Claudio Saccavini

1
Cross Enterprise Document Sharing(XDS)

• Claudio Saccavini
• IHE-Italy Project Manager
• O3 Consortium - University of Padova

2
IT Infrastructure Profiles

• 2004
• Patient Identifier Cross-referencing for MPI
  (PIX)
• Retrieve Information for Display (RID)
• Consistent Time (CT)
• Patient Synchronized Applications (PSA)
• Enterprise User Authentication (EUA)
• 2005
• Patient Demographic Query (PDQ)
• Cross Enterprise Document Sharing (XDS)
• Audit Trail and Note Authentication (ATNA)
• Personnel White Pages (PWP)
• 2006
• Cross-Enterprise User Authentication (XUA)
• Document Digital Signature (DSG)
• Notification of Document Availability (NAV)
• Patient Administration/Management (PAM)

• Cross-Enterprise Document Sharing (XDS)
  Registration, distribution and access across
  health enterprises of clinical documents forming
  a patient EHR

3
Cross-Enterprise Document Sharing (XDS)Abstract
/ Scope

• Provide support for document-based patient EHR
• Support for document storage within existing
  products
• Provide support for indexing of patient documents
• Support query and retrieval of patient documents
• Scalable architecture

4
Cross-Enterprise Document Sharing (XDS) Value
Proposition

• Points of view
• EHR-CR Care-delivery Record
• Patient information
• Managed by a Care Delivery Organization
• EHR-LR Longitudinal Record
• Documents shared by EHR-CR(s)
• Tracked by Registry
• Clinical Affinity Domain
• Group of healthcare enterprises (EHR-CR)
• Common set of policies
• Share a single registry

5
Cross-Enterprise Document Sharing (XDS) Value
Proposition

• Foundation for Health IT Infrastructures Shared
  Electronic Health Record, in a community, region,
  etc.
• Effective means to contribute and access
  clinical documents across health enterprises.
• Scalable sharing of documents between private
  physicians, clinics, long term care, pharmacy,
  acute care with different clinical IT systems.
• Easy access Care providers are offered means to
  query and retrieve clinical documents of interest.

6
Cross-Enterprise Document Sharing (XDS) Value
Proposition

• Distributed Each Care delivery organization
  publishes clinical information for others.
  Actual documents may remain in the source EHR-CR.
• Cross-Enterprise A Registry provides an index
  for published information to authorized care
  delivery organizations belonging to the same
  clinical affinity domain (e.g. an LHII).
• Document Centric Published clinical data is
  organized into clinical documents. using
  agreed standard document types (HL7-CDA,
  ASTM-CCR, PDF, DICOM, etc.)

7
Cross-Enterprise Document Sharing (XDS) Value
Proposition (cont)

• Document Content Neutral Document content is
  processed only by source and consumer IT systems.
• Standardized Registry Attributes Queries based
  on meaningful attributes ensure deterministic
  document searches.

8
Cross-Enterprise Document Sharing (XDS)
Transaction Diagram
9
Cross-Enterprise Document Sharing (XDS) Actors

• Document Source
• Source of documents and metadata about documents
• Document Repository
• Stores documents, requests indexing in Document
  Registry, supports retrieval
• Document Registry
• Indexes documents, supports search
• Patient Identity Source
• Feeds identity of known patients to Document
  Registry
• Document Consumer
• Initiates search and retrieval for consumer of
  documents

10
Actors Transactions
11
Actors Transactions

• Note 1 The Provide and Register Document Set is
  not required in implementations where the
  Document Source is grouped with the Document
  Repository Actor.
• Note 2 The Register Document Set Transaction is
  not required in implementations where the
  Document Registry Actor is grouped with the
  Document Repository Actor. However, it is
  strongly recommended that these transactions be
  supported to allow for future configuration with
  multiple Repositories.
• Note 3 If Assigning Authority of Patient ID
  presents in the Patient Identity Feed
  transaction, the Patient Identity Source is
  required to use an OID to identify the Assigning
  Authority. For technical details of the assigning
  authority information, see Transaction 8 in
  Technical Framework, Volume 2.

