Key Issues of Technical Interoperability Solutions in eHealth

1
Key Issues of Technical Interoperability
Solutions in eHealth

• Asuman Dogac
• IST-027065 RIDE Project

2
Outline of the Talk

• Introduction to the technical issues through a
  scenario
• Demonstration of EHR interoperability
• IHE Profiles
• CEN 13606 EHR Content Standard
• A brief Comparison of the EHR standards
• Current practices in EU Member States
• What lies ahead

3
Demo Scenario

• One sunny day in Malaga, a person in a meeting
  experiences a heart attack

• From the nearest hospital an
• ambulance is called

4
Demo Scenario

• On the way to the hospital, the paramedic obtains
  the demographic information of the patient from
  the patients citizen card and sends it to the
  hospital by using his mobile device
• This operation is actually calling the Admit
  Patient Web service of the hospital

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Demo Scenario

• The patient, Dr. Ilias Iakovidis has been living
  in Brussels for a long time
• He has had cardiovascular problems and had some
  surgeries and treatment at the Brussels Hospital
• Therefore, his EHR is in the Brussel Hospital
  Information system

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Demo Scenario

• Luckily, there exists a Common EU EHR Registry/
  Repository which is used by the hospitals in
  Spain and in Belgium to store clinical documents
  of patients

Common EU EHR Registry/Repository
Brussels Hospital
Malaga Hospital
Brugge Hospital
Barcelona Hospital
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Demo Scenario

• The emergency department of Malaga Hospital
  assigns a new patient identifier, PID 10000146
• The doctor searches their own hospital
  information system for clinical information about
  the patient

• No information about the patient
• Then the doctor queries the Common EU EHR
  Registry/Repository

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Demo Scenario

• Query Give me the EHRs of the patient with PID
  10000146
• Wrong PID PID is local to Malaga Hospital and we
  need the PID in the Common EU Registry/Repository
• Solution?

PID Manager
Ilias Iakovidis 22/03/1967
Name Ilias Iakovidis BirthDate
22/03/1967 10000146
Brussels Hospital
10001452
Malaga PID10000146 Common Rep ?
35000489
Common Rep/Reg
Malaga Hospital
Malaga Hospital
Before requesting the EHR, find out the PID in
the Common repository
A new patient is admitted
Common EU EHR Registry/Repository
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Demo Scenario

• Now the query is using the correct PID
• Registry returns document references
• Doctor selects the needed ones and the document
  is retrieved from the repository

PID 35000489 Give me the document references
doc1.xml doc2.xml ... docn.xml
Malaga Hospital
Common EU EHR Registry/Repository
doc2.xml
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Demo Scenario

• The other issue considered in the demonstration
  is authentication and audit trails
• The repository needs to be sure that Malaga
  Hospital and Brussels Hospital are authorized to
  communicate with it
• Also each hospital must be sure that the actor it
  communicates with is the real Repository

Try to unlock with public key. If it is opened
everything is OK
Lock with private key
Mutual Authentication
Allowed Nodes
Public Keys
Allowed Nodes
Public Keys
Common Rep/Reg
The same process is repeated on the other side
Malaga Hospital
Brussels Hospital
Common EU EHR Registry/Repository
Malaga Hospital
Private Keys
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Demo Scenario

• Furthermore, audit trail is essential
• It is necessary to allow a security officer in a
  healthcare institution to audit activities to
  detect improper creation, access, modification
  and deletion of Protected Health Information
  (PHI)
• In our scenario, we have a common audit
  repository
• Each application creates and sends an audit
  record to this repository after specified events

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Demo Scenario

• Both in the node authentication and audit trail,
  time is very important since it is a common
  variable used in the system
• Therefore, all applications should have
  consistent time (Recording the correct time in
  audit records, using correct timestamp
  authentications)
• In our demonstration, all aplications make their
  time consistent by asking the time to a common
  time server

What time is it?
What time is it?
UTC1
UTC1
Malaga Hospital
Brusells Hospital
101216
091328
101448
091328
101328
101328
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Demo Technologies Used

• NIST IHE XDS Registry Repository (common
  registry/repository) was available as public
  domain software from National Institute of
  Standards and Technology (NIST) from USA
• On top of this, we have implemented the following
  profiles (will be available as public domain
  software) - IHE PIX Manager (for patient ID
  manager) - IHE ATNA Profile (for node
  authentication TLS and audit trails) - IHE
  Consistent Time profile (SNTP)
• We have used
• Care2x HIS (a public domain Hospital Information
  System) 
• The document content standard is CEN 13606-2000

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The Technical Issues Needed to be Addressed

• Communication Protocols
• Most Commonly used is Internet Protocol (IP)
• Although IP seems to be common between health
  applications, various application protocols
  exists in the protocol stack of IP
• The communication chanels can be

Hospital A
Hospital B
HTTP
SMTP
FTP
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The Technical Issues Needed to be Addressed

