iehr-ciif ioc to foc transition strategy - osehra · iehr-ciif ioc to foc transition strategy ......

iEHR-CIIF IOC to FOC Transition Strategy

Stephen Hufnagel IPO S&I Branch Interoperability Architect

October 9, 2012-J

Working Draft; Not for Official Use

2

CIIF Brief Purpose

Present CIIF IOC to FOC Transition Strategy

1. Today: (BHIE & FHIE in sustainment), VLER

2. IOC: HDD, (BHIE & FHIE in sustainment), ESB SOA Suite, VLER

3. FOC: CIIF, ESB SOA Suite, VLER

NOTE: This brief has a high density of acronyms; to help you,

an acronym list is at the end of the brief.

See companion paper for CIIF modeling details and acronym glossary:

“CIMI Informatics Modeling Terms, Tools and Their iEHR Use” at

http://informatics.mayo.edu/CIMI/index.php/Main_Page Quick Links


http://informatics.mayo.edu/CIMI/index.php/Main_Page

3

1. IOC Definition and CIIF/Data Scrum Integration (3 slides)

2. IOC Healthcare Sharing

3. IOC HDD (2 slides)

4. IOC Engineering View (3 slides)

5. IOC CIIF View (7 slides)

6. Findings

7. Acronyms

8. Backup

1. Example Models for Heart Rate (5 slides)

2. CIIF IOC and FOC Details (3 slides)

3. Healthcare Services Platform (8 slides)

Contents


4

IOC Definition & CIIF/Data Scrum Integration 2+2+2+1 Model, Planned Completion by FY2014

• IOC Vision/Scope: iEHR stakeholders envision an IOC deployment

supporting meaningful improvements in care delivery and efficiency for DoD

and VA patients. Supporting this vision, IOC will target improved systems for

clinical documentation, document management, computable assessments,

pharmacy, lab and immunization systems, ordering, patient list and cohort

management, and patient content management within and between DoD and

VA systems.

• IOC will be successfully achieved when designated facilities have

implemented the new iEHR components in accordance with specific test and

acceptance criteria.


5

IOC Definition & CIIF/Data Scrum Integration

Integrated Clinical Core and User Experience (UX): With the acquisition and implementation in at least one

DoD and one VA facility in the Hampton Roads, VA and San Antonio, TX locations and available to at least a

subset of users, iEHR capabilities will be coordinated within a User Experience (UX) framework (Presentation

Layer) designed with the following features and clinical workflow tools:

1. By IOC, a clear technical roadmap for evolution from Janus 4.0 to target iEHR architecture and execution will be

underway.

2. Extensible UX design and application architecture that facilitates incorporation of new components from government

and other sources

3. Initial functionality of flexible desktop and workflow configurations supporting continual improvements in clinical processes

and care coordination

4. Coordinated patient context management between iEHR applications and features

5. Integrated display of access-controlled longitudinal health data from all relevant sites, including all accessible patient

document formats

6. Basic clinical note-writing, to include at a minimum text based clinical note creation that provides medical record entries

viewable through both iEHR and legacy systems

7. Write back capability for allergy documentation and a method for medication reconciliation will also be present at IOC

8. Patient list and cohort management, with this initial version limited to immunization capability/data

9. Improvements in enterprise-integrated, customizable Clinical Decision Support (CDS), adding the implementation of

“info buttons” to the continuing availability of legacy decision support functions

10. Initial implementation of computable/configurable forms with the underlying functionality

in place and at least one functional questionnaire/assessment form

CIIF/Data Scrum Specific Integration Needed


6

IOC Definition and CIIF/Data Scrum Integration Cont.

Infrastructure Capabilities: Much of the effort prior to IOC focuses on the capabilities which form the foundation on

which the remainder of the capabilities will rely. These system capabilities supporting iEHR will include:

1. Identity Management: the ability to uniquely identify patients, providers and other authorized users within the

system. This is intended to include eligibility and demographics (*needs to be confirmed with DMDC)

2. Single Sign On (SSO): an application that leverages a single login effort to automate the log in events for other

supported applications.

3. Access Control: provides role‐based privileges for access to iEHR capabilities and patient information

4. Privacy Management: provides effective controls for both limiting access to and auditing access of information

covered under the Health Insurance Portability and Accountability Act (HIPAA)

5. Ability to support data segmentation in accordance with applicable DoD and VA internal and external sharing

policies

6. Security: those technical considerations that preclude unauthorized access through either electronic “hacking” or

physical access to systems supporting the iEHR

7. Service Oriented Architecture (SOA) Suite to include an Enterprise Service Bus that will enable the DoD/VA to

transition from today’s reliance on point to point integration of legacy systems and data sources, to a central broker of

data and services that will enable an increased access to clinical information and a more manageable and cost

effective IT footprint across the enterprise

Next steps involve asserting by capability where S&I/CIIF/Data Scrum has a role.

