IHE provides a framework for implementing multiple healthcare IT standards to address specific clinical needs. It has grown from a project launched in 1998 involving healthcare providers, vendors, and standards groups. IHE defines integration profiles that specify how standards should be implemented together to enable interoperability. Examples include profiles for image and report sharing within and between healthcare enterprises using standards like DICOM and HL7.

1. IHE Update Chris Lindop, IHE Radiology Planning Co-chair

2. Why are standards important? The 1906 systems integration problem

3. Without standards, complex custom integrations… in the best of cases … Don’t even ask about the worst cases

4. Standards: Necessary…Not Sufficient Standards are Foundational - to interoperability and communications Broad - varying interpretations and implementations Narrow - may not consider relationships between standards domains Plentiful - often redundant or disjointed Focused - standards implementation guides focus only on a single standard IHE provides a standard process for implementing multiple standards

5. An Incremental Multi-Year Project Launched in 1998 Goal: Enhance the Access to Clinical Information Ensure Continuity and Integrity of Patient Information Speed Up the Integration in Healthcare Environments Fosters Communication Between Vendors of Medical Information Technology Prove that Integration is Attainable Based on Standards Participants: Representatives of Healthcare Providers Information Systems Vendors Imaging Systems Vendors Standardization Groups The IHE Initiative

6. IHE: A Framework for Interoperability A common framework for harmonizing and implementing multiple standards Application-to-application System-to-system Setting-to-setting Enables seamless health information movement within and between enterprises, regions, nations Promotes unbiased selection and coordinated use of established healthcare and IT standards to address specific clinical needs

7. IHE Participants and Relationships Participants include: Users - Clinicians, Staff, Administrators, CIOs, Governments (e.g. NIST, VA). Vendors - Information Systems and Equipment e.g., imaging, cardiology, devices Consultants Maintains formal liaison with Standards Development Organizations (SDOs): HL7, DICOM, ISO (Liaison D), others ISO TC215 (including ANSI) approved IHE Process and Profiles to be published as technical reports

8. Stakeholder Benefits Healthcare providers and support staff Improved workflows Information whenever and wherever needed Fewer opportunities for errors Fewer tedious tasks/repeated work Improved report turnaround time Vendors Align product interoperability with industry consensus Decreased cost and complexity of interface installation and management Focus competition on functionality/service space not information transport space SDOs Rapid feedback to adjust standards to real-world Establishment of critical mass and widespread adoption

9. IHE Organizational Structure IHE North America USA Canada IHE Asia Japan Korea Taiwan China IHE International Board Global Development Regional Deployment Contributing & Participating Vendors ACC ACCE ACEP JAHIS JIRA JRS METI-MLHW MEDIS-DC JAMI RSNA SFR SFIL SIRM BIR EuroRec COCIR EAR-ECR DRG ESC Professional Societies / Sponsors ACP GMSIHIMSS Radiology Cardiology IT Infrastructure Patient Care Coordination Patient Care Devices Laboratory Pathology Eye Care Radiation Oncology Public Health, Quality and Research IHE Asia-Pacific New Zealand Australia Malaysia IHE Europe France Netherlands Spain Sweden UK Italy Germany Norway Austria

10. International Growth of IHE Local Deployment National Extensions Promotional & Live Demonstration Events Funding Pragmatic global standards harmonization + best practices sharing France USA Germany Italy Japan UK Canada Korea Taiwan Norway Netherlands Spain China Austria 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Australia

11. Growth in IHE Domains Radiology (18) IT Infrastructure for Healthcare (17) Cardiology (7) Laboratory (6) Radiation Oncology (1) Patient Care Coordination (5) Patient Care Devices (1) Quality Eye Care (3) IHE Global Developments Integration Profiles (# X) – Solutions to Real-World Interoperability Needs & Problems: Within Clinical Departments e.g.: Radiology Cardiology Lab ... Across Departmental & Institutional Boundaries – XDS RHIOs (Regional Healthcare Information Organizations) EHR Enablers Year 1 (1999) Year 2 (2000) Year 3 (2001) Year 4 (2002) Year 5 (2003) Year 6 (2004) Year 7 (2005) Year 8 (2006) Year 9 (2007) Veterinary Endoscopy Pathology Pharmacy