12
Actors Options
Note1 For the XDS Document Consumer Actor,
either one or both of the two options shall be
selected.
13
Cross-Enterprise Document Sharing (XDS)
Standards Used

• Internet Standards
• HTML, HTTP,ISO, PDF, JPEG

• Electronic BusinessStandards
• ebXML, SOAP

• HealthcareContent Standards
• HL7 CDA, CEN EHRcomHL7, ASTM CCRDICOM

14
Cross-Enterprise Document Sharing (XDS)
Standards Used

• Two categories of standards used

XDS Content
XDS Infrastructure
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Cross-Enterprise Document Sharing (XDS)
Standards Used

• XDS Infrastructure Standards
• OASIS/ebXML
• Registry Information Model v2.0
• Basis of XDS Registry Information Model
• Registry Services Specifications v2.0
• Registry Services
• Messaging Services Specifications v2.0
• Offline protocols
• ISO/IEC 9075 Database Language SQL
• Registry Query Language
• SOAP with Attachments
• Protocol for communication with XDS Registries
  and Repositories
• SHA-1 FIPS 180-1
• Document Hashes

16
Cross-Enterprise Document Sharing (XDS)
Standards Used

• XDS Infrastructure Standards (cont)
• HL7 Version 2.3.1
• Messages for Patient Identity Management
• HL7 Version 2.5
• Datatypes for XDS Registry Attribute values
• HL7 CDA Release 1
• XDS Document concept definition
• Source of XDS Document Entry Attributes
• DICOM, ASTM CCR, HL7 CDA Release 2, CEN EHRcom
• Sources of XDS Document Entry Attributes

17
Cross-Enterprise Document Sharing (XDS)
Standards Used
XDS Infrastructure Standards (cont)

• HTTP
• Protocol for Retrieve Document
• Online SOAP bindings
• SMTP
• Offline ebMS bindings
• IETF
• Language Identifiers

• MIME
• Document Type codes
• UTF-8
• Encoding of Registry Attributes

18
Cross-Enterprise Document Sharing (XDS)
Standards Used

• XDS Content Standards
• Outside scope of XDS layer on top of XDS
• Documented as Document Content Profiles
• Document use cases and translation of document
  content into registry metadata
• Publishable separately
• Guide for writing DCPs available
• Intended mostly for IHE domain committees
• Of concern only to Document Source and Document
  Consumer actors
• Examples include HL7 CDA, DICOM, ASTM CCR

19
Cross-Enterprise Document Sharing (XDS) Proposed
Options

• Options center around Document Source actor
• Basic operations
• Submit single document
• Replace existing document
• Optional features
• Off-line mode
• Multi-document submission
• Document life-cycle management
• Submit addendum or transformation of document
• Folder management
• Create folder, add to folder

20
Cross-Enterprise Document Sharing (XDS) Related
Profiles

• Patient Identity
• Patient Identity Feed
• Notification
• from ADT system
• to Document Registry
• of patient admission/registration
• Submission to Registry requires validated patient
  ID
• Patient Demographics Query (PDQ)
• Identify patient based on query of demographic
  information
• Needed by Document Source assign correct patient
  ID
• Needed by Document Consumer query against
  correct patient ID

21
Cross-Enterprise Document Sharing (XDS)
Transaction Diagram
22
Cross-Enterprise Document Sharing (XDS) Patient
ID Management
23
Cross-Enterprise Document Sharing (XDS) Related
Profiles

• Time/Audit/Authentication
• Constant Time (CT)
• Audit Trail and Node Authentication (ATNA)
• Cross-Enterprise User Authentication (XUA)

24
Cross-Enterprise Document Sharing (XDS) Related
Profiles

• New related profiles
• Notification of Availability (NAV)
• Send notification that documents are available
• Digital Signature (DSG)
• Signing of documents in repository/registry

25
Cross-Enterprise Document Sharing (XDS) Document
Status

• Each XDS Document contained in a XDS Document
  Registry will be assigned one of the following
  Availability Status codes
• Approved Available for patient care (assumes
  that it is authenticated, if applicable)
• Deprecated Obsolete, but may still be queried
  and retrieved
• The XDS Document availability status is set to
  approved after the XDS Document Repository and
  the XDS Document Registry have successfully
  processed a submission request.

