ESP SDK Conceptual Architecture 1011-10-18 DRAFT - OSEHRA

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ESP SDK Conceptual Architecture 1011-10-18 DRAFT - OSEHRA Powered By Docstoc
					       CALL FOR PARTICIPATION
Please post your discussion comments at
http://www.osehra.org/group/architecture

This DRAFT document is a
 Request for Information
          (RFI)


      EHR Modernization                                -   Conceptual Architecture
   EHR Services Platform (ESP)                         - Software Development Kit (SDK)
              Open Source EHR Custodial Agent (OSEHRA) Architecture Committee
                                Stephen Hufnagel PhD, Chair

                                        In collaboration with
                          Health Architecture Interagency Group (HAIG)
              Nancy Orvis, MHA, CPHMS and Paul Tibbits, M.D., DoD and VA Co-Chairs

Current 180+ slide set Conceptual Architecture SDK and companion Implementation Guide (IG) is available at:
                             http://www.osehra.org/node/47/content/documents

                                       October 18, 2011 DRAFT-N
   ESP SDK                              WORKING DRAFT RFI: not for official use.                        1
 Preface
In March 2011, VA Secretary Eric Shinseki and DOD Secretary Robert Gates agreed on a common Electronic Health Record
(EHR) technical architecture, data and services and exchange standards for the joint integrated EHR system, where the joint
EHR will include both proprietary and open source software. The secretaries of the Veterans Affairs and Defense Departments
met on May 2 and June 30, 2011 to determine their next steps toward developing a common EHR..
“VA is developing an open source track to modernize VistA and will incorporate the approach in the joint EHR", Shinseki said.
“One of my objectives is to have minimal disruption in the hospitals as we evolve from VistA to the joint EHR system What I think
you will see us do is replace modules, do incremental upgrades.” … “In five or 10 years, there may not be one line of code left
from VistA. And in my ideal world, the users will have no idea that I have made any changes,” VA Secretary Eric Shinseki said.
“Our goals are to bring in as many private sector modules as possible and selecting the same thing to run between VA and DOD
so that we end up with a single, common electronic health record system,” Roger Baker, VA CIO said. OSEHRA sees private
modules including both open source or commercial; OSEHRA intends to foster innovation at the module level and encourages
Darwinian selection among competing modules based on cost, performance and support preferences.
 "We planned, as part of this EHR framework, to release all the documents, architecture, all these things. It will no longer be,
'you figure it out, you tell us a solution,'" said Col. Hon Pak, the Army medical department's chief information officer. "The open-
source custodial agent, largely a VA-led effort but we also participate, really gives you an opportunity in ways that we've never
had before." … "Having that venue now equalizes the playing ground so that small, innovative organizations can come and help
us figure things out." said Pak. Opening the door to nimble, innovative technologies is a core focus for Pak, who said “DoD is
looking for more modular capabilities.” All the Services "have pretty much bet the farm" that patient-centered medical home will
change healthcare, but he said they need the right tools to get there. "This idea around [health information exchange],
telehealth, mobile health, patient-centered medical home are really going to be the necessary ingredients that have to be
formulated to drive some of the transformation," Col. Pak said.
 This Software Development Kit (SDK) specifies the EHR Services Platform (ESP) to implement the vision expressed above .
                                                                                                                                       2
  ESP SDK                                        WORKING DRAFT RFI: not for official use.                                              2
  Executive Summary
                                                                  SAIF
                                                (Service Aware Interoperability Framework)
                                                   Conceptual Perspective
                                               EHR Services Platform
                                               SDK Scope
                                               Business Context
                                               Clinical/Work Process Architecture
                                               System Architecture
                                               Information Architecture
                                               Integration & Deployment Options
                                               Potential Applications
                                               Summary & Conclusion

                                                      Also See Companion
                                                    SAIF Logical Perspective
                                                   Implementation Guide (IG)



ESP SDK        WORKING DRAFT RFI: not for official use                                 3
    TALKING POINTS: SDK Purpose
    ESP enabled systems are a part of a joint DoD-VA Open Source EHR (OSEHR) Initiative


• The ESP Software Development Kit (SDK) presents the vision (this slide deck) and specifies
  the means (see the companion ESP Implementation Guide (IG)) for Open Source and vender
  applications to plug-&-play within future-state ESP enabled operating and data-access
  platforms; ESP enabled systems are composed of “information” services supporting efficient
  plug-&-play application-integration.

• The SDK development, following agile processes, is intended to become a clear, complete,
  concise, correct and consistent HL7 SAIF (Service Aware Interoperability Framework)
  conformant standards-based ESP enabled system SDK IG for vender and open-source
  developers.

• This comprehensive set of slides may be freely used or repurposed with appropriate attribution

     YOUR HELP IS REQUESTED IN VERIFYING, VALIDATING AND INCREASING THE
                         USABILITY OF THE ESP SDK
                                                                                             4
    ESP SDK                         WORKING DRAFT RFI: not for official use.                 4
       A five-color star “branding”
       indicates that a slide was
       adapted from Canada Health
       Infoway’s EHR Blueprint


                            ACKNOWLEDGEMENT

  This ESP SDK started with the Canada Health Infoway “Electronic Health
Record Blueprint” as a foundation; the SDK is being adapted to meet the Open
              Source EHR modernization situation and needs.

   https://www.infoway-inforoute.ca/working-with-ehr/knowledgeway/knowledge-center/657


   ESP SDK                       WORKING DRAFT RFI: not for official use.                5
                      DISCLAIMER
         THIS DRAFT SDK IS NOT LEGALLY BINDING
  AND DOES NOT REPRESENT OFFICIAL DOD OR VA POSITION.
• The DoD and VA wish to openly-and-transparently collaborate with the Open-Source EHR-Community;
  this is a new “agile acquisition” approach for the government and MUST evolve with lessons learned.
• This SDK, its companion Implementation Guide (IG) and related artifacts are DRAFT Working
  Documents, being coordinated by the Open Source EHR Custodial Agent (OSEHRA) Architecture
  Committee with the guidance of the DoD-VA Health Architecture Interagency Group (HAIG). The purpose
  is to seek EHR-modernization architectural-input from DoD & VA staff, contractors, partners,
  stakeholders, venders and open-source-community in an open-and-transparent collaborative-forum;
• The DRAFT Software Development Kit (SDK), its IG and any related documents MUST be considered a
  government Request for Information (RFI); without obligation to the government as we go through this
  new open-and-transparent agile-development-process;
• Once feedback has been received, OSEHRA Architecture Committee’s updates have been made and
  the SDK has been reviewed and approved by appropriate government leadership, DRAFT can be
  removed from the SDK and its IG and they will be versioned, time-stamped and an official government
  letter of endorsement MUST be attached.
        Only an official government-endorsed-and-versioned SDK, its IG and related artifacts
                  can be used in any government contract or acquisition process.

                                                                                                    6
    ESP SDK                            WORKING DRAFT RFI: not for official use.                     6
Technical Vision: EHR Service Platform (ESP)

                             INTEGRATED EHR SOLUTION


                          EHR SERVICES PLATFORM (ESP)

                                                                                      EHR IS
           Population            Population                                           Locator
                                   Health             EHR                Registries
             Health
                                   Data &            Data &               Data &
             Data &
                                  Services          Services             Services
            Services




           Information Access & Longitudinal Record Services (LRS)



                           EHR Information Services (EHR IS)




              Point of Service           Personal Health
                                                                     EHR Viewers
               Applications              Record Systems




 ESP SDK                               WORKING DRAFT RFI: not for official use.       See notes page   7
    TALKING POINTS: Technical Vision is to modernize and transition
    legacy to an EHR Services Platform (ESP) for Application Integration
•   An EHR Services Platform (ESP) facilitates application innovation; it is composed of
    separated operation, business-rule and information services to integrate plug-&-play
    applications; the ESP services MUST be used by ALL applications and ALL
    applications MUST be service-based.
•   As the ESP is fully-specified in the SDK Implementation Guide (IG), as standardized
    and reference implementations become available; then, general-purpose and domain-
    specific “best-of-class” certified applications can be user-selectable and evolve on a
    Darwinian basis. This is analogous to a Smart-Phone Application-Markets
•   Anyone can build and submit ESP services and/or applications for certification
•   The Open Source EHR Custodial Agent (OSEHRA) will IV&V and CM certified ESP
    application services and reference-implementations (e.g., gold builds).
•   DoD, VA, IHS and others may pick-&-choose, which certified applications they use.
•   Legacy-systems and ESP enabled systems can co-exist during long legacy transition
    periods across large enterprises. This is analogous to the PC and telecommunications
    evolution-revolution from the 1980s to now.                                           8
      ESP SDK                      WORKING DRAFT RFI: not for official use.             8
 Key Concepts: Federated EHR Services Architecture
                                                                                                     EHR IS         EHR IS
                                                                                                     Enabled       Enabled
                                 INTEGRATED EHR SOLUTION                                          Legacy System   PHR System



                               EHR SERVICES PLATFORM (ESP)                                                 EHR IS


                                                                                                     EHR IS       ESP Based
  Tier 3       Population            Population
                                                              EHR                  Registries
                                                                                                     Locator       System
Plug-&-Play
                 Health                Health
                                       Data &                Data &                 Data &
                 Data &
                                                            Services               Services
Data Stores     Services              Services




                                                                                  EAI IP

                                                                                                      Data Access
  Tier 2       Information Access & Longitudinal Record Services (LRS)
                                                                                                     Services Layer
    EHR
Information                    EHR Information Services (EHR IS)
  Services
                      EHR IP                       EHR IP                         EHR IP
                                                                                                       Application
                                                                                                      Services Layer
  Tier 1          Point of Service            Personal Health
Plug-&-Play        Applications               Record Systems
                                                                             EHR Viewers

Applications

                               IP is SOA Interoperability Profile aka Service Interface
                                      EAI is Enterprise Application Integration


  ESP SDK                            WORKING DRAFT RFI: not for official use.                   See notes page         9
 TALKING POINTS: Benefits
    The ESP can become the National and possible International EHR
     standard for “best-of-breed” Darwinian innovation, evolution or
                revolution where anyone can participate.
The SDK’s Standards-Based Best-Practices ensure consistency across:
   – Interoperable Application Service APIs
       • Common/ Engineering Service Bus (C/ESB)
       • Interoperable Plug-and-Play Applications
   – Interoperable Virtual Database (DB) APIs scalable from
       • Legacy MUMPS-globals acting as a DB to MS Access, Open or MS SQL, Oracle to
       • Massively-parallel high-performance grids running on commodity-hardware-blade-platforms
         (i.e., amazon.com & google.com models).
   –   ESP enabled Trading Partners
   –   Acquisitions (ESP SDK-IG as GFI for RFIs and RFPs)
   –   VA, DoD and IHS offices, staff and contractors
   –   Open Source and vender community

                                  D R A F T Talking Points                                         10
   ESP SDK                           WORKING DRAFT RFI: not for official use.
Legacy Transition Strategy


             INTEGRATED EHR SOLUTION                                                                                    LEGACY EHR SYSTEM

       EHR SERVICES PLATFORM (ESP)                                                                   EHR-IS ENABLED LEGACY INFRASTRUCTURE

Population               Data                                                                          Legacy                  Data
                                            EHR                 Registries                                                                        EHR
  Health              Warehouse                                                                                             Warehouse                                 Personal
  Data &
 Services
                        Data &
                       Services
                                           Data &
                                          Services
                                                                 Data &
                                                                Services
                                                                                                       Point of
                                                                                                       Service
                                                                                                                              Data &
                                                                                                                             Services
                                                                                                                                                 Data &
                                                                                                                                                Services            Health Record
                                                                                                                                                                      System
                                                                                                                                                                                    Legacy
                                                                                                      Application
                                                                                                                                                EAI IP


    Information Access & Longitudinal Record Services (LRS)                                               Information Access & Longitudinal Record Services (LRS)
                                                               EAI IP                  EHR-IS                                                                       EAI IP

                EHR Information Services (EHR IS)                                   Bi-Directional                    EHR Information Services (EHR IS)
                                                                                                                                                                                    EHR-IS
                                                                                     Information
                                                                                      Exchange
     EHR IP                      EHR IP                        EHR IP


     Point of                   Personal
     Service                  Health Record                   EHR Viewer
    Application                 Systems


          EAI is Enterprise Application Integration
                                                                                                      EHR-IS enabled legacy systems allow users to
 IP is SOA Interoperability Profile aka Service Interface                                            transition at a convenient time and then legacy
                                                                                                          systems can be gracefully shut down.




 ESP SDK                                                                     WORKING DRAFT RFI: not for official use.                                                                 11
TALKING POINTS: Transition Strategy based on ESP enabled systems
1. ESP kernel-services and data stores CAN be set-up at one-or-more data-centers (any cloud topology).
2. For pre-certification self-testing and attestation, venders and developers MUST be provided: i) SDK-IG,
   ii) an open-source test virtual-machine (VM) with the ESP set-of operating-and-data services, iii)
   clinically-meaningful test-database, test-scripts, certification-criteria.
   A. Agile SDK, ESP and application development and certification processes MUST have up-to-date
       VMs and ongoing regression testing to obtain/maintain “certified” status.
   B. Certified applications, test and certification VMs, test fixtures/scripts, test-results MUST be made
       available to anyone (e.g., open source community) to verify and validate test results & attestations.
3. One-or-more user-configurable ESP enabled viewers SHOULD be made freely available.
4. Legacy systems MUST be updated i) to “journal” their clinically-relevant data-store transactions with
   the ESP data-store and to query via the ESP, analogous to legacy “BHIE” DoD-VA sharing;
5. Terminology mapping SHOULD be a part of legacy-data transition.
6. To be repurposed to ESP capability, legacy-applications MUST conform to ESP SDK-IG and associated
   certification criteria.
7. Once certified ESP enabled viewer(s) and ESP enabled applications are available to clinical users, they
   CAN transition to modernized ESP based systems, while others might continue on legacy systems.
8. Clinically-meaningful legacy-data MUST be extracted to ESP before legacy systems are shut down.


                                                                                                        12
     ESP SDK                             WORKING DRAFT RFI: not for official use.                      12
     EHR Information Services (EHR IS)
     within EHR Services Platform (ESP)
EHR SERVICES PLATFORM (ESP)                                                                                                                    ORGANISATIONAL INFOSTRUCTURE

    Registries Data                     Population Health Data                                                         EHR Data                                               Data Warehouse
      & Services                             & Services                                                                & Services                                               & Services

        Client
       Registry                  Outbreak                   PHS                     Shared                   Drug              Diagnostic                                        Health
                                                                                                                                                    Laboratory
                                Management                Reporting              Health Record           Information            Imaging                                       Information
       Provider
       Registry


       Location
       Registry                             Business           EHR           Message             Normalization
                                             Rules            Index          Structures             Rules

     Terminology                                                       Information Access & Longitudinal Record Services (LRS)
       Registry

                                 IP is SOA Interoperability Profile aka Service Interface
                   EAI IP                                                                                                 Security Mgmt      Privacy Mgmt     Configuration     EAI IP
                                        EAI is Enterprise Application Integration
                                                                                                                           Rules/Data         Rules/Data       Rules/Data

                                                                      Common Information Integration Framework (CIIF) and Common Services
         EHR IS
                                                                                           Secure Communications Bus


                      EHR IP                     EHR IP                 EHR IP                     EHR IP                 EHR IP                  EHR IP                 EHR IP


                                                                       Radiology
                   Public Health                 Pharmacy                                        Lab System             Hospital, LTC,            Physician
                                                                        Center                                                                                          EHR Viewer
                     Services                     System                                            (LIS)                CCC, EPR                Office EMR
                                                                       PACS/RIS




                            Public Health              Pharmacist            Radiologist               Lab Clinician            Physician/             Physician/                Physician/
                              Provider                                                                                           Provider               Provider                  Provider
POINT OF SERVICE APPLICATIONS
      ESP SDK                                                           WORKING DRAFT RFI: not for official use.                                       See notes page                    13
   TALKING POINTS: Common Information Integration Framework (CIIF)



• The Common Information Integration Framework (CIIF) is a business-driven
 agile enterprise-information-management methodology and set of software-
 service technologies, which enable semantic interoperability of clinical data.
• The CIIF Team specifies or imposes a standards-based set of information
 services that enables any authorized empowered provider to care for any
 beneficiary regardless of location, organization or device.




                                                                                           14
   ESP SDK                    WORKING DRAFT RFI: not for official use.   See notes page   14
ERH Services Platform (ESP) enabled system (conceptual view)




                                                                                        15
   ESP SDK                  WORKING DRAFT RFI: not for official use.   See notes page    15
     TALKING POINTS: EHR Services Platform (ESP)
     Addressing Legacy Problems
1.   Innovation to revitalize legacy systems
     • Services within a standards-based component-architecture encourage lower-cost component innovation without
       requiring enterprise-wide expertise and extensive testing. SDK empowers individuals and avoids stovepipes.
2.   Interoperability among partners.
     • CIIF canonical information and terminology models can be used to map among heterogeneous system
       information exchanges. By adopting common EHR IS data, terminology, and communications standards; multiple
       organizations can share and ultimately harmonize Electronic Medical Records.
3.   Transition from legacy systems and data to an integrated EHR architecture.
     • Virtualization-Layers of Federated Standards-Based Services allow new and legacy COTS, GOTS and open-
       source applications, scalable databases and infrastructure to coexist.
4.   Agility to respond to rapid healthcare changes and related legislation.
     • Services within a standards-based component-architecture encourage faster and lower-cost changes to be made
       and tested within components without requiring enterprise-wide expertise and testing.
5.   High Costs of change and sustainment.
     • Virtualization-Layers of Federated Standards-Based Services make plug-and-play applications, databases and
       infrastructure possible, which can be treated as commodities and can be tested efficiently. Interchangeable-
       components can compete based, on functionality, quality, performance vs. cost, usability and supportability. Built
       In Test Environment (BITE) identifies faults early, improving robustness and reducing test costs. .
6.   Patient Safety issues resulting from software changes.
     • Component architecture localizes faults. BITE identifies faults early, improving system robustness, patient safety.
7.   Open Source Community Enablement
     • Virtualization-Layers of Federated Standards-Based Services support alternate configurations of applications,
       databases and infrastructure, which may be combinations of MUMPS, COTS, GOTS and open source code to
       meet the specific-needs of various stakeholder-and-user communities.                                        16
     ESP SDK                                WORKING DRAFT RFI: not for Points
                                          D R A F T Talkingofficial use.
HL7 Service Aware Interoperability Framework (SAIF)
Enterprise Compliance and Conformance Framework (ECCF)
                        Enterprise                    Information             Computational                     Engineering                   Technical
 ECCF                   Dimension
                        “Why” - Policy
                                                       Dimension
                                                     “What” - Content
                                                                               Dimension
                                                                                “How” - Behavior
                                                                                                                Dimension
                                                                                                             “Where” - Implementation
                                                                                                                                              Dimension
                                                                                                                                           “Where” - Deployments


                                                                                                              Inventory of
                                                    Inventory of
                                                                               Inventory of                   • SW Platforms, Layers
                                                     • Domain Entities                                                                      Inventory of
                                                                                • Functions-services           • SW Environments
                      Inventory of                  • Activities                                                                            • HW Platforms
                                                                               Requirements                   • SW Components
  Conceptual           • User Cases, Contracts
                       • Capabilities
                                                     • Associations
                                                     • Information
                                                                                • Accountability, Roles        • SW Services
                                                                                                                                             • HW Environments
                                                                                                                                             • Network Devices
  Perspective         Business Mission, Vision,        Requirements
                                                                                • Functional
                                                                                   Requirements, Profiles,
                                                                                                               • Technical
                                                                                                                  Requirements
                                                                                                                                             • Communication
                       Scope                         • Information Models                                                                       Devices
                                                                                   Behaviors, Interactions     • Enterprise Service Bus
                                                        o Conceptual                                                                        Technical Requirements
                                                                                • Interfaces, Contracts       Key Performance
                                                        o Domain
                                                                                                               Parameters



                                                                               Specifications
                                                                                • Use Cases, Interactions
                                                                                                              Models, Capabilities,        Models, Capabilities,
                                                                                • Components, Interfaces
                      Business Policies                                                                       Features and Versions for     Features and Versions for
                                                    Information Models        Collaboration
    Logical           Governance
                      Implementation Guides
                                                    Terminologies              Participations
                                                                                                               • SW Environments
                                                                                                               • SW Capabilities
                                                                                                                                             • HW Platforms
                                                                                                                                             • HW Environments
  Perspective         Design Constraints
                                                    Value Sets
                                                    Content Specifications
                                                                               Collaboration Types &
                                                                                Roles
                                                                                                               • SW Libraries                • Network Devices
                      Organization Contracts                                                                  • SW Services                 • Communication
                                                                               Function Types
                                                                                                               • SW Transports                 Devices
                                                                               Interface Types
                                                                               Service Contracts


                      Business Nodes               Schemas for                                              SW Specifications for        HW Deployment
                      Business Rules                • Databases               Automation Units               • Applications                Specifications
 Implementable        Business Procedures           • Messages                Technical Interfaces           • GUIs                       HW Execution Context
  Perspective         Business Workflows
                      Technology Specific
                                                     • Documents
                                                     • Services
                                                                               Technical Operations
                                                                               Orchestration Scripts
                                                                                                               • Components
                                                                                                              SW Deployment
                                                                                                                                            HW Application Bindings
                                                                                                                                            HW Deployment Topology
                       Standards                     • Transformations                                         Topologies                   HW Platform Bindings


        Five (5) Categories: Capability | Mission | Business Process | Infrastructure/Enterprise Architecture | Interoperability

                                                                                                                                                                         17
   ESP SDK                                               WORKING DRAFT RFI: not for official use.
TALKING POINTS: HL7 Service Aware Interoperability Framework
(SAIF) Conformant ESP Implementation Guide (IG)
• To be OSEHRA software-quality certified, ESP enabled applications
  MUST be conformant to the companion ESP SDK Implementation
  Guide (IG) which follows HL7 SAIF guidance.
          – The SDK slide set is the SAIF Conceptual Perspective
          – The SDK Implementation Guide is the SAIF Logical Perspective
          – Developers & Venders MUST deliver the SAIF Physical Perspective
• SAIF provides guidance; but, OSEHRA, DoD, VA, IHS and
  stakeholders MUST establish a consensus ESP IG, defining required
  architectural views (e.g., subset of DoDAF views) and appropriate
  specification language (e.g., BPMN, UML).
• The ESP companion SDK IG is HL7 SAIF conformant and defines
  software-engineering best-practices for interoperability Standards and
  Conventions (iSAC).
• Agile processes are being followed to define the SDK slides and IG;
  that is, there will be many incremental refinements.

