Health Information Technology Interoperability - MCST-CS - home

fortnecessityusefulSoftware and s/w Development

Dec 14, 2013 (4 years and 6 months ago)


Health Information Technology

Learning Objectives

After reading this chapter the reader should be able to:

• Identify the need for and benefits of interoperability

• Describe the concept of Health Information
Organizations and how they fit into the

Nationwide Health Information Network

• State the most important data standards and their role
in interoperability

• Describe the importance of data security and privacy as
part of HIPAA

Health information technology (HIT) interoperability
means that electronic applications, devices or
systems are able to exchange health

Interoperability is a critical element in the future
success of health information exchange (HIE) at the
local, regional and national level.

As an example, patient data within an electronic
health record is interoperable if it can be shared
with another computer or information network.

In 2008 the National Alliance for Health
Information Technology released a new

set of definitions that would help clarify the
ambiguity of several HIT terms:

Health Information Exchange
(HIE) is the “electronic
movement of health
related information among organizations
according to nationally recognized standards”.

Health Information Organization
(HIO) is “an organization
that oversees and governs the exchange of health
information among organizations according to nationally
recognized standards”.

Regional Health Information Organization
(RHIO) is “a health
information organization that brings together health care
stakeholders within a defined geographic area and governs
health information exchange among them for the purpose of
improving health and care in that


Health Information Interoperability


The government should develop incentives for physicians
and insurers that include grants and pay for performance

They should also work to revise or eliminate legal barriers
such as the Stark and Anti
Kickback laws.

Gaps in health IT adoption should be identified and
remedial policies should be developed.

The shortage in health IT manpower needs to be addressed
and corrected.

Lastly, the public needs to know that interoperability will
ultimately improve the quality of medical care and patient


There is a need to certify health IT products in
terms of functionality, security and

Data standards must be developed with the help
of the National Health Information Community

The NHIC should require HIT developers to cover
privacy specific problems and standards for labels
and packaging.


National standards for patient authentication
and identity need to be developed.

The Department of Health and Human Services
should work with other agencies to fund a
national health information network.

There should be criminal punishment for privacy
violations. Patients should not be discriminated
against based on health data

National Health Information

In order for Electronic Health Information to be interoperable we need to
focus on the following points:

• "Be a decentralized architecture built using the Internet linked by uniform

and a software framework of open standards and policies

• Reflect the interests of all stakeholders and be a joint public/private effort

• Be patient centric with sufficient safeguards to protect the privacy of
personal health information

• Have incentives to accelerate deployment and adoption of a NHIN

• Enable existing technologies, federal leadership, prototypes and
certification of EHRs

• Address better refined standards, privacy concerns, financing and
discordant laws regarding health information exchange"

• Leverage the Internet as an infrastructure; think web

• Build upon existing successes; take advantage of any existing

• Have a realistic implementation plan; build incrementally or
by phases or modules

• Develop strong physician involvement; involve medical
schools and medical societies

• Obtain hospital leadership commitment; much of the
information to be shared comes from hospital IT systems

• Obtain support from the business community; vendors who
have networking experience will be valuable partners

• Establish a neutral managing partner; a commission or
network authority

As a result for the previous
the following architecture was established:

This architecture consist of:

• NHIN Gateway implements the core services such as locating
patients at other health organizations within the NHIN and
requesting and receiving documents associated with the patient. It
also includes authenticating network participants, formulating and
evaluating authorizations for the release of medical information and
honoring consumer preferences for sharing their information

• Enterprise Service Component (ESC) provides enterprise
components including a Master Patient Index (MPI), Document
Registry and Repository, Authorization Policy Engine, Consumer
Preferences Manager, HIPAA
compliant Audit Log and others. This
element also includes a software development kit (SDK) for
developing adapters to plug in existing systems such as electronic
health records to support exchange of health information across the

• The Universal Client Framework enables agencies to develop end
user applications using the enterprise service components in the ESC

Web Services and Service Oriented

Before the internet data resided on a local PC or
server. Web services are platform independent
applications that communicate with other web
based applications/services over a network

HIOs are based on Internet
based web
services, we are adding a short primer on the
subject for
better understanding.

