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September, 2005 What IHE Delivers
XDS, XDM / XDR Point-to-Point Push of
Documents
Understanding IHEUnderstanding IHE
By Raghu KodumuriBy Raghu Kodumuri
112-12-201312-12-2013
2
Outline
XDS
Introduction to XDM/XDR
XDM
XDR
Summary
References
XDSCross-Enterprise Document Sharing
What is XDS ?
The Cross-Enterprise Document Sharing (XDS) IHE Integration Profile facilitates the registration, distribution and access across health enterprises of patient electronic health records
It provides a standards-based specification for managing the sharing of documents between any healthcare enterprise
44
XDS Affinity Domain
PMS
Physician Office
EHR System
Teaching HospitalCommunity
Clinic
Lab Info. System
PACS
PACS
Retrieve Document
Provide & Register
Register Document
(using Patient ID)
Query Document
(using Patient ID)
Document RegistryDocument
Repository
Document Repository
ED Application
PIX or PDQ
Query
PIX or PDQ
Query
ATNA
CT
Audit record repository Time server
Patient Demographics Supplier
Record Audit Event
Maintain
Time
Maintain
Time
Maintain
Time
XDS Workflow Health Information Exchange Network
14355M8354673993
L-716
A87631M8354673993
A8763114355L-716
Patient Identity XRef Mgr
Record AuditEvent
55
XDS Affinity Domains
Group of healthcare enterprises that have agreed to work together using a common set of policies and XDS-based infrastructures for sharing patient clinical documents. Some examples are:•Regional community of care•Nationwide EHR•Specialized or disease-oriented (cardio, diabetes, oncology)•Government-sponsored or federation of enterprises•Insurance provider supported communities
XDS profile is designed to accommodate a wide range of policies on:•Patient identification and consent•Controlling access to information•Format, content, structure, and representation of clinical information
66
Use Cases
• Patient Care Summary (e.g. within a region)– Publishing of Care Summaries by providers– Access to patient’s Care Summary in an emergency
• eReferral between primary and secondary care providers• Sharing of radiology reports and images between facilities• Sharing of laboratory reports by clinical laboratories with
ordering physicians and other care providers• ePharmacy between community pharmacy and
ambulatory physicians
77
Main Systems and Responsibilities
• A document Repository is responsible for storing documents in a transparent, secure, reliable and persistent manner and responding to document retrieval requests.
• A document Registry is responsible for storing information or metadata about those documents so that the documents of interest for the care of a patient may be easily found, selected and retrieved irrespective of the repository where they are actually stored.
• Any IT system (e.g. point of care) may act as a Document Sources or Document Consumers submitting documents for registration, or querying/retrieving relevant documents.
Notes:• Analogous to a library (book repository) and catalog/index• The Registry does not have access to the documents – an important
separation from security and privacy perspective• Multiple Repositories can be linked to one Registry
88
ConsumerConsumerRegistryRegistry
RepositoryRepository
11. Sources post . Sources post document packages document packages to the Repositoryto the Repository
22. Repository registers . Repository registers the documents the documents metadata and pointer metadata and pointer with the Registrywith the Registry
33. Consumers search . Consumers search for documents with for documents with specific informationspecific information
44. Consumers retrieve . Consumers retrieve selected documents selected documents from Repository (-ies)from Repository (-ies)
XDS Document (Metadata):
ClassPatient IdAuthorFacilityDate of Service…
XDS Document (Metadata):
ClassPatient IdAuthorFacilityDate of Service…
Source Source of of DocumentsDocuments
XDS Flow and Interactions
99
XDS Transaction Diagram
Patient Identity Patient Identity SourceSource
Document Document RegistryRegistry
Document Document RepositoryRepository
Document Document SourceSource
Document Document ConsumerConsumer
Patient Identity Feed [ITI-8]Patient Identity Feed [ITI-8]Patient Identity Feed HL7v3 [ITI-44]Patient Identity Feed HL7v3 [ITI-44]
Provide&RegisterProvide&RegisterDocument Set-b [ITI-41]Document Set-b [ITI-41]
Retrieve Document Set [ITI-43]Retrieve Document Set [ITI-43]
Registry Stored Query [ITI-18]Registry Stored Query [ITI-18]
Register Document Set-b [ITI-42]Register Document Set-b [ITI-42]
Integrated Document Source/RepositoryIntegrated Document Source/Repository
1010
XDS Actors
• Document Source – producer and publisher of documents, responsible for sending documents and their metadata to a Document Repository actor
• Document Repository is responsible for both the persistent storage of these documents as well as for their registration with the appropriate Document Registry
• Document Registry maintains metadata about each registered document and a link to the Document in the Repository where it is stored. Responds to queries from Document Consumer actors about documents meeting specific criteria.
