Health Document
Persistent
Complete
Ownership
Legally authenticated
Health Message
Transient
Context may be implied
In flight
Authenticity implied by context
IHE Document Sharing supports documents containing any type of clinical information, for example diagnostic imaging reports, referral reports or health summary reports. This flexibility allows the method of exchanging information to be independent of the type of information being exchanged and is referred to as content neutral or content agnostic. IHE Document Sharing is also flexible in terms of how the clinical information is represented in electronic form. This is called the format of the document. The simplest document format is a text document that contains only the words used to express the clinical information. Another very common format is PDF (Portable Document Format), which adds graphical formatting to the information which can then be consistently displayed by many systems. The preferred formats include more structured information, like the HL7 Clinical Document Architecture (CDA) standard. CDA encodes the clinical information in a standardized way, which allows both computer systems and humans to interpret and act on the clinical content. By contrast, textual and PDF formats require human interpretation in order to understand the content.
IHE and other organizations have profiles that define document content and format for specific, commonly occurring cases. For example, the IHE Laboratory domain has defined a content profile to support sharing laboratory reports. Likewise, the IHE Patient Care Coordination (PCC) domain has defined various content profiles including a Medical Summary content profile and an Emergency Department Referral content profile. In each of these cases, it is useful for IHE to profile (define) both the transport and the content of the documents so that true interoperability can more easily be achieved throughout the healthcare continuum.
Value of Metadata
Another key principle leveraged by IHE Document Sharing is the use of metadata. Metadata are data that provides information about one or more aspects of the document. IHE defines a collection of specific metadata attributes that accompany every document shared through an IHE profile. Example attributes are patient identifier, patient demographics, author, confidentiality, creation time, service time, healthcare facility, and practice setting. The values are collected prior to sending a document and can be used upon receipt of a document to administer and route the document in an appropriate way. By providing a standard set of metadata attributes a receiving system can manage the document without requiring access to the detailed clinical information contained within the document. The metadata aid in the document’s identity, discovery, routing, security, provenance, privacy, authenticity and electronic pre-processing. The set of metadata are defined to facilitate interoperability, so that receiving systems can manage, route and administer documents without having to interpret the contents of the document.
Document Sharing Governance
IHE enables interoperable sharing of documents but assumes this sharing occurs under a document sharing governance structure agreed to by all parties involved. The governance structure addresses all policy issues necessary to enable document sharing – content format and coding, and other operational characteristics. The IHE profiles are designed to be neutral, or agnostic, to governance and policy, while also being designed to support and enforce those governance and policy choices. The governance model may apply only within a small group, such as a hospital and small physician’s office, or may apply at a large level, like an entire nation. In fact, sometimes temporary or informal governance (e.g. via phone call) based on understanding of existing laws or customs is used for exchange among participants. Typically, in order to allow for effective and efficient interactions, the governance structure is formalized through some legal mechanism. Overlapping governance is common, where one set of agreements exist in the region and a different set of agreements exist across the nation, yet most organizations will eventually want to exchange documents regionally, nationally and internationally.
In addition to general governance agreements, a document sharing community should address the following issues:
Format of document content: To enable interoperable transfer of documents the receiving side must understand the format and structure generated by the sending side. Typically there is an agreement on a set of document formats, which must or may be supported. This could include unstructured content like PDF or text documents, or a more structured format like CDA or a specific implementation guide applied to CDA for a particular purpose. The key is to ensure that whatever type of content is shared, the receiving system is able to interpret the content in an appropriate way, either through human review or machine processing.
Coding within documents: Structured documents often include coded data derived from a coding system. Agreeing on which coding systems to use for specific data is often covered by an implementation guide for the structured document. Agreeing to an implementation guide, or a general guideline for coding systems to use, is necessary to ensure that every receiver of the document has the same understanding of its clinical content.
Coding of metadata: Metadata are pieces of information that provide facts about one or more aspects of the document. In the case of IHE-defined document exchange, specific metadata are coded within the structure of the content being exchanged. Some of that metadata have values chosen from a coding system defined by the governance of the sharing community. Because IHE profiles can be applied in many parts of the world where coding systems are different, IHE has not specified which code sets to use and this decision must be made among the systems exchanging documents.
Locating Sharing Partners
One of the challenges of sharing health information is finding the right places to send and search for information. This ability to discover sharing partners can be accomplished in many different ways and a clear preference is not yet apparent. In some environments, a directory or local service is provided which supports a search for electronic locations. This search could be by healthcare provider name, organization name or some other aspect of a healthcare facility that sufficiently identifies the other party for sharing of healthcare information. In some environments, the search for this information may be more difficult, requiring manual means, including phone calls and other actions to determine the appropriate electronic address. More sophisticated mechanisms are appearing which support searching by patient, meaning a search for which electronic partner has information about a particular patient.
IHE provides some building blocks to be applied to these problems. The Healthcare Provider Directory (HPD, http://wiki.ihe.net/index.php?title=Current_Published_ITI_Educational_Materials#Healthcare_Provider_Directories) profile supports a directory of individual and organizational providers. For locating sources of information about a particular patient, IHE supports the Patient Specific Health Data Locator found in the Cross-Community Patient Discovery (XCPD, http://wiki.ihe.net/index.php?title=Current_Published_ITI_Educational_Materials#Cross-Community:_Peer-to-Peer_sharing_of_healthcare_information) specification.
Document Sharing Models
There are several different approaches to organizing systems of health information exchange. IHE enables three common approaches through a set of profiles, which support interoperable exchange of health documents. These approaches, called Document Sharing Models, share the principles outlined above. Because the principles across the models are the same, it is relatively simple to implement more than one model in order to accomplish multiple objectives.
The key actors in health information exchange are:
Document Source Actors – those applications or modules that create the document to be shared.
Document Consumer Actors – those applications or modules that receive or retrieve the document to act on it (i.e., present it to the user, import it into the receiving system, etc.).
The value of the Document Sharing profiles is that they enable effective sharing of data among multiple, disparate systems in a way that minimizes the burden that data sharing imposes on those systems. These profiles may be categorized according to three different data sharing models:
Direct Push – in this model, clinical content in the form of documents and metadata is sent directly to a known recipient, or published on media for delivery. Document Sources send content directly to Document Consumers.
Centralized Discovery and Retrieve – in this model, a centralized locator is used to enable document sharing. Document Sources publish the location of documents to the locator. Document Consumers search the locator to discover document locations and pull a copy of the document.
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