Healthcare IT Interoperability: An Introduction and Technical Discussion

This presentation, given during the inaugural gathering of the Healthcare Interop Boston Meetup group, took a deep dive into the exciting and burgeoning realm of healthcare IT interoperability.

Group organizer and veteran software consultant David Vaccaro, in collaboration with the Cambridge Innovation Center, introduced attendees to the current landscape of healthcare interoperability while also venturing far down the path of various core standards including DICOM, XDS-I and FHIR.

The resulting discussion framed the group concept while also provided an opportunity to socialize and share related healthcare IT experience and technical information.

Transcript

1. Healthcare IT Interoperability: An Introduction and Technical Discussion 2018 A General Overview of Healthcare Interoperability Standards
2. Host: Cambridge Innovation Center CIC works with powerful, local partners to develop the critical networks that entrepreneurs need to grow effectively. For almost two decades, we have focused on strengthening vibrant communities, building collaborative work environments, and creating impactful programming to attract and support the very best entrepreneurs and their teams. • Founded in 1999 by MIT graduates Timothy Rowe and Andrew Olmsted • Headquartered in Kendall Square • Housed Hubspot, MassChallenge, GreatPoint Energy and Google Android. • Kendall Square space has grown from 2700 to 90,000 square feet of innovation space! • Locations in Boston, Miami, Philadelphia, St. Louis and Rotterdam About CIC  Coordinator: Kat Lazell
3. Organizer: David Vaccaro Veteran principal software consultant with over 20 years of professional software development experience including 16 years providing direct development consultation on a range of software development projects with a primary focus on healthcare.  dvaccaro@xinonix.com  www.linkedin.com/in/david-vaccaro  github.com/davidvaccaro • SaaS Clinical Trial Management Software • DICOM Medical Image Management Software • DICOM Teleradiology Management Software • Medical Billing Management and Interfacing Software • Anesthesia Quality Reporting (AQI – QCDR – NACOR) • Post-approval Clinical Trial Registry Infrastructure (EDC/ETL, E2B Safety Reporting) • Intellectual and Developmental Disabilities Management Platform (SIS - Public Health) Experience Committee Participation • IHE IT Infrastructure Technical Committee (ITI-51 “Patient Only Query” Option) • IHE Radiology Technical Committee
4. Concept: Healthcare Interop Boston Let's use this group to regularly meet, share and socialize our experience and knowledge of Healthcare IT technologies and interoperability standards through:  Single presenter, long presentation (Junto-style) meetings  Multiple presenter short fixed length talks (Lightening-style) meetings  Mini-connectathon meetings  Hackathon meetings  Everything in-between! Healthcare Information Technology and Interoperability  A vast and highly complex IT space  Growing rapidly particularly interoperability standards  Capable of improving patient outcomes, eliminating redundancy and reducing costs
5. Healthcare Information Stakeholders Hospitals Surgical Centers Healthcare Information Physician Practices Diagnostic Centers Pharmacies Nursing Home Rehab Centers Medical Billers Insurers Clinics Specialist Practices Home Care Community Health Support Government Universities Disease Registries Standards Organizations Life Sciences Industry Primary Stakeholders of an Integrated Healthcare Information System
6. Hospital Information Component Sub-Systems Vendor Neutral Archive (VNA) Radiology Information System (RIS) Electronic Medical/Health Records System (EMR/EHR) Oncology Information System (OIS) Cardiovascular Information System (CVIS) Patient Monitoring Systems (central, bedside, fetal) Hospital Management System (HMS) Pharmacy Information System Patient Administration System (PAS) Scheduling System Picture Archiving and Communication System (PACS) Imaging Modalities (CT, MRI, MII,PET, Ultrasound, X-ray) Medical Imaging Workstations Enterprise Master Patient Index (EMPI) Provider Portal Laboratory Information Management System (LIMS) Practice Management (PM) Third Party Interfaces Patient Portal A Selection of Common “Department Oriented” Hospital Information Sub-Systems
