Ulusal Saglik Bilisim Kongresi, Izmir,

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Interoperability of Healthcare Messages and
Electronic Healthcare RecordsProf. Dr. Asuman
Dogac, Gokce Laleci
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IST-027065 RIDE Project

• A Roadmap for Interoperability of eHealth Systems
  in Support of COM 356 with Special Emphasis on
  Semantic Interoperability
• PRIORITY 2.4.11 Integrated biomedical information
  for better health eHealth
• Coordinator METU-SRDC, Turkey,
• Partners OFFIS, Germany, IFOMIS, Germany,
  EUROREC, EU, CNR, Italy, NTUA, Greece, DERI,
  Ireland, IHE-D, Germany, OLE, Belgium

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Outline of the Talk

• The e-Health Initiatives in the USA
• The Solution METU-SRDC has developed
• Healthcare Message Interoperability
• The Current Situation in some of the EU Member
  States

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USA eHealth Administrative Organization
American Health Information Community Led by HHS
Secretary Michael Leavitt
Office of the National Coordinator Project
Officers
Privacy Security Solutions (HISPC)
Compliance Certification (CCHIT)
NHIN Prototype Contractors
Standards Harmonization Contractor (HITSP)
Continuous Interaction with Multiple Public and
Private Stakeholders
Consolidated Health Informatics (CHI)
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Breakthrough Areas

• Biosurveillance Transmit essential ambulatory
  care and emergency department visit, utilization,
  and lab result data from electronically enabled
  health care delivery and public health systems in
  standardized and anonymized format to authorized
  public health agencies within 24 hours
• Consumer Empowerment Deploy to targeted
  populations a pre-populated, consumer-directed
  and secure electronic registration summary.
  Deploy a widely available pre-populated
  medication history linked to the registration
  summary
• Electronic Health Record Exchange Deploy
  standardized, widely available, secure solutions
  for accessing current and historical laboratory
  results and interpretations in a patient-centric
  manner for clinical care by authorized parties

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Figure 5 HITSP EHR Interoperability
Specification1
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Demo Scenario Using the Standardsfrom the USA
Implementation Specification

• One sunny day in Izmir, a person in Ulusal
  Bilisim Saglik Kongresi experiences a heart
  attack

• From the nearest hospital an
• ambulance is called

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Demo Scenario

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

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Demo Scenario

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

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Demo Scenario

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

Common EU EHR Registry/Repository
Brussels Hospital
Izmir Hospital
Brugge Hospital
Ankara Hospital
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Demo Scenario

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

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

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Demo Scenario

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

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

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

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

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

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

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

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Demo Scenario

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

What time is it?
What time is it?
UTC1
UTC1
Izmir Hospital
Brusells Hospital
111216
091328
101448
091328
101328
101328
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Demo Technologies Used

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

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The Technical Issues Needed to be Addressed

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

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


12345
Iakovidis
Ilias
11011010
Network
12345
Iakovidis
Ilias
Application 1 HIS Database and back end
applications
Application 2 HIS Database and back end
applications
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Summary of EHR Standards
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Summary of EHR Standards
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eHealth Interoperability in Canada
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eHealth Interoperability in some of the EU member
states
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eHealth Interoperability in some of the EU member
states
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eHealth Interoperability in some of the EU member
states
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eHealth Interoperability in some of the EU member
states
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What Lies Ahead

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

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Thank you very much for your attention

• Any Questions?