IHE: Making Interoperability Global Is Becoming Big Business
 Integrating the Healthcare Enterprise (IHE) has gone from a small-time operation started a decade ago to a major league player in the healthcare interoperability game, and having very positive effects on patient care. Its reach now extends across 19 countries and addresses communication issues within nine different areas of healthcare. Now, the IHE stamp of compliance is what every medical device company wants.

In today's health IT environment, interoperability is the name of the game. If your systems cannot easily communicate with and integrate with other clinical and IT systems within a healthcare facility, you'll be left out in the cold. The Integrating the Healthcare Enterprise organization came on the scene in 1997 and immediately began tackling interoperability challenges between healthcare information systems, starting with radiology. The goal was to use common and established standards such as HL7 and DICOM, among others, to foster better communications among computer systems in healthcare. This was way before health IT was a buzz word. Years later, with the help of primary sponsors such as the Healthcare Information Management and Systems Society (HIMSS), Radiological Society of North America (RSNA), and American College of Cardiology (ACC), IHE has become a heavy hitter in the industry.

IHE's basic argument is that although standards are plentiful, they are often too broad or narrow depending on the situation, and they are commonly redundant. Thus, IHE functions as a means to sort out the standards and to offer ways for them to be implemented in very specific situations to foster interoperability.

Each year, the embodiments of IHE's efforts are the annual Connectathons — a health IT World Series of sorts — that bring together healthcare technology vendors to showcase their compliance with specific IHE Domain profiles. 1999 saw the inaugural Connectathon. Like IHE itself, the Connectathons — which currently take place in the U.S., Europe, and Asia — have grown and become more elaborate. For example, in 2006 the U.S. event was held in the RSNA headquarters basement in Chicago. Other years it was held in a parking garage. They wouldn't even fit in there now.

Health Imaging & IT visited the 2007 Connectathon in Chicago in January and spoke to Didi Davis, director of IHE for HIMSS, about why the events have so much appeal to vendors. Davis believes the collaborative atmosphere at such events is spurred on because vendors don't want to compete on interoperability; they want to compete on feature functionality.

In all, 80 organizations participated in the 2007 Connectathon, testing the interoperability of more than 160 systems and applications.

IHE's growing prominence has been gradually matched by its expansion to a wider variety of healthcare domains. The first IHE domain was radiology which sprouted in 2002, and now includes 18 of what the organization calls "integration profiles" designed to tackle specific workflow situations. Other domains adopted in recent years include: IT Infrastructure for Healthcare, Cardiology, Laboratory, Radiation Oncology, Patient Care Coordination, Patient Care Devices, and, most recently, Quality.

IHE Domain web resources

Eye Care

IT Infrastructure

Patient Care Coordination
Patient Care Devices




IHE begins its integration profile process in each instance by establishing use cases developed out of feedback from experts in specific fields. Put simply, a use case is an area where workflow could be improved by leveraging existing standards for interoperability to tackle a defined problem. Following this, technical experts are brought in who work for months to find solutions leveraging the standards. In some instances, Davis says, you could use 12 to 15 current standards to facilitate workflow. Technical specifications are developed and then tested at Connectathon events and other demonstrations. Vendors then can market their systems as having IHE compliance.

IHE in the spotlight

IHE's Interoperability Showcase at HIMSS in February in New Orleans was a chance for the organization to shine light on its present and future plans. To do this, IHE illustrated how patients and healthcare records move through scenarios that encompass the continuum of care. Multiple clinical scenarios focusing on clinician and patient information access via personal health records (PHRs) were demonstrated.

Seventy-six organizations participated, 51 of which were commercial vendors, representing an overall increase of six organizations over last year's HIMSS-IHE showcase.

Using a theater theme, attendees were handed a 24-page playbill-style event brochure that provided information regarding all the aspects of the showcase. Each vendor system became a different "cast member" participating in different play-like scenarios. Attendees got the opportunity to see workflows performed with various electronic health records from different vendors. Moreover, registered attendees were given fictional patient identities with demonstration images, referrals, and labs to watch them being fictionally admitted into every vendor system.

The approach was a success. Some 3,600 to 3,800 people took part in the play, including more than 700 virtual patient registrations. This included some big names within the healthcare IT world, with top representatives from the Office of the National Health Information Technology Coordinator (ONC) such as Robert M. Kolodner, MD, national coordinator, and John W. Loonsk, MD director, Office of Interoperability and Standards, as well as Tennessee Governor Phil Bredesen, chair of the National Governor's Association eHealth Initiative. In all, congressional leaders from 10 states toured the showcase demonstration.

A major outcome of the showcase was to successfully demonstrate communication within and among Regional Health Information Organizations (RHIOs). According to Davis, the demonstration simulated three RHIOs. We believe it is the largest multi-vendor prototype ever built. We had 51 system vendors linked together, sharing data seamlessly across enterprises, hospitals, and physician offices."

The prototype, made possible with multiple infrastructure vendors, involved three simulated communities with distinct configurations: 
  • Community Network A: 13 edge and three infrastructure systems;
  • Community Network B: 18 edge and four infrastructure systemsw; and
  • Community Network C: A security patient consent-based RHIO comprised of five edge systems and four infrastructure systems.
The security component within RHIO Community C was indicative of IHE's attempt to demonstrate secure information exchanges. "This year, every vendor in the booth had to adhere to the secured health information exchange," says Davis. This was the first IHE demonstration in which IHE security profiles were mandatory. The vendor systems had to demonstrate logging, authentication, and digital certificate exchange.

