Integrating the Healthcare Enterprise5

IHE IT Infrastructure (ITI)
Technical Framework
10

Volume 1(ITI TF-1)
Integration Profiles

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Revision 9.0 – Final Text
August 31, 201220

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IHE IT Infrastructure Technical Framework, Volume 1 (ITI TF-1): Integration Profiles______________________________________________________________________________CONTENTS
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1

1.1 OVERVIEW OF THE TECHNICAL FRAMEWORK .................................................................................................. 8
1.2 OVERVIEW OF THE IT INFRASTRUCTURE VOLUME 1 ........................................................................................ 9
1.3 AUDIENCE ........................................................................................................................................................ 9
1.4 RELATIONSHIP TO STANDARDS ...................................................................................................................... 10
1.5 RELATIONSHIP TO REAL-WORLD ARCHITECTURES ........................................................................................ 10
1.6 CONVENTIONS ............................................................................................................................................... 11
1.6.1
IHE Actor and Transaction Diagrams and Tables .............................................................................. 11
1.6.2
Process Flow Diagrams ...................................................................................................................... 11
1.6.3
Technical Framework Cross-references .............................................................................................. 12
1.7 SCOPE OF CHANGES INTRODUCED IN THE CURRENT YEAR ............................................................................ 12
1.8 SECURITY IMPLICATIONS ............................................................................................................................... 15
1.9 COMMENTS .................................................................................................................................................... 15
1.10
COPYRIGHT PERMISSION ........................................................................................................................... 16
1.11
IHE TECHNICAL FRAMEWORK DEVELOPMENT AND MAINTENANCE PROCESS .......................................... 16

30

35

40

2

IT INFRASTRUCTURE INTEGRATION PROFILES............................................................................... 17
2.1 DEPENDENCIES AMONG INTEGRATION PROFILES ........................................................................................... 17
2.2 INTEGRATION PROFILES OVERVIEW............................................................................................................... 20
2.2.1
This section is reserved. ....................................................................................................................... 20
2.2.2This section is reserved. ....................................................................................................................... 20
2.2.3
Retrieve Information for Display (RID) ............................................................................................... 20
2.2.4
Enterprise User Authentication (EUA) ................................................................................................ 20
2.2.5
Patient Identifier Cross-referencing (PIX) .......................................................................................... 21
2.2.6
Patient Synchronized Applications (PSA)............................................................................................ 21
2.2.7
Consistent Time (CT) ........................................................................................................................... 21
2.2.8
Patient Demographics Query (PDQ) .................................................................................................. 21
2.2.9
Audit Trail and Node Authentication (ATNA) ..................................................................................... 21
2.2.10
Cross-Enterprise Document Sharing (XDS) ................................................................................... 22
2.2.11
Personnel White Pages (PWP) ....................................................................................................... 22
2.2.12This section is reserved for Notification of Document Availability (NAV) ..................................... 22
2.2.13
Cross Enterprise User Assertion (XUA) ......................................................................................... 22
2.2.14
Patient Administration Management (PAM) .................................................................................. 23
2.2.15
Cross-Enterprise Document Reliable Interchange (XDR) .............................................................. 23
2.2.16
Cross-Enterprise Document Media Interchange (XDM) ................................................................ 23
2.2.17Retrieve Form for Data Capture (RFD) ......................................................................................... 23
2.2.18Cross-Community Access (XCA) .................................................................................................... 23
2.2.19Basic Patient Privacy Consents (BPPC)......................................................................................... 24
2.2.20
Scanned Documents Integration Profile (XDS-SD) ........................................................................ 24
2.2.21This section is reserved. .................................................................................................................. 24
2.2.22This section is reserved. .................................................................................................................. 24
2.2.23
Patient Identifier Cross-referencing HL7 V3 (PIXV3) ................................................................... 24
2.2.24
Patient Demographics Query HL7 V3 (PDQV3) ............................................................................ 24
2.2.25Multi-Patient Queries (MPQ) ......................................................................................................... 25
2.3 PRODUCT IMPLEMENTATIONS ........................................................................................................................ 26

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INTRODUCTION.............................................................................................................................................. 8

RETRIEVE INFORMATION FOR DISPLAY (RID) ................................................................................. 27
3.1
3.2

ACTORS/ TRANSACTIONS ............................................................................................................................... 28
RETRIEVE INFORMATION FOR DISPLAY INTEGRATION PROFILE OPTIONS ...................................................... 29______________________________________________________________________________
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3.3
4

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6

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CONSISTENT TIME (CT) ............................................................................................................................. 57
7.1
7.2
7.3

8

ACTORS/ TRANSACTIONS ............................................................................................................................... 57
CONSISTENT TIME INTEGRATION OPTIONS .................................................................................................... 58
CONSISTENT TIME PROCESS FLOW ................................................................................................................ 58

PATIENT DEMOGRAPHICS QUERY (PDQ) ............................................................................................ 59
8.1 ACTORS/ TRANSACTIONS ............................................................................................................................... 59
8.2 PATIENT DEMOGRAPHICS QUERY INTEGRATION PROFILE OPTIONS ............................................................... 60
8.2.2
Pediatric Demographics ...................................................................................................................... 60
8.3 PATIENT DEMOGRAPHICS QUERY PROCESS FLOW ......................................................................................... 61
8.3.1
Combined Use of PDQ with Other IHE Workflow Profiles ................................................................. 63
8.3.2
Supplier Data Configuration ............................................................................................................... 63

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PATIENT SYNCHRONIZED APPLICATIONS (PSA) .............................................................................. 53
6.1 ACTORS/ TRANSACTIONS ............................................................................................................................... 53
6.2 PATIENT SYNCHRONIZED APPLICATIONS INTEGRATION PROFILE OPTIONS.................................................... 54
6.3 PATIENT SYNCHRONIZED APPLICATIONS INTEGRATION PROFILE PROCESS FLOWS ....................................... 54
6.3.1
Use Case: Simple Patient Switching .................................................................................................... 547110

PATIENT IDENTIFIER CROSS-REFERENCING (PIX) .......................................................................... 42
5.1 ACTORS/ TRANSACTIONS ............................................................................................................................... 44
5.2 PATIENT IDENTIFIER CROSS-REFERENCING INTEGRATION PROFILE OPTIONS ................................................ 45
5.2.1
Pediatric Demographics ...................................................................................................................... 45
5.3 PATIENT IDENTIFIER CROSS-REFERENCING PROFILE PROCESS FLOWS ........................................................... 47
5.3.1
Use Case: Multiple Identifier Domains within a Single Facility/ Enterprise ...................................... 47
5.3.2
Use Case: Multiple ID Domains Across Cooperating Enterprises ..................................................... 48
5.3.3 Pediatric Demographic Option Use Cases .............................................................................................. 50
5.4 RELATIONSHIP BETWEEN THE PIX INTEGRATION PROFILE AND EMPI ........................................................... 51

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ENTERPRISE USER AUTHENTICATION (EUA) .................................................................................... 34
4.1 ACTORS/ TRANSACTIONS ............................................................................................................................... 34
4.2 ENTERPRISE USER AUTHENTICATION INTEGRATION PROFILE OPTIONS ......................................................... 36
4.3 ENTERPRISE USER AUTHENTICATION PROFILE PROCESS FLOW ..................................................................... 36
4.3.1
Basic User Authentication Process Flow ............................................................................................ 36
4.3.2
User Authentication with User Synchronized Applications Process Flow .......................................... 38
4.3.3
Fast User Switching with Multiple Applications Process Flow........................................................... 39

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RETRIEVE INFORMATION FOR DISPLAY PROCESS FLOW ................................................................................ 30

9

AUDIT TRAIL AND NODE AUTHENTICATION (ATNA) ...................................................................... 64
9.1 AUTHENTICATION .......................................................................................................................................... 65
9.1.1
User Authentication ............................................................................................................................. 65
9.1.2
Connection Authentication .................................................................................................................. 65
9.2 AUDIT TRAILS ................................................................................................................................................ 66
9.2.1
Audit Messages .................................................................................................................................... 67
9.2.2
Backwards Compatibility..................................................................................................................... 69
9.3 AUDIT TRAIL TRANSPORT .............................................................................................................................. 69
9.4 ACTORS/TRANSACTIONS ................................................................................................................................ 69
9.5 ATNA INTEGRATION PROFILE OPTIONS ........................................................................................................ 71
9.5.1
ATNA Encryption Option (retired) ...................................................................................................... 72
9.5.2
Radiology Audit Trail Option .............................................................................................................. 72
9.6 AUDIT TRAIL AND NODE AUTHENTICATION PROCESS FLOW ......................................................................... 72
9.6.1
Normal Node Process Flow ................................................................................................................. 72______________________________________________________________________________
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Unauthorized Node Process Flow ....................................................................................................... 75
9.6.2
9.6.3
Unauthorized User Process Flow ........................................................................................................ 76
9.7 RELATIONSHIP BETWEEN SECURE NODE, SECURE APPLICATION, AND OTHER ACTORS ................................. 76

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CROSS-ENTERPRISE DOCUMENT SHARING (XDS.B) ........................................................................ 78
10.1
ACTORS/TRANSACTIONS ........................................................................................................................... 80
10.1.1
Actors .............................................................................................................................................. 81
10.1.2
Transactions.................................................................................................................................... 82
10.1.3
XDS Document Contents Support ................................................................................................... 83
10.2
INTEGRATION PROFILE OPTIONS ............................................................................................................... 85
10.2.1Document Replacement Option. ..................................................................................................... 86
10.2.2Document Addendum Option .......................................................................................................... 86
10.2.3Document Transformation Option .................................................................................................. 86
10.2.4
Folder Management Option ............................................................................................................ 86
10.2.5 Asynchronous Web Services Exchange Option ....................................................................................... 86
10.3
INTEGRATION PROFILE PROCESS FLOW..................................................................................................... 87
10.4
GENERAL PRINCIPLES ............................................................................................................................... 92
10.4.1
EDR-CR Concept ............................................................................................................................ 92
10.4.2XDS Document Concept ................................................................................................................. 93
10.4.3
Submission Request......................................................................................................................... 94
10.4.4
Submission Set Concept .................................................................................................................. 94
10.4.5
Concept of Folder ........................................................................................................................... 95
10.4.6
Example of use of Submission Request, Submission Set and Folder............................................... 95
10.4.7XDS Registry Data Model and Attributes ....................................................................................... 97
10.4.8
Concept of an XDS Affinity Domain ............................................................................................... 99
10.4.9
Patient Identification Management ............................................................................................... 100
10.4.10
Document Lifecycle....................................................................................................................... 101
10.4.11
Document Query ........................................................................................................................... 103
10.5
IMPLEMENTATION STRATEGIES ............................................................................................................... 103
10.6
PATIENT IDENTIFIER COMMUNICATION REQUIREMENTS ......................................................................... 105
10.7
SECURITY CONSIDERATIONS ................................................................................................................... 106
10.7.1
Use of ATNA to address Basic Security ........................................................................................ 107
10.8
INTENTIONALLY LEFT BLANK ................................................................................................................. 108

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PERSONNEL WHITE PAGES (PWP) ....................................................................................................... 109
11.1
11.2
11.3

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ACTORS/ TRANSACTIONS ........................................................................................................................ 109
PWP INTEGRATION PROFILE OPTIONS .................................................................................................... 110
PWP INTEGRATION PROFILE PROCESS FLOW .......................................................................................... 110

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THIS IS RESERVED FOR NOTIFICATION OF DOCUMENT AVAILABILITY (NAV) .................. 112

13

CROSS ENTERPRISE USER ASSERTION (XUA) INTEGRATION PROFILE .................................. 113
13.1 USE CASES..................................................................................................................................................... 114
13.2 XUA DEVELOPMENT ..................................................................................................................................... 115
13.4 ACTORS/TRANSACTION ................................................................................................................................. 116
13.5 OPTIONS ........................................................................................................................................................ 118
13.6 GROUPING ..................................................................................................................................................... 118
13.6.1 Audit Trail and Node Authentication (ATNA) ....................................................................................... 118
13.6.2 Cross-Enterprise Document Sharing (XDS) ......................................................................................... 118
13.6.3 Enterprise User Authentication (EUA) ................................................................................................. 118
13.6.4 Any Web-Services Transaction that leverages ITI TF-2x: Appendix V ................................................. 119
13.7 PROCESS FLOW .............................................................................................................................................. 119
13.8 SECURITY CONSIDERATIONS.......................................................................................................................... 120______________________________________________________________________________
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14.1
PATIENT ADMINISTRATION MANAGEMENT USE CASES .......................................................................... 121
14.2
PATIENT IDENTITY MANAGEMENT USE CASE ......................................................................................... 121
14.2.1
Patient Encounter Management Use Case ................................................................................... 121
14.2.2
Actors/ Transactions ..................................................................................................................... 122
14.3
PATIENT ADMINISTRATION MANAGEMENT INTEGRATION PROFILE OPTIONS ......................................... 123
14.3.1
Merge Option ................................................................................................................................ 124
14.3.2
Link / Unlink Option ..................................................................................................................... 124
14.3.3Inpatient / Outpatient Encounter Management Option................................................................. 124
14.3.4
Pending Event Management Option ............................................................................................. 124
14.3.5
Advanced Encounter Management Option ................................................................................... 124
14.3.6
Temporary Patient Transfer Tracking Option .............................................................................. 125
14.3.7
Historic Movement Option ............................................................................................................ 125
14.4
PATIENT ADMINISTRATION MANAGEMENT INTEGRATION PROFILE ACTOR GROUPING .......................... 125
14.4.1
Actor Grouping of Patient Encounter Supplier ............................................................................ 125
14.4.2
Actor Grouping with other IHE Actors ......................................................................................... 126
14.5
PATIENT ADMINISTRATION MANAGEMENT PROCESS FLOW.................................................................... 126
14.5.1
Patient Identity Management ........................................................................................................ 126
14.5.2
Patient Encounter Management.................................................................................................... 128

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CROSS-ENTERPRISE DOCUMENT MEDIA INTERCHANGE (XDM) INTEGRATION PROFILE
138
16.1
ACTORS/ TRANSACTIONS ........................................................................................................................ 138
16.2
XDM INTEGRATION PROFILE OPTIONS ................................................................................................... 139
16.2.1
USB Option ................................................................................................................................... 140
16.2.2
CD-R Option ................................................................................................................................. 140
16.2.3ZIP over Email .............................................................................................................................. 140
16.2.4
ZIP over Email Response .............................................................................................................. 140
16.3
XDM PROCESS FLOW ............................................................................................................................. 140
16.4
DIGITAL COMMUNICATION ...................................................................................................................... 142
16.4.1
Actual Media Type ........................................................................................................................ 142
16.4.2
Virtual Media over a Network ...................................................................................................... 142
16.4.3
Media Content............................................................................................................................... 142
16.5
SECURITY CONSIDERATIONS ................................................................................................................... 143

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XDR INTEGRATION PROFILE ................................................................................................................ 135
15.1 ACTORS/ TRANSACTIONS ............................................................................................................................... 135
15.2 XDR INTEGRATION PROFILE OPTIONS .......................................................................................................... 136
15.2.1 Intentionally Left Blank......................................................................................................................... 136
15.2.2 Basic Patient Privacy Enforcement Option .......................................................................................... 136
15.3 XDR PROCESS FLOW ..................................................................................................................................... 136
15.4 DIGITAL COMMUNICATION ............................................................................................................................ 137
15.5 SECURITY CONSIDERATIONS.......................................................................................................................... 137

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PATIENT ADMINISTRATION MANAGEMENT (PAM) INTEGRATION PROFILE....................... 121

RETRIEVE FORM FOR DATA CAPTURE (RFD) PROFILE ............................................................... 144
17.1 USE CASES..................................................................................................................................................... 145
17.1.1 Investigational New Drug Clinical Trial Use Case .............................................................................. 145
17.1.2 Public Health Reporting Use Cases ...................................................................................................... 147
17.1.3 Pharmaco-vigilance Scenario .............................................................................................................. 148
17.1.4 Cardiology Research Use Cases .......................................................................................................... 149
17.1.5 Radiology Use Case – Clinical Impact Registry .................................................................................. 151
17.1.6 Data Clarification ................................................................................................................................ 151
17.2 ACTORS/ TRANSACTIONS ............................................................................................................................... 153______________________________________________________________________________
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17.2.1 Actors .................................................................................................................................................... 154
17.2.2 Transactions.......................................................................................................................................... 154
17.3 RETRIEVE FORM FOR DATA CAPTURE INTEGRATION PROFILE OPTIONS ........................................................ 155
17.3.1 Archive Form Option ............................................................................................................................ 155
17.3.2 Data Clarifications Option ................................................................................................................... 155
17.3.3 XForms Option...................................................................................................................................... 155
17.4 RETRIEVE FORMS FOR DATA CAPTURE PROCESS FLOW ................................................................................ 156
17.5 SECURITY CONSIDERATIONS.......................................................................................................................... 160
17.5.1 RFD Risk analysis Risk Assessment ...................................................................................................... 160
17.5.2 Recommendations ................................................................................................................................. 161

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18.1 ACTORS/ TRANSACTIONS ............................................................................................................................... 163
18.2 XCA INTEGRATION PROFILE OPTIONS .......................................................................................................... 164
18.2.1 XDS Affinity Domain Option................................................................................................................. 164
18.2.2 Asynchronous Web Services Exchange Option ..................................................................................... 165
18.2.3 Grouping Rules ..................................................................................................................................... 165
18.3 XCA PROCESS FLOW ..................................................................................................................................... 167
18.3.1 Use Cases .............................................................................................................................................. 167
18.3.2 homeCommunityId defined.................................................................................................................... 167
18.3.3 Detailed Interactions............................................................................................................................. 168
18.4 XCA SECURITY CONSIDERATIONS ................................................................................................................ 172
18.4.1 XCA Risk Assessment ............................................................................................................................ 172
18.4.2 Requirements/Recommendations .......................................................................................................... 172
18.4.3 Policy Choices ...................................................................................................................................... 173

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CROSS-COMMUNITY ACCESS (XCA) INTEGRATION PROFILE ................................................... 163

BASIC PATIENT PRIVACY CONSENTS INTEGRATION PROFILE................................................. 174
19.1
BASIC PATIENT PRIVACY CONSENT USE-CASES ..................................................................................... 175
19.1.1
Implied Consent vs. Explicit Consent ........................................................................................... 175
19.1.2
Wet Signature................................................................................................................................ 176
19.1.3
Advanced Patient Privacy Consents ............................................................................................. 177
19.2
CREATING PATIENT PRIVACY POLICIES .................................................................................................. 178
19.2.1
Summary of the creation and publication of the policies .............................................................. 179
19.3
ACTORS/TRANSACTIONS ......................................................................................................................... 179
19.3.1
Grouping ....................................................................................................................................... 180
19.4
BASIC PATIENT PRIVACY CONSENT PROFILE OPTIONS ........................................................................... 181
19.4.1
Intentionally Left Blank................................................................................................................. 181
19.4.2
Intentionally Left Blank................................................................................................................. 181
19.4.3
Basic Patient Privacy Acknowledgement Option .......................................................................... 181
19.4.4
Basic Patient Privacy Acknowledgement with Scanned Document Option .................................. 181
19.4.5
Patient Privacy Acknowledgement View Option........................................................................... 182
19.5
INTENTIONALLY LEFT BLANK ................................................................................................................. 182
19.6
BPPC PROCESS FLOW IN AN XDS AFFINITY DOMAIN ............................................................................ 182
19.6.1
Checking for a patient’s acknowledgement of a privacy policy .................................................... 182
19.6.2
Recording a patient’s acknowledgement of a privacy policy ........................................................ 182
19.6.3Publishing documents against a consent policy............................................................................ 182
19.6.4Using published documents .......................................................................................................... 183
19.7
SECURITY CONSIDERATIONS ................................................................................................................... 183

20 CROSS-ENTERPRISE SHARING OF SCANNED DOCUMENTS CONTENT INTEGRATIONPROFILE ................................................................................................................................................................. 185
20.1
USE CASES .............................................................................................................................................. 185
20.1.1
Content Use Cases ........................................................................................................................ 185______________________________________________________________________________
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Content Creator Use Cases .......................................................................................................... 186
20.1.2
20.1.3
Content Consumer Use Cases ....................................................................................................... 187
20.2
ACTORS/ TRANSACTIONS ........................................................................................................................ 187
20.3
SCANNED DOCUMENTS CONTENT INTEGRATION PROFILE OPTIONS........................................................ 188
20.4
SCANNED DOCUMENTS BINDINGS TO XDS, XDR, XDM ........................................................................ 188
20.5
SCANNED DOCUMENTS CONTENT PROCESS FLOW .................................................................................. 189

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RESERVED .................................................................................................................................................... 190

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DOCUMENT-BASED REFERRAL REQUEST INTEGRATION PROFILE (DRR) ............................ 191

23

PATIENT IDENTIFIER CROSS-REFERENCING HL7 V3 (PIXV3) .................................................... 192
23.1 ACTORS/TRANSACTIONS ............................................................................................................................... 192
23.2 PATIENT IDENTIFIER CROSS-REFERENCING HL7 V3 INTEGRATION PROFILE OPTIONS .................................. 194
23.2.1
Pediatric Demographics ............................................................................................................... 194
23.3 PATIENT IDENTIFIER CROSS-REFERENCING HL7 V3 INTEGRATION PROFILE PROCESS FLOWS ...................... 195
23.4 RELATIONSHIP BETWEEN THE PIXV3 INTEGRATION PROFILE AND EMPI ...................................................... 195
23.5 PATIENT IDENTIFIER COMMUNICATION REQUIREMENT ................................................................................. 195
23.6 SECURITY CONSIDERATIONS.......................................................................................................................... 196

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PATIENT DEMOGRAPHICS QUERY HL7 V3 (PDQV3)....................................................................... 197
24.1 ACTORS/TRANSACTIONS ............................................................................................................................... 197
24.2 PATIENT DEMOGRAPHICS QUERY HL7 V3 INTEGRATION PROFILE OPTIONS ................................................. 197
24.2.1
Continuation ................................................................................................................................. 198
24.2.2
Pediatric Demographics Option ................................................................................................... 198
24.3 PATIENT DEMOGRAPHICS QUERY HL7 V3 PROCESS FLOW ........................................................................... 199
24.3.1 Combined Use of PDQV3 with other IHE Workflow Profiles .............................................................. 199
24.3.2 Supplier Data Configuration................................................................................................................. 199
24.4 INTENTIONALLY LEFT BLANK ........................................................................................................................ 200
24.5 SECURITY CONSIDERATIONS.......................................................................................................................... 200

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MULTI-PATIENT QUERIES (MPQ) ......................................................................................................... 201
25.1 ACTORS/ TRANSACTIONS ............................................................................................................................... 201
25.2 MULTI-PATIENT QUERY INTEGRATION PROFILE OPTIONS .............................................................................. 202
25.2.2 Asynchronous Web Services Exchange Option ...................................................................................... 202
25.3 MPQ PROCESS FLOW .................................................................................................................................... 203
25.4 USE CASES..................................................................................................................................................... 203
25.4.1 Multi-Patient Query used in Public Health........................................................................................... 203
25.4.2 Technical Use Cases ............................................................................................................................. 205
25.5 SECURITY CONSIDERATIONS.......................................................................................................................... 205

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RESERVED .................................................................................................................................................... 207

GLOSSARY ............................................................................................................................................................. 250

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1 Introduction

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Integrating the Healthcare Enterprise (IHE) is an initiative designed to stimulate the integrationof the information systems that support modern healthcare institutions. Its fundamental objective
is to ensure that in the care of patients all required information for medical decisions is bothcorrect and available to healthcare professionals. The IHE initiative is both a process and aforum for encouraging integration efforts. It defines a technical framework for the
implementation of established messaging standards to achieve specific clinical goals. It includes
a rigorous testing process for the implementation of this framework. And it organizes
educational sessions and exhibits at major meetings of medical professionals to demonstrate thebenefits of this framework and encourage its adoption by industry and users.
The approach employed in the IHE initiative is to support the use of existing standards, e.g.,
HL7, ASTM, DICOM, ISO, IETF, OASIS and others as appropriate, rather than to define newstandards. IHE profiles further constrain configuration choices where necessary in thesestandards to ensure that they can be used in their respective domains in an integrated manner
between different actors. When clarifications or extensions to existing standards are necessary,
IHE refers recommendations to the relevant standards bodies.
This initiative has numerous sponsors and supporting organizations in different medical specialty
domains and geographical regions. In North America the primary sponsors are the Healthcare
Information and Management Systems Society (HIMSS) and the Radiological Society of North
America (RSNA). IHE Canada has also been formed. IHE Europe (IHE-EUR) is supported by alarge coalition of organizations including the European Association of Radiology (EAR) andEuropean Congress of Radiologists (ECR), the Coordination Committee of the Radiological andElectromedical Industries (COCIR), Deutsche Röntgengesellschaft (DRG), the EuroPACS
Association, Groupement pour la Modernisation du Système d'Information Hospitalier(GMSIH), Société Francaise de Radiologie (SFR), Società Italiana di Radiologia Medica(SIRM), and the European Institute for health Records (EuroRec). In Japan IHE-J is sponsoredby the Ministry of Economy, Trade, and Industry (METI); the Ministry of Health, Labor, andWelfare; and MEDIS-DC; cooperating organizations include the Japan Industries Association ofRadiological Systems (JIRA), the Japan Association of Healthcare Information Systems Industry(JAHIS), Japan Radiological Society (JRS), Japan Society of Radiological Technology (JSRT),
and the Japan Association of Medical Informatics (JAMI). Other organizations representing
healthcare professionals are invited to join in the expansion of the IHE process acrossdisciplinary and geographic boundaries.

1.1 Overview of the Technical Framework
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This document, the IHE IT Infrastructure Technical Framework (ITI TF), defines specificimplementations of established standards to achieve integration goals that promote appropriate
sharing of medical information to support optimal patient care. It is expanded annually, after aperiod of public review, and maintained regularly through the identification and correction oferrata. The current version, Revision 9.0 for Final Text, specifies the IHE transactions defined______________________________________________________________________________
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and implemented as of August 2012. The latest version of the document is always available via
the Internet at http://www.ihe.net/Technical_Framework.
The IHE IT Infrastructure Technical Framework identifies a subset of the functional componentsof the healthcare enterprise, called IHE actors, and specifies their interactions in terms of a set ofcoordinated, standards-based transactions. It describes this body of transactions in progressively
greater depth. The present volume (ITI TF-1) provides a high-level view of IHE functionality,
showing the transactions organized into functional units called integration profiles that highlighttheir capacity to address specific IT Infrastructure requirements.
Volumes 2a, 2b, and 2x of the IT Infrastructure Technical Framework provide detailed technicaldescriptions of each IHE transaction used in the IT Infrastructure Integration Profiles. Volume 3
contains content specification and specifications used by multiple transactions. These volumes
are consistent and can be used in conjunction with the Integration Profiles of other IHE domains.
The other domains within the IHE initiative also produce Technical Frameworks within theirrespective areas that together form the IHE Technical Framework. For example, the following
IHE Technical Framework(s) are some of those which are available:• IHE IT Infrastructure Technical Framework• IHE Cardiology Technical Framework• IHE Laboratory Technical Framework• IHE Patient Care Coordination Technical Framework• IHE Radiology Technical Framework
Where applicable, references are made to other technical frameworks. For the conventions onreferencing other frameworks, see ITI TF-1: 1.6.3.

1.2 Overview of the IT Infrastructure Volume 1
370

The remainder of Section 1 further describes the general nature, purpose and function of theTechnical Framework. Section 2 introduces the concept of IHE Integration Profiles that make up
the Technical Framework.
Section 3 and the subsequent sections of this volume provide detailed documentation on each
integration profile, including the IT Infrastructure problem it is intended to address and the IHE
actors and transactions it comprises.

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The appendices following the main body of the document provide a summary list of the actors
and transactions, detailed discussion of specific issues related to the integration profiles and aglossary of terms and acronyms used.

1.3 Audience

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The intended audience of this document is:• IT departments of healthcare institutions• Technical staff of vendors participating in the IHE initiative______________________________________________________________________________
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Experts involved in standards development
Those interested in integrating healthcare information systems and workflows

1.4 Relationship to Standards
385

The IHE Technical Framework identifies functional components of a distributed healthcare
environment (referred to as IHE actors), solely from the point of view of their interactions in thehealthcare enterprise. At its current level of development, it defines a coordinated set oftransactions based on ASTM, DICOM, HL7, IETF, ISO, OASIS and W3C standards. As thescope of the IHE initiative expands, transactions based on other standards may be included as
required.

390

In some cases, IHE recommends selection of specific options supported by these standards;
however, IHE does not introduce technical choices that contradict conformance to thesestandards. If errors in or extensions to existing standards are identified, IHE’s policy is to reportthem to the appropriate standards bodies for resolution within their conformance and standards
evolution strategy.

395

IHE is therefore an implementation framework, not a standard. Conformance claims for products
must still be made in direct reference to specific standards. In addition, vendors who have
implemented IHE integration capabilities in their products may publish IHE Integration
Statements to communicate their products’ capabilities. Vendors publishing IHE Integration
Statements accept full responsibility for their content. By comparing the IHE Integration
Statements from different products, a user familiar with the IHE concepts of actors andintegration profiles can determine the level of integration between them. See ITI TF-1: Appendix
C for the format of IHE Integration Statements.

400

1.5 Relationship to Real-world Architectures
405

410

415

The IHE actors and transactions described in the IHE Technical Framework are abstractions of
the real-world healthcare information system environment. While some of the transactions are
traditionally performed by specific product categories (e.g., HIS, Clinical Data Repository,
Radiology Information Systems, Clinical Information Systems or Cardiology Information
Systems), the IHE Technical Framework intentionally avoids associating functions or actors withsuch product categories. For each actor, the IHE Technical Framework defines only thosefunctions associated with integrating information systems. The IHE definition of an actor should
therefore not be taken as the complete definition of any product that might implement it, norshould the framework itself be taken to comprehensively describe the architecture of a healthcare
information system.
The reason for defining actors and transactions is to provide a basis for defining the interactions
among functional components of the healthcare information system environment. In situations
where a single physical product implements multiple functions, only the interfaces between the
product and external functions in the environment are considered to be significant by the IHE
initiative. Therefore, the IHE initiative takes no position as to the relative merits of an integrated
environment based on a single, all-encompassing information system versus one based on______________________________________________________________________________
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420

multiple systems that together achieve the same end. IHE demonstrations emphasize theintegration of multiple vendors’ systems based on the IHE Technical Framework.

1.6 Conventions
425

This document has adopted the following conventions for representing the framework concepts
and specifying how the standards upon which the IHE Technical Framework is based should beapplied.
1.6.1 IHE Actor and Transaction Diagrams and Tables

430

Each integration profile is a representation of a real-world capability that is supported by a set ofactors that interact through transactions. Actors are information systems or components of
information systems that produce, manage, or act on categories of information required byoperational activities in the enterprise. Transactions are interactions between actors that
communicate the required information through standards-based messages.
The diagrams and tables of actors and transactions in subsequent sections indicate whichtransactions each actor in a given profile must support.

435

440

The transactions shown on the diagrams are identified both by their name and the transaction
number as defined in ITI TF-2a and 2b. The transaction numbers are shown on the diagrams as
bracketed numbers prefixed with the specific Technical Framework domain.
In some cases, a profile is dependent on a prerequisite profile in order to function properly andbe useful. For example, Enterprise User Authentication depends on Consistent Time. These
dependencies can be found by locating the desired profile in Table 2-1 to determine which
profile(s) are listed as prerequisites. An actor must implement all required transactions in theprerequisite profiles in addition to those in the desired profile.
1.6.2 Process Flow Diagrams
The descriptions of integration profiles that follow include process flow diagrams that illustrate
how the profile functions as a sequence of transactions between relevant actors.

445

450

These diagrams are intended to provide an overview so the transactions can be seen in thecontext of an institution’s workflow. Certain transactions and activities not defined in detail by
IHE are shown in these diagrams in italics to provide additional context on where the relevant
IHE transactions fit into the broader scheme of healthcare information systems.
These diagrams are not intended to present the only possible scenario. Often other actor
groupings are possible, and transactions from other profiles may be interspersed.
In some cases the sequence of transactions may be flexible. Where this is the case there will
generally be a note pointing out the possibility of variations. Transactions are shown as arrows
oriented according to the flow of the primary information handled by the transaction and notnecessarily the initiator.

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455

1.6.3 Technical Framework Cross-references
When references are made to another section within a Technical Framework volume, a section
number is used by itself. When references are made to other volumes or to a Technical
Framework in another domain, the following format is used:<domain designator> TF-<volume number>: <section number>, where

460<domain designator> is a short designator for the IHE domain (ITI = IT Infrastructure, RAD =Radiology)<volume number> is the applicable volume within the given Technical Framework (e.g., 1, 2a,2b, 2x, 3), and<section number> is the applicable section number.

465

470

For example: ITI TF-1: 3.1 refers to Section 3.1 in volume 1 of the IHE IT Infrastructure
Technical Framework. RAD TF-3: 4.33 refers to Section 4.33 in volume 3 of the IHE Radiology
Technical Framework. ITI TF-2x: Appendix B refers to Appendix B in volume 2x of the IHE IT
Infrastructure Technical Framework.
When references are made to Transaction numbers in the Technical Framework, the following
format is used:[<domain designator>-<transaction number>], where<transaction number> is the transaction number within the specified domain.
For example: [ITI-1] refers to Transaction 1 from the IHE IT Infrastructure Technical
Framework.

475

1.7 Scope of Changes Introduced in the Current YearThe IHE Technical Framework is updated annually to reflect new profiles, corrections and newtransactions used in those profiles.
This Version of the IT Infrastructure Technical Framework finalizes the following Integration
Profiles.

480

1.

Retrieve Information for Display (RID) – a simple and rapid read-only access topatient information necessary for provision of better care. It supports access to existing
persistent documents in well-known presentation formats such as CDA, PDF, JPEG,
etc. It also supports access to specific key patient-centric information such as allergies,
current medications, summary of reports, etc. for presentation to a clinician.

485

2.

Enterprise User Authentication (EUA) – a means to establish one name per user that
can then be used on all of the devices and software that participate in this integration
profile, greatly facilitating centralized user authentication management and providing
users with the convenience and speed of a single sign-on. This profile leverages
Kerberos (RFC 1510) and the HL7 CCOW standard (user subject).

490

3.

Patient Identifier Cross-referencing (PIX) – provides cross-referencing of patient
identifiers from multiple Patient Identifier Domains. These patient identifiers can then______________________________________________________________________________
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be used by identity consumer systems to correlate information about a single patientfrom sources that know the patient by different identifiers. Includes the Pediatric
Demographics option.
495

4.

Patient Synchronized Applications (PSA) – a means for viewing data for a single
patient using independent and unlinked applications on a user's workstation, reducing
the repetitive tasks of selecting the same patient in multiple applications. Data can beviewed from different Identifier Domains when used with the Patient Identifier Crossreferencing Integration Profile to resolve multiple identifications for the same patient.
This profile leverages the HL7 CCOW standard specifically for patient subject context
management. .

5.