                                                                               18
ESP SDK                         WORKING DRAFT RFI: not for official use.      18
 Generally, only the preceding Executive Summary is distributed via e-mail
  ESP SDK Conceptual View
    The most-current 180+ slide ESP SDK Conceptual Architecture and
      The most-current evolving ESP SDK Implementation Guide (IG)
can be downloaded at: http://www.osehra.org/node/47/content/documents
                                                            Next: ESP SDK Future-State
                                                            SAIF Conceptual Perspective
                                                           EHR Services Platform concepts
                                                           SDK Scope
                                                           Business Context
                                                           Clinical/Work Process Architecture
                                                           System Architecture
                                                           Information Architecture
                                                           Integration & Deployment Options
                                                           Potential Applications
                                                           Summary & Conclusion

                                                                     CALL FOR PARTICIPATION
                                                             Please post your discussion comments at
                                                              http://www.osehra.org/group/architecture


ESP SDK                    WORKING DRAFT RFI: not for official use                                 19
Abbreviations
AKA        Also Known As
BITE       Built in Test Environment
CM         Configuration Management
DI         Diagnostic Imaging
DoD        Department of Defense
EAI        Enterprise Application Integration
EHR IS     EHR Information Services
ESP        HER Services Platform
ESB        Engineering Service Bus
HAIMS      Health Artifact and Image Management Solution
ICIB       Interagency Clinical Informatics Board
IG         Implementation Guide
IHS        Indian Health Services
IP         Interoperability Profile / Specification
IV&V       Independent Verification and Validation
LIS        Laboratory Information Systems
LRS        Longitudinal Record Service
OSEHR      Open Source EHR
OSEHRA     OSEHT Custodial Agent
RFI        Request for Information
RIS        Radiology Information System
SAIF       HL7’s Service Aware Interoperability Framework
SDK        Software Development Kit
SDO        Standards Development Organization
SOA        Service Oriented Architecture
TSA        Telehealth Scheduling Application
VA         Veterans Administration
VHA        Veterans Health Administration
VM         Virtual Machine



                                                                                     20
 ESP SDK                                  WORKING DRAFT RFI: not for official use.    20
Suggested Plan of Actions and Milestones (POA&M) to
Refactor & Certify Legacy MUMPS within ESP Enabled System
1.   CY2011: Verified System Architecture, Product Baseline and Roadmap
2.   CY2012: Prepare
     • Complete ESP SDK through Open-Source-Community & DoD, VA, IHS collaboration
     • Specify future-state ESP Key Performance Parameters (KPPs) and implementation constraints
     • Get ESP SDK officially endorsed by DoD and VA leadership; work ESP SDK through HL7, OASIS & OMG SDOs
     • Specify OSEHR automated ESP enabled system certification-test-scripts & Built-in-Test-Environment (BITE)
     • Proof-of-concept refactoring-prototype (e.g., scheduling, clinical & nursing notes modules)
     • ESP enabled system & test environment prototype in a Virtual Machine (VM)
3.   CY2013: Build Critical Components
     • Construct automated-certification test-scripts for ESP & key applications
     • Construct ESP Built-in-Test-Environment (BITE)
     • Construct ESP reference-implementation in a VM test environment
     • Refactor & certify VistA Kernel & FileMan into as ESP enabled system
4.   CY2014: Build Necessary Components
     • Refactor & certify strategically important applications to be ESP conformant.
     • Refactor & certify other modules/routines in MUMPS to use ESP SDK specified services
5.   CY2015: Integrate and Make Everything Work to Users Satisfaction
     • ESP Integrate & certify other-available critical-components ESP (e.g., VLER, pharmacy, lab, imaging)
                                                                                                                   21
                                            applications RFI: not for official
       Performance optimize ESP & integratedWORKING DRAFTto meet KPPsuse.
     • ESP SDK                                                                                                    21
   Suggested OSEHRA Role in MUMPS Code Refactoring

1. Thought Leadership
2. OSEHR System Architecture, Product Definition and Roadmap
3. Technical, Operational and Functional Certification
4. Open Source Tools, Test & Collaboration Environment Management
5. Configuration Management of:
     1. OSEHR Services Platform (ESP) Software Development Kit (SDK)
     2. Codebase
     3. Certification test artifacts (fixtures, results, attestations)
6. Technical/ Standards Mentoring, Verification and Validation of:
     1. Refactoring
     2. ESP system enablement (Refactored VistA Kernel & Fileman Modules)
     3. Automated Certification test scripts, fixtures & Built-in-Test-Environment (BITE)
     4. Operational/technical/functional testing and certification
7. Open Source Community Engagement and Professional Organizations Evangelism


                                                                                             22
    ESP SDK                                WORKING DRAFT RFI: not for official use.         22
  Outline
                                              ESP SDK Future-State
                                           SAIF Conceptual Architecture
                                            EHR Services Platform Concepts
                                            ESP SDK Scope
                                            Business Context
                                            Clinical/Work Process Architecture
                                            System Architecture
                                            Information Architecture
                                            Integration & Deployment Options
                                            Potential Applications
                                            Summary & Conclusion

                                                      CALL FOR PARTICIPATION
                                                       Please post comments at
                                               http://www.osehra.org/group/architecture


ESP SDK     WORKING DRAFT RFI: not for official use                                 23
EHR IS Benefits

   • Increases availability & accessibility of information  patient safety &
     quality of care
   • Eliminates/reduces costly data mapping
   • Clarifies & communicates improved requirements (for vendors)
   • Provides common reproducible software development processes
     (interoperability design patterns)
   • Encourages faster-and-lower-cost changes
   • Supports efficient legacy transition to modernized systems
   • Assures consistent information context and meaning




                                                                            24
ESP SDK                    WORKING DRAFT RFI: not for official use.        24
ESP SDK Scope



                      EHR IS CONCEPTUAL LAYER ADDRESSES BUSINESS CONTEXT
                                (Mission, objectives, stakeholders, benefits)


             WORK PROCESS               INFORMATION                       SYSTEM       TECHNOLOGY

              framework V1                                              framework V1
Conceptual        YES
              framework V2
                                            YES
                                         framework V2                       YES
                                                                        framework V2


Logical          YES
              framework V2                  YES
                                         framework V2                      YES
                                                                        framework V2


Physical



                                 EHR IS Implementations




ESP SDK                      WORKING DRAFT RFI: not for official use.                               25
  Architecture Perspectives

                  Business
                 Architecture


                                  Clinical
 Potential
                                Work Process
Applications
                                Architecture



                CONTEXT
Integration &
                                  System
 Deployment
                                Architecture
   Models



                 Information
                 Architecture




ESP SDK                         WORKING DRAFT RFI: not for official use   26
  Architecture Perspectives

                  Business
                 Architecture


                                  Clinical
 Potential
                                Work Process
Applications
                                Architecture



                CONTEXT
Integration &
                                  System
 Deployment
                                Architecture
   Models



                 Information
                 Architecture




ESP SDK                         WORKING DRAFT RFI: not for official use   27
    Business Context




ESP SDK            WORKING DRAFT RFI: not for official use   28
Healthcare Industry                                                                 Federal Agencies
                                                                                       and States
                                                                                                                            Elected
                                                                                                                            Federal
                                                                                                                          Government

                                      Planning &                                          Provides $
                                      Resources




      Planning &                                                                                                                             Tax
      Resources                                                                                                                              $$$
                                            VHA, MHS, IHS, SSA,
                                             State Agencies, etc.

                                                                               Homecare

                       Community                                                                       Emergency
                       Care Center                                                                     Services




                                                                                                                                   Patient




Providers
                                                           Clients/Patients
                                                                                                               Pharmacy
            Specialist Clinic




                           Hospital
                         Emergency                                                                      Laboratory



                                                                                  Diagnostic




 ESP SDK                                                  WORKING DRAFT RFI: not for official use                                            29
 International Industry: IT Spending Comparisons


                                     IT spending as a % of total expenditures
         Financial Services                                                                                                                                         12.1

               Government                                                                     5.7

                    Telcos                                                                  5.5

Worldwide Health Providers                                                    4.2

             Transportation                                         3.3

                    Utilities                                2.7                                                                                                            HELP NEEDED
                                                                                                                                                                            This slide should
                   Textiles                             2.2
                                                                                                                                                                             be updated to
             Manufacturing                           1.9
                                                                                                                                                                               current US
                 Petroleum                        1.7                                                                                                                            figures
              Pulp & Paper                       1.6

      Canadian Healthcare                      1.4

               Food & Bev                    1.2

                                SOURCE: Gartner Group – as reported in the Health Services Restructuring Commission’s (www.hsrc.gov.on.ca) report: Ontario Health Information Management Action Plan, June 1999




                                                  HELP NEEDED validating that this Canada Health Infoway based-
                                                      slide applies to the US ESP/EHR IS situation & needs.
   ESP SDK                                           Please send your feedback to HufnagelS@OSEHRA.org
                                                          WORKING DRAFT RFI: not for official use.                                                                                                                30
Mean Hospital: IT spending in Canada <2%


                    IT budgets as a % of total hospital budget
less than 1%                                                                                                                                                25


     1-1.4%                                                                                                                                                            27


   1.5-1.9%                                                                                                                                                            27          HELP NEEDED
                                                                                                                                                                                   This slide should
     2-2.4%                                                                        12                                                                                               be updated to
                                                                                                                                                                                      current US
2.5% or more                                                            10                                                                                                              figures
               0                          5                          10                          15                          20                          25                            30




               SOURCE: 2003 Report on I.T. in Canadian Hospitals: Top issues, applications and vendors. Canadian Healthcare Technology, 2003. CIHI NHex 2002 (Hospital Expenditures)




                                                        HELP NEEDED validating that this Canada Health Infoway based-
                                                            slide applies to the US ESP/EHR IS situation & needs.
 ESP SDK                                                   Please send your feedback to HufnagelS@OSEHRA.org
                                                                WORKING DRAFT RFI: not for official use.                                                                                        31
   Why an ESP?
   The World of Healthcare
   is Changing…


  The Old World                                        The New World
  Provider-focused                                     Patient & family-focused
  Illness centric                                      Medical home and wellness care
  Site-of-care centric                                 Continuum of care & case management
  Episode Management                                   Disease and demand management
  Supply Management                                    Collaborative, evidence-based decisions
  Solitary decision making                             Meaningful-Use objectives, metrics & criteria
  Inefficiency                                         Patient safety, quality and effectiveness
  De-centralized, generalized care                     Centralized, specialized care




ESP SDK                              WORKING DRAFT RFI: not for official use       See notes page      32
  Why an EHR IS?
  The World of Healthcare
  is Changing…




   The changes in healthcare require
   significant capability from the
   health infostructure; this capability
   does not fully exist today




ESP SDK                      WORKING DRAFT RFI: not for official use   33
   The Timing Has Never Been Better!




                  WILL              CONVERGENCE                                          CAPACITY
• Public wants more                                                                      • Better infrastructure
  accessibility                                                                          • More mature
• Health Authorities                                                                       application
  recognize benefits                                                                       technologies
• Increased financial
  pressures
• Healthcare
  professionals
  embracing technology                         CAPABILITY
• Willingness to
                                   • Political will
  collaborate
                                   • Funding is now available
                                   • mandated to pursue investments
                         HELP NEEDED validating that this Canada Health Infoway based-
                             slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                     Please send your feedback to HufnagelS@OSEHRA.org
                                 WORKING DRAFT RFI: not for official use.                                          34
    EHR IS:
    Key Concepts




ESP SDK            WORKING DRAFT RFI: not for official use   35
EHR
An Electronic Health Record (EHR) provides each individual with a secure and
private lifetime record of their key health history and care within the health system.
The record is available electronically to authorized health providers and the
individual anywhere, anytime in support of high quality care.
This record is designed to facilitate the sharing of data – across the continuum of
care, across healthcare delivery organizations and across geographies.




ESP SDK                                 WORKING DRAFT RFI: not for official use          36
Interoperable EHR Solution

The Interoperable EHR Solution is a combination of
people, organizational entities, business processes,
systems, technology and standards that interact and
exchange clinical data to provide high quality and
effective healthcare.




ESP SDK                              WORKING DRAFT RFI: not for official use   See notes page   37
EHR Information Services (EHR IS)
 The EHR Information Services are a collection of common and reusable
 component-services in support of a diverse set of health information
 management applications. It consists of interoperable software-solutions
 for the EHR, semantically-interoperable data and terminology for the EHR
 and secure information-exchange standards for the EHR.




ESP SDK                             WORKING DRAFT RFI: not for official use   See notes page   38
EHR IS Outcomes
Providers                                                                                         Researchers & Health
• Relevant data, granular,                                                                        Surveillance
  computable if needed                                                                            Professionals
• Real time                                                                                   • Computable data
• Rapid access from multiple                                                                  • Appropriately summarized
  locations, anywhere,                                                                          data
  anytime
                                                                                              • Anonymized in framework
• Decision support
                                                                                              • Designed for analysis:
    •   Clinical reference data                   Authoritative,                                   •   Statistical sampling
    •   Guidelines & protocols
                                                 reliable, secure,                                 •   Trends
    •   Common terms & codes
                                                      private                                      •   Outbreak detection
• Case management &                                                                                •   Outcome analysis
  workflow                                                                                    •   Regional
• Safety                                                                                      •   National
• Improved quality of care
• Regulation & accountability

                                                                                          Payer/Payee
Patient/Public/Clients                                                                    • Relevant data to adjudicate claim
• Convenient, relevant access to                                                          • Workflow management
  accredited health information
• Access to relevant personal health       Public Sector Health Managers
  information                              •   Registry solutions & initiatives
• Safety                                   •   Objective analysis of results & benefits
• Improved quality of care                 •   Management reports
                                           •   Funding & resource allocation
                                           •   Policy
                                  HELP NEEDED validating that this Canada Health Infoway based-
                                      slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                              Please send your feedback to HufnagelS@OSEHRA.org
                                          WORKING DRAFT RFI: not for official use.
Key EHR IS Architecture Concepts

                                    INTEGRATED EHR SOLUTION


                                    EHR Services Platform (ESP)
                                                                                                 EHR IS
                                                                                                 Locator

              Population                  Health
                                                             EHR                Registries
                Health                 Information
                                                            Data &               Data &
                Data &                     Data
                                                           Services             Services
               Services                Warehouse




              Information Access & Longitudinal Record Services (LRS)



                                EHR Information Services (EHR IS)




                 Point of Service              Point of Service
                                                                           EHR Viewer
                   Application                   Application




ESP SDK                              WORKING DRAFT RFI: not for official use.                See notes page   40
EHR Services Platform (ESP) Recommended Approach
for Partner Collaboration
        EHR IS ENABLED SYSTEM SOLUTION                                                         EHR IS ENABLED SYSTEM SOLUTION

                 EHR INFOSTRUCTURE (EHRi)                                                               EHR INFOSTRUCTURE (EHRi)

    Population               Health                                                        Population               Health
                                                EHR                 Registries                                                         EHR                 Registries
      Health              Information                                                        Health              Information
                                               Data &                Data &                                                           Data &                Data &
      Data &                  Data                                                           Data &                  Data
                                              Services              Services                                                         Services              Services
     Services             Warehouse                                                         Services             Warehouse




        Information Access & Longitudinal Record Services (LRS)                                Information Access & Longitudinal Record Services (LRS)



                    EHR Information Services (EHR IS)                                                      EHR Information Services (EHR IS)




         Point of                    Point of                                                   Point of                    Point of
         Service                     Service                      EHR Viewer                    Service                     Service                      EHR Viewer
        Application                 Application                                                Application                 Application




                            ESP                    ESP                  ESP      ESP          ESP                   ESP                    ESP




                                                        HELP NEEDED validating that this Canada Health Infoway based-
                                                            slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                                    Please send your feedback to HufnagelS@OSEHRA.org
                                                                WORKING DRAFT RFI: not for official use.                                   See notes page               41
    EHR IS Infostructure: Conceptual Architecture
ORGANISATIONAL INFOSTRUCTURE

   Registries Data                  Population Health Data                                                      EHR Data                                                    Data
     & Services                          & Services                                                             & Services                                                Warehouse

       Client
      Registry                Outbreak                 PHS                   Shared                   Drug              Diagnostic                                          Health
                                                                                                                                            Laboratory
                             Management              Reporting            Health Record           Information            Imaging                                         Information
      Provider
      Registry


      Location
      Registry                          Business           EHR          Message           Normalization
                                         Rules            Index         Structures           Rules

    Terminology                                                   Information Access & Longitudinal Record Services (LRS)
      Registry



                                                                                                                    Security Mgmt
                                                                                                                                      Privacy Data       Configuration
                                                                                                                        Data

                                                                                     Information and Common Services
        EHR IS
                                                                                       Secure Communications Bus




                                                                  Radiology
                  Public Health              Pharmacy                                     Lab System             Hospital, LTC,           Physician
                                                                   Center                                                                                         EHR Viewer
                    Services                  System                                         (LIS)                CCC, EPR               Office EMR
                                                                  PACS/RIS




                        Public Health              Pharmacist           Radiologist             Lab Clinician            Physician/             Physician/                 Physician/
                          Provider                                                                                        Provider               Provider                   Provider
POINT OF SERVICE



                                                        HELP NEEDED validating that this Canada Health Infoway based-
                                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                Please send your feedback to HufnagelS@OSEHRA.org
                                                                WORKING DRAFT RFI: not for official use.                                        See notes page                         42
Guiding Principles for EHR Services Platform (ESP)


• Patient-centric                                           • Leverage legacy systems & solutions
                                                                 •   VA VistA
• Easially customized views of all clinical data
                                                                 •   MHS AHLTA
• Value add for the provider                                     •   Open Source Applications

• Timely, accurate information                              • Design for phased rollout with near
• Enable sharing at local, regional,                          term results
  cross-organizational                                      • Scalable
                                                                 •   Individual provider’s Point-of-Service (POS)
• Interoperable, integrated applications
                                                                 •   Specialty, Ancillary, Public Health POSs
• Standards based                                                •   Interoperating with large -o-massive Enterprise

• Computable where required                                 • Extensible to support future growth
• Replicable solution – patterns, components                • Pragmatic and Cost-effective
                                                            • Secure & private
                                                            • Allow for innovation & competition
                                                                 •   Open Source commodity applications
                                                                 •   Best –of-class COTS applications

                                                            • Comprehensive




                                 HELP NEEDED validating that this Canada Health Infoway based-
                                     slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                             Please send your feedback to HufnagelS@OSEHRA.org
                                         WORKING DRAFT RFI: not for official use.                                      43
                                                                                                                            HELP NEEDED
   Generations of EHR Capabilities                                                                                          This slide should
                                                                                                                              be updated

         Full                                                                                                               Gen 5
                                                                                                                            The Mentor


                                                                                                         Gen 4
                                                                                                         The Colleague



Functionality                                                                  Gen 3
                                                                               The Helper



                                                  Gen 2
                                                  The Documentor



                         Gen 1
                         The Collector

    Minimal
                             1993                    1998                  2005                        2010              2015+

                                                                                          End of 2009
                Source: Gartner (December 2005)
                                                                Availability of Products



    ESP SDK                                                 WORKING DRAFT RFI: not for official use.                      See notes page   44
A Few Misconceptions About integrated EHR Solutions



Misconception                                              Reality
• A person’s health data is in only one                    • EHR: an integrated service covering
  physical EHR                                               all available integrated EHR Solutions;
• All data for a person must be in the                       a client’s record is seen as coming from
  EHR to have value and generate                             a single integrated EHR
  adoption                                                 • Quality, safety & effectiveness
• An Organization is a provider practice                     enhanced with only subsets of clinically
                                                             relevant data available for sharing
• The EHR is a data warehouse to
  support research and surveillance                        • An organization is any geo-political
                                                             entity mandated or chartered to govern
                                                             the operation of an integrated EHR
                                                             Solution
                                                           • The EHR IS: an information support
                                                             service available to caregivers in the
                                                             daily context of care provision work
                                                             activities




                               HELP NEEDED validating that this Canada Health Infoway based-
                                   slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                           Please send your feedback to HufnagelS@OSEHRA.org
                                       WORKING DRAFT RFI: not for official use.                         45
                 Future-State-Architecture
      GOAL: To Support Modular Plug-&-Play Innovation
 Incremental           Little Impact on links    Modular
  Innovation          between components       Plug-&-Play
                      (e.g., Interoperability)  Innovation

                                                                                                                 OBJECTIVE
                                                                                               A change-immune domain-specific component-
                                                                                              architecture emphasizing interoperable standards-
                                                                                             based services, resulting-in simpler, loosely-coupled,
                                                                                                and less-costly agile module-level innovation.