12. Proven Standards Adoption Process User Site IHE Technical Framework IHE Integration Profiles at the heart of IHE : Detailed selection of standards and options each solving a specific integration problem A growing set of effective provider/software-developer agreed solutions Vendors can implement with ROI Providers can deploy with stability Process started in 1998; continuously improved IHE Connect-a-thon Results IHE Integration Profiles B IHE Integration Profile A Easy to Integrate Product s IHE Demonstration RFP Standards Product IHE Integration Statement IHE Connect-a-thon Product With IHE

13. IHE Technical Frameworks Implementation Guide for each Integration Profile An Integration Profile : A Set of Actors Exchanging Transactions Use cases Process Flows For each transaction: Std referenced Options specified Mapping required Actors Transactions

14. IHE Connectathon Cross-vendor, live, supervised, structured tests All participating vendors’ products tested together in the same place/time Experts from each vendor available for immediate problem resolution… fixes are done in minutes, not months!! Each vendor tests with multiple trading partners (actual product to actual product) Testing of real-world clinical scenarios using IHE Integration Profiles

15. Connectathon Status North American Jan 28 – Feb 1, Chicago, IL 70 Vendors, 136 products Japan February, Tokyo, Japan 36 Vendors, 60 systems Europe 20-26 April, Oxford, England 72 Vendors, 120 products China May, Beijing Australia July

16. IHE Testing Process Users Sponsors: Project Management Team Vendors Sponsors: Exhibits Develop Testing Tools Testing Tools Implement Profile Actors In-House Testing Connectathon Demonstration Deploy Systems Testing Results Approves Test Logs IHE Technical Framework (IHE Profile Specifications) Product + Integration Statement

17. Encouraging Vendors to Implement IHE Profiles Connectathon participation is open to all “software developers”, vendors, open source, providers Interoperability Specifications (IHE Profiles) are set before users issue call for participation with deadline (applicants have to bid) Vendors that implement IHE profiles assume strategic and marketing advantages Vendors who pass the IHE Connectathon are given the opportunity to demonstrate IHE capabilities during major conferences (HIC2008, etc.) Many “carrots”, but only one stick: If you don’t play, you can’t pass!!

18. Radiology Profiles - Consistent Presentation of Images Evidence Document Key Image Notes Simple Image & Numeric Reports Presentation of Grouped Procedures Post-Processing Workflow Reporting Workflow Charge Posting Patient Info. Reconciliation Scheduled Workflow Mammo-graphy Image Image Fusion Teaching Files & Clinical Export Import Reconcil-iation Workflow Radiation Emission Monitoring Mammo-graphy Acquisition Workflow Access to Radiology Information Portable Data for Imaging Audit Trail & Node Authentication – Radiology Option Cross-Enterprise Document Sharing for Imaging NM Image Card Option

19. IHE Radiology – Integration Profiles Workflow Scheduled Workflow Patient Information Reconciliation Post-Processing Workflow Reporting Workflow Import Reconciliation Workflow Mammography Acquisition Workflow** Infrastructure Access to Radiology Information Portable Data for Imaging Cross-Enterprise Data Sharing for Images Security: Audit Trails & Node Authentication Charge Posting Teaching Files & Clinical Trials Export Presentation & Content Consistent Presentation of Images Key Image Notes Image Fusion ** Presentation of Grouped Procedure Evidence Documents Simple Image & Numeric Reports NM Image* Mammography Image Radiation Emission Monitoring** * Cardiology Option – in Trial Implementation ** in Trial Implementation Publications Radiology Users Guide Mammography Users Guide

20. IHE Scheduled Workflow Profile Registration Orders Placed Orders Filled Film Film Folder Image Manager & Archive Film Lightbox report Report Repository Diagnostic Workstation Modality acquisition in-progress acquisition completed acquisition completed images printed Acquisition Modality