• Document Consumer queries a Document Registry for documents meeting certain criteria, and retrieves selected documents from one or more Document Repository actors
• Patient Identity Source provides unique identifier for each patient and maintaining a collection of identity traits. This facilitates the validation of patient identifiers by the Registry Actor in its interactions with other actors
• Integrated Document Source/Repository combines the functionality of the Document Source and Document Repository actors into a single actor that does not expose the Provide and Register Document Set transaction
1111
XDS Transactions (1)
• Provide and Register Document Set – For each document in the submitted set, the Document Source Actor provides both the documents as an opaque octet stream and the corresponding metadata to the Document Repository. The Document Repository is responsible to persistently store these documents, and to register them in the Document Registry using the Register Documents transaction.
• Register Document Set allows a Document Repository Actor to register one or more documents with a Document Registry, by supplying metadata about each document to be registered. This document metadata will be used to create an XDS Document Entry in the registry.
1212
XDS Transactions (2)
• Patient Identity Feed conveys the patient identifier and corroborating demographic data, in order to populate the Document Registry with patient identifiers that have been registered for the XDS Affinity Domain. (At least one of the options [ITI-8] or [ITI-44] must be supported.)
• Registry Stored Query is issued by the Document Consumer Actor to a Document Registry. It will return registry metadata containing a list of document entries found to meet the specified criteria including the locations and identifier of each corresponding document in one or more Document Repositories.
• Retrieve Document Set – initiated by a Document Consumer. The Document Repository shall return the document set that was specified by the Document Consumer.
1313
XDS Document Content Types
XDS profile is content agnostic – it can be used with a variety of document types, including:•XDS-SD: Scanned document, plain text or PDF/A, in HL7 CDA R2 format•XDS-MS: Medical summary in HL7 CDA format•XDS-I: Radiology report in plain text of PDF format, or reference to a collection of DICOM SOP Instances in a manifest document in the DICOM Key Object Selection format
Also supported are many other document content profiles specified by the IHE Patient Care Coordination, Laboratory, Cardiology, Pharmacy Technical Frameworks
1414
XDS – Actors and Options
ActorsActors OptionsOptions ReferenceReference
Document Source
Document Replacement ITI TF-1: 10.2.1
Document Addendum ITI TF-1: 10.2.2
Document Transformation ITI TF-1: 10.2.3
Folder Management ITI TF-1: 10.2.4
Basic Patient Privacy Enforcement ITI TF-2b:3.41.4.1.3.1
Document Repository
Document Registry Patient Identity Source
Patient Identity Feed ITI TF-2a: 3.8
Patient Identity Feed HL7v3 ITI TF-2b: 3.44
Document ConsumerBasic Patient Privacy Enforcement
ITI TF-2a: 3.18.4.1.3.5ITI TF-2b: 3.43.4.1.3.1
Basic Patient Privacy Proof ITI TF-2a: 3.18.4.1.3.6
1515
Standards Used
• ebRIM OASIS/ebXML Registry Information Model v3.0 • ebRS OASIS/ebXML Registry Services Specifications v3.0• ITI TF-2x: Appendix V
– WS-I Profiles BP 1.1, BSP 1.0– WS-* Specifications (SOAP 1.2, MTOM/XOP)
1616
Security and Privacy Considerations
• All actors be grouped with a ATNA Secure Node Actor or Secure Application Actor resulting in each node (systems supporting XDS actors) of the XDS Affinity Domain should have audit and security mechanisms in place
• Transactions between different secure nodes that use ATNA are encrypted
• Each XDS Transaction will result in an audit event record sent to an ATNA Audit Record Repository Actor from each XDS actor
• Timestamp consistency is provided by Consistent Time (CT) profile
1717
18
Introduction to XDM/XDRPoint-to-Point Push of Documents refers to: Cross-Enterprise Document Media Interchange (XDM) Cross-Enterprise Document Reliable Interchange (XDR)
Based on XDS XDM = push of XDS metadata and documents on media/email XDR = push of XDS metadata and documents over SOAP Maximal re-use of XDS objects & meta-data
As with XDS both are “document content agnostic” Provides a framework for use of content profiles (e.g., XDS-MS, XD-Lab,
XPHR, etc.)
