonize and catalogue priority IERs, DRs and candidate services
• Mar 2009 – map priority IERs, DRs and candidate services to EHR-S FM
• Jun 2009 - Mappings of V2.5, V3 products to EHR-S FM
• Jun 2009 - Present at HL7 SOA Conference (for peer feedback)
• Sep 2009 – Report on Vaccination and Adverse Event Prototype
• Oct 2009 – Healthcare SOA Reference Architecture (H-SOA-RA) version 2.0
• Nov 2009 - HSSP Practical Guide for SOA in Health Care, Part II: Case Study
• Jan 2010 - EHR-SD RM white paper for HL7 committee comments, to socialize the project.
• Sep 2010 - EHR-SD RM Balloted as informative document
• Sep 2011 - EHR-SD RM Balloted as a standard
7
2008 Project GoalHealthcare SOA Reference Architecture (H-SOA-RA)
NationalFederated
Healthcare Industry
VA/ DoD Interagency
DoD
TMA
Military Services
INTE
GR
ATIO
N
Joining Forces to Improve Effectiveness, Efficiency, and Service delivery
CO
LLA
BO
RA
TIO
N
INTER-AGENCY
Key Business DriverPatient Centric Processes
Key Architectural ObjectiveStandardized Technical Solutions aligned with
Core Business Processes.
Identifying Opportunities to Leverage Technology and Alleviate Redundancy or Agency IT Overlap
88
2008 Health SOA Reference Model Glossary (example)
MHS/VAPROPOSEDSERVICES
SOA SERVICE DEFINITIONS
Access to Care Functions
IDENTITY Identify and/or lookup subjects-of-care, providers, payers, employers, material resources, and references to various parts of the EHR (hosted locally and/or remotely).
Patient Maintain current directory of patient information in accordance with relevant privacy and other applicable laws, regulations, and conventions, including, when available, full name, address or physical location, alternate contact person, primary phone number, and relevant health status. Provide the patient's location information within a facility's premises.
Guarantor Collect, record, and update a core set of information to ensure accurate beneficiary guarantor identification and health plan information. Provide information of Related by genealogy (blood relatives). Provide information of Related by insurance (domestic partner, spouse, guarantor). Provide information of Related by other means (e.g. epidemiologic exposure)
Provider Maintain a current directory of practitioners that, in addition to demographic information, contains data needed to determine levels of access required by the EHR security system. Maintain current directory of provider information in accordance with relevant laws, regulations, and conventions, including full name, address or physical location, and a 24x7 telecommunications address (e.g. phone or pager access number) for the purposes of the following: Provide provider location or contact information on a facility's premises. Provide provider location or contact information on a facility's premises. Provide provider location or contact information when on call. Provide locations or contact information at which the provider practices, in order to direct patients or queries.
Next of Kin Collect, record, and update a core set of information to ensure accurate next of kin identification and health plan information.
Supplier Collect, record, and update a core set of information to ensure accurate Supplier Information.
Insurer Collect, record, and update a core set of information to ensure accurate Insurer Information.
Facility Collect, record, and update a core set of information to ensure accurate Facility Information.
9
2008 Healthcare SOA FrameworkBased on HL7 EHR System Functional Model &
Thomas Erl’s SOA Layers
9 9
HL7 System Functions
Direct Care Supportive Information Infrastructure
Other
Business Process
Value Chains
CompositeServices
(Svcs)
Federated Composition (e.g., Choreograph or Orchestration) Within and Across Business Areas
Core Bus Svcs
Functional Areas + Focal Classes
Functional Areas + Focal Classes
Functional Areas + Focal Classes
Functional Areas + Focal Classes
Entity Svcs IM IM IM Info Reporting/IM
Agnostic Svcs
C r o s s T e c h n I c a l “Common S e r v I c e s”(e.g., Security, Privacy, Auditing, Logging…)
App Svcs Amb Care Sys,In Pt Care Sys
Log Sys, Fin Sys, Dec Support Sys
Data MartsRepositories
Business Objects
ImpProfiles
IHE Profiles Analysis Profiles Communications Profiles/Stacks
Implementation Profiles
10
SUPPLY CHAIN (ORDER/CHARGE)
Anatomy of Ancillary Systems
AUTHORIZATION
DOCUMENT
RECORDS MANAGEMENT
DECISION SUPPORT
PERFORMANCE
DATA MANAGEMENT
SCHEDULING
IDENTITY
TERMINOLOGY
LABORATORY RADIOLOGY PHARMACY CARDIOLOGY OT/PT/SPEECH
s
CO
RE
B
US
INE
SS
S
ER
VIC
ES
ContentsEHR System Design Reference Model
(EHR-SD RM)
• Background– 2008 Project Results– 2009 HL7 EHR SD RM Project plan
• What Changed in 2009– ARRA (American Reinvestment and Recovery Act)– HITSP Harmonization Framework for reuse– HITSP Capabilities
• Information Exchanges Interface Standards Specifications– HITSP Service Collaborations
• EHR SD RM Model– Jan 2009 baseline project– Sep 2009 Information Model (IM) additions– 2010 EHR SD RM Model with HITSP Capabilities, IM & ARRA
• Vaccination and Adverse Event Reporting Prototype– AHIC Use Cases– EHR-S FM– HITSP Capabilities
• Next Steps 11
12
Information Exchange Number
Exchange Action
Exchange Content
What System initiates this exchange?