 Little impact on                                                                                                  Great impact on
  components                                                                                                        components

           PROBLEM
 Little innovation, long lead times and
  high costs resulting from complex
      highly-coupled components


                                          Start                                                                Radical
Architectural                                                                                                 Innovation
 Innovation                                        Great Impact on links
                                                   between components
                                                   (e.g., interoperability)
                                                                                                                                                46
 ESP SDK                                          WORKING DRAFT RFI: not for official use.
Coordination Across the Enterprise


                    Common                                             EHR IS
                    Services
                      Bus                                      Terminology Model
                     (CSB)                                       Services Model
                                          Translation          Information Model
                   Rules Engine
                                            Service                 Rule Set
                 Technical Services
                                             MDR               Mapping to Legacy
                                                              Data Standardization

                                         Services
                                      Communications
                                                            Physical
                                                           Data Model


                                           Caching                                             Outside
                                          Database                                     • Clinical Measures
                                          Topologies                                   • Capabilities
                                           Latency                                     • Applications
                                                                                       • Adapters


                                      Infrastructure

                                                                                                             47
 ESP SDK                    WORKING DRAFT RFI: not for official use.                 See notes page
The EHR IS drives the ESP enabled run-time environment


            EHR IS




                                                                    48
  ESP SDK               WORKING DRAFT RFI: not for official use.   48
Pharmacy Delivery Use Case –
The EHR IS Leads the Way




            Translation Services                 Mediation Services                    Rules Engine




                           Common Information Interoperability Framework (EHR IS)
              Common Information Model, Common Terminology Model, Information Exchange Specifications,
                                    Translation Service Common Data Standards:


                                                                                                               49
  ESP SDK                             WORKING DRAFT RFI: not for official use.                See notes page
    Business/Clinical Scope




ESP SDK             WORKING DRAFT RFI: not for official use   50
EHR IS Serving Healthcare Service Delivery
                                                EHR IS ENABLED SYSTEM SOLUTION                                                                                                     EHR IS ENABLED SYSTEM SOLUTION

                                                      EHR INFOSTRUCTURE (EHRi)                                                                                                           EHR INFOSTRUCTURE (EHRi)


                                                                Health                                                                                                                             Health
                                 Population Health                                EHR                  Registries                                                   Population Health                                 EHR                    Registries
                                                             Information                                                                                                                        Information
                                      Data &                                     Data &                 Data &                                                           Data &                                      Data &                   Data &
                                                                 Data                                                                                                                               Data
                                     Services                                    Services              Services                                                         Services                                     Services                Services
                                                             Warehouse                                                                                                                          Warehouse




                                         Information Access & Longitudinal Record Services (LRS)                                                                            Information Access & Longitudinal Record Services (LRS)




                                                           EHR Information Services (EHR IS)                                                                                                  EHR Information Services (EHR IS)




                                        Point of Service             Poin of Service                                                                                       Point of Service             Point of Service
                                                                                                    EHR Viewer                                                                                                                            EHR Viewer
                                          Application                 Application                                                                                            Application                  Application




                                                                                   Homecare                                                                                                                                Homecare

              Community                                                                                                   Emergency                    Community                                                                                                Emergency
             Care Center                                                                                                  Services                    Care Center                                                                                               Services




                                                           Clients/Patients                                                                                                                   Clients/Patients

    Specialist                                                                                                                    Pharmacy   Specialist                                                                                                                 Pharmacy
       Clinic                                                                                                                                   Clinic



                      Hospital                                                                                      Laboratory                                 Hospital                                                                                   Laboratory
                    Emergency                                                                                                                                Emergency




                                                                                       Diagnostic                                                                                                                            Diagnostic




                                                                                               HELP NEEDED validating that this Canada Health Infoway based-
                                                                                                   slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                                                                           Please send your feedback to HufnagelS@OSEHRA.org
                                                                                                       WORKING DRAFT RFI: not for official use.                                                                                                                                    51
Population/Public Health Business Requirements

• Focuses on managing health status of populations
• Managed and executed through complex network of public/private organizations acting at different
  levels of the health system (Federal, State, Regional, Local, Individual)
• Involves:
    •   Research & analysis to identify/define population health programs
    •   Surveillance activities to detect and pro-actively react to potential population health problems
    •   Application of health programs to prevent the appearance and/or dissemination of preventable diseases
    •   Active management of communicable disease outbreaks
    •   Active management of the delivery of health services to individuals in the context public health related programs
• Current focus limited to:
    •   Surveillance and detection (focused on human health-related diseases)
    •   Outbreak Management
    •   Public Health Alert Management
    •   Disease Information Dissemination
    •   Immunization Management
    •   Communicable Disease Case Management




                                     HELP NEEDED validating that this Canada Health Infoway based-
                                         slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                 Please send your feedback to HufnagelS@OSEHRA.org
                                             WORKING DRAFT RFI: not for official use.                                       52
Integrating Population/Public Health in the Architecture

Candidate services required to support:
• Surveillance & Detection: There is a business need for a Health information data warehouse
• Outbreak Management: requires the addition of a new category of service called Population
  Health Services where a specific service is introduced to address outbreak management;
  analogous services will evolve.
• Common Information Integration Framework (EHR IS): addresses the need for a formal
  terminology registry system that maintains information and terminology models for clinical
  domains and other key terminologies required for many services of the ESP
• Public Health Alert Management
   • Public health disease alert reporting requires use of specific applications also positioned as Population Health services
   • Public health alerts dissemination relies on terminology registry and EHR IS Alerts and Notification services

• Immunization Management
   • Immunization programs and their management requires a specific application that would live under the Population Health
     services category
   • Delivery of immunisation would be tracked by the drug information domain as part of the EHR

• Communicable Disease Case Management
   • Delivery of health services in relation with the treatment of a CD case would be tracked by the shared health record and other
     domains as part of the EHR
   • Management of a CD case from the perspective of the public health specialists involved in detection and tracking would require a
     specific application that would live under the Population Health services category




                                          HELP NEEDED validating that this Canada Health Infoway based-
                                              slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                      Please send your feedback to HufnagelS@OSEHRA.org
                                                  WORKING DRAFT RFI: not for official use.                                              53
Integrating Public Health in the Architecture

Some Public Health business requirements can be sustained by the
existing services of the EHR Infostructure
• Public Health Alert Management: EHR IS and LRS to provide for mechanism to help with
  detection & reporting on communicable diseases
• Immunization Management: Drug Information Domain is the home of immunization
  information as part of the core clinical data in client’s health records. EHR IS and LRS to
  provide mechanisms to communicate the data and coordinate its location and access within
  the EHRi
• Communicable Disease Case Management: CD Cases, from the perspective of the EHR
  are treated like any other health delivery encounter




                               HELP NEEDED validating that this Canada Health Infoway based-
                                   slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                           Please send your feedback to HufnagelS@OSEHRA.org
                                       WORKING DRAFT RFI: not for official use.                 54
      EHR IS Serving Public Health Service Delivery
ORGANIZATIONAL INFOSTRUCTURE                             Immunization
                                                           “Registry“
      Registries Data                     Population Health Data                                                         EHR Data                                                   Data Warehouse
        & Services                             & Services                                                                & Services                                                   & Services

           Client
          Registry                  Outbreak                  PHS                     Shared                   Drug               Diagnostic                                           Health
                                                                                                                                                       Laboratory
                                   Management               Reporting              Health Record           Information             Imaging                                          Information
          Provider
          Registry
                                       Case
        Reference                   Management
       Management
          Location
          Registry                        Business               EHR            Message            Normalization
                                           Rules                Index           Structures            Rules                                                                   PHS Data
        Terminology
                                                                                                                                                                              Warehouse
                                                                          Information Access & Longitudinal Record Services (LRS)                                              Services
          Registry
                                                                                                          Content &
                                              Alert Notification                                                                    Security &
                                                                              Messaging                  Knowledge
                                                  Services                                                                       Privacy Services
                                                                                                         Management           Security Mgmt
                                                                                                                                                Privacy Data        Configuration
                                                                                                                                  Data

                                                                                             Information and Common Services
             EHR IS
                                                                                               Secure Communications Bus

         PHS Systems
        Operational data

                                                                                             Radiology                                    Hospital,
PHS                                             Other PH                Pharmacy                                   Lab System                                Physician
        CM     OM     AM     IM*                                                              Center                                     Community,                                  EHR Viewer
 A                                              System(s)                System                                       (LIS)                                 Office EMR
                                                                                             PACS/RIS                                    etc… EPR


      Public Health Surveillance Portal


                                                                            Pharmacist              Radiologist          Lab Clinician         Physician/            Physician/             Physician/
                                                Public Health Providers                                                                         Provider              Provider               Provider
POINT OF SERVICE



                                                               HELP NEEDED validating that this Canada Health Infoway based-
                                                                   slide applies to the US ESP/EHR IS situation & needs.
       ESP SDK                                                    Please send your feedback to HufnagelS@OSEHRA.org
                                                                       WORKING DRAFT RFI: not for official use.                                             See notes page                        55
Telehealth Business Requirements

• Telehealth: the use of information & communication technologies to deliver health
  services in contexts where the providers and clients are in separate locations
• Telecommunication infrastructure is a pre-requisite
• Telehealth solutions enable health service delivery channels:




    Tele-consultations          Tele-education                 Tele-homecare                        Tele-triage




     Videoconferencing         Videoconferencing             Active or passive                  Centralized call centers
     stations, communication   stations used for             monitoring of remote               to offer first line delivery
     enabled medical           training/education            patients for pre-/                 of service to clients as
     devices                                                 post-op procedures,                part of primary care and
                                                             chronic diseases                   emergency response
                                                             management, etc


• Scheduling solutions – a key enabler required for the effective use of telehealth service delivery
• EHR Infostructures support telehealth applications as per any other Point-of-Service Application



                                HELP NEEDED validating that this Canada Health Infoway based-
                                    slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                            Please send your feedback to HufnagelS@OSEHRA.org
                                        WORKING DRAFT RFI: not for official use.                                               56
    EHR IS Serving Telehealth Scheduling
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data         Population Health Data                                                    EHR Data                                                   Data
     & Services                 & Services                                                           & Services                                               Warehouse

       Client
      Registry         Outbreak            PHS                   Shared                   Drug              Diagnostic                                          Health
                                                                                                                                Laboratory
                      Management         Reporting            Health Record           Information            Imaging                                         Information
      Provider
      Registry


      Location
      Registry              Business           EHR          Message           Normalization
                             Rules            Index         Structures           Rules

    Terminology                                       Information Access & Longitudinal Record Services (LRS)
      Registry



                                                                                                         Security Mgmt     Privacy           Configuration
                                                                                                          Rules/Data      Rules/Data          Rules/Data

                                                                         Information and Common Services
        EHR IS
                                                                           Secure Communications Bus




                                                                         Patient          End-user                           Referring                 Attending
                                                                          Info              Info                             Physician                 Physician
                                                                                                                               Site                       Site
                                                                         Event                Clinical
             TSA                                                         History              Profile
           Database
                                                                                               Video
                                                                    Scheduling
                                                                                              Session                              Physician/                  Physician/
POINT OF SERVICE                                                                                                                    Provider                    Provider


                                                                                                 Telehealth Scheduling Application (TSA)

                                            HELP NEEDED validating that this Canada Health Infoway based-
                                                slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                    Please send your feedback to HufnagelS@OSEHRA.org
                                                    WORKING DRAFT RFI: not for official use.                                       See notes page                          57
EHR IS Framework: Tele-Consultation
               EHR INFOSTRUCTURE (EHRi)                                                               EHR INFOSTRUCTURE (EHRi)


 Population                  Health                                                     Population              Health
                                              EHR               Registries                                                        EHR               Registries
   Health                 Information                                                     Health             Information
                                             Data &              Data &                                                          Data &              Data &
   Data &                     Data                                                        Data &                 Data
                                            Services            Services                                                        Services            Services
  Services                Warehouse                                                      Services            Warehouse




   Information Access & Longitudinal Record Services (LRS)                                Information Access & Longitudinal Record Services (LRS)



                       EHR Information Services (EHR IS)                                                  EHR Information Services (EHR IS)




                                                                  Live Video-Conferencing
                                                                          Session
    Local Electronic                          Telehealth                                                    Telehealth                         Local Electronic
    Medical Record                            Application                                                   Application                        Patient Record
                                                                  Tele-Consultation Devices Data




                                                       HELP NEEDED validating that this Canada Health Infoway based-
                                                           slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                                   Please send your feedback to HufnagelS@OSEHRA.org
                                                               WORKING DRAFT RFI: not for official use                                                            58
EHR IS Framework: Tele-Homecare
               EHR INFOSTRUCTURE (EHRi)                                                              EHR INFOSTRUCTURE (EHRi)


 Population              Health                                                        Population              Health
                                           EHR                   Registries                                                      EHR               Registries
   Health             Information                                                        Health             Information
                                          Data &                  Data &                                                        Data &              Data &
   Data &                 Data                                                           Data &                 Data
                                         Services                Services                                                      Services            Services
  Services            Warehouse                                                         Services            Warehouse




   Information Access & Longitudinal Record Services (LRS)                               Information Access & Longitudinal Record Services (LRS)



                   EHR Information Services (EHR IS)                                                     EHR Information Services (EHR IS)




                                                                                  Tele-Homecare Data Feed
                  Local Electronic                              Homecare                                                         Homecare
                  Medical Record                             Application Server                                              Client Application
                                                                                    Tele-Consultation Devices




                                                    HELP NEEDED validating that this Canada Health Infoway based-
                                                        slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                                Please send your feedback to HufnagelS@OSEHRA.org
                                                            WORKING DRAFT RFI: not for official use                                                             59
EHR IS Framework: Tele-Triage
               EHR INFOSTRUCTURE (EHRi)                                                                         EHR INFOSTRUCTURE (EHRi)


 Population              Health                                                                   Population              Health
                                                      EHR                   Registries                                                      EHR               Registries
   Health             Information                                                                   Health             Information
                                                     Data &                  Data &                                                        Data &              Data &
   Data &                 Data                                                                      Data &                 Data
                                                    Services                Services                                                      Services            Services
  Services            Warehouse                                                                    Services            Warehouse




   Information Access & Longitudinal Record Services (LRS)                                          Information Access & Longitudinal Record Services (LRS)



                   EHR Information Services (EHR IS)                                                                EHR Information Services (EHR IS)




                                    Patient Info   End-user Info
                                                                                                                                          Personal
                                      Event          Clinical               Tele-Triage
                                      History        Profile                                                                            Health Record
                                                                            Application
                                    Scheduling Video Session                                                                             Application



                                    EHR Viewer




                                                                   HELP NEEDED validating that this Canada Health Infoway based-
                                                                       slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                                               Please send your feedback to HufnagelS@OSEHRA.org
                                                                           WORKING DRAFT RFI: not for official use                                                         60
    Clinical, Business &
    Socio-economic Drivers
    for integrated EHR
    solutions




ESP SDK             WORKING DRAFT RFI: not for official use   61
Why is Value Created by an integrated EHR solution?

• Healthcare professionals make clinical decisions based on knowledge
   • Encounter and Case Management,
   • Care Plan,
   • Health Concern Tracking
   • Analytics
• Better knowledge translates to better care
• Knowledge starts with accurate, relevant clinical information
• The EHR creates the capability to share relevant clinical information
• The 5 Rs of the EHR:
   • The right information
   • About the right client
   • Available to the right person
   • In the right place
   • At the right time



                              HELP NEEDED validating that this Canada Health Infoway based-
                                  slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                          Please send your feedback to HufnagelS@OSEHRA.org
                                      WORKING DRAFT RFI: not for official use.                62
How Is Value Delivered By An ESP Enabled System?
The value of the ESP Enabled System for clients, families and their
providers increases with the completeness of the information contained
as well as the level of standardization of the data




                                                                                Point of
                                                                             greatest value
       Extent of the Care
     Continuum Involved
(PCP office, Hospital, Long
Term Care Homecare, etc.)




                                                        # of Data Domains Included
                                                 (Encounter Summaries, Lab, DI, Drugs, etc.)

                              HELP NEEDED validating that this Canada Health Infoway based-
                                  slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                          Please send your feedback to HufnagelS@OSEHRA.org
                                      WORKING DRAFT RFI: not for official use.                 See notes page   63
    Why Pursue The EHR IS: Circle of Care

                                                                      Homecare


                           Clinic                                                                   Emergency Services




Community                                                                                                                Pharmacy
Care Center




               Specialist Clinic                                                                            Laboratory




                                      Hospital                                         Diagnostic
                                    Emergency




     ESP SDK                                WORKING DRAFT RFI: not for official use.                   See notes page               64
                                                                                                      DoD priorities:
                                                                                                      1. Experience of care
    Why Pursue The EHR: Benefits                                                                      2. Readiness
                                                                                                      3. PopHealth
                                                                                                      4. Per capita costs
                                                                   Homecare


                           Clinic                                                                   Emergency Services




Community                                                                                                                Pharmacy
Care Center

                                      QUALITY                                 SAFETY




                                                      ACCESSIBILITY




               Specialist Clinic                                                                            Laboratory




                                       Hospital                                     Diagnostic
                                     Emergency



                                    HELP NEEDED validating that this Canada Health Infoway based-
                                        slide applies to the US ESP/EHR IS situation & needs.
     ESP SDK                           Please send your feedback to HufnagelS@OSEHRA.org
                                            WORKING DRAFT RFI: not for official use.                   See notes page               65
The EHR IS is a Key to a
Renewed Health System!




integrated EHR Solutions provide
  an opportunity to
• Improve the quality, safety,
  accessibility and timeliness of care
• Support more informed healthcare
  decision making, research and
  management
• Improve the efficiency of the healthcare
  system and reduce costly duplication
• Maximize return on IT investments
• Achieve standards based solution
  allowing interoperability



ESP SDK                         WORKING DRAFT RFI: not for official use   66
EHR IS Key Clinical & Business Requirements

• Life-long longitudinal record of clinical data
• Allowing private and secured access to data made available in EHR
• Focused on clinically relevant data shared beyond organizational boundaries
• Support for accurate, complete, timely delivery of information
• Shared across multiple organizations, Organizations
• Adaptive to the future of healthcare delivery in the 21st Century
• Requiring ongoing governance and operations management with 24/7 high
  availability service
• Affordable in relation to complexity and size of integration challenges (connecting large
  numbers health points of service)
• Scalable to allow continuous, extensive growth of clinical and financial ROI
    • More POS applications sourcing data to EHR
    • More users accessing and using data from EHR
    • Allowing natural growth of capabilities towards Generation 3 and beyond




                              HELP NEEDED validating that this Canada Health Infoway based-
                                  slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                          Please send your feedback to HufnagelS@OSEHRA.org
                                      WORKING DRAFT RFI: not for official use.                See notes page   67
Different Approaches To
Achieving EHR IS




 ESP SDK            WORKING DRAFT RFI: not for official use   68
    EHR IS: How Do We Do This?
    Sharing Information From Multiple Systems
                                                                    Homecare



                           Clinic                                                                   Emergency Services




Community                                                                                                                Pharmacy
Care Center




                                                 INTEGRATED VIEW
                                                   Clients/Patients




               Specialist Clinic                                                                            Laboratory




                                      Hospital                                         Diagnostic
                                    Emergency




     ESP SDK                                WORKING DRAFT RFI: not for official use.                                                69
Methods of Sharing EHR Information


The “Big Database        Broadcast to all or              The “Big Index in                       Use of a
   in the Sky”           a logical subset of                  the Sky”                        shared reference
                         Systems (caching)                                                   information source
• All Point-of-Service   • Replication of data           • EHR Index or locator              • POS systems
  (POS) systems share      from one system to              service that holds                  populate it
  same data store          all other relevant/             links to all POS                  • POS systems or
                           participating POS               systems where                       viewers reference it
                           systems                         information resides
                                                                                             • External to the
                         • Every POS                     • Each POS system                     “operational” store
                           system holds same               interfaces to other
                           information                     systems




                             HELP NEEDED validating that this Canada Health Infoway based-
                                 slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                         Please send your feedback to HufnagelS@OSEHRA.org
                                     WORKING DRAFT RFI: not for official use.                                         70
    Key Factors Affecting How to Share

    • Sharing creates some very profound issues & requirements                                                           DEERS EDIPN
          • Unique identification of clients, providers, service delivery locations, etc.
                                                                                                                       Service is the DoD-
          • Protecting privacy and confidentiality of patients and providers while
            simultaneously not limiting the ability to deliver appropriate services
                                                                                                                        VA unique person
          • Ensuring information is stored, shared securely
                                                                                                                          identification
          • Ensuring compatibility of how data is interpreted/understood --- EHR IS
                                                                                                                             solution
    • Issues the same no matter which model is chosen to share patient
      identified information
    • Governance model for healthcare means these issues are organizational
      responsibilities – requirements vary
    • People increasingly mobile, especially when considering long periods
      of time
    • Provider’s confidence in the mechanisms to enable sharing is crucial


The DoD & VA use the Electronic Data Interchange Personal Number, or EDIPN, is a unique number assigned to a record in the United States Department of
Defense's Defense Enrollment and Eligibility Reporting System (DEERS) database. A record in the DEERS database is a person plus personnel category (e.g.
                                                        contractor, reservist, civilian, active duty, etc.).



                                               HELP NEEDED validating that this Canada Health Infoway based-
                                                   slide applies to the US ESP/EHR IS situation & needs.
     ESP SDK                                      Please send your feedback to HufnagelS@OSEHRA.org
                                                       WORKING DRAFT RFI: not for official use.                                                   71
The Integration Challenge
of integrated EHR
Solutions




 ESP SDK            WORKING DRAFT RFI: not for official use   72
    Integrating Heterogeneous Systems

                                                                      Homecare


                           Clinic                                                                   Emergency Services




Community                                                                                                                Pharmacy
Care Center




                                                   Clients/Patients




               Specialist Clinic                                                                            Laboratory




                                      Hospital                                         Diagnostic
                                    Emergency




     ESP SDK                                WORKING DRAFT RFI: not for official use.                                                73
    Integrating Heterogeneous Systems: Hospital


                                       Hospital Emergency               Homecare


                           Clinic                                                                          Emergency Services




                                           Finance,                                         Electronic
                                                                              Order/                         Specialized
                                          inventory,          ADT                            Patient                            Pharmacy
                                                                              Results                          Care
                                            payroll                                          Record

Community                                                                                                                        Pharmacy
Care Center



                                          Human                                            Clinical Data      Radiology
                                         Resources
                                                           Scheduling
                                                       Clients/PatientsLaboratory           Repository         PACS
                                                                                                                                Emergency




               Specialist Clinic                                                                                   Laboratory




                                      Hospital                                           Diagnostic
                                    Emergency




     ESP SDK                                  WORKING DRAFT RFI: not for official use.                                                      74
    Integrating Heterogeneous Systems: Hospital

                                                                     Homecare


                        Clinic                  Clinic                                               Emergency Services




                                                                                                        Electronic
                                                                                      Accountiing/
                                                                      Scheduling                         Medical
                                                                                        Billing
                                                                                                         Record
Community                                                                                                                  Pharmacy
Care Center




                                                  Clients/Patients




               Specialist Clinic                                                                              Laboratory




                                     Hospital                                         Diagnostic
                                   Emergency




     ESP SDK                               WORKING DRAFT RFI: not for official use.                                                   75
    Locations of Electronic Clinical Data Today: Number of
    Systems to Integrate
                                                                   Homecare


                           Clinic                                                                   Emergency Services




Community
Care Center
                                    DoD/VA each have                                                                     Pharmacy



                                    • 100+ regional systems/hospitals
                                    • 1000+ clinics
                                           Clients/Patients

                                    • 100,000+ clinical staff
                                    • 1,000,000+ patients

               Specialist Clinic                                                                            Laboratory




                                       Hospital                                     Diagnostic
                                     Emergency



                                    HELP NEEDED validating that this Canada Health Infoway based-
                                        slide applies to the US ESP/EHR IS situation & needs.
     ESP SDK                           Please send your feedback to HufnagelS@OSEHRA.org
                                            WORKING DRAFT RFI: not for official use.                                                76
Integrating Health Information Systems: Key Challenges

• Protecting Privacy
   •   Governance, accountability & data custodianship
   •   Controlling access
   •   Managing & applying consent directives
   •   Controlling feeds and queries to the data
   •   Trust relationships & contracts
• Existence & availability of data thru EHR IS
   • Discovery capability
   • Availability in electronic format
   • Timeliness
• Harmonization through EHR IS
   • Data structures (format)
   • Vocabularies (encoding, normalization)
   • Semantics
• Heterogeneous technology environments
• Number of organizations, connection points & systems
• Costs inherent to integration



                               HELP NEEDED validating that this Canada Health Infoway based-
                                   slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                           Please send your feedback to HufnagelS@OSEHRA.org
                                       WORKING DRAFT RFI: not for official use.                77
Recommended Approach:
The Cost of Integration
As A Key Driver




ESP SDK           WORKING DRAFT RFI: not for official use   78
Integrating Health Information Systems:
Point-to-Point Connectivity
                             SYSTEMS TO CONNECT

          Appl 1 1
             App                                                AppAppl 2
                                                                    1
                                                                                         Costs basis
                                                                                         • Cost of one integration
                                    Contracts                                                • Simple = $32K; Medium = $95K;
                     App 1                                 App 1
                                                                                               Complex = $190K
                                        2
                             SYSTEMS TO CONNECT
                                                                                         Futile approach
                                                                                         • 38,783 systems (Canadian example)
             App 1
          Appl 1 App 1                                              1
                                                                AppAppl 2
                                                                                         • Simple = $4,527; Medium = $20,081;
                                                                                           Complex = $14,175
                               Appl 3 App 1
                                  App 1                                                  • 1.5 B integration points
                                                  6                                      • $183.928 B
                             SYSTEMS TO CONNECT