26
Cross-Enterprise Document Sharing (XDS) Document
Relationship

• XDS Documents may be related to predecessor
  documents by one of three methods
• Replacement,
• Addendum
• Transformation
• Transformation-Replacement
• These relationships between XDS Documents are
  tracked in the XDS Document Registry.

27
ebXML Registry vs XDS

• XDS is a Profile of the ebXML Registry standard
• ebXML Registry is two standards
• ebRIM (Registry Info Model)
• ebRS (Registry Services - protocols)
• XDS uses a SMALL subset of ebRIM and ebRS

28
ebRIM

• ebRIM defines a language for describing documents
• This language is constructed as objects and
  attributes of objects
• It is expressed as XML
• AKA Metadata

29
ebRS

• Defines the methods/verbs/requests

30
Submission

• From Doc Src to Repository
• Contents
• Metadata
• 0 or more Documents
• Encoding SOAP with Attachments

31
Protocol Layering

• Metadata Documents
• within
• SOAP with Attachments
• within
• HTTP Post
• within

32
Query

• ebRIM defines relational views into metadata
  storage
• Queries are written in subset of SQL
• XDS defines the necessary queries

33
Key ebRS Methods

• Document Source
• SubmitObjectsRequest
• Document Consumer
• AdhocQueryRequst
• Registry Adaptor
• ApproveObjectsRequest
• DeprecateObjectsRequest

34
Submission
35
Submission
36
Submission Set
37
Some important ebRIM objects are
38
Primary XDS Objects

• XDSDocumentEntry (ExtrinsicObject)
• Represents document in repository
• Contains many detailed attributes
• XDSSubmissionSet (RegistryPackage)
• Records
• Documents submitted together
• Significant clinical events
• Contains many detailed attributes

39
A Document is

• A bit stream stored in a Repository
• A metadata element in the Registry representing
  the content in the Repository
• XDSDocumentEntry
• ExtrinsicObject

40
XML - XDSDocumentEntry

• ltrimObjectRef id"urnuuid7edca82f-054d-47f2-a03
  2-9b2a5b5186c1" /gt
• ltrimExtrinsicObject
• objectType"urnuuid7edca82f-054d-47f2-a032-9b2
  a5b5186c1" gt
• ltrim/ExtrinsicObjectgt

Declares object in registry
41
XML - XDSSubmissionSet

• ltrimRegistryPackage idssgt
• lt/rimRegistryPackagegt
• ltrimClassification
• classifiedObjectss
• classificationNode"urnuuida54d6aa5-d40d-43f9
  -88c5-b4633d873bdd"/gt
• ltrimObjectRef id"urnuuida54d6aa5-d40d-43f9-88c
  5-b4633d873bdd"/gt

Defines submission set
42
XML - adding Document to Submission Set

• ltrimExtrinsicObject iddocgt
• lt/rimExtrinsicObjectgt
• ltrimRegistryPackage idss
• lt/rimRegistryPackagegt
• ltrimAssociation
• associationType"HasMember"
• sourceObjectss"
• targetObjectdoc"gt

43
XML - Submission

• ltrsSubmitObjectsRequestgt
• ltrsLeafRegistryObjectListgt
• ltrimExtrinsicObjectgt
• lt/rimExtrinsicObjectgt
• ltrimRegistryPackagegt
• lt/rimRegistryPackagegt
• lt/rsLeafRegistryObjectListgt
• lt/rsSubmitObjectsRequestgt