7. Interoperability: For Systems Integration “The process of bringing together component sub-systems into one aggregated, cooperative, overarching system.” Some Examples:  Integration of Radiology Content (from RIS/PACS/VNA or outside imaging center) with EHR/EMR/HIS or HIE  Integration of Billing Content with Third Party Medical Billing Provider and/or payers  Integration of Lab Data, Report Content , Orders (from LIS or outside laboratory) with EHR/EMR/HIS or HIE Some Standards/Technologies Used:  HL7 V2 Messages (feed-oriented)  ADT – Admit, Discharge, Transfer  ORM – Order  ORU – Observation Result  DFT – Detailed Financial Transaction  MLLP – Minimum Lower Layer Protocol  CDA – Clinical Document Architecture (HL7 V3)  CCD – Continuity of Care Document (HL7 V3)  XDS-I – Cross Enterprise Document Sharing for Imaging (service-oriented)  RIM – Registry Information Model (OASIS ebXML)  DICOM – Digital Imaging and Communications in Medicine  HTTP/SOAP
8. System Integration Example: Billing Interface Billing Interface Source Healthcare Facility Feed MLLP/ SFTP Insurance Claims Clearinghouse MSH|^~\&|SENDING_APP|SENDING_FAC|RECEIVING_APP|RECEIVING_FAC|20110613072049||ADT^A08|934579920110613072049|P|2.3|||| EVN|A08|20110613072049||| PID|1||135769||MOUSE^MICKEY^||19281118|M|||123 Main St.^^Lake Buena Vista^FL^32830||(407)939-1289^^^theMainMouse@disney.com||||| PV1|1|O|||||7^Disney^Walt^^MD^^^^||||||||||||||||||||||||||||||||||||||||||||| GT1|1|78|MOUSE^MARSHALL^||123 Main St.^^Lake Buena Vista^FL^32830|(407)939-1289^^^^^^||19190101|M|||||||||||||||||||||||||||||||||||||||||||||| IN1|1||1|ABC Insurance Medicaid|P O Box 12345^^Atlanta^GA^30348|Claims^Florida |(555)555-1234^^^^^^|G1234|||||||G|Mouse^Mickey|SELF| IN2||||||ZYX1234589-1||||ZYX1234589-1|||||||||||||||000079||||||||||||||||||||||||||||||||||||||(206)446-5080^^^^^260^4465080|||||||||SELF Paper Record Paper Record Paper Record (PDF) HL7 ADT + Document Management System Paper Record (PDF) Paper Record (PDF) Paper Record (PDF) Submit Feed MLLP/ SFTP HL7 ADT HL7 DFT +
9. Interoperability: For Reusable Platforms “Platforms are composed of open standards, open source tools for developers building apps, and a publicly accessible app gallery. “ Some Examples (from http://apps.smarthealthit.org/ ):  Patient or Provider Portal Radiology Viewing Application/Components  Patient Data Aggregated Viewing Application Integration  Cardiac Risk Assessment App  Bilirubin Chart Visualization App  Chest Pain Visualization Assessment App  Any Telemedicine App Some Standards/Technologies Used:  HL7 FHIR  OAUTH2  CDA – Clinical Document Architecture (HL7 V3)  CCD – Continuity of Care Document (HL7 V3)  DICOM – Digital Imaging and Communications in Medicine  HTTP/REST
10. Reusable Platform Example: DICOM Viewing SMART App Picture Archiving and Communication System (PACS) Enterprise Master Patient Index (EMPI) Electronic Health Records System (EHR) Radiology Information System (RIS) FHIR/REST-based Interoperability Layer FHIR Document Reference FHIR Imaging Study FHIR Document Manifest WADO-URI WADO-RS FHIR Patient
11. Standards Organizations: Standard Creators National Institute of Standards and Technology (NIST) • Weights and Measures • Too many standards to list Health Level 7 International (HL7) • HL7 V2 (ADT, ORU, DFT) , HL7 V3 (CDA, CCD), FHIR, MLLP National Electrical Manufacturers Association (NEMA) • DICOM – Digital Imaging and Communications in Medicine • DICOMweb – Standard for REST-based DICOM transactions International Health Terminology Standards Development Organization (IHTSDO) • SNOMED CT - Systematized Nomenclature of Medicine (Clinical Terms) International Standards Organization (ISO) • Names, Date and Time formats, Country and Language codes • Too many standards to list! Regenstrief Institute, Inc. • LOINC – Logical Observation Identifiers Names and Codes Organization for the Advancement of Structured Information Standards (OASIS) • RIM – ebXML Registry Information Model • RS – ebXML Registry Services Specification • SAML, PKCS, WS-Context, Internet Engineering Task Force (IETF) • TCP/IP, DNS, FTP, SSH, UUID (pretty much everything undergirding the net) International Telecommunication Union • OID – Object Identifiers
12. Standards Organizations: Standard Coordinators & Promoters Integrating the Healthcare Enterprise (IHE) • Cardiology • Dental • Eye Care • IT Infrastructure (ITI)  Audit Trail and Node Authentication (ATNA)  Basic Patient Privacy Consents (BPPC)  Consistent Time (CT)  Cross-Community Access (XCA)  Cross-Community Patient Discovery (XCPD)  Cross-Enterprise Document Repliable Interchange (XDR)  Cross-Enterprise Document Sharing (XDS.b)  Cross-Enterprise Sharing of Scanned Documents (XDS-SD)  Multi-Patient Queries (MPQ)  Patient Demographics Query (PDQ)  Patient Identifier Cross-Referencing (PIX) • Pathology and Laboratory Medicine • Patient Care Coordination • Patient Care Devices • Pharmacy • Quality, Research and Public Health • Radiation Oncology • Radiology (RAD)  Cross-Enterprise Document Sharing form Imaging (XDS-I.b) Healthcare Information and Management Systems (HIMSS) Radiological Society of North America (RSNA)