  App 1       App 1
           Appl 1 App 1                                        1
                                                           AppAppl 2        App 1


                                                                                        We need a different approach
  App 1       App 1
           Appl 3 App 1                                        1
                                                           AppAppl 4        App 1



                                     12
                             Interfaces = N (N-1)

                                              HELP NEEDED validating that this Canada Health Infoway based-
                                                  slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                          Please send your feedback to HufnagelS@OSEHRA.org
                                                      WORKING DRAFT RFI: not for official use.                                 79
Integrating Health Information Systems:
Hospital Networks Approach
                             SYSTEMS TO CONNECT

          Appl 1 1
             App                                                AppAppl 2
                                                                    1
                                                                                         Costs basis
                                                                                         • Cost of one integration
                                    Contracts                                                • Simple = $32K; Medium = $95K;
                     App 1                                 App 1
                                                                                               Complex = $190K
                                        2                                                Hypothesis
                             SYSTEMS TO CONNECT
                                                                                         • 1,126 Hospital networks, each
          Appl 1 App 1
             App 1                                              AppAppl 2
                                                                    1                      includes 71 systems to integrate and
                                                                                           group (EAI) in 44 points of
                                                                                           integration
                               Appl 3 App 1
                                  App 1
                                                                                         • 1,892 (44 x 43) integrations per
                                                  6                                        network totalling 2.1 M (1,126 x
                             SYSTEMS TO CONNECT
                                                                                           1,892) (Canadian example)
                                                                                         • Assuming existence of standardized
              App 1
           Appl 1 App 1                                        1
                                                           AppAppl 2
  App 1                                                                     App 1
                                                                                           protocol for interfaces
                                                                                         • $68.172 M          (if Simple – $32K)
  App 1       App 1
           Appl 3 App 1                                        1
                                                           AppAppl 4        App 1        • $202.316 M (if Medium – $95K)

                                     12                                                 We need a different approach
                             Interfaces = N (N-1)

                                              HELP NEEDED validating that this Canada Health Infoway based-
                                                  slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                          Please send your feedback to HufnagelS@OSEHRA.org
                                                      WORKING DRAFT RFI: not for official use.                                     80
Rational for Recommended Approach

• Only cost effective scenario to handle degree of application integration required
• Maximized ability to deliver proper response time and consistent access to data
  across thousands of source systems
• Maximized ability to apply privacy and security policies in a harmonized and
  consistent fashion
• Enables evolutionary path to semantic harmonization of health information
  across service delivery points
• Enables high degree of scalability from local health services integration, to
  regional, state and cross-organizational
• Enables high degree of flexibility in reconfiguration of health services
  delivery networks




                            HELP NEEDED validating that this Canada Health Infoway based-
                                slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                        Please send your feedback to HufnagelS@OSEHRA.org
                                    WORKING DRAFT RFI: not for official use.                81
  Architecture Perspectives

                  Business
                 Architecture


                                  Clinical
 Potential
                                Work Process
Applications
                                Architecture



                CONTEXT
Integration &
                                  System
 Deployment
                                Architecture
   Models



                 Information
                 Architecture




ESP SDK                         WORKING DRAFT RFI: not for official use   82
EHR IS Work Process Architecture

• The EHR Clinical Reference Framework: Life of the Lamberts
• Depiction of the use of an integrated EHR Solution in different contexts of health
  service delivery
   • 14 different storyboards created
   • Extensible by adding new use cases
   • System or security administration use cases not represented
• Life of the Lamberts
   • Patient centric framework
   • Focused on different members of a family and their health status evolution
   • Focused on health related events
• Represented with UML use case notation
• Published as artefacts under the Artefact Repository
   • Available in HTML and PDF format
   • Available in Magic Draw format and XMI for upload to other case tools

          Functional/Clinical Help needed downloading, verifying, validating
                the 14 storyboards and integrating them into the SDK
     https://www.infoway-inforoute.ca/working-with-ehr/knowledgeway/knowledge-center/657
                             HELP NEEDED validating that this Canada Health Infoway based-
                                 slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                         Please send your feedback to HufnagelS@OSEHRA.org
                                     WORKING DRAFT RFI: not for official use.                83
    EHR IS Reference Architecture




                                                                                                                                    Comm Step Put New Patient
                                                                                                                                                  EHR IS
                                                                                                                                          POS APPLICATION
                                                                                                                                                       SIGNIFICANT REUSE
                                                                 Encounter
                                                                                                                                                              HERE

        Life Of                         COPD                     Encounter                     Clinical Activity                Clinical Events              EHR IP
     The Lamberts                     Storyboard                                                                                                         Add New Patient
                                                                    New                             New                          Clinic Visit
                                      Storyboard              Family Physician                Family Physician                   Admission                     EHR IP
                                                                  Activity                        Activity
                                      Storyboard                                                                                                               EHR IP
                                                                                               Clinical Activity                Clinical Events

                                                                                                                                Clinical Events                EHR IP

                  EHR IP                  EHR IP             EHR IP
                                                            Radiology              EHR IP                  EHR IP                  EHR IP                 EHR IP
                Public Health            Pharmacy                                Lab System             Hospital, LTC,            Physician
                                                             Center                                                                                     EHR Viewer
                  Services                System                                    (LIS)                CCC, EPR                Office EMR
                                                            PACS/RIS




                      Public Health            Pharmacist        Radiologist          Lab Clinician                Physician/            Physician/             Physician/
                        Provider                                                                                    Provider              Provider               Provider
POINT OF SERVICE



                                                    HELP NEEDED validating that this Canada Health Infoway based-                                 EHR IS
                                                        slide applies to the US ESP/EHR IS situation & needs.                                    Reference
    ESP SDK                                            Please send your feedback to HufnagelS@OSEHRA.org
                                                           WORKING DRAFT RFI: not for official use                                              Architecture            84
      Documenting EHRi Services Requirements
 ORGANIZATIONAL INFOSTRUCTURE

      Registries Data                       Population Health Data                                                       EHR Data                                                      Data
        & Services                               & Services                                                              & Services                                                  Warehouse
                    EAI IP


          Client
         Registry                      Outbreak              PHS                     Shared                    Drug                Diagnostic                                          Health
                                                                                                                                                       Laboratory
                                      Management           Reporting              Health Record            Information              Imaging                                         Information
                    EAI IP




         Provider
         Registry                       EAI IP              EAI IP                   EAI IP                  EAI IP                 EAI IP                EAI IP
                    EAI IP




         Location
         Registry                           Business             EHR            Message           Normalization
                                             Rules              Index           Structures           Rules
                    EAI IP




        Terminology
          Registry                                                        Information Access & Longitudinal Record Services (LRS)

                                                                                                  EAI IP

                                                                                                                               Security Mgmt       Privacy          Configuration
                             EHR IS                                                               EAI IP                        Rules/Data        Rules/Data         Rules/Data

                                                                                             Information and Common Services
           EHR IS
                                                       IP “Put”                                       IP “Get”
                                                                                 IP “List” Secure Communications Bus                      IP “List”                  IP “Get”
                                                             EHR IP                     EHR IP                        EHR IP                     EHR IP                     EHR IP
IP is Interoperability Profile                               Data                       Data                          Data                       Data                       Data

EAI is Enterprise Application Integration              EHR IP                     EHR IP                       EHR IP                        EHR IP                    EHR IP

                                                    Hospital, LTC,               Physician                   Physician
                                                                                                                                         EHR Viewer                  EHR Viewer
                                                     CCC, EPR                   Office EMR                  Office EMR




 POINT OF SERVICE                                           Radiologist               Lab Clinician                   Physician/                 Physician/                 Physician/
                                                                                                                       Provider                   Provider                   Provider



                                                                HELP NEEDED validating that this Canada Health Infoway based-                                        EHR IS
                                                                    slide applies to the US ESP/EHR IS situation & needs.                                           Reference
       ESP SDK                                                     Please send your feedback to HufnagelS@OSEHRA.org
                                                                        WORKING DRAFT RFI: not for official use.                                                   Architecture                   85
    People Use Cases: Caregiver Perspective
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data                 Population Health Data                                              EHR Data                                               Data
     & Services                         & Services                                                     & Services                                           Warehouse

               • First class of SDK informative deliverables are contextual & informational
               • They describe the end-user functional requirements and assumptions for use of an integrated EHR Solution
                 (DoDAF OV-3: Operational Resource Flow Matrix)
               • Establish when POS applications expected to interact with an EHRi in the context of daily work activities
                 for caregivers (DODAF OV-6c: Event-Trace Description aka BPMN use case diagrams)
               • ESP SDK is only documenting Interoperability Specifications (ISs); not internal EHR features.
               • Scope is broad enough to cover large spectrum of healthcare and public health service delivery to
                 achieve representative set
                                                                                                           Security Mgmt      Privacy       Configuration
                                                                                                            Rules/Data       Rules/Data      Rules/Data

                                                                            Information and Common Services
        EHR IS
                                                                               Secure Communications Bus




                                             EHR INTERFACE REQUIREMENTS DOCUMENTATION
                                                            Radiology
                 Public Health           Pharmacy                                 Lab System            Hospital, LTC,          Physician
                                                             Center                                                                                  EHR Viewer
                   Services               System                                     (LIS)               CCC, EPR              Office EMR
                                                            PACS/RIS
                                                             Storyboards,                      Events, Encounters,                    Clinical Activities,
                      Stakeholder Entities
                                                              Use Cases                         Episodes of Care                   Information Exchanges

                       Public Health          Pharmacist         Radiologist           Lab Clinician            Physician/           Physician/             Physician/
                         Provider                                                                                Provider             Provider               Provider
POINT OF SERVICE



                                                    HELP NEEDED validating that this Canada Health Infoway based-
                                                        slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                            Please send your feedback to HufnagelS@OSEHRA.org
                                                            WORKING DRAFT RFI: not for official use.                                                                86
    EHR Interoperability Profile (EHR IP)
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data                 Population Health Data                                               EHR Data                                        Data
     & Services                         & Services                                                      & Services                                    Warehouse

           • Second class of SDK normative deliverables; specify the interfaces between POS applications
             and ESP Enabled System (DODAF SV-6: Systems Resource Flow Matrix & SvcV-6: Services Resource Flow
             Matrix)
           • Establishes a language to describe types of service requests made to an EHRi (DODAF SV-1: Systems
             Interface Description & SvcV-1: Services Context Description)
           • Positions which data to be exchanged by referring to data views of the data model (DODAF DIV-1:
             Conceptual Data Model & DIV-2: Logical Data Model)
           • Assumes SOAP-based web services calls where XML encoded HL7 V3 message requests … V3?
             and responses are carried between POS applications and the EHRi



        EHR IS



                                                                EHR Interoperability Profile (IP)
                                                             Radiology
                 Public Health           Pharmacy                                  Lab System          Hospital, LTC,          Physician
                                                               Center                                                                            EHR Viewer
                   Services               System       Information Exchange                              CCC, EPR
                                                                                      (LIS) Information Exchange              Office EMR
                                                             PACS/RIS
                                                            Content Standards               Transport Standards



                       Public Health          Pharmacist             Radiologist        Lab Clinician            Physician/         Physician/         Physician/
                         Provider                                                                                 Provider           Provider           Provider
POINT OF SERVICE



                                                    HELP NEEDED validating that this Canada Health Infoway based-
                                                        slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                            Please send your feedback to HufnagelS@OSEHRA.org
                                                            WORKING DRAFT RFI: not for official use.                                                           87
    EHR Infostructure IP (EHR I-IP)
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data             Population Health Data                                            EHR Data                                   Data
     & Services                     & Services                                                   & Services                               Warehouse

       Client
      Registry             Outbreak            PHS               Shared                Drug             Diagnostic                          Health
                                                                                                                            Laboratory
                          Management         Reporting        Health Record        Information           Imaging                         Information
      Provider
      Registry
           • Third class of SDK normative deliverables; specify inner workings within ESP Enabled System Infostructure to
             orchestrate and process transactions (DODAF SV-10c: Systems Event-Trace Description & SvcV-10c:
      Location
      Registry               Business     EHR       Message     Normalization
             Services Event-Trace Description)
                              Rules      Index      Structures     Rules

           • Express
    Terminology                                      Information transactions (DODAF SV-5a: Operational Activity to Systems
                         sequencing of activities to process Access & Longitudinal Record Services (LRS)
      Registry
                 Function Traceability Matrix & SvcV-5: Operational Activity to Services Traceability Matrix)
           • Express expected capabilities of services within an EHRi to process transactions (DODAF CV-3: Capability
                                                                                   Security Mgmt  Privacy   Configuration
             Phasing)                                                               Rules/Data   Rules/Data  Rules/Data

                                                                      Information and Common Services
        EHR IS
                                                                        Secure Communications Bus




                                          INFOSTRUCTURE INTEROPERABILITY PROFILE

                                       Infostructure                   Infostructure                          Generic Interface
                                             IP                     Services Catalogue                         Specification



POINT OF SERVICE



                                                 HELP NEEDED validating that this Canada Health Infoway based-
                                                     slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                         Please send your feedback to HufnagelS@OSEHRA.org
                                                        WORKING DRAFT RFI: not for official use.                                                       88
    Enterprise Application Integration (EAI IP)
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data             Population Health Data                                            EHR Data                                    Data
     & Services                     & Services                                                   & Services                                Warehouse

       Client
      Registry             Outbreak             PHS              Shared                Drug             Diagnostic                           Health
                                                                                                                             Laboratory
                          Management          Reporting       Health Record        Information           Imaging                          Information
      Provider
      Registry
            • Fourth class of SDK normative deliverables; specify inner workings within ESP Enabled System Applications
      Locationto orchestrate and process transactions (DODAF SV-10c: Systems Event-Trace Description & SvcV-10c:
      Registry               Business       EHR       Message   Normalization
              Services Event-Trace Description)
                              Rules        Index     Structures     Rules

           •
    TerminologyExpress                               process transactions (DODAF SV-5a: Operational Activity to Systems
                         sequencing of activities to Information Access & Longitudinal Record Services (LRS)
      Registry
                 Function Traceability Matrix & SvcV-5: Operational Activity to Services Traceability Matrix)
            • Express expected capabilities of services within an EHRi to process transactions (DODAF CV-3: Capability
                                                                                    Security Mgmt  Privacy   Configuration
              Phasing)                                                               Rules/Data   Rules/Data  Rules/Data

                                                                      Information and Common Services
        EHR IS
                                                                        Secure Communications Bus




                           Enterprise Application Integration Interoperability Profile / Specification


                                       Application                   Application                         Generic Interface
                                           IP                    Services Catalogue                       Specification



POINT OF SERVICE



                                                 HELP NEEDED validating that this Canada Health Infoway based-
                                                     slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                         Please send your feedback to HufnagelS@OSEHRA.org
                                                         WORKING DRAFT RFI: not for official use.                                                       89
  Architecture Perspectives

                  Business
                 Architecture


                                  Clinical
 Potential
                                Work Process
Applications
                                Architecture



                CONTEXT
Integration &
                                  System
 Deployment
                                Architecture
   Models



                 Information
                 Architecture




ESP SDK                         WORKING DRAFT RFI: not for official use   90
    EHR Infostructure: Services Drill-Down
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data                  Population Health Data                                                      EHR Data                                                   Data
     & Services                          & Services                                                             & Services                                               Warehouse

       Client
      Registry                Outbreak                 PHS                   Shared                   Drug              Diagnostic                                         Health
                                                                                                                                           Laboratory
                             Management              Reporting            Health Record           Information            Imaging                                        Information
      Provider
      Registry


      Location
      Registry                          Business           EHR          Message           Normalization
                                         Rules            Index         Structures           Rules

    Terminology                                                   Information Access & Longitudinal Record Services (LRS)
      Registry



                                                                                                                    Security Mgmt      Privacy          Configuration
                                                                                                                     Rules/Data       Rules/Data         Rules/Data

                                                                                     Information and Common Services
        EHR IS
                                                                                       Secure Communications Bus




                                                                  Radiology
                  Public Health              Pharmacy                                     Lab System             Hospital, LTC,          Physician
                                                                   Center                                                                                        EHR Viewer
                    Services                  System                                         (LIS)                CCC, EPR              Office EMR
                                                                  PACS/RIS




                        Public Health              Pharmacist           Radiologist             Lab Clinician            Physician/           Physician/                  Physician/
                          Provider                                                                                        Provider             Provider                    Provider
POINT OF SERVICE



                                                        HELP NEEDED validating that this Canada Health Infoway based-
                                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                Please send your feedback to HufnagelS@OSEHRA.org
                                                                WORKING DRAFT RFI: not for official use.                                                                              91
    EHR Infostructure: Standards Based Connectivity
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data                              Population Health Data                                                             EHR Data                                                        Data
     & Services                                      & Services                                                                    & Services                                                    Warehouse
                  EAI IP


        Client
       Registry                          Outbreak                    PHS                     Shared                      Drug              Diagnostic                                              Health
                                                                                                                                                                   Laboratory
                                        Management                 Reporting              Health Record              Information            Imaging                                             Information
                  EAI IP




       Provider
       Registry                            EAI IP                   EAI IP                    EAI IP                   EAI IP                EAI IP                 EAI IP
                  EAI IP




       Location
       Registry                                     Business            EHR             Message           Normalization
                                                     Rules             Index            Structures           Rules
                  EAI IP




     Terminology
       Registry                                                                   Information Access & Longitudinal Record Services (LRS)

                                                                                                            EAI IP
                                           IP is Interoperability Profile
                                           EAI is Enterprise Application Integration                                                    Security Mgmt
                                                                                                                                         Rules/Data
                                                                                                                                                            Privacy
                                                                                                                                                           Rules/Data
                                                                                                                                                                                Configuration
                                                                                                                                                                                 Rules/Data
                           EAI IP                                                                           EAI IP
                                                                                                     Information and Common Services
            EHR IS
                                                                                                       Secure Communications Bus
                             EHR IP                       EHR IP                   EHR IP                    EHR IP                     EHR IP                   EHR IP                    EHR IP
EHR SCP
Standards                            EHR IP Standards          EHR IP Standards          EHR IP Standards            EHR IP Standards        EHR IP Standards         EHR IP Standards            EHR IP Standards

                             EHR IP                       EHR IP                   EHR IP                    EHR IP                     EHR IP                   EHR IP                    EHR IP

                                                                                  Radiology
                           Public Health                 Pharmacy                                           Lab System              Hospital, LTC,               Physician
                                                                                   Center                                                                                                EHR Viewer
                             Services                     System                                               (LIS)                 CCC, EPR                   Office EMR
                                                                                  PACS/RIS




POINT OF SERVICE                    Public Health              Pharmacist               Radiologist              Lab Clinician              Physician/                Physician/                  Physician/
                                      Provider                                                                                               Provider                  Provider                    Provider




                                                                      HELP NEEDED validating that this Canada Health Infoway based-
                                                                          slide applies to the US ESP/EHR IS situation & needs.
     ESP SDK                                                             Please send your feedback to HufnagelS@OSEHRA.org
                                                                              WORKING DRAFT RFI: not for official use.                                                                                        92
    EHR Infostructure: Secure Communications Bus
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                        EHR Data             Data
     & Services             & Services                                               & Services         Warehouse




                     Secure Communications Bus

                                 MESSAGING

                      Transformation             Routing
                         Services                Services

                      Encrypt/Decrypt           En/Decoding
                         Services                Services

                          Parser                Serialization
                         Services                Services


        EHR IS
                                    PROTOCOL                    Secure Communications Bus

                       App Protocol        Network Protocol
                         Services             Services




POINT OF SERVICE



                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                       93
    EHR Infostructure: Common Services
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data           Population Health Data                                                 EHR Data                                            Data
                                    COMMON SERVICES
                                  & Services                                                        & Services                                        Warehouse
     & Services

           INTEROP                                    PRIVACY & SECURITY
          Interoperability   Identity Protection            Anonymization          Consent Directives
             Services             Services                    Services              Mgmt Services

        Search/Resolution      Identity Mgmt              User Authentication          Encryption
            Services             Services                      Services                 Services

                              Access Control               Secure Auditing           Digital Signature
       INTEGRATION               Services                     Services                   Services

        Service Catalogue
                                                           General Security
            Services
                                                              Services

         Broker Services                                                                                 Security Mgmt    Privacy     Configuration
                             SUBSCRIPTION                 MANAGEMENT                  GENERAL             Rules/Data     Rules/Data    Rules/Data
        Mapping Services
                              Alert/Notification             Management Information and Common Services
                                                                                         Auditing
        EHR IS                    Services                    Services                   Services
        Queuing Services

                                  Pub/Sub                   Configuration               Log Mgmt
          CONTEXT                 Services                    Services                   Services

        Caching Services                                     Policy Mgmt             Exception/Error
                                                              Services              Handling Services
          Session Mgmt
            Services




POINT OF SERVICE



                                                   HELP NEEDED validating that this Canada Health Infoway based-
                                                       slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                           Please send your feedback to HufnagelS@OSEHRA.org
                                                           WORKING DRAFT RFI: not for official use.                                                          94
    EHR Infostructure: Longitudinal Record Services (LRS)
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                                EHR Data                                             Data
     & Services             & Services                                                       & Services                                         Warehouse




                                                                                               Longitudinal Record Services (LRS)

                                                                                                                      DATA
                                                                                                        Key Mgmt                 Data
                       Business            EHR          Message         Normalization                   Services                Services
                        Rules             Index         Structures         Rules
                                                                                                           ETL                 Replication
                                                  Information Access & Longitudinal Record Services (LRS)Services               Services



                                                                                                                    BUSINESS
                                                                                                       Data Quality          Normalization
                                                                                                        Services               Services
        EHR IS
                                                                                                         Domain Business Components
                                                                                                    (Registries, EHR, Domains, User, Context)


                                                                                                       EHR Index             Business Rules
                                                                                                        Services                Services

                                                                                                      Orchestration            Assembly
                                                                                                        Services               Services




POINT OF SERVICE



                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                                                               95
    EHR Infostructure: Longitudinal Record Services (LRS)
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data                Population Health Data                                                EHR Data                                             Data
     & Services                        & Services                                                       & Services                                         Warehouse
    The EHR Index maintains a sequential list of all events that affect the clinical
    picture of a client. It also provides the location where the data relevant to each
    event is kept in the EHRi. It can be used to retrieve the history of events for a
    client or to trace the information about a specific event.                                            Longitudinal Record Services (LRS)

                                                                                                                                 DATA
                                                                                                                   Key Mgmt                 Data
    EHR INDEX                     Business            EHR          Message         Normalization                   Services                Services
    Event ID (Instance ID of an    Rules
                                  event)             Index         Structures         Rules