Web services require three

basic platform elements:

• SOAP (Simple Object Access Protocol): a
communication protocol between applications. It is a
vendor independent format (XML based) for sending
messages over the Internet. It reuses the HTTP for
transporting data as messages

• WSDL (Web Services Description Language): a XML
document used to describe and locate web services

• UDDI (Universal Description, Discovery and Integration):
a directory for storing information about web services,
described by WSDL. UDDI communicates via the SOAP

Several models
of health
exchange data storage have appeared:

• Federated

means that data will be stored
locally on a server at each entity such as
hospital, pharmacy or lab. Data therefore has to
be shared among the users of the HIO

• Centralized

means that the HIO operates a
central data repository that all entities must

• Hybrid

a combination of some aspects of
federated and centralized model

Pros and Cons of

In order for a HIO to succeed, multiple
participants will need to be involved in the
planning phase
. Examples would be:

• Insurers (payers)

• Physicians

• Hospitals

• Medical societies

• Medical schools

• Medical Informatics programs

• State and local government

• Employers

• Consumers

• Pharmacies and pharmacy networks

• Business leaders and selected vendors

• Public Health departments

Multiple functions need to be addressed by a
HIO such as:

• Financing: it will be necessary to obtain short term start up money and
more importantly a long term business plan to maintain the program

• Regulations: what data, privacy and security standards are going to be

• Information technology: who will create and maintain the actual network?
Who will do the training? Will the HIO use a centralized or de
centralized data

• Clinical process improvements: what processes will be selected to improve?
Claims submission? Who will monitor and report the progress?

• Incentives: other than marketing what incentives exist to have the disparate
forces join?

• Public relations (PR): you need a PR division to get the word out regarding
the potential

benefits of creating a HIO

• Consumer participation: in addition to the obvious stakeholders you need
input from consumers/patients26

Health Information

• Everyone has a different business model. Is this a public
utility with no public funding?

• Who will fund HIOs long term? Insurers? Employers?
Consumers? Neither private nor government organizations
take full responsibility. What happens when the grant money


• Will we have universal standards or different standards for
different HIOs?

• There could be dependence on vendors. BCBS of Tennessee
partnered with Cerner who has an EHR product and will
receive a per member per month subscription fee

• What should be done with geographical gaps in HIOs and
what regions should they
cover? Should
they be based on
geography, insurance coverage or prior history?

• Are poorer cities, states and regions at a disadvantage?

• How can you create a NHIN if multiple HIOs fail and the
adoption rate of EHRs is low?

• The federal government is funding NHIN trials with grant
money. Will they fund all
HIOs to
connect to the NHIN?

• What are the incentives for competing hospitals and their
CIOs/CEOs in the average city
or region
to collaborate?

• Who will accredit HIOs, CCHIT or the Electronic Healthcare
Accreditation Commission

Data Standards

According to the Institute of Medicine’s 2003
report Patient Safety: Achieving a New Standard
for Care

“One of the key components of a national health
information infrastructure will be data standards
to make that information understandable to all

data standards and how
facilitate the transmission
of data.

Extensible Markup Language (XML

• Although XML is not really a data standard it has
become a programming markup language standard for
health information exchange. In order for disparate
health entities to share messages and retrieve results, a
common programming language is necessary

• XML is a set of predefined rules to structure data so it
can be universally interpreted and understood

• XML consists of elements and attributes

• Elements are tags that can contain data and can be
organized into a hierarchy

• Attributes help describe the element

XML Example


<car id= “Ford” model=”2008”>

<phone id =”1”> All phone information

<number>9216604</number >



<car id=”Chevy” model=”2008>

<phone id = “2”> All phone information




Health Level Seven (HL7)

• A not
profit standards development organization (SDO) with chapters in 30

• Health Level Seven’s domain is clinical and administrative data transmission and
perhaps is the most important standard of all

• "Level Seven" refers to the highest level of the International Organization for
Standardization (ISO)

• HL7 is a data standard for communication/messages between:

o Patient administrative systems (PAS)

o Electronic practice management

o Lab information systems (interfaces)

o Dietary

o Pharmacy (clinical decision support)

o Billing

o Electronic health records

• HL7 uses XML markup language

• The most current version of the HL7 standard is 3.0 but version 2.0 still widely in use

• The Clinical Document Architecture (CDA) is part of the HL7 standard and makes
documents human readable and machine

by using XML.