What System (s) consume this exchange? Qualifier
SendBlood Lab Report
Laboratory Information System
PHR System EHR System Public Health Information System TBD
SendSpecimen Lab Report
Laboratory Information System
PHR System EHR System Public Health Information System TBD
HITSP 2009 Model for IERs
Reusable Facets Lexical Consistency
A new 2009 conceptHITSP Capability
• A HITSP capability is an implementable business service that specifies interoperable information exchanges using HITSP constructs.
• It is meant to supports stakeholder requirements and as part of its design, it includes workflow, information content, infrastructure, security and privacy.
• Capabilities include constraints and operate on specific network topologies (contexts)
• Capabilities have options: subsets of the data content can be sent or received as appropriate by a system implementing a capability.
The 2009 Refined HITSP Framework
Business RequirementsIdentifies interoperability business needs
Interoperability Specification
• Identifies what HITSP capabilities and constructs to use to meet Business Needs
• Defines Requirements, Context and Constraints for those capabilities and constructs
Base Standard#1
Base Standard#n
Base Standard#2
Base Standard#...
CompositeStandard#1
CompositeStandard#...
CompositeStandard#m
SDOs
Component
Transaction
Transaction Package
Available for Internal reuse or repurposingComponent
TransactionConstructs
Transaction
Transaction Package
HITSP ConstructsHITSP Capabilities
Component
ServiceCollaborations
ServiceCollaboration
TransactionConstructs
Transaction
Transaction Package
14
1515
2009 HITSP Reuse Framework
GREEN Elements are reusable!
16
HITSP Model To Link Requirements to Design
HITSP Constructs• Transaction• Transaction Packages• Component• Services
1717
2009 HITSP Requirements Analysis Framework
GREEN Elements are reusable!
1818
2009 Design Specifications Framework
GREEN Elements are reusable!
19
HITSP List of Priority Information Exchanges
1. Demographics
2. Problem List
3. Medications
4. Immunizations
5. Allergies
6. Progress Notes and Other Narrative Documents (History and
Physical, Operative Notes, Discharge Summary)
7. Departmental Reports (Pathology/Cytology, GI, Pulmonary, Cardiology etc.)
8. Laboratory Results
9. Microbiology
10. Images
11. Administrative Transactions (Benefits/Eligibility, Referral/Authorization, Claims/Remittance)
12. Quality Measures
13. Privacy and Security
20
HITSP List of Priority Capabilities
1. HITSP/CAP117 Communicate Ambulatory and Long Term Care Prescription
2. HITSP/CAP118 Communicate Hospital Prescription
3. HITSP/CAP119 Communicate Structured Document
4. HITSP/CAP120 Communicate Unstructured Document
5. HITSP/CAP121 Communicate Clinical Referral Request
6. HITSP/CAP122 Retrieve Medical Knowledge
7. HITSP/CAP123 Retrieve Existing Data
8. HITSP/CAP124 Establish Secure Web Access
9. HITSP/CAP125 Retrieve Genomic Decision Support
10. HITSP/CAP126 Communicate Lab Results Message
11. HITSP/CAP127 Communicate Lab Results Document
12. HITSP/CAP128 Communicate Imaging Information
13. HITSP/CAP129 Communicate Quality Measure Data
14. HITSP/CAP130 Communicate Quality Measure Specification
15. HITSP/CAP131 Update Immunization Registry
16. HITSP/CAP132 Retrieve Immunization Registry
Information
17. HITSP/CAP133 Communicate Immunization Summary
18. HITSP/CAP135 Retrieve and Populate Form
19. HITSP/CAP136 Communicate Emergency Alert
20. HITSP/CAP137 Communicate Encounter Information Message
21. HITSP/CAP138 Retrieve Pseudonym
22. HITSP/CAP139 Communicate Resource Utilization
23. HITSP/CAP140 Communicate Benefits and Eligibility
24. HITSP/CAP141 Communicate Referral Authorization
25. HITSP/CAP142 Retrieve Communications Recipient
26. HITSP/CAP143 Manage Consumer Preference and Consents
2121
Service Traceability EHR-S, HITSP and CCHIT
ContentsEHR System Design Reference Model
(EHR-SD RM)
• Background– 2008 Project Results– 2009 HL7 EHR SD RM Project plan
• What Changed in 2009– ARRA (American Reinvestment and Recovery Act)– HITSP Harmonization Framework for reuse– HITSP Capabilities
• Information Exchanges Interface Standards Specifications– HITSP Service Collaborations
• EHR SD RM Model– Jan 2009 baseline project– Sep 2009 Information Model (IM) additions– 2010 EHR SD RM Model with HITSP Capabilities, IM & ARRA
• Vaccination and Adverse Event Reporting Prototype– AHIC Use Cases– EHR-S FM– HITSP Capabilities
• Next Steps 22
23
Approach
• Service Oriented Architecture based on– Thomas Erl’s SOA layers (De Facto Standard)
• Business Process Value Chains, Composite Services• Core Business Services, Entity Services• Agnostic Services, Application Services, Implementation Profiles
– HL7 EHR System Functional Model (EHR-S FM)• 160+ Standardizes EHR system functions
– Requirements and Test criteria standardized at National Level– Objective Strategic Planning and Investment Portfolio line
costing.– HITSP Capabilities and Interoperability Specifications
• Federal Mandate for Design Interoperability Specifications• Traceable to Enterprise Architecture
– ARRA Meaningful Use Measures
24
January 2009 EHR SD RM ProjectEHR System Design Reference Model (EHR-SD RM)
class EHR-SD RM (Base Project)
HITSP Constructs
+ Component (C)+ Transaction (T)+ Transaction Package (TP)+ Service Collaboration (SC)
Information Exchange Requirement (IER)
+ Exchange Action+ Exchange Attribute+ Exchange Content+ Systems
EHR-SD RM
+ Clinical Document Architecture (CDA)+ EHR SD RM+ MHS/VA Data Model+ MHS/VA Information Model+ Reference Information Model (RIM)
Service
Design Specification
+ Capability+ conditions+ metadata
Interface
Thomas Erl SOA Layers
+ Business Process Value Chains+ Composite Services+ Core Business Services+ Entity Services+ Agnostic Services+ Application Services+ Implementation Profiles
EHR-S FM
+ EHR-S FM+ Direct Care+ Supportive+ Information Infrastructure
Selected Standard
Realize relationship: a source object implements or Realizes its destination object. Realize connectors are used to express traceability and completeness in the model.