Consistent Time (CT) – mechanisms to synchronize the time base between multiple
actors and computers. Various infrastructure, security, and acquisition profiles require
use of a consistent time base on multiple computers. The Consistent Time Profile
provides a median synchronization error of less than 1 second.

6.

Patient Demographics Query (PDQ) – provides ways for multiple distributed
applications to query a patient information server for a list of patients, based on userdefined search criteria, and retrieve a patient’s demographic (and, optionally, visit orvisit-related) information directly into the application. Includes the Pediatric
Demographics option.

7.

Audit Trail and Node Authentication (ATNA) – establishes the characteristics of a
Basic Secure Node:• It describes the security environment (user identification, authentication,authorization, access control, etc.) assumed for the node so that security reviewers
may decide whether this matches their environments.
• It defines basic auditing requirements for the node
• It defines basic security requirements for the communications of the node using
TLS or equivalent functionality.
• It establishes the characteristics of the communication of audit messages between
the Basic Secure Nodes and Audit Repository nodes that collect audit
information.
• This profile has been designed so that specific domain frameworks may extend it
through an option defined in the domain specific technical framework.
Extensions are used to define additional audit event reporting requirements,
especially actor specific requirements. The Radiology Audit Trail option in the
IHE Radiology Technical Framework is an example of such an extension.

8.

Personnel White Pages (PWP) – provides access to basic human workforce user
directory information. This information has broad use among many clinical and nonclinical applications across the healthcare enterprise.

9.

Cross-Enterprise Document Sharing (XDS) – enables a number of healthcaredelivery organizations belonging to an XDS Affinity Domain (e.g., a community of

500

505

510

515

520

525

530

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documents as they proceed with their patients’ care delivery activities. This profile isbased upon ebXML Registry standards and SOAP. It describes the configuration of an
ebXML Registry in sufficient detail to support Cross Enterprise Document Sharing.

535
10.

Cross-Enterprise User Assertion Profile (XUA) - provides a means to communicate
claims about the identity of an authenticated principal (user, application, system...) intransactions that cross enterprise boundaries. To provide accountability in these crossenterprise transactions there is a need to identify the requesting principal in a way thatenables the receiver to make access decisions and generate the proper audit entries. The
XUA Profile supports enterprises that have chosen to have their own user directorywith their own unique method of authenticating the users, as well as others that may
have chosen to use a third party to perform the authentication.

11.

Patient Administration Management (PAM) - provides patient identity, registration,and encounter management transactions in a healthcare enterprise as well as acrossenterprises.

12.

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.

13.

Basic Patient Privacy Consents (BPPC) - provides a mechanism to record the patient
privacy consent(s), and a method for Content Consumers to use to enforce the privacy
consent appropriate to the use. This profile complements XDS by describing amechanism whereby an XDS Affinity Domain can develop and implement multiple
privacy policies, and describes how that mechanism can be integrated with the access
control mechanisms supported by the XDS Actors (e.g., EHR systems).

14.

Cross Enterprise Sharing of Scanned Documents (XDS-SD) – A profile whichassociates structured, healthcare metadata with non-healthcare specific document
format to maintain the integrity of the patient health record as managed by the source
system

15.

Cross-Enterprise Document Reliable Interchange (XDR) - provides document
interchange using a reliable messaging system. This permits direct document
interchange between EHRs, PHRs, and other healthcare IT systems in the absence of adocument sharing infrastructure such as XDS.

16.

Multi-Patient Queries - defines a mechanism to enable aggregated queries to a
Document Registry based on certain criteria needed by areas related to data analysis,
such as quality accreditation of health care practitioners or health care facilities, clinicalresearch trial data collection or population health monitoring..

17.

Patient Identifier Cross-referencing HL7 V3 (PIXV3) – provides cross-referencingof patient identifiers from multiple Patient Identifier Domains. These patient identifiers
can then be used by identity consumer systems to correlate information about a single

540

545

550

555

560

565

570

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patient from sources that know the patient by different identifiers. This profile uses
HL7 V3 as the message format, and SOAP-based web services for transport.
575

580

585

18.

Patient Demographics Query HL7 V3 (PDQV3) - provides ways for multiple
distributed applications to query a patient information server for a list of patients, basedon user-defined search criteria, and retrieve a patient’s demographic information
directly into the application. This profile uses HL7 V3 as the message format, andSOAP-based web services for transport.

19.

Cross-Community Access (XCA) - supports the means to query and retrieve patient
relevant medical data held by other communities. A community is defined as acoupling of facilities/enterprises that have agreed to work together using a common setof policies for the purpose of sharing clinical information via an establishedmechanism.

20.

Retrieve Form for Data Capture (RFD) - provides a means for the retrieval andsubmission of forms data between physicians/investigators and electronic data capturesystems or other data collection agencies.

1.8 Security Implications
590

595

600

IHE transactions often contain information that must be protected in conformance with privacy
laws and regulations, such as HIPAA or similar requirements in other regions. IHE includes a
few security and privacy-focused profiles listed below. Other IHE Profiles generally do not havespecific privacy protections, but rather expect a proper grouping with one or more of the security
profiles:• The Audit Trail and Node Authentication (ATNA) profile specifies a means to ensure that
nodes in a network are authenticated.
• The ATNA profile specifies an audit message for reporting security- and privacy-relevant
events.
• The Enterprise User Authentication (EUA) profile specifies a means to authenticate systemusers and to share knowledge of the authenticated users among applications.
• The Personnel White Pages (PWP) profile provides a repository that may be used to holdsystem users' identification data.
Implementers may follow these IHE profiles to fulfill some of their security needs. It is
understood that institutions must implement policy and workflow steps to satisfy enterpriseneeds and to comply with regulatory requirements.

1.9 Comments
605

IHE International welcomes comments on this document and the IHE initiative. They can besubmitted using the Web-based comment form at www.ihe.net/iti/iticomments.cfm or by sending
an email to the co-chairs and secretary of the IT Infrastructure domain committees at iti@ihe.net.

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1.10 Copyright Permission
610

Health Level Seven, Inc., has granted permission to the IHE to reproduce tables from the HL7
standard. The HL7 tables in this document are copyrighted by Health Level Seven, Inc. All rights
reserved. Material drawn from these documents is credited where used.

1.11 IHE Technical Framework Development and Maintenance
Process
615

620

The IHE IT Infrastructure Technical Framework is continuously maintained and expanded on anannual basis by the IHE IT Infrastructure Technical Committee. The development andmaintenance process of the Framework follows a number of principles to ensure stability of thespecification so that both vendors and users may use it reliably in specifying, developing andacquiring systems with IHE integration capabilities.
The first of these principles is that any extensions, clarifications and corrections to the Technical
Framework must maintain backward compatibility with previous versions of the framework inorder to maintain interoperability with systems that have implemented IHE Actors andIntegration Profiles defined there.
The IHE IT Infrastructure Technical Framework is developed and re-published annuallyfollowing a three-step process:

625

1.

The IT Infrastructure Technical Committee develops supplements to the current stableversion of the Technical Framework to support new functionality identified by the IHE
Strategic and Planning Committees and issues them for public comment.

2.

The Committee addresses all comments received during the public comment period andpublishes an updated version of the Technical Framework for “Trial Implementation.”
This version contains both the stable body of the Technical Framework from thepreceding cycle and the newly developed supplements. It is the version of the Technical
Framework used by vendors in developing trial implementation software for the annual
IT Infrastructure Connectathon.

3.

The Committee regularly considers change proposals to the Trial Implementation
version of the Technical Framework, including those from implementers who
participate in the Connectathon. After resolution of all change proposals received
within 60 days of the Connectathon, the Technical Framework version is published as“Final Text”.

630

635

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2 IT Infrastructure Integration Profiles
640

645

IHE IT Infrastructure Integration Profiles (Figure 2-1), offer a common language that healthcare
professionals and vendors can use to discuss integration needs of healthcare enterprises and theintegration capabilities of information systems in precise terms. Integration Profiles specify
implementations of standards that are designed to meet identified clinical needs. They enable
users and vendors to state which IHE capabilities they require or provide, by reference to thedetailed specifications of the IHE IT Infrastructure Technical Framework.

650

Integration profiles are defined in terms of IHE Actors and transactions. Actors (see ITI TF-1:
Appendix A) are information systems or components of information systems that produce,
manage, or act on information associated with clinical and operational activities in the enterprise.
Transactions (see ITI TF-1: Appendix B) are interactions between actors that communicate therequired information through standards-based messages.
Vendor products support an Integration Profile by implementing the appropriate actor(s) andtransactions. A given product may implement more than one actor and more than one integration
profile.

Cross-Enterprise
Document Sharing
Registration, distribution andaccess across healthenterprises of clinicaldocuments forming a patientelectronic health record

Retrieve
Retrieve Information
Informationforfor Display
Display

Personnel White Page
Access to workforce
contact information

AccessAccessa apatient’s
patient’sclinicalclinicalinformation
anddocuments
in inainformation
anddocuments
formata readybe presented
formattoreadyto be
to the requestingpresented user

Patient Demographics
Queryto the requesting user

Patient Synchronized
Applications

Audit Trail & Node
Authentication
Patient Identifier
Patient Identifier
Cross-referencingfor
Cross-referencing
MPI
for MPI

655

Map patient identifiers
Map patient
identifiers
acrossindependent
across independent
identification
domains
identification domains

Synchronize multiple
applications on a desktop to thesame patientCentralized privacy audit trail
and node to node authentication
to create a secured domain.

Enterprise User
Authentication
Provide users a single nameand centralized authentication
process
across all systems

Consistent Time
Coordinate time acrossnetworked systems

Figure 2-1: IHE IT Infrastructure Integration Profiles

2.1 Dependencies among Integration Profiles
660

Dependencies among IHE Integration Profiles exist when implementation of one integration
profile is a prerequisite for achieving the functionality defined in another integration profile.
Figure 2-1 provides a graphical view of the dependencies among IHE IT Infrastructure
Integration Profiles. The arrows in the figure point from a given integration profile to the______________________________________________________________________________
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integration profile(s) upon which it depends. Table 2-1 defines these dependencies in tabular
form.
665

Some dependencies require that an actor supporting one profile be grouped with one or more
actors supporting other integration profiles. For example, Enterprise User Authentication (EUA)
requires that different participating actors be grouped with the Time Client Actor thatparticipates in the Consistent Time (CT) Integration Profile. The dependency exists because
EUA actors must refer to consistent time in order to function properly.

670

Table 2-1: Integration Profiles Dependencies
Integration Profile

Depends on

Dependency Type

Retrieve Information for Display
Integration (RID)

NoneEnterprise User Authentication(EUA)

Consistent Time

Each actor implementing EUA
shall be grouped with the Time
Client Actor

Required to manage
expirations ofauthentication tickets

Patient Identifier Crossreferencing (PIX)

Consistent Time

Each actor implementing PIX
shall be grouped with the Time
Client Actor

Required to manage andresolve conflicts in
multiple updates.

None

Purpose-Patient Synchronized Applications
(PSA)

None

None

-

Consistent Time (CT)

None

None

-

Patient Demographics Query
(PDQ)

None

None

-

Personnel White Pages (PWP)

None

None

-

Audit Trail and Node
Authentication (ATNA)

Consistent TimeAn ATNA Secure Node Actor
shall be grouped with the Time
Client Actor

Required for consistenttime in audit logs.

Cross-Enterprise Document
Sharing (XDS)

Audit Trail andNodeAuthentication

Each XDS Actor shall begrouped with the ATNA Secure
Node or Secure Application
Actor.

Required to manage audit
trail of exported PHI, node
authentication andtransport encryption.

Cross-Enterprise Document
Sharing (XDS)

Consistent Time

Each XDS actor shall be groupedwith the Time Client Actor

To ensure consistency
among document andsubmission set dates.

Cross-Enterprise User Assertion
(XUA)

None

None

Patient Administration
Management (PAM)

None

None

-

Cross-Enterprise Document MediaInterchange (XDM)

Audit Trail andNodeAuthentication

Each XDM Actor shall begrouped with Secure Node or
Secure Application Actor

Requires audit trails.

Cross-Enterprise Document MediaInterchange (XDM)

Any IHE Content
ProfileThe Portable Media Importer
shall be grouped with a Content
Consumer of one or more IHE
Content Profile

Enables some form ofprocessing of imported
medical data.

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Integration Profile
Basic Patient Privacy Consent(BPPC)

Depends on
XDS, XDM or
XDR

Dependency Type

PurposeThe BPPC Content Creator shallbe grouped with an XDS or XDRDocument Source Actor, or an
XDM Portable Media Creator.

The content of a Basic
Patient Privacy Consent
Acknowledgement
document is intended foruse in XDS, XDR and
XDM.

The BPPC Content Consumer
shall be grouped with an XDS
Document Consumer, or an XDRDocument Recipient, or an XDM
Portable Media Importer.
Basic Patient Privacy Consent(BPPC)

Cross Enterprise
Sharing of
ScannedDocuments

The BPPC Content Consumer
shall be grouped with the XDSSD Content Consumer.

Enables capturing of wet
signatures on patients'
consent documents.

Cross Enterprise Sharing of
Scanned Documents (XDS-SD)

XDS, XDM or
XDR

The XDS-SD Content Creator
shall be grouped with an XDS orXDR Document Source Actor, or
an XDM Portable Media Creator.

The content of this profile
is intended for use in XDS,XDR and XDM.

The XDS-SD Content Consumer
shall be grouped with an XDS
Document Consumer, or an XDRDocument Recipient, or an XDM
Portable Media Importer.
Cross-Enterprise Document
Reliable Interchange (XDR)

ATNA

Each XDR Actor shall begrouped with Secure Node or
Secure Application Actor

Requires securecommunication and audit
trails.

Multi-Patient Queries (MPQ)

Audit Trail andNodeAuthentication

Each Document Registry actor
and each Document Consumer
shall be grouped with a Secure
Node or a Secure Application
Actor

Required to manage audit
trail of exported PHI, node
authentication andtransport encryption

Multi-Patient Queries (MPQ)

Consistent Time

Each Document Registry actor
and each Document Consumer
shall be grouped with the Time
Client Actor.

To ensure consistency
among document andsubmission set datesPatient Identifier CrossReferencing HL7 V3Consistent Time

Each actor implementing PIXv3
shall be grouped with the Time
Client Actor

Required to manage andresolve conflicts in
multiple updatesPatient Demographics Query HL7
V3 (PDQv3)

None

None

Cross-Community Access (XCA)

Audit Trail andNodeAuthentication

Each XCA Actor shall begrouped with Secure Node Actor
or Secure Application

Required to manage audit
trail of exported PHI, node
authentication andtransport encryption.

Cross-Community Access (XCA)

Consistent Time

Each XCA Actor shall begrouped with the Time Client
Actor.

To ensure consistency
among document andsubmission set dates.

Retrieve Form for Data Capture
(RFD)

None

None

-

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To support a dependent profile, an actor must implement all required transactions in theprerequisite profiles in addition to those in the dependent profile. In some cases, the prerequisite
is that the actor selects any one of a given set of profiles.
675

2.2 Integration Profiles Overview
In this document, each IHE Integration Profile is defined by:• The IHE actors involved• The specific set of IHE transactions exchanged by each IHE actor.

680

685

690

These requirements are presented in the form of a table of transactions required for each actor
supporting the Integration Profile. Actors supporting multiple Integration Profiles are required tosupport all the required transactions of each Integration Profile supported. When an Integration
Profile depends upon another Integration Profile, the transactions required for the dependent
Integration Profile have not been included in the table.
Note that IHE Integration Profiles are not statements of conformance to standards, and IHE is nota certifying body. Users should continue to request that vendors provide statements of theirconformance to standards issued by relevant standards bodies, such as HL7 and DICOM.
Standards conformance is a prerequisite for vendors adopting IHE Integration Profiles.
Also note that there are critical requirements for any successful integration project that IHE
cannot address. Successfully integrating systems still requires a project plan that minimizes
disruptions and describes fail-safe strategies, specific and mutually understood performance
expectations, well-defined user interface requirements, clearly identified systems limitations,detailed cost objectives, plans for maintenance and support, etc.
2.2.1 This section is reserved.
2.2.2 This section is reserved.

695

2.2.3 Retrieve Information for Display (RID)

700

Retrieve Information for Display enables simple and rapid access to patient information for
better care. It supports access to existing persistent documents in well-known presentation
formats such as CDA, PDF, JPEG, etc. It also supports access to specific key patient-centric
information such as allergies, current medications, summary of reports, etc. for presentation to aclinician. It complements workflows from within the users’ on-screen workspace or application.
By linking it with two other IHE profiles - Enterprise User Authentication and Patient Identifier
Cross-referencing, this profile’s reach can extend across organization boundaries within anenterprise. This IHE Integration Profile leverages HTTP, Web Services, IT presentation formats
and HL7 CDA Level 1.

705

2.2.4 Enterprise User Authentication (EUA)
Enterprise User Authentication defines a means to establish one name per user that can then be
used on all of the devices and software that participate in this integration profile. It greatly______________________________________________________________________________
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710

facilitates centralized user authentication management and provides users with the convenienceand speed of a single sign-on. This profile leverages Kerberos (RFC 1510) and the HL7 CCOW
standard (user subject). User authentication is a necessary step for most application and data
access operations and streamlines workflow for users. Future profiles will deal with othersecurity issues, such as authorization management.
2.2.5 Patient Identifier Cross-referencing (PIX)715

The PIX profile supports the cross-referencing of patient identifiers from multiple Patient
Identifier Domains. These cross-referenced patient identifiers can then be used by “identity
consumer” systems to correlate information about a single patient from sources that “know” thepatient by different identifiers. This allows a clinician to have more complete view of the patient
information.
2.2.6 Patient Synchronized Applications (PSA)

720

725

Patient Synchronized Applications supports viewing data for a single patient among otherwise
independent and unlinked applications on a user's workstation. Its implementation reduces therepetitive tasks of selecting the same patient in multiple applications. It also improves patient
safety by reducing the chance of medical errors caused by viewing the wrong patient's data. Itsability to work with the Patient Identifier Cross-referencing provides a seamless environment forclinicians and IT staff. This profile leverages the HL7 CCOW standard specifically for patient
subject context management.
2.2.7 Consistent Time (CT)730

Consistent Time Profile defines mechanisms to synchronize the time base between multiple
actors and computers. Various infrastructure, security, and acquisition profiles require use of aconsistent time base on multiple computers. The Consistent Time Profile provides mediansynchronization error of less than 1 second. Configuration options can provide bettersynchronization. The Consistent Time profile specifies the use of the Network Time Protocol(NTP) defined in RFC 1305.
2.2.8 Patient Demographics Query (PDQ)

735

Patient Demographics Query provides ways for multiple distributed applications to query apatient information server for a list of patients, based on user-defined search criteria, and retrievea patient’s demographic (and, optionally, visit or visit-related) information directly into theapplication.
2.2.9 Audit Trail and Node Authentication (ATNA)

740

Audit Trail and Node Authentication establishes the characteristics of a Basic Secure Node:1.

It describes the security environment (user identification, authentication, authorization,access control, etc.) assumed for the node so that security reviewers may decide
whether this matches their environments.

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745

750

2.

It defines basic auditing requirements for the node3.

It defines basic security requirements for the communications of the node using TLS orequivalent functionality.

4.

It establishes the characteristics of the communication of audit messages between the
Basic Secure Nodes and Audit Repository nodes that collect audit information.

5.

It defines a Secure Application actor for describing product configurations that are notable to meet all of the requirements of a Secure Node.

Note:

ATNA security considerations require the use of Secure Nodes. The Secure Application is defined to permit
product configurations to indicate that the product is ready for easy integration into a Secure Node environment
because it performs all of the security related functions that are directly related to the application function. See
ITI TF-1: 9.7 for more details.

755This profile has been designed so that specific domain frameworks may extend it through an
option defined in the domain specific technical framework. Extensions are used to define
additional audit event reporting requirements, especially actor specific requirements. The
Radiology Audit Trail option in the IHE Radiology Technical Framework is an example of suchan extension.

760

2.2.10 Cross-Enterprise Document Sharing (XDS)

765

Cross-Enterprise Document Sharing enables a number of healthcare delivery organizations
belonging to an XDS Affinity Domain (e.g., a community of care) to cooperate in the care of apatient by sharing clinical records in the form of documents as they proceed with their patients’care delivery activities. Federated document repositories and a document registry create alongitudinal record of information about a patient within a given XDS Affinity Domain. This
profile is based upon ebXML Registry standards and SOAP. It describes the configuration of an
ebXML Registry in sufficient detail to support Cross Enterprise Document Sharing.
2.2.11 Personnel White Pages (PWP)

770

775

Personnel White Pages Profile (PWP) provides access to basic human workforce user directory
information. This information has broad use among many clinical and non-clinical applications
across the healthcare enterprise. The information can be used to enhance the clinical workflow(contact information), enhance the user interface (user friendly names and titles), and ensure
identity (digital certificates). This Personnel White Pages directory will be related to the User
Identity provided by the Enterprise User Authentication (EUA) Integration Profile previously
defined by IHE.
2.2.12 This section is reserved for Notification of Document Availability (NAV)
2.2.13 Cross Enterprise User Assertion (XUA)

780

Cross-Enterprise User Assertion provides a means to communicate claims about the identity ofan authenticated principal (user, application, system...) in transactions that cross-enterpriseboundaries. To provide accountability in these cross enterprise transactions there is a need to
identify the requesting principal in a way that enables the receiver to make access decisions and______________________________________________________________________________
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generate the proper audit entries. The XUA Profile supports enterprises that have chosen to havetheir own user directory with their own unique method of authenticating the users, as well asothers that may have chosen to use a third party to perform the authentication.
785

790

795

2.2.14 Patient Administration Management (PAM)
The Patient Administration Management Integration Profile establishes the continuity andintegrity of patient data, and additional information such as related persons (primary caregiver,guarantor, next of kin, etc.). It coordinates the exchange of patient registration and update
information among systems that need to be able to provide current information regarding apatient’s encounter status and location. This profile supports ambulatory and acute care use
cases including patient identity feed, admission and discharge, and transfer and encounter
management, as well as explicit and precise error reporting and application acknowledgment.
The PAM profile supports two patient encounter management scenarios: either one single central
patient registration system serving the entire institution, or multiple patient registration systems
collaborating as peers serving different clinical settings in an institution.
2.2.15 Cross-Enterprise Document Reliable Interchange (XDR)

800

Cross-Enterprise Document Reliable Interchange (XDR) provides document interchange using a
reliable messaging system. This permits direct document interchange between EHRs, PHRs, andother healthcare IT systems in the absence of a document sharing infrastructure such as XDS
Registry and Repositories.
2.2.16 Cross-Enterprise Document Media Interchange (XDM)

805

Cross-Enterprise Document Media Interchange provides document interchange using acommon 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.
2.2.17 Retrieve Form for Data Capture (RFD)810

The Retrieve Form for Data Capture Profile (RFD) provides a method for gathering data within auser’s current application to meet the requirements of an external system. RFD supports theretrieval of forms from a form source, display and completion of a form, and return of instancedata from the display application to the source application.
2.2.18 Cross-Community Access (XCA)815

The Cross-Community Access profile supports the means to query and retrieve patient relevant
medical data held by other communities. A community is defined as a coupling offacilities/enterprises that have agreed to work together using a common set of policies for the
purpose of sharing clinical information via an established mechanism. Facilities/enterprises may
host any type of healthcare application such as EHR, PHR, etc. A community is identifiable by aglobally unique id called the homeCommunityId. Membership of a facility/enterprise in one______________________________________________________________________________
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820

community does not preclude it from being a member in another community. Such communities
may be XDS Affinity Domains which define document sharing using the XDS profile or any
other communities, no matter what their internal sharing structure.
2.2.19 Basic Patient Privacy Consents (BPPC)

825

The Basic Patient Privacy Consents profile provides a mechanism to record the patient privacy
consent(s), and a method for Content Consumers to use to enforce the privacy consent
appropriate to the use. This profile complements XDS by describing a mechanism whereby an
XDS Affinity Domain can develop and implement multiple privacy policies, and describes howthat mechanism can be integrated with the access control mechanisms supported by the XDS
Actors (e.g., EHR systems).
2.2.20 Scanned Documents Integration Profile (XDS-SD)

830

835

A variety of legacy paper, film, electronic and scanner outputted formats are used to store andexchange clinical documents. These formats are not designed for healthcare documentation, andfurthermore, do not have a uniform mechanism to store healthcare metadata associated with the
documents, including patient identifiers, demographics, encounter, order or service information.
The association of structured, healthcare metadata with this kind of document is important tomaintain the integrity of the patient health record as managed by the source system. It isnecessary to provide a mechanism that allows such source metadata to be stored with the
document.
2.2.21 This section is reserved.
Future.
2.2.22 This section is reserved.

840

Future.
2.2.23 Patient Identifier Cross-referencing HL7 V3 (PIXV3)

845

850

The functionality of this profile is identical to the PIX profile described in section 2.2.3. The
differences are in the format of the messages, and in the use of SOAP-based web services. Thesechanges make this profile well suited for use within an existing IT infrastructure for crossenterprise data access and exchange. The PIXV3 profile supports the cross-referencing of patient
identifiers from multiple Patient Identifier Domains. These cross-referenced patient identifiers
can then be used by “identity consumer” systems to correlate information about a single patientfrom sources that “know” the patient by different identifiers. This allows a clinician to have more
complete view of the patient information.
2.2.24 Patient Demographics Query HL7 V3 (PDQV3)
The functionality of this profile is identical to the PDQ profile described in section 2.2.6. The
differences are in the format of the messages, and in the use of SOAP-based web services. These______________________________________________________________________________
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855

changes make this profile well suited for use within an existing IT infrastructure for crossenterprise data access and exchange. The PDQV3 profile provides ways for multiple
organizations, or multiple distributed applications to query a patient information server for a listof patients, based on user-defined search criteria, and retrieve a patient’s demographic
information directly into the application.

860

2.2.25 Multi-Patient Queries (MPQ)The Multi-Patient Queries profile defines a mechanism to enable aggregated queries to a
Document Registry based on certain criteria needed by areas related to data analysis, such as
quality accreditation of health care practitioners or health care facilities, clinical research trial
data collection or population health monitoring.

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865

870

2.3 Product Implementations
Developers have a number of options in implementing IHE actors and transactions in productimplementations. The decisions cover three classes of optionality:• For a system, select which actors it will incorporate (multiple actors per system areacceptable).
• For each actor, select the integration profiles in which it will participate.
• For each actor and profile, select which options will be implemented.
All required transactions must be implemented for the profile to be supported (refer to thetransaction descriptions in ITI TF-2a and ITI TF-2b).

875

Implementers should provide a statement describing which IHE actors, IHE integration profiles
and options are incorporated in a given product. The recommended form for such a statement isdefined in ITI TF-1: Appendix C.

880

In general, a product implementation may incorporate any single actor or combination of actors.
When two or more actors are grouped together, internal communication between actors is
assumed to be sufficient to allow the necessary information flow to support their functionality;
for example, the Context Manager uses the Patient Identifier Cross-reference Consumer Actor to
obtain the necessary patient identifier mapping information from the Patient Identifier Crossreference Manager. The exact mechanisms of such internal communication are outside the scopeof the IHE Technical Framework.

885

When multiple actors are grouped in a single product implementation, all transactions originatingor terminating with each of the supported actors shall be supported (i.e., the IHE transactions
shall be offered on an external product interface).
The following examples describe which actors typical systems might be expected to support.
This is not intended to be a requirement, but rather to provide illustrative examples.

890

A departmental system, such as a laboratory information system or a radiology picture archiving
and communication system might include an Information Source Actor as well as a Kerberized
Server Actor.
A clinical repository might include an Information Source Actor as well as a Kerberized Server
Actor and a Patient Identifier Cross-reference Consumer Actor.

895

A context management server might include a Context Management Actor as well as a Patient
Identifier Cross-reference Consumer Actor.

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3 Retrieve Information for Display (RID)

900

905

910

The Retrieve Information for Display Integration Profile (RID) provides simple and rapid readonly access to patient-centric clinical information that is located outside the user’s current
application but is important for better patient care (for example, access to lab reports fromradiology department). It supports access to existing persistent documents in well-known
presentation formats such as CDA (Level 1), PDF, JPEG, etc. It also supports access to specific
key patient-centric information such as allergies, current medications, summary of reports, etc.
for presentation to a clinician. It complements workflows with access from within the users’ onscreen workspace or application to a broad range of information.
In this profile, the Information Source is solely responsible to turn the healthcare specificsemantics into what this IHE Integration Profile calls a “presentation” format. As a consequence
the Display actor may process and render this “presentation” format with only generic healthcaresemantics knowledge. Different formats have specific characteristics in terms of (1) server
imposed limitations and (2) flexibility of display on the client side to render within its display
constraints (e.g., a generic CDA level 1 style sheet).
The Information Source is entirely responsible for the information returned for display and its
clinical accuracy.

915

920

925

This profile offers the capability to leverage industry standards that address both the structure
and content of documents that may be returned by information sources. Where this profilereferences HL7 Clinical Documentation Architecture (CDA), it limits itself to the approved CDA
Level 1. Furthermore, it only uses a subset of CDA Level 1 that facilitates making information
available for display.
Future extensions to the IHE IT Infrastructure TF will more fully leverage CDA Release 2 andother industry standards, and will incorporate vocabularies such as SNOMED and Clinical
LOINC as well as clinical templates.
This profile does not provide specific requirements on the means of assuring access control orsecurity of information in transit. Such measures shall be implemented through appropriate
security-related integration profiles, such as Enterprise User Authentication (see ITI TF-1:4). ITI
TF-1: Appendix E describes the process flows for usage of the Retrieve Information for Display
Integration Profile in conjunction with the Enterprise User Authentication and Patient Identifier
Cross-referencing Integration Profiles.

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930

3.1 Actors/ Transactions

935

Figure 3.1-1 shows the actors directly involved in the Retrieve Information for Display
Integration Profile and the relevant transactions between them. Other actors that may be
indirectly involved due to their participation in User Authentication and Patient Identifier Crossreferencing are not shown.

Retrieve Specific Info for Display [ITI-11]

Display
Retrieve Document for Display [ITI-12]

Information
SourceFigure 3.1-1: Retrieve Information for Display Actor Diagram

940

945

Table 3.1-1 lists the transactions for each actor directly involved in the Retrieve Information for
Display Integration Profile. In order to claim support of this Integration Profile, animplementation must perform the required transactions (labeled “R”). A complete list of options
defined by this Integration Profile and that implementations may choose to support is listed in
ITI TF-1: 3.2.
Table 3.1-1: Retrieve Information for Display Integration Profile - Actors and Transactions
Actors
Display
Information
SourceTransactions

Optionality

SectionRetrieve Specific Info for Display [ITI-11]

R

ITI TF-2a: 3.11

Retrieve Document for Display [ITI-12]

R

ITI TF-2a: 3.12

Retrieve Specific Info for Display [ITI-11]

R (see below)

ITI TF-2a: 3.11

Retrieve Document for Display [ITI-12]

R (see below)

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Transaction [ITI-11] is required if one of the following Options is selected by the Information
Source Actor (See ITI TF-1: 3.2):
950
Summary of All Reports
Summary of Laboratory Reports
Summary of Radiology Reports
Summary of Cardiology Reports
Summary of Surgery Reports

955

Summary of Intensive Care Reports
Summary of Emergency Reports
Summary of Discharge Reports
Summary of Prescriptions
List of Allergies and Adverse Reactions
List of Medications

960
Transaction [ITI-12] is required if the Persistent Document Option is selected by the Information
Source Actor (See ITI TF-1: 3.2).

965

The means for a Display Actor to obtain documents’ unique identifiers in order to retrieve them
via Transaction [ITI-11] may be either via Transaction [ITI-12] or by other means that areoutside the scope of the RID Integration Profile.

3.2 Retrieve Information for Display Integration Profile Options
Options that may be selected for this Integration Profile are listed in the Table 3.2-1 along with
the IHE actors to which they apply.
970

Table 3.2-1: Retrieve Information for Display - Actors and Options
Actor

Options

Information Source

Vol & Section

None

Display--

Persistent Document

ITI TF-2a: 3.12

Summary of All Reports (note2)

ITI TF-2a: 3.11

Summary of Laboratory Reports (note2)

ITI TF-2a: 3.11

Summary of Radiology Reports (note2)

ITI TF-2a: 3.11

Summary of Cardiology Reports (note2)

ITI TF-2a: 3.11

Summary of Surgery Reports (note2)

ITI TF-2a: 3.11

Summary of Intensive Care Reports (note2)

ITI TF-2a: 3.11

Summary of Emergency Reports (note2)

ITI TF-2a: 3.11

Summary of Discharge Reports (note2)

ITI TF-2a: 3.11

Summary of Prescriptions (note2)

ITI TF-2a: 3.11

List of Allergies and Adverse Reactions

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Actor

975

980

985

990

Options

Vol & Section

List of Medications (note1)

ITI TF-2a: 3.11

Note1:

List of Medications includes the list of medications currently known to be administered to the patient. It differsfrom the Summary of Prescriptions, in that the latter reflects what has been prescribed to the patient, but are notnecessarily any longer administered.

Note2:In all the above options, “summary of reports” means that a general patient context (patient name, etc.) isprovided along with a list of entries, where an entry includes key attributes such as date, specialty, and additional
information sufficient to allow the viewer to select an entry. An entry may reference a persistent document for
RID or other application defined RID summaries. Beyond these general guidelines, the specific content may
likely be influenced by the context of use and customer desires. Such summaries are non-persistent in that they
are likely to be updated in the course of patient care.

3.3 Retrieve Information for Display Process Flow
This section describes the process and information flow when displayable patient information isretrieved from an information source. Three cases are distinguished.
Case 1-Retrieve Specific Information for Display: The first case describes use cases when thedisplay actor and the person associated are requesting some information related to a patient. A
somewhat specific request for information is issued (e.g., Retrieve a summary of laboratory
reports) for a specific Patient ID to an Information Source Actor. The patient ID is assumed to beunambiguous as fully qualified with the assigning authority. A number of additional filtering
keys may be used (last N reports, date range, etc.) depending on the specific type of request
issued. The Information Source Actor responds with presentation-ready information that it
considers relevant to the request. This Integration Profile leaves entire flexibility to the
Information Source Actor to organize the content and presentation of the information returned.
The Display Actor simply displays the information to the person that triggered the request. The
Information Source Actor shall respond with an error message when it does not support the
specific type of request or does not hold any records for the requested patient ID.

