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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 1 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 2 Architecture is Federated and Decentralized: Once records are located, the health information flows peer-to-peer – with patient’s authorization 3 The architecture supports point of care information sharing and population-based reporting 4 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) 5 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 6 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 7 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 8 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 9 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 10 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 11 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 12 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 13 14 Patient Match • Incoming PID Fields Matched Against DB • Algorithm Tuned to Local Conditions • False Positives Tuned to < 1 in 100,000 15 16 Underlying Technologies • • • • • • TCP/IP SOAP Web Services HL7/NCPDP messaging standards LOINC codes NDC codes 17 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 18 What did we learn from the prototype work? 19 Authentication 20 Patient demographic entry 21 Query options 22 Viewer results display 23 Viewer results display -- more 24 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) 25 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 26 What Common Framework technical resources are available? 27 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) 28 29