Functions and Services differ in that a service enforces encapsulation (e.g., information hiding), has associated governance and a distributed user resource sharing agreement (DURSA), which defines the business rules for a service's information exchanges.
EHR-S FM is EHR System Functional-ModelEHR-SD RM is EHR Software-System-Service Design Reference-Model
MHS IM/IT
+ Capability
VA IM/IT
+ Capability
requirementsdesign
Legend
realize
HITSPCapabilities/Services
25
2010 Information Model ProjectFederal Health Information Model and Standards (FHIMS)
class EHR-SD RM (FHIMS)
HITSP Constructs
+ Component (C)+ Transaction (T)+ Transaction Package (TP)+ Service Collaboration (SC)
HITSP Capability
+ Information Exchange+ option+ Scenario
EHR-SD RM
+ Clinical Document Architecture (CDA)+ EHR SD RM+ MHS/VA Data Model+ MHS/VA Information Model+ Reference Information Model (RIM)
Service
Design Specification
+ Capability+ conditions+ metadata
Interface
EHR-S FM
+ EHR-S FM+ Direct Care+ Supportive+ Information Infrastructure
requirementsdesign
Legend
Requirement
Selected Standard
Realize relationship: a source object implements or Realizes its destination object. Realize connectors are used to express traceability and completeness in the model.
Proposed Federal Health Information Model
Proposed Federal Health Data Model
Functions and Services differ in that a service enforces encapsulation (e.g., information hiding), has associated governance and a distributed user resource sharing agreement (DURSA), which defines the business rules for a service's information exchanges.
EHR-S FM is EHR System Functional-ModelEHR-SD RM is EHR Software-System-Service Design Reference-Model
Reference Information Model (RIM)
NEW
Clinical Document Architecture (CDA)
Information Exchange Requirement (IER)
+ Exchange Action+ Exchange Attribute+ Exchange Content+ Systems
MHS/VA Information Model
NEW
MHS/VA Data Model
NEW
Certification Criteria
+ Capability
ARRA Meaningful Use Measures
+ Stakeholder
NEW
realize
26
2010 ProjectIntegrated EHR-SD RM, FHIMS,
HITSP Capabilities and ARRA Meaningful Useclass EHR-SD RM
HITSP
HL7
HITSP Constructs
+ Component (C)+ Transaction (T)+ Transaction Package (TP)+ Service Collaboration (SC)
HITSP Capability
+ Scenario+ Information Exchange+ option
Information Exchange Requirement (IER)
+ Systems+ Exchange Content+ Exchange Action+ Exchange Attribute
Service
Design Specification
+ Capability+ conditions+ metadata
Interface
Thomas Erl SOA Layers
+ Business Process Value Chains+ Composite Services+ Core Business Services+ Entity Services+ Agnostic Services+ Application Services+ Implementation Profiles
EHR-S FM
+ EHR-S FM+ Direct Care+ Supportive+ Information Infrastructure
requirementsdesign
Legend
Requirement
Selected Standard
Certification Criteria
+ Capability
Realize relationship: a source object implements or Realizes its destination object. Realize connectors are used to express traceability and completeness in the model.
MHS IM/IT
+ Capability
VA IM/IT
+ Capability
Proposed Federal Health Information Model
Proposed Federal Health Data Model
A HITSP Capability is in the interoperability space between systems.
Functions and Services differ in that a service enforces encapsulation (e.g., information hiding), has associated governance and a distributed user resource sharing agreement (DURSA), which defines the business rules for a service's information exchanges.