995______________________________________________________________________________
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Display

Information
SourcePrepareSpecific
Information for
Display

Information
not found orinformation
type notsupported

Retrieve SpecificInfo for Display [ITI-11]

Request for
Information ona patient
Display
Information

Retrieve SpecificInfo for Display [ITI-11]

Request for
Information ona patient
Display Error

Figure 3.3-1: Case 1: Retrieve Specific Information for Display Process Flow

1000

1005

1010

1015

Case 2 - Retrieve a Document: The second case describes use cases when the Display Actor andthe person associated are requesting a uniquely identified document such as a report, an image,an ECG strip, etc. The Information Source Actor responds to the request by using one of the
proposed formats to provide the presentation-ready content of the object it manages. The detailed
presentation and the clinical integrity of the content of the document are under the control of theInformation Source Actor. The Display Actor simply displays the presentation-ready document
content to the person that triggered the request. The Information Source Actor shall respond withan error message when the requested document is unknown or when none of the formats
acceptable to the Display Actor is suitable to present the requested document.
The main difference between the Retrieve Specific Information and the Retrieve Documenttransactions is that the latter applies to a uniquely identifiable persistent object (i.e. retrieving thesame document instance at a different point in time will provide the same semantics for its
presented content). For the Retrieve Specific Information transaction, this information is always
related to a well-identified patient (Patient ID), but its content, although of a specific type (labsummary, or radiology summary, list of allergies) is generally dynamic (i.e. retrieving the same
type of specific information at a different point in time is likely to result in different content; forexample, a list of allergies may have been updated between two requests).
Note: This Integration profile is not intended for highly dynamic information such as that used for patient monitoring.

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Display

Information
SourcePrepareSelected
Document for
Display

Retrieve Document
for Display [ITI-12]

Requested
Document does
not exist or
client proposed
formats notsupported

Retrieve Document
for Display [ITI-12]

Request forDocument
Display
Document
Content

Request forDocument
Display Error

Figure 3.3-2: Case 2: Retrieve a Document Process Flow

1020

1025

Case 3 - Retrieve Specific Information for Display and Retrieve several Documents Process
Flow: The third case combines the two cases above with the capability to associate in sequence
the Retrieve Specific Information and the Retrieve Document for Display transactions. This
allows for links to persistent documents within the returned specific information or for having
persistent documents reference other persistent documents. For example, the user requests asummary of recent discharge reports, and then selects a specific document referenced in thatsummary list. From the discharge report displayed to the user, the user selects a specific surgery
report. This surgery report is retrieved and displayed.

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Display

Information
SourcePrepareSpecific
Information for
Display

PrepareSelected
Document for
Display

PrepareSelected
Document for
Display

1030

1035

Retrieve SpecificInfo for Display [ITI-11]

User Requests
Information on apatient
Display
Information

Retrieve Document for
Display [ITI-12]

User Requests a
Document referenced inprevious information
returned
Display
Document Content

Retrieve Document for
Display [ITI-12]

User Requests a
Document referenced
in previous document
Display
Document
Content

Figure 3.3-3: Case 3: Retrieve Summary Information for Display and Retrieve several
Documents Process Flow

The same Display Actor may involve more than one Information Source Actor by sequentially
issuing different transactions. This Integration Profile assumes that the Display Actors may be
configured a priori with one or more remote Information Source Actors along with the type of
retrieve transactions/type of requests/specific keys suitable for the application context fromwhich this Retrieve Information for Display requests are issued. Future Integration Profiles may
facilitate such site-specific configuration tasks.

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4 Enterprise User Authentication (EUA)
1040

1045

1050

Enterprise User Authentication Profile (EUA) – This defines a means to establish one name peruser that can then be used on all of the devices and software that participate in this integration
profile. It greatly facilitates centralized user authentication management and provides users withthe convenience and speed of a single sign-on. This profile leverages Kerberos (RFC 1510) andthe HL7 CCOW standard (user subject). User authentication is a necessary step for mostapplication and data access operations and it is a workflow improvement for the users. The IHE
EUA Profile adds value to the CCOW specification for the user subject by specifying the user
subject and CCOW user subject suffix. This profile does not address security features such as
audit trails, access control, authorization management and PKI. Future profiles will be developed
to address these security features in a manner complementary to this EUA profile.
The environment is assumed to be a single enterprise, governed by a single security policy andhaving a common network domain. Unsecured domains -- in particular, Internet access -- are ofinterest, but not in the scope of this profile. Considerations for applications such as telemedicine
and patient remote access to healthcare data are therefore also not in its scope. See ITI TF-=:
Appendix G.
Node and machine authentication is specified in the IHE Basic Security Profile as specified in
the IHE Radiology Technical Framework and is not part of this profile.

1055

1060

4.1 Actors/ Transactions
A number of transactions used in this profile conform to the Kerberos v5 standard, defined in
RFC 1510. This standard has been stable since 1993, is widely implemented on current operating
system platforms, has successfully withstood attacks in its 10-year history, and is fullyinteroperable among platforms. For example, Sun Solaris, Linux, AIX, HPUX, IBM-z/OS, IBMOS400, Novell, MAC OS X, and Microsoft Windows 2000/XP all implement Kerberos in aninteroperable manner. This is not a complete list; many other vendors also support Kerberos.

1065

For additional detailed information on Kerberos, beyond what is specified in this profile, wesuggest these references:• RFC 1510 - http://www.ietf.org/rfc/rfc1510.txt• MIT's Kerberos home page - http://web.mit.edu/kerberos/www/• The Moron's Guide to Kerberos - http://www.isi.edu/~brian/security/kerberos.html• Microsoft Kerberos information
http://www.microsoft.com/TechNet/prodtechnol/windows2000serv/deploy/kerberos.asp

1070

Kerberos implementations are widely available worldwide. Kerberos does include cryptographythat may have restricted use laws in some countries. The US export regulations can be found at
http://www.bxa.doc.gov/Encryption.
Figure 4.1-1 shows the actors directly involved in the Enterprise User Authentication Profile andthe relevant transactions between them. The box labeled "Other IHE Actor" represents actors
from other integration profiles that are meant to be grouped with the nearby actor from within______________________________________________________________________________
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1075

this profile. Other actors that may be indirectly involved due to their use of authentication, etc.
are not shown.
Kerberos
Authentication Server

Get User Authentication[ITI-2] ↑Kerberized Server

Other IHE Actor↑ Get Service
Ticket [ITI-3]↑ KerberizedCommunication [ITI-4]

ClientAuthentication
Agent
Join Context [ITI-5]↓
Change Context [ITI-6] ↓Leave Context [ITI-7] ↓Context Manager

Other IHE
Transaction

Other IHE Actor
Join Context [ITI-5] ←Follow Context [ITI-13] →Leave Context [ITI-7] ←User Context
Participant

Figure 4.1-1: Enterprise Authentication Actor Diagram

1080

1085

Table 4.1-1 lists the transactions for each actor directly involved in the Enterprise User
Authentication Profile. In order to claim support of this Integration Profile, an implementationmust perform the required transactions (labeled “R”). Transactions labeled "O" are optional. A
complete list of options defined in this Integration Profile and that implementations may choose
to support is listed in ITI TF-1: 4.2.
Table 4.1-1: Enterprise User Authentication Profile - Actors and Transactions
Actors
Kerberos Authentication Server
Client Authentication Agent

Transactions

Optionality

SectionGet User Authentication [ITI-2]

R

ITI TF-2a: 3.2

Get Service Ticket [ITI-3]

R

ITI TF-2a: 3.3

Get User Authentication [ITI-2]

R

ITI TF-2a: 3.2

Get Service Ticket [ITI-3]

R

ITI TF-2a: 3.3

Kerberized Communication [ITI-4]

R

ITI TF-2a: 3.4

Join Context [ITI-5]

O [Note1]

ITI TF-2a: 3.5

Change Context [ITI-6]

O [Note1]

ITI TF-2a: 3.6

Leave Context [ITI-7]

O [Note1]

ITI TF-2a: 3.7

Kerberized Server

Kerberized Communication [ITI-4]

R

ITI TF-2a: 3.4

User Context Participant

Join Context [ITI-5]

R

ITI TF-2a: 3.5

Follow Context [ITI-13]

R

ITI TF-2a: 3.13

Leave Context [ITI-7]

R

ITI TF-2a: 3.7______________________________________________________________________________
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ActorsTransactions

Context Manager

Optionality

SectionJoin Context [ITI-5]

R

ITI TF-2a: 3.5

Follow Context [ITI-13]

R

ITI TF-2a: 3.13

Leave Context [ITI-7]

R

ITI TF-2a: 3.7

Change Context [ITI-6]

R

ITI TF-2a: 3.6

Note 1: When the Authentication for User Context Option is supported, then the transaction is required.

1090

1095

CCOW facilitates the sharing of the identity of a EUA authentication user but does not provide
for the authentication of users. In order for the Context Manager and User Context Participant toparticipate in the EUA profile it is required that the Client Authentication Agent supports theAuthentication for User option. This design provides the User Context Participant with aconsistent and enterprise recognized user identity, but does not define access to the Kerberos
credentials. Future IHE profiles may address this limitation. Note that the Client Authentication
Agent is the key actor when PSA and EUA are combined. See the use case outlined in ITI TF-1:
4.3.2. Applications that implement both the Client Authentication Agent Actor and the User
Context Participant Actor shall support configurations where either Actor is disabled.
In any single user environment there shall be only one Client Authentication Agent for one user.
In a multi-user environment there shall not be more than one Client Authentication Agent per
user.

4.2 Enterprise User Authentication Integration Profile Options
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Options that may be selected for this Integration Profile are listed in Table 4.2-1 along with theActors to which they apply. Dependencies between options when applicable are specified innotes.
Table 4.2-1: Enterprise User Authentication - Actors and Options

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Actor

Options

Vol & Section

Kerberos Authentication Server

No options defined

Client Authentication Agent

Authentication for User Context-ITI TF-2a: 3.6

Kerberized Server

No options defined--Context Manager

No options defined--User Context Participant

No options defined--

4.3 Enterprise User Authentication Profile Process Flow
4.3.1 Basic User Authentication Process Flow
The following diagram describes the sequence of events in the use of Enterprise User
Authentication:______________________________________________________________________________
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Client Authentication
Agent
Login orSession Start

Kerberos
Authentication Server

Other IHE Actor(RID)

Kerberized
ServerOther IHE Actor(RID)

Get User Authentication [ITI-2]
Internal TGTManagement

Get Service Ticket [ITI-3]
Internal Ticket
Management

Internal user
authentication

Internal
validate TGT

Kerberized Communication [ITI-4]
Other IHE Transaction

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Figure 4.3.1-1: Basic Process Flow in Enterprise User Authentication Profile1120

The sequence of events in the use of Enterprise User Authentication is:• The user begins the session. This initiates a local username/password authentication thatis converted into the challenge/response system used by Kerberos to avoid transmitting
the password over the network. This information is used as part of the Get User
Authentication Transaction to get a “Ticket Granting Ticket” (TGT).
• The TGT is saved and managed internally by the Client Authentication Agent Actor. The
TGT acts as confirmation that the user has been authenticated.
• For each service that has been Kerberized, the Client Authentication Agent Actor uses the
Get Service Ticket Transaction to obtain a service ticket. The service ticket is then usedas part of the Kerberized Communication Transaction.

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A Kerberized Communication is a Kerberos data exchange that is integrated into anotherprotocol, such as HL7 or DICOM, which is used in another IHE transaction. The details of
Kerberization vary and are described separately for the protocols that have been Kerberized. The
Kerberization enables the other IHE Actors involved in the other transaction to use the identityof the authenticated user for purposes such as user authorization or audit messages.

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The Client Authentication Agent Actor also maintains an internal cache of credentials such as the
TGT and service tickets. It renews the tickets as necessary to deal with ticket expirations, re-uses
tickets while they are still valid, and removes credentials from the cache when the user session______________________________________________________________________________
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ends. The Client Authentication Agent shall make the Kerberos credentials available using the
local operating system mechanisms. Other IHE Actors that need the Kerberos credentials arestrongly encouraged to obtain them using the local operating system mechanisms. Operating
system support for ticket management has been implemented and has been defined for various
operating systems.
4.3.2 User Authentication with User Synchronized Applications Process Flow1135

In this use case an application supporting user authentication on the same desktop as anotherapplication is synchronized to the same user identity, thus giving the user a single-sign-on
experience.
The following diagram describes the sequence of events in the use of User Authentication with
User Synchronized Applications:
Client Authentication
Agent
Login orSession Start
Internal TGTManagement

Kerberos
Authentication Server

User Context
ParticipantContext Manager

Join Context
Get User
Authentication[ITI-2]

Internal
User
Authentication

Join Context[ITI-5]

Switch User
Identity

Follow Context[ITI-13]

Switch User
Identity to
NULL

Follow Context[ITI-13]

Change Context [ITI-6]

Logout or
Session End

Internal TGT
destruction

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Change Context [ITI-6](NULL)

Figure 4.3.2-1: Process Flow with User Synchronized Applications

The sequence of events of the User Authentication with User Synchronized Applications is:• The user initiates a login by starting the Client Authentication Agent.
• The Client Authentication Agent joins the CCOW user context by sending a Join Context
Transaction to the Context Manager Actor. At this point there is no user identity in thecontext.
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•
•
•

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The user provides their username and password to the Client Authentication Agent. Thisauthentication information is converted into the challenge/response system used by
Kerberos to avoid transmitting the password over the network. This information is usedas part of the Get User Authentication Transaction to get a “Ticket Granting Ticket”(TGT).
The TGT is saved and managed internally by the Client Authentication Agent Actor. The
TGT acts as confirmation that the user has been authenticated.
A Change Context Transaction is sent to the Context Manager Actor with the users fully
qualified user name.
The user is now logged in to the User Context Participant.
When the user ends the session, a Change Context Transaction is sent to the Context
Manager Actor with a NULL user name.
The user is logged out of the User Context Participant.

4.3.3 Fast User Switching with Multiple Applications Process Flow
The use model in the clinical environment can be characterized as multiple clinicians using thesame workstation for short intervals of time many times a day. In this shared workstation
environment the user requires quick access to the patient data contained in the applications.
Traditional methods of logging in and out of the workstation at the operating system or network
level can take too long and typically force the applications to terminate. This means that theapplication clients will potentially need to initialize and establish new database connections,introducing further delay to the Clinician access to patient data. The CCOW standard and more
specifically the “user” subject provides a means in combination with the Enterprise
Authenticator to allow the user to authenticate at the application level and have all of the otherapplications tune to the new user.
The following diagram describes the sequence of events in the case of Fast User Switching with
Multiple Applications:______________________________________________________________________________
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ClientAuthentication
Agent

User Context
Participant 1

Context
Manager

User Context
Participant 2

Join Context [ITI-5]
Get User
Authentication [ITI-2](from Kerberos
Authentication
Server), User A

Change Context [ITI-6]
Join Context [ITI-5]
Follow Context [ITI-13]

Join Context [ITI-5]
Follow Context [ITI-13]

User A
leaves area
Get User
Authentication [ITI-2](from Kerberos
Authentication
Server), User B

User B
Logs Out

Switch toUser A

Change Context [ITI-6]
Switch toUser B
User B closes
application

Follow Context [ITI-13]

Follow Context [ITI-13]

Switch toUser B

Leave Context [ITI-7]

Change Context [ITI-6]

Follow Context [ITI-13]
User B
logged Off

Figure 4.3.3-1: Fast User Switching when using Multiple Applications

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The process flow would be similar to the following:
Clinician A launches and authenticates via an application containing the Client Authentication
Agent (refer to Figure 4.3.3-1 for details). This actor joins the context session and performs acontext change to set Clinician A as the user in context.

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Clinician A launches the clinical data repository application, containing a User Context
Participant Actor, depicted as User Context Participant 1. The actor joins the context session,
gets the current user from the Context Manager, and logs clinician A into the application.
Clinician A launches a cardiology application, containing a User Context Participant Actor,
depicted as User Context Participant 2. The actor joins the context session, gets the current userfrom the Context Manager, and logs clinician A into the application.
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Clinician A does his job and then gets called away and leaves the workstation.
Clinician B approaches the workstation and authenticates using the Client Authentication Agent.
This results in a context change from Clinician A to Clinician B being set in context without thedelay typically associated with a logout and login at the operating system level. The clinical datarepository and the cardiology application are notified of the context change by the Context
Manager resulting in Clinician A being logged out of both applications and Clinician B being
logged into both applications.
Clinician B does his job and then closes the clinical data repository application, which leaves thecontext prior to terminating the application.

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Clinician B is finished reviewing patient data within the cardiology application and logs out
using the Client Authentication Agent. This forces a context change to remove the current userfrom the context, which results in the user being logged out of the cardiology application.

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5 Patient Identifier Cross-referencing (PIX)
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The Patient Identifier Cross-referencing Integration Profile (PIX) is targeted at healthcare
enterprises of a broad range of sizes (hospital, a clinic, a physician office, etc.). It supports the
cross-referencing of patient identifiers from multiple Patient Identifier Domains via thefollowing interactions:• The transmission of patient identity information from an identity source to the Patient
Identifier Cross-reference Manager.
• The ability to access the list(s) of cross-referenced patient identifiers either via a query/
response or via update notification.
By specifying the above transactions among specific actors, this integration profile does notdefine any specific enterprise policies or cross-referencing algorithms. By encapsulating thesebehaviors in a single actor, this integration profile provides the necessary interoperability while
maintaining the flexibility to be used with any cross-referencing policy and algorithm as deemed
adequate by the enterprise.
The following diagram shows the intended scope of this profile (as described above).
Patient Identity Feed
& Patient Identity
References

Patient
Identifier
Domain C

Patient
Identity
Feed

Patient Identity
SourceInternal
Domaintransactions

Patient Identifier
Cross-reference Domain
Patient Identifier
Cross-referenceManager
Patient
Identity
Feed

Patient
Identity
Cross
References

Patient Identity
SourceInternal
Domaintransactions

Patient Identifier
Cross-reference
ConsumerOther
IHE Actor

Patient Identifier
Cross-reference
ConsumerOther
IHE Actor

Patient Identifier
Domain A

Patient
Identity
Cross References

Patient Identifier
Domain B

Figure 5-1: Process Flow with Patient Identifier Cross-referencing

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The diagram illustrates two types of Identifier Domains: a Patient Identifier Domain and a
Patient Identifier Cross-reference Domain.
A Patient Identifier Domain is defined as a single system or a set of interconnected systems thatall share a common identification scheme (an identifier and an assignment process to a patient)______________________________________________________________________________
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and issuing authority for patient identifiers. Additionally, a Patient Identifier Domain has thefollowing properties:• A set of policies that describe how identities will be defined and managed according to
the specific requirements of the domain.
• An administration authority for administering identity related policies within the domain.
• A single system, known as a patient identity source system, that assigns a unique
identifier to each instance of a patient-related object as well as maintaining a collection ofidentity traits.
• Ideally, only one identifier is uniquely associated with a single patient within a given
Patient Identifier Domain, though a single Patient Identity Source Actor may assign
multiple identifiers to the same patient and communicate this fact to the Patient Identifier
Cross-reference Manager. For a description of how the Patient Identifier Cross-referenceManager Actor responds to requests for a list of cross-referenced identifiers that include
these “duplicates” see ITI TF-2a: 3.9.4.2.2.6).
• An “Identifier Domain Identifier” (known as assigning authority) that is unique within a
Patient Identifier Cross-reference Domain.
• Other systems in the Patient Identifier Domain rely upon the identifiers assigned by thepatient identity source system of the domain to which they belong.
A Patient Identifier Cross-reference Domain consists of a set of Patient Identifier Domains
known and managed by a Patient Identifier Cross-reference Manager Actor. The Patient
Identifier Cross-reference Manager Actor is responsible for creating, maintaining and providing
lists of identifiers that are aliases of one another across different Patient Identifier Domains.

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The Patient Identifier Cross-reference Domain embodies the following assumptions aboutagreement within the group of individual Identifier Domains:• They have agreed to a set of policies that describe how patient identities will be crossreferenced across participating domains;• They have agreed to a set of processes for administering these policies;• They have agreed to an administration authority for managing these processes andpolicies.
All these assumptions are critical to the successful implementation of this profile. This
integration profile imposes minimal constraints on the participating Patient Identifier Domains
and centralizes most of the operational constraints for the overall Patient Identification Crossreference Domain in the Patient Identifier Cross-reference Manager Actor. If the individual
Identifier Domains cannot agree to the items outlined above, implementation of this profile may
not provide the expected results.
The Patient Identifier Cross-reference Manager Actor is not responsible for improving thequality of identification information provided to it by the Identity Source Actors. It is assumed
that the Identity Source actors are responsible for providing high quality data to the Patient
Identifier Cross-reference Manager. For example, the Patient Identifier Cross-reference Manager
Actor is NOT responsible to provide a single reference for patient demographics. The intent is to______________________________________________________________________________
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leave the responsibility for the quality and management of its patient demographics informationand the integrity of the identifiers it uses within each Patient Identity Domain (Source actors).
When receiving reports and displays from multiple PIX domains, it is inevitable that some ofthose reports and displays will have inconsistent names.
The Patient Identifier Cross-reference Consumer may use either a query for sets of crossreference patient identifiers or use both a notification about cross-reference changes and a querytransaction. In the case of using a notification, the Patient Identifier Cross-reference Consumer
may also use the PIX Query Transaction to address situations where the Patient Identifier Crossreference Consumer may be out of synch with the Patient Identifier Cross-reference Manager.
This Integration Profile does not specify the consumer policies in using the PIX Query
Transaction (ITI TF-2a: 3.9).
For a discussion of the relationship between this Integration Profile and an enterprise masterpatient index (eMPI) see ITI TF-1: 5.4.

5.1 Actors/ Transactions
Figure 5.1-1 shows the actors directly involved in the Patient Identifier Cross-referencing
Integration Profile and the relevant transactions between them. Other actors that may be
indirectly involved due to their participation in other related profiles are not shown.
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Patient Identity Source

Patient Identity
Management
HL7 V2.5 [ITI-30]↓

Patient Identifier
Cross-reference
Consumer

Patient Identity Feed
[ITI-8]↓↓ PIX Query [ITI-9]↑ PIX Update Notification [ITI-10]

Patient Identifier Crossreference Manager

Figure 5.1-1: Patient Identifier Cross-referencing Actor Diagram

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Table 5.1-1 lists the transactions for each actor directly involved in the Patient Identifier Crossreferencing Profile. In order to claim support of this Integration Profile, an implementation must
perform the required transactions (labeled “R”). Transactions labeled “O” are optional. A
complete list of options defined by this Integration Profile and that implementations may choose
to support is listed in the ITI TF-1: 5.2.

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Table 5.1-1: Patient Identifier Cross-referencing Integration for MPI Profile - Actors andTransactions
ActorsTransactions

Patient Identity Source

Patient Identifier Cross-reference Consumer
Patient Identifier Cross-reference Manager

Optionality

SectionPatient Identity Feed [ITI-8]

R

ITI TF-2a: 3.8

Patient Identity Management [ITI30]

OITI TF-2b: 3.30

PIX Query [ITI-9]

R

ITI TF-2a: 3.9

PIX Update Notification [ITI-10]

O

ITI TF-2a: 3.10

Patient Identity Feed [ITI-8]

R

ITI TF-2a: 3.8

Patient Identity Management [ITI30]

OITI TF-2b: 3.30

PIX Query [ITI-9]

R

ITI TF-2a: 3.9

PIX Update Notification [ITI-10]

R

ITI TF-2a: 3.10

5.2 Patient Identifier Cross-referencing Integration Profile Options
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Options that may be selected for this Integration Profile are listed in the Table 5.2-1 along with
the Actors to which they apply. Dependencies between options when applicable are specified innotes.
Table 5.2-1: Patient Identifier Cross-referencing - Actors and Options
Actor

Options

Vol & Section

Patient Identity Source

Pediatric
Demographics

ITI TF-1: 5.2.1

Patient Identifier Cross-reference Manager

Pediatric
Demographics

ITI TF-1: 5.2.1

Patient Identifier Cross-reference Consumer

PIX Update Notification

ITI TF-2a: 3.10

5.2.1 Pediatric Demographics

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The experience of immunization registries and other public health population databases has
shown that matching and linking patient records from different sources for the same individual
person in environments with large proportions of pediatric records requires additional
demographic data.
In particular, distinguishing records for children who are twins, triplets, etc. – that is, avoiding
false positive matches - may be difficult because much of the demographic data for the two
individuals matches. For instance, twin children may have identical last names, parents,
addresses, and dates of birth; their first names may be very similar, possibly differing by only
one letter. It can be very difficult for a computer or even a human being to determine in thissituation whether the slight first name difference points to two distinct individuals or just atypographical error in one of the records. Additional information is extremely helpful in making
this determination.
Pediatric Demographics makes use of the following six additional demographic fields to aid
record matching in databases with many pediatric records.
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Field

Reason for inclusion

Value

Mother’s Maiden Name

Any information about the mother is
helpful in making a match

Helps create true positive matches

Patient Home
TelephoneA telecom helps match into the righthousehold

Helps create true positive matches

Patient Multiple Birth
Indicator

Indicates this person is a multiple twin, triplet, etc.

Helps avoid false positive matches ofmultiplesPatient Birth OrderDistinguishes among those multiples.

Helps avoid false positive matches ofmultiples

Last Update Date/Time,
Last Update Facility

These fields, although not strictly
demographic, can effectively substitutewhen multiple birth indicator and birthorder are not collected. They indirectly
provide visit information. Provider
visits on the same day may likely
indicate two children brought to adoctor together.

Helps avoid false positive matches ofmultiplesPatient Identity Source actors which support the Pediatric Demographics option are required tosupport the Patient Identity Management [ITI-30] transaction and shall provide values, whenavailable, for the fields identified as Pediatric Demographics fields.
Patient Identifier Cross-reference Manager actors which support the Pediatric Demographics
option are required to support the Patient Identity Management [ITI-30] transaction, and if values
for one or more of the Pediatric Demographics fields are specified in the Patient Identity
Management [ITI-30], they shall be considered as part of the matching algorithm of the PIXManager.

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Pediatric Demographics are defined as all of the following:• Mother’s Maiden Name
• Patient Home Telephone• Patient Multiple Birth Indicator• Patient Birth Order• Last Update Date/Time• Last Update Facility

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Pediatric Demographic is particularly focused on two data issues:• Locating a record where the data or the search criterion have differences, but both thedata record and the search criterion represent the same person, and______________________________________________________________________________
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Avoiding improper linkage of very similar records that do not belong to the same person.
This problem is most often encountered in multiple birth situations where twins may be
given extremely similar names

5.3 Patient Identifier Cross-referencing Profile Process FlowsThe following sections describe use cases that this profile addresses.
5.3.1 Use Case: Multiple Identifier Domains within a Single Facility/ Enterprise

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A clinician in the Intensive Care Unit at General Hospital is reviewing a patient chart on the
Intensive Care information system and wishes to review or monitor the patient’s glucose level,
which is included in a laboratory report stored in the hospital’s main laboratory system. The
Intensive Care system needs to map its own patient ID, which it generates internally, to thepatient’s medical record number (MRN), which is generated from the hospital’s main ADT
system and is used as the patient identity by the lab system. In this case the Intensive Caresystem is essentially in a different identifier domain than the rest of the hospital since it has its
own notion of patient identity.
In this scenario, the hospital’s main ADT system (acting as a Patient Identity Source) would
provide a Patient Identity Feed (using the patient’s MRN as the identifier) to the Patient
Identifier Cross-reference Manager. Similarly, the Intensive Care system would also provide a
Patient Identity Feed to the Patient Identifier Cross-reference Manager using the internallygenerated patient ID as the patient identifier and providing its own unique identifier domain
identifier.
Once the Patient Identifier Cross-reference Manager receives the Patient Identity Feedtransactions, it performs its internal logic to determine which, if any, patient identifiers can be“linked together” as being the same patient based on the corroborating information included in
the Feed transactions it has received. The cross-referencing process (algorithm, human decisions,etc.) is performed within the Patient Identifier Cross-reference Manager and is outside the scopeof IHE. (See ITI TF-2a: 3.9.4.2.2.6 for a more complete description of the scope of the crossreferencing logic boundary).
The Intensive Care system wants to get lab information associated with a patient that the
Intensive Care system knows as patient ID = ‘MC-123’. It requests the lab report from the lab
system using its own patient ID (MC-123) including the domain identifier/ assigning authority.
Upon receipt of the request, the lab system determines that the request is for a patient outside ofits own identifier domain (ADT Domain). It requests a list of patient ID aliases corresponding topatient ID = ‘MC-123’ (within the “Intensive Care domain”) from the Patient Identifier Crossreference Manager. Having linked this patient with a patient known by medical record number =‘007’ in the ‘ADT Domain’, the Patient Identifier Cross-reference Manger returns this list to thelab system so that it may retrieve the lab report for the desired patient and return it to the
Intensive Care system. Figure 5.3-1 illustrates this process flow.

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Patient Identity
Source (Intensive
Care domain)

Display (Intensive
Care domain)

Patient Identifier
Cross-referenceManager

Patient Identity
Source (ADTdomain)Patient Identifier Crossreference Consumer/Information Source (Labsystem - ADT domain)

Patient Identity Feed [ITI-8]
Apply Xref
logic

ADT feed within
Intensive Care ID
domainPatient Identity
Feed [ITI-8]
Apply Xref
logic

ADT feed
within ADT
ID domain

Retrieve Document for Display[ITI-12] - Request
PIX Query [ITI-9]

Retrieve Document for Display [ITI-12] - Response

Use
locally
known ID
to select
lab report

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Figure 5.3-1: Multiple ID Domains in a Single Facility Process Flow in PIX Profile
Note: Request and Response portions of the Retrieve Document for Display transaction are not part of this profile andincluded for illustration purposes only.

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5.3.2 Use Case: Multiple ID Domains Across Cooperating Enterprises
A healthcare enterprise is established by the consolidation of two hospitals, each having its own
separate patient registration process run by different hospital information systems. When apatient is treated in one hospital, the access to its electronic records managed by the otherhospital is necessary. The following use case illustrates this scenario.

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Hospitals A and B have been consolidated and have a single Patient Identifier Cross-referenceManager that maintains the ID links between the two hospitals. Each hospital has a different HIS
that is responsible for registering patients, but they have consolidated their cardiology
information systems. The cardiology system has been configured with a Patient Identifier Crossreference Consumer to receive patient identity notifications when cross-referencing activity
occurs.

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A patient is registered and then has some diagnostic stress tests done at hospital A. The
cardiology information system queries the Patient Identifier Cross-reference Manager to get a listof possible ID aliases for the patient to see if any past cardiology reports may be available. No
patient ID aliases are found. Sometime later the same patient goes to hospital B to have a second
diagnostic stress test done. The patient is registered via the HIS in hospital B which then sends______________________________________________________________________________
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that identity information to the Patient Identifier Cross-reference Manager. The Patient Identifier
Cross-reference Manager determines this is in fact the same patient as was registered previously
at hospital A. The cardiology information system was previously configured with the Patient
Identifier Cross-reference Manager to receive notifications, thus a notification is sent to thecardiology system to inform it of the patient identifier aliases. This notification is done to allow
systems that are aware of multiple identifier domains to maintain synchronization with patient
identifier changes that occur in any of the identifier domains that they are aware of.
Figure 5.3-2 illustrates the process flow for this use case.
Patient Identity
Source (domain
A)

Patient Identifier
Cross-referenceManager

Patient Identifier Crossreference Consumer(cardiology info system
in domain A)

Patient Identity
Feed [ITI-8]
ADT feed within
ID domain

PIX Query [ITI-9]

Patient Identity
Source (domain B)

Apply Xref
logic

Patient Identity
Feed [ITI-8]

PIX Update
Notification[ITI-10]

Apply Xref logic anddetermine consumers
interested in
notifications

Logic toconsolidate
internal data oflinked patients

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Figure 5.3-2: Multiple ID Domains Across Cooperating Enterprises Process Flow in PIX
ProfileNote: PIX Update Notifications are not sent for the first Patient Identity Feed for a patient, since no cross-referencing
activity occurred after this first Patient Identity Feed Transaction.
.

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5.3.3 Pediatric Demographic Option Use Cases
The following sections describe use cases that the Pediatric Demographics option addresses.
5.3.3.1 Use Case: High Quality Demographic Feed from a Birth Registry1405

A regional Immunization Information System (IIS) receives birth registry information about apair of twins. These twins are named “Lalainne” and “Lalannie” Smith. All of the data elementsin the received registration are populated, and they are all identical, except for the Given Name,
the Birth Order, and the Birth Certificate #. The IIS cross-referencing system can clearly
identify this very similar data as belonging to two separate individuals, because they are both
flagged as having been part of a Multiple Birth, their Birth Order numbers are different, and their
Birth Certificate #s are different.

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5.3.3.2 Use Case: Normal Demographic Feed from a Point of Care

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A couple years later, the mother of these two twins, who has now divorced and remarried, takes
them to Pediatric Healthcare, where they get the immunizations appropriate for 2 year olds.
Pediatric Healthcare completes a registration for each of them, and submits the resulting data to
the IIS. This data has their new Family Name as “Gomez,” but the clerks had appropriately
recorded the Birth Order of each twin. Again, the IIS was able to distinguish the two registration
records as belonging to separate individuals, and it was able to match them up to their earlier
records because the mother’s Maiden Name was present in both the earlier records and therecords submitted from Pediatric Healthcare. Pediatric Healthcare was able to download the fullimmunization history of each twin.

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5.3.3.3 Use Case: Minimal Demographic Feed from a Health Fair

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The Jackson County Health Department puts on an annual Health Fair in a shopping mall every
August, partly to screen school age children for the minimum shots required for admission to thefirst grade. Mrs. Gomez is now working to pay for her new apartment, but her sister-in-law takes
the children to the Health Fair where they are given shots based on the paper “yellow card” thesister-in-law brings with the two twins. Jackson County Health Department staff records thechildren’s names, and the shots they were given. This information is entered into the computer
back at the Clinic the next day, and submitted to the regional IIS.
At this point, even though both children’s names were misspelled as “Lane” and “Lanna”, theImmunization Registry was again able to recognize that the records belonged to twins rather than
the same person because, although the demographic data was almost identical, the Last Update
Date/Time were very close (Date was the same) and Last Update Facility indicated the same
clinic. Unfortunately, they didn’t write down the mother’s information at the Health Fair, but
recorded her sister-in-laws name and address instead, so the Immunization Registry was not able
to automatically link this new information to the information it already had for “Lalainne” and“Lalannie”.
Other Possibilities:______________________________________________________________________________
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A better outcome could have happened if the clinic had recorded any one of several different
data elements that would have helped tie this new data to the previous data. Any one of theMothers Maiden Name (even the Mother’s First Name component), the Home Phone Number, or
the unique identifier for the kids which was printed on the “yellow card” from PediatricHealthcare would have helped.

5.4 Relationship between the PIX Integration Profile and eMPI
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The PIX Integration Profile achieves the integration of disparate Patient Identifier Domains byusing a cross-referencing approach between Patient Identifiers associated with the same patient.
This section discusses how this approach is compatible with environments that wish to establish
master patient identifiers (MPI), or enterprise MPI (eMPI) systems. An eMPI may be considereda particular variation in implementation of the PIX Integration Profile.
The concept of an MPI is a rather broad concept, yet it is most often associated with the creationof a master patient identifier domain. Such a master domain is considered more broadly
applicable or more “enterprise-level” than the other patient identifier domains it includes. Such ahierarchical inclusion of patient identification domains into a “master patient identification
domain” can be considered a particular case of patient cross-reference, where the patient
identifiers in the various domains are cross-referenced to the patient identifiers of the masterdomain. Two possible configurations are depicted by Figure 5.4-1.