CIIF/Data Scrum Specific Integration Needed


7

Current and IOC Health Data Sharing

As of August 31, 2012

VA

• 93.2 million lab results

• 15.0 million radiology reports

• 95.8 million pharmacy records

• 113 million standard ambulatory data records

• 5.2 million consultation reports

• 3.4 million deployment-related health

assessments on more than 1.5 million individuals

• 4.5 million correlated patients, including

2.1 million patients not in FHIE repository

• 164,950 average weekly FHIE/BHIE queries

3rd qtr FY 2012

• Computable pharmacy and allergy exchange

on more than 1,546,470

DoD

Data on Separated Service Members • Outpatient pharmacy data

• Inpatient and outpatient laboratory results and radiology reports

• Allergy information

• Consult reports

• Admission, discharge, transfer information

• Standard ambulatory data record elements

(including diagnosis and treating physician)

• Pre-/post-deployment health assessments

• Post-deployment health reassessments

• Patient history

• Discharge summaries

Data on OIF/OEF Polytrauma Patients • Radiology images

• Scanned medical records

Data on Shared Patients • Current Viewable Data

– Outpatient pharmacy data

– Inpatient and outpatient laboratory and radiology results

– Discharge summaries (57* DoD sites = 100% of inpatient beds)

– Inpatient consultations, operative reports, history and physical

reports, transfer summary notes, initial evaluation notes,

procedure notes, evaluation and management notes, pre-

operative evaluation notes, and post-operative evaluation and

management notes (58* DoD sites - available to all DoD

providers and VA providers enterprise wide)

– Allergy data and problem list data

– Theater clinical data: Theater inpatient notes, outpatient

encounters, and ancillary clinical data

– Ambulatory encounters, procedures, and vital signs

– Family, social, and other history, and questionnaires

• Current Computable Data (limited VA sites) – enables drug-drug

and drug allergy safety checks and alerts

– Pharmacy data

– Medication allergy data

* Wilford Hall closed their inpatient beds and San Antonio MMC

(formerly BAMC) has taken over inpatient care for AF in San Antonio

(effective Oct 2011)

Federal Health Information Exchange

Live data flow beginning 2002; data from 1989 forward

One-way, monthly transfer of health data

Bidirectional Health Information Exchange

Live data flow beginning 2004; data from 1989 forward

Two-way, on-demand view of health

data available in real-time

Health data on more than 5.8 million

Service members

All VA Medical

Facilities

5 VA Polytrauma Centers

(Tampa, Richmond, Minneapolis,

Palo Alto, San Antonio) One-way transfer of health data initiated

at time of decision to transfer patient

Viewable data exchange between all DoD

and VA medical facilities as of July 2007

From Walter Reed National Military

Medical Center in Bethesda and Brooke AMC

• Radiology images for more than 535 patients

• Scanned records for more than 650 patients Live data flow beginning March 2007

• VLER Health

• IOC VA-HDD mapping:

Patient : Pharmacy data,

Problem Lists, Allergies,

Lab, Results & Reports,

Document Titles.


8

IOC HDD Logical Mapping at Salt Lake City

HDD

NCID SNOMED-CT

RxNORM

CPT CDW VUID VistA SA VistA HR

443

<Substance>

<acetylsalicylic

acid (ASA) ID:

123455>

<Orderable drug

Brand Name ID>

<Aspirin: 82464>

2214 945 ASP A112

812 <Condition:

diagnosis><Cold> N/A 9923 123 Cld CD8

123

<Procedure Test

Result Name:>

< Red Blood

Count>

N/A 1324 98231 RBC RBC

923

DoD

specific

term

VA term

HDD/CDR mapped to standards

VA data mapped

to CDW

New concepts are added as needed

CDW mapped to

standards

Current work will see

if applicable for all sites

MAP MAP


9

IOC OpenHDD

• Information Models

– Data storage will use existing models within CDR

• Installer

– Includes Software Development Kit with documentation of how to use OpenHDD tools will enable integrator to develop to those information models

• Database (mysql) redesign will optimize latency

• Standard based APIs

– HL7 CTS 1.2

• Interface to add content

– SMEs review updates to ensure consistency of the model


10

IOC Engineering View

LCS FEP HP - UX

O r a

c l e

L i s

t e n e r

CHCS VMS ( DEC )

LCS w ith ICD & Mid - tier

( OS varies )

Web Logic ( HP )

F i r e w

a l l

CWS FEP ( Primary ) HP - UX

CWS FEP ( Secondary )

HP - UX

CWS FEP HP - UX

CWS FEP HP - UX

Tuxedo Masters CWS FEPS

Backup EMSS HP - UX

Primary EMSS HP - UX

LCS FEP HP - UX

CDR HP

Superdome Clients

.)