EHR-S FM is EHR System Functional-ModelEHR SD RM is EHR Software-System-Service Design Reference-Model
EHR-SD RM
+ Clinical Document Architecture (CDA)+ EHR SD RM+ MHS/VA Data Model+ MHS/VA Information Model+ Reference Information Model (RIM)
Reference Information Model (RIM)
NEW
NEW
Clinical Document Architecture (CDA)
Meaningful Use Criteria
+ StakeholderARRA Requirement for Certified EHR Systems
NEW
MHS/VA Information Model
MHS/VA Data Model
realize
HITSPCapabilities/Services
27
Benefits
1. Faster, Better, Cheaper Integrated Requirements-Design Process2. Strategic Plan based on International and National Standards3. Objective Investment Portfolio Cost Estimation4. Minimize the Chance of Year of Execution Unfunded Requirements (UFRs)5. IM and IT aligned on Consistent Catalogue of Services6. MHS EHR Interoperability alignment with National Agenda
1. Manage Care Support Contractor (MCSC) interoperability2. VA interoperability
7. Consistent with Enterprise Architecture
28
Prototype Approach
• Build Integrated Requirements Design CONOPS package based on
– Service Oriented Architecture categorized and populated by
• Candidate Services Derived from following Thomas Erl’s
Service Oriented Design Principles
• HL7 EHR System Functional Model Requirements and
• HITSP Interoperability Specifications
ContentsEHR System Design Reference Model
(EHR-SD RM)
• Background– 2008 Project Results– 2009 HL7 EHR SD RM Project plan
• What Changed in 2009– ARRA (American Reinvestment and Recovery Act)– HITSP Harmonization Framework for reuse– HITSP Capabilities
• Information Exchanges Interface Standards Specifications– HITSP Service Collaborations
• EHR SD RM Model– Jan 2009 baseline project– Sep 2009 Information Model (IM) additions– 2010 EHR SD RM Model with HITSP Capabilities, IM & ARRA
• Vaccination and Adverse Event Reporting Prototype– AHIC Use Cases– EHR-S FM– HITSP Capabilities
• Next Steps 29
30
EHR-SD RM PrototypeRequirements from 2008 AHIC Use Cases
• Use Case 1: Immunization and Response Management (IRM) and • Use Case 2: Public Health Case Reporting (PHCR)
– The IRM AHIC Use Case and HITSP Interoperability Specification are intended to support current interoperability approaches between EHRs and Immunization Information Systems while allowing for a migration toward emerging interoperability implementations and document sharing environments where PHRs are able to be included in the information flow
– The Interoperability Specification also allows for basic electronic information exchanges to enable requirement communications and alerting mechanisms and to lay the foundation for future clinical support capabilities
– The Public Health Case Reporting AHIC Use Case and HITSP Interoperability Specification supports the bi-directional information exchanges of the Public Health Case Reporting process
– The Public Health Case Reporting Use Case addresses numerous domains which have similar content and processes at a high level, but which also are dissimilar in report content details and case management processes when considering any specific report
31
EXAMPLE ARTIFACT: Vaccine and Drug Administration and Reporting Information Exchanges
32
EXAMPLE ARTIFACT Vaccine and Drug Administration and Reporting Use Case
Full use case available at: http://healthit.hhs.gov/portal/server.pt?open=512&objID=1255&parentname=CommunityPage&parentid=1&mode=2&in_hi_userid=10741&cached=true
33
EHR-SD RM PrototypeInformation Exchange Requirements (IERs)
Use Case 1: Immunization and Response Management (IRM)
• IER10 Identify patient
• IER13 Send/receive notification of document availability
• IER18 Send/receive clinical document
• IER26 Identify communication recipients
• IER27 Send non-patient notification message or alert
• IER40 Query for existing data
• IER42 Request/receive medical concept knowledge
• IER54 Query/response for clinical message data
• IER67 Send/receive clinical message
• IER78 Send/receive Vaccine Inventory Requirements
• IER79 Query/response for inventory usage data
• IER80 Send/receive Vaccine Inventory Data
For details, see HITSP IS 10 Immunization and Response
Management, available at www.HITSP.org
Blue Italics indicates IERs, which are common to 1-IRM and 2-PHCR
34
• DR08 Unstructured Data• DR11 Immunization response data • DR12 Adverse Event Report • DR13 Drug/Vaccine Inventory Data • DR14 Drug/Vaccine Inventory Usage Data • DR15 Drug/Vaccine Inventory Availability Data• DR16 Supply Chain Management Vaccine Recall • DR17 Decision Support Data • DR18 Vaccination Data • DR19 Medication Administration data • DR20 Aggregate Inventory of Available Vaccine • DR21 Terminology Data • DR22 Generic Alert Data • DR23 Consumer Vaccination View
34
EHR-SD RM PrototypeData Requirements (DRs)
Use Case 1: Immunization and Response Management (IRM)
For details, see HITSP IS 10 Immunization and Response
Management, available at www.HITSP.org
Blue Italics indicates common across IRM and PHCR
35 35
EHR-SD RM PrototypeIRM Information Exchange Requirements (IERs)
Use Case 2: Public Health Case Reporting (PHCR)
• IER10 Identify patient
• IER13 Send/receive notification of document availability
• IER18 Send/receive clinical document
• IER26 Identify communication recipients
• IER27 Send non-patient notification message or alert
• IER29 Send/receive electronic form for data capture
• IER40 Query for existing data
• IER42 Request/receive medical concept knowledge
• IER49 Report confirmation
For details, see HITSP IS 10 Immunization and Response
Management, available at www.HITSP.org
Blue Italics indicates common across 1-IRM and 2-PHCR
36 36
EHR-SD RM PrototypeData Requirements (DRs)
Use Case 2: Public Health Case Reporting (PHCR)
• DR08 Unstructured Data
• DR17 Decision Support Data
• DR21 Terminology Data
• DR24 Case Report Pre-populate Data