Patient Identity
Cross-referenceManager

Patient Identification
Domain C(Master Domain)

Patient Identification
Domain A

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Master Patient Index
MasterPatient
Index

Master (C) Patient
Identity Source

Patient Identity Cross-referenceManager

Patient Identification
Domain C(Master Domain)

Master (C) Patient
Identity Source

Patient Identification
Domain B

Patient Identification
Domain A

Two domains included in a Master Patient Index

Patient Identification
Domain B

The same configuration represented as 3 cross-referenced domains

Figure 5.4-1: PIX Profile Relationship to eMPI

Figure 5.4-1 above shows how the Master Patient Identifier Domain (Domain C), in a typical
MPI approach, is simply another patient Identification Domain when considered in a Crossreferencing approach. The decision to place enterprise-wide systems such as Clinical Data
Repositories into the so-called master domain is simply a configuration choice. In addition, sucha configuration sometimes assumes that any system in Patient Domain A not only manages the______________________________________________________________________________
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patient Identifiers of Domain A but is also aware of those of Domain C. In the Patient Identifier
Cross-reference Integration Profile, this is a configuration choice where certain systems havebeen designed and configured to operate across multiple domains. Thus the entity often called an
MPI (shown by the oval) is actually the combination of a Patient Identity Source Actor (ADT)
along with a Patient Identifier Cross-reference Manager.
The PIX Integration Profile can coexist with environments that have chosen to deploy a distinct
MPI, and provides a more scalable approach. Many other configurations can also be deployed, inparticular those where the creation of a master domain “including” the other domains is notnecessary (i.e., a simple federation of domains where none is actually the master).

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6 Patient Synchronized Applications (PSA)
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The Patient Synchronized Applications Profile (PSA) enables single patient selection for theuser working in multiple applications on a workstation desktop. With this Integration Profile
patient selection in any of the applications causes all other applications to tune to that same
patient. This allows a clinician to use the application they are most familiar with to select thepatient and have that selection reflected in the other applications they are using follow along.
This profile leverages the HL7 CCOW standard, specifically for patient subject context
management. The scope of this profile is for sharing of the CCOW Patient subject only. The IHE
PSA profile adds value to the CCOW specification for the patient subject by further constraining
the patient identifier to ensure consistency across applications supporting PSA, providing
guidance for consistent behavior across applications supporting PSA and ensuring consistentinteraction with the Patient Identifier Cross-reference Consumer Actor across the enterprise.
For applications that require user authentication, IHE recommends implementation of theEnterprise User Authentication Profile, as opposed to other means, such as a CCOW
Authentication Repository. ITI TF-1:4 describes the Enterprise User Authentication Profile andthe use of the CCOW user subject.

6.1 Actors/ Transactions
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Figure 6.1-1 shows the actors directly involved in the Patient Synchronized Applications
Integration Profile and the relevant transactions between them. Other actors that may be
indirectly involved due to their participation in other profiles are not shown.

Join Context [ITI-5] →Patient Context
Participant
Actor

Change Context [ITI-6] →← Follow Context [ITI-13]

Context Manager
Actor

Leave Context [ITI-7] →Figure 6.1-1: Patient Synchronized Applications Profile Actor Diagram

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Table 6.1-1 lists the transactions for each actor directly involved in the PSA Profile. In order toclaim support of this Integration Profile, an implementation must perform the required
transactions (labeled “R”).
The Patient Context Participant Actor shall support all four transactions identified in Figure 6.1-1
as defined in ITI TF-2a. The Patient Context Participant Actor shall respond to all patient context
changes. This actor shall set the patient context provided the application has patient selection
capability.

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It may include a number of other components such as the context management registry andpatient mapping agent.
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The Context Manager Actor may be grouped with a Patient Identifier Cross-referencing (PIX)
Consumer Actor of the Patient Identity Cross-referencing Profile; see ITI TF-2x: Appendix D fora description of the additional responsibilities placed on the Context Manager Actor in this case.
Table 6.1-1: Patient Synchronized Applications Integration Profile - Actors andTransactions
ActorsTransactions

Patient Context ParticipantContext Manager

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Optionality

SectionJoin Context [ITI-5]

R

ITI TF-2a: 3.5

Change Context [ITI-6]

R

ITI TF-2a: 3.6

Leave Context [ITI-7]

R

ITI TF-2a: 3.7

Follow Context [ITI-13]

R

ITI TF-2a: 3.13

Join Context [ITI-5]

R

ITI TF-2a: 3.5

Change Context [ITI-6]

R

ITI TF-2a: 3.6

Leave Context [ITI-7]

R

ITI TF-2a: 3.7

Follow Context [ITI-13]

R

ITI TF-2a: 3.13

6.2 Patient Synchronized Applications Integration Profile Options
Options that may be selected for this Integration Profile are listed in Table 6.2-1 along with theactors to which they apply. Dependencies between options, when applicable, are specified innotes.
Table 6.2-1: Patient Synchronized Applications - Actors and Options

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Actor

Options

Vol & Section

Patient Context Participant

No options defined--Context Manager

No options defined--

6.3 Patient Synchronized Applications Integration Profile Process
Flows
The Patient Synchronized Applications Integration Profile provides maximum value when a userneeds to use more than one application simultaneously. The process flow outlined in ITI TF-1:
6.3.1 depicts a use case where the applications only participate in the PSA profile. The process
flow outlined in ITI TF-1: Appendix E illustrates when the PSA and Enterprise User
Authentication (EUA) profiles are deployed together.
6.3.1 Use Case: Simple Patient Switching
When the PSA profile is not grouped with EUA profile only the patient identity is passed incontext. This use case does not explicitly identify the method of user authentication, as it may______________________________________________________________________________
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not be required by the application or may be accomplished by other means. In this use case both
applications share the same patient identifier domain. The process flow for this use case is:
The clinician launches the clinical data repository application, depicted as Patient Context
Participant Actor 1. The clinical data repository application joins the context session for theclinician desktop.

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The clinician selects patient A in the clinical data repository application. The clinical datarepository application sets the identifier for patient A in context.
The clinician launches a cardiology application, depicted as Patient Context Participant Actor 2.
The Cardiology application joins the context session, gets the identifier for patient A fromcontext, and tunes its display to patient A.

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The clinician selects patient B in the cardiology application. This action results in the initiationof a Change Context transaction by the cardiology application (Patient Context Participant Actor
2). All non-instigating applications participate via the Follow Context transaction, which resultsin the selected patient being displayed in the clinical data repository application (Patient Context
Participant Actor 1).

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The clinician closes the clinical data repository application. The clinical data repository
application leaves the context prior to terminating the application.
The clinician closes the cardiology application. The cardiology application leaves the context
prior to terminating the application.
Figure 6.3-1 illustrates the process flow for this use case.

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Patient Context
Participant 1(clinical datarepository)

Context
Manager

Patient Context
Participant 2(cardiology)

Join Context [ITI-5]
User selects
patient A

Change Context [ITI-6]

Join Context [ITI-5]
Follow Context [ITI-13]
Application tunes topatient A

Follow Context [ITI-13]
User closes
application

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Change Context [ITI-6]

User selects patient
B

Leave Context [ITI-7]

User closes
application

Leave Context [ITI-7]

Figure 6.3-1: Simple Patient Switching Process Flow______________________________________________________________________________
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7 Consistent Time (CT)
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The Consistent Time Integration Profile (CT) provides a means to ensure that the system clocks
and time stamps of the many computers in a network are well synchronized. This profile
specifies synchronization with a median error less than 1 second. This is sufficient for most
purposes.
The Consistent Time Integration Profile defines mechanisms to synchronize the time basebetween multiple actors and computers. Various infrastructure, security, and acquisition profiles
require use of a consistent time base on multiple computers. The Consistent Time profile
requires the use of the Network Time Protocol (NTP) defined in RFC 1305. When the Time
Server is grouped with a Time Client to obtain time from a higher tier Time Server, the Time
Client shall utilize NTP. For some Time Clients that are not grouped with a Time Server, SNTP
may be usable.
This profile was previously a portion of the Radiology Basic Security Profile, but it has a variety
of other infrastructure uses.
Note:

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This profile corresponds to a portion of the IHE Radiology Technical Framework, Basic Security Profile. It is
required by more than just radiology systems. It is needed by several of the profiles in the IHE IT Infrastructure
and will also be needed by Cardiology. It is therefore being re-located from IHE Radiology into IHE IT
Infrastructure. There are no changes to the requirements, so actors that supported the Radiology Basic Secure
Node or Time Server do not need modification. The Maintain Time [RAD TF-3: 4.33] transaction fromRadiology and the Maintain Time [ITI TF-2a: 3.1] transaction for IT Infrastructure are the same.

7.1 Actors/ Transactions
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Figure 7.1-1 shows the actors directly involved in the Consistent Time Profile and the relevanttransactions between them. Other actors that may be indirectly involved because of their
participation in profiles that require consistent time are not shown.

Time Server

Maintain Time
[ITI-1]↑Time Client

Figure 7.1-1: Consistent Time Profile Actor Diagram

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Table 7.1-1 lists the transactions for each actor directly involved in the Consistent Time
Integration Profile. In order to claim support of this integration profile, an implementation must
perform the required transactions (labeled “R”).
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Table 7.1-1: Consistent Time - Actors and Transactions
Optionality

SectionTime Server

Actors

Maintain Time [ITI-1]

TransactionsR

ITI TF-2a: 3.1

Time Client

Maintain Time [ITI-1]

R

ITI TF-2a: 3.1

7.2 Consistent Time Integration Options
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Options that may be selected for this integration profile are listed in the Table 7.2-1 along withthe actors to which they apply.
Table 7.2-1: Consistent Time - Actors and Options
Actor

Options

Vol & Section

Time Server

Secured NTP

ITI TF-2a: 3.1.4-1Time Client

SNTP, Secured NTP

ITI TF-2a: 3.1.4-1

7.3 Consistent Time Process Flow
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This section describes the typical flow related to the Consistent Time Profile. In the process flow
Figure 7.3-1, the Time Client B and Time Server B have been grouped. When a Client andServer are grouped they utilize internal communications mechanisms to synchronize their time.
Time Server A

Time Client C

Time Client B

Maintain Time [ITI-1]

Time Server B
Maintain Time [ITI-1]

Maintain Time [ITI-1]

Figure 7.3-1: Basic Process Flow in Consistent Time Profile

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The Time Client B maintains time synchronization with the Time Server A. The Time Server B
is internally synchronized with Time Client B. The Time Client C maintains timesynchronization with Time Server B.
The NTP protocol has been designed to provide network time services for synchronization withthis kind of cascaded synchronization. The achievable accuracy is dependent on specific detailsof network hardware and topology, and on details of computer hardware and software
implementation. The Time Server and Time Client are grouped to provide synchronizationcascading and reduce network traffic.
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8 Patient Demographics Query (PDQ)
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The Patient Demographics Query Integration Profile (PDQ) provides ways for multiple
distributed applications to query a patient information server for a list of patients, based on userdefined search criteria, and retrieve a patient’s demographic (and, optionally, visit or visitrelated) information directly into the application.

8.1 Actors/ Transactions
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Figure 8.1-1 shows the actors directly involved in the Patient Demographics Query Integration
Profile and the relevant transactions between them. Other actors that may be indirectly involved
due to their participation in Patient ID Cross-referencing, etc. are not necessarily shown.

Patient Demographics
Supplier

Patient
Demographics
Query [ITI-21] ↑↑ Patient Demographics andVisit Query [ITI-22]

Patient Demographics
Consumer

Figure 8.1-1: Patient Demographics Query Profile Actor Diagram

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Table 8.1-1 lists the transactions for each actor directly involved in the Patient Demographics
Query Profile. In order to claim support of this Integration Profile, an implementation must
perform the required transactions (labeled “R”). Transactions labeled “O” are optional. A
complete list of options defined by this Integration Profile and that implementations may choose
to support is listed in ITI TF-1: 8.2.
Table 8.1-1: Patient Demographics Query Integration Profile - Actors and Transactions
ActorsTransactions

Optionality

SectionPatient Demographics Consumer

Patient Demographics Query [ITI-21]

R

ITI TF-2a: 3.21

Patient Demographics and Visit Query[ITI-22]OITI TF-2a: 3.22

Patient Demographics Query [ITI-21]

R

ITI TF-2a: 3.21

Patient Demographics and Visit Query[ITI-22]OITI TF-2a: 3.22

Patient Demographics Supplier______________________________________________________________________________
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8.2 Patient Demographics Query Integration Profile Options
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Options that may be selected for this Integration Profile are listed in Table 8.2-1 along with theactors to which they apply. Dependencies between options when applicable are specified innotes.
Table 8.2-1: Patient Demographics Query - Actors and Options
Actor

Options

Vol & Section

Patient Demographics Consumer

Patient Demographics and Visit Query

ITI TF-2a: 3.22

Pediatric Demographics

ITI TF-1: 8.2.2

Patient Demographics and Visit Query

ITI TF-2a: 3.22

Pediatric Demographics

ITI TF-1: 8.2.2

Patient Demographics Supplier8.2.2 Pediatric Demographics
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The experience of immunization registries and other public health population databases has
shown that retrieving patient records for an individual person in environments with large
proportions of pediatric records requires additional demographic data.
Information about the mother of the patient or a household telephone number is helpful inretrieving records in large population databases where data quality may be uneven.

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Certain other demographics fields are important to include in the query response as they may be
used by the Patient Demographics Consumer in verifying the identity of the patient, in particular,
they aid in distinguishing records for twins, triplets, and so forth.
Pediatric Demographics makes use of the following six additional demographic fields to aid
record matching in databases with many pediatric records.
Field

Reason for inclusion

Value

Mother’s Maiden Name

Any information about the mother is
helpful in making a match

Helps create true positive matches

Patient Home
TelephoneA telecom helps match into the righthousehold

Helps create true positive matches

Patient Multiple Birth
Indicator

Indicates this person is a multiple twin, triplet, etc.

Helps avoid false positive matches ofmultiplesPatient Birth OrderDistinguishes among those multiples.

Helps avoid false positive matches ofmultiples

Last Update Date/Time,
Last Update Facility

These fields, although not strictly
demographic, can effectively substitute

Helps avoid false positive matches ofmultiples______________________________________________________________________________
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Field

Reason for inclusion

Value

when multiple birth indicator and birthorder are not collected. They indirectly
provide visit information. Provider
visits on the same day may likely
indicate two children brought to adoctor together.

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Patient Demographics Consumer actors which support the Pediatrics Demographics option will
be able to provide Pediatric Demographics query parameter fields in the Patient Demographics
Query transaction [ITI-21], and shall be able to receive and process any values returned for thefields identified as Pediatric Demographics.
Patient Demographics Supplier actors which support the Pediatrics Demographics option will beable to match on values provided for any Pediatric Demographics fields in the Patient
Demographics Query transaction [ITI-21]. and shall return values, when available, for the fields
identified as Pediatric Demographics.
Pediatric Demographics query parameter fields are:• Mother’s Maiden Name
• Patient Home Telephone
Pediatric Demographics are defined as all of the following:• Mother’s Maiden Name
• Patient Home Telephone• Patient Multiple Birth Indicator• Patient Birth Order• Last Update Date/Time• Last Update Facility

8.3 Patient Demographics Query Process Flow
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The Patient Demographics Supplier performs the following functions.
• It receives patient registration and update messages from other systems in the enterprise(e.g., ADT Patient Registration systems), which may or may not represent different
Patient ID Domains. The method in which the Patient Demographics Supplier obtains
the updated patient demographic information is not addressed by this profile.
• It responds to queries for information.

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Specific methods for acquiring demographic information are beyond the scope of this Profile. It
is a prerequisite that the Patient Demographics Supplier possess current demographic
information. One method by which current demographic information may be obtained is for the
Patient Demographic Supplier to be grouped with another IHE actor, such as Order Filler, thateither maintains or receives such information.

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In all cases, the Patient Demographics Supplier receives a Patient Demographics Query or
Patient Demographics and Visit Query request from the Patient Demographics Consumer, and______________________________________________________________________________
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returns demographics (and, where appropriate, visit) information from the single domain that is
associated with the application to which the query message is sent. Identifier information may
be returned from multiple or single domains; see the “Using Patient Data Query (PDQ) in a
Multi-Domain Environment” section (ITI TF-2x: Appendix M) for a discussion of thearchitectural issues involved.
Use Case 1: Patient Information Entering at Bedside

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An admitted patient is assigned to a bed. The patient may or may not be able to provide
positive ID information. The nurse needs to enter patient identity information into somebedside equipment to establish the relationship of the assigned bed to the patient. The
equipment issues a query for a patient pick list to a patient demographics supplier thatprovides data for a patient pick list. Search criteria entered by the nurse might include
one or more of the following:• Partial or complete patient name (printed on the patient record or told by thepatient)• Patient ID (this may be obtained from printed barcode, a bed-side chart, etc.)• Partial ID entry or scan.
• Date of birth / age range• Bed ID
The system returns a list of patients showing the MRN, full name, age, sex, room/bed,
and admit date, and displays the list to the nurse. The nurse then selects the appropriate
record to enter the patient identity information into the bedside equipment application.
Use Case 2: Patient Identity Information Entering in Physician Offices

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A patient visits a physician office for the first time. The nurse needs to register thepatient; in doing so, it is desired to record the patient’s demographic data in the practicemanagement information system (PMIS). The physician office is connected to a hospitalenterprise’s central patient registry. The nurse issues a patient query request to the central
patient registry, with some basic patient demographics data as search criteria. In the
returned patient list, she picks up an appropriate record for the patient, including the
hospital’s patient ID, to enter into the PMIS. (Note that the PMIS uses a different Patient
ID domain than that of the central patient registry.)
The PMIS uses its own patient identifier, coordinating this identifier with the patient
identifier returned in the pick list (sharing the hospital’s Patient ID Domain) to retrieve
information from the hospital’s clinical repository.

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Use Case 3: Patient Demographics Query in an Enterprise with Multiple Patient ID Domains
A lab technician enters some basic demographics data (e.g., patient name) into a lab
application to query a patient demographics supplier to identify a patient for his lab
exams. As the application also needs the patient identifier in another Patient ID Domain
in the enterprise for results delivery, the application is configured to receive patient IDs
from other domains in the query response.
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Patient Demographics
Consumer

Patient Demographics
Supplier

Patient Demographics Query[ITI-21]
Patient Demographics Response[ITI-21]

Patient Demographics and Visit
Query [ITI-22]

Patient Demographics and Visit
Response [ITI-22]

Figure 8.2-1: Basic Process Flow in Patient Demographics Query Profile

8.3.1 Combined Use of PDQ with Other IHE Workflow Profiles
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When the Patient Demographics Supplier Actor is grouped with actors in other IHE profiles that
perform patient information reconciliation activities (e.g., Radiology PIR), the PDQ Supplier
Actor may use the updated information to respond to PDQ Queries. In addition, the Patient
Demographics Query Profile may play an integral workflow role in conjunction with other IHE
Profiles.

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8.3.2 Supplier Data Configuration
A Patient Demographics Supplier Actor that holds demographic information for a single Patient
ID domain shall provide matches in that domain.

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In the case where the Patient Demographics Supplier Actor holds demographic information for
multiple Patient ID domains, the Patient Demographics Supplier Actor shall return information
for the domain associated with MSH-5-Receiving Application and MSH-6-Receiving Facility.
See the “Using Patient Data Query (PDQ) in a Multi-Domain Environment” section (ITI TF-2x:
Appendix M) for a further discussion of this case and an illustration of the supportingarchitecture.
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9 Audit Trail and Node Authentication (ATNA)

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The Audit Trail and Node Authentication (ATNA) Integration Profile establishes security
measures which, together with the Security Policy and Procedures, provide patient information
confidentiality, data integrity and user accountability. This environment is considered the
Security Domain and can scale from a department, to enterprise or XDS Affinity Domain. The
ATNA model considers that within the secure domain the following is true:

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1. All machines are host authenticated. (There are various means of accomplishing this.)This authentication identifies the machine as being one that is known to the security
system of the hospital, with known security characteristics. Unknown machines might be
granted access, but with the caveat that they are only granted access to information that is
authorized for disclosure to the public or to unknown machines. (A patient might choose
to allow information such as appointment schedules to be at risk of machine disclosure by
unknown machines while not allowing more sensitive PHI to be disclosed.)
2. The host identification is used to determine what (if any) access should be granted toautomated processes on that host, and/or persons under the direction of that host’s access
controls. In practice the automated processes play a critical role, managing issues likepre-fetching, thus person authentication/identification is not sufficient.
3. The secure node is responsible for providing reasonable access controls. This typically
includes user authentication and authorization. The value of this user authentication needs
to be balanced against the possible safety and patient health impacts of delaying deliveryof care by the additional authentication steps.
4. The secure node is also responsible for providing security audit logging to track security
events. In healthcare this audit log is often more useful than strict access controls andshould be relied upon even in emergencies.

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This model is partially driven by the underlying assumption that there will be situations where
documents are being exchanged between machines and stored on the recipient. This is partly
driven by the need for healthcare systems to operate in disasters and overload situations, where
the network operation is limited or destroyed. It is not safe to assume that clients are display
only. So there will be semi-permanent copies of most information kept. Even in normal
operation, healthcare providers may have only 15 minutes per patient. Good healthcare systemdesign recognizes the need to not waste any of those seconds searching and transferring
documents over a network. The documents are transferred in advance, and are kept locally until
it is determined that they are no longer needed. There are thin client display only applications inhealthcare, but they are limited to uses that can fail without introducing risks to safety or patient
health, but a complete security/privacy design requires handling situations where data is stored
after retrieval.
ATNA Governance Assumptions
The underlying assumptions are:______________________________________________________________________________
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•

•
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•

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•

•
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All systems that are members of the secure domain implement a Secure Node Actor for the
ATNA profile. The ATNA profile defines transactions between the secure nodes to create asecure domain that is under the management of a domain security officer.
All applications on a secure node will comply with ATNA requirements, regardless ofwhether they are IHE Actors or not. They apply to all IT assisted activities that directly
create, access, update, and delete PHI, not only those specified by IHE and performed by
IHE actors.
IHE addresses only those security requirements related to systems within the scope of IHE
healthcare applications. It does not address other security requirements such as defending
against network attacks, virus infection, etc. The principal objective of the Audit Trail
mechanism is to track data access to PHI, not IHE transactions.
Mobile equipment can participate in the Audit Trail and Node Authentication Integration
Profile, but special issues related to mobile equipment are not explicitly addressed in thisprofile.
ATNA assumes that physical access control, personnel policies and other organizational
security considerations necessary to make an enterprise compliant with security and privacy
regulations are in place.

9.1

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Authentication

ATNA contributes to access control by limiting network access between nodes and limiting
access to each node to authorized users. Network communications between secure nodes ina secure domain are restricted to only other secure nodes in that domain. Secure nodes limit
access to authorized users as specified by the local authentication and access control policy.
9.1.1 User Authentication

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The Audit Trail and Node Authentication Integration Profile requires only local user
authentication. The profile allows each secure node to use the access control technology of its
choice to authenticate users. The use of Enterprise User Authentication is one such choice, but it
is not necessary to use this profile.
9.1.2 Connection Authentication

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The Audit Trail and Node Authentication Integration Profile requires the use of bi-directional
certificate-based node authentication for connections to and from each node. The DICOM, HL7,
and HTML protocols all have certificate-based authentication mechanisms defined. Theseauthenticate the nodes, rather than the user. Connections to these machines that are not bidirectionally node-authenticated shall either be prohibited, or be designed and verified to prevent
access to PHI.
Note:

1800

Communications protocols that are not specified by IHE profiles, e.g., SQL Server, must be bi-directionallyauthenticated if they will be used for PHI. This profile does not specify how that authentication is to be
performed.

This requirement can also be met by ensuring complete physical network security with strict
configuration management. This means that no untrusted machine can obtain physical access to______________________________________________________________________________
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1810

any portion of the network. Making the connection authentication configurable enhances
performance in physically secured networks. A Secure Node Actor shall be configurable tosupport both connection authentication and physically secured networks.
IHE does not mandate the use of encryption during transmission. Most hospital networks
provide adequate security through physical and procedural mechanisms. The additional
performance penalty for encryption is generally not justified for these networks. This profile
mandates the use of the TLS security negotiation mechanism for all communications between
secure nodes as a means of ensuring that they only communicate with other authorized securenodes. It permits the negotiation of encryption if both nodes are configured to request andsupport encryption. This allows installation of IHE secure nodes into environments where the
network is not otherwise secured.

9.2 Audit Trails
1815

1820

1825

1830

1835

User Accountability is provided through Audit Trail. The Audit Trail needs to allow a security
officer in an institution to audit activities, to assess compliance with a secure domain’s policies,
to detect instances of non-compliant behavior, and to facilitate detection of improper creation,access, modification and deletion of Protected Health Information (PHI). PHI is considered to be
the patient-identifiable information records (e.g., Registration, Order, Study/Procedure, Reports,
Images, and Presentation States). PHI may be accessed by users or exchanged between thesystems. This includes information exported to and imported from every secured node in the
secure domain.
The user accountability is further enhanced through a standards based Centralized Audit Record
Repository, that provides a central Audit Record repository as the simplest means to implement
security requirements. A transfer of Audit Records from all the IHE actors to the Audit Record
Repository reduces the opportunities for tampering and makes it easier to audit the department.
Disconnected nodes may store audit data for transfer to the Audit Repository upon reconnection
to the secure domain network.
The audit trail contains information so that questions can be answered such as:• For some user: which patients’ PHI was accessed?
• For some patient PHI: which users accessed it?
• What user authentication failures were reported?
• What node authentication failures were reported?
The Audit Trail and Node Authentication Profile provides tools that are useful for enterprises
attempting to become compliant with privacy and security regulations (HIPAA, European,
Japanese, etc.), but the profile does not itself make the enterprise compliant. For guidance on
proper audit log management enterprises should look to documents such as NIST SP 800-92 –Guide to Computer Security Log Management.

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9.2.1 Audit Messages
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1845

The use of auditing as part of a security and privacy process is appropriate for situations where
the people involved are generally trustworthy and need a wide range of flexibility to respondrapidly to changing situations. This is the typical healthcare provider environment. Auditing
tracks what takes place, and the people involved know that their actions are being audited. Thismeans that the audit records must capture event descriptions for the entire process, not just forindividual components that correspond to individual IHE actors.
The IHE audit trail is the first of several profiles that correspond to different forms of access
control and authentication. Auditing is always needed independent of the access control andauthentication method chosen.
The IHE-specified audit flow is illustrated in Figure 9.2-1.

1850

1855

1860

1.

Real world activities take place, and some of these activities involve the applications
processing of a device that includes support for some IHE profiles. This product hascomponents that may correspond to specific IHE Actors. The product may also haveother capabilities that are independent of IHE recommendations.

2.

A wide variety of events take place during this process. Some of these events are
directly related to IHE Actor activities. Others may be indirectly related, and stillothers are not related to any IHE specification. The events are both extremely detailed
minor events, such as keystrokes, and high level events such as analyzing a diagnostic
study. Very few of these events are relevant to security and privacy auditing. Most are
too low level to be useful or are otherwise irrelevant.

3.

The “Security Audit and Access Accountability Message XML Data Definitions for
Healthcare Applications” (RFC-3881) defines an XML schema for reporting events thatare relevant to security and privacy auditing. It was defined in cooperation with the
ASTM, HL7, and DICOM standards organizations and the NEMA/COCIR/JIRA
Security and Privacy Committee. The IHE recommends the use of the RFC-3881
format, and recommends reporting only events that it can describe.

4.

DICOM has standardized some of the audit message vocabulary. The DICOM Audit
Message Vocabulary extends the basic vocabulary provided with RFC-3881, and also
further specifies some optional elements in RFC-3881. An example of vocabularyextension is the addition of a coded value to indicate that a field contains a DICOM
Study Instance UID. An example of optional element specification is the requirementthat the UserID field in RFC-3881 messages shall be the user ID used by the local
device operating system, and that the AlternateID shall be the user ID used by theenterprise authentication system (if it is different).

5.

This profile defines other events that do not correspond to events defined in the
DICOM vocabulary. These events are describable by RFC-3881, and this profile
includes requirements for such descriptions.

6.

IHE auditing specifies that when using the RFC-3881, events that can be describedusing the DICOM vocabulary they shall be reported using the DICOM vocabulary,

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even if the device is not otherwise a DICOM compliant device. Events that do notmatch the DICOM vocabulary shall be reported using RFC-3881 vocabulary or otherextensions. Events that cannot be reported using RFC-3881 are not candidates forreporting.

1880

7.

The local site will then apply its own reporting policies. The IHE profile specifies thecapabilities that should be present for audit reporting, and also that there should becontrols present to allow the local site security administration to control reporting
detail. The IHE profile does not specify any audit reporting functions or formats.

8.

IHE specifies events that must be reported in the audit trail. There are other events
related to security, which may be reported in the audit trail or by other means. This
profile does not describe them and does not require that they use this reporting format
or mechanism. Examples of such events are OS login, network routing and firewall
logs.

1885

1890

Product
Capabilities

IETF CAM

Standard Audit
Vocabularies (e.g.
DICOM)
Product Audit
Capabilities
Reported Events

Application
Audit Repository

Application
Activities

SystemAll Events

Items in Bold outline
are defined by the
ATNA profile

1895

IHE Audit
Vocabulary
Extensions

Reportable Events

Site Policies

Describable
EventsFigure 9.2-1: Flow of Events into Audit Messages______________________________________________________________________________
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9.2.2 Backwards Compatibility

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1905

This profile also defines the continued use of messages that are formatted in accordance with the
IHE Provisional Audit Message format from the deprecated Basic Security Profile in IHE
Radiology Technical Framework. This older format describes events that are suitable forreporting in Radiology and other diagnostic and treatment activities. These events are a subset of
the kind of events that can be described using RFC-3881 and the DICOM vocabulary.
The IHE ATNA Profile also allows for the reporting of these events using the Provisional format
over either of the IHE specified transport mechanisms. The intention is that products will
gradually transition from the Provisional message format to RFC-3881 format, but it isrecognized that this transition will take time and that there is a significant installed base.
The Provisional format is unlikely to be of interest to other healthcare applications, which should
use the RFC-3881 format and DICOM Vocabulary where appropriate.

9.3 Audit Trail Transport
1910

The Audit Trail and Node Authentication Integration Profile specifies the use of Syslog
Protocols as the mechanism for logging audit record messages to the audit record repository.
There are two recognized transports specified:

1915

1920

1) Transmission of Syslog Messages over UDP (RFC5426) with The Syslog Protocol (RFC5424)
which formalizes and obsoletes Syslog (RFC-3164). There are, several known limitations thatseem significant but have not been a problem in practice:• There is no confirmation to the sender that the audit record message was received at thedestination• There is no option to encrypt the audit record messages• Authentication by means of certificates of the sending nodes and the central audit repository
is not possible• Messages may be truncated or lost.
2) Transmission of Syslog Messages over TLS (RFC5425) with The Syslog Protocol (RFC5424)
which formalizes sending syslog messages over a streaming protocol protectable by TLS.

9.4 Actors/Transactions
1925

Table 9.4-1 lists the transactions for each actor directly involved in the Audit Trail and Node
Authentication Integration Profile. In order to claim support of this Integration Profile, animplementation must perform the required transactions (labeled “R”). Transactions labeled “O”
are optional. A complete list of options defined by this Integration Profile that implementations
may choose to support is listed in ITI TF-1: 9.4. Their relationship is shown in Figure 9.4-1.

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Secure Nodegrouped with
Any IHE Actor

Time Server

ITI-20: Record Audit Event↓ ITI-1:

Maintain Time

Secure Nodegrouped with
PHI Application↔ ITI-20: Record
Audit Event

Audit Repository

ITI-19: Node
Authentication 
Secure Nodegrouped with
Any IHE Actor

1930

ITI-20: Record Audit Event↑Figure 9.4-1: Audit Trail and Node Authentication Diagram

When an implementation chooses to support this Integration Profile for an actor, that actor shallbe grouped with the Secure Node actor. It is required that all IHE actors and any other activities
in this implementation support the Audit Trail and Node Authentication Integration Profile.
1935

A means must be provided to upload the required certificates to the implementation, e.g., via
floppy disk or file transfer via network.
Non-IHE applications that process PHI shall detect and report auditable events, and protect
access.

1940

Table 9.4-1: Audit Trail and Node Authentication Integration Profile - Actors andTransactions
Actor

Transactions

Optionality

SectionAudit Record Repository

Record Audit Event [ITI-20]

R

ITI-2a: 3.20

Secure Node

Authenticate Node [ITI-19]

R

ITI-2a: 3.19

Record Audit Event {ITI-20}

R

ITI-2a:3.20

Secure Application

Maintain Time [ITI-1]

R

ITI-2a: 3.1

Authenticate Node [ITI-19]

O

ITI-2a: 3.19

Maintain Time [ITI-1]

O

ITI-2a: 3.1

Record Audit Event [ITI-20]

O

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1950

1.

The Authenticate Node transaction for all network connections that may expose private
information as specified in ITI TF-2a: 3.19.

2.

All local user activity (login, logout, etc.) protected to ensure only authorized users.

3.

The Record Audit Event as specified in ITI TF-2a: 3.20

The difference between the Secure Node and the Secure Application is the extent to which theunderlying operating system and other environment are secured. A Secure Node includes all
aspects of user authentication, file system protections, and operating environment security. The
Secure Application is a product that does not include the operating environment. The Secure
Application provides security features only for the application features. See ITI TF-1: 9.7 for the
relationships among a Secure Node, Secure Application, and other actors.
1. The Audit Repository shall support:

1955

1960

2. Both audit transport mechanisms.
3. Any IHE-specified audit message format, when sent over one of those transportmechanisms. Note that new applications domains may have their own extended
vocabularies in addition to the DICOM and IHE vocabularies. This also means that an
ATNA Audit Repository is also automatically a Radiology Basic Security profile Audit
Repository because it must support the IHE Provisional Message format and it must
support the BSD syslog protocol.
4. Self protections and user access controls.
This profile does not specify other functions for the Audit Repository, but it is expected thatmost repositories will perform screening, reporting, archival, etc.

1965

9.5 ATNA Integration Profile Options
Options that may be selected for this Integration Profile are listed in the Table 9.5-1 along withthe actors to which they apply. Dependencies between options when applicable are specified innotes.
Table 9.5-1: ATNA - Actors and Options
Actor

Options

Audit Record Repository

None

Vol & Section-

Secure NodeRadiology Audit Trail

RAD TF-1: 2.2.1;
RAD TF-3: 5.1

Secure Application
Radiology Audit Trail

RAD TF-1:2.2.1; RAD
TF-3:5.1

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9.5.1 ATNA Encryption Option (retired)
The ATNA Encryption Option is now retired as the ITI-19: Node Authentication transaction
requires support for Encryption.
9.5.2 Radiology Audit Trail Option
1975

The Radiology Audit Trail provides specific requirements as to which audit events IHE
Radiology actors are required to send. It also details the specific format of certain audit events
based on the Radiology actor.