44
XML - Attributes

• XDSDocumentEntry and XDSSubmissionSet
• Large number of attributes defined by XDS
• Some Required, some Optional
• Tables 3.14.4.1-5 and 3.14.4.1-6 define
  attributes with examples

45
XML - Attribute Types

• Main
• Slot
• Classification
• External Identifier

46
XML - Main Attribute Type

• Attribute of main element
• ltrimExtrinsicObject
• objectType
• mimeTypetext/xmlgt
• Name and Description elements
• ltrimNamegt
• ltrimLocalizedString value "test 11731"/gt
• lt/rimNamegt
• Applies to submission set as well

47
XML - Slot Attribute Type

• Name/Value pairing
• May have multiple unordered values (controlled by
  XDS)
• ltrimSlot name"authorPerson"gt
• ltrimValueListgt ltrimValuegtWelbyMarcus
  DrMDlt/rimValuegt
• ltrimValuegtJonesBarnabyDrMDlt/rimValuegt
  
• lt/rimValueListgt
• lt/rimSlotgt

48
XML - Classification

• 3 part coding (coding scheme, code value, code
  value display name)
• ltrimClassification classificationScheme
  "urnuuidf4f85eac-e6cb-4883-b524-f2705394840f"
  classifiedObject"theDocument"
  nodeRepresentationcode_value" gt
• ltrimNamegt
• ltrimLocalizedString valuecode value
  display name"/gt
• lt/rimNamegt
• ltrimSlot name"codingScheme"gt
• ltrimValueListgt
• ltrimValuegtCoding scheme namelt/rimValuegt
• lt/rimValueListgt
• lt/rimSlotgt
• lt/rimClassificationgt

Which coded attribute
49
XML - Classification (2)

• classificationScheme - identifies which coded
  attribute (classCode, eventCode,
  healthcareFacilityTypeCode, etc.)

50
XML - External Identifiers

• Labeled with type, value,
• and name
• ltrimExternalIdentifier
• identificationScheme"urnuuid58a6f841-87b3-4a3e-
  92fd-a8ffeff98427"
• value 6578946amp1.3.6.1.4.1.21367.2005.3.7
  ampISO"gt
• ltrimNamegt
• ltrimLocalizedString
• value "XdsDocumentEntry.patientId"/gt
• lt/rimNamegt
• lt/rimExternalIdentifiergt

type
value
name
51
Attribute Order

• The order in which attributes are coded is
  important/restricted
• Main (element attributes and title/description)
• Slots
• Classifications
• External Identifiers

52
Submission Response

• ltRegistryResponse
• codeContext"Test 11710" status"Success" gt
• lt/RegistryResponsegt

53
SOAP

• HTTP Header
• ---blank line---
• HTTP Body - SOAP encoded

54
HTTP/SOAP Header

• POST /ebxmlrr/registry/soap HTTP/1.1
• Accept /
• Accept-Language en-us
• Referer http//sst138.ncsl.nist.gov/web/soap/soap
  -diag-client.htm
• Content-Type text/xml charsetutf-8
• SOAPAction ""
• Accept-Encoding gzip, deflate
• User-Agent Mozilla/4.0 (compatible MSIE 6.0
  Windows NT 5.1)
• Host gunshot.ncsl.nist.gov8080
• Connection Keep-Alive
• Cache-Control no-cache
• Content-Length 851

55
HTTP/SOAP Body

• lt?xml version"1.0" ?gt
• ltSOAP-ENVEnvelope xmlnsSOAP-ENV"http//schemas.
  xmlsoap.org/soap/envelope/"gt
• ltSOAP-ENVHeader/gt
• ltSOAP-ENVBodygt
• ltrsSubmitObjectsRequestgt
• lt/rsSubmitObjectsRequestgt
• lt/SOAP-ENVBodygt
• lt/SOAP-ENVEnvelopegt