    Parent Folder ID                                                                                                  ETL                 Replication
                                                             Information Access & Longitudinal Record Services (LRS)Services               Services
    Focal Class Type
    Focal Act Subject (Client ECID)
    Focal Act Author (Provider)                                                                                                BUSINESS
    Focal Act Service Delivery Location                                                                           Data Quality          Normalization
    Focal Act Timestamp                                                                                            Services               Services
       EHR IS
    Focal Act Status
                                                                                                                    Domain Business Components
    Focal Act Language                                                                                         (Registries, EHR, Domains, User, Context)
    Focal Act Type:
          • Act Mood (e.g. Order Request)                                                                         EHR Index             Business Rules
                                                                                                                   Services                Services
          • Act Class Code (type of class, e.g. Lab order)
          • Act Code (Class value, e.g. CBC)                                                                     Orchestration            Assembly
    Focal Act Source ID (ID provided by POS)                                                                       Services               Services

    Focal Act Template ID
    Focal Act Data Location ID (URI)

POINT OF SERVICE



                                                   HELP NEEDED validating that this Canada Health Infoway based-
                                                       slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                           Please send your feedback to HufnagelS@OSEHRA.org
                                                           WORKING DRAFT RFI: not for official use.                                                               96
    EHR Infostructure: EHR IS Locator Data
CROSS-ORGANIZATIONAL INFOSTRUCTURE
                                                                                                                   •   EHRi Client ID (resolved ECID)
                                                                                                                   •   CR instance ID (OID root)
                                                                                            EHR IS                 •   EHRi instance ID (which instance of an EHRi)
                                                                                            Locator                •   EHRi URI (the URI to access the EHR IS)
                                                                                                                   •   Optimized for performance
                                                                                                                         • Information type (drug, lab, DI) (derived from HL7 act classes)
                                                                                                                         • First created date
                                                                                                                         • Last updated date


ORGANIZATIONAL INFOSTRUCTURE

                     EHR IS ENABLED SYSTEM SOLUTION                                                        EHR IS ENABLED SYSTEM SOLUTION

                           EHR INFOSTRUCTURE (EHRi)                                                                EHR INFOSTRUCTURE (EHRi)

              Population                Health                                                        Population               Health
                                                           EHR                 Registries                                                        EHR                 Registries
                Health               Information                                                        Health              Information
                                                          Data &                Data &                                                          Data &                Data &
                Data &                   Data                                                           Data &                  Data
                                                         Services              Services                                                        Services              Services
               Services              Warehouse                                                         Services             Warehouse




                   Information Access & Longitudinal Record Services (LRS)                               Information Access & Longitudinal Record Services (LRS)



                               EHR Information Services (EHR IS)                                                        EHR Information Services (EHR IS)




                     Point of                   Point of                                                   Point of                   Point of
                     Service                    Service                      EHR Viewer                    Service                    Service                      EHR Viewer
                    Application                Application                                                Application                Application



POINT OF SERVICE


                                                               HELP NEEDED validating that this Canada Health Infoway based-
                                                                   slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                       Please send your feedback to HufnagelS@OSEHRA.org
                                                                       WORKING DRAFT RFI: not for official use.                                                                              97
    Centralized Service Approach
CROSS-ORGANIZATIONAL INFOSTRUCTURE
                                                                                                                     EHR IS
                                                                                                                     Locator




ORGANIZATIONAL INFOSTRUCTURE

           EHR IS ENABLED SYSTEM SOLUTION                                                    EHR IS ENABLED SYSTEM SOLUTION                                              EHR IS ENABLED SYSTEM SOLUTION

                  EHR INFOSTRUCTURE (EHRi)                                                           EHR INFOSTRUCTURE (EHRi)                                                    EHR INFOSTRUCTURE (EHRi)


     Population               Health                                                    Population               Health                                             Population               Health
                                               EHR                  Registries                                                    EHR                  Registries                                             EHR                  Registries
       Health              Information                                                    Health              Information                                             Health              Information
                                              Data &                 Data &                                                      Data &                 Data &                                               Data &                 Data &
       Data &                  Data                                                       Data &                  Data                                                Data &                  Data
                                             Services               Services                                                    Services               Services                                             Services               Services
      Services             Warehouse                                                     Services             Warehouse                                              Services             Warehouse




       Information Access & Longitudinal Record Services (LRS)                            Information Access & Longitudinal Record Services (LRS)                     Information Access & Longitudinal Record Services (LRS)



                       EHR Information Services (EHR IS)                                                  EHR Information Services (EHR IS)                                           EHR Information Services (EHR IS)




        Point of Service          Point of Service                                         Point of Service          Point of Service                                  Point of Service          Point of Service
                                                                 EHR Viewer                                                                         EHR Viewer                                                                  EHR Viewer
          Application               Application                                              Application               Application                                       Application               Application




POINT OF SERVICE
                               Organization                                                                     Organization                                                                 Organization



                                     A                                                                                B                                                                            C
                                                                                 HELP NEEDED validating that this Canada Health Infoway based-
                                                                                     slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                                         Please send your feedback to HufnagelS@OSEHRA.org
                                                                                         WORKING DRAFT RFI: not for official use.                                                                                                               98
    Distributed Service Approach
CROSS-ORGANIZATIONAL INFOSTRUCTURE
                                                                                                 EHR IS Locator Synchronization



                                                                                 EHR IS                                                                                EHR IS
                                                                                 Locator                                                                               Locator



ORGANIZATIONAL INFOSTRUCTURE

           EHR IS ENABLED SYSTEM SOLUTION                                                       EHR IS ENABLED SYSTEM SOLUTION                                                        EHR IS ENABLED SYSTEM SOLUTION

                  EHR INFOSTRUCTURE (EHRi)                                                              EHR INFOSTRUCTURE (EHRi)                                                              EHR INFOSTRUCTURE (EHRi)


     Population               Health                                                       Population               Health                                                       Population               Health
                                               EHR                  Registries                                                       EHR                  Registries                                                       EHR                  Registries
       Health              Information                                                       Health              Information                                                       Health              Information
                                              Data &                 Data &                                                         Data &                 Data &                                                         Data &                 Data &
       Data &                  Data                                                          Data &                  Data                                                          Data &                  Data
                                             Services               Services                                                       Services               Services                                                       Services               Services
      Services             Warehouse                                                        Services             Warehouse                                                        Services             Warehouse




       Information Access & Longitudinal Record Services (LRS)                               Information Access & Longitudinal Record Services (LRS)                               Information Access & Longitudinal Record Services (LRS)



                       EHR Information Services (EHR IS)                                                     EHR Information Services (EHR IS)                                                     EHR Information Services (EHR IS)




        Point of Service          Point of Service                                            Point of Service          Point of Service                                            Point of Service          Point of Service
                                                                 EHR Viewer                                                                            EHR Viewer                                                                            EHR Viewer
          Application               Application                                                 Application               Application                                                 Application               Application




POINT OF SERVICE
                               Organization                                                                        Organization                                                                           Organization



                                     A                                                                                   B                                                                                      C
                                                                                 HELP NEEDED validating that this Canada Health Infoway based-
                                                                                     slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                                         Please send your feedback to HufnagelS@OSEHRA.org
                                                                                         WORKING DRAFT RFI: not for official use.                                                                                                                            99
    EHR IS Locator: LRS Integrated Approach
CROSS-ORGANIZATIONAL INFOSTRUCTURE
                                                                     EHR IS
                                                                     Locator



ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                                EHR Data         Data
     & Services             & Services                                                       & Services     Warehouse

       Client
      Registry


      Provider
      Registry


      Location
      Registry         Business            EHR          Message         Normalization
                        Rules             Index         Structures         Rules

    Terminology                                   Information Access & Longitudinal Record Services (LRS)
      Registry




        EHR IS




POINT OF SERVICE



                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                          100
    LRS Integrated Services Approach
CROSS-ORGANIZATIONAL INFOSTRUCTURE
                                                                                               Client Registry Synchronization




ORGANIZATIONAL INFOSTRUCTURE

           EHR IS ENABLED SYSTEM SOLUTION                                                    EHR IS ENABLED SYSTEM SOLUTION                                              EHR IS ENABLED SYSTEM SOLUTION

                  EHR INFOSTRUCTURE (EHRi)                                                           EHR INFOSTRUCTURE (EHRi)                                                    EHR INFOSTRUCTURE (EHRi)


     Population               Health                                                    Population               Health                                             Population               Health
                                               EHR                  Registries                                                    EHR                  Registries                                             EHR                  Registries
       Health              Information                                                    Health              Information                                             Health              Information
                                              Data &                 Data &                                                      Data &                 Data &                                               Data &                 Data &
       Data &                  Data                                                       Data &                  Data                                                Data &                  Data
                                             Services               Services                                                    Services               Services                                             Services               Services
      Services             Warehouse                                                     Services             Warehouse                                              Services             Warehouse




       Information Access & Longitudinal Record Services (LRS)                            Information Access & Longitudinal Record Services (LRS)                     Information Access & Longitudinal Record Services (LRS)



                       EHR Information Services (EHR IS)                                                  EHR Information Services (EHR IS)                                           EHR Information Services (EHR IS)




        Point of Service          Point of Service                                         Point of Service          Point of Service                                  Point of Service          Point of Service
                                                                 EHR Viewer                                                                         EHR Viewer                                                                  EHR Viewer
          Application               Application                                              Application               Application                                       Application               Application




POINT OF SERVICE
                               Organization                                                                     Organization                                                                 Organization



                                     A                                                                                B                                                                            C
                                                                                 HELP NEEDED validating that this Canada Health Infoway based-
                                                                                     slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                                         Please send your feedback to HufnagelS@OSEHRA.org
                                                                                         WORKING DRAFT RFI: not for official use.                                                                                                               101
    EHR Infostructure: EHR Data Domain Services
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                            EHR Data                                Data
     & Services             & Services                                                   & Services                            Warehouse


                                                        Shared                 Drug              Diagnostic
                                                                                                                  Laboratory
                                                     Health Record         Information            Imaging




                                                                      SHARED HEALTH RECORD

                                                                                         DATA

                                                                          Key Mgmt                  Data
                                                                          Services                 Services




        EHR IS                                                                       BUSINESS
                                                                           Domain Business Components
                                                                      (Registries, EHR, Domains, User, Context)


                                                                        Normalization           Business Rules
                                                                          Services                 Services

                                                                     EHRi Interoperability        Assembly
                                                                          Services                Services




POINT OF SERVICE



                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                                             102
    EHR Infostructure: EHR Viewer
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                     EHR Data                                 Data
     & Services             & Services                                            & Services                             Warehouse




                                                                                     EHR VIEWER


                                                                         EHRi Interoperability       Data
                                                                              Services              Services




                                                                                        EHR Viewer
                                                                                Business Objects Components


                                                                            Normalization        Business Rules
                                                                              Services              Services
        EHR IS
                                                                              End-user              End-user
                                                                         Navigation Services     Display Services




                                                                                                                    EHR Viewer




                                                                                                                          Physician/
                                                                                                                           Provider
POINT OF SERVICE



                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                                         103
    EHR Infostructure: Client Registry
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                   EHR Data                  Data
     & Services             & Services                                          & Services              Warehouse

       Client
      Registry


      Provider
      Registry


      Location
      Registry


    Terminology
      Registry




        EHR IS




POINT OF SERVICE



                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                      104
    EHR Infostructure: Why A Client Registry?
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                    EHR Data                      Data
     & Services             & Services                                           & Services                  Warehouse

       Client
      Registry


      Provider
      Registry


      Location
      Registry
                                         Has Mr. Lambert had any ER
    Terminology                          visits since I’ve last seen him
      Registry
                                                  one year ago?



        EHR IS




                                                            Patient      End-user
                                                             Info          Info                         EHR Viewer

                                                             Visit          Drug
                                                            History        Profile

                                                                         Diagnostic
                                                          Laboratory
                                                                          Imaging                             Physician/
                                                                                                               Provider
POINT OF SERVICE

                                                                              EHR VIEWER

                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                             105
EHRi Client Registry: The Challenge



                                                     EMPI




                                      1: A 123 Robert Lambert 1 Main St
                                      1: B 456 Bob Lambert 1 Main St
                                      1: C 789 Robert Lambert 1 Main St
                                      1: C 987 Robert Lambert 1 Main St

                                      2: B 444 Robert Lambert 2 Elm St




         Pharmacy                                     Lab                                                  ???


            A                                        B                                                    C
123 Robert Lambert 1 Main St              456 Bob Lambert 1 Main St                            789 Robert Lambert 1 Main St
                                          444 Robert Lambert 2 Elm St                          987 Robert Lambert 1 Main St



                               HELP NEEDED validating that this Canada Health Infoway based-
                                   slide applies to the US ESP/EHR IS situation & needs.
 ESP SDK                          Please send your feedback to HufnagelS@OSEHRA.org
                                       WORKING DRAFT RFI: not for official use.                                               106
     EHRi Client Registry: What Data?




     The generation (or sourcing)                                        Name
                                                                         Birthdate
     of the EHRI Client Identifier                                       Gender               Address       SSN
     (ECID) is a service offered                                                              Phone         ULI
     by the Client Registry.                                                                                             MDR ID
                                                                                                            ECID
                                                                                                                         Lab ID
     The ECID is the foundation                                                                                                                Eligibility status
     for interoperability both                                                                                                                 Coverage details
     locally and across EHR
     Infostructures.




   MDR – Medical Device Regulations                    Static, natural          Dynamic, natural    Static, artificial   Dynamic, artificial          Core system data
   SSN – Social Security Number                        person identity
                                                       information
                                                                                person identity
                                                                                information
                                                                                                    person-identifying
                                                                                                    information
                                                                                                                         person-identifying
                                                                                                                         information
                                                                                                                                                      about the person

   ULI – Unique Lifetime Identifier
 The DoD & VA ULI is called Electronic Data Interchange Personal Number, or EDIPN, is a unique number assigned to a record in the United States Department
of Defense's Defense Enrollment and Eligibility Reporting System (DEERS) database. A record in the DEERS database is a person plus personnel category (e.g.
                                                          contractor, reservist, civilian, active duty, etc.).
                                                 HELP NEEDED validating that this Canada Health Infoway based-
                                                     slide applies to the US ESP/EHR IS situation & needs.
      ESP SDK                                       Please send your feedback to HufnagelS@OSEHRA.org
                                                         WORKING DRAFT RFI: not for official use.                                                               107
   EHRi Client Registry: Interoperability Pattern
ORGANIZATIONAL

                      ECID: J1 Root ID. Client ID                                           ECID: J2 Root ID. Client ID


                                 Client                                                                Client
                                Registry                                                              Registry
                                  J1                          Active synchronization                    J2
                                                              of travelling clients only




            Client                           Client
           Registry                         Registry
            J1.1                             J1/2




                            Applications                                                              Applications




                                             HELP NEEDED validating that this Canada Health Infoway based-
                                                 slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                     Please send your feedback to HufnagelS@OSEHRA.org
                                                     WORKING DRAFT RFI: not for official use.                             108
    EHR Infostructure: Provider Registry
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                   EHR Data                  Data
     & Services             & Services                                          & Services              Warehouse

       Client
      Registry


      Provider
      Registry


      Location
      Registry


    Terminology
      Registry




        EHR IS




POINT OF SERVICE



                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                      109
    EHR Infostructure: Why A Provider Registry?
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data     Population Health Data                                    EHR Data                      Data
     & Services             & Services                                           & Services                  Warehouse

       Client
      Registry


      Provider
      Registry


      Location
      Registry


    Terminology
                                       Have any new test results been
      Registry                               published for me?




        EHR IS




                                                            Patient      End-user
                                                             Info          Info                         EHR Viewer

                                                             Visit          Drug
                                                            History        Profile

                                                                         Diagnostic
                                                          Laboratory
                                                                          Imaging                             Physician/
                                                                                                               Provider
POINT OF SERVICE

                                                                              EHR VIEWER

                                        HELP NEEDED validating that this Canada Health Infoway based-
                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                                WORKING DRAFT RFI: not for official use.                             110
   Provider Registry: Data Sources
ORGANIZATIONAL


                                                                                         Unlicensed
                                Doctors              Dentists
                                                                                          Providers




                                                          EHR SCP Standards
                                                           Provider Registry




                                                                 Provider
                                                                 Registry




                                                           EHR SCP Standards
                                                            Provider Registry



                 Applications                                   Applications                              Applications




REGIONAL



                                          HELP NEEDED validating that this Canada Health Infoway based-
                                              slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                  Please send your feedback to HufnagelS@OSEHRA.org
                                                  WORKING DRAFT RFI: not for official use.                               111
    Standards-based
    Solutions: What Does
    It Mean?




ESP SDK             WORKING DRAFT RFI: not for official use   112
integrated EHR Solutions: Key Architectural Requirements



                                                                  Standardized        Standardized
                                                                  Architecture         Interfaces

Standards-based

Solutions
                                                                                       Standardized
                                                                  Standardized
                                                                                    Data Vocabularies
                                                                 Data Structures
                                                                                     (encoding rules)




                                                                Standardized
                                                             Functional Behaviour




ESP SDK                WORKING DRAFT RFI: not for official use                                          113
Standards-based Solutions

Why Standards?
• They facilitate information exchange; are a critical foundation
  for EHR                                                                                       An OSEHRA role is to
• They create opportunity for future cost reduction as vendors
  and systems converge on national and international standards
                                                                                                encourage standards
• They ease effort required for replication
                                                                                                and requirements for
                                                                                                robust, interoperable
Mandatory Investment Eligibility Requirements                                                     EHR products for
• Compliance to standards (infostructure, architecture)                                           improved clinical
• Initiatives must comply with existing guidelines or standards                                      outcomes
  adopted by US Health and Human Services (HHS)
• Where standards or guidelines do not exist, projects must
  support longer-term interoperability and congruence of
  solutions




                                HELP NEEDED validating that this Canada Health Infoway based-
                                    slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                            Please send your feedback to HufnagelS@OSEHRA.org
                                        WORKING DRAFT RFI: not for official use.                                 114
Principles for Establishing ESP Enabled System Standards

• The HL7 has created Principles for Establishing EHR interoperability
• Standards to provide guidance in the adoption of standards-based solutions
• As the ESP SDK evolves, there are many assumptions made that, once implemented in
  the architecture, can no longer be considered assumptions anymore: they are now
  principles about the function of EHR IS Infostructures and EHR IS Solutions that need
  to guide detailed design and development of solutions and Business-driven Adoption of
  existing standards where ever possible




                           HELP NEEDED validating that this Canada Health Infoway based-
                               slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                       Please send your feedback to HufnagelS@OSEHRA.org
                                   WORKING DRAFT RFI: not for official use.                115
Principles for Establishing EHR IS Standards

• Standards initiatives to be driven by the business of healthcare with a
  clearly defined business need
• Existing standards work must be leveraged wherever possible and
  practical with an approach that includes adoption, or adaptation of
  existing standards, before development
• Health Level 7 V3 messaging standard required for all new message
  development related to EHR
• Investments predicated on a commitment to implement
  national EHR Services standards
• Standards to be established, tested, refined and evaluated within the
  context of early adopter implementations
• We should support early adopter investment projects that have the
  establishment of National standards as their goal


                         HELP NEEDED to confirm
                         Official DoD-VA Principles


                            HELP NEEDED validating that this Canada Health Infoway based-
                                slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                        Please send your feedback to HufnagelS@OSEHRA.org
                                    WORKING DRAFT RFI: not for official use.                See notes page   116
Principles for Establishing EHR IS Standards

• Establishing standards is an evolutionary process and will not be
  perfect the first time; implementation of standards that are not fully
  balloted may be needed
• OSEHRA program is committed to supporting influencing EHR
  national and international standards
• OSEHRA program and its stakeholders will work with other
  organizations undertaking similar EHR initiatives to leverage their
  work and bring synergies to the projects as they move toward balloted
  standards
• OSEHRA program and its stakeholders will partner with HL7, IHE,
  OASIS, IHTSDO and other standards organizations in the
  establishment of EHR IS standards
• Establishment of EHR IS related standards is coordinated via an
  open, transparent and inclusive Stakeholder Collaboration Process

                         HELP NEEDED to confirm
                           Appropriate Principles


                            HELP NEEDED validating that this Canada Health Infoway based-
                                slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                        Please send your feedback to HufnagelS@OSEHRA.org
                                    WORKING DRAFT RFI: not for official use.                See notes page   117
Standards Collaboration Process (SCP)

•   An integral element of and key
                                            GOVERNANCE
    requirement for the establishment
                                                                                        EHR Standards Steering Committee
    of an interoperable Electronic
    Health Record (EHR)
•




                                                                                                                                                                               STRATEGIC COLLABORATION/COORDINATION
                                                                                       National EHR Standards Advisory Committee
    The EHR Standards
    Collaboration Process includes
    those Organizations, standards-
    related organizations, healthcare       REGIONAL                                                      Telehealth
                                            DEVELOPMENT
    professionals and vendors that
    will build, operate and use an
    integrated EHR Services Platform                                                                      Lab
    (ESP)




                                                                                                                                                           Infostructure/EHR
                                            Interoperable




                                                                                                                                   Expert Working Groups
•   The EHR Standards Collaboration         EHR                                                           Diagnostic Imaging
    Process will establish standards for
    investments through collaboration
    and consensus                                                                                         Drugs


                                                                                                          Registries


                                                                                                          Infostructure




                                                   National Standards working groups




                                      HELP NEEDED validating that this Canada Health Infoway based-
                                          slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                  Please send your feedback to HufnagelS@OSEHRA.org
                                              WORKING DRAFT RFI: not for official use.                                                                                                118
EHR IS Standards: Status

Needed Standards                                                               Suggested Projects
Groups
• Drugs                                                                        • ESP SDK
                                              Health Surveillance
• Client Registry                                                              • EHR Data Definition & Standards
• Provider Registry                                                            • Standards Collaboration Process
                                                   Telehealth
• DI/Tele-radiology                                                            • Standards Tactical Plan
• Laboratory                                                                   • Artefacts Repository
• Clinical Terminology                                Lab                      • Telehealth ISO Interoperability
• EHR Technical Standards                                                      • Telehealth CCHSA Accreditation
  (coming soon)                               Diagnostic Imaging               • Client Registry
• EHR Clinical Standards                                                       • Provider Registry
  (coming soon)                                                                • Laboratory Nomenclature & Messaging
                                                     Drugs
• Public Health (coming soon)                                                  • NeCST: electronic claims messaging
                                                   Registries                  • EHR Clinical Terminology Integration
                                                                               • EHR Profiles for Interoperability
                                                                                 between DI, Registries & Consumers
                                                integrated EHR
                                                                               • EHR-EHR IS Evolution Project
                                                                               • Privacy & Security Architecture Project

                                HELP NEEDED to confirm
                                     Current Status


                                  HELP NEEDED validating that this Canada Health Infoway based-
                                      slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                              Please send your feedback to HufnagelS@OSEHRA.org
                                          WORKING DRAFT RFI: not for official use.                                     119
   EHR IS Infostructure: Standards-based Connectivity
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data                     Population Health Data                                                     EHR Data                                 Data
     & Services                             & Services                                                            & Services                             Warehouse
               EAI IP




              Architecture Standards                                                Data Messaging Standards
               EAI IP




                                  EAI IP                EAI IP                 EAI IP                 EAI IP               EAI IP       EAI IP
              • ESP Blueprint                                                       • Client Registry
               EAI IP




              • EHR Use Cases                                                       • HL7 Provider Registry
              • FHIM/EHR Data Model                                                 • HL7 Pharmacy
               EAI IP




              • EHR IS Services Model                                               • Laboratory
                                                                                             EAI IP
              • EHR Interoperability Profiles                                       • Public Health Services Standards
              • Terminology Standards
                 EAI IP                                                             • Public Health Surveillance Standards
                                                                                       EAI IP


              • Terminology implemented in data
            EHR IS                                                                  • Diagnostic Imaging/Teleradiology (in planning)
                 messaging standards                                                • Clinical Messaging (in planning) IP
                        EHR IP                 EHR IP                 EHR IP             EHR IP        EHR IP        EHR                              EHR IP
EHR SCP
Standards                   EHR IP Standards       EHR IP Standards
                                                                                    • TechnicalIPStandards EHR IP Standards StdV-1: Standards
                                                                          EHR IP Standards    EHR Standards
                                                                                                              (DODAF              EHR IP                  EHR IP Standards

                        EHR IP                 EHR IP                 EHR IP             EHR IP
                                                                                      Standards ProfileEHR IP DoD-VA shared
                                                                                                            aka              EHR IP                   EHR IP

                                                                                      Standards Profile)



POINT OF SERVICE           Public Health           Pharmacist             Radiologist             Lab Clinician            Physician/    Physician/       Physician/
                             Provider                                                                                       Provider      Provider         Provider




                                                         HELP NEEDED validating that this Canada Health Infoway based-
                                                             slide applies to the US ESP/EHR IS situation & needs.
     ESP SDK                                                Please send your feedback to HufnagelS@OSEHRA.org
                                                                 WORKING DRAFT RFI: not for official use.                                                        120
    Service-oriented
    Architecture (SOA):
    What Does It Mean?