LCS FEPS

iEHR SOA Suite

Local MTFs

CHDR App Server HP - UX

TRACH II Web Server Windows

TRACH II App Server Windows

CHDR Interface Engine HP - UX

PDTS

To the VA IE server

CWS FEP HP - UX

Vista

iEHR Portal

MCMS

VA

All Sites

TMDI ( CDR Sync Servers )

PDTS

CPRS

DRAFT FEP

redesign

Affected

end user devices

Increased

CDR

Capacity

Replacement of front end processors for VA data.

Expansion of CDR. (3 locations: Primary Computing Facility, Alternative computing facility and APPTE)

RLUS RLUS

RLUS

RLUS

11

IOC Engineering Project Schedule

Month

1 Month

2

Month

3

Month

5

Month

7

Month

9 Month

4

Month

8

Month

10

Project start

when

funding

applied

(11/2/12)

Final

Report

from

SLC

mapping

Option 1:

Start SA and

HR mapping

Option 2:

Utilize CDW

mappings

for all site

solution

Move VistA

into DT&E

Start AOA on

Front End

Processor

(FEP)

replacement

Complete

and

Maintain

VistA/CDW

mapping

FEP CDR

Begin

development

of FEP

solution with

VistA

“Go Live” -

FEP solution

with VistA

….

Month

17 –

June

2014

Project start

utilizing

DHIMS

SOPs.

FEP PDR Tentative

FEP

Testing

Readiness

Report

Month

6

Data IPT delivers

RLUS

requirements and

specifications to

integrator

Incremental Delivery by integrator

Final Delivery of

RLUS services

from integrator


12

IOC Engineering Deliverables

1. SLC mapping report

– Will determine strategy for enterprise mapping

2. San Antonio and Hampton Roads mapping.

– Option 1: Site by Site mapping

– Option 2: CDW to HDD mapping

3. FEP development

– On DHIMS platform (x86)

– Better performance

– Accept VA data to the CDR

4. Increased capacity at the CDR for additional data

– Primary Computing Facility

– Alternative Computing Facility

– AHLTA Pre-processing Testing Environment

5. UX access to joint data in CDR

6. Sync of data to legacy sources Working Draft; Not for Official

Use

13

IOC to FOC Seamless Transition Using CIIF & (RLUS + VDR) & (RLUS + VPR)

INTEGRATED iEHR SOLUTION

HEALTHCARE SERVICES PLATFORM (HSP)

iEHR UX

Framework VistA / VDB AHLTA / CDR

RLUS

Locator

Common Information Integration Framework (CIIF)

Clinical & Business Services & ESB SOA Suite

iEHR

VDR

Service

Systems BHIE FHIE

RLUS Retrieve

Locate

Update

Service

RLUS adds legacy

systems into the

iEHR VDR backend.

Legacy systems can

be shut down after

iEHR has subsumed

their functionality

RLUS RLUS

RLUS RLUS VPR

RLUS


14

CIIF Design Time Environment

class CIIF Models

Logical

Detailed Clinical Model (DCM)

Enumerated

Value Set

Model Driven Health Tool (MDHT)

Generated Clinical Templates

- Model Driven Health Tool

- Mirth Connect Interface Engine

Reference

Terminology

Federal Health Information Model (FHIM)

Manually-Generated Clinical Template

Core Information Component (CIC) Mind Map

Common Logical Information Model (CLIM)

Conceptual

Implementable

Clinical Templates

are the key to

interoperabilityCIMI Model

US Realm / iEHR

Standard Model

Reusable Model

Legend

bind

*

aggregate1

11..*

1..