21. Portable Data for Imaging Media Creator CD DVD * USB * DICOM Data Web Data (Optional) DICOM DICOM DICOM Web Data Required to cleanup Patient ID, Acc#, etc. * New Option Printer [Media Reader] Image Display [Media Reader] PACS [Media Importer] John Doe PC Browser

22. PDI Use Case for External Acquisition Radiology Enterprise A Radiology Enterprise B Provider A Radiology Site B PACS A Portable Data Creator 2. Radiology Site B creates portable media with patient images 1. Provider A orders External Radiology Procedure 3. Portable Media is sent to Reading Site A via CD. Patient Data is imported and read. 4. Study Results sent to Provider Radiologist PDI Disk Patient Data

23. PDI Use Case for Patient Referral Radiology Enterprise B Radiology Enterprise A PACS B Portable Data Creator 2.Relevant Data (including film) is collected and Enterprise A creates portable media with patient’s radiology information. 1. Request for Patient’s case data to be transferred from Enterprise A to B. 3.Data is transported to Site B via CD. Patient Demographics are reconciled and data is imported into archive. 4. Patient Data is now associated with B’s electronic health record system. Patient Data

24. XDS-I Actors and Transactions

25. Sharing Radiology Reports and Images in a Regional Health Information Network Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network PACS B PACS A Radiology-to-radiology Radiology-to- Physicians

26. Radiology Strategic Profile Deployment for 2008 Global Deployment priority PDI USA, Australia, Germany XDS-I Canada and other International Regional Projects TCE RSNA SWF/PIR Most Global Interoperability profile

27. Sharing and Accessing Electronic Health Records IHE offers interoperability for local, regional, specific, or national health information exchange Goal is to enable exchange between providers’ clinical and administrative systems and ancillary IT systems (EHRs,Lab, Pharma, Payers, etc.) and personal health record systems. Objective is to empower the consumers in having “shared EHR information” between all of its potential healthcare providers (if authorized) and self. Objective is to empower the providers in choosing when and what information to share, and to trust the information they may use in the care of their patients.

28. IHE Integration Profiles for Health Info Nets What is available and has been added in 2007 Clinical and PHR Content Health Data Exchange Patient ID Mgmt Other Final Text Approved Trial Implementation-2007 – Final Txt 2008 Security & Privacy Emergency Referrals Format of the Document Content and associated coded vocabulary PHR Extracts/Updates Format of the Document Content and associated coded vocabulary ECG Report Document Format of the Document Content and associated coded vocabulary Lab Results Document Content Format of the Document Content and associated coded vocabulary Scanned Documents Format of the Document Content Imaging Information Format of the Document Content and associated coded vocabulary Medical Summary ( Meds, Allergies, Pbs) Format of the Document Content and associated coded vocabulary Patient Demographics Query Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Notification of Document Availability Notification of a remote provider/ health enterprise Request Form for Data Capture External form with custom import/export scripting Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a longitudinal record Cross-Enterprise Document Pt-Pt Reliable Interchange Cross-Enterprise Document Media Interchange Cross-Community Access Consistent Time Coordinate time across networked systems Audit Trail & Node Authentication Centralized privacy audit trail and node to node authentication to create a secured domain. Basic Patients Privacy Consents Establish Consents & Enable Access Control Document Digital Signature Attesting “true-copy and origin Cross-Enterprise User Attestation User Attributes fro Access Control

29. Enterprise Enterprise Enterprise Enterprise Imaging Center Hospital B Hospital A Emergency Room PCP Patient Admin Repository Repository Repository Repository Cross-Enterprise Document Registry (XDS) Cross-Enterprise Document Sharing

30. Storage Services Enterprise Enterprise Enterprise Imaging Center Hospital B Hospital A Emergency Room PCP Patient Admin Repository Repository Repository Repository Cross-Enterprise Document Registry (XDS) Cross-Enterprise Document Sharing Practice Data Centre

31. Cross-Enterprise Document Sharing (XDS) Transaction Diagram

32. Document Content and Modes of Document Exchange Document Exchange Integration Profiles Document Sharing XDS.a XDS.b Media Interchange XDM Reliable Interchange XDR Doc Content Profiles Consent BPPC Emergency EDR Pre Surgery PPH P Scanned Doc XDS-SD XDS Stored Query & Patient Identity Merge Cross-Community Access XCA Laboratory XD*-Lab PHR Exchange XPHR Discharge & Referrals XDS-MS Imaging XDS-I