9.6 Audit Trail and Node Authentication Process Flow
1980

1985

1990

The security measures in the Audit Trail and Node Authentication Integration Profile are user
authentication, node authentication, and generation of audit records. Node authentication anduser authentication define a number of transactions that establish the concept of a Secure Nodeand a collection of connected Secure Nodes in a secure domain. Generation of audit records
requires a set of audit trigger events and a definition of the content of the audit records. This
profile specifies two acceptable message formats:
1. Messages formatted in accordance with the IHE Audit Message format. This is acombination of the DICOM Audit Messages format and IHE extensions. The IHE
extensions to RFC-3881 add event codes and information needed for uses that are notwithin the domain of the DICOM Standard.
2. The predecessor IHE Provisional Audit Message format. This format was defined as aninterim format while the standards work to define the Common Audit Message format
and vocabularies progressed through the standards organizations.
Based on the work done in ASTM (E2147-01 Standard Specification for Audit and Disclosure Logs for Use in
Health Information Systems) and HL7 (Framework for Audit Messages), IHE defined a detailed set of audit
trigger events, a set of general audit messages with the content for the audit record, and a mapping for each eventto a general audit message. The content of the audit record has been specified by means of an XML Schema (seeITI TF- 2x: Appendix F).

1995

In the following paragraphs three typical process flows are described for situations in whichauthorized users, unauthorized users, and unauthorized nodes attempt to gain access to protected
health information (PHI).
2000

9.6.1 Normal Node Process Flow
The following scenario shows how the IHE security measures operate for authorized access to
PHI from an authorized node in the network:

2005

1.

Time synchronization occurs independently. These transactions may take place at any
time. Correct time is needed to generate Audit Records with a correct timestamp.

2.

A user logs on to Image Display/Secure Node actor.
The user enters valid credentials and is authorized to access the node.

3.

The node generates audit records.

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4.

The user wants to query/retrieve and view some images.
Before image transactions can take place, an authentication process between the Image
Display/Secure Node actor and the Image Manager/Image Archive/Secure Node actor
takes place.

5.

Following node authentication, the node initiates the query/retrieve transactions.

6.

The node generates audit records.

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Image Display/
Secure Node

Image Manager/
Image Archive/
Secure Node

Maintain Time
[ITI-1]

Audit Record
Repository/
Secure Node

Maintain Time [ITI-1]

Time
Server

Maintain Time
[ITI-1]

Record Audit Event [ITI-20](User Authenticated)
Authenticate
Node [ITI-19]
Query
ImagesRetrieve
ImagesView Images

Record Audit Event[ITI-20](Query Images)
Record Audit Event[ITI-20](Retrieve Images)

Record Audit Event[ITI-20](Retrieve Images)
Record Audit Event[ITI-20](Instances Used)

2015

Figure 9.6-1: Authorized Node Process Flow______________________________________________________________________________
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9.6.2 Unauthorized Node Process Flow2020

The following scenario shows how the IHE security measures help to prevent unauthorizedaccess to PHI from an unauthorized node in the network:
1. An unauthorized node tries to query the Lab Automation Manager/Secure Node actor for
information. This fails because no authentication has taken place, and an audit record isgenerated.

2025

2. The unauthorized node tries an authentication process with the Lab Automation
Manager/Secure Node. This fails because the Lab Automation Manager/Secure Node will
not trust the certificate presented by the Malicious Node, and an audit record is generated.
Note that the sequencing of the transactions is just one example; transactions from anunauthorized node are totally unpredictable and may happen in any order.

2030
Lab Automation
Manager/
Secure Node

Unauthorized
Node

Query
ImagesAuthentication
Authenticate failure
Node [ITI-19]

Audit Record
Repository/
Secure Node

Record Audit Event [ITI-20](Node Authentication Failure)
Record Audit Event [ITI-20](Node Authentication Failure)

Authentication
failureFigure 9.6-2: Unauthorized Node Process Flow2035______________________________________________________________________________
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9.6.3 Unauthorized User Process Flow
The following scenario shows how the IHE security measures help to prevent unauthorizedaccess to PHI from an unauthorized user in the healthcare enterprise:
2040

1.

An unauthorized user tries an authentication process with the ECG Display/Secure
Node actor. This fails because the ECG Display/Secure Node actor detects that the username and credentials presented are not valid at this secure node, and an audit record isgenerated.
Audit Record
Repository/
Secure NodeECG Display/
Secure NodeTime
Server

Maintain Time
[ITI-1]

Maintain Time [ITI-1]

Local User
Authentication(unauthorized user)
Record Audit Event[ITI-20](User Authenticated)

2045

Figure 9.6-3: Unauthorized User Process Flow

9.7 Relationship between Secure Node, Secure Application, and other
Actors2050

2055

The allocation of responsibilities when an actor is grouped with a secure node can be complex
when different parties are responsible for different parts of the system. This situation arises
frequently in situations like web server applications, where there is an operating system, a web
server framework, and individual web applications. These might all be from different vendors.
Each of these components has a role in performing security related tasks. There is also a system
integrator who is responsible for assembling these components into the final complete system. It
is the responsibility of the system integrator to insure that all of the necessary security functions
are implemented by the appropriate system component.

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Note:

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2065

The system integrator might be a product vendor, outside consultant or internal staff. IHE does not specify
business relationships. The term is used here to indicate a functional role, not a business relationship.

IHE has split these into two primary categories:• The healthcare functions. These are identified as IHE actors. IHE does not specify how
functional actors are implemented. Multiple actors might be implemented by one web
application, and it may take multiple web applications to implement one IHE actor. IHE
allocates functions to the actors and it is the implementer’s task to allocate these to individual
web applications.
• The underlying operating environmental components. The IHE identifies these as the Secure
Node actor. It is the system integrator that determines how the functions of the Secure Nodeactor are allocated to individual components.

2075

When a product claims support for the Secure Application actor, it is claiming that it performs
those functions that are appropriate to its IHE task. This will certainly include some audit
responsibilities, will probably include some communications security responsibilities, and may
include other security responsibilities. The specifics of these responsibilities depend upon thefunctions and options of that product. For example, a product that includes a user login
capability will generate user related audit events and perform the user authentication. In
contrast, a single function web application might only generate audit messages related to its
function, and will depend upon the external secure node environment for other functions.

2080

This means that product descriptions must be sufficient for the system integrator to determine
whether all of the necessary security functions are present. If the single purpose web application
is depending on the web server environment to provide node authentication, this must be clear tothe system integrator. Not all web server environments provide that authentication, and theintegrator will need to ensure that authentication is provided when needed.

2070

When describing what security features have been implemented in a product, the following rules
apply:

2085

2090

1.

If the product claims to include the Secure Node actor, the product has been integrated
so that all of the operating system and other environmental security features are present.

2.

If the product claims only to include the Secure Application actor, that indicates that
only those security features that apply to the application features are provided by the
product.

Product selection can then use the IHE conformance claim for a summary view of the security
features provided by the product. The system integrator can use this information to determine
what additional products or integration work will be needed to establish the functionality
provided by a Secure Node if the application products are only Secure Applications.

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10 Cross-Enterprise Document Sharing (XDS.b1)
2095

The Cross-Enterprise Document Sharing (XDS.b) IHE Integration Profile facilitates theregistration, distribution and access across health enterprises of patient electronic health records.
Cross-Enterprise Document Sharing is focused on providing a standards-based specification for
managing the sharing of documents between any healthcare enterprise, ranging from a private
physician office to a clinic to an acute care in-patient facility.

2100

In the rest of the ITI Technical Framework the term XDS refers generically to any flavor of
XDS, currently only XDS.b¹.
The XDS.b IHE Integration Profile assumes that these enterprises belong to one or more XDS
Affinity Domains. An XDS Affinity Domain is a group of healthcare enterprises that haveagreed to work together using a common set of policies and share a common infrastructure.

2105

2110

2115

2120

2125

Examples of XDS Affinity Domains include:• Community of Care supported by a regional health information organization in order to serve
all patients in a given region.
• Nationwide EHR• Specialized or Disease-oriented Care
• Cardiology Specialists and an Acute Cardiology Center• Oncology network• Diabetes network• Federation of enterprises• A regional federation made up of several local hospitals and healthcare providers• Government sponsored facilities (e.g., VA or Military)• Insurance Provider Supported Communities
Within an XDS Affinity Domain, certain common policies and business rules must be defined.
They include how patients are identified, consent is obtained, and access is controlled, as well as
the format, content, structure, organization and representation of clinical information. This
Integration Profile does not define specific policies and business rules, however it has been
designed to accommodate a wide range of such policies to facilitate the deployment of standardsbased infrastructures for sharing patient clinical documents. This is managed through federated
document repositories and a document registry to create a longitudinal record of information
about a patient within a given XDS Affinity Domain. These are distinct entities with separate
responsibilities:• A document repository is responsible for storing documents in a transparent, secure, reliableand persistent manner and responding to document retrieval requests.

1

XDS.b is used because in prior versions of the Technical Framework there was an XDS.a. With TF Version 7.0
XDS.a has been deprecated.

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•

2130

2135

2140

2145

A document registry is responsible for storing information about those documents so that the
documents of interest for the care of a patient may be easily found, selected and retrieved
irrespective of the repository where they are actually stored.

The concept of a document in XDS is not limited to textual information. As XDS is document
content neutral, any type of clinical information without regard to content and representation is
supported. This makes the XDS IHE Integration Profile equally able to handle documents
containing simple text, formatted text (e.g., HL7 CDA Release 1), images (e.g., DICOM) or
structured and vocabulary coded clinical information (e.g., CDA Release 2, CCR, CEN ENV
13606, DICOM SR). In order to ensure the necessary interoperability between the document
sources and the document consumers, the XDS Affinity Domain must adopt policies concerning
document format, structure and content.
The XDS Integration Profile is not intended to address all cross-enterprise EHR communicationneeds. Some scenarios may require the use of other IHE Integration profiles, such as Patient
Identifier Cross-Referencing, Audit Trail and Node Authentication, Cross-Enterprise User
Authentication, and Retrieve Information for Display. Other scenarios may be only partially
supported, while still others may require future IHE Integration profiles, which will be definedby IHE as soon as the necessary base standards are available. Specifically:1.

The management of dynamic information such as allergy lists, medication lists,
problem lists, etc. is not addressed by XDS. However, the Retrieve Information for
Display Integration Profile does provide some transactions (e.g., LIST-ALLERGIES,
LIST-MEDS) that may be used to provide an elementary support of such capabilities.
A complementary approach to managing updates and structured application access tosuch dynamic clinical information may be expected as a separate Integration Profile in
the future.

2.

The placing and tracking of orders (e.g., drug prescriptions, radiology orders, etc.) is
not supported by XDS. This does not preclude the use of XDS to store and registerorders and corresponding results when such artifacts need to be recorded in thepatient’s health record. However, XDS provides no facilities for tracking progress ofan order through its workflow, and therefore is not intended for order management. A
complementary approach to cross-enterprise order workflow (ePrescription, eReferral)
may be expected as separate Integration Profiles in the future.

3.

The operation of any XDS Affinity Domain will require that a proper security model be
put in place. It is expected that a range of security models should be possible.
Although the XDS Integration Profile is not intended to include nor require any specificsecurity model, it is expected that XDS implementers will group XDS Actors withactors from the IHE Audit Trail and Node Authentication and will need an AccessControl capability that operates in such a cross-enterprise environment. Specific IHE
Integration Profiles complementary to XDS are available (e.g., Cross-Enterprise User
Authentication, Document Digital Signature, etc.).

4.

The establishment of independent XDS Affinity Domains will call for their federation,as patients expect their records to follow them as they move from region to region, or
country to country. IHE foresees a need for transferring information from one XDS

2150

2155

2160

2165

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Affinity Domain to another, or to allow access from one XDS Affinity Domain to
documents managed in other XDS Affinity Domains. XDS has been designed with thisextension in mind. The Cross-Community Access (XCA) Integration Profile thatcomplements XDS provides this function.

2170

5.
2175

XDS does not address transactions for the management or configuration of an XDS
Affinity Domain. For example, the configuration of network addresses or the definitionof what type of clinical information is to be shared is specifically left up to the policies
established by the XDS Affinity Domain.

10.1 Actors/Transactions
Patient Identity Source

Patient Identity Feed [ITI-8]
Patient Identity Feed HL7v3 [ITI-44]↓
Registry Stored Query[ITI-18] ←Document Consumer

Document Registry↑ Register Document Set – b [ITI-42]

Document Source

Provide&Register
Document Set – b [ITI-41]→

Document Repository

Retrieve Document Set [ITI-43]←

Integrated Document Source/Repository

Figure 10.1-1b: Cross-Enterprise Document Sharing – b (XDS.b) Diagram

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Table 10.1-1b: XDS.b - Actors and Transactions
ActorsDocument Consumer

Transactions

Optionality

SectionRegistry Stored Query [ITI-18]

R

ITI TF-2a: 3.18

Retrieve Document Set [ITI-43]

R

ITI TF-2b: 3.43

Document Source

Provide and Register Document Set-b[ITI-41]R

ITI TF-2b: 3.41

Document Repository

Provide and Register Document Set-b[ITI-41]R

ITI TF-2b: 3.41

Register Document Set-b [ITI-42]

R

ITI TF-2b: 3.42

Document Registry

Retrieve Document Set [ITI-43]

R

ITI TF-2b: 3.43

Register Document Set-b [ITI-42]

R

ITI TF-2b: 3.42

Registry Stored Query [ITI-18]

R

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ActorsIntegrated Document
Source/Repository
Patient Identity Source

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Transactions

Optionality

SectionPatient Identity Feed [ITI-8]

O (Note 2)

ITI TF-2a: 3.8

Patient Identity Feed HL7v3 [ITI-44]

O (Note 2)

ITI TF-2b: 3.44

Register Document Set-b [ITI-42]

R

ITI TF-2b: 3.42

Retrieve Document Set [ITI-43]

R

ITI TF-2b: 3.43

Patient Identity Feed [ITI-8]

O (Note 1,2)

ITI TF-2a: 3.8

Patient Identity Feed HL7v3 [ITI-44]

O (Note 1,2)

ITI TF-2b :3.44

Note 1:

If Assigning Authority of Patient ID presents in the Patient Identity Feed or Patient Identity Feed HL7v3
transaction, the Patient Identity Source is required to use an OID to identify the Assigning Authority. For
technical details of the assigning authority information, see ITI TF-2a: 3.8.

Note 2:Document Registry and Patient Identify Source shall implement at least one of Patient Identity Feed or Patient
Identity Feed HL7v3.

10.1.1 Actors
10.1.1.1 Document Source
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The Document Source Actor is the producer and publisher of documents. It is responsible forsending documents to a Document Repository Actor. It also supplies metadata to the Document
Repository Actor for subsequent registration of the documents with the Document Registry
Actor.
10.1.1.2 Document Consumer

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The Document Consumer Actor queries a Document Registry Actor for documents meetingcertain criteria, and retrieves selected documents from one or more Document Repository actors.
10.1.1.3 Document Registry

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The Document Registry Actor maintains metadata about each registered document in a document
entry. This includes a link to the Document in the Repository where it is stored. The Document
Registry responds to queries from Document Consumer actors about documents meeting specificcriteria. It also enforces some healthcare specific technical policies at the time of document
registration.
10.1.1.4 Document Repository

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The Document Repository is responsible for both the persistent storage of these documents aswell as for their registration with the appropriate Document Registry. It assigns a uniqueId to
documents for subsequent retrieval by a Document Consumer.
10.1.1.5 Patient Identity Source
The Patient Identity Source Actor is a provider of unique identifier for each patient andmaintains a collection of identity traits. The Patient Identify Source facilitates the validation ofpatient identifiers by the Registry Actor in its interactions with other actors.
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10.1.1.6 Integrated Document Source/Repository
The Integrated Document Source/Repository combines the functionality of the Document Source
and Document Repository actors into a single actor that does not initiate nor accept the Provide
ad Register Document Set transaction. This actor may replace the Document Repository actor
from the perspective of the Register Document Set or Retrieve Document transactions.

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10.1.2 Transactions
10.1.2.1 Provide and Register Document Set

2220

A Document Source Actor initiates the Provide and Register Document Set Transaction. For
each document in the submitted set, the Document Source Actor provides both the documents as
an opaque octet stream and the corresponding metadata to the Document Repository. The
Document Repository is responsible to persistently store these documents, and to register them inthe Document Registry using the Register Documents transaction by forwarding the document
metadata received from the Document Source Actor.
10.1.2.2 Register Document Set

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A Document Repository Actor initiates the Register Document Set transaction. This transaction
allows a Document Repository Actor to register one or more documents with a Document
Registry, by supplying metadata about each document to be registered. This document metadata
will be used to create an XDS Document Entry in the registry. The Document Registry Actor
ensures that document metadata is valid before allowing documents to be registered. If one ormore documents fail the metadata validation, the Register Document Set transaction fails as awhole.
To support composite documents, an XDS Document may be a multipart document. The
Document Repository must handle multi-part data sets as an “opaque entity”. The Document
Repository does not need to analyze or process its multi-part structure nor the content of any
parts in the context of the XDS Integration Profile.

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10.1.2.3 Intentional left blank
10.1.2.4 Registry Stored Query

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The Registry Stored Query transaction is issued by the Document Consumer Actor on behalf of acare provider (EHR-CR) to a Document Registry. The Document Registry Actor searches theregistry to locate documents that meet the provider’s specified query criteria. It will return
registry metadata containing a list of document entries found to meet the specified criteria
including the locations and identifier of each corresponding document in one or more Document
Repositories.
In a Stored Query, the definition of the query is stored on the Registry actor. To invoke thequery, an identifier associated with the query is transmitted along with parameters defined by thequery. This has the following benefits:______________________________________________________________________________
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1. Malicious SQL transactions cannot be introduced
2. Alternate database styles and schemas can be used to implement the Document
Registry actor. This is because the style of SQL query statements is directly related tothe table layout in a relational database.
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This profile does not define how Stored Queries are loaded into or implemented in the Document
Registry actor.
10.1.2.5 Intentionally left blank
10.1.2.6 Patient Identity Feed

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The Patient Identity Feed Transaction conveys the patient identifier and corroborating
demographic data, captured when a patient’s identity is established, modified or merged or incases where the key corroborating demographic data has been modified. Its purpose in the XDS
Integration Profile is to populate the registry with patient identifiers that have been registered for
the XDS Affinity Domains.

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The Patient Identify Feed Transaction defined in ITI TF-2a:3.8 for HL7v2 and in ITI TF-2b: 3.44
for HL7v3 uses standard HL7 encoding of Patient Identifiers. This is standard encoding for HL7
applications; receiving applications are expected to extract the required data for their use.

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When combined with the other XDS transactions, Document Registry actors and other actors thatreceive HL7 data with Patient Identifiers are required to map the data received in the HL7
message to the format specified in those other XDS transactions. In those transactions, thePatient ID is treated using ebXML encoding rules and not HL7 encoding rules. Specifically, thePatient ID will be treated as a string, and extra components entered in that string shall cause
those transactions to fail. XDS actors are required to use the specified encoding for Patient ID
values in other transactions and not merely copy the value received in an HL7 transaction.

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XDS.b implementations shall support either Patient Identity Feed (ITI TF-2a: 3.8) or Patient
Identity Feed HL7v3 (ITI TF-2b: 3.44) or both. It is important to note that the version of HL7
implemented by XDS.b and Patient Identity Feed in a single domain or community need tomatch in order to allow interoperability. In the case of mixed scenarios, translation between
Patient Identity Feed (ITI TF-2a:3.8) and Patient Identity Feed HL7v3 (ITI TF-2b: 3.44) will be
required via a bridge or interface engine.
10.1.2.7 Retrieve Document Set
A Document Consumer Actor initiates the Retrieve Document Set transaction. The Document
Repository shall return the document set that was specified by the Document Consumer.
10.1.3 XDS Document Contents Support

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The following table lists a few of the document contents supported in other IHE Integration
Profiles, which specify concrete content types for sharing of clinical documents in various
domains. These profiles are built on the XDS profile, and may define additional constraints andsemantics for cross-enterprise document sharing in their specific use cases.
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Table 10.1-1: List of IHE Integration Profiles and Document Types They Support
IHE Technical
Framework
DomainIntegration Profile
Name

Document Content Supported

IT Infrastructure

An example of an ITI
domain content profile
defining a document that
may be exchanged using
XDS is Cross-Enterprise
Sharing of Scanned
Documents (XDS-SD).
Refer to ITI TF-3:5 for other
ITI content specifications.

Scanned document, plain text or PDF/A, in HL7 CDA R2 format

Patient Care
Coordination

An example of a PCC
domain content profile
defining a document that
may be exchanged using
XDS is Cross-Enterprise
Sharing of Medical
Summaries (XDS-MS).
Refer to PCC TF-1 for otherdocument content profiles.

Medical Summary in the HL7 CDA format

Radiology

Cross-Enterprise Document
Sharing for Imaging (XDSI)Radiology Diagnostic Report in the plain text or PDF formats
Reference to a collection of DICOM SOP Instances in a manifest
document in the DICOM Key Object Selection format

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10.2 Integration Profile Options
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Options that may be selected for this Integration Profile are listed in Table 10.2-1-b along with
the Actors to which they apply. Dependencies between options when applicable are specified innotes.
Table 10.2-1b: XDS.b - Actors and Options
Actor
Document Source

Options

Vol & Section

Document Replacement

ITI TF-1: 10.2.1

Document Addendum

ITI TF-1: 10.2.2

Document Transformation

ITI TF-1: 10.2.3

Folder Management

ITI TF-1: 10.2.4

Basic Patient Privacy Enforcement

ITI TF-2b:3.41.4.1.3.1

Asynchronous Web Services Exchange

ITI TF-1: 10.2.5

Document Repository

Asynchronous Web Services Exchange

ITI TF-1: 10.2.5

Document Registry (Note 2)

Patient Identity Feed (Note 1)

ITI TF-2a: 3.8

Patient Identity Feed HL7v3 (Note 1)

ITI TF-2b: 3.44

Asynchronous Web Services Exchange

ITI TF-1: 10.2.5

Document Replacement

ITI TF-1: 10.2.1

Document Addendum

ITI TF-1: 10.2.2

Document Transformation

ITI TF-1: 10.2.3

Folder Management

ITI TF-1: 10.2.4

Basic Patient Privacy Enforcement

ITI TF-2b: 3.42.4.1.4.1

Asynchronous Web Services Exchange

ITI TF-1: 10.2.5

Basic Patient Privacy Enforcement

ITI TF-2a: 3.18.4.1.3.5

Integrated Document Source /Repository

Document Consumer

ITI TF-2b: 3.43.4.1.3.1

Patient Identity Source

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Basic Patient Privacy Proof

ITI TF-2a: 3.18.4.1.3.6

Asynchronous Web Services Exchange

ITI TF-1: 10.2.5

Patient Identity Feed (Note 1)

ITI TF-2a: 3.8

Patient Identity Feed HL7v3 (Note 1)

ITI TF-2b: 3.44

Note 1:Document Registry and Patient Identify Source shall implement at least one of Patient Identity Feed or Patient
Identity Feed HL7v3.

Note 2:

An XDS.b Document Registry has always been required to validate that documents that are registered do containa confidentialityCode from an XDS Affinity Domain vocabulary. The BPPC profile is giving some structure to
this XDS Affinity Domain defined vocabulary.

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10.2.1 Document Replacement Option.
In this option the Document Source or Integrated Document Source/Repository shall offer theability to submit a document as a replacement for another document already in theregistry/repository. Grouping with Document Consumer can be used to obtain the most recent
metadata and ids to be used in the replace submission.

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10.2.2 Document Addendum Option
In this option the Document Source or Integrated Document Source/Repository shall offer theability to submit a document as an addendum to another document already in theregistry/repository.
10.2.3 Document Transformation Option

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In this option the Document Source or Integrated Document Source/Repository shall offer theability to submit a document as a transformation of another document already in theregistry/repository.
10.2.4 Folder Management Option

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In this option the Document Source offers the ability to perform the following operation:• Create a folder 2• Add one or more documents to a folder
Note: In order to support document addition to an existing folder, grouping with the Document Consumer may benecessary in order to Query the registry (e.g., for UUIDs of existing folder).

10.2.5 Asynchronous Web Services Exchange Option
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Actors that support this option shall support the following:• Document Source Actor shall support Asynchronous Web Services Exchange for theProvide & Register Document Set – b [ITI-41] transaction• Document Consumer Actor shall support Asynchronous Web Services Exchange for theRegistry Stored Query [ITI-18] and Retrieve Document Set [ITI-43] transactions• Document Repository Actor shall support Asynchronous Web Services Exchange for theProvide & Register Document Set – b [ITI-41] and Register Document Set – b [ITI-42], andRetrieve Document Set [ITI-43] transactions• Document Registry Actor shall support Asynchronous Web Services Exchange for theRegistry Stored Query [ITI-18] and Register Document Set – b [ITI-42] transactions

2

The term “folder” comes from the medical community which commonly places patient records in folders
for specific purposes. In computer science terminology this concept is most consistent with the UNIX directoryformat, where a file can be simultaneously within multiple directories.

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Use of Synchronous or Asynchronous Web Services Exchange is dictated by the individual
install environment and affinity domain policy. Refer to section ITI TF-2x: V.5 Synchronousand Asynchronous Web Services Exchange for an explanation of Asynchronous Web Services
Exchange.

10.3 Integration Profile Process Flow
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A typical patient goes through a sequence of encounters in different care settings. In each caresetting, the resulting patient information is created and managed by multiple care delivery
information systems (EHR-CRs). Through a sequence of care delivery activities, a number ofclinical documents are created. The EHR-LR provides the means to share the relevant subset ofthese documents, as they are contributed by the various EHR-CRs that are part of the same XDS
Affinity Domain.
Example: Cardiac Patient Management Scenario

Figure 10.3-1: Cardiac Patient Management Scenario Transaction Process Flow

2345

This scenario spans about 3 weeks of a patient’s cardiac episode. The patient presents to her
primary care provider (PCP) with complaints of shortness of breath, nausea, tiredness and chest
pains. This doctor works closely with a local hospital that has recently established a cardiac care______________________________________________________________________________
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network that allows PCPs, cardiologists, laboratories and two local hospitals to share clinicaldocuments to improve patient care. This cardiac network is part of a local care data exchange
community that has been set-up in this community and to which the care plan to which thispatient belong has encouraged patients to subscribe. Our patient has been provided a healthrecord account number.
1.

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During the patient examination, the PCP records the complaint, and determines that heshould perform an ECG. He queries the cardiac care network to see if there are prior
ECG reports (step 1 in Figure 10.3-2), using a coded document class “report” and acoded practice setting “cardiology” established by the cardiac care network for ECG
reports. Among the matching Documents, he locates a prior ECG report that is thenretrieved (step 2 in Figure 10.3-2). He compares the two results and determines that thepatient should be referred to a cardiologist. He searches for additional reports in the
cardiac care network (step 3 in Figure 10.3-2) for this patient, but finds none.
Using the ambulatory EHR system, he creates a submission request onto the patients’
health record account number for a “PCP office visit” that includes a submission set
consisting of three new documents (visit note, referral letter, new ECG report) and of
one reference to the prior ECG report (step 4 in Figure 10.3-2). Following the
Cardiology Network XDS Affinity Domain policy, he creates a “cardiac assessment”
Folder to contain all four documents in order to facilitate collaboration with the
cardiologist.
The repository used by the ambulatory EHR system will then register the documentsthat are part of this submission request (step 5 in Figure 10.3-2).
Document Consumer:(PCP EHR-CR)

Document Source:(PCP EHR-CR)

Document Repository:(Cardiology Network)

Document Registry:(Cardiology Network)

1. Query Documents
2. Retrieve Document
3. Query Documents
4. Provide andRegister Document

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5. Register Document
S t

Figure 10.3-2: PCP Query Transactions Process Flow

The PCP EHR system implements the Document Consumer and Document Source
actors to issue the Query, Retrieve and Provide & Register transactions as shown in
Figure 10.3-2. The transactions are processed by the Document Repository and theDocument Registry provided by the cardiology care network.

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2.

The patient appointment with the cardiologist is scheduled. The patient goes to the lab
for the lab tests required before appointment. The lab creates a submission set with aclinical code of “laboratory tests” containing the lab results. The lab is not aware of the“cardiology assessment” folder.

3.

The cardiologist sees the patient. He queries the repository for any patient’s records ina “cardiac assessment” folder (step 1 in Figure 10.3-3). Available are the visit notefrom the PCP, the ECG and prior ECG, and the referral letter, which he retrieves andreviews (steps 2-5 in Figure 10.3-3). He also queries for recent lab reports, and finds
the lab results (step 6 in Figure 10.3-3). This is also retrieved and reviewed (step 7 inFigure 10.3-3).
The cardiologist performs an ultrasound, dictates a visit note, and orders a nuclear
stress test. The visit note and ultrasound images and report are registered as a“cardiologist office visit” submission set and placed in the “cardiac assessment” Folder.
In addition, the lab report is added to the “cardiac assessment” Folder (step 8 in Figure10.3-3).

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Document Consumer:(PCP EHR-CR)

Document Repository:(Cardiology Network)

Document Source:(PCP EHR-CR)

Document Registry:(Cardiology Network)

1. Query Documents
2. Retrieve Document
3. Retrieve Document
4. Retrieve Document
5. Retrieve Document
6. Query Documents
7. Retrieve Document
8. Provide andRegister Document

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Figure 10.3-3: PCP Query Transactions Process Flow4.

The patient is seen at a radiology facility for the nuclear stress test. The test is
performed, and the radiologist dictates the report. The nuclear stress test report isregistered in a “radiology examination” submission set and associated with the “cardiac
assessment” Folder

5.

Although she has a scheduled appointment with her cardiologist in two days, she wakes
up with severe chest pain. On the way to work, she decides to go to the emergency
room (ER) of her local hospital. The ER doctor uses the hospital EHR system to query
the cardiac care network registry and repositories for documents related to the patient inreverse chronological order (step 1 in Figure 10.3-4). Available documents from latest
cardiology related Folder are the visit notes from the PCP and cardiologist, the recent
and prior ECGs, the lab results, and the ultrasound images and report, and the nuclear
stress test images and report.

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9. Register Document
S t______________________________________________________________________________
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The ER doctor orders lab tests, ECG, and places the patient under monitoring. The lab
tests and ECG are placed in the hospital EHR that acts as a Document Repository Actor
for the cardiac network. Abnormal cardiac activity requires a catheterization,
diagnostics and possibly intervention. The ER doctor admits the patient to thecardiology service and contacts the cardiologist.

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Document
Consumer:(ER EHR-CR)

Document
Repository:(Hospital
EHR-CR)

Document
Repository:(Cardiology
Network)Document
Registry:(Cardiology
Network)

1. Query Documents

2. Retrieve Document
2. Retrieve Document

Figure 10.3-4: ER Query Transactions Process Flow

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6.

While talking to the ER physician, the cardiologist accesses the cardiac care networkfrom his home office. He queries for all documents related to the patient since the lastvisit in his office. The nuclear stress test report that he did not previously review isavailable, along with lab results and ECG results from the ER. The two physicians
determine a plan of care and the cardiologist makes arrangements to see the patient in
the hospital.

7.

As the patient is transferred from the ER, the ER visit notes are submitted as an“emergency department visit” submission set and placed in a newly created “cardiology
treatment” Folder along with the earlier lab and ECG results.

8.

The patient is transferred to an inpatient bed with the following sequence of events.
• The patient is scheduled for a catheterization procedure in cath lab.
• Additional lab tests are ordered and performed.
• A diagnostics procedure is performed in cath lab.
• An intervention with the placement of a stent is performed.
• A cath intervention report is dictated.
• Patient is returned to monitored care for recovery.
• Education given to patient and family.

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• Cardiologist orders lab tests to be completed prior to scheduled follow-up visit.
The admission assessment, lab results, cath intervention report and key images, anddischarge summary form a “cardiology intervention” submission set, which isregistered with the cardiac care network registry in the “cardiac treatment” Folder
started by the ER.

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9.

The patient returns to the cardiologist for the post discharge follow-up visit. The
resulting visit note, cardiac rehab and summary letters are placed in a “cardiology
office visit” submission set and in the “cardiac treatment” Folder.

10.

The patient goes to rehab sessions as scheduled by the cardiologist. The patient
recovers and is seen by the PCP and cardiologist for routine visits.

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10.4 General Principles
10.4.1 EDR-CR Concept
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An EHR-CR or Care-delivery Record abstracts the information system or systems of a caredelivery organization, which may support a broad variety of healthcare facilities: private
practice, nursing home, ambulatory clinic, acute care in-patient facility, etc.
Typically a patient goes through a sequence of encounters in different care settings as depicted in
the figure below.
Long-Term Care
Acute Care
(Inpatient)

Other Specialized Care(incl. Diagnostics Services)

PCPs and Clinics(Outpatient)

Encounters2450
Figure 10.4.1-1: Sequence of encounters across care delivery organizations

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It is out of the scope of this IHE Integration Profile to define or restrict the type of care provided,
nor the internal workflow of a care delivery organization. The EHR-CR system participates only
to the cross-enterprise clinical document sharing as Document Source and Document Consumer
Actors according to the following principles:
1. EHR-CR as Document Source contributes documents in any one of the document formats
that are supported by the XDS Affinity Domain (e.g., CDA Release 1, CDA Release 2
with specific templates, DICOM Composite SOP Classes, ASTM-CCR, CEN ENV
13606 etc.).

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2. This Profile does not require that the EHR-CR as Document Sources and Consumers
store and manage their internal information in the form of documents as they are sharedthroughout the XDS Affinity Domain.
3. By grouping a Document Source with a Document Repository, an EHR-CR may leverage
existing storage provide a unified access mechanism without needing to duplicate
storage.
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4. EHR-CRs as Document Sources and Consumers are responsible to map their local codes
into the XDS Affinity Domain codes if necessary.
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The XDS Documents shared by the EHR-CR and tracked by the XDS Registry form aLongitudinal Record for the patients that received care among the EHR-CRs of the XDS Affinity
Domain.

Figure 10.4.1-2: Contributing and sharing to a patients’ longitudinal health record

2475This shared clinical record is called an EHR-LR in this Integration Profile.
10.4.2 XDS Document Concept
An XDS Document is the smallest unit of information that may be provided to a Document
Repository Actor and be registered as an entry in the Document Registry Actor.

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An XDS Document is a composition of clinical information that contains observations andservices for the purpose of exchange with the following characteristics: Persistence, Stewardship,
Potential for Authentication, and Wholeness. These characteristics are defined in the HL7
Clinical Document Architecture specification. An XDS Document may be human readable (withthe appropriate application). In any case, it should comply with a published standard defining its
structure, content and encoding. IHE intends to define content-oriented Integration Profiles
relying on such content standards to be used in conjunction with XDS.
The XDS Integration Profile manages XDS Documents as a single unit of information; it does
not provide mechanisms to access portions of an XDS Document. Only the Document Sources______________________________________________________________________________
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or Document Consumers have access to the internal information of the XDS Document. Whensubmitted for sharing, an XDS Document is provided to the Document Repository Actor as anoctet stream. When retrieved through the Retrieve Document Set transaction, it shall beunchanged from the octet stream that was submitted.
The Document Source Actor is responsible for producing the metadata that will be submitted to
the Document Registry Actor to form the XDS Document Entry that will be used for query
purposes by XDS Consumer Actors. The Document Source maintains responsibilities over the
XDS Documents it has registered. It shall replace XDS Documents that may have been
submitted in error. See ITI TF-1: Appendix K for a more detailed discussion of the concept of
XDS Document.
XDS Documents are required to be globally uniquely identified. See ITI TF-2x: Appendix B fora definition of globally unique identifiers.