1

transform

1..*

compose

1

UML-inheritance

bind


15

FOC CIIF Run-Time Environment

class CIIF Within Run-Time

iEHR

Reusable Component

Capability / Application

Infrastructure Services Clinical ServicesBusiness

Services

Service

External System

UX Framework

VDR RLUS

CTRCTSETL

IzLab Rx

CIMI Reusable Model

US Realm iEHR

Standard Model

CIIF Content

Legend

HDD

VistA AHLTA

VPR

Service Systems

IOC

Note

WriterCPOE CCSI&FCM

FOC

Capabilities

BITE

CIIF IOC = HDD + RLUS


16

FOC CIIF & (RLUS + VDR) & (RLUS + VPR) Within iEHR Healthcare Services Platform

17

S&I Branch Deliverables Within IOC & FOC CIIF - CIPT Engagement Process

Business Process Capability Engagement

Cap

abili

ty

CIP

TS

&I B

ran

ch

Develop RFI BJP

Start

Develop RFP BJP

Manage Acquisition

& Deployment

End

Develop Conceptual

Models

Start

Develop Logical

Models

Develop

Implementable

Models Deployment

Manage CTS, CTR,

ETL Content

CICs CLIMsAnalysis

DCMsBITE, CTS, CTR, ETL

Content Updates

PM

s

Sustain Capability

Clinical

Templates

CIPT & iEHR Sustainment

CIIF

CIIF Content

Legend

Issue RFI

Start

Issue RFP

18

FOC S&I Branch Deliverables for CIIF’s BITE, CTS, CTR, ETL Services*

Built In Test Environment (BITE) Content

• Schematron Test Schemas

Common Terminology Service (CTS) Content

• Terminology mapped across time and values

Clinical Template Repository (CTR) Content

• clinical Document Schemas

• Clinical Message Schemas

• NIEM IEPD Schema

• Component/Service Schema

Extraction Transfer Load (ETL) Content

• Mirth Interface Engine Schemas

* CIIF Services are the responsibility of the System Engineering Branch


19

Findings

1. S&I Branch provides BITE, CTS, CTR & ETL content; not actual services.

2. RLUS VDR is a concept that needs to be prototyped in the ESB Sandbox

3. S&I will work with CIMI & other SDOs to facilitate FOC modeling

– Detailed Clinical Models are very different from traditional process models.

– OMG Archetype (AML) Profile for UML & MDHT AML implementation needed

– Funding of AML and MDHT is core to automating processes

4. VA data standardization and mapping at CDW could facilitate and reduce

cost for IOC & FOC

– Salt Lake City VAMC HDD Mapping project will confirm strategy within 2 months

5. An Analysis-of-Alternatives is needed for VA data integration into CDR


20

Acronyms

AML Archetype Modeling Language UML-Profile

BIM Business Information Model

BITE Built In Test Environment

BJP Business Justification Package

BPM Business Process Model

CCS Care Coordination Service

CDS Clinical Document Architecture

CIMI Clinical Information Model Initiative

CLIM Common Logical Information Model

CIC Core Information Component (Mind Map)

CPOE Computerized Physician Order Entry

CSP HL7 Clinical Statement Pattern

CTR Clinical-Template Repository

CTS Common Terminology Service

DAM Domain Analysis Model (DAM)

DCM Detailed Clinical Model

EHR-S FIM EHR System Function & Information Model

ETL Extract, Transform, Load Service

FHIM Federal Health Information Model

FOC Final Operating Capability

HDD Health Data Dictionary

IBRM Integrated Business (activity)

Reference Model

I&FCM Inventory and Funds-Control

Management

iEHR Integrated Electronic Health Record

IOC Initial Operating Capability

Iz Immunization

JPS JSR 286 Portlet Service

JSR Java Specification Request

MDHT Model Driven Health Tool

NIEM National Information Exchange Model

RDF Resource Description Framework

RLUS Retrieve, Locate, Update Service

RIM Reference Information Model

RM Reference Model

Rx Pharmacy

SCS Structured-Content-Specification

VDR Virtual Data Repository

VPR Virtual Patient Repository

21

Backup

Example CIIF Models

• Heart Rate (5 slides)

• CIIF Design Time Environment

• CIIF Run Time Environment (2 slides)

• iEHR Healthcare Services Platform (8 slides)


22

Example Models for Heart Rate

23 Working Draft; Not for Official Use

24

“Computable Information” means structured, discrete, coded, typed and fully-defined provided by CIIF clinical models.

HR = 82

HR 82

December 3, 2011 HR 82, 122/82, RR 16, T 98.6, SaO2 98%,...

20111203

20111203

Etc..

title=HR value=82 time =20111203 code=8867-4

Method, exercise level, patient position/orientation, measurement site,

pain level, fetal v. maternal, rhythm, variability, current

medication/blood/fluid rates, etc.