When to use When document sharing infrastructure not in place Where XDS is not desirable or available to one of the participants Complementary to sharing documents via XDS
Use Cases XDM / XDR
19
SpecialistPrimary Care
Extended Care
Hospital
11 Primary refers patient to specialist (XDR)
Specialist sends summary report back (XDR)22
Primary refers patient to hospital (XDR)
33 Remote advice (XDM using Email)
44
55
Hospital sends discharge summary back (XDR)
66
Patient Transfer to Extended Care Facility (XDM using media)
77
Summary report to Primary (XDM using media)
88
20
XDMCross-Enterprise Document Media Interchange
21
XDM
Documents and metadata shared using standard media types (e.g., email, CD, USB)
Intended to be easy to implement using: Existing email clients CD burners USB ports
Meant for person-to-person communication In pocket media Send via email
Imposes common file and directory structure
22
XDM
Supports transfer of data about multiple patients within one exchange Multiple submission sets
Requires recipient to support human intervention to control importing of data Manual operation
Works with XDS XDS Query/Retrieve can feed XDM transmission Point-to-point push via XDM can feed XDS submission
23
XDM
Use Cases
Physician to Patient to Specialist• Test result and referral information given to patient on
CD-R to be taken to specialist of his choice.
Patient Visiting ED• Patient maintains copy of his EHR at home and brings
a memory stick with him to the ED.
Physician to Physician• Primary physician emails zip file attachment about his
patient to specialist
24
XDMActors & Transaction
Portable Media Creator• Assemble the media content and store it on the media
to be distributed
Portable Media Importer• Read the Document Submission Set content in order to
access the document(s) and metadata; and perform import of the documents. This actor may have to create or convert metadata that was not included on the media.
25
XDMOptions
• Note 1: At least one of these options is required. To enable better interoperability, it is highly recommended that the actors support all the options
• Note 2: This requires the ZIP over Email option.
XDM
26
XDM Push of Health Information
PhysicianOffice
Hospital
Discharge summary +Lab report
Write
Read
InterchangeMedia Discharge summary
+ Lab report
Read
Home
Including Email
27
XDMStandards DICOM PS 3.10 Media Storage and File Format for Data Interchange
(DICOM file format). http://dicom.nema.org/
DICOM PS 3.12 Media Formats and Physical Media for Data Interchange, Annex F - 120mm CD-R media, Annex R - USB Connected Removable Devices, Annex V - ZIP File Over Media, and Annex W - Email Media. http://dicom.nema.org/
XHTML™ 1.0 The Extensible HyperText Markup Language (Second Edition). A Reformulation of HTML 4 in XML 1.0. W3C Recommendation 26 January 2000, revised 1 August 2002. http://www.w3.org/TR/xhtml1.
XHTML™ Basic. W3C Recommendation 19 December 2000. http://www.w3.org/TR/xhtm-basic.
MDN: RFC 3798 Message Disposition Notification. http://www.rfc-editor.org/rfc/rfc3798.txt
28
XDMSecurity & Privacy The Portable Media Importer should check the hash value and size as
found in the XDS metadata to detect corruption within the metadata or media.
Basic Patient Privacy Enforcement Option In the case the media used is the ZIP file over Email, the transaction
should be secured by S/MIME (see IHE ATNA) and comply with the security process as defined in the DICOM Part 15 Appendix (Secure Use of ZIP File Media over Email)
Portable Media Importers/Exporters that import/export media should generate one or more ATNA “Import”/”Export” events into the audit trail to describe the media event.
Document Encryption Supplement includes both Document encryption and XDM media encryption.