• DR22 Generic Alert Data
• DR23 Consumer Vaccination View
• DR24 Case Report Pre-populate Data
• DR25 Case Report Content
• DR26 Reporting Criteria Content
• DR59 Generic Alert Data For details, see HITSP IS 10 Immunization and Response
Management, available at www.HITSP.org
Blue Italics indicates common across IRM and PHCR
37 37
EHR-SD RM PrototypeInformation Exchange Requirements (IERs)
HITSP Security and Privacy
• IER01 Provide authorization and consent
• IER02 Send data over secured communication channel
• IER03 Create audit log entry
• IER04 Synchronize system time
• IER05 Verify entity identity
• IER06 Provide proof of document integrity and origin
• IER55 Anonymize patient identifiable data
• IER56 Pseudonymize patient identifying information
For details, see HITSP IS 10 Immunization and Response
Management, available at www.HITSP.org
Blue Italics indicates common across IRM and PHCR
38
EXAMPLE ARTIFACT HL7 Requirements and Certification Criteria and HITSP Design
class EHR-S FM: CAP131 Update Immunization Registry
DC.1.8.2 (Manage Immunization Administration) CAP132 Retrieve Immunization Registry Information
CAP131 Update Immunization Registry
CAP133 Communicate Immunization Summary
HL7EHR System
Functional Model
HITSPInteroperability Specifications
39
EXAMPLE ARTIFACT EHR-S Requirements
class DC.1.8.2 (Manage Immunization Administration)
+ 1.The system SHALL provide the ability to recommend required immunizations, and when they are due, during an encounter based on widely accepted immunization schedules.+ 1.The system SHALL provide the ability to recommend required immunizations, and when they are due, during an encounter based on widely accepted immunization schedules.+ 2.The system SHOULD provide the ability to recommend required immunizations based on patient risk factors.+ 2.The system SHOULD provide the ability to recommend required immunizations based on patient risk factors.+ 3.The system SHALL perform checking for potential adverse or allergic reactions for all immunizations when they are about to be given.+ 3.The system SHALL perform checking for potential adverse or allergic reactions for all immunizations when they are about to be given.+ 4.The system SHALL provide the ability to capture immunization administration details, including date, type, lot number and manufacturer.+ 4.The system SHALL provide the ability to capture immunization administration details, including date, type, lot number and manufacturer.+ 5.The system SHOULD provide the ability to capture other clinical data pertinent to the immunization administration (e.g. vital signs).+ 5.The system SHOULD provide the ability to capture other clinical data pertinent to the immunization administration (e.g. vital signs).+ 6.The system SHALL record as discrete data elements data associated with any immunization.+ 6.The system SHALL record as discrete data elements data associated with any immunization.+ 7.The system SHOULD provide the ability to associate standard codes with discrete data elements associated with an immunization.+ 7.The system SHOULD provide the ability to associate standard codes with discrete data elements associated with an immunization.+ 8.The system SHALL provide the ability to update the immunization schedule.+ 8.The system SHALL provide the ability to update the immunization schedule.+ 9.The system SHOULD provide the ability to prepare a report of a patient‘s immunization history upon request for appropriate authorities such as schools or day-care centers.+ 9.The system SHOULD provide the ability to prepare a report of a patient‘s immunization history upon request for appropriate authorities such as schools or day-care centers.+ 10.The system SHALL conform to function DC.1.4.1 (Manage Allergy, Intolerance and Adverse Reaction Lists).+ 10.The system SHALL conform to function DC.1.4.1 (Manage Allergy, Intolerance and Adverse Reaction Lists).+ 11.The system SHOULD transmit required immunization information to a public health immunization registry.+ 11.The system SHOULD transmit required immunization information to a public health immunization registry.+ 12.The system SHOULD receive immunization histories from a public health immunization registry.+ 12.The system SHOULD receive immunization histories from a public health immunization registry.
DC.1.8.2 Conformance Criteria
+ 1.The system SHALL provide the ability to recommend required immunizations, and when they are due, during an encounter based on widely accepted immunization schedules.+ 2.The system SHOULD provide the ability to recommend required immunizations based on patient risk factors.+ 3.The system SHALL perform checking for potential adverse or allergic reactions for all immunizations when they are about to be given.+ 4.The system SHALL provide the ability to capture immunization administration details, including date, type, lot number and manufacturer.+ 5.The system SHOULD provide the ability to capture other clinical data pertinent to the immunization administration (e.g. vital signs).+ 6.The system SHALL record as discrete data elements data associated with any immunization.+ 7.The system SHOULD provide the ability to associate standard codes with discrete data elements associated with an immunization.+ 8.The system SHALL provide the ability to update the immunization schedule.+ 9.The system SHOULD provide the ability to prepare a report of a patient‘s immunization history upon request for appropriate authorities such as schools or day-care centers.+ 10.The system SHALL conform to function DC.1.4.1 (Manage Allergy, Intolerance and Adverse Reaction Lists).+ 11.The system SHOULD transmit required immunization information to a public health immunization registry.+ 12.The system SHOULD receive immunization histories from a public health immunization registry.