The CCD will have 17 data content/component
modules as part of the C32 standards
as noted
in the table below. Each module will have
additional data elements:

Digital Imaging and Communications in
Medicine (DICOM)

• DICOM was formed by the National Electrical
Manufacturers Association (NEMA) and the

American College of Radiology. They first met in 1983
which suggests that early on they

recognized the potential of digital x

• As more radiological tests became available digitally, by
different vendors, there was a need

for a common data standard

• DICOM supports a networked environment using TCP/IP
protocol (basic Internet protocol)

• DICOM is also applicable to an offline environment

Institute of Electrical and Electronics
Engineers (IEEE).

IEEE is the organization responsible

for writing standards for medical devices. This
includes infusion pumps, heart monitors and
similar devices.

Logical Observations: Identifiers,
names and codes (LOINC)

• This is a standard for the electronic exchange of
lab results back to hospitals, clinics and payers. HL7
is the messaging standard, whereas LOINC is the
interpretation standard

• The LOINC database has more than 30,000 codes
used for lab results. This is necessary as multiple
labs have multiple unique codes that would
otherwise not be interoperable

• The lab results portion of LOINC includes
chemistry, hematology, serology, microbiology and

• The clinical portion of LOINC includes vital signs, EKGs, echocardiograms,
gastrointestinal endoscopy, hemodynamic data and others

• A LOINC code example is 2951
2 for serum sodium; there would be another
code for urine sodium. The formal LOINC name for this test is:


• LOINC is accepted widely in the US, to include federal agencies. Large
commercial labs such as Quest and

have already mapped their
internal codes to LOINC

• RELMA is a mapping assistant to assist mapping of local test codes to LOINC

• LOINC is maintained by the

Institute at the Indiana School of
Medicine. LOINC and RELMA are available free of charge to download from

• For more detail on LOINC we refer you to an article by McDonald

Lab Interoperability and
Connectivity Standards (ELINCS)

• ELINCS was created in 2005 as a lab interface for ambulatory EHRs
and a further “constraint” or refinement of HL7

• Traditionally, lab results are mailed or faxed to a clinician’s office and
manually inputted into an EHR. ELINCS would permit standardized
messaging between a laboratory and a clinician’s ambulatory EHR

• Standard includes:

o Standardized format and content for messages

o Standardized model for exchanging messages

o Standardized coding (LOINC)

• The Certification Commission for Healthcare Information Technology
(CCHIT) has proposed that ELINCS be part of EHR certification

• HL7 plans to adopt and maintain the ELINCS standard

• California Healthcare Foundation sponsored this data standard

National Council for Prescription Drug
Programs (NCPDP)

• A standard for exchange of prescription
related information

• The standard facilitates pharmacy

• It is the standard for billing retail drug sales

Systematized Nomenclature
: Clinical

SNOMED is the clinical terminology commonly used in software applications
including EHRs

• SNOMED is also known as the International Health Terminology

• This standard was developed by the American College of Pathologists. In 2007
ownership was
transferred to the International Health Terminology Standards
Development Organization

• SNOMED will be used by the FDA and the Department of Health and Human Services

• This standard currently includes about 1,000,000 clinical descriptions

• Terms are divided into 11 axes or categories

• The standard provides more detail by being able to state condition A is due

• SNOMED links to LOINC and ICD

• SNOMED is currently used in over 40 countries

• EHR vendors like Cerner and Epic are incorporating this standard into their products

• There is some confusion concerning the standards SNOMED and ICD
9; the
used primarily
for billing and the former for communication of clinical conditions


A study at the Mayo Clinic showed that SNOMED
CT was
able to accurately describe 92% of the most common
patient problems 73

CT Example: Tuberculosis


1 4 8 0 0

. . . .

. . . .

. . . Tuberculosis

. . Bacterial infections

. E = Infectious or parasitic diseases

D = disease or diagnosis

International Classification of Diseases
9th revision (ICD

9 is published by the World Health
Organization to allow mortality and morbidity data
from different countries to be compared

• Although it is the standard used in billing for the
past 30 years, it is not ideal for distinct clinical

10 will provide a more detailed description
with 7 rather than 5 digit codes. ICD
10 would
result in about 200,000 codes instead of the 24,000
codes currently used.