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Networking and Health Information Exchange, Health Data Interchange Standards

Audio Transcript

Slide 1
Welcome to Networking and Health Information Exchange, Health Data
Interchange Standards. This is lecture c.

The component, Networking and Health Information Exchange, addresses what is


required to accomplish networking across and among disparate organizations who have
heterogeneous systems.

Unit 5 covers Health Data Interchange Standards and consists of three lectures. Over
these three lectures, we will talk about the different standards that may be used to share
health data among disparate groups, frequently identified as messaging standards.

Lecture c focuses on other SDOs that are used to exchange data other than clinical.
These standards include DICOM imaging standards, NCPDP pharmacy services
standards, IEEE medical device standards, X12N reimbursement standards, and
profiling and implementation guide services from IHE. You may encounter one or all of
these standards, depending on your job, and the size of your facility. At least some
knowledge of these standards will be useful.

Slide 2
The Objectives for this unit, Health Data Interchange Standards, are to:

Understand linking and aggregating data at all levels,


Understand how data may be interchanged among heterogeneous settings without
loss of information,
Understand HL7 v2.x messaging communication standards,
Understand HL7 v3.0 messaging standards, and
Understand other data interchange standards including DICOM for imaging
standards, NCPDP for prescriptions and medication reimbursement, IEEE for device
interface standards, ASC X12N for claims and reimbursement standards, ASTM for
document exchange, and IHE for profiles and registry standards.

Health IT Workforce Curriculum Networking and Health Information Exchange 1


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Slide 3
Additional Objectives for this unit, Health Data Interchange Standards, are to:

Explain how model-based standards are created,


Define the methodology development framework,
Describe HL7 v3.0 messaging standards,

And to understand

Imaging standards,
Standards for pharmacy services,
Interface standards for medical devices,
Claims and reimbursement standards,
Concept of profiling , and
Use and value of implementation guides.

Slide 4
Digital Imaging and Communication in Medicine (DICOM) is an international standards
body for the transfer of radiologic images and other medical information between
computers. All PACS systems will use the DICOM standards.

DICOM also embraces JPEG and MPEG standards as part of their imaging package,
although these standards were created by another group. The global universality of
these standards provides a major step toward interoperability. The part of the standard
for images specifically has withstood the test of time and is truly interoperable. The
additional supporting standards that provide information about how the image was taken
and specifically about the subject or patient and clinical data overlaps with other
standards, and does have some variability among different settings.

The DICOM standard resulted from a joint effort between the American College of
Radiology and the National Electrical Manufacturers Association, starting in 1983.
Subsequently, DICOM became an independent organization and a global standards
body. The current version of the standard, v3.0 was published in 1993.

Slide 5
DICOM v3.0 supports communication services for a point-to-point environment and for a
networked environment. The upper-layer service supports the use of a fully-conformant
stack of OSI protocols to achieve effective communication. It supports a wide variety of
international standards-based network technologies using a choice of physical networks
such as Ethernet, FDDI, ISDN, X.25, dedicated digital circuits, and other local area
network and wide area network technologies. In addition, the same upper-level service
can be used in conjunction with TCP/IP transport protocols.

Health IT Workforce Curriculum Networking and Health Information Exchange 2


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
A single DICOM file contains both a header which stores information about the patient's
name, the type of scan, image dimensions, etc., as well as all of the image data which
can contain information in three dimensions.

DICOM is the most common standard for receiving scans from a hospital or any health
facility.

DICOM also supports other standards including Structured Reports and Web-access to
persistent objects. These later standards are also ISO standards. DICOM is a liaison
group to ISO TC 215.

Slide 6
The National Council for Prescription Drug Programs (NCPDP) is an ANSI-accredited
SDO representing virtually every sector of the pharmacy services industry. The diverse
membership provides leadership and healthcare business solutions through education
and standards, created using the consensus building process. NCPDP has been named
in US federal legislation, including HIPAA, the Medicare Prescription Drug,
Improvement, and Modernization Act, and in the meaningful use requirements. These
standards are used for the reimbursement of prescription drugs.

NCPDP members have created standards such as the Telecommunication Standard


and Batch Standard, the SCRIPT Standard for Electronic Prescribing, and
Manufacturers Rebate Standard and more, to improve communication within the
pharmacy industry.

The current version of the Telecommunications Standard is version D, release 0. The


Batch standard which does the same thing is version 1.1. The Batch Standard was
named in HIPAA Final Rule. The SCRIPT standard, current version 10, release 4, is
used to exchange prescription information between the physician or prescriber and a
pharmacy. It is also used for managing refills and for communication information about
drugs dispensed.