40
EXAMPLE ARTIFACT EHR-S FM Dependencies
class DC.1.8.2 (Manage Immunization Administration)
See Also
DC.1.3.2 (Manage Patient Advance Directives)
DC.1.4.4 (Manage Immunization List)
S.1.1 (Registry Notification)
S.2.2.2 (Standard Report Generation)
S.3.7.1 (Clinical Decision Support System Guidelines Updates)
IN.1.6 (Secure Data Exchange)
IN.1.7 (Secure Data Routing)
IN.2.4 (Extraction of Health Record Information)
IN.2.5.1 (Manage Unstructured Health Record Information)
IN.2.5.2 (Manage Structured Health Record Information)
IN.4.1 (Standard Terminologies and Terminology Models)
IN.3 Registry and Directory Services
IN.4.2 (Maintenance and Versioning of Standard Terminologies)
IN.4.3 (Terminology Mapping)
IN.5.1 (Interchange Standards)
IN.5.2 (Interchange Standards Versioning and Maintenance )
IN.6 Business Rules Management
41
EXAMPLE ARTIFACTHITSP Interoperability Design Specifications
uc CAP131 Update Immunization Registry
CAP131 Update Immunization RegistryContent Consumer
Content Creator
Message Receiver
Message Sender
Request Patient Identification
Request HL7 Message
Respond to HL7 Message
HITSP/C72 Immunization Message Component
HITSP/T24 Pseudonymize
HITSP/SC110 - Request Patient Identifier
HITSP/SC115 – HL7 Messaging
42
Sample of Standards used within HITSP Components within IS10
1. Standard: HITSP Construct2. Accredited Standards Committee (ASC) X12 Standards Release 004010 HITSP/C80 - Clinical Document and Message Terminology3. American Medical Association (AMA) Current Procedural Terminology (CPT®) Fourth Edition (CPT-4); CPT Evaluation and Management Codes HITSP/C80 - Clinical Document and Message
Terminology4. ASTM International Standard Guide for Electronic Authentication of Health Care Information: # E1762-95 (2003) HITSP/C26 - Nonrepudiation of Origin5. CDC Race and Ethnicity Code Sets HITSP/C80 - Clinical Document and Message Terminology6. Center for Disease Control and Prevention Implementation Guide for Immunizations Data Transaction using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol. Implementation Guide Version
2.2 June 2006 HITSP/C70 - Immunization Query and Response, HITSP/C72 - Immunization Message, HITSP/C80 - Clinical Document and Message Terminology7. Digital Imaging and Communications in Medicine (DICOM) Part 3.12: Media Formats and Physical Media for Media Interchange HITSP/T33 - Transfer of Documents on Media8. European Telecommunications Standards Institute (ETSI) Technical Specification TS 101 903: XML Advanced Electronic Signatures (XadES) HITSP/C26 - Nonrepudiation of Origin9. Federal Information Processing Standards (FIPS) Codes for the Identification of the States, the District of Columbia and the Outlying Areas of the United States, and Associated Areas Publication # 5-2,
May, 1987 HITSP/C80 - Clinical Document and Message Terminology10. Food and Drug Administration (FDA) - Unique Ingredient Identifier (UNII) HITSP/C80 - Clinical Document and Message Terminology11. Food and Drug Administration (FDA) - National Drug Code (NDC) HITSP/C80 - Clinical Document and Message Terminology12. Health Care Provider Taxonomy HITSP/C80 - Clinical Document and Message Terminology13. Health Level Seven (HL7) Clinical Document Architecture (CDA) Release 2.0 HITSP/C78 - Immunization Document, HITSPC83 - CDA Content
Modules14. Health Level Seven (HL7) Common Terminology Services (CTS) Release 1 HITSP/T66 - Retrieve Value Set15. Health Level Seven (HL7) Implementation Guide for CDA Release 2: History and Physical (H&P) Notes HITSP/C83 - CDA Content Modules16. Health Level Seven (HL7) Implementation Guide for CDA Release 2: Consultation Note HITSP/C83 - CDA Content Modules17. Health Level Seven (HL7) Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), April 01, 2007 HITSP/C83 - CDA Content Modules18. Health Level Seven (HL7) Standard Code Set CVX - Vaccines Administered HITSP/C80 - Clinical Document and Message Terminology19. Health Level Seven (HL7) Standard Code Set MVX - Manufacturers of Vaccines HITSP/C80 - Clinical Document and Message Terminology20. Health Level Seven (HL7) V3 RBAC, R1-2008, HL7 Version 3 Standard: Role Based Access Control (RBAC) Healthcare Permissions Catalog, Release 1, February 2008, HITSP/TP20 - Access Control 21. Health Level Seven (HL7) Version 2.3.1 HITSP/C70 - Immunization Query and Response22. Health Level Seven (HL7) Version 2.3.1 Chapter 2 – Control, Chapter 3 – Patient Administration HITSP/TP22 - Patient ID Cross-Referencing23. Health Level Seven (HL7) Version 2.5, Chapter 2 – Control, Chapter 3 – Patient Administration, Chapter 5 – Query HITSP/TP22 - Patient ID Cross-Referencing24. Health Level Seven (HL7) Version 2.5, Chapter 2 – Control, Chapter 3 – Patient Administration, Chapter 5 - Query HITSP/T23 - Patient Demographics Query25. Health Level Seven (HL7) Version 2.5.1 HITSP/C80 - Clinical Document and Message Terminology26. Health Level Seven (HL7) Version 3.0 - Vocabularies and Value Sets HITSP/C80 - Clinical Document and Message Terminology27. Health Level Seven (HL7) Version 3.0 Context-Aware Information Retrieval Specification: URL Implementation Guide HITSP/T81 - Retrieval of Medical Knowledge
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Work PlansEHR-SD RM Next Steps
1. EHR SD RM Framework– Populate the framework with candidate healthcare Information Exchanges/ capabilities/
services, based on HL7 EHR-S Functional Model
2. Information Model– Loosely-coupled top-down Framework– Rigorously specified bottom up structure/ content
3. Publish HL7 HSSP Practical Guide for SOA in Healthcare Part 2: Case Study4. Socialize EHR SD RM5. Collaborate with others6. Informative ballot in 2010
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Questions??
What was omitted?
Suggestions for improvement?
How should the model be represented?
What should be balloted in 2010?
45
Questions?