13. IHE Connectathon North America
14. Questions So Far?
15. Cross-Enterprise Sharing of Diagnostic Documents and Imaging An Overview of Diagnostic Document and Imaging Standards Including XDS.b, XDS-I.b, MDH/FHIR, WIA/DICOMweb
16. Cross-Enterprise Document Sharing for Imaging Document and Image Sharing Infrastructure Query Consumer Source Provide Diagnostic Information Sharing Primary Actors Retrieve Report This is some report details so that this fake report looks Image Report This is some report details so that this fake report looks Image
17. Cross-Enterprise Document Sharing Profile (XDS.b) Document Source Document Registry Document Repository Document Consumer Patient Identity Source Provide Register Feed Query Retrieve IHE XDS.b Actors and Transactions
18. Cross-Enterprise Document Sharing Profile (XDS.b) Document Source Document Registry Document Repository Document Consumer Patient Identity Source Provide Register Feed Query Retrieve IT Infrastructure (ITI) Domain Technical Framework Designations ITI-41 ITI-42 ITI-18 ITI-43 ITI-8
19. Cross-Enterprise Document Sharing for Imaging Profile (XDS-I.b) Imaging Document Source Document Registry Document Repository Imaging Document Consumer Patient Identity Source Provide Register Feed Query Retrieve (KOS Manifest) IT Infrastructure (ITI) and Radiology (RAD) Domain Technical Framework Designations RAD-68 ITI-42 ITI-18 ITI-43 ITI-8 Retrieve (DICOM Image) RAD-55 / RAD-69
20. RAD-68 - Provide and Register Imaging Document Set - MTOM/XOP (XDS-I.b) Imaging Document Source Document Repository XDS-I.b Repository Submission including CDA Documents and KOS Manifest RAD-68 Provide and Register Imaging Document Set SOAP Message Transmission Optimization Mechanism/XML-binary Optimized Packaging (HTTP POST - RFC1341 MIME Multipart Content Type) ebXML KOS Manifest (DICOM) CDA (XML) CDA (XML) DICOM Storage
21. Electronic Business using eXtensible Markup Language (ebXML) XDS-I.b Repository Submission Metadata - ebXML Backbone - Domain Specific Data ebXML RIM/RS/LCM 2.0 OASIS ebXML Neutral Backbone - Registry Information Model - Registry Service Specification - Life Cycle Manager Interface Domain Specific Value Data -HL7 (Composite ID - CX, XCN, DTM, etc.) - Logical observation Identifiers Names and Codes (LOINC) - Object Identifiers (OID) - IHE Metadata Code Values
22. DICOM Key Object Selection Manifest (DICOM KOS / SR) DICOM Structured Report (SR) Identifying a Set of DICOM Instances DICOM Key Object Selection (KOS) Manifest / DICOM Structured Report (SR)
23. HL7 Clinical Document Architecture (CDA) CDA Document – Structured or Wrapped – Plain Representation or Encoded (Base64) CDA Structured Document – Wrapped Document – Raw, Plain Text and PDF Encoded
24. XDS-I.b with Cross-Enterprise Document Reliable Interchange Profile (XDS-I.b / XDR) Imaging Document Source Document Registry Document Repository Imaging Document Consumer Patient Identity Source Provide Register Feed Query Retrieve (KOS Manifest) IT Infrastructure (ITI) and Radiology (RAD) Domain Technical Framework Designations RAD-68 ITI-42 ITI-18 ITI-43 ITI-8 Retrieve (DICOM Image) RAD-55 / RAD-69 Document Recipient Provide ITI-41 DICOM Storage
25. Mobile Access to Health Documents Profile (MHD) Document Sharing Infrastructure Find Document Responder Document Consumer Document Recipient Retrieve Document Source Provide IHE MHD Actors and Transactions
26. Mobile Access to Health Documents Profile Paired with XDS.b (MHD / XDS.b) XDS.b Document Registry XDS.b Document Source XDS.b Document Repository XDS.b Document Consumer Patient Identity Source Provide Register Feed Find Retrieve MHD Document Responder MHD Document Consumer Query MHD Document Recipient Retrieve MHD Document Source Provide IT Infrastructure (ITI) Domain Technical Framework Designations ITI-18 ITI-43 ITI-8 ITI-41 ITI-67 ITI-68 ITI-65 ITI-42
27. Mobile Access to Health Documents Profile - XDS.b on FHIR (MHD / FHIR / XDS.b) XDS.b Document Registry XDS.b Document Source XDS.b Document Repository XDS.b Document Consumer Patient Identity Source Provide Register Feed Find Retrieve MHD Document Responder MHD Document Consumer Query MHD Document Recipient Retrieve MHD Document Source Provide IT Infrastructure (ITI) Domain Technical Framework Designations - FHIR Resources ITI-18 ITI-43 ITI-8 ITI-41 ITI-67 DocumentReference DocumentManifest ITI-68 Binary ITI-42 ITI-65 DocumentReference DocumentManifest Binary