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10.4.3 Submission Request

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An XDS Submission Request is a means to share XDS Documents. It may be conveyed:• by a Document Source Actor in a Provide and Register Document Set Transaction to theDocument Repository Actor, or• by a Document Repository Actor in a Register Document Set Transaction to theDocument Registry Actor
An XDS Submission Request contains elements of information that will ensure the proper
registration of XDS Documents. These are:

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1.

Metadata to be placed in Document Entries for new XDS Documents being submitted,

2.

A Submission Set that includes the list of all new XDS Documents and Folders being
submitted and optionally a list of previously submitted XDS Documents,

3.

If desired, Folders to be created with the list of included XDS Documents (newdocument being submitted as well as previously submitted),4.

If desired, addition to previously created Folders of lists of XDS Documents (newdocument being submitted as well as previously submitted), and5.

Zero or more XDS Document octet streams for the new XDS Documents being
submitted.

Following a successful Submission Request, new XDS Documents, Submission Set, and Folders
included in the Submission Request are available for sharing in an XDS Affinity Domain. In caseof failure to process a Submission Request, the Submission Set and any XDS Documents andFolders shall not be registered.
10.4.4 Submission Set Concept
An XDS Submission Set is related to care event(s) of a single patient provided by the caredelivery organization EHR-CR performing the submission request. It creates a permanent record______________________________________________________________________________
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of new XDS Documents as well as pre-existing (i.e. already registered) XDS Documents thathave a relationship with the same care event(s). It also includes the record of new XDS Folders
creation.
An XDS Submission Set shall be created for each submission request. It is related to a single
Document Source Actor and is conveyed by a single Provide & Register Document Set
Transaction or a Register Document Set Transaction.

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The Document Registry may be queried to find all documents registered in the same XDS
Submission Set.
The same XDS Document, initially registered as part of a Submission Set, may also bereferenced by later XDS Submission Set. This allows older documents relevant to the present
care of a patient to be associated with more recent Submission Sets.

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XDS provides complete flexibility to EHR-CRs to relate Documents and Submission Sets to anencounter, a visit, an episode of care, or various workflow processes within EHR-CRs.
10.4.5 Concept of Folder

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The purpose of an XDS Folder is to provide a collaborative mechanism for several XDS
Document Sources to group XDS Documents for a variety of reasons (e.g., a period of care, aproblem, immunizations, etc.) and to offer the Document Consumers a means to find allDocument Entries placed in the same Folder. The following principles apply to an XDS Folder:
1.

A Folder groups a set of XDS Documents related to the care of a single patient,2.

One or more Document Source Actors may submit documents in a given Folder,3.

A Folder may be created by a Document Source and/or predefined in an XDS Affinity
Domain,4.

The content of a Folder is qualified by a list of codes/meaning,

5.

Document Source Actors may find existing Folders by querying the Document Registryor by means outside the scope of XDS (e.g., Cross-enterprise workflow, such
ePrescription, eReferral, etc.),

6.

Once created a Folder is permanently known by the Document Registry,

7.

Placing previously existing Documents in Folders is not recorded as part of theSubmission Set,

8.

Folders in XDS may not be nested,

9.

The same documents can appear in more than one Folder, and

10.

Folders have a globally unique identifier.

10.4.6 Example of use of Submission Request, Submission Set and Folder
The sequence of figures below shows an example of a submission request that includes two new
documents, a reference to a pre-existing document and the use of two folders. The first figure______________________________________________________________________________
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depicts the initial state of a Document Registry in which two Documents have been submitted
where one is associated with a Folder A. The second figure depicts a submission request that
adds two new documents, placing one of them into a pre-existing folder and the other one into a
new Folder B.

Figure 10.4.6-1: Example of a submission flow to an XDS Registry

From the above example, the contents of a Submission Set are shown by the figure below. The
Document Entries associated with the Submission Set are logical part of the Submission Set.
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Submission
Set
2

Document
Entry

Document
Entry

New
Submission

Previous
Submission

Folder B

Document
Entry
New
Submission

Figure 10.4.6-2: The logical content of a Submission Set

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10.4.7 XDS Registry Data Model and Attributes
The XDS Integration Profile provides a means to place documents in a repository chosen by theDocument Source, and also to place information about this document (or metadata) in an entry of
the Document Registry that manages the XDS Affinity Domain.

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The term metadata reflects that this information is “about” the documents. The purpose of wellspecified document metadata is to enable a uniform mechanism for Document Consumers tolocate clinical documents of interest much in the way a card catalog in a library helps readers
find the book they want.
This section addresses the high-level data model in which the metadata is registered and against
which queries of the XDS Document Registry are performed. Then it presents the specificattributes that may be registered and used to filter the document entries of the registry.
10.4.7.1 XDS Document Registry Data Model
The following entities are used in the XDS Document Registry Data Model:

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XDS Document Entry: Information entity managed by a Document Registry Actor that contains
a set of metadata describing the major characteristics of an XDS Document along with a link to
the Document Repository Actor where the actual XDS Document may be retrieved.
XDS Document: A stream of bytes stored in a Document Repository Actor and pointed to by an
XDS Document Entry.

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XDS Folder: A logical container that groups one or more XDS Document Entries in any way
required (e.g., by source care delivery activities, by episode, care team, clinical specialty or
clinical condition). This kind of organizing structure is used variably: in some centers andsystems the Folder is treated as an informal compartmentalization of the overall health record; inothers it might represent a significant legal portion of the EHR relating to the originating______________________________________________________________________________
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enterprise or team. The Folder is a means of providing organization of XDS Documents (orComposition in EHRCOM). The same XDS Document Entry may belong to zero or more
Folders.
XDS Submission Set: When XDS Documents are registered by a Document Source Actor, theyshall be included in one and exactly one Submission Set. An XDS Submission Set groups zeroor more new XDS Documents and references to already registered XDS Documents to ensure apersistent record of their submission.

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XDS Submission Request: A Submission Request includes one and only one Submission Set,
zero or more new XDS Folders and assignment of XDS Documents into new or existing Folders.
A Submission Request is processed in an atomic manner by the Document Repository and theDocument Registry (i.e. all XDS Documents included or referenced in a Submission Set as wellas the Folders and inclusion of Folders references are registered or none will). This ensures thatthey are all made available to Document Consumer Actors at the same time.
XDS Folder

10-n

Is associated with

Was initially submitted in

Clinical Affinity Domain[EHR LR] Patient1

1

1
Belongs to

XDS Submission Set
1

1

Was initially submitted in

References

Local [EHR-CR] Patient
At the time of submission
1

1

1

1-n

1

XDS Document Entry

Was submittedfor1
References

1

XDS Document in Repository

Figure 10.4.7-1: XDS Document Registry Data Model

10.4.7.2 Attributes of the XDS Document Entries
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The specific attributes of each entity in the above registry data model have been selected fromdocument header attributes from several standards (see ITI TF-2x: Appendix L), including:• ANSI/HL7 CDA R1-2000______________________________________________________________________________
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•
•
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HL7 CDA Release 2 (draft) Document header definition (Dec 2003 Committee Ballot)
Composition attributes from EHR ENV 13606 (draft)

XDS defines a well-focused set of primary attributes that support the most common use cases tosearch the most relevant documents. These include:
Patient Id
Service Start and Stop Time
Document Creation Time
Document Class Code and Display Name
Practice Setting Code and Display Name
Healthcare Facility Type Code and Display Name
Availability Status (Available, Deprecated)
Document Unique Id

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The three codes (Document Class, Practice Setting and Healthcare facility Type) are code set
that are expected to generally include a limited number of values (between 10 and 100), thus
ensuring a reasonably easy search capability.
A number of additional query attributes or attributes used to perform a secondary selection inorder to decide to retrieve a specific document are also defined by this Integration Profile. At theDocument Level, these include a fine grained Document Type (e.g., LOINC classification), a listof Event Code that can be used as key word, the document author and associated institution, thedocument relationship to manage replacement addendum and a variety of transformations, aconfidentiality code, language code, etc.
The complete list of attributes and their definition is documented in ITI TF-3: 4.1.
10.4.8 Concept of an XDS Affinity Domain

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An XDS Affinity Domain is an administrative structure made of a well-defined set of Document
Source Actors, set of Document Repositories, set of Document Consumers organized around asingle Document Registry Actor that have agreed to share clinical documents.
Note:

Document Sources, Repositories and Consumers may belong to more than one XDS Affinity Domain and sharethe same or different documents. This is an implementation strategy and will not be further described.

Note:

the XDS Integration Profile does not support the federation of XDS Affinity Domains directly, but the CrossCommunity Access (XCA) profile addresses the cooperation of multiple Document Registry Actors serving
different XDS Affinity Domains.

A number of policies will need to be established in an XDS Affinity Domain in order to ensure
effective interoperability between Document Sources and Consumers. Some of the key technicalpolicies include (A more extensive list of policy agreements that need to be made by XDS
Affinity Domains is discussed in ITI TF-1: Appendix L):
1.

The document formats that will be accepted for registration

2.

The various vocabulary value sets and coding schemes to be used for the submission of
metadata of document, submission set and folders registration.

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3.

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The Patient Identification Domain (Assigning Authority) used by the Document
Registry.

See ITI TF-1: Appendix K for a detailed discussion of the concepts of XDS Affinity Domain.
10.4.9 Patient Identification Management
Since the central focus of the DS Integration Profile is “sharing documents”, it is critical thateach document be reliably associated with the corresponding patient (Patient Id).
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The XDS Document Registry is not intended to be an authority for patient identification anddemographics information. This Integration Profile uses a Patient Identity Source Actor as theauthoritative source of Patient Identifiers (master patient ID) for the XDS Affinity Domain.
Note:

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This Integration Profile can be easily extended to support a scenario where no master patient ID is defined (i.e. no
Patient Identity Source for the XDS Affinity Domain). Such an option would require the use of federated patient
identities at the time of query of the XDS Document Registry.

The following principles are defined:
1.

The Patient Identifier Domain managed by the Patient Identity Source Actor in the
XDS Affinity Domain is the source of patient identifiers (and merge operations) usedby the XDS Document Registry to link Documents to a specific Patient. This Patient
Identifier Domain is called the XDS Affinity Domain Patient Identification Domain(XAD-Pid Domain).

2.

Submission Requests for Documents related to Patients with IDs not registered in the
XDS Affinity Domain Patient Identifier Domain shall be rejected by the XDS
Document Registry.

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3.

The XDS Document Registry will contain certain patient information (e.g., source
patient ID, Surname, Given Name, Sex, Birthdate) for the purpose of audits andpotential verification by Document Consumers. As this Integration Profile does notmake any assumptions about the referential integrity and update of this information,these fields 3 shall not be used as query matching keys.

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4.

As XDS Document Sources and Consumers may belong to different Patient
Identification Domains, these systems need to cross-reference their own local Patient
ID to the corresponding patient ID in the XAD-Pid Domain of the Registry. Preferably,
these systems may choose to use the IHE Patient Identifier Cross-referencing
Integration Profile (See ITI TF-1: Appendix E.3) for this purpose.

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5.

The XDS Document Registry is responsible for validating Document metadata inaccordance with the XDS Affinity Domain’s policies. The Document Registry should
reject submissions Requests that do not conform to these policies.

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3

It is possible to submit a new document to replace a previously submitted one, with a new document entry
created in the registry to correct for errors in the submitted document in the original submission request. However
this is not a mechanism that updates only the metadata, as the replaced document is only deprecated and remains
pointed by the original metadata.

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The figure below depicts an example of an XDS Affinity Domain with its Patient Identifier
Domain (called XAD) and two EHR-CRs where the cross-referencing is performed internally to
the Document Source and the Document Consumer Domains (Domain C and Domain D2
respectively).

Patient Identity
SourcePatient Identity Feed
Dm=XAD, Pid=Px

XDS Document
Registry

Dm=XAD
Pid=PxXDS Document
SourceXDS Doc Entry
Dm=XAD
Pid=Px
Dm=C
Pid=PcXDSDoc

XDS Doc Entry
Dm=XAD
Pid=Px
Provide &Register

XDS Document
Repository
XDS Doc

Patient
Identification
Domain C

Query

XDS Document
Consumer
Dm=XAD
Pid=Px
Dm=D2
Pid=PdPatient
Identification
Domain D2

Patient
Identification
Domain XAD

Figure 10.4.9-1: XDS Affinity Domain with patient ID cross-referencing internal to the
EHR-CRs

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10.4.1010.4.10.1

Document Lifecycle
Document Availability Status

Each XDS Document contained in a XDS Document Registry will be assigned one of thefollowing Availability Status codes:
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Approved:

Available for patient care (assumes that it is authenticated, if applicable)______________________________________________________________________________
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Deprecated:

Obsolete, but may still be queried and retrieved

The XDS Document availability status is set to “approved” after the XDS Document Repository
and the XDS Document Registry have successfully processed a submission request.
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Note:

ebXML Registry Services defines a Status of Submitted, which is used in a transient manner to provide an atomic
submission. It is not significant to make this specific status externally visible.

An “approved” XDS Document may be changed to “deprecated” under the primary
responsibility of its original Document Source with possible patient supervision. It is part of
security policies that are beyond the scope of the XDS Integration Profile to have the XDS
Repository/Registry enforce this ownership. The reason and responsible party for deprecating a
document are tracked as part of the XDS Document Registry audit trail, which is a required
capability. A “deprecated” Document remains available for Document Consumer queries.
Except for the status change, a “deprecated” Document Entry metadata remains the same as
when it was in the “approved” status.
An “approved” or “deprecated” XDS Document Entry may be deleted. This change is associatedwith the decision to completely remove a Document from an XDS Document Repository and thecorresponding Document Entry from the XDS Document Registry. The XDS Affinity Domain
shall establish the security policies associated with Document deletion. There are no transactions
defined by this Integration Profile to support such operation.
See ITI TF-1: Appendix K for a detailed discussion of the concepts of XDS Document life cycle.

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10.4.10.2

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XDS Documents may be related to predecessor documents by one of three methods:• Replacement,• Addendum• Transformation• Transformation-Replacement

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Document Relationships

These relationships between XDS Documents are tracked in the XDS Document Registry. The
parent relationship attribute contained in the metadata of such Documents is a coded value that
describes the type of relationship. An original Document has no parent and consequently its
parent Id and parent relationship are absent. XDS Document Registry shall reject submissions
that contain relationships to documents that are not registered or have been “deprecated”.
Document stubs are supported by XDS to allow for a valid relationship to a known but notregistered Document.
A replacement document is a new version of an existing document. The replacement document
has a new document Id; its parent Id attribute contains the document Id of the Document Entry
associated with the previous version of the XDS Document, and parent relationship contains thecode “RPLC”. The Document Entry for the previous version shall have its Availability Statuschanged to “deprecated”.
An addendum is a separate XDS Document that references a prior document, and may extend oralter the observations in the prior document. It modifies the parent document, but the parent______________________________________________________________________________
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document remains a valid component of the patient record and shall remain in the state“approved” or available for care. The addendum XDS Document metadata contains the identifierof the previous XDS Document version in parent Id, and its parent relationship contains the code
“APND”.
A transformed document is derived by a machine translation from some other format. Examplesof transformed documents could be CDA documents converted from DICOM Structured
Reporting (SR) reports, or a rendering of a report into a presentation format such as PDF. The
transform XDS Document contains the document Id of the previous version in parentId, and its
parent relationship contains the code “XFRM”. XDS Affinity Domains may define rules that
determine whether or not a transformed XDS Document replaces the source, but typically thiswould not be the case. If it is, an additional parent relationship of type “RPLC” is to be used.
10.4.112745

Document Query

Query return info shall be either:• a list of Registry Objects Values (e.g., XDS Document Entries)• a list of Registry Objects UUIDs. This allows an XDS Document Consumer to receive apotentially long list of matching entries and to request them by subsets.

10.5 Implementation Strategies

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The XDS Integration profile addresses the requirements of three major implementation strategies
reflecting different groupings of actors within an EHR-CR as well as different configurations of
the EHR-LR. This range of implementation strategies reflects the need to accommodate avariety of workflows and configurations. These implementation strategies may coexist in someenvironments. Other implementation strategies are possible.
• Strategy 1: Repository at the Source. A single information system acts as both the Document
Source and Document Repository for the documents it creates and registers with theDocument Registry• Upon completion of a phase of care, an EHR-CR will register a submission-set of documents
in a Document Repository Actor with which it is grouped (same system). Then it registers
this set of documents (newly created and priors documents of interest) with the Document
Registry Actor [2].
• Any other Document Consumer Actor in the XDS Affinity Domain may query the Document
Registry Actor to find documents related to all phases of care for the patient [3]. It may
choose to retrieve some of these documents from any Document Repository Actor [4].

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EHR-CR

EHR-CR
Document
Registry

2 Register
Document Source
Document
Repository

3 Query

Document
Consumer

4 Retrieve

Figure 10.5-1: Implementation Strategy with Repository at the Source

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•

•

Strategy 2: Third Party Repository. The EHR-CR does not wish to be a Document
Repository Actor, but rather uses the services of a third party Document Repository Actor towhich it entrusts the documents it creates. First it provides both the metadata and the set of
documents to this Document Repository Actor [1], which in turn forwards the registration
request for the set of documents (newly created and prior documents of interest) to theDocument Registry Actor [2].
Any other Document Consumer Actor may query the Document Registry Actor to find out
about documents related to all phases of care for the patient [3]. It may choose to retrievesome of these documents from any Document Repository Actor [4].
EHR-CR

EHR-CR
Document
Registry

3 Query

2 Register

Document Source

1 Provide &RegisterDocument
Consumer

4 Retrieve
Document
Repository

Figure 10.5-2: Implementation Strategy with 3rd party repository

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EHR-CR

EHR-CR

Document
Registry

3 Query
Document
ConsumerDocument
Repository

Document Source

1 Provide &Register

4 Retrieve______________________________________________________________________________
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Figure 10.5-3: Implementation Strategy with 3rd party central repository and registry

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•

•

Strategy 3: Direct Patient Transfer-Referral. The Document Source Actor completes a phaseof care for a patient. It decides to directly provide and register [1] the set of documents(newly created and prior documents of interest) with a Document Repository [2] that has
been grouped along with the Document Registry with the EHR-CR Document Consumer(Grouped Actors).
In this case the span of the XDS Affinity Domain may be quite limited as it could be defined
to cover only the two EHR-CRs. However the same transaction [1] applies. Note that, in
this implementation strategy the other transactions, although supported by the actors, are notused by the Document Consumer since the Document Registry and Document Repository
reside within the Document Consumer.

EHR-CR

EHR-CR
Document Source

Document
ConsumerDocument
Registry

1 Provide & Register

Document
Repository

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Figure 10.5-4: Direct patient referral with registry and repository at consumer

Patient access to an EHR-LR may be supported by a specialized EHR-CR (i.e. a portal)
implementing the Document Source and Document Consumer Actors.

10.6 Patient Identifier Communication Requirements
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When using ITI Transaction 8 as the patient identity feed, ITI TF-2a: 3.8 defines the format
requirements for the patient identifier in PID-3. Specifically, the value for PID-3.4, Assigning
Authority can be omitted, expressed using the first subcomponent (namespace ID) or the second
and third subcomponents (universal ID and universal ID type). These rules shall apply in thisprofile:2800

1. If the Patient Identity Source does not include a value for PID-3.4, Assigning Authority,
thena. PID-3, Patient Identifier List, is constrained to include one entry referring to one
identifier.

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b. The Patient Identity Source and Document Registry shall agree that all messages
from this source shall refer to a single assigning authority.
2. If PID-3.4 does contain a value for PID-3.4, Assigning Authority, then______________________________________________________________________________
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a. The Patient Identifier Source may send multiple patient identifiers with properly
formatted components. The Document Registry shall be responsible for selecting
the one identifier from the Patient Identifier List (not necessarily in the first
position) that is too used to register the selected patient.
b. As specified in ITI TF-2a: 3.8, the value for PID-3.4, Assigning Authority, can be
expressed using the first subcomponent (namespace ID) or the second and third
subcomponents (universal ID and universal ID type). Both methods shall be
accepted by the Document Registry and shall be considered as equivalent.

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When using ITI Transaction 44 The Assigning Authority is required.
ITI Transactions 18, 41 and 42 express patient ID as a string that is not parsed using typical HL7
parsing logic; please refer to requirements for Patient ID in those transactions. Document
Registry actors will have to map between the Patient ID feed provided in ITI-8 or ITI-44 as
described above and the PID provided by those transactions in this profile.

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XDS.b implementations shall support either Patient Identity Feed (ITI TF-2a: 3.8) or Patient
Identity Feed HL7v3 (ITI TF-2b: 3.44) or both. It is important to note that the version of HL7
implemented by XDS.b and Patient Identity Feed in a single domain or community need tomatch in order to allow interoperability. In the case of mixed scenarios, translation between
Patient Identity Feed (ITI TF-2a: 3.8) and Patient Identity Feed HL7v3 (ITI TF-2b: 3.44) will be
required via a bridge or interface engine.

10.7 Security Considerations

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Coordinating the security and privacy policies of all the care delivery organizations in an XDS
Affinity Domain may be a challenge. An agreement is needed on security procedures, goals,
auditing, record keeping, etc. This can result in changes to other enterprise policies, such as
human resources procedures. XDS Affinity Domain members are trusting to some extent theaccess of their published data by other members of the XDS Affinity Domain. The level ofcontrol is dependent on Policies and application of other security and privacy profiles offered by
IHE. This relationship requires a close ongoing partnership that ensures ongoing maintenance ofpolicies, procedures, and activities. If laws change, relevant policies must be adjusted
throughout the group. Corporate changes to group members affect the policies. Security events
must be managed as a group. This must be managed as a long-term activity, not a one-time
event.
Particular problem areas are likely to be:• Authorized access and modification policies. The details of access policies are likely to haveenterprise differences and conflicts that must be resolved. The XDS Affinity Domain
relationships also introduce new policy requirements. For example, changes to employment(e.g., employee hiring and firing) must now include suitably rapid notifications to other XDS
Affinity Domain members. (See ATNA and XUA)
• Changes to privacy restrictions (e.g., divorces) now require full XDS Affinity Domain
notifications, not merely enterprise notifications. (See BPPC)______________________________________________________________________________
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•

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•

•
•
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•

Audit trail and access record keeping are often quite sensitive internal enterprise activities
that must now be appropriately coordinated with the full XDS Affinity Domain. (See ATNA
and section 10.8.1)
Changes to laws and regulations now affect not only the policies of the individual
enterprises; they also must be reflected in the XDS Affinity Domain relationship contracts,
policies, and procedures.
Patient identity management. (See PIX/PDQ/XCPD)
Patients may have access through an authorized Document Consumer or Document Source
implemented in an application such as a PHR.
Trans-border communication of Personal Health Information (PHI) often presents legal andregulatory issues.

ITI TF-2x: Appendix K goes into more detail listing many of the threats, objectives, policies, andmitigations that need to be coordinated among XDS Affinity Domain members.
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The XDS Integration Profile for two main reasons does not prescribe such Security and Privacy
policies. First, it is clear that the broad range of possible solutions to these policies that will
depend on the legal framework and the types of healthcare system, calls for XDS to be offer suchflexibility. Decisions in this domain will have some impact on the implementations of XDS
Actors, but it is expected that these will be minimal.
10.7.1 Use of ATNA to address Basic Security

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The XDS profile requires all actors be grouped with a Secure Node Actor as defined in the IHE
Audit Trail and Node Authentication Integration profile. This use of the ATNA profile in an
XDS Affinity Domain does not require a centralized XDS Affinity Domain Audit Repository
Actor.
The use of ATNA along with XDS does require that each member of the XDS Affinity Domain
does have audit and security mechanisms in place. See ITI TF-2x: Appendix K.
The individual actors involved are often members of different secure domains, as
illustrated in Figure 3.14.5.1-2. The data transfers between different secure domains mayneed different protection than transfers within a secure domain. The use of encryption andother security mechanisms will depend upon the policies of the domains involved.

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Transfers within a single secure domain may choose to omit encryption if it is unnecessary, so it
is recommended that the online transfer security mechanisms be configurable. Certificate
management and exchange is defined as part of the XDS Affinity Domain business relationships
and no IHE Integration Profile is specified at this time, see ITI TF-1: Appendix L.
Each transaction will result in audit records describing the transaction. Each secure domain has
its own audit server to capture the records for the actors that are within that domain. Access toaudit records by other enterprises within the XDS Affinity Domain is managed and controlled by
the business relationship terms of the XDS Affinity Domain. There is no automatic IHE
transaction for such access.
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The audit records that shall be generated (references IHE ATNA Integration Profile) by normal
XDS activities are defined in the appropriate Security Considerations section of each transaction:

Security Domain B
Repository
Registry
Encrypted,
S/MIME, Signed
if Offline
Encrypted,
TLS,
Authenticated if
OnlineSecurity Domain A
SourceSecurity Domain C
Comsumer

Repository

All Actors are part of the same Clinical Affinity Domain

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Figure 10.7-1: - Example Security Domain Relationships

Security and Privacy can be further addressed through the application of IHE-BPPC, IHE-XUA.
See these profiles for their impact and use.
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11 Personnel White Pages (PWP)

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The Personnel White Pages (PWP) Profile provides access to basic directory information onhuman workforce members to other workforce members within the enterprise. This information
has broad use among many clinical and non-clinical applications across the healthcare enterprise.
The information will be used to1.

enhance the clinical workflowa) contact information,b) phone numbers,c) email address

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2.

enhance the user interfacea) displayable names,b) titles

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This Personnel White Pages Profile specifies a method of finding directory information on theUser Identities (user@realm) supplied by the Enterprise User Authentication (EUA) Integration
Profile. This Profile assumes but does not define access controls, and audit trails. The use of the
PWP Profile is intended for use within a healthcare enterprise. Extension to support sharing of
the PWP between healthcare enterprises is possible but not fully addressed by this profile. The
PWP profile is the first step on an IHE roadmap that includes Digital Certificates, Encryption,
Digital Signatures, Medical Credentials, and Roles.
The directory need not support use cases beyond healthcare operations (e.g., Human Resource
Operations), but does not forbid a properly designed overlap with other use cases. This profile
does not intend for patients or other individuals that are not acting as part of the humanhealthcare workforce.

11.1 Actors/ Transactions
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Figure 11.1-1 shows the actors directly involved in the PWP Integration Profile and the relevanttransactions between them. Other actors that may be indirectly involved due to their
participation in EUA profile are not necessarily shown.

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Personnel White Pages
Consumer
Find Personnel White Pages [ITI-23]

Query Personnel White Pages [ITI-24]

DNS Server

Personnel White Pages Directory

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Figure 11.1-1: Personnel White Pages Profile Actor Diagram

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Table 11.1-1 lists the transaction for each actor directly involved in the PWP Profile. In order toclaim support of this Integration Profile, an implementation must perform the required
transactions (labeled “R”). Transactions labeled “O” are optional. A complete list of options
defined by this Integration Profile and that implementations may choose to support is listed in
ITI TF-1: 11.2.
Table 11.1-1: PWP Integration Profile - Actors and Transactions
ActorsTransactions

Optionality

Section

Personnel White Pages Consumer

Find Personnel White Pages[ITI-23]O

ITI TF-2a: 3.23

Query Personnel White Pages[ITI-24]R

ITI TF-2a: 3.24

DNS Server

Find Personnel White Pages[ITI-23]R

ITI TF-2a: 3.23

Personnel White Pages Directory

Query Personnel White Pages[ITI-24]R

ITI TF-2a: 3.24

11.2 PWP Integration Profile Options
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Options that may be selected for this Integration Profile are listed in Table 11.2-1 along with theActors to which they apply. Dependencies between options when applicable are specified innotes.
Table 11.2-1: PWP Integration Profile - Actors and Options
Actor

Options

Vol & Section

Personnel White Pages Consumer

no option-

DNS Server

no option-

Personnel White Pages Directoryno option-

11.3 PWP Integration Profile Process Flow
The Personnel White Pages Profile addresses the following use cases:______________________________________________________________________________
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•

•

•
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•

A Clinical user logs into an acquisition device that is acting as a Personnel White Pages
Consumer. The clinical application queries the DNS Server Actor using [ITI-23] to findthe Personnel White Pages Directory. The clinical application then queries [ITI-24] the
Personnel White Pages Directory using the user’s username and displays the user’s fullname with First Name, Middle, and Last. There are information fields to support both
European and Asian naming conventions.
The Clinical user acquires clinical data. The application queries [ITI-24] the Personnel
White Pages Directory for the user’s demographics to include the user’s organization
identification to embed in the data record.
The User then needs to send this report by means of email to a colleague. The application
allows the user to search [ITI-24] the Personnel White Pages Directory for the destination
user, and selects the destination user’s email address.
The User reviews an existing clinical report and finds initials have been recorded in thereport. The user system does a query [ITI-24] of the Personnel White Pages Directory forthe initials found in the report and the system displays the displayable name(s).
Personnel White
Pages Consumer

DNS Server

Personnel White
Pages Directory

Find Personnel White
Pages [ITI-23]

Query Personnel White Pages [ITI-24]

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Figure 11.2-1: Basic Process Flow in PWP Profile______________________________________________________________________________
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12 This is reserved for Notification of Document Availability (NAV)______________________________________________________________________________
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13 Cross Enterprise User Assertion (XUA) Integration Profile
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The Cross-Enterprise User Assertion Profile (XUA) provides a means to communicate claims
about an authenticated principal (user, application, system...) in transactions that cross enterpriseboundaries. To provide accountability in these cross-enterprise transactions there is a need to
identify the requesting user in a way that enables the receiver to make access decisions andproper audit entries. The XUA Profile supports many solutions including enterprises that havechosen to have their own user directory with their own unique method of authenticating theusers, and others that have chosen to use a third party to perform the authentication.
There are transactions defined by IHE that cross enterprise boundaries and are web-services
based on ITI TF-2x: Appendix V. The existing IHE profiles for an authenticated user identity(IHE Enterprise User Authentication Profile [EUA]) are not intended to function in crossenterprise transactions. In a cross-enterprise environment it is more likely that the transactions
will be going between two enterprises that maintain their own independent user directories (IHE
Personnel White Pages [PWP]). This type of requirement is the focus of the Identity Federation
standards. Identity Federation has received much attention by the security and the platforms
industry. Identity Federation is agnostic to the type of user directory; it allows for a centralizeduser directory, but also supports the more powerful federation of user directories. Identity
Federation supports:• A Country that delegates the provisioning of all users into a single assigning authority
domain (e.g., France) and provides a common service that handles all user authentication
requests• Support for centralized user directories• A Region that knits together a network of cooperating hospitals and clinics where eachhospital/clinic manages its own users.
• Support for distributed user directories• Patients who wish to use an identity provider of their choosing (e.g., ISP, email provider).
• Support for non-healthcare specific user directories• A Hospital that provisions users by issuing identity badges with picture and name printed,
RFID for building access, and smart-card for strong authentication• Support for claims about the method used to authenticate the user (e.g., strong authentication
methods such as smart-cards)• A Small clinic in a rural setting that supports a dozen users.
• Support for small scale systems (e.g., user at a kiosk, system using simple passwords)• A General practice doctor retrieving results of a test performed by an outpatient clinic, where
the outpatient clinic wants to have an audit trail specific to the user requesting theinformation.
• Support for the service provider to get a user identity for audit log purposes______________________________________________________________________________
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An automated System, based on a scheduled procedure, that is capable of being a delegate
for a doctor pre-fetches the available documents so that it can determine a relevant few
documents to offer to the doctor when the patient arrives

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The XUA Profile leverages Web-Services Security, SAML 2.0 Token Profile and the various
profiles from W3C, and OASIS to support identity federation. In this way we will be able to takeadvantage of the vast experience of the communities outside of healthcare standards. This profile
leverages the experience of programs around the globe that have started work with SAML in
healthcare.

13.1 Use Cases
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The XUA profile supports complex environments, for example one where two different trust
domains are operating under different technology, procedures, role-models, etc. They arecooperating in the XDS Affinity domain under an overarching trust relationship policy (See ITI
TF-2x: Appendix L) that indicates that these differences can be rationalized. The XDS
transactions are transferring control from one entity to another, for example, when using XDS to
exchange data between a single doctor practice and large multi-site hospital. It is not likely thatthey will all agree to the same access control model (organizational roles, functional roles,
workflows, permissions, etc.). It is not necessary to have the same access control across these
entities, but it is reasonable that at the policy level they will agree to a set of processing rules.
This illustrates an important fact that the XUA is useful for security audit logging, but is to alesser extent useful for access controls.
The following is a list of use-cases that have been proposed for XUA. Some of these use-cases
will not be supported due to lack of standards or sufficient guidance on the proper solution.
1. Country that provisions users into a single assigning authority domain (e.g., Germany)and handles all user authentication requests•

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Support for centralized user directories

2. Region that knits together many competing hospitals and clinics where eachhospital/clinic manages its own users.
•

Support for distributed user directories

3. Patients who wish to use their email provider as their authentication authority uses a
PHR-like application to access their own information in an XDS Affinity Domain.
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Support for non-healthcare specific user directories

4. Hospital that issues identity badges with picture and name printed, RFID for building
access, and smart-card for strong authentication•
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Support for claims about the method used to authenticate the user (e.g., strong
authentication methods such as smart-cards)

5. Small clinic in a rural setting that supports a dozen users.
•

Support for small scale systems (e.g., user at a kiosk, system using simple passwords)______________________________________________________________________________
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6. General practice doctor who retrieving results of a test performed by an outpatient clinic,
where the outpatient clinic wants to have an audit trail specific to the user requesting.
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7. System, based on a scheduled procedure, pre-fetches the available documents so that it
can determine a relevant few documents to offer to the doctor when the patient arrives.
•

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Support for identifying the user as the system for tasks that are not initiated by ahuman user

8. User using Registry or Repository where the service provider wants to be assured that theuser has been authenticated to a specific assurance level. This is not a case of not trusting
the system, but recognition that the requester supports different levels of authentication.
For example the system supports a proximity card as a form of authentication, as well as
Smart-Card with PIN. This is not a replacement for ATNA access controls which give
distributed access controls.
•

User Identity with level of assurance of that identity is needed.

9. Specialized XDS Affinity Domain for Emergency Dataset. In this case the transfer of
information to the XDS Consumer is not critical to fully control, and thus theadministration is willing to accept requests from any system as long as they can provide auser-assertion from a trusted source. This trusted-source may be a specialized identity
provider for First Responders. (See RSA Pilot)•

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Support for the service provider to get a user identity for audit log purposes

In this case only a user identity with proper linkage to a trusted identity provider isneeded. No specific attributes are needed.

