Inter-institutional Data Sharing, Standards and Legal

Arthur Davidson, MD, MSPH

Agency for Healthcare Research and Quality, Washington, DC

June 9, 2005

Funded in part through a contract with Agency for Health Care Research and Quality (AHRQ), and the Foundation for eHealth Initiative (FeHI) and their cooperative agreement with HRSA, Office for the Advancement for Telehealth (OAT). 

The contents of this presentation are solely the responsibility of the author and do not necessarily represent the official view of AHRQ, HRSA/OAT or FeHI.

Colorado Health Information Exchange

Goal: Create a local health information infrastructure for clinicians to access patient information across individual health care institutions

Colorado Health Information Exchange 2 Complementary Initiatives

Build upon what exists• Denver Health (DH)

• 150,000 residents (25% of population) • Kaiser Permanente of Colorado (KPC)

• 3rd largest CO HMO (350,000 members) • The Children’s Hospital (TCH)

• Largest pediatric specialty care provider• University of Colorado Hospital (UCH)

• Largest Metro area teaching hospital

COHIE to CORHIO

COHIELearning

Laboratory

Steering Committee

Working groups:• Technical• Clinical• Evaluation• Legal• Organizational

Community Advisory Council

Colorado Regional Health Information OrganizationA sharing, self-sustaining non-profit structure that:

Promotes legal

agreements for

participation and access

Maintains a robust

technical environment

Defines clinical value

through policy and procedures

Manages the budget and

sustainable business

model

Supports national

standards and public

health interfaces

PROJECT(10/2004)

VISION(10/2009)

COHIE: 2005 plan

RHIO: 2005 vision

Organizational / Governance Layer

Inter-Enterprise Utility Services

Network Transport

Inter-Enterprise Business Services

Internal OperationsLayer

Operating Entity

Organizing / Convening Entity

Participating Entity

Operational / Project Sub-committee

Financing Entity

Operational / Project Sub-committee

Message Standards Validation

InternetLeased Private

Network

Message or Other Storage

Privacy / Security

Authorization

Record Locator

(MPI)

Hosted Routing Services

Customer / User Portal

Call Center

Message Translation

Message Handling

Process- / Data Content-Specific

Applications

Standard Software Applications /

Services / ToolsAdapter Adapter Adapter Adapter

Hospital Information

System

Electronic Medical Record (EMR) System

Physician OfficePractice

Management System

Lab,/ Diagnostic Imaging /

Ancillary System

Adapter Payer Claims SystemAdapter

Pharmacy / PBM

SystemAdapter

Public Health / Disease Surveillance SystemAdapter

Adapter Adapter

Adapter

The “Primary” Scenario

• Clarifies the scope (common understanding)

• Provides a structure to focus meetings and discussion

• Creates a mechanism for logging issues and decisions

Colorado Health Information Exchange (COHIE): Scenario (Use Case), draft 12/22/04 - AD

a) Patient seizes, taken toThe Children's Hospital(TCH) EmergencyDepartment (ED)

c) Consent given?

b) Patient registration androutine informed consentwhich includes permision toelectronically query formatching patients acrossCOHIE partners. Patientmay "opt out".

a) Secure TCH registrationsystem message received atCOHIE; seek potentialmatches in unified masterpatient index (UMPI); uniqueUMPI identifier created;patient's consent storedcentrally with TCH identifier

e) ED Physician securelyreviews list of potentialmatches, confirms atrue match and sendsmessage to COHIE

f) COHIE receives alllaboratory, radiology,pharmacy and clinicalconsultation Information fromparticipatingpartners;organizes andpresents health history inweb page for viewing at TCH.

SCENARIO ASSUMPTION (USE CASE Pre-condition):

4 year old boy with history of prior seizures. Born prematurely at University of Colorado Hospital (UCH) with prolonged stay in NICU 1 year ago had first seizure while a Kaiser (KP) patient. Evaluated with CT scan, EEG and neurologist visit. Started on

unknown medication at that time. Patient lost health insurance coverage, transferred care to Denver Health (DH) outpatient clinic about 6 months ago. Seen at Westwood Family Health Center for blood test and change in medication about 3 days ago

STARTSCENARIO

i) ED Physician uses allhealth information toprovide best, costeffective, treatment forpatient.

END SCENARIO

YES

g) COHIE maintains a completeaudit log: who accessed thesystem, when, whatinformation was shared, and itssource

ED Physicianprovides treatmentwith limitedmedical historyfrom parent/patient

may requireadditional (andpotentiallyunnecssary ) blood tests, radiologic tests

NO

e) COHIE sends secure datarequest to retrieve patientclinical information

b) COHIE UMPI sends asecure message toparticipating partnersseeking any potentialmatches to this patient.

a) Secure message fromCOHIE received byparticipating partners(DH, KP, UCH)requesting potentialmatches .

d) ED Physician uniquelyidentified / authenticatedon the COHIE system

h) ED Physician securelyreviews clinical data inbrowser window

Desired information: medication used drug level EEG results CT scan results newborn, neurology and primary care exam findings

and diagnosis name/institution/contact method for treating MDs

b) Potential matchesidentified and messagereturned to COHIE fromeach partner.

c) Potential matches mergedand prepared as oneCOHIE web page forviewing at TCH

d) COHIE UMPI storesmatch with linking (TCH,DH, KP, UCH) identifiers

c) Secure COHIEmessage received byDH, KP/UCHrequesting clinical data

d) Clinical repositorydata identified andmessage preparedfor COHIE from DH/KP/UCH.

Partner Institutions (3)

COHIE (2)

The Children's Hospital (1)

f) Secure COHIEmessage received byTCH requesting clinicaldata

g) Clinical repositorydata identified andmessage preparedfor COHIE from TCH.

COHIE Working GroupsIterative reviews

COMPONENTSLegal

ClinicalTechnical

Research/Evaluation

Timeline – October 2005• MPI prototype, record locater service (RLS)

• Data sharing agreement: based on IN• avoids multiple BAA• no research references

• Incidental disclosures: CFH Policy Group• Design modification: ? near 100% match for

disclosure (high threshold to start), role-based threshold (ED vs. referral MD), challenge to business case

• Minimum certainty before RLS returns demographic information to the requester

• Minimum number of required demographic fields supplied by the requester before the RLS returns demographic information.

Timeline – October 2006

• Proxy servers with standardized data• Laboratory (LOINC, SNOMED encoded)• ICD-9 billing diagnoses• HL7 messaging

• V2.x for MPI queries to/from institutional MPI• V3.0 for clinical data

• Future: (after 10/06)• Arden syntax/GLIF for guideline

implementation on aggregated data

CORHIO Process

• Colorado Health Institute (neutral convener)• Legal support • Explore/define relationship COHIE ⇔ CORHIO• Working Group

• Business plan• Articles of incorporation (501c3)• Defining the board• Education/public relations

• Community Advisory Council (greater than 40 members, most HIT projects going on in Colorado

CORHIO Candidate Partners