33. XDS-MS Medical Summary S S t t r r u u c c t t u u r r e e d d C C o o n n t t e e n n t t w w i i t t h h c c o o d d e e d d s s e e c c t t i i o o n n s s : :   Reason for Referral     Vital Signs     M M e e d d i i c c a a t t i i o o n n   Studies     A A l l l l e e r r g g i i e e s s   Social History     P P r r o o b b l l e e m m s s   Care Plan Structured and Coded Header Patient, A uthor, Authenticator, Institution, Time of Service, etc. Header always structured and coded Title - coded sections with non - structured nor coded content (text, lists, tables).  Simple Viewing (XML Style sheet) Level 1 Level 2 XDS-MS enables both semantical interoperability and simple viewing ! Text Structure Entry Text Structure Entry Med, Problems and Allergies required as highly structured text.  Text easy to import/parse Text Structure Entry Level 3 Med Problems a nd Allergies have a required fine - grain structure with optional coding. Coding Scheme not standardized, but explicitly identified. Coded Section Entry Coded Section Entry Coded Section Entry Level 3

34. IHE, global standards-based profiles adopted by several national & regional projects Quebec, Toronto, Alberta, British Columbia Canada Infoway Denmark (Funen) Italy (Veneto) Spain (Aragon) NCHICA – N. Carolina Italy (Conto Corrente Salute) Boston Medical Center - MA France DMP UK CfH (Radiology WF) Philadelphia HIE CHINA-MoH Lab results sharing KeyHIE – Pennsylvania CHINA-Shanghai Imaging Info Sharing JAPAN-Nagoya Imaging Info Sharing South Africa Malaysia Singapore VITL-Vermont CareSpark – TN & VA Netherland Amsterdam Lower Austria Austria

35. New Trial Implementation Profiles IT Infrastructure (ITI) : Asynchronous Web Services Exchange Emergency Contact Information (ECON) White Paper Pediatric Demographics Option Referral Requests: Media Referral Request (MRR), Shared Documents Referral Request (SRR), Referral Request Content (RRC) Sharing Value Sets (SVS)) Cross Enterprise Sharing of Scanned Documents (XDS-SD) Patient Care Devices (PCD) : Alarm Communication Management (ACM) Rosetta Terminology Mapping (RTM) Point-of-Care Infusion Verification (PIV) Anatomopathology Pathology Workflow Radiology Mammography Acquisition Workflow Radiation Exposure Monitoring Supplements available for download at http://www.ihe.net/Technical_Framework/index.cfm

36. Italy (Genoa Region)

37. Italy (Genoa Region) In service since January 2006. 4 Hospitals and 500 physician offices. EMRs import and export documents from their local records. All vendor products required to pass IHE-Europe connectathon in April 2005. Patients chose to join through one of their care provider Infrastructure includes: XDS Registry XDS Repository shared at the regional level PIX for patient Id linking Doc content is CDA with PDF content. Plan in place to move to CDA rel 2 with structured data. IHE (XD*-Lab) CDA Lab primary candidate.

38. Austria (Lower Austria and National) Lower Austria Region (around Vienna) Deployed in 2007 - Operational. 1.5 Million patients on-line. 11 hospitals connected. Use IHE profiles: XDS, PIX, XDS-SD, ATNA, XUA, BPPC. National project launched in 2007 (ELGA). Given the success to deploy the first region is about one year. Roll-out includes: Ministry backing of IHE conformance (IHE-Eu Connectathon) Extending to Ambulatory Physicians in 2008 Step-wise introduction of structured and coded content with HL7 CDA based IHE Content Profiles. Lower Austria Austria