The current version of the manufacturer rebate standard is version 4, release 1. Other
NCPDP standards include a financial information reporting standard, a billing unit
standard, a Medicaid subrogation standard which permits a Medicaid agency to
communicate to a processor for reimbursement, a formulary and benefit standard, a
post adjudication standard, and a prescription file transfer standard.

NCPDP also works with HL7 for Electronic Prescribing Coordination. This activity
correlates portions of NCPDP script into HL7 v2.n standards for new prescriptions,
changes to prescriptions, refills, cancellation of prescriptions, compliance notification

Health IT Workforce Curriculum Networking and Health Information Exchange 3


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
and sharing medication history information. This work is particularly important to
improve patient safety.

The NCPDP Billing Unit Standard provides a well-defined billing standard for use in
pharmacy transactions.

The XML standard for NCPDP provides a model-based approach to NCPDP standards.

Slide 7
NCPDP has a series of Implementation Guides (IG) that explain and support the use of
the standards. These guides include:
Financial Information Standard IG
Formulary and Benefit Standard IG
Functional Profiles for EHR Systems
Pharmacy ID Card IG
Script IG
Specialized standard IG and
Telecommunication Standard IG

Details on these standards and implementation guides can be obtained from NCPDP.

Slide 8
The resources that are used across all standards include a data dictionary which
contains names, definitions, and other attributes of all data elements used in all NCPDP
standards. The External Code List is a list of value codes with descriptions for data
elements used in NCPDP standards. The data elements are defined in the data
dictionary.

NCPDP has a collaborative and harmonization relationship with HL7 for electronic
prescribing coordination.

Slide 9
The Institute of Electrical and Electronic Engineering (IEEE) creates standards in many
areas. This lecture only focuses on those standards related to medical devices. IEEE
works collaboratively with ISO, CEN, HL7, and DICOM to create these standards, and,
as a result, contributes greatly to interoperability.

The following slides identify the IEEE medical device standards that are in use or are
being developed. IEEE has created a family of standards that defines the entire seven-
layer communications requirements for the medical information bus.

Health IT Workforce Curriculum Networking and Health Information Exchange 4


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
IEEE, working with the above groups, is also producing waveform standards. More
recently, the group is developing personal device standards.

Slide 10
All of the IEEE standards are identified by the initial number 11073 and, as such, are
often referred to as the 11073 family of standards. The specific identification number is
a five digit number (nnnnn) that identifies the type of standard.

Types include guidelines or information or background, point-of-care standards,


transport profile, application profile, interface profile, models, and nomenclature. These
standards address interoperability for a group of medical devices, using different forms
of interface.

The next series of slides identify the IEEE medical devices by the year in which they
were published.

Slide 11
The interface profiles deal with every way in which a medical device can be connected
to a system: cable, infrared, and wireless. It is a higher-level, generic standard.

The 30200 is a transport profile for cable-connected devices and was published in 2000.

Slide 12
These IEEE standards were created in 2004. All are point-of-care medical device
communication standards.

10101 Nomenclature identified objects and attributes related to medical devices;


uses the Object Identifier code (OID)
10201 Domain information model. Defines DIM and a service model for standardized
device communication
20101 application profile, base standard. Provides a common background for
assembly and transmission of objects and their attributes
30200 Transport profile cable connected
30300 Transport profile infrared wireless

The first 3 standards are core standards for the 11073 series.

Health IT Workforce Curriculum Networking and Health Information Exchange 5


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Slide 13
In 2007, the standard ISO 11073-92001 Medical waveform format encoding rules was
introduced.

Slide 14
Technical report 00101 is a guideline standard for the use of wireless devices.

In 2008, IEEE began to develop a set of personal health device standards using the
label device specialization. These standards all have the leading category identifier 104
followed by the two-digit personal device identifier. Appliances covered in 2008 include
the pulse oximeter, the blood pressure monitor, the thermometer, the weighing scale,
and body composition analyzer.

Note: These standards became ISO standards in 2010 as part of an IEEE/ISO shared
standards agreement.

These personal devices standards are increasingly important, as we move into personal
health records and personal responsibility for ones own health. Many of these devices
will be found in the homes or worn.

Slide 15
Other devices include cardiovascular fitness and activity monitor, strength fitness
equipment, such as treadmills and independent living activity hub, which is important for
an ageing population. Another standard is analytical instruments point-of-care test.