Contact us:
Project info available at:
• http://hitsp.wikispaces.com/HITSP+MODEL
• http://hssp.wikispaces.com/Reference+Architecture
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Backup
47
Learning Objective
• Understand how to leverage SOA and Information Exchange Requirements (IER) in the System Design Reference Model
– Audience: Developers and Managers
– Analytic Process: How to integrate a healthcare system design or acquisition specification, with national standards • HL7, HITSP and CCHIT standards
– Benefits: Understand what is needed to create standards-based EHR interoperability at the Service level • Management level understanding supports funding justification
– Understanding of services as automating business functions
– Consistent reqmts, design-specs and implementations
– Better costing
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Candidate Services Sources
• 2008 H-SOA-RA: Identity, Terminology, Authorization, Scheduling, Supply Chain (Order/charge), Document Records Management, Decision Support, Performance, Data Management
• DoD-VA Sharing Project: Pharmacy Data, Clinical Data (Theater), Allergy Data, Lab Results, Discharge Summaries, SADR, Radiology Reports, Assessments (Pre/Post), Inpatient Consults
• NHIN Services: Subject Discovery, Query for Documents, Retrieve Documents, Query Audit Log, Authorization Framework, Consumer Preference Profile, Messaging Platform, Pseudonymization, Health Information Event Messaging, NHIE Service Registry
• HITSP Constructs as Services: Document Sharing, Patient Indexing, Security, Content Definition, Healthcare Services, Health Coverage, Decision Support, Dynamic Data, Data Aggregation, General Communication
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Discussion Topics
• H-SOA Reference Architecture Project deliverables
• 2009 HITSP work on Information Exchanges (IEs) among Use Cases
• Building content of System Domain Reference Model (RM)
– From HL7, HITSP, DOD components
• Use Case Public Health & Emergency Response (PHER)
• System Domain (SD) analysis on PHER
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2009 Tasks
• 2009 Work Through HITSP
• Prototype
• HITSP IER Model
• Candidate Services
• Next Steps / Work Plan
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2008 ResultsHealthcare SOA Reference Architecture
H-SOA-RA
• H-SOA-RA: Overall Goal– Service Traceability
– EHR System Functional Model (EHR-S)
– Healthcare SOA Reference Architecture
– Notional Functional Example
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Exchange Content Number
Exchange Content Name
Definition of the Exchange Content Data Requirements
Genomic Decision Support Data
Information from genetic/genomic knowledge sources and/or decision support modules within EHRs (including Fx HX and Test Results)
DR1 Demographic Data DR3 Clinical History DR4 Personal genetic/genomic data DR5 Family genetic/genomic information DR8 Unstructured Data
HITSP Exchange Content Contain Data Requirements (DRs)
CDA and ANSI X12 Data ModulesReusable DRs Lexical Consistency
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HL7 EHR System Functional Model (EHR-S)> 230 System Functions in 4 level categorization(see separate spreadsheet for full enumeration)
NOTE: “Other” Category - The EHR-S model does NOT include Electronic Resource Planning (ERP) / Logistics and Financial components, which are needed for completeness of a military EHR.
Other O-1 Electronic Resource Planning (ERP)
O-2 Finances
O-3 Other
Business
Entity(Information)
Choreography
Infrastructure
Choreography
Business
Business
Infrastructure
Infrastructure
Infrastructure
Entity(Information)
Ser
vice
Typ
es
Sys
tem
Fun
ctio
ns
Choreography
Business
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Ap
plic
atio
n la
yer
Se
rvic
es
inte
rfa
ce la
yer
Bu
sin
ess
p
roce
ss la
yer
SOA LayersFocus on the Business Processes and Services [Thomas Erl]
.NET J2EE Legacy
Source: Service-Oriented Architecture, Thomas Erl
orchestration service layer
business service layer
application service layer
SystemComponentsand Services
Business Capabilities and Services
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SOA Service ModelsPotential Service Layers [Thomas Erl]
Service Model DescriptionApplication Service
A generic category used to represent services that contain logic derived from a solution or technical platform. Services are generally distinguished as application services when creating abstraction layers.
Business Service
A generic category used to represent services that contain business logic. When establishing specialized service layers, services that fall into the business service layers are collectively referred to as business. However, individually these services are classified as entity-centric (e.g., information) or task-centric business services.
Controller Service
A Service that composes others. Variations of this model exist, depending on the position of the controller in the composition hierarchy. The patent controller service can be classified as the master controller and a service that composes a subset of a larger composition can be labeled as sub-controller.
Coordinator Services
Three service models are derived from the concept of coordination: the coordinator, the atomic transaction coordinator, and the business activity coordinator. All three models are specific to the WS-Coordination specification and related protocols.
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SOA Service ModelsPotential Service Layers [Thomas Erl] (cont)
Entity-centric Business Service
A business process-agnostic variation of the business service that represents one or more related business entities. This type of service is created when establishing a business service layer.
Hybrid Service
A service that contains both business and application logic. Most services created as part of traditional distributed solutions fall into this category. When organizing services into abstraction layers, hybrid services are considered part of the application service layer.
Integration Service
An application service that also acts as an endpoint to a solution for cross-referencing integration purposes.
Process Service
A service that represents a business process as implemented by an orchestration platform and described by a process definition. Process services reside in the orchestration service layer.
Task-Centric Business Service
A business process-specific variation of the business service that represents an atomic unit of process logic. Task-centric services are different from process services in that the process logic is provided by the underlying service logic, not by a separate process definition.
