1 Toward a Service-Oriented Public Health Infrastructure Alean Kirnak, Software Partners LLC...

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Alean Kirnak, Software Partners [email protected] 2009

Copyright 2009 Software Partners LLC

2007-2008 PHDSC white paper: silos repeat functionality and don’t talk to each other

In 2008-2009, PHDSC developed a Service-Oriented Architecture White Paper with IHE

New standards offer new workflow possibilities and related cost savings

www.ihe.net A Service-Oriented Architecture View of IHE Profiles, Kirnak, Moehrke, Painter.

Messages Documents Services

3Copyright 2009 Software Partners LLC

Point-to-point communication HL7 V2 Implementation Guides

MSH|^~\&|XDSDEMO_ADT|XDSDEMO|SWPartner_PIX|SWPartner_PIX|200908301933||ADT^A04^ADT_A01|00000188|P|2.3.1|….



Copyright 2009 Software Partners LLC 6


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Identification ServiceOperati

on Description

Register

This operation inserts a Source ID/Entity ID pair and supplied Traits into the index with implicit linking to other matching Source ID/ Entity ID pairs, based on the configured internal matching algorithm.

Update This operation updates the Traits stored in the index for the Entity identified by the supplied Source ID/Entity ID pair.

List

This operation retrieves all the Source ID/Entity ID pairs that are linked to the supplied Source ID/Entity ID pair. The operation can be filtered with the sourceConstraintSet property of the EISSearchQualifier to only return entities within specified Source domains.

QueryThis operation provides the means to perform a broad search of all records in the index whose traits match some criteria in the supplied search criteria.

LinkThis operation provides the means to create an explicit (as opposed to automatic) linking between two Source ID/Entity ID pairs in the index.

UnlinkThis operation provides the means to create an explicit (as opposed to automatic) linking between two Source ID/Entity ID pairs in the index.

MergeThis operation provides the means to explicitly consolidate index Source ID/Entity ID pairs in the index.



Web-based Application

Registry Data Store

Data Stores

All Registry Application Functions:

Identity Resolution

Retrieval/Update of Data

Decision Support

Population Studies

HL7 V2

Hospital #2

Clinic #2

Hospital #1 user

Clinic #1 user

Other user

Stakeholders

Other user

Point to point:

Hub:

Bus:


Approximately 75 U.S. Immunization Information Systems (IISs)

Completely connected point-to-point IIS network: 74 * 75 / 2 = 2775 connections

Assume 200 regional provider EHRs per IIS:200 * 75 = 15,000 connections

Each connection costs $10K-$30K per side $40K each * 17,775 =$711,000,000


Labs Meds Allergies Problem Lists Cancer Registries Adverse Events …etc. Intra-enterprise communication Provider-to-Provider communication ... 100 domains increases cost to

$71,100,000,000


Patient Identification Maintenance of Connections Data Models Decision Support Reporting


Providers are the producers of electronic health information

Patients are the consumers

Providers will not pay


Reduce number of connections through bus architecture◦ SOA

Create repeatable connections◦ Plug and play standards like IHE

Collapse common functionality◦ Reuse infrastructure like Patient Identification

Create common information model◦ Use Continuity of Care Document

Improve the delivery of information to consumers so payors will eventually pay◦ To their other providers◦ To public health◦ To patients directly


Service Interfaces

Identity Resolution

Decision Support

Retrieve and Update

Hospital #2

Clinic #2

Hospital #1 EMR

Clinic #1 EMR

Internet

Browser interface

Existing IIS

Master Person Index

Document Repository

Data Stores

Document Registry

Services

Other Service

Security

Data Transform


Existing IIS

Existing IIS

75 U.S. IISs Each connected to one Identification Service

running a standard interface: 75 connections 200 provider EHRs per IIS: 200 * 75 = 15,000 Averaging 30 installations each of 500 EHR

products = 500 + 75 = 575 Each connection costs $10K-$30K

◦ Service consumer only! $20K each * 575 =$11,500,000 total plug and play connections means:

For a single service i.e. Patient Identification



Interoperability cost becomes function of:

# of service consumers * # of services


3 services * 575 EHR flavors * 20K =

$34,500,000 vs $71,100,000,000


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Capability Patient Identification Data Retrieval and Update Decision SupportStandards Org HL7

Service SpecificationIdentification Service Functional

Model (SFM) Retrieve, Locate, Update SFM Decision Support SFMStandards Org OMG

Service Specification Identification Service Specification Retrieve, Locate, Update Tech SpecDecision Support Service

SpecProfile Org IHESOA Profile SOA White PaperProfile Org IHE

Immunization Profile PIX/PDQ POIZ ScopeImmunization

ContentImmunization

Content

Request for Clinical

Guidance (Immunization

Content payload)

Profile Org AIRA/CDC

Immunization Profile

In progress: 2.5 Implementation

Guide

In progress: 2.5 Implementation

Guide

Immunization Profile

2.3.1 Implementation

Guide

2.3.1 Immunization

Implementation Guide

Standards Org HL7

Original Standard Version 2Version 3 Patient Admin messaging Version 2

Version 3 Immunization

(POIZ) messaging

Version 3 Care Record CDA

Version 3 Care Record CDA

Version 3 Care Record

messaging


2. Primary Care Provider, State 2

IHE Infrastructure

Immunization Information System (IIS)

1. Primary Care Provider, State 1

PHIN 2009 - IHE Interoperability Showcase Public Health Immunization Scenario

Decision Support Service

Yellow Card Service

3. Infrastructure

4. Local Public Health Dept. State 2

An 18 month-old patient without immunization record visits PCP11. PCP1 queries the local EMR 2. EMR queries IIS (QED)3. IIS returns immunization to EMR 4. PCP1 receives list of immunizations via EMR 5. Immunizations are administered 6. PCP1 updates EMR 7. EMR updates IHE Registry & Repository (XDS-MS, IC) and IIS (HL7

2.3.1) via Gateway

The same patient, now a 5 year-old, visits PCP2 in a different state, again without an immunization record

1. PCP2 queries EMR 2. EMR queries the HIE (PIX, PDQ, XDS-MS)3. HIE returns immunization to EMR 4. PCP2 receives list of immunizations via EMR 5. Immunizations are administered6. PCP2 updates EMR 7. EMR updates IHE Registry & Repository (XDS-MS, IC) and IIS (HL7 2.3.1) via the Gateway

<<Explanation of IHE Infrastructure, Gateway, Immunization Information System, Decision Support Service and Yellow Card Service. >>

A measles outbreak is occurring in a large county in State 2. The child’s parent calls the local health department to confirm the child’s measles immunization status

1. Epidemiologist authenticates using a Identity Service Provider (TP 20, C19)

2. Authenticated epidemiologist queries the HIE using child’s name, gender, and birthday (PDQ)

3. IHE Infrastructure returns a list of matching records4. Epidemiologist selects appropriate record; request for immunization

records sent, then results returned (XDS, IC)5. Request for immunization recommendations (IDSS) , results returned6. Yellow Card requested and returned as PDF to be printed and mailed


Education◦ Little understanding of SOA yet

Broader View◦ Groups like HITSP must take the broad view◦ “SOA Governance”

Overcoming status quo thinking◦ Vested interests in preserving inefficient approaches

Funding◦ Support innovative approaches as well as status quo

Collective Action


“The Internet disrupted the music business; Google disrupted the media…. Buzzwords such as “Health Care

2.0”, … could soon acquire real meaning.”

- The Economist, Oct 25, 2008


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