An application profile standard was published in 2008 for an optimized exchange


protocol.

Slide 16
In 2009, a standard was published for a glucose monitor as a personal device. This
standard also became an ISO standard in 2010.

The standard ISO 11073-91064 Computer-assisted electrocardiography was


introduced in 2009.

Slide 17
2010 continued the creation of personal device standards: Body composition analyzer,
the peak expiratory flow monitor, and a medication monitor. Another standard produced
was Interface profile for cabled Ethernet.

Health IT Workforce Curriculum Networking and Health Information Exchange 6


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Slide 18
IEEE has a very aggressive agenda. Currently under development are a series of
standards, identified on these three slides. Some of the standards are revisions of older
standards; others are amendments to existing standards. Of an informative nature is an
overview standard for the 11073 family of standards and a set of three standards for
nomenclature or glossary for medical device standards, for annotated ECG, and for
implantable cardiac devices. The annotated ECG standard defines the set of
measurements that accompany the waveform useful for the EHR or PHR.

Other standards include a domain information model for medical devices, one of which
is XML schema based.

Slide 19
Several other personal device standards are under development pulse oximeter
(revision), basic ECG (1-3 lead, waveform), respiration rate monitor, glucose monitor
(revision), international normalized ratio (INR) monitor, and an insulin pump. The INR
measures the time it takes for blood to clot and compares it to an average. Monitoring
the INR can be an important step in managing health. It is important to note that, as
technology progresses, many of these standards will be revised and updated. It is
important to access either IEEE or ISO to get the latest version of a particular standard.

Slide 20
Continuing, personal device standards under development include a revision of the
cardiovascular fitness and activity monitor.

The 20nnn codes are application profiles and include standards for association control
function, polling mode, baseline asynchronous mode, remote control, and a common
network infrastructure. These standards deal with applications interfacing with medical
devices.

Slide 21
Two amendments to standards are under development: For optimized exchange
protocol and transport profile for cable connected devices.

The last standard under development is a transport profile for RF wireless in a local
area network.

The time to publication for these standards will vary from one to three years.

Health IT Workforce Curriculum Networking and Health Information Exchange 7


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Slide 22
X12 has developed standards for the exchange of purchase-order data, invoice data,
and other commonly- used business documents. The X12n subcommittee is
responsible for business standards that are related to healthcare specifically,
standards that deal with claims and the reimbursement process.

The X12n standards use an EDI structure called transaction sets. Each transaction set
is composed of a header, and one or more control segments that relate to the purpose
of the standard. Data segments are defined in a data segment dictionary. Data
elements are defined in a data element dictionary. Composite data structures are
defined in a composite data dictionary, and control segments and binary segments are
defined in a data-segment dictionary.

X12n standards are required by HIPAA and are mentioned in the final rule for
Meaningful Use.

Slide 23
This slide illustrates the family of X12n standards that support the exchange of data
among providers and payers, as well as data exchange with employers related to
reimbursement.

270 is an Eligibility Inquiry from the provider and 271 is the payers response.

837 is the payers claim submission and 835 is the payers claim payment or advice.

276 is a claim status request from the provider and 277 is the claim status notification or
a request for additional information from the payer.

275 is additional information from the provider.

278 is healthcare review from payer.

Coupled to the employer or sponsor are 834 for benefits enrollment and 829 for
premium payment.

Claims attachments the clinical data that supports the claim standards have been
jointly developed by X12N and HL7. The current version uses the HL7 CDA.

Slide 24
The ASTM is a large, international standards developing organization. ASTM creates
standards in many areas. E31 is the Technical Committee that creates standards in the
healthcare area. It is a very small part of ASTM and its activity is rather limited in this

Health IT Workforce Curriculum Networking and Health Information Exchange 8


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
area. ASTM creates two standards that relate to the exchange of data. The first, a
Standard Guide for Properties of a Universal Healthcare Identifier (UHID), has been
around for many years. It is a useful document that does address issues of a personal
identifier and defines well required properties of that identifier. The other standard, the
Standard Specification for Continuity of Care Record, is currently the most popular and
most used ASTM E31 standard.

Slide 25
The Continuity of Care Record (CCR) is a core dataset of relevant administrative,
demographic and clinical data about a patient. It may address a single encounter or
multiple encounters. A primary use is to exchange information between physicians, for
example, for a referred patient to a consultant.

The core data set permits most information that would exist in an EHR to be exchanged.
The CCR data may be displayed by the receiver or merged into an EHR. The CCR uses
an XML syntax, and may employ a strict schema to support interoperability.