Plus Context!

units=BPM


25

Heart rate, pulse rate, etc. are measurements, and need to share aspects with all other measurements


26

Detailed Clinical Model

XML message instance

Value set specifications


27

IOC FOCUS: CIIF Design-Time CIMI Models Used Within CIIF

class CIIF Design-Time, Showing CIMI Models Used Within CIIF

Logical

HL7 RIM

HL7 CSP

ArchetypeDCM

Reference

Terminology

FHIM

EHR-S FIM

CIC Mind Maps

CLIM / SCS / CSP CIMI RM

HL7 DCM

HL7 DAM

Conceptual

CIMI Model

US Realm / iEHR

Standard Model

Reusable Model

Legend

Functional

Requirements Use CasesIBRMBPM

BIM

Candidate DCM

«trace»

11..*

«trace»

«trace»

transform

bind

«trace»

*aggregate

1

«trace»

bindtransform

11..*

«trace»

«trace»

{ADL constraints}

«trace»

transform

*

1..*

«trace»

1..*

0..*

«trace»

«trace»

«trace»

«trace»

transformtransform

28

IOC FOCUS: iEHR Run-Time CIIF Content Used Within iEHR

class CIIF IOC Run-Time

iEHR

Reusable Component

Capability / Application

Infrastructure Services Clinical ServicesBusiness

Services

Service

External System

UX Framework

VDR RLUS

JPS

IzLab Rx

CIMI Reusable Model

US Realm iEHR

Standard Model

CIIF Content

Legend

HDD

VistA AHLTA

VPR

Service Systems

IOC

Note

WriterCPOE CCSI&FCM

"has-a"

"depends-on"

"is-a"

information

exchange "has-a"

aggregate

"orchastration of 1-or-more"


29

IOC FOC Transition: Run-Time CIIF Content Used Within iEHR

30

iEHR Healthcare Services Platform (HSP)

iEHR is intended to be a Healthcare Services Platform (HSP)

emphasizing the reuse of

• high quality clinical/business, infrastructure services,

• a User Experience (UX) framework and a

• virtual data repository (VDR).

The HSP is intended to be an interoperability-framework for

• COTS (Commercial Off-The-Shelf),

• GOTS (Government Off-The-Shelf) and

• Open-Source Components.


31


All medical specialty-domains should each be an orchestration of

HSP services; where, each medical-specialty domain has its own

• data-and-terminology models,

• business-rules,

• workflows,

• reports and displays

in accordance with scope-of-practice, organizational policy, iEHR

governance and jurisdictional law.


32


Individual capabilities must build upon the HSP foundation and

support the iEHR transition strategy by focusing on

• VDR legacy-system data integration using the HL7/OMG specified

RLUS (Retrieve, Locate, and Update Service) database front-end;

• to insure interoperability, capabilities must use the underlying iEHR

HSP CIIF (Common Information Interoperability Framework)

specified data structures and services,

• UX framework


33


• IOC may use HSP clinical/business services, which are provided by

legacy-system’ service-facades.

• If a capability includes a turn-key COTS or GOTS component, it must

have exit ramps (e.g., service invocations) enabling the use of the CIIF,

UX framework and VDR.

• FOC (Final Operating Capability) must exclusively use iEHR HSP

services.


34


Most importantly, the key clinical/business services are:

Virtual Patient Record (VPR) Service to collate data from all legacy sources

and use it as if it were coming from one source

RLUS (Retrieve, Locate Update Service) fronted databases and COOP

(continuity-of-operation) and performance caches

CIIF (Common Information Interoperability Framework) information-and-

terminology models and services supporting VPR


35


Care Coordination Services enabling “medical-home” type patient-care

management

Problems, including Diagnosis and Allergies

Treatments, including Medication List and Procedures

Diagnostic Test Results, including Radiology Reports, Radiology Images,

Pulmonary Function Tests, Electrocardiograms, Laboratory Test Results,

Microbiology Results, Pathology Reports, Synoptic Pathology Reports,

Pathology Images

Demographics, Advance Directives and Patient / Family Preferences


36


Orders Management Service integrated within the Care Coordination Service

to avoid duplicate entry

Note Writer Service integrated within the Care Coordination Service to avoid

duplicate entry

Inventory and Funds Control Management Services

CDS (Clinical Decision Support), possibly built from the SOA Suite Business

Rules Service

UX Portal Framework enabling CM (context management), AM (access

management), ID (identification). Portlets are pluggable user interface

components, secure-mobile devices and medical-domain-specific portlets


37


• Identity Management Service (see VA IAM - Identity and Access

Management)

• Results Retrieval Service

The desired solution follows software engineering “best practices” to separate::

• Data, Business rules, Application code, Presentation framework services

• Common services (e.g., SOA Suite, Enterprise Service Bus, security, UX

framework, reporting tools),

• Core business services and orchestrated business workflow & business

“value chain” services


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