10. User acting in an identified clinical role accesses the Registry where the Registry wants
to know the user identity and the role they are acting in to record the identity and role in
the audit log.
•

Support inclusion of functional roles as named vocabulary•

The Role of the user as the data subject (patient)

11. Service provider wants to enforce some form of access controls based on the user identity
and/or functional role.
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Support for the service provider to augment access controls based on some nonspecified rules that are applied to the user and/or functional role

12. Access to a document by an individual that can’t be identified because the Assertion
Provider is not accessible

13.2 XUA Development
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The vast majority of the use-cases (items 1-11) rely on claims about an authenticated identity,
which a SAML 2.0 Identity Assertion can provide. This is a mature standard produced by
OASIS. XUA Profile is focused on Web-Services transactions that follow ITI TF-2x: Appendix
V. XUA specifies that when a Cross-Enterprise User Assertion is needed, these Web-Services______________________________________________________________________________
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transactions will additionally use the Web-Services Security header with a SAML 2.0 Token
containing the identity Assertion. As with any IHE profile, the applications are not forbidden touse other methods of providing the principal (user) identity, providing that interoperability has
been assured through some policy.
A very clear need on all the use-cases is the recording of the user identity in any security audit
logs. The XUA profile does not define these auditable events. The need to record a security audit
event is driven by the grouped transactions (e.g., Registry Stored Query, and Retrieve Document
Set). XUA does specify how to reference the Identity Assertion in an ATNA Audit Message.
The method of authenticating the principal (user) and the method that the X-Service User Actor(e.g., XDS.b Document Consumer) uses to get the Identity Assertion are outside the scope of thisprofile.

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There are principal (user) attributes that appear to be needed in the use-cases: Doctor, Patient,
Guardian, Emergency-Access. The Identity Assertion can contain attributes about the principal(user). At this time it is not clear what standards to use to identify these attributes and theirvalues, so this is left to specific implementations that have defined a local vocabulary or
vocabulary translation.

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The method used by the X-Service User (e.g., XDS.b Document Consumer) Actor to determine
the contents of the Identity Assertion is outside the scope of this profile. This might beaccomplished using the SAML Metadata and WS-Policy.
It is expected that extending this solution to HL7 and DICOM will be supported in the future.

13.4 Actors/Transaction
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Figure 13.4-1 shows the actors directly (Bold and Solid Boxes) involved in the XUA Integration
Profile and the relevant transactions between them (Bold and Solid Line). The diagram also
shows ancillary actors (Dashed and Grey Boxes) that are not profiled but include interactions(Dashed and Grey Lines). Actors grouped with are shown as the dashed line between the XService User and the X-Service Provider.

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Figure 13.4-1: Cross-Enterprise User Assertion Actor Diagram

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Table 13.4-1 lists the transactions for each actor directly involved in the XUA Profile. The
ancillary actors and associated transactions may be supported by various technologies andsystem configurations varying from internal shared services to infrastructures for identity
management.
In order to claim support of this Integration Profile, an implementation must perform therequired transactions (labeled “R”). Transactions labeled “O” are optional. A complete list of
options defined by this Integration Profile and that implementations may choose to support islisted in ITI TF-1: 13.5.
Table 13.4-1: XUA - Actors and Transactions
Actor

Transaction

Optionality

Section

X-Service User

Provide X-User Assertion [ITI-40]

R

ITI TF-2b: 3.40

X-Service Provider

Provide X-User Assertion [ITI-40]

R

ITI TF-2b: 3.40______________________________________________________________________________
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13.5 Options
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Options that may be selected for this Integration Profile are listed in Table 13.5-1 along with theActors to which they apply. Dependencies between options when applicable are specified innotes.
Table 13.5-1: XUA - Actors and Options
Actor

OptionSection

X-Service User

None

-

X-Service Provider

None

-

13.6 Grouping
13.6.1 Audit Trail and Node Authentication (ATNA)
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The X-Identity Assertion is valuable and must be protected against confidentiality risks. In someProfiles (e.g., XDS), there is already an inherited requirement to group with ATNA Secure Nodeor Secure Application Actor. This grouping forces the network transactions to utilize mutuallyauthenticated and encrypted TLS or equivalent. This is leveraged by XUA to support theprotection of the X-User Assertion to some risks to confidentiality and integrity. When ATNA
Secure Node or Secure Application grouping is not required, there will need to be some othermechanism to protect the Provide X-User Assertion.
ITI TF-2b: 3.40.4.2 includes encoding rules for representing an X-User Assertion in an ATNA
Audit Message.
13.6.2 Cross-Enterprise Document Sharing (XDS)

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When an XDS.b Document Consumer is grouped with X-Service User Actor, the XDS.b
Document Consumer shall conform to all the requirements in the Provide X-User Assertion
Transaction. The Document Consumer will obtain a properly scoped XUA Assertion targeted for
the XDS.b Document Registry or XDS.b Document Repository. The method used may bethrough internal means, SAML 2.0 Core protocols, WS-Trust, or any other means.
The XDS.b Document Registry and XDS.b Document Repository when grouped with the XUA
X-Service Provider Actor shall conform to all the requirements in the Provide X-User Assertion
Transaction. The XUA Profile does not constrain how the Assertion can be used (e.g., ignored,
access control, etc.).
13.6.3 Enterprise User Authentication (EUA)3135

An application that groups EUA and XUA Actors may use WS-Trust to get the X-User Assertion
from the Security Token Service (STS). In this case the AuthnContextClassRef element of the
SAML assertion shall be:urn:oasis:names:tc:SAML:2.0:ac:classes:Kerberos______________________________________________________________________________
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This conversion from one security token format to another is documented in the WS-Truststandard, and not further profiled by IHE.
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13.6.4 Any Web-Services Transaction that leverages ITI TF-2x: Appendix V
Any Actor that uses Web-Services according to ITI TF-2x: Appendix V may be grouped with theappropriate XUA Actors. The Actor grouped with X-Service User Actor, the Requesting Actor,
shall conform to all the requirements in the Provide X-User Assertion Transaction. The method
used may be through internal means, SAML 2.0 Core protocols, WS-Trust, or any other means.
The actor grouped with the X-Service Provider Actor shall conform to all the requirements in theProvide X-User Assertion Transaction. The XUA Profile does not constrain how the Assertion
can be used (e.g., ignored, access control, etc.).

13.7 Process Flow

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Figure 13.6-1: Cross-Enterprise User Assertion Process Flow

In the above flow we are showing more actors than are specified in this profile. This is a diagram
showing a possible grouping with IHE-EUA (User Authentication Provider), IHE-PWP (User
Directory Provider), and a SAML Identity Provider (X-Assertion Provider). The User______________________________________________________________________________
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Authentication Provider, User Directory Provider and X-Assertion Provider are not profiled here,
but rather are shown to give a context to the XUA transactions.
In this figure the dark lines represent the X-User Assertion transaction. The dashed lines
represent other standards based transactions that may be used. Web-Services session A and B
show an example where one X-User Assertion is used to cover two Web-Services transactions,where Web-Services Session C is using a different X-User Assertion. This may be due to adifferent user, timeout of the previous X-User Assertion, or some other reason.

13.8 Security Considerations
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The security risk assessment for XUA enumerates assets, threats, and mitigations. The security
risk assessment for the Actors that are grouped (e.g., Registry Stored Query and Retrieve
Document Set) with the XUA Actors are out of scope of the XUA profile, please look at thosetransactions for the Security Considerations. The complete risk data are stored and available
from IHE. The purpose of this risk assessment is to notify vendors and healthcare providers ofsome of the risks that they are advised to consider in implementing XUA Actors. For general
IHE risks and threats, please see ITI TF-1: Appendix L. The vendor is also advised that manyrisks cannot be mitigated by the IHE profile and instead responsibility for mitigation istransferred to the vendor, and occasionally to the affinity domains, individual enterprises andimplementers. In these instances, IHE fulfills its responsibility to notify affected parties throughthe use of the following sections.

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14 Patient Administration Management (PAM) Integration Profile
14.1 Patient Administration Management Use Cases
The Patient Administration Management Integration Profile defines transactions based onmessage exchanges to support patient identity and encounter information, as well as movements
within an acute care encounter. These can be represented by the following use cases.

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14.2 Patient Identity Management Use CaseA Patient Registration application decides to create a new patient John Smith, based on patient
information input from Hospital Sun. At this time, however, there is a limited set of personal
information traits of John Smith available. His date of birth, home address, and home phone
number are unknown. The registration application creates the patient identity and sends a Patient
Creation message to its downstream applications with the set of known personal information
traits.
The next day, detailed personal information about John Smith becomes available. The
registration application updates its patient identity record, and sends out a Patient Update
message.

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After a week, the registration application creates a temporary patient identity John Doe based on
input from Imaging Center Moon. After reconciliation of the temporary patient, it updates John
Doe’s demographics to (a new instance of) John Smith, and changes the temporary Patient
Identifier originally assigned to a permanent identifier.
After human inspection, it turns out that these two identities of John Smith represent the same
person. The operator decides to merge the second identity to the previously established identity
John Smith. A Patient Merge is communicated downstream.
14.2.1 Patient Encounter Management Use Case

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Patient Alan Alpha arrives for an annual exam at a clinic. The registration system sends thepatient registration information to the local ancillary systems, and the affiliated hospital's ADT
system.
The exam of Alan Alpha reveals a serious condition, and an immediate hospital admission isrecommended. Alan Alpha is referred to the affiliated hospital for admission. He is pre-admitted
in the hospital for relevant diagnostic tests. The tests confirm the condition, and the patient isadmitted in the hospital's ICU. During the stay in the ICU, the patient's insurance is verified, andthe updated information is sent from the hospital’s ADT system to the hospital’s ancillarysystems.
After a day in the ICU, Alan Alpha’s condition has improved, and he is transferred to a regularbed. The nurse recording the transfer makes a mistake, and enters the wrong room and bed. Afterdiscovering the error, the transfer is canceled, and the correct transfer is recorded. The patient is
now recovered and about to leave the hospital. According to the hospital's procedures, he is______________________________________________________________________________
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transferred to an outpatient unit for administering follow-up tests. The patient is registered in the
Hospital Outpatient Registration System.
The outpatient encounter of Alan Alpha is completed; based on satisfactory test results, he isdischarged from the hospital and the Outpatient Registration system.
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In this use case, two patient encounter management systems (the hospital ADT system and thehospital Outpatient Registration system) cooperate as peers.
14.2.2 Actors/ Transactions

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Figure 14.1-1 shows the actors directly involved in the Patient Administration Management
Integration Profile and the relevant transactions between them. Other actors that may be
indirectly involved because of their participation in other IHE Integration Profiles, such asRadiology Scheduled Workflow, Patient Identity Cross-Referencing Integration Profiles, etc., arenot shown.

Figure 14.1-1: Patient Administration Management Actor Diagram

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Table 14.2-1 lists the transactions for each actor directly involved in the Patient Management
Integration Profile. In order to claim support of this Integration Profile, an implementation must
perform the required transactions (labeled “R”). A complete list of options defined by thisIntegration Profile that implementations may choose to support is listed in Table 14.2-1.

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Table 14.2-1: Patient Administration Management - Actors and Transactions
ActorsTransactions

Optionality

SectionPatient Demographics Supplier

Patient Identity Management[ITI-30]R

ITI TF-2b: 3.30

Patient Demographics Consumer

Patient Identity Management[ITI-30]R

ITI TF-2b: 3.30

Patient Encounter Supplier

Patient Encounter Management[ITI-31]R

ITI TF-2b: 3.31

Patient Encounter Consumer

Patient Encounter Management[ITI-31]R

ITI TF-2b: 3.31______________________________________________________________________________
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14.3 Patient Administration Management Integration Profile Options
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Options that may be selected for this Integration Profile are listed in Table 14.3-1 along with theActors to which they apply. Dependencies between options when applicable are specified innotes.
Table 14.3-1: Patient Administration Management - Actors and Options
Actor
Patient Demographics Supplier

Patient Encounter Consumer

Vol & Section

Merge (Note 1)

ITI TF-2b: 3.30

Link / Unlink (Note 1)

ITI TF-2b: 3.30

Merge (Note 1)

ITI TF-2b: 3.30

Link / Unlink (Note 1)

ITI TF-2b: 3.30

Inpatient / Outpatient Encounter
Management

ITI TF-2b: 3.31

Pending Event Management (Note 2)

ITI TF-2b: 3.31

Advanced Encounter Management

ITI TF-2b: 3.31

Temporary Patient Transfer Tracking

ITI TF-2b: 3.31

Historic Movement

ITI TF-2b: 3.31

Inpatient / Outpatient Encounter
Management

ITI TF-2b: 3.31

Pending Event Management (Note 2)

ITI TF-2b: 3.31

Advanced Encounter Management

ITI TF-2b: 3.31

Temporary Patient Transfer Tracking

ITI TF-2b: 3.31

Historic Movement

ITI TF-2b: 3.31

Patient Demographics Consumer
Patient Encounter Supplier

Options

Note 1: An IHE National Extension shall select at least one of the Merge and Link / Unlink Options, and shall mandate thesame option for both the Patient Demographics Supplier and the Patient Demographics Consumer
implementations in its realm to ensure interoperability.

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Note 2: The Pending Event Management Option depends on the Inpatient / Outpatient Encounter Management Option. An
implementation supporting the Pending Event Management Option must also support the Inpatient / Outpatient
Encounter Management Option.

The PAM profile offers a large number of options to support the exchange of patient
demographic and encounter data in a wide variety of environments. Particularly, this profile
addresses both acute care settings and ambulatory healthcare organizations. It is unlikely that one
particular environment will need all the options.
On one hand, an ambulatory care community might need only the pair of actors Patient
Demographics Supplier/Patient Demographics Consumer, using transaction ITI-30. On the other
hand, the exchange of patient demographic and encounter data between a hospital patient
administration system and its ancillary systems (laboratory, radiology, cardiology, etc.) might befully satisfied with the pair of actors Patient Encounter Supplier/Patient Encounter Consumer,
using transaction ITI-31 with the only option “Inpatient/Outpatient Encounter Management”.
Hence, the first decision that must be made by a healthcare organization for the deployment of
this profile is to select the proper actors and the appropriate set of options to cover its needs,______________________________________________________________________________
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ensuring that each selected option will be supported by the actors on both ends of thetransactions.
Furthermore, as an IT Infrastructure profile, the PAM profile may not be used standalone.
Rather, its actors and transactions will be leveraged by other domain integration profiles (inradiology, cardiology, laboratory, or in cross enterprise document sharing). Here again, the firstdecision that will be taken by the IHE committee that wishes to leverage PAM for its domain,
will be to select the proper set of options and to ascertain the consistent use of these options in its
domain.
Thus, during the building process of IHE domain technical frameworks, as well as in the
deployment process, the PAM profile will be constrained to reduce its original number of
options.
However, to accommodate situations in which a consumer application would not support an
option implemented by a supplier application, the PAM profile states that the consumer
application shall application-reject a message that it does not support (see ITI TF-2x: C.2.3).
14.3.1 Merge Option

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The Merge Option defines the information exchange needed to manage the merging of patient
identifiers.
14.3.2 Link / Unlink Option
The Link / Unlink Option defines the information exchanges needed to manage the linking andunlinking of patient identifiers, respectively.

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14.3.3 Inpatient / Outpatient Encounter Management Option
The Inpatient / Outpatient Encounter Management Option extends the basic patient encounter
management functions by defining the information exchanges needed for pre-admitting a patientand for transferring a patient from one location to another location in the enterprise, as well as
for changing patient class.

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14.3.4 Pending Event Management Option
The Pending Event Management Option extends the basic patient encounter management
functions by defining the information exchanges needed for supporting pending events, e.g.,admission, transfer, and discharge.
14.3.5 Advanced Encounter Management Option

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The Advanced Encounter Management Option extends the basic patient encounter management
functions by defining a set of messages for handling patient temporary absence, changing
attending doctor in an encounter, and moving accounts among different patient identities.

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14.3.6 Temporary Patient Transfer Tracking Option
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The Temporary Patient Transfer Tracking Option defines the information exchange needed for
tracking a temporary leave / return of a patient from / to a care facility.
14.3.7 Historic Movement Option

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The Historic Movement Option extends the basic patient encounter management functions, aswell as the following Options:• Inpatient / Outpatient Encounter Management• Pending Event Management• Advanced Encounter Management Options.
The Historic Movement Option provides a means to uniquely identify any movement event
conveyed in the underlying information exchange. This enables updates of such events at any
later time point after they were initially reported.

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14.4 Patient Administration Management Integration Profile Actor
Grouping
14.4.1 Actor Grouping of Patient Encounter Supplier

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In order to obtain patient identity and demographics information to serve its patient encountermessage functions in transaction ITI-31, a Patient Encounter Supplier is required to be groupedwith either a Patient Demographics Supplier or a Patient Demographics Consumer, as shown in
Figure 14.4-1.

Figure 14.4-1: Patient Encounter Supplier Grouping Requirements

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On the other hand, transaction ITI-31 is self-contained in a sense that the Patient Encounter
Supplier sends both patient encounter information and patient identity and demographics
information (in the context of the encounter data) to the Patient Encounter Consumer. In
addition, transaction ITI-31 also allows the Patient Encounter Supplier to send messages to the______________________________________________________________________________
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Patient Encounter Consumer for patient identity maintenance in the encounter context, including
patient update and identity merge. There is no required grouping for the Patient Encounter
Consumer.
14.4.2 Actor Grouping with other IHE Actors

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The PAM profile provides an infrastructure in a healthcare enterprise or across a number ofenterprises to distribute the patient identity, demographics, and encounter information, in orderto enable various clinical functions in clinical settings. The PAM actors can be grouped withactors in other IHE Integration Profiles.
One possible grouping is between the Patient Demographics Supplier actor in the PDQ profileand either the Patient Demographics Supplier actor or the Patient Demographics Consumer actor
in this profile, to add query support defined in the Patient Demographics Query transaction to thesame set of patient information managed in the PAM profile.

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Furthermore, the Patient Demographics Supplier actor in the PDQ profile can be grouped with
the Patient Encounter Supplier actor of this profile. Due to the required grouping of the Patient
Encounter Supplier actor (see ITI TF-1: 14.4.1), such a grouping can provide query support
defined in both the Patient Demographics Query and Patient Demographics and Visit Query
transactions to the same set of patient and encounter information that is managed in the PAM
profile.
These are some examples of possible grouping of the PAM actors with other IHE actors. Manyother possibilities may be useful (either to provide additional values or to allow profile structuresimplification). For example, in the radiology scheduled workflow (SWF) profile, the Order
Placer and Order Filler actors can be grouped with the Patient Encounter Consumer actor.

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14.5 Patient Administration Management Process Flow
14.5.1 Patient Identity Management
The Patient Identity Management incorporates the following process flows. This refines the usecase shown in ITI TF-1: 14.1.1.
14.5.1.1 Patient Identity Creation and Maintenance

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Create Patient. The Patient Demographics Supplier decides to create a new patient John
Smith, based on patient information input from Hospital Sun. At this time, however, there isa limited set of personal information traits of John Smith available. His date of birth, homeaddress, and home phone number, e.g., are unknown. The Patient Demographics Suppliercreates the patient identity and sends a Patient Creation message to the Patient Demographics
Consumer with the set of known personal information traits.
Update Patient Demographics. The next day, detailed personal information about John Smith
becomes available. The Patient Demographics Supplier updates its patient identity record,and sends out a Patient Update message, including date of birth, home address and homephone number.

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Create Temporary Patient. After a week, the Patient Demographics Supplier creates a
temporary patient identity John Doe based on input from Imaging Center Moon.
Update Patient Demographics and Change Patient Identifiers After reconciliation of thetemporary patient, the Patient Demographics Supplier updates John Doe’s demographics to(a new instance of) John Smith, and changes the temporary Patient Identifier originallyassigned to a permanent identifier
Merge Patient Identifiers. After human inspection, it turns out that the two patients named
John Smith in the Patient Demographics Supplier actually represent the same real-world
patient. The operator decides to merge the two patient identities. The Patient Demographics
Supplier sends a Patient Merge message to the Patient Demographics Consumer.

The following diagram shows the process flow:
Patient
Demographics
SourcePatient
Demographics
Consumer
Create Patient

ITI-030: Patient Identity Management – Create Patient
ITI-030: Patient Identity Management – Update
Patient Demographics
Create Temporary Patient
ITI-030: Patient Identity Management – Create Patient
ITI-030: Patient Identity Management – Update
Patient Demographics
ITI-030: Patient Identity Management – Change
Patient Identifiers
ITI-030: Patient Identity Management – Merge Patient

Figure 14.5-1: Patient Identity Management Process Flow in PAM Profile

14.5.1.2 Alternative Process Flow
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Link Patient Identifiers. A similar situation as that mentioned above, except that the local
procedures request the Patient Demographics Supplier to link these two duplicated patient
records instead of merging them. The operator performs the link function. The Patient
Demographics Supplier sends a Patient Identifiers Link message to the Patient Demographics
Consumer.

The following diagram shows the alternate portion of the process flow:
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Patient
Demographics
SourcePatient
Demographics
Consumer

ITI-030: Patient Identity Management – Link Patient

Figure 14.5-2: Patient Identity Management Alternate Process Flow in PAM Profile

14.5.2 Patient Encounter Management
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The Patient Encounter Management incorporates the following process flows:
14.5.2.1 Inpatient/Outpatient Encounter and Pending Event Management
In this section, inpatient/outpatient encounter management process flow is described in anenvironment that involves a number of instances of Patient Encounter Supplier and Patient
Encounter Consumer. This refines the use case shown in ITI TF-1: 14.1.2

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In some institutions, there may be one central Patient Encounter Supplier, while others may havemultiple Patient Encounter Suppliers serving patient encounter management functions indifferent clinical settings (e.g., hospital inpatient, hospital outpatient, clinics). It is the
responsibility of a healthcare institution to define the actor roles of its systems, as well as toconfigure the relationship of a Patient Encounter Supplier and its Patient Encounter Consumers,
to satisfy their business process models.
As shown in Figure 14.5-3, in the healthcare institution of this process flow, there are threePatient Encounter Suppliers, each of which serves a number of Patient Encounter Consumers in a
specific clinical setting of the institution.
Clinic’s Patient
Registration
SystemHospital’s ADT
SystemSupplier

Patient Encounter
Consumer

Patient Encounter
Consumer

Patient Encounter
Supplier

Clinic’s Ancillary
System

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Patient Encounter
Supplier

Hospital’s
Outpatient
Registration
SystemHospital’s Ancillary
SystemPatient Encounter
Consumer

Patient Encounter
Consumer

Figure 14.5-3: System and PAM Actor Role Configuration

The systems involved in this process flow implement the following PAM roles:• Clinic Registration System as Patient Encounter Supplier• Clinic Ancillary System as Patient Encounter Consumer______________________________________________________________________________
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Hospital ADT system as both Patient Encounter Supplier and Patient Encounter Consumer
Hospital Ancillary system as Patient Encounter Consumer
Hospital Outpatient Registration System as both Patient Encounter Supplier and Patient
Encounter Consumer

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•

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Note that the Hospital ADT and Outpatient Registration Systems play both the roles of Patient
Encounter Supplier and Patient Encounter Consumer, and cooperate as peers. The relationshipbetween the Patient Encounter Supplier and Patient Encounter Consumer in the same system isdependent on the clinical application logic implemented in the institution, and the definition ofthis relationship is beyond the scope of the PAM Integration Profile.

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The process flow in Figure 14.5-4 is described in the following:• Patient Registration: A patient arrives for an annual exam at a clinic. The patient record has
been created previously by a Patient Demographics Supplier, and exists in the clinic’s
registration system through its grouping with the Patient Demographics Supplier actor. The
clinic’s registration system sends the Patient Registration message to the local ancillarysystems, and the affiliated hospital’s ADT system.
• Change Outpatient to Inpatient: The exam reveals a serious condition of the patient, and an
immediate hospital admission is recommended. The patient is referred to the affiliatedhospital for admission. A Change Outpatient to Inpatient message is sent to the hospital’s
ADT System.
• Pre-admit Patient for Hospitalization: The patient is pre-admitted in the hospital for
relevant diagnostic tests. The hospital ADT system sends Patient Pre-Admit message to the
Hospital Ancillary System.
• Patient Admitted Notification: The tests confirm the condition, and the patient is admitted tothe hospital’s ICU. The hospital ADT system sends an Admission Notification message to
the Ancillary System.
• Patient Insurance Information Update: During the stay in the ICU, the patient’s insurance
is verified, and the updated information is sent from the hospital ADT to the Hospital
Ancillary System.
• Patient Location Transfer: After a day in the ICU, the patient’s condition has improved,
and the patient is transferred to a regular bed. The hospital ADT system sends a Patient
Transfer message to the Hospital Ancillary System.
• Patient Location Transfer Error Reconciliation: The nurse recording the transfer makes a
mistake, and enters the wrong room and bed. After discovering the error, the hospital ADT
system sends a Cancel Patient Transfer message to the Hospital Ancillary System, followed
by a new Patient Transfer message.
• Patient Pending Discharge: The patient is now recovered and about to leave the hospital.
The ADT system sends a Patient Pending Discharge message to the Hospital Ancillary
System.

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•

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Change Inpatient to Outpatient: According to the hospital’s procedures, the patient istransferred to an outpatient unit for administration of follow-up tests. The ADT system sends
a Change Inpatient to Outpatient message to the Hospital Outpatient Registration System.
Register Patient as Outpatient: The patient is registered in the Hospital Outpatient
Registration System, which sends a Patient Registration message to the Hospital ADT systemand the Hospital Ancillary System.
Patient Discharged from Outpatient System: The outpatient encounter is completed. A
Patient Discharge message is sent to the Hospital ADT System and to the Hospital Ancillary
System.
Patient discharged from Hospital ADT System: Based on satisfactory test results, the patient
is discharged. The hospital ADT system sends a Patient Discharge message to the Hospital
Ancillary System.

The following diagram shows the process flows of the discussed use cases:
Clinic’s Patient Registration System
Patient Encounter
Supplier

Clinic’s Ancillary. System
Patient Encounter
Consumer

Hospital’s Ancillary System

Hospital’s ADT System
Patient Encounter
Consumer

Patient Encounter
Consumer

Patient Encounter
SourceHospital’s Outpatient Registration. System
Patient Encounter
Consumer

Patient Encounter
Source

ITI-031: Patient Encounter
Management – Patient Registration
ITI-031: Patient Encounter Management – Patient Registration
ITI-031: Patient Encounter Management – Change Outpatientto Inpatient

ITI-031: Patient Encounter
Management – Patient Pre-Admit
ITI-031: Patient Encounter
Management – Admitted Notification
ITI-031: Patient Encounter
Management – Patient Update
ITI-031: Patient Encounter
Management – Patient Transfer
ITI-031: Patient Encounter Management– Cancel Patient Transfer
ITI-031: Patient Encounter
Management – Patient Transfer
ITI-031: Patient Encounter
Management – Pending Discharge
ITI-031: Patient Encounter Management –Change Inpatient to Outpatient
ITI-031: Patient Encounter Management– Patient Registration
ITI-031: Patient Encounter Management – Patient Registration
ITI-031: Patient Encounter Management– Patient Discharge
ITI-031: Patient Encounter Management – Patient Discharge

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ITI-031: Patient Encounter Management– Patient Discharge

Figure 14.5-4: Inpatient / Outpatient Encounter Management Process Flow in PAM Profile

14.5.2.2 Advanced Encounter Management
•
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Attending Physician Change: A patient’s attending physician changes during an inpatient
stay. The Patient Encounter Supplier sends a notification message that contains the name of
the new attending doctor to the Patient Encounter Consumer.
Cancellation of Attending Physician Change: A notification of change of a patient’s
attending physician was sent in error. The Patient Encounter Supplier sends a cancellation______________________________________________________________________________
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•
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•
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message that contains the name of the old attending doctor to the Patient Encounter
Consumer.
Leave of Absence: An inpatient is authorized a weekend leave of absence from the medical
center. The Patient Encounter Supplier sends a notification message to the Patient Encounter
Consumer that contains the date and time of the leave of absence and of the expected return.
Cancellation of Leave of Absence: A notification that an inpatient was authorized aweekend leave of absence was sent in error. The Patient Encounter Supplier sends acancellation message to the Patient Encounter Consumer.
Return from Leave of Absence: An inpatient returns to the medical center from a weekend
leave of absence. The Patient Encounter Supplier sends a notification message to the Patient
Encounter Consumer that contains the date and time of the expected return and of the actual
return.
Cancellation of Return from Leave of Absence: A notification that an inpatient returned
from a weekend leave of absence was sent in error. The Patient Encounter Supplier sends acancellation message to the Patient Encounter Consumer.
Move Account: The Patient Encounter Supplier sends a message that incorrectly associates
Account 12345 with Patient A; in fact, Account 12345 should be associated with Patient B.
To effect a correction, the Patient Encounter Supplier sends a message to the Patient
Encounter Consumer that contains the account identifier and the identifiers of the patient
records between which the account association is to be moved.

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The following diagram shows these discussed use cases:
Patient Encounter
Consumer

Patient Encounter
Supplier
ITI-031: Patient Encounter Management –Attending Physician Change
ITI-031: Patient Encounter Management –Cancellation of Attending Physician Change

ITI-031: Patient Encounter Management – Leaveof Absence
ITI-031: Patient Encounter Management –Cancellation of Leave of Absence
ITI-031: Patient Encounter Management – Returnfrom Leave of Absence
ITI-031: Patient Encounter Management –Cancellation of Return from Leave of Absence
ITI-031: Patient Encounter Management – Move
Account
ITI-031: Patient Encounter Management – Update
Patient Demographics

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Figure 14.5-5: Advanced Encounter Management Process Flow in PAM Profile

14.5.2.3 Historic Movement Management

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Historic tracking of patient admissions, discharges, and other movements may be needed in somehealthcare institutions. Such historic events may need to be tracked even beyond the boundary ofan episode of care. In order to facilitate this tracking, the Patient Encounter Supplier may send
the messages in ITI TF-1: 14.5.2.1 and 14.5.2.2 to the Patient Encounter Consumer, with theaddition of an identifier for the particular encounter with which the patient admission, discharge,
or movement is associated.
• Patient Location Transfer: A patient is transferred to bed 23 of Room B after a few days ofstay in ICU. The hospital ADT system sends a Patient Transfer message (including theelements provided in the Historic Movement Management Option) to the downstream
applications.
• Update Previous Transfer Event. After two days, the operator of the ADT system detectsthat the transfer destination and time in the previously sent Patient Transfer message were
wrong. He corrects the errors and an Update Historic Patient Transfer message is sent out, tocommunicate the true room / bed information and the true transfer time.

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The following diagram shows these use cases:
Patient Encounter
Supplier

Patient Encounter
Consumer
Patient Transferred to
Bed 23 of Room B
ITI-031: Patient Encounter Management– Patient Transfer

Detects the error in previous
Transfer message, andcorrect transfer bed / roomand time information.
ITI-031: Patient Encounter Management– Update Historic Patient Transfer

Figure 14.5-6: Historic Movement Management Process Flow in PAM Profile

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14.5.2.4 Temporary Patient Transfer Tracking
•

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Departure to Temporary Location: A chest X-ray is scheduled for an inpatient. To perform
this service, the patient needs to be moved from her inpatient bed in the medical service to
the Radiology department. When the patient departs from her inpatient bed, the Patient
Encounter Supplier sends a notification message to the Patient Encounter Consumer that
contains the temporary location to which the patient is being moved.
Arrival at Temporary Location: When the patient arrives at the Radiology department, thePatient Encounter Supplier sends a notification message to the Patient Encounter Consumer
that contains the temporary location to which the patient has been moved.
Cancellation of Departure to Temporary Location: It is incorrectly communicated that apatient left her inpatient bed to move to the Cardiology department for treatment. The
Patient Encounter Supplier sends a cancellation message to the Patient Encounter Consumer
that contains the patient’s location(s) (permanent and / or temporary) prior to the time of theerroneously communicated departure.
Cancellation of Arrival at Temporary Location: It is incorrectly communicated that apatient, having left her inpatient bed, arrived in the Surgery department for treatment. The
Patient Encounter Supplier sends a cancellation message to the Patient Encounter Consumer
that contains the patient’s location(s) (permanent and / or temporary) prior to the time of theerroneously communicated arrival.

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The following diagram shows these discussed use cases:
Patient Encounter
Consumer

Patient Encounter
Supplier
ITI-031: Patient Encounter Management –Departure to Temporary Location

ITI-031: Patient Encounter Management – Arrivalat Temporary Location
ITI-031: Patient Encounter Management –Cancellation of Departure to Temporary Location
ITI-031: Patient Encounter Management –Cancellation of Arrival at Temporary Location

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Figure 14.5-7: Temporary Patient Transfer Tracking Process Flow in PAM Profile______________________________________________________________________________
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15 XDR Integration Profile
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Cross-Enterprise Document Reliable Interchange (XDR) provides document interchange using a
reliable messaging system. This permits direct document interchange between EHRs, PHRs, andother healthcare IT systems in the absence of a document sharing infrastructure such as XDS
Registry and Repositories.
XDR provides a reliable and automatic transfer of documents and metadata for one patient
between EHR systems even in the absence of an XDS infrastructure. XDR supports the reuse of
the Provide and Register Set transaction-b with Web-Services as transport. Transfer is directfrom source to consumer, no repository or registry actors are involved.
XDR is document format agnostic, supporting the same document content as XDS and XDM.
Document content is described in XDS Document Content Profiles. Examples are XDS-MS,
XD-LAB, XPHR, and XDS-SD.

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XDR defines no new metadata or message formats. It leverages XDS metadata with emphasis on
patient identification, document identification, description, and relationships.

15.1 Actors/ Transactions
Figure 15.1-1 shows the actors directly involved in the XDR Integration Profile and the relevanttransactions between them. Other actors that may be indirectly involved due to their
participation in XDS, PIX or XUA are not shown.
3535
Provide and Register Document Set-b [ITI-41] →Document
SourceDocument
RecipientFigure 15.1-1: XDR Actor Diagram

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Table 15.1-1 lists the transactions for each actor directly involved in the XDR Profile. In order toclaim support of this Integration Profile with one or more actors, an implementation must
perform the required transactions (labeled “R”). Transactions labeled “O” are optional. A
complete list of options defined by this Integration Profile and that implementations may choose
to support is listed in Volume I, Section 15.2.
Table 15.1-1: XDR Integration Profile - Actors and Transactions
ActorsDocument Source

Transactions

Optionality

Provide and Register Document Set-b[ITI-41]

R

Section in Vol. 2
ITI TF-2:3.41______________________________________________________________________________
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ActorsDocument Recipient

Transactions

Optionality

Provide and Register Document Set –b[ITI-41]

R

Section in Vol. 2
ITI TF-2:3.41

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15.2 XDR Integration Profile Options
Options that may be selected for this Integration Profile are listed in Table 15.2-1 along with theActors to which they apply. Dependencies between options when applicable are specified innotes.
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Table 15.2-1: XDR - Actors and Options
Actor

Options

Vol & Section

Document Source

Basic Patient Privacy Enforcement

ITI-TF-2b: 3.41.4.1.3.1

Document Recipient

Basic Patient Privacy Enforcement

ITI-TF-2b: 3.41.4.1.3.1

15.2.1 Intentionally Left Blank
15.2.2 Basic Patient Privacy Enforcement Option
For this option, see ITI-TF-2b: 3.41.4.1.3.1

15.3 XDR Process Flow3555

XDR describes the exchange of a set of a patient’s documents between healthcare providers,such as: physicians, hospitals, special care networks, or other healthcare professionals.
Where XDS Registry/Repositories are not yet implemented or available for the exchange of
information, XDR is the viable approach.