ESP SDK             WORKING DRAFT RFI: not for official use   121
Level of Encapsulation Can Vary:
Five Normal Forms of Encapsulated Software


          External access
                             1                            2                      3                  4                    5
               Other data




                Own data




    Encapsulated software




    Programmatic interface


                                 Overloaded,                One complete          Own data only        Exclusive data      Opaque data
                                 incomplete; any data       function; any data




                             Source: Gartner




                                               HELP NEEDED validating that this Canada Health Infoway based-
                                                   slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                           Please send your feedback to HufnagelS@OSEHRA.org
                                                       WORKING DRAFT RFI: not for official use.                    See notes page        122
SOA as an Enabler

Applications of SOA in EHRi Solutions
• Repurposed legacy applications to offer services as part of
  SOA-based EHR Infostructure
• New breed of services to enable coordinated transactions in an EHR
  Infostructure (e.g. Information Access & Longitudinal Record
  Services (LRS))
• Use of commercially available solutions to enable components of
  EHR Infostructure

Two Degrees of Separation
• Services exposed outside of an EHRi in the form of supported EHR
  Interoperability Profiles for an entire Infostructure perceived as a
  single system with transactional services
• Services within an EHR Infostructure to optimize scalability,
  maintainability and functional flexibility




                            HELP NEEDED validating that this Canada Health Infoway based-
                                slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                        Please send your feedback to HufnagelS@OSEHRA.org
                                    WORKING DRAFT RFI: not for official use.                123
    First Degree: The EHR Service
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data                     Population Health Data                          EHR SERVICE                         EHR Data                                                       Data
     & Services                             & Services                                                                     & Services                                                   Warehouse
                                                      Get Outbreak                      List CD Report
       Client
            Get Client ID                                                                                                        List DI Results                        Get DI Report
                                                       Case Data                             Events
      RegistryResolution         Outbreak                    PHS                     Shared                   Drug                 Diagnostic                                            Health
                                                                                                                                                         Laboratory
                                Management                 Reporting              Health Record           Information                Imaging                                          Information
      Provider
      Registry                                                 List Encounter                            List Laboratory
                 Get Provider                                                                                Results                                   Stream DI Image
                                                                   Events
                 Information
      Location
      Registry                             Business             EHR             Message          Normalization
                                            Rules              Index            Structures          Rules

            List
    Terminology Service                                                    List Laboratory Orders
                                                                                                               Get Laboratory Result
                                                                        Information Access & Longitudinal Record Services (LRS)
      Registry Delivery                                                                                                                                     List Medications
             Locations
                                                Get Encounter
                                                  Summary
                                                                                                                                  Security         Privacy Data       Configuration
                     Get Clinical                                                Get Client
                                                                                                                       Get Prescription
                     Dashboard                                                  Demographic Information and Common Services
        EHR IS
                                                                                               Secure Communications Bus




                                                                         Radiology
                  Public Health                 Pharmacy                                          Lab System                Hospital, LTC,             Physician
                                                                          Center                                                                                               EHR Viewer
                    Services                     System                                              (LIS)                   CCC, EPR                 Office EMR
                                                                         PACS/RIS




                           Public Health               Pharmacist                Radiologist             Lab Clinician              Physician/               Physician/                 Physician/
                             Provider                                                                                                Provider                 Provider                   Provider
POINT OF SERVICE



                                                              HELP NEEDED validating that this Canada Health Infoway based-
                                                                  slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                      Please send your feedback to HufnagelS@OSEHRA.org
                                                                      WORKING DRAFT RFI: not for official use.                                                                                 124
    Second Degree: Inside The EHR Infostructure
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data         Population Health Data
                                                                  EHRi SERVICES                     EHR Data                                                      Data
     & Services
        CR                      & Services                                                          & Services                                                  Warehouse
      Services                             Detection
                      Outbreak                                  Shared Health              Drug                    DI                  Lab
       Client                             & Reporting
                       Services                                Record Services           Services               Services             Services
      Registry        Outbreak             Services
                                            PHS                   Shared                  Drug               Diagnostic                                           Health
                                                                                                                                  Laboratory
                     Management           Reporting            Health Record          Information             Imaging                                          Information
        PR
      Provider
      Services
      Registry

        LR                                                                                                             Assembly
      Location
      Services             Business            EHR           Message         Normalization                             Services
      Registry                                                             EHR Index
                            Rules             Index          Structures          Rules
                                               Orchestration                Services
    Terminology                                  Services
    Terminology         Rules                          Information Access & Longitudinal Record Services (LRS)
                                                                                                  Normalization
      Registry
     Services          Services
                                                                                                     Services


                                                                                                          Security Mgmt
                        A&A                     Brokering             Consent                  Session                      Privacy Data
                                                                                                                      Logging                  Configuration
                                                                                                              Data
                       Services                 Services              Services                 Services               Services
                                                                        Information and Common Services
        EHR IS
                                                                          Secure Communications Bus
                                                                                 EHR IP




                                                                                  Any
                                                                            Point-of-Service
                                                                              Application




POINT OF SERVICE



                                             HELP NEEDED validating that this Canada Health Infoway based-
                                                 slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                     Please send your feedback to HufnagelS@OSEHRA.org
                                                     WORKING DRAFT RFI: not for official use.                                         See notes page                    125
    Functioning Principles




ESP SDK              WORKING DRAFT RFI: not for official use   126
Functioning Principles/Rules

• Home/no-home EHR                                        • Level of parameterization
• EHRi Identifier Management                              • Primary Purpose for EHRi repositories
• EHR Index                                               • Other uses of the EHR IS (POS to POS)
• ESP Locator                                             • Multilingual capabilities
• POS to EHRi interface                                   • Runtime environment
• Level of transparency of EHR to                         • Performance principles – targets
  POS applications                                        • POS Integration environment
• Transaction scope                                       • Error Handling
• Trust Models valid for an EHRi                          • Consent
• EHR IS normalization of                                 • Authentication & Authorization
  information/terminology
                                                          • OIDS as a principle
• Auditing, logging, use of logs
                                                          • Prospective Events
• HL7 V3 (Messaging and templates)




                               HELP NEEDED validating that this Canada Health Infoway based-
                                   slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                           Please send your feedback to HufnagelS@OSEHRA.org
                                       WORKING DRAFT RFI: not for official use.                     127
  Architecture Perspectives

                  Business
                 Architecture


                                  Clinical
 Potential
                                Work Process
Applications
                                Architecture



                CONTEXT
Integration &
                                  System
 Deployment
                                Architecture
   Models



                 Information
                 Architecture




ESP SDK                         WORKING DRAFT RFI: not for official use   128
EHRi Conceptual Data Model

                                                                                      Governance

• High-level model representing
  generalized concepts
    • Encounter Management,
    • Care Plan Service,                                         Role                               Event Linkage
    • Health Concern Tracking
    • Analytics
• Event driven model to represent instances of                                          Event
  clinical service impacting a patient record
• Broad range of event typing – governance,
  people playing roles, delivery, environment,
  resource                                                      People                                 Place
• Derived from the Federal Health Information
  Model (FHIM)
• Detailed Clinical Models (DCLs)                                                     Capability
• Aligned and mapped to HL7 V3 RIM
• Mapped against several local and
  international EHR data models
                                                               Resource                             Environment
• More detailed views available – transactional
  views, domain views




                                    HELP NEEDED validating that this Canada Health Infoway based-
                                        slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                                Please send your feedback to HufnagelS@OSEHRA.org
                                            WORKING DRAFT RFI: not for official use.                                129
Components of Computable Data

                              • An Terminology is a formal representation of healthcare knowledge as a set of concepts , called
       Terminology            terms, and the relationships between those terms.
          Model               • An information model is a representation of concepts, relationships, constraints, rules, and
                              operations to specify data semantics for healthcare.

    Concepts
    Concept relationships
    Concept definitions
    Terms
    Hierarchies
    Clinical propositions                       Information
    Standard terminologies                         Model
    Mappings                                                                                      Instances of data using
    Not patient specific                                                                           model and dictionary
                                            Structural layout                                     Event based
                                            Clinical definition                                   Constrained by model
                                            Hierarchical in nature                                Patient specific
                                            Contains fields for discrete values
                                            Fields tied to dictionary
                                            Defines “valid data”                                      Repository
                                            Not patient specific




                                                                                                                                  130
ESP SDK                              WORKING DRAFT RFI: not for official use.                        See notes page
Key Terms and Concepts …
    Terminology




 The approach to common terminology is for both agencies to use SNOMED +
  Extensions = Lingua Franca for semantically interoperable Terminology. The
      EHR Services Platform will incorporate the EHR IS Information and
     terminology models as the logical data models for our shared (virtual)
  repositories; thereby, improving semantic interoperability and performance.
                                                                                         131
  ESP SDK                   WORKING DRAFT RFI: not for official use.   See notes page   131
Use Case Example: Patient is Admitted with “Cold” Symptoms
As-Is = Different Points of Entry Can Have Different Interpretations of “Cold”

  As-Is…                                                                               To Be…
                                                         Private Health Sector
         MHS                        VA                                & Other
                                                                                                         Cold
                                                                                             cold
           GUI                     GUI                                GUI


      SERVICES                                                                                      C.O.L.D.
                                SERVICES                          SERVICES




   Cold =                 cold =                          C.O.L.D. =                  EHR IS =
   Patient is diagnosed   Patient is diagnosed as         Patient is diagnosed with   The right diagnosis based
   with the Common        psychologically unfeeling       Chronic Obstructive Lung    on the right data applied in
   Cold                   and distant                     Disease                     the right context



   The EHR IS reduces redundancies, leverages agency resources, provides contextual information, and
         ensures data integrity across DoD and VA applications, directly improving continuity of care



                                                                                                                     132
   ESP SDK                                WORKING DRAFT RFI: not for official use.                              132
                                                                                                                      132
HDD and SNOMED-CT mapping work - Mapping Example (not actual codes)


HDD                             RxNORM
             SNOMED-CT                                  MEDCIN                 CPT       CHCS 1       VistA 1
NCID

          <Substance>
                            <Orderable drug
         <acetylsalicylic
 443                        Brand Name ID>                2214                 N/A        ASP          A112
          acid (ASA) ID:
                            <Aspirin: 82464>
             123455>

           <Condition:
 812                              N/A                     9923                  123        Cld         CD8
        diagnosis><Cold>

         <Procedure Test
          Result Name:>
 123                              N/A                     1324                 98231      RBC          RBC
           < Red Blood
             Count>

                                                                                       DoD specific
 923                                                                                                  VA term
                                                                                          term




                                                                                                            133
   ESP SDK                          WORKING DRAFT RFI: not for official use.              See notes page   133
EHR IS Services
                                         Services Provided by EHR IS
  •   Translation – syntactic and semantic data harmonization using standard information models and
      SNOMED CT and extensions as the EHR IS conical terminology and ESP data stores’ native
      terminology.
        •    Syntactic field mapping and conformance
        •    Semantic terminology mediation and value normalization
  •   Mediation - a mediation service can handle the transformation from one information-exchange payload-
      format and transport to another.
  •   Built-In-Test-Environment (BITE) - for run-time information-exchange integrity-checking.
  •   Common Terminology Services 2 (CTS2) - CTS 2 terminology services
  •   Metadata Service – provides information schemas and terminology bindings

                                           Services Used by EHR IS
  • Identification – Who are you looking for?
  • Authentication – Who are you?
  • Authorization –What are you allowed to know or do?
  • Secure Data Transport - Standards-based information exchanges.
  • RLUS - Retrieve, Locate, Update Service
  • Rules Engine – – A business rule service enables policies and other operational decisions to be defined,
    tested, executed and maintained separately from application code.
                                                                                                                134
  ESP SDK                                WORKING DRAFT RFI: not for official use.                              134
  Architecture Perspectives

                  Business
                 Architecture


                                  Clinical
 Potential
                                Work Process
Applications
                                Architecture



                CONTEXT
Integration &
                                  System
 Deployment
                                Architecture
   Models



                 Information
                 Architecture




ESP SDK                         WORKING DRAFT RFI: not for official use   135
    EHR IS Integration
    Layer: Evolutionary Path




ESP SDK              WORKING DRAFT RFI: not for official use   136
      Interim State: No EHR Services (Undesirable)
                                                                                                                                                    Each Organization Infostructure
                                                                                                                                                    level system uses patient and other
 ORGANIZATIONAL INFOSTRUCTURE                                                                                                                       required strong identifiers (e.g.
                                                                                                                                                    provider, encounter) based on
      Registries Data                                                                                                               EHR Data        point-of-service generated IDs
        & Services                                                                                                                  & Services      (e.g. MRNs). The CR-EMPI source
                                                                                                                                                    systems make the CR-EMPI aware
                                                                                                                          Drug                      of client identifiers. The Point-of-
                             CR API




            Client                                                                                                    Information                   Service applications and
           Registry                                                                                                     System                      Infostructure systems query the
       CR API
                                                                                                                      Repository                    CR EMPI for these identifiers in
                                                                                                                                                    order to access data within any
                                                                                                                                                    Infostructure System. The level of
                                                                                                                     DR API                         queries and maintenance of MRNs
                                                                                                                                                    in the EMPI is not scalable to
                                                                                                                                                    hundreds or thousands of Point-of-
                                                                                                                                                    Service systems. There are
            Search/Resolve




HL7 (CR)                                                                                                                        HL7 v3 (Rx)         performance issues accessing
                                                                                                                                                    CR/EMPI for every Drug system
                                                                                                                                                    interaction.



                                      Client Registration                                Pharmacy Profile
                                      1) Search client                                   4) Request drug profile
                                      2) Create new client                               5) Request DUR
                                      3) Update existing client                          6) Enter new prescription




     PATIENT ENCOUNTER
     Client Registration                                    CR API   DR API
                                                                                                                                HL7 v3 (Rx)
                                                                                                                                                                  CR API
     1) Search client                                        Pharmacy
     2) Create new client                                                                                                                                          EHR Viewer
                                                              System                                                                                              DR API
     3) Update existing client
                                                                                                                                                 HL7 (CR)
     Pharmacy Profile
     4) Request drug profile
     5) Request DUR
     6) Enter new prescription
                                                                     Pharmacist                                                                                             Physician
 POINT OF SERVICE



                                                                              HELP NEEDED validating that this Canada Health Infoway based-
                                                                                  slide applies to the US ESP/EHR IS situation & needs.
       ESP SDK                                                                   Please send your feedback to HufnagelS@OSEHRA.org
                                                                                      WORKING DRAFT RFI: not for official use.                     See notes page                  137
    Interim State: EHR IS Without LRS
                                                                                                                                                                  The Client Registry system
ORGANIZATIONAL INFOSTRUCTURE                                                                                                                                      “determines” a global unique ID
                                                                                                                                                                  (EHR ID) for patients. The Drug
   Registries Data                   Client Registration                                                                         EHR Data
     & Services                                                                                                                  & Services                       Informaton System (DIS) will
                                     1) Search client                     Search/
                                                                                                                                                                  use the EHR patient ID to store
                                     2) Create new client                 Resolve
                                                                                                                       Drug                                       prescribing and dispensing data.
                                     3) Update existing client       Get EHR ID                                                                                   Point-of-Service applications
                   EAI IP




                                                                                                          EAI IP
         Client                                                                                                    Information
        Registry                                                                                                     System                                       query the Client Registry and
                                                                                      HL7 v3 (Rx)
                                                                             HL7                                   Repository                                     obtain the EHR patient ID and
                                                                             (CR)                                                                                 will use this ID as a token
                                                                                       Pharmacy Profile                                                           throughout the entire business
                                                                                       4) Request drug profile                                                    transaction. This model
                                                                                       5) Request DUR                                                             eliminates the need for
                                                                                       6) Enter new Prescription                                                  communication between the
                            EAI IP




      Determine
     EHR Client ID                                                                                                                                                DIS and CR and reduces the
                                                                                                                                                                  transactions to the CR to one
                                                                                                                                                                  per business transaction.



                                                                                                                                     Security Mgmt    Privacy          Configuration
                                                                                                                                      Rules/Data     Rules/Data         Rules/Data

                                                                                             Information and Common Services
          EHR IS
                                                                                               Secure Communications Bus


   PATIENT ENCOUNTER
   Client Registration
   1) Search client
   2) Create new client                                                                                  HL7                                  HL7
                                                 EHR IP




                                                                                                                                                                              EHR IP
                                                          Pharmacy
   3) Update existing client                                                                                                                                                           EHR Viewer
                                                           System
   Pharmacy Profile
   4) Request drug profile
   5) Request DUR
   6) Enter new prescription

                                                                Pharmacist                                                                                                                 Physician
POINT OF SERVICE



                                                                       HELP NEEDED validating that this Canada Health Infoway based-
                                                                           slide applies to the US ESP/EHR IS situation & needs.
     ESP SDK                                                              Please send your feedback to HufnagelS@OSEHRA.org
                                                                               WORKING DRAFT RFI: not for official use.                                                                             138
    Interim State: EHR IS Without LRS
ORGANIZATIONAL INFOSTRUCTURE
                                                                                                                                                                        The Client Registry determines
   Registries Data                                                                      EHR Data & Services                                                             a global unique ID (EHR ID) for
                               Client Registration
     & Services                                                                                                                                                         patients. The DIS will use the
                               1) Search client
                               2) Create new client                                                                                                                     EHR patient ID to store
                                                                                      Search/Resolve
                               3) Update existing client                                                                                                                prescribing and dispensing
                                                                                 Get EHR ID
                   EAI IP




         Client                                                                                                                                                         data. EHR services will use the
        Registry                                                                                                                                 Drug                   CR to map any local MRN found
                                                                                                      HL7       HL7 v3 (Rx)




                                                                                                                                    EAI IP
                                                                                                                                             Information                within transactions to the
                                       Information Access & LRS                                       (CR)                                     System                   corresponding EHR client ID.
                                                                                                                                             Repository                 The POS applications do not




                                                                          Data Access
                                     Business Components                                                                                                                necessarily have to be aware of
                                                                                               EHR               Pharmacy Profile                                       the EHR client ID or they can
                                       CR API    DR API                                       Index
      Determine                                                                                                  4) Request drug profile                                continue to provide this ID
     EHR Client ID                                                                                               5) Request DUR                                         themselves after querying the
                                                                                                                 6) Enter new Prescription                              CR (compatible with prior
                                                                                                                                                                        model).


                                                                                                                                      Security Mgmt         Privacy          Configuration\
                                                                                                                                       Rules/Data          Rules/Data         Rules/Data

                                                                                                      Information and Common Services
          EHR IS
                                                                                                        Secure Communications Bus


   PATIENT ENCOUNTER
   Client Registration
   1) Search client
   2) Create new client                                                                                          HL7                               HL7
                                                EHR IP




                                                                                                                                                                                   EHR IP
                                                         Pharmacy
   3) Update existing client                                                                                                                                                                EHR Viewer
                                                          System
   Pharmacy Profile
   4) Request drug profile
   5) Request DUR
   6) Enter new prescription

                                                             Pharmacist                                                                                                                           Physician
POINT OF SERVICE



                                                                    HELP NEEDED validating that this Canada Health Infoway based-
                                                                        slide applies to the US ESP/EHR IS situation & needs.
     ESP SDK                                                           Please send your feedback to HufnagelS@OSEHRA.org
                                                                            WORKING DRAFT RFI: not for official use.                                                                                     139
    Target State: Full Featured EHR IS Infostructure
ORGANIZATIONAL INFOSTRUCTURE                                                                                                                   The client, provider, location
                                                                                                                                               registries and EHR Services
   Registries Data                  Population Health Data                                                      EHR Data                                                Data
                                                                                                                                               determine (respond with)
     & Services                          & Services                                                             & Services                                          Warehouse
                                                                                                                                               global unique ids for patient,
       Client                                                                                                                                  providers, encounters and other
      Registry                Outbreak                 PHS                   Shared                   Drug              Diagnostic             required strong identifiers. All
                                                                                                                                                                      Health
                                                                                                                                           Laboratory
                                                                                                                                               Infostructure systems use these
                             Management              Reporting            Health Record           Information            Imaging                                  Information
                                                                                                                                               unique IDs to store clinical data
      Provider
                                                                                                                                               about a person. The EHR
      Registry
                                                                                                                                               Services will map any local ID
                                                                                                                                               to the corresponding EHR ID.
      Location                                                                                                                                 The Domain services (DIS,
      Registry                          Business           EHR          Message           Normalization
                                                                                                                                               DI, Lab) systems rely on the
                                         Rules            Index         Structures           Rules
                                                                                                                                               EHR Services to ensure that
    Terminology                                                                                                                                the necessary EHR IDs are
                                                                  Information Access & Longitudinal Record Services (LRS)
      Registry                                                                                                                                 provided with every transaction.