39. USA (Philapdelphia Region) Philadelphia Health Info Exchange in service since 2005. Focused on images and reports sharing. 5 Hospitals + Imaging Center + Public Health The Hospital of the University of Pennsylvania Thomas Jefferson University Hospital Children’s Hospital of Philadelphia Presbyterian Medical Center Pennsylvania Hospital UPHS Community Radiology Philadelphia Department of Public Health Migration to XDS, ATNA, PIX and XDS-I completed in 2007. Demonstrated live at RSNA-Chicago Nov 2007

40. USA (Other) HITSP (HHS sponsored) accepted 8 IHE Integration profiles for: Lab results distribution and sharing, Registration and Medication History for Consumers, Biosurveillance. 2 NHIN-1 Pilots (CSC and IBM) leveraged IHE profiles (Med Summaries and Lab). South Shore, MA: Operational (Inpatient and Emergency Dept) NHIN-2 Trial Implementations (NCHICA, Virginia & CareSpark HIEs) Several HIEs projects are actively planning the use of IHE Vermont State KeyHIE (PA) eHealthConnecticut Boston Medical Center and affiliated clinics

41. IHE Profiles are consistent with HHS Accepted Standards (HITSP Interoperability Specifications)

42. From Standards to Solving a Use Case AHIC/ONC HITSP Interoperability Specifications + Constructs Standards Adoption/Profiling Technical Use Case Driven Base Standards Foundations IHE HL7, NCPDP, X12, DICOM, ISO, etc… Business Use Case

43. Conformance Testing & Certification IHE Conformance Testing CCHIT Certification Interoperability Specifications + Constructs Standards Adoption/Profiling Technical Use Case Driven Base Standards Foundations

44. Canada Canada Health Infoway: national Commitment to XDS/XDS-I for imaging sharing 4 infrastructure tenders awarded in 2007/2008 to date so resulting in over 1/3 of Canadian patients covered: Toronto East Network - Ontario Montreal McGill - Quebec Alberta British Columbia Includes XDS, ATNA, PIX and XDS-I. Planned to become live 2008 in Quebec, Ontario, Alberta, British Columbia.

45. France (National DMP) Prototype RFP call for tender mid-2005. Confirmed requirement to use to IHE profiles: XDS, ATNA, XUA, BPPC, etc. Encourage vendors to submit their products to the IHE-Europe Connectathon (April 2007-Berlin). Implementation plan under revision. Infrastructure to include: XUA from User Authentication Portal and BPPC for privacy XDS Registry/XDS Repositories ATNA for audit trail and node authentication. Doc content to be: CDA rel 2 patient summary (close to XDS-MS), Hprim with migration to IHE XD*-Lab for Lab, Scanned Doc (PDF) and imaging (XDS-I).

46. Other Commitments China MoH selected XDS and XD*-Lab (CDA) for lab info sharing. XDS-I in Shanghai. Israel, Jordan, Palestinian Authority Public Health Info Affinity Domain (XDS, ATNA, XD*Lab) Middle east Consortium for infectious Disease Surveillance Netherlands Amsterdam region network project launched 2007. XDS-I. Japan Nagoya region network project operational late 2007. XDS, XDS-I Kobe with imaging info sharing South Africa National project launched in 2007. Tender awarded. Operational in 2008.

47. How to Participate As a User or Vendor Committee Member Become a member of relevant Domains Planning or Technical Committees As a User, Consultant or Vendor Interested Observer Provide Public Comments on Technical Framework Supplements Attend Demonstrations, Educational Events and Workshops

48. How to Use IHE As a Vendor Implementer Implement IHE Integration Profiles Test systems through Connectathon process Publish an IHE Integration Statement for products As a User Implementer or Consultant Use IHE Integration Profiles to develop interoperability strategy Use Connectathon Results and Integration Statements to evaluate vendors Demand IHE Integration Profile compliance in RFPs

49. Providers and Vendors Working Together to Deliver Interoperable Health Information Systems in the Enterprise and Across Care Settings http://www. ihe .net http://www. ihe .net.au

50. More Resources - www. ihe .net Frequently Asked Questions Integration Profiles in Technical Frameworks: Cardiology IT Infrastructure Laboratory Patient Care Coordination Patient Care Devices Radiation Oncology Radiology Connectathon Results Vendor Products Integration Statements Participation in Committees and Connectathons