• Message Interoperability
• To be able to exchange information among
  heterogeneous healthcare information systems,
  messaging interfaces (also called interface
  engines) are used
• Currently, the Health Level 7 (HL7) Version 2
  Messaging Standard is the most widely implemented
  message interface standard in the healthcare
  domain
• Another one is HL7 v3 standard and there is no
  well defined mapping between them
• Proprietary messages are also used in the
  healthcare domain

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Message Interoperability
Interface Engine
Interface Engine
Transmitting
HL7-I12 Patient Referral
HL7-I12 Patient Referral


12345
Iakovidis
Ilias
11011010
Network
12345
Iakovidis
Ilias
Application 1 HIS Database and back end
applications
Application 2 HIS Database and back end
applications
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Messaging Standards

• Various Messaging Standards exists on current
  communication protocols SOAP, ebXML messaging,
  EDI
• The communicating applications on both sides
  should support the same messaging standard
• Extracting the message payload
• Handling the Headers

SOAP
ebXML Messaging
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Communicating through Web Services
Processing
Processing
Transmitting
HL7- I12
Patient Referral Web Service
HL7- I12
ltpatientgt
ltpatientgt
ltidgt
lt/idgt
ltidgt
lt/idgt
12345
ltnamegt
ltnamegt
Ilias
lt/namegt
lt/namegt
ltsurnamegt
ltsurnamegt
Iakovidis
11011010
lt/surnamegt
lt/surnamegt
lt/patientgt
lt/patientgt
HTTP over TCP/IP
12345
Ilias
Iakovidis
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EHR Content Interoperability

• There are several standards development efforts
  such as
• Health Level 7 (HL7) Clinical Document
  Architecture (CDA)
• CEN EN 13606 EHRcom
• openEHR
• These standards aim to structure and markup the
  clinical content for the purpose of exchange

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GEHR/openEHR Initiative

• This approach uses a two-level methodology to
  model the EHR structure
• In the first level, a generic reference model
  that is specific to the healthcare domain is
  developed and contains only a few classes (e.g.
  role, act, entity, participation)
• In the second level, healthcare and application
  specific concepts such as blood pressure, lab
  results etc. are modeled as archetypes, that is,
  constraint rules that specialize the generic data
  structures that can be implemented using the
  reference model
• EN 13606-2 will be based on Archetypes

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CEN/TC 251 and ENV/EN 13606 EHRcom

• A message-based standard for the exchange of
  electronic healthcare records.
• It consists of five parts
• The Reference Model,
• Archetype Interchange Specification,
• Reference Archetypes and Term Lists,
• Security Features, and
• Exchange Models (communication protocol).

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HL7 Clinical Document Architecture (CDA)

• CDA is organized into three levels where each
  level iteratively adds more structure to clinical
  documents
• Level One focuses on the content of narrative
  documents with high-level context such as
  parties, roles, dates and time, places and
  structural organization of headings
• Level Two models the fine-grained observations
  and instructions within each heading through a
  set of RIM Act classes
• Level Three specifies semantics each information
  entity by a unique code which enables machine
  processing

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IHE Cross-Enterprise Document Sharing (XDS)

• There is also an industry initiative called
  Integrating the Healthcare Enterprise (IHE) which
  specified the Cross-Enterprise Document Sharing
  (XDS) integration profile for this purpose
• The basic idea of IHE XDS is to store healthcare
  documents in an ebXML registry/repository
  architecture to facilitate their sharing
• IHE XDS handles healthcare documents in a content
  neutral way

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IHE Cross-Enterprise Sharing of Medical Summaries
(XDS-MS)

• XDS-MS is a mechanism to automate sharing of
  Medical Summaries between care providers.
• Medical Summary Types episodic care,
  collaborative care and permanent care
• Specifies content as HL7 CDA and Care Record
  Summary (CRS)

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IHE Retrieve Information for Display (RID)

• RID provides a simple and rapid read-only access
  to patient-centric clinical information that is
  located outside the user's current application
• Supports access to documents with CDA Level One,
  PDF and JPG formats
• It is defined as a Web service by providing its
  WSDL description with a binding to HTTP GET

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Summary of EHR Standards
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Summary of EHR Standards
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OTHER ISSUES IN EHR INTEROPERABILITY

• For EHR interoperability, further technical
  issues that must also be addressed include
• Mapping the patient identifiers among different
  healthcare applications
• Authenticating the users across the enterprises
• Guaranteeing that all the computers involved have
  consistent time
• Authenticating Nodes and Obtaining Audit Trail

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eHealth Interoperability in USA
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eHealth Interoperability in Canada
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eHealth Interoperability in Australia
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eHealth Interoperability in some of the EU member
states
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eHealth Interoperability in some of the EU member
states
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eHealth Interoperability in some of the EU member
states
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eHealth Interoperability in some of the EU member
states
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eHealth Interoperability in some of the EU member
states
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What Lies Ahead

• The RIDE (http//www.srdc.metu.edu.tr/webpage/proj
  ects/ride/) Project is addressing these issues to
  propose possible alternatives
• It will prepare a roadmap for the technical
  interoperability of eHealth systems
• Please stay tuned

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Thank you very much for your attention

• Any Questions?