                                                                                                                    Security Mgmt      Privacy       Configuration
                                                                                                                     Rules/Data       Rules/Data      Rules/Data

                                                                                     Information and Common Services
        EHR IS
                                                                                       Secure Communications Bus




                                                                  Radiology
                  Public Health              Pharmacy                                     Lab System             Hospital, LTC,          Physician
                                                                   Center                                                                                     EHR Viewer
                    Services                  System                                         (LIS)                CCC, EPR              Office EMR
                                                                  PACS/RIS




                        Public Health              Pharmacist           Radiologist             Lab Clinician            Physician/           Physician/             Physician/
                          Provider                                                                                        Provider             Provider               Provider
POINT OF SERVICE



                                                        HELP NEEDED validating that this Canada Health Infoway based-
                                                            slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                Please send your feedback to HufnagelS@OSEHRA.org
                                                                WORKING DRAFT RFI: not for official use.                                                                    140
    ESP Infostructure:
    Deployment Models




ESP SDK            WORKING DRAFT RFI: not for official use   141
 ORGANIZATIONAL
                 Large & Medium Deployment Models
                                          Client                   Provider                     Laboratory                Drug
   REGIONAL/




                                         Registry                  Registry                     Repository              Repository                                   Larger size Organizations
                                                                                                                                                                     • Organizational or regional Client
                                              REGION 1                                                       REGION 2                                                  and Provider and Location
                                                                                                                                                                       Registries
                                    DI                     Shared                             DI                       Shared                                        • Organizational or regional Lab,
                                 Repository             Health Record                      Repository               Health Record
                                                                                                                                                                       Drug Repositories and EHR IS
                                                                                                                                                                     • Supra-regional LRS, Shared Health
                         Information Access & Longitudinal Record Services (LRS)     Information Access & Longitudinal Record Services (LRS)
LOCAL/REGIONAL




                                                                                                                                                                       Record and DI Repositories and
                                                                        Information and Common Services                                                                EHR Viewer
                        EHR IS
                                                                            Secure Communications Bus                                                                • ESP Locator across organizations
                                                                                                                                                                       or regions
                                                  EHR
                                CIS                                 EMR                              CIS                     EMR
                                                 Viewer                                                        EHR                                                   • Local EMR, CIS and other
                                                                                                              Viewer                                                   applications



                                                                                                                   Client                      Provider                   Laboratory                Drug
                                                                                            ORGANIZATIONAL        Registry                     Registry                   Repository              Repository
                 Medium size Organizations
                                                                                              REGIONAL/


                 • Organizational or regional Client and
                   Provider and Location Registries                                                                                               Shared                   DI
                                                                                                                                               Health Record            Repository
                 • Organizational or regional Lab, Drug,
                   Diagnostic Imaging (DI), Shared Health
                                                                                                                                        Information Access & Longitudinal Record Services (LRS)
                   Record, LRS, EHR IS and EHR Viewer
                 • ESP Locator across Organizational or                                                                                                   Information and Common Services
                                                                                                              EHR IS
                   regional                                                                                                                                 Secure Communications Bus

                 • Local EMR, CIS and other applications
                                                                                            LOCAL




                                                                                                                                                                  EHR
                                                                                                                                                 CIS                              EMR
                                                                                                                                                                 Viewer




                                                                            HELP NEEDED validating that this Canada Health Infoway based-
                                                                                slide applies to the US ESP/EHR IS situation & needs.
                  ESP SDK                                                      Please send your feedback to HufnagelS@OSEHRA.org
                                                                                    WORKING DRAFT RFI: not for official use.                                                                                   142
   Small Organizations
REGIONAL

                                                                                            Diagnostic
                                                    Client              Provider
                                                                                           Imaging (DI)
                                                   Registry             Registry
                                                                                            Repository



                                                                        Shared
                                                                     Health Record
                                                                       Drug/Lab



                                                 Information Access & Longitudinal Record Services (LRS)



                                                                 Information and Common Services
        EHR IS
                                                                    Secure Communications Bus


LOCAL
                                                      CIS              EHR Viewer            EMR




   •    Regional Client, Provider & Location Registry
   •    integrated hospital CIS solution fulfilling the roles of the Regional EHR Services, Laboratory and Drug services
   •    Regional Diagnostic Imaging (DI) Service
   •    Regional EHR IS & EHR Viewer
   •    Local physician office systems & other CIS connect as POS Systems




                                          HELP NEEDED validating that this Canada Health Infoway based-
                                              slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                  Please send your feedback to HufnagelS@OSEHRA.org
                                                  WORKING DRAFT RFI: not for official use.                                 143
    Model 1: Single EHR Infostructure
REGIONAL
                           Registry & Data Services                                                                            EHR Data & Services


     Client          Provider               Location           Terminology                                                              Drug
    registry         Registry               registry             Registry                                                           Information



                                                                                                         EHR Data & Services


                                                                                         Shared               Diagnostic
                                                                                                                                    Laboratory
                                                                                      Health Record          Imaging (DI)




                                     Business           EHR          Message          Normalization
                                      Rules            Index         Structures          Rules

                                                               Information Access & Longitudinal Record Services (LRS)



                                                                                                                 Security Mgmt         Privacy           Configuration
                                                                                                                  Rules/Data          Rules/Data          Rules/Data
                                                                                  Information and Common Services
         EHR IS
                                                                                    Secure Communications Bus



                                                                Radiology
               Public Health              Pharmacy                                     Lab System             Hospital, LTC,             Physician
                                                                 Center                                                                                           EHR Viewer
                 Services                  System                                         (LIS)                CCC, EPR                 Office EMR
                                                                PACS/RIS




                     Public Health              Pharmacist           Radiologist             Lab Clinician             Physician/                 Physician/             Physician/
POINT OF SERVICE       Provider                                                                                         Provider                   Provider               Provider




                                                       HELP NEEDED validating that this Canada Health Infoway based-
                                                           slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                               Please send your feedback to HufnagelS@OSEHRA.org
                                                               WORKING DRAFT RFI: not for official use.                                                                         144
    Model 2: Shared EHR Infostructure
REGIONAL
                             Registry & Data Services                                                                             EHR Data & Services


     Client           Provider                Location            Terminology                                                              Drug
    registry          Registry                registry              Registry                                                           Information




REGIONAL                                      REGION 1                                                                 REGION 2                                              …


                     Shared              Diagnostic                                           Shared              Diagnostic                                             Shared
                                                                 Laboratory                                                               Laboratory
                  Health Record         Imaging (DI)                                       Health Record         Imaging (DI)                                         Health Record




                  Business             EHR          Message         Normalization           Business            EHR          Message         Normalization
                   Rules              Index         Structures         Rules                 Rules             Index         Structures         Rules

                   Information Access & Longitudinal Record Services (LRS)                   Information Access & Longitudinal Record Services (LRS)



                                                                                                                   Security Mgmt           Privacy          Configuration
                                                                                                                    Rules/Data            Rules/Data         Rules/Data
                                                                                    Information and Common Services
         EHR IS
                                                                                       Secure Communications Bus



                                                                   Radiology
               Public Health              Pharmacy                                        Lab System            Hospital, LTC,               Physician
                                                                    Center                                                                                           EHR Viewer
                 Services                  System                                            (LIS)               CCC, EPR                   Office EMR
                                                                   PACS/RIS




                      Public Health              Pharmacist              Radiologist           Lab Clinician              Physician/                 Physician/             Physician/
POINT OF SERVICE        Provider                                                                                           Provider                   Provider               Provider




                                                         HELP NEEDED validating that this Canada Health Infoway based-
                                                             slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                                 Please send your feedback to HufnagelS@OSEHRA.org
                                                                 WORKING DRAFT RFI: not for official use.                                                                          145
           Model 3: Distributed EHR Infostructures
REGIONAL
                                    Registry & Data Services                                                                                EHR Data & Services


            Client            Provider                       Location            Terminology                                                           Drug
           registry           Registry                       registry              Registry                                                        Information



REGIONAL                                                                   REGIONAL                                                     REGIONAL
                                     EHR Data & Services                                               EHR Data & Services                                              EHR Data & Services




POINT OF                                                                   POINT OF                                                     POINT OF
SERVICE                                                                    SERVICE                                                      SERVICE




                           Region 1                                                            Region 2                                                            Region X


   Least leverage                                                                                                                                                          Most leverage




                No            Different                     Different       Specification      Data        Business          Business          User           Same      Use shared
              solution      specification                  standards        & standards        model       process             rules         Interface       solution    service



                      Reuse drives down cost, accelerates timelines, reduces risk and enables interoperability

                                                                        HELP NEEDED validating that this Canada Health Infoway based-
                                                                            slide applies to the US ESP/EHR IS situation & needs.
           ESP SDK                                                         Please send your feedback to HufnagelS@OSEHRA.org
                                                                                WORKING DRAFT RFI: not for official use.                                                                      146
    Regional/Organizational Deployment Decisions
                                                                                                                    Business choices?
REGIONAL                                                                                                            • Who, where, when, what
                           Registry & Data Services                                                                       EHR Data & Services
                                                                                                                    • Clinical value
     Client          Provider               Location           Terminology                                          • Adoption Drug
    registry         Registry               registry             Registry                                                          Information
                                                                                                                    Solution development choices?
                                                                                                                    • Services/functions
                                                                                                         EHR Data & Services
                                                                                                                    • Data persistence
                                                                                         Shared              Diagnostic
                                                                                      Health Record                •
                                                                                                              Imaging Communication standards
                                                                                                                             Laboratory

                                                                                                                    • Data standards
                                                                                                                    • Integration tooling
                                     Business           EHR          Message          Normalization
                                      Rules            Index         Structures        Rules/Data                   Evolution plan?
                                                                                                                   •      functionality when
                                                               Information Access & Longitudinal Record Services (LRS) What
                                                                                                                    • EHR Service evolution path

                                                                                                                    Deployment configuration choices?
                                                                                                                            Privacy
                                                                                                                Security Mgmt        Configuration
                                                                                                                    Data             Rules/Data          Rules/Data
                                                                                  Information and Common Services
                                                                                                                    • State vs regional
         EHR IS                                                                                                     • Single Solution/many deployments
                                                                                    Secure Communications Bus
                                                                                                                    • Multiple solutions
                                                                Radiology
               Public Health              Pharmacy                                     Lab System            Hospital, LTC,             Physician
                                                                 Center                                                                                         EHR Viewer
                 Services                  System                                         (LIS)               CCC, EPR                 Office EMR
                                                                PACS/RIS




                     Public Health              Pharmacist           Radiologist             Lab Clinician            Physician/                 Physician/           Physician/
POINT OF SERVICE       Provider                                                                                        Provider                   Provider             Provider




                                                       HELP NEEDED validating that this Canada Health Infoway based-
                                                           slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                               Please send your feedback to HufnagelS@OSEHRA.org
                                                               WORKING DRAFT RFI: not for official use.                                                                      147
  Architecture Perspectives

                  Business
                 Architecture


                                  Clinical
 Potential
                                Work Process
Applications
                                Architecture



                CONTEXT
Integration &
                                  System
 Deployment
                                Architecture
   Models



                 Information
                 Architecture




ESP SDK                         WORKING DRAFT RFI: not for official use   148
   EHR Infostructure Deployment
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data             Population Health Data                                                   EHR Data                                                  Data
     & Services                     & Services                                                          & Services                                              Warehouse

         Client
        Registry         Outbreak              PHS                   Shared                   Drug             Diagnostic                                         Health
                                                                                                                                  Laboratory
                        Management           Reporting            Health Record           Information           Imaging                                        Information
        Provider
        Registry


        Location
        Registry               Business            EHR          Message           Normalization
                                Rules             Index         Structures           Rules

       Terminology                                        Information Access & Longitudinal Record Services (LRS)
         Registry



                                                                                                            Security Mgmt
                                                                                                                            Privacy Data       Configuration
                                                                                                                Data

                                                                             Information and Common Services
          EHR IS
                                                                               Secure Communications Bus




   •      Strategic planning                              •    Testing (compliance)
   •      Change management                               •    System implementation
   •      System development/integration                  •    Education & training
   •      EHR SCP message development                     •    Operation & maintenance




                                                HELP NEEDED validating that this Canada Health Infoway based-
                                                    slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                        Please send your feedback to HufnagelS@OSEHRA.org
                                                        WORKING DRAFT RFI: not for official use.                                                                        149
 ESP Data: Value Enabler For Existing Applications
  EHR Infostructure (EHRi)

                                                                                                                  • Client data           • Clinical notes
                                                                                                                  • Provider data         • Observations/
                                                                                                                  • Location data           problems/conditions
 EHR IS ENABLED SYSTEM                                                                                            • Privacy data          • Orders/Results data
 SOLUTION                   Population                Health
EHR INFOSTRUCTURE (EHRi)                                                 EHR                   Registries         • Security data         • Referrals data
                              Health               Information
                                                                        Data &                  Data &            • Encounter data        • Lab data
                              Data &                   Data
                                                                       Services                Services                                   • Pharmacy data
                             Services              Warehouse                                                      • Blood/allergy/
                                                                                                                                          • Diagnostic Imaging
         EHR IS
                                                                                                                    immunization data
                                                                                                                  • Encounter summaries     data




            EHR SCP                  EHR SCP                              EHR SCP                               EHR SCP                         EHR SCP
            Standards                Standards                            Standards                             Standards                       Standards




                             ADT         CDR       PMS            Rx         Lab          DI


        Data loading                Enhanced                             Enhanced                    Chronic Disease Health Education       Custom projects
         Data feeds                presentation                         presentation                         Health Prevention               Data Mining




      Initial data load/      Hospitals/private clinics/
                                                                    Laboratories/pharmacy /                      Self-care                Research/surveillance
   data feeds/integration   emergency/homecare/specialty
                                                                          diagnostics
         of systems               centers/LT care




   ESP SDK                                                 WORKING DRAFT RFI: not for official use.                             See notes page                150
    End-User Perspective: EHR Viewer
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data        Population Health Data                                                   EHR Data                                                  Data
     & Services                & Services                                                          & Services                                              Warehouse

       Client
      Registry        Outbreak            PHS                   Shared                   Drug             Diagnostic                                         Health
                                                                                                                             Laboratory
                     Management         Reporting            Health Record           Information           Imaging                                        Information
      Provider
      Registry


      Location
      Registry             Business           EHR          Message           Normalization
                            Rules            Index         Structures           Rules

    Terminology                                      Information Access & Longitudinal Record Services (LRS)
      Registry



                                                                                                       Security Mgmt
                                                                                                                       Privacy Data       Configuration
                                                                                                           Data

                                                                        Information and Common Services
        EHR IS
                                                                          Secure Communications Bus




                                                                        Patient          End-user
                                                                         Info              Info                                                    EHR Viewer

                                                                         Visit                Drug
                                                                        History              Profile

                                                                                        Diagnostic
                                                                   Laboratory
                                                                                         Imaging                                                            Physician/
                                                                                                                                                             Provider
POINT OF SERVICE

                                                                                                EHR VIEWER

                                           HELP NEEDED validating that this Canada Health Infoway based-
                                               slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                   Please send your feedback to HufnagelS@OSEHRA.org
                                                   WORKING DRAFT RFI: not for official use.                                                                        151
    End-User Perspective: EMR Application
ORGANIZATIONAL INFOSTRUCTURE

   Registries Data         Population Health Data                                                   EHR Data                                                  Data
     & Services                 & Services                                                          & Services                                              Warehouse

       Client
      Registry         Outbreak            PHS                   Shared                   Drug             Diagnostic                                         Health
                                                                                                                              Laboratory
                      Management         Reporting            Health Record           Information           Imaging                                        Information
      Provider
      Registry


      Location
      Registry              Business           EHR          Message           Normalization
                             Rules            Index         Structures           Rules

    Terminology                                       Information Access & Longitudinal Record Services (LRS)
      Registry



                                                                                                        Security Mgmt
                                                                                                                        Privacy Data       Configuration
                                                                                                            Data

                                                                         Information and Common Services
        EHR IS
                                                                           Secure Communications Bus




                                                                         Patient          End-user                                                   Physician
                                                                          Info              Info                                                    Office EMR
                                                                         Patient               Drug
             EMR                                                         History              Profile
           Database
                                                                                         Diagnostic
                                                                    Laboratory
                                                                                          Imaging                                                            Physician/
                                                                                                                                                              Provider
POINT OF SERVICE

                                                                                                 EMR APPLICATION

                                            HELP NEEDED validating that this Canada Health Infoway based-
                                                slide applies to the US ESP/EHR IS situation & needs.
    ESP SDK                                    Please send your feedback to HufnagelS@OSEHRA.org
                                                    WORKING DRAFT RFI: not for official use.                                                                        152
 ESP Data: Enables New Classes of Applications
  EHR Infostructure (EHRi)

                                                                                                                                           • Client data           • Clinical notes
                                                                                                                                           • Provider data         • Observations/
                                                                                                                                           • Location data           problems/conditions
 EHR IS ENABLED SYSTEM                                                                                                                     • Privacy data          • Orders/Results data
 SOLUTION
EHR INFOSTRUCTURE (EHRi)
                                                                                                                                           • Security data         • Referrals data
                                                        Population              Health
                                                                                                    EHR                   Registries       • Encounter data        • Lab data
                                                          Health             Information
                                                                                                   Data &                  Data &          • Blood/allergy/        • Pharmacy data
                                                          Data &                 Data
 EHR Information Services (EHR IS)
                                                                                                  Services                Services           immunization data     • Diagnostic Imaging
                                                         Services            Warehouse
                                                                                                                                           • Encounter summaries     data




                                        EHR SCP                              EHR SCP                                 EHR SCP                             EHR SCP
                                        Standards                            Standards                               Standards                           Standards




                           ?                ?            ?           ?           ?            ?              ?           ?             ?



                                     Decision support                    Automated workflow
                                       The Helper                         Drug interactions                      New applications                     Custom projects
                                       The Mentor                         Abnormal results                       Patient monitoring                    Data mining




                                                                                                                        Patients




    ESP SDK                                                                      WORKING DRAFT RFI: not for official use.                                                              153
Deployment Configurations:
 Hybrid Open Source and
  COTS-based Solutions




 ESP SDK            WORKING DRAFT RFI: not for official use   154
      COTS: CIS with Integrated Viewer
ORGANIZATIONAL INFOSTRUCTURE

     Registries Data                                                                             Population Health Data                        EHR Data
       & Services                                                                                     & Services                               & Services
                    EAI IP


          Client
         Registry                                                                                                PHS                 Drug
                                                                                        Outbreak                                                       Diagnostic
                                                                                                               Reporting         Information
                                                                                        Services                                                        Imaging
                                                                                                               Services            System
                    EAI IP




        Provider
        Registry                                                                                                                   EAI IP                   EAI IP
                    EAI IP




        Location                                                                                                                 CLINICAL INFORMATION SYSTEM
        Registry

                                                                                                                                      Shared           Laboratory
                    EAI IP




       Terminology                                                                                    EAI
                                                                                                                                   Health Record
         Registry                               Consent Management
                                                                                   Interoperability      General
                                                                                                                                   Laboratory Shared Health Record
                                                                                   Integration           Subscription
                                             Authentication/Acess Control
                                                                                   Context               Management               Longitudinal Record Services (LTS)
                                                  Auditing/Logging                      Secure Communications Bus
                                                                                                                                            EHR Viewer Server


IP is Interoperability Profile
                                                                       EHR IP Transactions: Get, Put, List; National and
EAI is Enterprise Application Integration
                                                                                International EHR Standards




                               EHR IP        EHR IP                  EHR IP            EHR IP                  EHR IP          EHR IP                  EHR IP

                                                                  Radiology
                             Public Health   Pharmacy                                Lab System              Hospital, LTC,    Physician             EHR Viewer
                                                                   Center
                               Services       System                                    (LIS)                 CCC, EPR        Office EMR               Client
                                                                  PACS/RIS


POINT OF SERVICE



                                                   HELP NEEDED validating that this Canada Health Infoway based-
                                                       slide applies to the US ESP/EHR IS situation & needs.
      ESP SDK                                         Please send your feedback to HufnagelS@OSEHRA.org
                                                           WORKING DRAFT RFI: not for official use.                                                                  155
       COTS: Clinical Information System (CIS) with External Viewer
  ORGANIZATIONAL INFOSTRUCTURE

       Registries Data                                                                            Population Health Data                        EHR Data
         & Services                                                                                    & Services                               & Services
                     EAI IP


           Client
          Registry                                                                                                PHS                 Drug
                                                                                         Outbreak                                                       Diagnostic
                                                                                                                Reporting         Information
                                                                                         Services                                                        Imaging
                                                                                                                Services            System
                     EAI IP




          Provider
          Registry                                                                                                                  EAI IP                   EAI IP
                     EAI IP




          Location                                                                                                                CLINICAL INFORMATION SYSTEM
          Registry
                     EAI IP




        Terminology                                                                                    EAI
                                                                                                                                       Shared           Laboratory
          Registry                               Consent Management                                                                 Health Record
                                                                                    Interoperability      General
                                                                                    Integration           Subscription              Laboratory Shared Health Record
                                              Authentication/Acess Control
                                                                                    Context               Management
                                                                                                                                   Longitudinal Record Services (LTS)
                                                   Auditing/Logging                      Secure Communications Bus



IP is Interoperability Profile                                          EHR IP Transactions: Get, Put, List; National and
EAI is Enterprise Application Integration                                        International EHR Standards




                                EHR IP        EHR IP                  EHR IP            EHR IP                  EHR IP          EHR IP                EHR IP

                                                                   Radiology
                              Public Health   Pharmacy                                Lab System              Hospital, LTC,    Physician           EHR Viewer
                                                                    Center
                                Services       System                                    (LIS)                 CCC, EPR        Office EMR             Client
                                                                   PACS/RIS


  POINT OF SERVICE



                                                    HELP NEEDED validating that this Canada Health Infoway based-
                                                        slide applies to the US ESP/EHR IS situation & needs.
        ESP SDK                                        Please send your feedback to HufnagelS@OSEHRA.org
                                                            WORKING DRAFT RFI: not for official use.                                                                  156
       COTS Based: Enterprise Application Centric (EAI) Centric
  ORGANIZATIONAL INFOSTRUCTURE

       Registries Data                                                       Population Health Data                                        EHR Data
         & Services                                                               & Services                                               & Services
                     EAI IP


           Client                                                                                                          CIS:
          Registry                                                                           PHS                                              Drug
                                                                      Outbreak                                         Shared Health                         Diagnostic
                                                                                           Reporting                                      Information
                                                                      Services                                           Record &                             Imaging
                                                                                           Services                                         System
                                                                                                                        Laboratory
                     EAI IP




          Provider
          Registry                                                                                                        EAI IP            EAI IP             EAI IP
                     EAI IP




          Location
          Registry


                                                                                                                                       Enterprise Application Integration (EAI)
                     EAI IP




        Terminology                                                                                        EAI
          Registry                               Consent Management
                                                                                        Interoperability     General                    is the unrestricted sharing of data and
                                              Authentication/Acess Control
                                                                                        Integration          Subscription                 business processes throughout the
                                                                                        Context              Management                networked applications or data sources
                                                   Auditing/Logging                          Secure Communications Bus                            in an organization.