28. Mobile Access to Health Documents for Imaging With XDS-I.b on FHIR (MHD / FHIR / XDS-I.b) XDS.b Document Registry XDS-I.b Imaging Document Source XDS.b Document Repository XDS.b Document Consumer Patient Identity Source Provide Register Feed Find Retrieve MHD Document Responder MHD Imaging Document Consumer Query MHD Document Recipient Retrieve MHD Document Source Provide IT Infrastructure (ITI) and Radiology (RAD) Domain Technical Framework Designations - FHIR Resources ITI-18 ITI-43 ITI-8 ITI-41 ITI-67 DocumentReference DocumentManifest ITI-68 Binary ITI-42 ITI-65 DocumentReference DocumentManifest Binary Retrieve Imaging Find Imaging ITI-??? ImagingManifest ImagingStudy RAD-55 / RAD-107 WADO-URI WADO-RS
29. Fast Healthcare Interoperability Resources DocumentReference Resource (FHIR) FHIR DocumentReference Resource FHIR DocumentReference Resource FHIR Attachment - MIME Type of Document Content - FHIR Binary Resource Reference
30. Fast Healthcare Interoperability Resources ImagingStudy Resource (FHIR) FHIR ImagingStudy Resource FHIR ImagingStudy Resource DICOM Identifiers - StudyInstanceUID - SeriesInstanceUID - SOPInstanceUID - SOPClassUID
31. Web-based Image Access Profile (WIA) Imaging Document Sharing Infrastructure Query Imaging Document Responder Imaging Document Consumer Imaging Document Source Retrieve Actors and Transactions
32. Web-based Image Access Profile (WIA) Imaging Document Sharing Infrastructure Query Imaging Document Responder Imaging Document Consumer Imaging Document Source Retrieve Radiology (RAD) Domain Technical Framework Designations RAD-107 WADO-RS RAD-129 QIDO-RS
33. Web Access to DICOM Objects (WADO) Overview (WADO-URI / WADO-RS) Imaging Document Consumer Imaging Document Source Retrieve WADO Parameter and Action Details RAD-55 WADO-URL WADO-URI Parameters - studyUID - seriesUID - objectUID - contentType - charset - anonymize - annotation - rows - columns - region - windowCenter - windowWidth - frameNumber - imageQuality - presentationUID - presentationSeriesUID - transferSyntax WADO-RS Parameters - annotation (patient, technique) - charset - quality - viewport (vw, vh) - window (center, width, shape) RAD-107 WADO-RS WADO-RS Actions - Retrieve Study http://location/studies/studyUID - Retrieve Series http://location/studies/studyUID/series/seriesUID - Retrieve Instance http://location/studies/studyUID/series/seriesUID/instances/instanceUID - Retrieve Frames http://location/studies/studyUID/series/seriesUID/instances/instanceUID/frames/frameList - Retrieve Study Metadata http://location/studies/studyUID/metadata - Retrieve Series Metadata http://location/studies/studyUID/series/seriesUID/metadata - Retrieve Instance Metadata http://location/studies/studyUID/series/seriesUID/instances/instanceUID/metadata - Retrieve Bulk Data http://lbulkdataURL
34. Query based on ID for DICOM Objects (QIDO) Overview (QIDO-RS) Imaging Document Consumer Imaging Document Responder Retrieve QIDO Parameter and Action Details QIDO-RS Parameters - annotation (patient, technique) - query - limit - offset RAD-129 QIDO-RS QIDO-RS Actions - Search for Studies http://location/studies?query - Search for Series http://location/studies/studyUID/series?query http://location/series?query - Search for Instances http://location/studies/studyUID/series/seriesUID/instances?query http://location/studies/studyUID/?query http://location/instances?query
35. DocumentReferenceInteractor .Composer() .baseUrl("http://..../fhir-server/") .setParameter("identifier", patientId) .setStatus(DocumentReference.Status.CURRENT) .compose() .search(new retrofit2.Callback<Bundle>() { @Override public void onResponse(Call<Bundle> call, Response<Bundle> response) { // TODO – Process the Bundle of DocumentReferences } }); https://github.com/davidvaccaro/RetroFHIR https://github.com/davidvaccaro/GsonFHIR
36. Healthcare IT Interoperability: An Introduction and Technical Discussion 2018 An Overview of General Healthcare Interoperability and Standards