The content of the CCR has been incorporated into the HL7 CDA as an implementation
guide called the Continuity of Care Document.

Slide 26
The goal of the Integrating the Healthcare Environment (IHE) is to stimulate the
integration of healthcare information resources and promote the adoption of standards.

It is not a standards developing organization it identifies and promotes the use of


other SDOs.

IHE works with specific clinical domain organizations to understand requirements and
develops profiles and implementation guides to support those requirements.

In many cases the profile requires the use of several standards. This approach does
enable interoperability in a controlled way. IHE has value locally, across multiple
enterprises, regionally, nationally, and globally.

Slide 27
IHE has played a major role in defining requirements and promoting the development of
standards to meet those requirements. Their incentive for participation is the opportunity
to demonstrate that their systems can operate efficiently in standards-based, multi-
vendor environments with the functionality of real hospital and clinic information
systems. IHE enables vendors to direct product development resources toward building
increased functionality. The IHE Connectathon, held annually at HIMSS and also at

Health IT Workforce Curriculum Networking and Health Information Exchange 9


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
other locations internationally, provides the opportunity for vendors to test and prove
their ability to work with other systems.

Slide 28
This slides shows activity with IHE working with medical specialty groups to create
profile or implementation guides for specific domains. Domains currently addressed
include IT infrastructure, radiology, cardiology, laboratory, patient care coordination,
patient care devices, radiation oncology, and eye.

Slide 29
All of these document exchange profiles are cross enterprise.

XDS supports records sharing. XDS typically uses HL7 CDA documents. XDS
supports a document registry with a queryable index of metadata and references to all
documents shared within a connected enterprise. Using XDS, IHE provides for storage
and retrieval of clinical data (usually documents).

XDR (Cross-Enterprise Document Reliable Interchange) is intended to be a light-weight,


point-to-point introduction to XDS. It uses the Provide and Register Document Set
transaction, originally defined in XDS, to move documents and associated metadata
between two systems. It does not use the Document Repository and Document Registry
actors from XDS. In short, it does not define an environment for sharing -- that would be
XDS -- but instead a way of transporting documents and metadata about documents
from one system to another.

Cross-Enterprise Document Media Interchange (XDM) provides document interchange


using a common file and directory structure over several standard media. This permits
the patient to use physical media to carry medical documents. This also permits the use
of person-to-person email to convey medical documents.

PIX reconciles information on patients from multiple domains to a single cross-


referenced set of IDs for each patient.

PDQ returns demographic information and identifiers of patients based on specified


demographic criteria.

XCA supports the means to query and retrieve patient-relevant data held by other
communities i.e. another RHIO.

These products work together to support interoperability and the sharing of data among
sites.

Health IT Workforce Curriculum Networking and Health Information Exchange 10


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Slide 30
The Cross-Enterprise Document Sharing (XDS) enables the sharing of documents
across the entire healthcare spectrum hospitals, clinics, physicians, social services
and other resources. XDS provides a distributed collaborative approach to sharing
documents using a federated approach. It functions much like a book library that has a
central index. XDS enables users to retrieve documents such as letters, records,
results, images, and folders. The XDS registry contains standard metadata about each
document and where it is located.

XDS has 5 actors or components:

The Document Source submits documents (for example an HL7 CDA) to a local
Repository with metadata about each. The metadata is based on the ebXML Registry
Information Model. Registry services and protocols define the services and protocols
which support the uses.

The Document Repository provides a persistent store for each document.

The Document Registry provides an index to all registered documents.

The Document Consumer submits a query about a patient to the registry which returns
the locations of relevant documents. The consumer then may retrieve the desired
documents.

The Patient Identity Source provides a consistent way of identifying patients across the
affinity domain.

Slide 31
This concludes Networking and Health Information Exchange.

This unit has introduced you to a series of standards that are used for networking
between sites at all levels. Much of the focus was on clinical messaging standards
namely HL7 v2.n and v3 standards. You were also introduced to imaging standards,
pharmacy services standards, medical device standards, and claims and
reimbursement standards. Finally we looked at an organization that provided profiles
and implementation guides that put these standards together to support end-to-end
interoperability.

Slide 32
No audio.

Health IT Workforce Curriculum Networking and Health Information Exchange 11


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.
End.

Health IT Workforce Curriculum Networking and Health Information Exchange 12


Version 3.0/Spring 2012 Health Data Interchange Standards
Lecture c
This material Comp9_Unit5c was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.