IP is Interoperability Profile                                          EHR IP Transactions: Get, Put, List; National and
EAI is Enterprise Application Integration                                        International EHR Standards




                                EHR IP        EHR IP                  EHR IP                EHR IP                 EHR IP               EHR IP             EHR IP

                                                                   Radiology
                              Public Health   Pharmacy                                     Lab System            Hospital, LTC,         Physician         EHR Viewer
                                                                    Center
                                Services       System                                         (LIS)               CCC, EPR             Office EMR           Client
                                                                   PACS/RIS


  POINT OF SERVICE



                                                    HELP NEEDED validating that this Canada Health Infoway based-
                                                        slide applies to the US ESP/EHR IS situation & needs.                                                              157
                                                                                                                                                                           157
        ESP SDK                                        Please send your feedback to HufnagelS@OSEHRA.org
                                                            WORKING DRAFT RFI: not for official use.                                                                      157
  ESP SDK: In Summary




ESP SDK      WORKING DRAFT RFI: not for official use   158
EHR IS As Design Pattern & Standard

Provides specifications for provider
organizations & the vendor community
to design and develop:
•   EHR infostructure
•   Interfaces to allow existing systems to
    interoperate using EHR infostructure
•   New applications that take advantage of the
    EHR infostructure to provide added value to
    service providers, patients; to promote
    wellness
• Provides design pattern & set of
standardized specifications that:
•   Provide flexibility to meet the variety found in
    existing service delivery settings while
    providing an ability for Organizations to evolve
    their solution set, leveraging their current
    investments in systems
•   Allowing the managed addition of contributors
    to and users of Electronic Health Records




ESP SDK                                        WORKING DRAFT RFI: not for official use   159
 From Concept to Implementation



     interoperable ESP SDK                    The second vehicle for                        This process will be the
     provides the Blueprint for               testing and refining the                     test-bed for the EHR IS
        transition to working               Blueprint specifications is                          specifications
      interoperability through:              adoption by the vendor                  • Elements of the EHR IS Blueprint
                                           community and acquisitions                  specifications will be updated by
• partnering with Organizations               of “interoperable ready”
  ready to build interoperability                                                      these project teams as the concepts
                                                     applications                      are tested and refined
  between existing systems
                                           • Major vendors have                      • Implementation guidelines will be
• Organizations ready to incorporate
                                             incorporated the EHR IS                   produced to assist others in
  their registries and domain
                                             architectural approach into               implementing these capabilities
  repositories
                                             their product strategies
                                           • The EHR IS can provide the
                                             framework for Organizations to
                                             evaluate vendor provided
                                             solutions and ensure they will
                                             work with their evolving EHR
                                             IS infostructures

CONCEPT                                                                               IMPLEMENTATION




                                       HELP NEEDED validating that this Canada Health Infoway based-
                                           slide applies to the US ESP/EHR IS situation & needs.
 ESP SDK                                  Please send your feedback to HufnagelS@OSEHRA.org
                                               WORKING DRAFT RFI: not for official use.                                      160
Maintaining the EHR IS as a
National / International Standard

                                             • It is critically important to have a stable, managed
                                               specification for interoperability
                                                  •   Organizations and provider organizations need to be
                                                      confident that their commitment to implementing EHR
                                                      infostructure is based on a sound specification that will
                                                      be maintained and managed
                                                  •   Implementations of the infostructure will reveal where
                                                      the specification needs to be adjusted to optimize
                                                      performance and ensure reliability
                                             • For this reason, the EHR IS specifications will be
                                               subject to the Standards Collaboration Process
                                                  •   Ensuring broad participation in requirements definition
                                                  •   Providing foreknowledge of the financial and change
                                                      management requirements to all affected groups
                                                      and organizations
                                                  •   Providing a scope and change-management model for
                                                      the EHR IS specifications themselves




                    HELP NEEDED validating that this Canada Health Infoway based-
                        slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                Please send your feedback to HufnagelS@OSEHRA.org
                            WORKING DRAFT RFI: not for official use                                        161
The EHR IS Architecture In Summary: EHR Repository



Concepts                                                    Benefits
• Patient’s data is stored and accessed                     • Interoperability, performance, scalability
  from one logical EHR                                      • Provider adoption, supports use cases
• Patient’s longitudinal clinically relevant                  across continuum of care, timely and
  information, authoritative & reliable                       accurate for provider
• EHR IS co-exists with legacy                              • Preserves investments, does not
  domain repositories                                         unnecessarily duplicate data
• EHR IS may be implemented at any                          • Flexibility, configurable to local & regional
  organizational level                                        needs
• EHR IS has a common definition                            • Cost effective, standards-based,
                                                              Interoperability




                                 HELP NEEDED validating that this Canada Health Infoway based-
                                     slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                             Please send your feedback to HufnagelS@OSEHRA.org
                                         WORKING DRAFT RFI: not for official use.                             162
The Architecture In Summary: EHR IS



Concepts                                                 Benefits
• EHR IS (EHR Information Services (EHR                  • Common and standards based is most cost
  IS)) provides common way to interoperate                 effective, secure & private; applications
  with EHRs, registries, domain repositories               focus on clinical logic vs. integration logic
• Provider applications interoperate through             • Cost effective environment for broad set of
  EHR IS to access HER, providing semantic                 provider applications, standards based
  interoperability                                         integration
• EHR IS provides peer-to-peer trusted                   • Secure & private, efficient, scalable, cost
  communication and value-added                            effective and standard runtime environment,
  Information and Common Services to                       responsive
  enable interoperability across the
  continuum of care and across
  Organizations




                              HELP NEEDED validating that this Canada Health Infoway based-
                                  slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                          Please send your feedback to HufnagelS@OSEHRA.org
                                      WORKING DRAFT RFI: not for official use.                             163
The Architecture In Summary: ESP



Concepts                                                Benefits
• Common standards will enable integration              • Reduces design, development, test &
  & interoperability                                      operational costs
• Standard message data protocol for                    • True interoperability, international standard
  external communications is HL7 V3                       will incent vendors
• Registries have common definition                     • Interoperability, cost, security & privacy
  nationally and internationally




                             HELP NEEDED validating that this Canada Health Infoway based-
                                 slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                         Please send your feedback to HufnagelS@OSEHRA.org
                                     WORKING DRAFT RFI: not for official use.                             164
The Architecture In Summary: Applications



Concepts                                                    Benefits
• Messages initiated by point-of-care                       • Low cost and common model of integration,
  applications populate EHR with clinical                     secure and private, scalable, extensible,
  data                                                        preserves current investments
• Provider applications read data out of                    • Mass customized views of data tailored to
  the EHR via the EHR IS in addition to                       provider needs, secure and private,
  their operational data stores                               scalable, authoritative, reliable, responsive
• Use cases, business rules and                             • Vendors compete and innovate, extensible,
  visualization of data is a function of the                  value added services for providers
  point-of-care application




                                 HELP NEEDED validating that this Canada Health Infoway based-
                                     slide applies to the US ESP/EHR IS situation & needs.
ESP SDK                             Please send your feedback to HufnagelS@OSEHRA.org
                                         WORKING DRAFT RFI: not for official use.                             165
         CALL FOR PARTICIPATION
        Please post your comments at
  http://www.osehra.org/group/architecture




You may get the most current version of this document and submit suggestions for improvement at:
                       http://www.osehra.org/node/47/content/documents


                      CALL FOR PARTICIPATION
        See companion ESP SDK Implementation Guide (IG),
        which is also under development. Your help is solicited.

                                    Thank you!
    ESP SDK                           WORKING DRAFT RFI: not for official use.             166
                                      Backup



                The following slides are more technical in nature
and will be discussed in the EHR Services Platform SDK Implementation Guide




ESP SDK                    WORKING DRAFT RFI: not for official use.       167
HL7 EHR System Functional Model (EHR-S)
(> 230 System Functions in 4 level categorization, (see attached spreadsheet for full enumeration)
                                                                                                  Business


                                                                                                Choreography


                                                                                                Choreography


                                                                                                  Business




                                                                                                                                 Service Types
System Functions




                                                                                                    Entity
                                                                                                (Information)

                                                                                                  Business

                                                                                                Infrastructure
                                                                                                    Entity
                                                                                                (Information)
                                                                                                Infrastructure
                                                                                                Infrastructure

                                                                                                Infrastructure

                                                                                                  Business
                                                                                                Choreography

                    Other    O-1   Electronic Resource Planning (ERP)
                                                                                            NOTE: “Other” Category - The EHR-S model does
                             O-2   Finances                                                 NOT include Electronic Resource Planning (ERP) /
                                                                                            Logistics and Financial components, which are
                             O-3   Other                                                    needed for completeness of a military EHR.




                                                                                                                                                 168
                   ESP SDK                       WORKING DRAFT RFI: not for official use.
  Approach to Architectural Traceability

       Core Projects                                  Interoperability Projects                                  Product Line
Plan for New, Improved, Sustained or Sunset                      Conceptual Independent Model                      Inventory
                Capabilities                                      Platform Independent Model
                                                                                                                Inventory of Systems and their
                                                                    Platform Specific Model
                                                                                                                  Capabilities and Functions
                                                                                  CUIs
                                                     CUIs                                         CUIs

      Architectural                                                                                             Architectural
        Business                                                   System                                        Information
       Viewpoints                                                Architecture                                    Viewpoints
     Conceptual Independent Model                                                                        CUIs   Conceptual Independent Model
                                              CUIs
      Platform Independent Model                                                                                 Platform Independent Model
        Platform Specific Model                                                                                    Platform Specific Model


                                                                                                  CUIs
                                                     CUIs                          CUIs
    Architectural                                                                                                 Architectural
Engineering/Technical                                                                                              Behavioral
     Viewpoints       Innovation/ Prototype Projects                                                               Viewpoints
        Conceptual Independent Model                             Conceptual Independent Model                    Conceptual Independent Model
         Platform Independent Model                               Platform Independent Model                      Platform Independent Model
           Platform Specific Model                                  Platform Specific Model                         Platform Specific Model


                                                            Key to Traceability
Traceability is achieved by using Concept Unique (numeric) Identifiers (CUIs) from the HL7 EHR System Functional Model (EHR-S FM)
       as attributes to all artifacts. This is analogous to a library system, which uses Dewey decimal numbers as book identifiers.
                                                                                                                                           169
       ESP SDK                                         WORKING DRAFT RFI: not for official use.
Healthcare SOA Framework
Based on HL7 EHR System Functional Model & Thomas Erl’s SOA Layers
  HL7 System          Direct Care                    Supportive                           Information              Other
  Functions 
                                                                                         Infrastructure
   Business
   Process
 Value Chains

  Composite
                          Federated Composition (e.g., Choreograph or Orchestration) Within and Across Business Areas
   Services

Core Business           Functional                    Functional                         Functional              Functional
                   Areas + Focal Classes         Areas + Focal Classes              Areas + Focal Classes   Areas + Focal Classes
  Services
    Entity              Information                    Information                          Information          Information
                       Management                     Management                           Management           Reporting and
   Services                                                                                                     Management
   Agnostic                                       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…)
   Services
  Application         Ambulatory Care            Logistics Systems                         Data Marts          Business Objects
                          Systems,               Financial Systems                         Repositories
   Services       In Patient Care Systems     Decision Support Systems
Implementation     Integrated Healthcare            Analysis Profiles                    Communications     Implementation Profiles
                  Enterprise (IHE) Profiles                                               Profiles/Stacks
   Profiles
                                                                                                                                170
    ESP SDK                                   WORKING DRAFT RFI: not for official use.                                            170
                          EHR DATA REUSE THROUGH H-SOA-RA
                              ACROSS EPISODES OF CARE



                 Previous Episode                                                              Current Episode
                   Of Care EHR                                                                  Of Care EHR




                                                             IDENTITY
                                                                                               Data Must Be Verified
                                                  • Patient Demographics                           And Updated
                                                  • Provider Demographics
                                                  • Insurer Demographic
                              Reusable Services




                                                           Terminology
                                                  • Chronic Diagnoses
                                                  • Procedure History


                                                             Document
                                                  • Patient History
                                                  • Summary Lists
                                                     - Medication List
                                                     - Allergy/Adverse Reaction List
                                                     - Immunization
     ESP
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    ANATOMY OF AN ANCILLARY SYSTEM


                                  LABORATORY   RADIOLOGY           PHARMACY                 CARDIOLOGY   OT/PT/SPEECH




                                                                    IDENTITY

                                                                TERMINOLOGY
        CORE BUSINESS SERVICES




                                                              AUTHORIZATION

                                                                 SCHEDULING

                                                SUPPLY CHAIN           (ORDER/CHARGE)

                                                                   DOCUMENT

                                                       RECORDS MANAGEMENT
    s
                                                            DECISION SUPPORT

                                                                PERFORMANCE

                                                           DATA MANAGEMENT
     ESP
1/8/2013                         SDK                       WORKING DRAFT RFI: not for official use.                     172
         Ancillary                                                                                                        INTEGRATED
         Systems                                                                                                         REQUIREMENTS
                                                                                                                            DESIGNS:
                                                                                                                            Putting the




                                                                                                        Inter-Service
                           IDENTITY                                                                                          H-SOA-RA




                                                                                 TEST ONLY
                                                                   INPATIENT
                       TERMINOLOGY                                                                                        Pieces Together
                       AUTHORIZATION
Core Business




                                                                                                                                Federated
                                                                                                                                 Business
                        SCHEDULING




                                                                                                                                 Services
  Services




                                                                                                    Inter-Agency
                        SUPPLY CHAIN:




                                                                       ER
                      (ORDERS/CHARGES)
                         DOCUMENT




                                                                       ASU
                     RECORDS MANAGEMENT




                                                                               OUTPATIENT OTHER
                                                                                                                            Federated Services,
                                                                                                                            may be categorized by:




                                                                   CLINIC
                     DECISION SUPPORT




                                                                                                  Providers
                                                                                                                             -- Encounter Types




                                                                                                   Across
                       PERFORMANCE                                                                                           -- CMS billing category
                                                                                                                             -- Record type
                     DATA MANAGEMENT                                                                                         -- Care setting type
Services
Agnostic




                           ANALYTIC                                                                                          -- etc.

                          SUPPORT                                                                                       Data sets are defined for
                                                                                                                         each system functional-
           ESP SDK      IT PLATFORM DRAFT RFI: not for official use.
                                 WORKING                                                                                capability-service module   173
  Case Management
    Coordination Across SOAs and the Continuum

                                           c
             COORDINATION ` ACROSS LEVELS OF CARE, PROVIDERS and LOCATIONS

                                                                               Skilled        Custodial                                      Prevention/
 Wartime                      Acute           Acute           Chronic                                         Home
                ER                                                             Long             Long                       Outpatient        Wellness
 Theater                    Inpatient         Rehab.          Rehab.                                          Health
                                                                               Term             Term
                                                                               Care             Care


                                                                                                  Care Continuum




                Coordination ACROSS SOAS
                          ORDERS          BENEFIT      AUTHORIZATION       COMMUNICATION      DISCHARGE/
               CARE
ASSESSMENT                   &          MANAGEMENT            &              (FACILITATION     TRANSFER    REFERRAL    RECORD   EDUCATION.   TRANSPORT
             PLANNING                                                         ADVOCACY)
                        SCHEDULING                     UTILIZATION MGT.                        PLANNING



                  ROLE OF CASE MANAGER
                                                                                                                                                 174
      ESP SDK                                          WORKING DRAFT RFI: not for official use.                                                    174
                   ADDRESSING REAL BUSINESS ISSUES THROUGH H-SO

•   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)
•   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)


                                                                                                          175
                                                                                                           175
      ESP SDK                        WORKING DRAFT RFI: not for official use.                              175
                                                                               DoDAF 2.x Views
AV-1: Overview and Summary Information.
AV-2: Integrated Dictionary                                 SV-1: Systems Interface Description
                                                            SV-2: Systems Resource Flow Description
CV-1: Vision
                                                            SV-3: Systems-Systems Matrix
CV-2: Capability Taxonomy
                                                            SV-4: Systems Functionality Description
CV-3: Capability Phasing
                                                            SV-5a: Operational Activity to Systems Function Traceability Matrix
CV-4: Capability Dependencies
CV-5: Capability to Organizational Development Mapping      SV-5b: Operational Activity to Systems Traceability Matrix
CV-6: Capability to Operational Activities Mapping          SV-6: Systems Resource Flow Matrix
CV-7: Capability to Services Mapping                        SV-7: Systems Measures Matrix
                                                            SV-8: Systems Evolution Description
DIV-1: Conceptual Data Model                                SV-9: Systems Technology & Skills Forecast
DIV-2: Logical Data Model                                   SV-10a: Systems Rules Model
DIV-3: Physical Data Model                                  SV-10b: Systems State Transition Description
                                                            SV-10c: Systems Event-Trace Description
OV-1: High-Level Operational Concept Graphic
OV-2: Operational Resource Flow Description
                                                            SvcV-1: Services Context Description
OV-3: Operational Resource Flow Matrix
OV-4: Organizational Relationships Chart                    SvcV-2: Services Resource Flow Description
OV-5a: Operational Activity Decomposition Tree              SvcV-3a: Systems-Services Matrix
OV-5b: Operational Activity Model                           SvcV-3b: Services-Services Matrix
OV-6a: Operational Rules Model                              SvcV-4: Services Functionality Description
OV-6b: State Transition Description                         SvcV-5: Operational Activity to Services Traceability Matrix
OV-6c: Event-Trace Description                              SvcV-6: Services Resource Flow Matrix
                                                            SvcV-7: Services Measures Matrix
PV-1: Project Portfolio Relationships                       SvcV-8: Services Evolution Description
PV-2: Project Timelines
                                                            SvcV-9: Services Technology & Skills Forecast
PV-3: Project to Capability Mapping
                                                            SvcV-10a: Services Rules Model
StdV-1: Standards Profile                                   SvcV-10b: Services State Transition Description
     ESP SDK
StdV-2: Standards Forecast                                  SvcV-10c: official use.
                                                 WORKING DRAFT RFI: not forServices Event-Trace Description
     Future-State Architecture
     Software Development Kit (SDK)
     Draft Specifications needed by Fall 2011 *
1.   Built-In-Test-Environment (BITE) Service Specification to support automated fault-detection
     resulting from distributed ad-hoc partners & plug-and-play applications.
     • Model-Driven Health-Tool defines run-time schematron test fixtures.
     • Performance-Monitoring-Component Service-Specification to trace run-time execution
       pathways and measure latency to support, system tuning, automated testing and
       certification.
     • Code-Coverage Regression-Test and Stress-Test Tool-Specification, to support
       automated testing and certification of “happy path” and fault recovery pathways.
     • Cross-Reference Tool-Specification to automatically map module-module and module-
       data dependencies and certify no unexpected changes.
     • Pretty-Printer Tool-Specification to certify software-module Standards and Conventions
       (SAC) & to do syntax verification and readability reformatting.

               * Must be done in collaboration with DoD-VA joint ESP initiative and open source community.




                                                                                                             177
     ESP SDK                                 WORKING DRAFT RFI: not for official use.
     Future-State Architecture
     Software Development Kit (SDK)
     Draft Specifications needed by Fall 2011 *
2.     SAIF ECCF Implementation Guide (IG) for documenting component Interoperability
       Specifications, which will support new development, repurposing, reimplementation,
       automated testing and certification.
3.     SAIF ECCF Tool Specification to manage module Interoperability Specifications, which
       will support new development, repurposing, reimplementation, automated testing and
       certification.
4.     ESB Services Specification of ESP Tier 1-2 Application Virtualization-Layer of
       federated standards-based services.
5.     Database Services Specification of ESP Tier 2-3 Database Virtualization-Layer of
       federated standards-based services.
6.     Standards and Conventions (SAC), updated to modern SOA software engineering
       practices, as defined by Thomas Erl.
               * Must be done in collaboration with DoD-VA joint ESP initiative and open source community.


                                                                                                             178
     ESP SDK                                 WORKING DRAFT RFI: not for official use.
     NIST 7497 Security Architecture *
     Design Principles

1.     Perform Information Assurance Risk assessments of shared information;

2.     Create “master” trust agreements describing requirements for a trust
       domain;

3.     Separate authentication/credential management and
       authorization/privilege management;

4.     Develop data protection capabilities as plug-and-play services;

5.     Maintain a standards-based, technology-neutral, and vendor-neutral
       architecture.


      * NIST IR 7497, Security Architecture Design Process for Health Information Exchanges (HIEs), Sept. 2010,
                           available at http://csrc.nist.gov/publications/PubsNISTIRs.html


                                                                                                                  179
     ESP SDK                               WORKING DRAFT RFI: not for official use.
    NIST 7497 Security Architecture
    Enabling Services
1. Risk Assessment is a Security and Privacy Principles, which means to identify security
   and privacy risks to HIE operations based on threats, assets, vulnerabilities, and likelihood
   of threat success.
2. Entity Identity Assertion (Authentication) is HITSP Construct * SC110 & C19, which
   ensures that an entity is the person or application that claims the identity provided.
3. Credential Management is a Security Principles, which means to manage the life cycle of
   entity credentials used for authentication and authorization.
4. Access Control (Authorization) is HITSP Construct * SC108 & TP20, which ensures that
   an entity can access protected resources if they are permitted to do so.
5. Privilege Management is a Security Principles, which means to manage the life cycle of an
   entity’s authorization attributes (e.g., roles, permissions, rules) for making access control
   decisions.
6. Collect and Communicate Audit Trail is HITSP Construct * SC109 & T15, which defines
   and identifies security-relevant events and the data to be collected and communicated as
   determined by policy, regulation, or risk analysis.

                                                                                               180
   ESP SDK                           WORKING DRAFT available at use.
                             * HITSP constructs areRFI: not for official www.HITSP.org
     NIST 7497 Security Architecture
     Enabling Services
7.    Document Integrity is HITSP Construct * T31, which validates that the contents of a
      document have not been changed in an unauthorized or inappropriate manner.
8.    Secured Communication Channel is HITSP Construct * SC109 & SC112, which
      ensures that the mechanism through which information is shared or transmitted
      appropriately protects the authenticity, integrity, and confidentiality of transactions to
      preserve mutual trust between communicating parties.
9.    Document Confidentiality is a Security Principles, which means to prevent the
      unauthorized disclosure of a document that is exchanged or shared.
10. De-identification is a Privacy Principles, which means to remove individual identifiers
    from a health record, or replace them with other information such as pseudonyms, so that
    it cannot be used to identify an individual.
11. Non-Repudiation of Origin is HITSP Construct * C26, which provides the proof of the
    integrity and origin of data in an unforgettable relationship which can be verified by any
    party.
12. Manage Consent Directives is HITSP Construct * TP30, which ensures that individually
    identifiable health information is accessed only with an individual’s consent.

                                                                                                   181
     ESP SDK                          WORKING are Talking Points
                                    constructs DRAFT RFI: not for official use.
                             * HITSPD R A F T available at www.HITSP.org
NIST 7407 Security Architecture
 Web-Service Security-Standards




                                                                 182
ESP SDK               WORKING DRAFT RFI: not for official use.
NIST 7497 Security Architecture
Notional Development Process




                                                                183
  ESP SDK            WORKING DRAFT RFI: not for official use.

				
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