IHE also highlighted exploratory areas of integration in its "New Directions" groups, with participation of Bio-Pharma companies in the Life Sciences realm focused on clinical trials and biosurveillance initiatives. "HIMSS in general has never had pharmaceutical companies come to the shows and IHE in general has never had pharma companies participate, so this was a huge growth area for us," says Davis.

Other first-time participants included CAQH (Council for Affordable Quality Healthcare) which demonstrated interoperability processes similar to IHE's for financial and administrative transactions.

IHE also emphasized its support for the ELINCS (EHR-Lab Interoperability and Connectivity Standards) for lab interchange. "ELINCS asked IHE and HL7 to support the ELINCS specification going forward so we'll be working with them," says Davis. ELINCS is one of the specifications that the Health Information Technology Standards Panel (HITSP) leveraged in their Electronic Health Record Interoperability Specification.

Another area of the sprawling showcase demonstrated clinical data exchange among patient care devices (PCDs). Six patient-care vendors showcased seven devices at the event, showing the ability to pull data directly from a patient care device in acute-care settings. In future years, the demonstration will expand to include PCDs in other settings, as well.

Mastering the domains

IHE currently encompasses eight active healthcare domains: Cardiology (seven profiles), Eye Care (three), IT Infrastructure (17), Laboratory (six), Patient Care Coordination (five), Patient Care Devices (one), Radiology (18) and Radiation Oncology (one). Each of these domains has published a Technical Framework containing IHE Profiles — essentially guidelines for implementing established standards to address critical clinical use cases. More than 200 organizations worldwide have participated in the development and implementation of these profiles, Davis says.

The 10th and most recent, a domain addressing issues related to Quality, held its kickoff meeting in April. The initial work product under development is to define standard mechanisms for sharing guidelines in cardiac care.

"What we are doing in the Quality domain is not creating the guidelines themselves. We are going to leverage Quality guidelines that have already been created," says Davis. IHE will "create an infrastructure to disseminate these Quality guidelines into the clinical workflow and capture data for quality reporting as a feedback loop to assess if the guidelines are appropriate."

The first Cardiac Quality profile will be introduced by July.

Overall, the Quality domain will look to identify the discrete data elements that are needed for quality reporting so that an EHR can capture quality data and export it for reporting, says Davis.

Meanwhile, each of the eight other domains will introduce at least one new profile this year. Most of the well-established domains usually publish three or four profiles a year. The exception this year will be Radiology which will focus on extending the usage of existing profiles — although look for at least one (maybe two) new Radiology profiles before year's end. This is very good news. It means that the Radiology domain has cleared many of the known interoperability hurdles and can now go back and improve what already exists.

Newly introduced last year, the PCDs domain successfully introduced one profile last year which have been adopted by numerous vendors. Overall, IHE feels that patient device interoperability is an area the organization can really assist with. The next push will be "targeting more of the acute care setting, not just the ICU and the OR, but the devices across the hospitals," as well as possibly venturing into devices for long-term care, Davis says.

Patient Care Coordination will be looking at some of the additional patient care requirements from a personal healthcare perspective. For instance, IHE will address what kind of data healthcare providers need to capture from a PHR perspective. This will involve using the HITSP-recommended CCD (Continuity of Care Document) standard, which is a mapping of the CCR (Continuity of Care Record) and CDA (Clinical Document Architecture).

The Infrastructure domain is looking at ways to improve communication between RHIOs, thus a profile for cross-RHIO communication also will be unveiled later this year.

Making a business out of it

Because of IHE's increasing size, and the demands and costs of trying to facilitate the growth of all of its initiatives globally, the organization this year hopes to incorporate itself. The IHE Strategic Development Committee, which includes representatives from each of the IHE domains and each national and regional development group, recently unanimously approved an updated set of governance principles. Their approval is a step toward legal incorporation.

The education efforts, Connectathons, and other demonstrations are all deployment activities that are done differently in each country. For example, Europe has its own Connectathon as does Asia, even though each uses the same tools. Ten domains and all of the test tools that come with it get to be very costly to maintain. The hope is that through a more formal structure, IHE will have access to more resources, financial or otherwise, to help keep up with the growth.

Knowing the ropes
Curious to know more about the history of IHE, what it can offer you, how it works, and how to get started, or the nitty gritty regarding Technical Framework or integration statements? Visit ihe.net/About/ihe_faq.cfm

On the horizon
JUNE 11-13, 2007  IHE Workshop 2007: Changing the Way Healthcare Connects
Doubletree Hotel, Oak Brook, Ill.

This workshop focuses on user/provider training.  Education will be presented in the form of roundtable discussions led by RHIO architects in current IHE deployments. Days two and three will focus on vendor education regarding the new profiles coming this year and an overview for any vendors new to IHE. Key presentations: HITSP, IHE and the National Health Information Infrastructure; IHE and the NHIN/RHIO roundtable; and Developments in the IHE Clinical and Operational Domains.

AUGUST  IHE will issue an open call for participants in the 2008 Connectathon.