IHE XDS Implementation Issues Part 1.

The Integrating Healthcare Enterprise (IHE) Cross Enterprise Document Sharing (XDS) profile has been widely implemented and many vendors have tested and demonstrated its functionality at the previous connectathons, however, actual deployments have been very limited. Reasons for the very sparse implementations range from infrastructure issues, to lack of detail in the specifications, and the need to specialize and customize the metadata that is used to register and maintain the documents that are managed. The underlying issue is that XDS is not merely an interface standard but, more importantly, very much a workflow profile, which means that the differences between different institutions and even more different regions or even countries make it hard to have a one-size-fits-all implementation.

This four-part discussion will attempt to examine the issues in more detail. In part one I am going to give a high level overview of the XDS, followed by the XDS-ITI relationship discussion, the discussion of the XDS family (XDR, XDM, XCA). In part four will talk about the issues that have arisen during early implementations.

XDS is an IHE integration profile that facilitates the registration, distribution, and access of electronic health records across healthcare enterprises. It provides a framework for sharing documents, which includes images between practitioners and organizations. Some of the typical use cases are the publishing of patient care summaries by healthcare providers, the access of patient records, regardless of where they are stored in case a patient is admitted to an ER, sharing relevant information between a primary physician and specialists, sharing radiology images and reports, lab results, and exchange  pharmacy information.

If a system claims support for XDS, the first question to always ask is which of the possible actors is implemented. For example, a system such as a PACS can send information about its documents that are to be shared using XDS, a Vendor Neutral Archive or VNA can archive and manage documents and/or images and have an XDS interface to register it with a regional Health Information Exchange (HIE). A physician can access the HIE to search for relevant documents and pull them from a XDS compliant archive. The actors with corresponding functionality and transactions that are defined include the so-called Document Source, Repository, Registry, Document Consumer, and Patient Identity to provide unique patient identification. It is uncommon for a system to provide all of this information; most vendors use as one or more of these actors. To make sure that there are no gaps, one should map all of the actors using the vendor’s IHE integration profile definitions, which are available from the vendor.

The XDS-I, i.e. Cross Enterprise Document Sharing for Imaging has exactly the same structure, and number of actors. The difference is that the document source is an imaging document source instead and the same applies to the consumer. The transactions are obviously different as well, as we use DICOM transactions to exchange the image documents.

The transactions between the different actors are well defined in the IHE technical framework documents, for the XDS it is the ITI or IT Infrastructure framework and for the radiology it is the RAD or Rapid Application Development  framework. In some cases, there are different options for the transactions, for example, there is a HL7 version 2 and version 3 option for the patient identity feed, which basically translates into a traditional ADT (Admit-Discharge-Transfer) transaction (A01, A04, A05, A08, A40) for V2 or a XML encoded one for V3. Similarly, for the image retrieval one can select the traditional DICOM WADO http URI transaction or the newer SOAP based messaging WADO version.

I like to compare XDS to an engine, which has several components, for example, it has a transmission, cylinders, alternator, etc. The same is true with XDS, it consists of several actors and all are needed to make it work. It is important to validate that all parts are present to make it work. Expanding on the engine analogy, it needs other parts such as a chassis, wheels, steering controls, etc. to make it into a fully functioning device such as a car, truck, or motorcycle. That is where the other ITI profiles play a role, such as security, patient information management, workflow, provider, personnel and content management. These will be discussed in part two. For a more extended coverage of this subject see the video.

HIMSSLA in Sao Paulo: Latin America is catching up.

The exhibition floor was quite busy.

I like the international HIMSS meetings much better than the big USA-based ones. Take for example HIMSSLA, which was held on Sept.18 and 19 in Sao Paulo, Brazil. The attendance was small, probably 500 or so, but the speakers were top notch and the attendees were definitely the local top decision-makers and movers and shakers in industry and government. If nothing else, the hotels are better and less expensive compared to Chicago, for example, and the food is the best (don’t get me started on the excellent Brazilian coffee). Of course it is a little bit further than Chicago, but an eight hour direct international flight is not bad at all and priced not that much more than a domestic flight in the US.

Latin America is definitely catching up, during the conference, HIMSS presented two awards to hospitals that achieved stage 6 status in the HIMSS Analytics EMR adoption model. These hospitals are working on getting to stage seven already, so there is great progress being made with implementing EMR technology.

The Brazilian government in 2011 set requirements for interoperability standards such as IHE XDS, PIX/PDQ and a couple others so there is a big emphasis on interoperability. However, there is still a lot of education and learning to be done about connectivity and there are still hurdles to overcome, but the intention is clearly there and the activity at the HIMSS showed that people are serious about it.

As I mentioned, there were top notch speakers both from the US, such as the executive director of Kaiser Permanente, the CEO of the New York eHealth collaborative, and global director of health from Accenture, but also from Latin America. It is always very motivating to see how these leaders see the future of healthcare evolving and how they implemented healthcare IT to achieve major improvements in quality and patient care while also reducing cost. Of course, there is still a certain amount of crystal ball gazing when thinking about how healthcare delivery might change over the next five to 10 years, but hearing how these leaders see the impact of social media, mobile health and home health is encouraging.

One thing is clear, the care of a patient does not stop when he or she leaves a hospital, rather, it is when it continues by following up with phone calls, emails between physicians and patients, tele-consultations, uploading of personal data such as weight, blood pressure, glucose meter readers, and even pacemaker recordings into Personal Health Records often on a daily basis. That is how re-admissions can be prevented and how real, fundamental improvements can be made in the care of patients.

Several presentations showed evidence of how this clearly worked for them. Many improvements

were also made by being able to mine the data from the EMR and share it back with not only the decision- makers, but more importantly, with the people on the frontlines (physicians, nurses, care coordinators, etc.) so they can see how to make an impact.

Larry Garber from Atrius Health in Massachusetts showed that his organization typically spends $10,700 on patient healthcare costs through EMR implementation and using tools to mine and share the data, compared to the Massachusetts average of $13,000. Similarly, Accountable Care Organizations (ACO’s) in the US have saved $500 million so far, and this is just the beginning. There is still a lot of work to be done but it is clear that investing in healthcare IT pays off when done well and smartly.

In conclusion, I definitely recommend attending one or more of the international conferences, the smaller scale makes it much more effective and less tiresome, and again, the venue’s are great! I know I’ll be in Brazil next year again for sure!