56
SOAP with Attachments

• Used to transfer metadata and documents from
  Document Source to Document Repository

57

• POST /ebxmlrr/registry/soap HTTP/1.1
• Content-Type multipart/related type"text/xml"
  boundary---------------------------7d4285f14803b8
  
• SOAPAction ""
• -----------------------------7d4285f14803b8
• Content-Type text/xml
• lt?xml version"1.0" ?gt
• ltSOAP-ENVEnvelope xmlnsSOAP-ENV"http//schemas.
  xmlsoap.org/soap/envelope/"gt
• ltSOAP-ENVHeader/gt
• ltSOAP-ENVBodygt
• ltrsSubmitObjectsRequestgt
• ltrsLeafRegistryObjectListgt
• ltrimExtrinsicObject id"doc_1"/gt
• lt/rsLeafRegistryObjectListgt
• lt/rsSubmitObjectsRequestgt
• lt/SOAP-ENVBodygt
• lt/SOAP-ENVEnvelopegt
• -----------------------------7d4285f14803b8

hdr
metadata
doc
Note extra dashes
58
Be Careful

• Technically, XDS implementations must be able to
  handle any of the legal XML escape sequences
• amp for
• apos for '
• lt for lt
• gt for gt
• quot for "

59
Be Careful

• SELECT eo.id FROM ExtrinsicObject eo,
  ExternalIdentifier ei
• WHERE
• eo.id ei.registryobject AND
  ei.identificationScheme'urnuuid58a6f841-87b3-4a
  3e-92fd- a8ffeff98427' AND
• ei.value'NIST-query-2amp1.3.6.1.4.1
  .21367.2005.3.7ampISO' AND
• eo.status 'Approved'

60
Be Careful

• select extrinsicobject.id from extrinsicobject,ext
  ernalidentifier where
• extrinsicobject.objecttype
• aposurnuuid7edca82f-054d-47f2-a032-9b2a5b5186c
  1apos and
• extrinsicobject.status aposApprovedapos and
• externalidentifier.identificationscheme
• aposurnuuid58a6f841-87b3-4a3e-92fd-a8ffeff9842
  7apos and
• externalidentifier.value
• apos47122048ampAO_PD_ASSIPCAampISOapos
  and extrinsicobject.id
• externalidentifier.registryobject

61
Be Careful

• ltSubmitObjectsRequest xmlns"urnoasisnamestceb
  xml-regrepregistryxsd2.1"gtltns1LeafRegistryObje
  ctList xmlnsns1"urnoasisnamestcebxml-regrep
  rimxsd2.1"gt
• ....
• ltns1ValueListgt

62
Supporting Infrastructure
NIST Implementation
63
Basics

• Tomcat (assuming Java)
• Apache - supports bidirectional authentication
  (half of ATNA)
• Ebxmlrr - Source Forge project
• Iheos - Source Forge project

64
Testing Resources
65
Resources on ihe.net

• Schema
• Examples
• Registry initialization metadata

66
Test Kit

• Defines all tests for all XDS transactions
  including optional ones
• Includes example source code and metadata

67
Metadata Cookbook

• Primer on XDS metadata
• Will be updated for this season

68
NIST Public Registry

• Implements Registry and Repository actors
• Instrumented to capture and log all events
• Logs viewable by tester
• Web page for tester to register patient IDs for
  testing
• Will be used for pre-Connectathon testing of Doc
  Src and Doc Con actors
• Will be present at Connectathon
• Will be present at HIMSS

69
Test Result Reporting

• Will use Web tool
• Web tool, XDS test logging, XDS test requirements
  all linked

70
Last but not least ...

• www.o3consortium.org
• Registry and Repository implementation
• to test your actors
• before Barcelona 2006 Connect-a-thon
• Marco Biasio
• mbiasio_at_rad.unipd.it
• 39 049 8212378
• skype mbiasio

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