XDM ReferencesPrimary ITI TF-1 Section 16 Cross-Enterprise
Document Media Interchange (XDM)
Underlying Technical Framework Content ITI TF-2b
• Section 3.32 Distribute Document Set on Media ITI TF-2x
• Appendix T Use of eMail (Informative) ITI TF-3
• Section 4.1 XDS Metadata Model
Supplement supporting Limited Metadata Support for Metadata-Limited Document Sources
29
30
XDRCross-Enterprise Document Reliable Interchange
31
Documents and metadata pushed using a SOAP protocol
Permits directed push between EHRs, PHRs, and other health IT systems in the absence of XDS or XCA infrastructure
Allows for transfer of documents for a single patient (one submission set)
Supports the reuse of the Provide and Register Document set (ITI-41) with web services as transport
Complementary to XCA’s point-to-point query infrastructure by providing directed push mechanism using the same underlying standard.
XDR
32
More like XDS than XDM Direct transfer between source and recipient No registry or repository actors involved
Works with XDS XDS Query/Retrieve can feed XDR transmission Point-to-point push via XDR can feed XDS submission
XDR
33
Use Cases
Primary Physician to Specialist• Referral information for patient sent to specialist
ahead of visit
Hospital to Long-term Care• Patient summary information sent to long-term care
facility upon patient transfer from hospital
Physician to Physician• Patient MRI test results sent from physician in
specialized care facility to another specialist for consultation
XDR
34
Document Source A system that submits documents and associated metadata to a Document Recipient
Metadata Limited Document Source A system that submits documents and associated metadata similar to a Document
Source but is limited in the quantity of metadata it is able to provide.
Document Recipient A system that receives a set of documents and makes it available to the intended
recipient (who can choose to view it or integrated it into the EHR)
XDR – Actors & Transactions
35
XDR - Options
Actor Options Vol & Section
Document Source Basic Patient Privacy Enforcement
ITI-TF-2b: 3.41.4.1.3.1
Metadata-Limited Document Source
Basic Patient Privacy Enforcement
ITI-TF-2b: 3.41.4.1.3.1
Document Recipient Basic Patient Privacy Enforcement
Accepts Limited Metadata
ITI-TF-2b: 3.41.4.1.3.1
ITI TF-1:15.2.3
XDR
36
Send Over Web Services Receive
A referral summary A referral summary
SpecialistOffice
PhysicianOffice
XDR Exchange of Health Information
37
Standards ebRIM - OASIS/ebXML Registry Information Model v3.0
ebRS- OASIS/ebXML Registry Services Specifications v3.0
ITI TF-2x: Appendix V Web Services for IHE Transactions. Contains references to all Web Services standards and requirements of use
MTOM - SOAP Message Transmission Optimization Mechanism http://www.w3.org/TR/soap12-mtom/
XOP - XML-binary Optimized Packaging http://www.w3.org/TR/2005/REC-xop10-20050125/
XDR
38
Security & Privacy
Basic Patient Privacy Enforcement Option ATNA Secure Node required for both actors Management of patient identification in order to perform
patient reconciliation correctly upon importation of documents.
Relevant XDS Affinity Domain security considerations are discussed in the XDS Security Considerations Section (see ITI TF-1: 10.7)
XDR
XDR ReferencesPrimary ITI TF-1
• Section 15 Cross-Enterprise Document Reliable Interchange (XDR)
Underlying Technical Framework Content ITI TF-1
• Appendix J Content and Format of XDS Documents• Appendix K XDS Concept Details
ITI TF-2b• Section 3.41 Provide and Register Document Set-b
ITI TF-2x• Appendix V “Web Services for IHE Transactions”
ITI TF-3• Section 4.1 XDS Metadata Model
Supplement supporting Metadata-Limited Document Sources Support for Metadata-Limited Document Sources
39
XDM
XDR
XDS
40
Publish Query/Retrieve
Send to
Existing Reliable
Messaging System Receive
WriteRead
Interchange Media
M8354673993
A8763114355L-716
XDS INFRASTRUCTUR
E
XCAQuery/Retrieve
Including Email
M8354673993
A8763114355L-716
XDS INFRASTRUCTUR
E M8354673993
A8763114355L-716
Other INFRASTRUCTUR
E
Document Document SourcesSources
Document Document Consumers/ Consumers/
RecipientsRecipients
Health Document Exchange OptionsFlexible Infrastructure
More Information
41
IHE Web site: www.ihe.net IHE official materialTechnical Framework documents
IHE Wiki site: wiki.ihe.net IHE committee pages Implementation Notes Ongoing committee work
IHE ITI technical committee mailing list http://www.ihe.net/IT_infra/committeesAt the bottom of the page is a place to join the mailing list
42
THANK YOUTHANK YOU