Service Model Description
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EHR Data Reuse Through H-SOA-RAAcross Episodes of Care
• Patient Demographics• Provider Demographics• Insurer Demographic
IDENTITY
Terminology
Document
• Chronic Diagnoses• Procedure History
• Patient History• Summary Lists - Medication List - Allergy/Adverse Reaction List - Immunization
Current EpisodeOf Care EHR
Previous EpisodeOf Care EHR
Reu
sabl
e S
ervi
ces Data Must Be Verified
And Updated
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Federated Services [1]
• Federation is a state achieved by extending SOA into the realm of service-oriented integration• A number of key WS-* extensions provide feature-sets that support the attainment of
federation• Most notable among these are the specifications that implement the concepts of
orchestration and choreography• Establishing SOA within an enterprise does not necessarily require that you replace what you
already have• One of the most attractive aspects of this architecture is its ability to introduce unity
across previously non-federated environments• While web-services enable federation, SOA promotes this cause by establishing and
standardizing the ability to encapsulate legacy and non-legacy application logic and by exposing it via a common, open, and standardized communications framework• WSRP (Web Services for Remote Portals) is the cornerstone of federated services• SAML (Security Assertions Markup Language) is commonly used• ALSO: WS-Security, WS-Trust, WS-Policy, WS-Federation• Additional info at: https://www120.livemeeting.com/cc/bea/viewReg
[1] SOA: Principles of Service Design, by Thomas Erl, Prentice Hall, July 07
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Leveraging SOA Processing in the Enterprise
BusinessServices
Information Services
InfrastructureServices
ApplicationServices
Choreographies(Orchestration Services)
Legacy
60IT PLATFORM
SUPPORT
ANALYTIC
DATA MANAGEMENT
PERFORMANCE
DECISION SUPPORT
RECORDS MANAGEMENT
DOCUMENT
SUPPLY CHAIN: (ORDERS/CHARGES)
SCHEDULING
AUTHORIZATION
TERMINOLOGY
IDENTITY
RADIOLO
GY
LABORATORY
PHARMACY
CLI
NIC
AS
U
T
ES
T O
NLY
O
UT
PA
TIE
NT
OT
HE
R
INP
AT
IEN
T E
R
CARDIOLO
GY
PT/O
T/SPEECH
DIETARY
SPECIALTY CARE
Ancillary Systems
Co
re B
usi
nes
s S
ervi
ces
INTEGRATEDREQUIREMENTS
DESIGNS: Putting the H-SOA-RA
Pieces Together
RESPIRATORY
Fed
erat
ed B
usi
nes
sS
ervi
ces
Ag
no
stic
S
ervi
ces
Federated Services, may be categorized by: -- Encounter Types -- CMS billing category -- Record type -- Care setting type -- etc.
Data sets are defined for each system functional-
capability-service moduleIn
ter-
Age
ncy
Inte
r-S
ervi
ceA
cros
sP
rovi
ders
61
IT PLATFORM
SUPPORT
ANALYTIC
DATA MANAGEMENT
PERFORMANCE
DECISION SUPPORT
RECORDS MANAGEMENT
DOCUMENT
SUPPLY CHAIN:
(ORDER/CHARGE)
SCHEDULING
AUTHORIZATION
TERMINOLOGY
IDENTITY
RADIOLO
GY
LABORATORY
PHARMACY
CLI
NIC
AS
U
T
ES
T O
NLY
O
UT
PA
TIE
NT
OT
HE
R
INP
AT
IEN
T
ER
CARDIOLO
GY
PT/OT/H
SPEECH
DIETARY
SPECIALT
Y CARE
AncillaryApplications
Co
re E
HR
-S S
ervi
ces
RESPIRATORY
Patient Encounter Types
Fed
erat
ed
Ser
vice
s
Composite Services, which may be categorized by: -- CMS billing category -- Record type -- Care setting type -- etc.
Data sets are defined for each service – application – encounter type module
CASE MANAGEMENT
COORDINATION
AC
RO
SS
CA
RE
CO
NT
INU
UM
AC
RO
SS
SE
RV
ICE
S (
SO
As)
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Case Management Coordination Across SOAs and the Continuum
ASSESSMENTCARE
PLANNING
ORDERS &
SCHEDULING
BENEFITMANAGEMENT
AUTHORIZATION &
UTILIZATION MGT.
COMMUNICATION(FACILITATION
ADVOCACY)
DISCHARGE/TRANSFERPLANNING
REFERRAL RECORD TRANSPORT
ROLE OF CASE MANAGER
AcuteInpatient
ChronicRehab.
OutpatientWartimeTheater
ER AcuteRehab.
SkilledLongTerm Care
CustodialLongTermCare
HomeHealth
Prevention/Wellness
Care Continuum
Coordination ACROSS SOAS
cCOORDINATION ` ACROSS LEVELS OF CARE, PROVIDERS and LOCATIONS
EDUCATION.
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Potential Benefits: Process Improvement through H-SOA-RA
Elimination of Process Obstacles would result in:– Length of Stay Reduction– Improved Patient Outcomes / Reduced Risk– Revenue Improvement– Staff Efficiencies– Improved Patient and Staff Satisfaction– Reduced IT Expenditure/Maintenance Costs – Improved Information Accuracy and Availability
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Addressing Real Business Issues Through H-SOA-RA
• Incomplete/Inaccurate Demographic Data– Identity Service
• Incomplete/Inaccurate Insurance Information – Authorization Service
• Unauthorized Service– Authorization Service
• Diagnosis/Procedure Coding Errors– Terminology Service
• Service Delays– Scheduling Service
• Incomplete and Inefficient Charge Capture– Supply Chain Service
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Addressing Real Business Issues Through H-SOA-RA
• Non-indicated or Contra-indicated Services– Decision Support/Authorization Services
• Delays in EHR Document Production and Provision– Document Service)
• Billing Delays and Errors – (Supply Chain/ Billing/Collection Services)
• Not fully coordinated Scheduling – Scheduling Service)
• Lack of fully integrated Patient Assessment and Treatment Plan – (Document Service/ Decision Support Service)
• Delayed or Lack of Medical Record Access– (Record Service)