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In a situation where the information is going to an automated application or robust systemcapable of automated storage or processing of documents relative to one patient, XDR is theappropriate profile.
The XDR integration profile is intended only for exchange of patient related medical documents
and not intended to address all cross-enterprise EHR communication needs.
Use Cases:

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1.

Dr. Primary refers his aging patient Mr. Robinson to his first appointment with agastroenterology specialist.
Since there is no XDS repository available at the gastro clinic, Dr. Primary cannot use
XDS to communicate the XDS-MS referral to Dr. Gastro. Also, since there is noaffinity domain linking Dr. Primary and Dr. Gastro, XDR is preferable to XDS for the______________________________________________________________________________
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exchange of Mr. Robinson’s referral information. XDR is also appropriate for Dr.
Gastro’s documents communication to Dr. Primary.
2.

Mabel is transferred from a hospital setting to her retirement home for long-term care.
XDR: Mabel’s information can be transferred from the hospital to the long-term carefacility’s EHR application for future review by her attending physicians and nurses,
through XDR.

3.

Stanley’s recent MRI has generated unusual results that Stanley’s primary physician
would like to consult with another specialist in a specialized cancer facility locatedacross the state. Since there is not likely to be an affinity domain between the remotehealth environments, XDR can be used instead.

4.

Mrs. Sweettooth has been diagnosed with adult diabetes and her specialized circle ofcare has not yet gotten organized to provide shared access to a common repository.
Until they do, they will need to exchange her information peer-to-peer using XDR.

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This profile is only defining the digital transport mechanism used for such use cases, content
transported will be detailed by Content Profiles such as the ones defined by the IHE PCC(Patient Care Coordination) domain.
Document Source

Document Recipient

Provide and Register Document Set-b [ITI-41]

Figure 15.3-1: Process Flow in XDR Profile

15.4 Digital communication
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It is a web service based HTTP message.

15.5 Security Considerations

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The Profile assumes that the health organizations that are using Document Source and Document
Recipient have an agreement defining when they can interchange PHI. This may require an
explicit patient consent (depending on the regulation) and an agreement on how to manage thepotential inconsistency between the security policies. The main aspects that should be covered bythis agreement are similar to XDS – See Appendix L. In the case of XDR, the EHR-to-EHR (orPHR) communication is a transient XDS Affinity Domain. In addition, the following aspects
should be covered:• Management of Patient identification in order to perform patient reconciliation correctly
upon importation of the documents.
Both Actors for this Profile require a grouping with Secure Node.
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16 Cross-Enterprise Document Media Interchange (XDM) Integration
Profile3605

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Cross-Enterprise Document Media Interchange (XDM) provides document interchange using acommon file and directory structure over several standard media types. 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. XDM supports the transfer of data about multiple patients
within one data exchange.
Physician to patient to physician - Bob has an MRI and cancer is diagnosed. He is given a CDR with his MRI results and referral information on it to give to the specialist of his choice.
Patient visiting ED - In addition, Bob, the informed patient, maintains a copy of his EHR record
at home and can bring the CD-R with him when he visits the ED for an unrelated emergency.

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Physician to physician - Dr. Primary refers his aging patient Mr. Robinson to his first
appointment with a gastroenterology specialist. He transfers relevant documents in a zip fileattached to an email to the specialist.
The common thread of these use cases is that they are person-to-person communications. The
XDM solution is intended to be easy to implement with pre-existing email clients, CD burners
and USB ports. XDM does not include any additional reliability enhancements. XDM requiresthat the recipient be able to support human intervention in order to manually control theimporting of the data (patient ID reconciliation, selection of patient of interest from possibly
multiple patients’ documents on the media).
XDM is document format agnostic, supporting the same document content as XDS and XDR.
Document content is described in XDS Document Content Profiles. Examples are XDS-MS,
XPHR, XDS-SD, and XD*-LAB.

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XDM defines no new metadata. It leverages XDS metadata with emphasis on patient
identification, document identification, description, and relationships.
A directory and file structure is documented for populating the media. This structure maintains
separate areas for each patient listed and is supported on all referenced media types. Media andthe structure were selected based on experience with media interoperability in Radiology, i.e.
PDI profile. The media selected are the widespread CD-R, USB removable media, and email
with ZIP attachment.

16.1 Actors/ Transactions
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Figure 16.1-1 shows the actors directly involved in the XDM Integration Profile and the relevanttransactions between them. Other actors that may be indirectly involved due to their
participation in XDS, PIX or PDI are not shown.

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Portable Media Creator

Distribute Document Set on Media [ITI-32] →Portable Media Importer

Figure 16.1-1: XDM Actor Diagram

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Table 16.1-1 lists the transactions for each actor directly involved in the XDM Profile. In orderto claim support of this Integration Profile with one or more actors, an implementation must
perform the required transactions (labeled “R”). Transactions labeled “O” are optional. A
complete list of options defined by this Integration Profile and that implementations may choose
to support is listed in ITI TF-1: 16.2.

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Table 16.1-1: XDM Integration Profile - Actors and Transactions
ActorsTransactions

Optionality

Portable Media Creator

Distribute Document Set on Media[ITI-32]R

ITI TF-2b: 3.32

Portable Media Importer

Distribute Document Set on Media[ITI-32]R

ITI TF-2b: 3.32

Section

16.2 XDM Integration Profile Options
Options that may be selected for this Integration Profile are listed in Table 16.2-1 along with theActors to which they apply. Dependencies between options when applicable are specified innotes.
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Table 16.2-1: XDM - Actors and Options
Actor

Options

Portable Media Creator

USB (Note 1)

ITI TF-1: 16.2.1

CD-R (Note 1)

ITI TF-1: 16.2.2

ZIP over Email (Note 1)

ITI TF-1: 16.2.3

Basic Patient Privacy
Enforcement

ITI TF-2b: 3.32.4.1.4.1

Zip over Email Response(Note2)

ITI TF-1: 16.2.4

USB (Note 1)

ITI TF-1: 16.2.1

CD-R (Note 1)

ITI TF-1: 16.2.2

ZIP over Email (Note 1)

ITI TF-1: 16.2.3

Basic Patient Privacy
Enforcement

ITI TF-2b: 3.32.4.1.4.1

Zip over Email Response(Note2)

ITI TF-1: 16.2.4

Portable Media Importer

Vol & Section

Note 1:

At least one of these options is required for each Actor. In order to enable a better interoperability, is highly
recommended that the actors support all the options.

Note 2:This option requires the ZIP over Email Option.

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16.2.1 USB Option
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In this option the Portable Media Creator writes a set of documents on USB media. The media is
physically transported to the Portable Media Importer which then imports the document set.
16.2.2 CD-R Option
In this option the Portable Media Creator writes a set of documents on CD-R media. The media
is physically transported to the Portable Media Importer which then imports the document set.

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16.2.3 ZIP over EmailIn this option the Portable Media Creator creates an ordinary ZIP file of the virtual media
containing document set(s). The ZIP file is attached to an Email sent to the Portable Media
Importer which then retrieves the Email and imports the ZIP file containing the document set.

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16.2.4 ZIP over Email Response
In this option the Portable Media Importer sends a response (MDN Based) to the Portable Media
Importer to acknowledge that the Import operation of the Document Set(s) received was
successful.
If this option is supported, the ZIP over Email option shall be supported.

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XDM describes the exchange of a set of a patient’s documents between healthcare providers,such as: physicians, hospitals, special care networks, or other healthcare professionals.
Where XDS is not desirable or available for one of the participants in the exchange of
information, XDM is a viable option.

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XDM should be used in a situation where the information receiver is an individual who will
manually interpret or examine the data and associated documents as though they were using
physical media. XDM also allows for the exchange of documents relating to multiple patients,
since the data will be interpreted manually by human intervention.
The XDM integration profile is intended only for exchange of personal medical documents andnot intended to address all cross-enterprise EHR communication needs. Some use cases may
require the use of other IHE integration profiles such as XDS, DSG, PIX, and ATNA. Other use
cases may only be partially supported, while still others may require future IHE integration
profiles.
Use Cases:
1.

Dr. Primary refers his aging patient Mr. Robinson to his first appointment with agastroenterology specialist.
In a case where either Dr. Primary’s office or Dr. Gastro’s clinic was not able tohandle secure email, or other sustained online point-to-point communications(e.g.: http over VPN), the XDM profile would provide further solutions for the______________________________________________________________________________
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simpler environment, such as the use of physical media, or email where theinterchanged document set will be manually interpreted by a human intervention.

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2.

In a hospital, or in the case of a family physician not using robust EHR, thepatient could be handed a CD or USB media with their discharge information on
it to bring with them to their follow-up visit with their family physician.

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3.

Mabel is transferred from a hospital setting to her retirement home for long-term care.
If the hospital does not have an EHR application that automatically interprets her
medical data and shares it with the necessary members of her health team, theinformation can be transferred manually directly to the file clerk, intake
coordinator, records manager, or primary physician depending on theorganization’s resource model.

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4.

Stanley’s recent MRI has generated unusual results that Stanley’s primary physician
would like to consult with another specialist in a specialized cancer facility locatedacross the state. Since there is not likely to be an affinity domain between the remotehealth environments, XDM can be used instead.

5.

Bob, the informed patient, maintains a copy of his Personal Health Record (PHR) at
home. In this situation, Bob can be given a copy of his medical information on physicalmedia such as a CD-ROM to take home with him. Bob now has an advantage that hecan continue to have his complete medical record available with him on sudden
emergency department visits, even when he is on an out-of-state trip where the new ED
would have no access to the repository of his home affinity domain.

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In a hospital that does not have an XDS infrastructure; the XDS-MS content profile
discharge use case can also be handled by XDM. For example:

This profile is only defining the digital transport mechanism used for such use cases. Content
transported will be detailed by Content Profiles such as the ones defined by the IHE PCC(Patient Care Coordination) domain.

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Portable Media Creator

Portable Media Importer

Distribute Document Set on Media [ITI-32]

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Figure 16.3-1: Process Flow in XDM Profile

16.4 Digital communication
16.4.1 Actual Media Type
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The media can be either CD-R or a USB media device, because these are the most common
media types in other industries for the portable transport of electronic information. This
supplement requires using one of these media types, depending on the use case. The benefit andrisks of the reusability of the media deployed should be taken into account, especially when the
media is under the control of the patient.
Note:

1. Because the size of documents to be exchanged rarely requires more than the capacity of a CD, and the format
for storing data on various different recordable DVD media is not totally stable yet, this profile is following the
restriction defined in the IHE RAD PDI Profile, to not use recordable DVD media at this time.
2. CD-RW is excluded from this profile because field experiences with CD-RW in radiology with this media
showed significant interoperability problems and significant accidental damage levels.

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3. The CD-R media is limited to the 74 minute blanks because the long playing CD-R format gains the larger
capacity by eliminating one level of error correction and detection. The resulting much higher undetected error
rate is considered unacceptable for medical data.

16.4.2 Virtual Media over a Network
The media can be a ZIP file containing the document set and sent via a secure email message.
16.4.3 Media Content
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The requirements for media content are intended to promote the simple transfer of medical
documents, including patient summaries, lab results, discharge letters and reports, and to allow
for the viewing of such documents on general purpose computers by care providers or patients.
Created media are required to contain documents and the relevant associated metadata.

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The media contains one or more Submission Sets including the documents and the associatedmetadata, organized in a well-defined directory structure starting at the root level.
The media content can be made web viewable by a web browser by providing optional files
containing HTML content. This content must be based on the original documents in order toensure consistency. Any ordinary web browser can be used to read these files. The Portable
Media Importer ignores these files. They are just intended for the human recipient.
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Additional content may be present (files, directories), but can be ignored by the Portable Media
Importer.
To summarize, the Portable Media Importer has two complementary ways to access the media
and its content through a basic web browser:• By inspecting in the directory dedicated to XDM all the subdirectories that contain aspecifically named metadata file compatible with XDM• By presenting to the user the HTML index file that lists the submission sets and documents
contained in the media.
Access to the content of an individual document is outside the scope of this Integration Profileand shall be addressed in specific IHE document content Integration Profiles.

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16.5 Security considerations

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The Profile assumes that the Healthcare delivery organizations that are using Portable MediaCreator and Importer have an agreement defining when they can interchange PHI. This may
require an explicit patient consent (depending on existing regulations) and an agreement on how
to manage the potential inconsistency between the security policies. The main aspects that should
be covered by this agreement are similar to XDS – See ITI TF-1: Appendix L. In addition, thefollowing aspects should be covered:• Management of Patient identification in order to perform patient reconciliation correctly
upon importation of the documents.
• Measures taken to avoid or limit loss of media or email, and detect that which occurs.

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In the case of physical media, security responsibilities for confidentiality and integrity aretransferred to the patient by providing the media to the patient. In this case it is the patient’s
responsibility to protect the media, and the patient has the authority to disclose the contents ofthe media as they choose. They disclose the contents by providing the media.
The Portable Media Creator in most cases does not know who the ultimate Importer will be, thus
rendering encryption impractical.
In the case of transfer over email using a ZIP attachment, the transaction is secured by the use of
S/MIME.
Both Actors for this Profile require a grouping with an ATNA Secure Node or Secure
Application.

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17 Retrieve Form for Data Capture (RFD) Profile

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The Retrieve Form for Data Capture (RFD) profile provides a method for gathering data within auser’s current application to meet the requirements of an external system. RFD supports theretrieval of a form from a form source, the display and completion of the form, and the return of
instance data from the display application to a receiving application. In addition, RFD provides amechanism to amend data that was previously captured.
Consider the case where a healthcare provider site uses an Electronic Health Record (EHR) to
document patient care. In this case, the EHR acts as the local home application for theprovider’s personnel. Suppose an external agency, through some contractual arrangement,
requires data from the provider, some of which reside in the EHR’s database, the rest requiring
data entry by the EHR’s users. RFD enables the EHR user to retrieve a data capture form fromthe external agency, to fill out the form, and to return the data to the external agency withoutleaving the provider’s local home application, the EHR. The profile also permits the external
agency to indicate that there is a need to clarify points about the data so captured and provides
the mechanisms to allow the data to be modified.
Many potential uses of RFD want the form to dynamically pre-populate forms from the hostapplication’s database, that is have the form delivered with host application database values
filled in to appropriate fields of a form. RFD permits automatic form population and provides a
generic mechanism by which this can be accomplished. However, the profile does not speak to
the issue of content, remaining silent on normative vocabularies and other enablers of semanticinteroperability. Specific domain groups – clinical trials, drug safety, bio-surveillance – willbuild on RFD by contributing content specifications or by evaluating and recommending existing
content standards that will operate within RFD. When RFD, as an infrastructure profile,
integrates with domain-specific content standards, a much greater level of interoperability will
result.
The RFD profile provides a generic polling mechanism to allow an external agency to indicate
issues with data that have been captured and enable the healthcare provider to correct the data.
The profile does not dictate the mechanism employed or content required to achieve suchcorrections.

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In this profile, the external agency provides data capture forms in a schema appropriate to its
domain. The profile intends to minimize the work that the displaying application should do, andto bring over fully functional forms that carry with them the instruction necessary to complete
the form. RFD also supports archiving a copy of the completed form.
RFD offers the capability to leverage industry standards that address both the structure andcontent of forms used for data capture. HL7’s Individual Case Safety Record (ICSR) and
CDISC’s Operational Data Model (ODM) provide examples.
The infrastructure provided by the RFD profile can be utilized by many domain groups and thefollowing domain-specific use cases illustrate the wide variety of uses to which RFD can bemade.
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17.1 Use Cases
The following use cases indicate how this profile might be used by various disciplines. The RFD
profile enables all of these use cases. It does not implement any of them. Actual discipline
specific profiles that specify both the use of RFD and the rules for data objects are expected infuture domain-specific IHE profiles.

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17.1.1 Investigational New Drug Clinical Trial Use Case
The setting for the clinical trial use case is a physicians’ practice where patient care is deliveredside-by-side with clinical research. The site, Holbin Medical Group, is a multi-site physician
practice, employing over 100 physicians in a variety of specialties. Holbin’s CEO encourages
the physicians to participate as site investigators for pharmaceutical-sponsored clinical trials;
Holbin provides support for clinical research activities in the form of a Research Department of
twelve dedicated study coordinators, mostly RNs, along with clerical and data-entry support
personnel. Holbin Medical Group uses an Electronic Health Record (EHR) and a number ofsponsor-provided Electronic Data Capture (EDC) systems for documenting clinical trial
activities. (For our purposes, an EHR is any application which is the primary site fordocumenting patient care, and retrieving patient care information. Thus we include in our spanof interest many systems installed today that are not quite EHRs in the strictest sense, but which
would still benefit from this approach.)
Holbin’s involvement in a clinical study begins when the Research Department receives arequest for proposal from a study sponsor. A Study Coordinator, Patricia Zone, RN, evaluates
the RFP for business viability and clinical appropriateness, and provides the requested
documentation back to the sponsor. After being selected as a site for the trial, identified as#1234, and providing the required regulatory documentation to the sponsor, the physician
identified as the Principal Investigator and other study personnel receive protocol-specifictraining from the sponsor. During the trial set-up period, Patricia ensures that the appropriate
system security is in place for this protocol, recruits patients to participate as subjects according
to inclusion and exclusion criteria described in the study protocol, schedules patient visits,manages data capture and data entry, and performs all the attendant financial tasks.
Patricia contacts Corey Jones, a patient at Holbin, about participating in the trial, and Corey
agrees to participate as a subject. Patricia registers Corey in the EHR as a subject in trial #1234,
using the EHR’s patient index. She schedules Corey’s study visits using the EHR schedulingmodule, and flags the visits as pertaining to the trial #1234. After the set-up stage, the site
initiates clinical trial care and trial-specific documentation.
The use case continues with current state and desired state scenarios, which describe data capture
utilizing EDC technology during a patient clinical trial visit before and after the RFD
implementation.
17.1.1.1 Current State
Corey Jones arrives at the clinic for a scheduled trial visit and meets with Patricia Zone for aface-to-face interview. Patricia logs into the EHR and documents the visit with a terse entry:______________________________________________________________________________
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‘Mrs. Jones comes in for a clinical trial visit associated with study #1234.’ Patricia interviews
Mrs. Jones, makes some observations, and records her observation on a source paper document.
She looks up recent lab results in the EHR and records them in the Case Report Form (CRF).
The EHR provides only a portion of the data required to complete the form, the rest comes fromthe interview and observations. (Estimates on the percentage of data required for a clinical trialthat would be available in an EHR vary from 5% to 40%. Even in the best case, the EHR
typically captures only a subset of the data required by a study protocol.)The completed source document is forwarded to Bob, the data entry person. Bob identifies the
CRF as belonging to trial #1234, and selects the trial #1234 EDC system, which may be housed
on a dedicated laptop provided by the sponsor or may be accessible via a browser session
connected to the Sponsor’s EDC system via the Internet. He takes a three ring binder off the
shelf and refers to his ‘crib sheet’ to get the instructions for how to use this particular system. He
logs into the EDC application, using a user name and password unique to this system, and enters
the data into the correct electronic case report form (eCRF) for that trial visit. Once the source
document has been processed, Bob files it in a ‘banker’s box’ 4 as part of the permanent source
record of the trial (in order to meet the requirements of the Federal Code of Regulations 21CFR
312:62).

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In addition to trial #1234, Bob performs data entry on eight additional EDC systems, five on
dedicated laptops and three that are web-based. The web-based EDC systems save on table
space, but still require entries in the three ring binders where Bob puts his ‘crib sheets’. It is achore to make sure that data from a particular trial gets entered into the corresponding laptop
with its unique login ritual and data capture form, so Bob experiences much frustration in dealing
with this unwieldy set of systems. Bob is a conscientious employee, and stays current in his
work. But in many other sites the data entry person holds the CRF for a period of time before
entering the data, perhaps entering data twice a month, or entering the data the week before themonitor visit occurs.

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17.1.1.2 Desired State

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Mrs. Jones arrives for a visit and Patricia logs into the EHR, pulls up Mrs. Jones’s record, andidentifies the scheduled clinical trial visit. Because of the patient identification and schedulingsteps that took place in the set-up stage, the EHR recognizes Mrs. Jones as a subject in Trial
1234, and requests an electronic case report form from trial #1234’s EDC system, using RFD. If
the trial is sufficiently complex, the retrieved form may contain a list of relevant forms from the
EDC system for Patricia to choose from. When the correct context is established between the
EHR and the EDC, Patricia selects the clinical research tab within the EHR application to reveal
the appropriate form. The EHR checks Patricia’s credentials, confirms that she is empowered toview the form, and displays the form. The data capture form is essentially the same form that the
EDC system would offer for this visit, and its presentation may take on some of the look and feelof the EHR’s user interface. The use of a crib sheet may still be necessary, althoughsophisticated forms should carry with them information on how to fill out the form.

4

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Patricia interviews Mrs. Jones and enters data into the clinical trial form. Data from the EHR
database may be pre-populated into the proper data fields (which have built-in edit checks).
Upon completing the form, Patricia hits the submit button, and the EHR returns the complete
form to the EDC system, using RFD. A copy of the document is archived in the site clinical trial
document vault as part of the permanent source record of the trial.
17.1.2 Public Health Reporting Use Cases
17.1.2.1 Public Health Scenario 1

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17.1.2.1.1 Current State
Mrs. Smith presents to the Emergency Department of the Community Hospital with digestive
complaints. The health care provider sends samples to the lab. The laboratory identifies
cryptosporidium. The laboratory personnel query the laboratory database for weekly required
public health reporting. Cases are identified, and information from the laboratory information
system is copied to the public health form, printed, and sent to the public health authority. The
public health officials review the reports submitted from the health care providers in thejurisdiction and identify that multiple cases of cryptosporidium have been presenting to area
hospitals. Notification of the event is communicated to health care providers in the area to notify
them to watch for additional cases. Water supplies servicing the affected areas are tested andtreated accordingly. However, with the delay in the detection process caused by the paper-based
process, numerous additional cases of cryptosporidium infection present for care.
17.1.2.1.2 Desired State

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Mrs. Smith presents to the Emergency Department of the Community Hospital with digestive
complaints. The health care provider sends samples to the lab. The laboratory identifies
cryptosporidium. The laboratory system identifies this test result as a required public healthreport and sends it to the state DOH using PHIN standards as soon as the result is verified in thelaboratory system. In addition or alternatively, a form is retrieved using the RFD profile from the
Biowatch public health system. The case reporting form is presented to the provider, prepopulated with EHR mapped data. The healthcare provider fills out the remaining supplemental
information and submits this data electronically to the public health authority. The public healthauthority receives numerous electronic reports from laboratories and health care providers in thejurisdiction. Notification is sent to area health care providers and laboratories in the area to notify
them to watch for additional cases. Water supplies servicing the area are tested and treatedaccordingly. With the early detection through process automation, further illness in thecommunity is minimized.
17.1.2.1.3 Anthrax and Avian Influenza Scenarios: Disease Monitoring Based on
Presumptive Diagnoses and/or Patient ‘Problems’

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Anthrax: Patient presents at ED with rapidly progressive respiratory symptoms. Gram stain of
sputum reveals gram positive rods, chest X-ray reveals a widened mediastinum, and patient's
condition rapidly deteriorates. Culture of sputum in laboratory is suspicious for Bacillus______________________________________________________________________________
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anthracis. State DOH contacted and specimens sent for confirmation. Once confirmed, the state
DOH notifies appropriate local, regional, state, and federal officials (e.g., CDC, FBI,USAMRID), and notifies local hospitals, providers, and media. (This involves a bioterrorist
scenario on the back end after ID confirmation – the influenza scenario below does not, but
probably invokes the same pathways.)
Once notified of the potential for additional cases, the ED performs STAT Gram stains on sputa
and PA/Lateral Chest Xrays for all patients presenting with rapidly progressive respiratory
symptoms. Presence of Gram positive rods in sputum is entered directly into the lab system OR
by designated ER staff into a specific ADT field on the patient ADT screen in the CIS forinternal / external surveillance reporting. Rapid reading of Chest Xray with mediastinal
widening is entered in a specific ADT field by designated staff (e.g., Radiology technician) on
behalf of physician. Entry of information in these fields creates a transaction of the information
to the local public health department biosurveillance system (BIS) as presumptively diagnosed
inhalational anthrax. The BIS aggregates information received from multiple sites to present thelocation, origin and extent of presumptive and defined case presentation.
Influenza: Physicians around hospital and hospital ED get rapidly increasing number of patientswith respiratory symptoms suggestive of a viral infection, but no increased prevalence of similar
symptoms in surrounding hospitals. Rapid test for influenza A/B is positive in many of thepatients and epidemic influenza is circulating in the community. Respiratory culture is negative
for bacterial pathogen at 24 hr., but viral culture is positive for influenza A. AH5N1 is suspected
due to association of patients with each other and “dead chickens”. All specimens are sent tostate DOH ASAP for ID. State lab identifies AH5N1. Follow-up similar to #1 above. The followup once notification is disseminated from health department(s) to local providers, is similar tothe presumptive diagnosis information transmission to public health BIS. A more robust method
for collection of presumptive diagnoses in either scenario (but not near-term) is to use
standardized “problem” terms (using SNOMED) for selection of presumptive problems as part ofroutine operations of a CIS for physician order entry and for physician and nursing
documentation.
The difference in these two scenarios is that the Anthrax case involves syndromic surveillance(severe respiratory symptoms and a widened mediastinum on X-ray: need radiology surveillanceand cross-correlation to ED and Lab – much more complex.)
17.1.3 Pharmaco-vigilance Scenario

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A community-based physician, Dr. Cramp, sees a patient in an outpatient clinic and accesses thepatient’s electronic health record which reveals that the patient is on one of the new statin drugs.
The physical examination turns up muscle weakness in the patient’s calves, which the physician
recognizes as a possible adverse reaction to the statin. He orders a total creatinine kinase lab test
to help in diagnosing the problem.
17.1.3.1 Current State

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Dr. Cramp exits the EHR and, using a web browser, goes to http://www.fda.gov/medwatch/. Hebrings up form FDA 3500, for ‘voluntary reporting of adverse events noted spontaneously in the______________________________________________________________________________
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course of clinical care’. He navigates through several screens of routing and instructions toarrive at the first screen of the actual form, which requests patient identifier, age at time of eventor date of birth, sex, and weight; the second screen requests seven entries: a classification of theevent, classification of outcome, event date, report date, description, relevant tests (he notes thata test has been ordered), and other relevant history (the last three fields are text entry); the thirdand fourth screens ask for details about the product ; and so forth. In actuality, the current stateis that this form is seldom completed.
17.1.3.2 Desired State

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Dr. Cramp sees the patient and accesses the EHR as above. Upon finding the potential problem,
he clicks on an ‘Adverse Event Reporting’ button which brings up FDA form 3500, using the
EHR user interface. The form is presented with the demographics already completed. The
product name is part of the working context of the EHR session, and is automatically loaded into
the appropriate field. Dr. Cramp completes the empty fields of the form and submits directly to
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RFD takes care of retrieving the form from MedWatch, displaying it, and returning the form to
FDA. Note that the profile does not address whether or not the EHR stores a copy of the form or
preloads it with EHR data. Simply using the EHR to display, complete, and submit the form issufficient. The EHR and the site might decide to capture and store the form in the EHR
database, which would be a permitted extension of the profile, but not necessary.

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17.1.4 Cardiology Research Use Cases
17.1.4.1 Cardiology Use Case 1 - Submission to National, State and Regional Data
Registries

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Several jurisdictions have mandatory requirements for submission of data for particular cardiac
procedures, (e.g., New York State for angioplasty and cardiac surgery, or the US for
implantation of cardioverter defibrillators in Medicare patients). Additionally, many institutions
participate in voluntary regional or national data registries, notably the NCDR™ National
Cardiovascular Data Registry.
A single cardiac patient’s data may be submitted to multiple registries. It is therefore useful fordata collections for multiple submissions to be done simultaneously, so that the nurse preparing
the data can review the patient medical record once and extract relevant data to each of thesubmission forms. Additionally, the patient’s “medical record” is in fact spread across several
electronic and paper-based systems, so that repeated access in the preparation of multiple
submissions must be minimized.
Most of the cardiac registry submissions require data from several encounters. E.g., the NCDR
gathers data on patients who undergo diagnostic cardiac catheterization followed by apercutaneous coronary intervention (PCI). If the patient had presented to the Emergency
Department with an ST-elevation infarction, only a small portion of the NCDR-required data isgathered in association with the catheterization procedure. The following information is needed
to complete the NCDR data set: Date of previous CABG, date of previous PCI, time of arrival in______________________________________________________________________________
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the ER, baseline laboratory data (BUN, creatinine), information from the patient’s history(family history of CAD, history of stroke, pulmonary and renal disease, etc.), measured cardiac
ejection fraction prior to PCI, QCA findings, inventory of the devices used (including bar codes),and medications administered.
Thus, the preparation of the submission must be done incrementally at each encounter, and/or
retrospectively at a time that all the information can be determined. Incremental preparation is
problematic, since at the initial encounters it is not known what procedures the patient will
undergo, and hence what registries’ data forms need to be filled in. Purely retrospective datacollection is similarly problematic, as it is better to obtain the data when it is produced, rather
than needing to search through the record for it.
Carl Cardiac, a patient, presents at the ED with chest pain, and based on ECG and history iswhisked to the cath lab for a diagnostic and interventional procedure. During the PCI, while
things are slow during the angioplasty balloon inflation, Ted Tech, the cath lab technologist,
calls up the (empty) state and national angioplasty registry forms from the forms repository onto
the cath lab logging system, and begins filling in relevant information from the case. During
post-procedure clean-up, he completes as much information as he knows, and stores the partiallyfilled-in forms back to the forms repository.
At the end of the month, Nancy Nurse is assigned the task of completing the registry datacollection for that month’s cath patients. She retrieves a list of cath patients, and for each one
pulls up partially completed forms. When she gets to Carl’s name, she pulls up the forms as
partially completed by Ted, and accesses Carl’s lab results, cath procedure report, nursing notesfrom the CCU, and discharge summary report. She fills in the remainder of the registry forms,
and stores the completed forms back to the repository.
At the end of the quarter, Adele Admin uses a specialized application to retrieve all thecompleted forms for the national registry for the quarter from the repository, and to prepare thesubmission. She does a similar task with an application that processes the state registry forms.
17.1.4.2 Cardiology Use Case 2 – Performance Measures

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4045

A major issue in cardiology is improving the quality of care by monitoring select performancemeasures. There is a strong collaborative arrangement between the ACC, AHA, CMS, JCAHO,
and AHRQ on the development and use of performance measures, such as the new ACC/AHA
Clinical Performance Measures for Adults With ST-Elevation and Non–ST-Elevation
Myocardial Infarction.
These performance measures require data collection, similar to the collection of data forsubmission to registries. However, after collection of data for a particular time period, further
analysis on the total patient population must be applied to obtain an appropriate denominator forthe reported measures (i.e., certain patients must be retrospectively excluded from the population
data set).

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17.1.5 Radiology Use Case – Clinical Impact Registry4050

As part of the effort to assess the impact of PET imaging on cancer patient management, theCenters for Medicare and Medicaid Services have predicated reimbursement, for a number ofotherwise non-reimbursed procedures, on the submission of study data to a National Oncologic
PET Registry (NOPR) operated by the American College of Radiology atwww.cancerpetregistry.org.
This use case involves a sequence of forms which must be submitted for a given patient study
and includes overlaps with the billing process.

4055

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PET Facilities are required to register their site with NOPR. Because access to NOPR is limited
to registered facilities and because the facility depends on complete submission to get the
reimbursement, the PET Facility has the primary responsibility and direct access for submitting
all data. The referring physician does not have access to NOPR.
Paul Positron, a patient, presents with indications of stomach cancer (or other indication covered
only by participation in the NOPR). His physician, Dr. Jones, refers him to PET-Pros, aparticipating PET facility. PET-Pros obtains basic demographic information from Dr. Jones andsubmits this information to NOPR via a Web form, at which time a Registry case number isassigned by NOPR.
Once a Registry case number is created, NOPR emails Dr. Jones the Pre-PET Form that must becompleted with case specific clinical details and forwarded to PET-Pros for entry into the NOPR
database by midnight of the day of the PET scan.
At some time before the PET study, or when Paul arrives for the PET scan, PET-Pros provides
Paul with the ACR IRB-approved standard NOPR Patient Information Sheet. Paul can contact
the NOPR directly for more information, if necessary. Paul indicates his NOPR consent verballyto staff at the PET facility, either on the day of the PET study or within two working days after
the PET study is completed. Written consent is not required. PET-Pros notes in the PET ReportForm, if the patient gave or withheld consent for use of his data in future NOPR research.
Once the PET scan has been performed and reported, PET-Pros submits a study completion form
and a report form (including the report provided to Dr. Jones) to NOPR.

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NOPR emails Dr. Jones the Post-PET Form for completion. This form collects information
relating to the impact of the scan. It also includes an ACR IRB-approved Referring Physician
Information Sheet and indication whether physician consent for use of the response data in future
NOPR research has been given or withheld. The Post-PET form must be completed, forwarded
to PET-Pros and entered into the NOPR database within 30 days of the PET scan.

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The NOPR database notifies PET-Pros when all case data have been entered so that the facility
can bill CMS for the study. PET-Pros can check on the case status of their patients at any timeusing the PET Facility Reporting Tools available on the NOPR Web site.
17.1.6 Data Clarification

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checks (edit checks) that result in sponsor data queries for clarification, correction, orverification relating to previously submitted data. These queries about previously submitted data
are provided to the EHR system upon request. Note that there is no automated notification to the
EHR that these queries for clarification / correction / verification exist. It is up to the EHR toperiodically make requests when working with a sponsor that performs these edit checks.
Performing these longitudinal edit checks on submitted data does not apply to all use cases.
17.1.6.1 Current State - query process

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Edit checks built in to eCRFs can facilitate accurate and complete data capture; however, it isprobable that during the course of a trial, some data elements will need to be reviewed by the site
for clarification, correction, or verification. As data managers review the data (through manual
and/or system-supported validation processes), they identify missing, incomplete, or potentiallydiscrepant data (e.g. a site reports a patient was prescribed penicillin for a headache). Data
queries are generated through an EDC system and sent back to the site for clarification/correction/ verification by the research coordinator. For each data query, the coordinator mustreference the source record where the data element was originally documented and compare thequeried data element to the source. On occasions, the site may need to contact the patient if thesource is incomplete (e.g., a stop date on a medication). Clarifications to the data are
documented by the coordinator in the source and if it is determined that the source record is inerror, corrections are clearly documented in the source per GCP guidelines. The coordinator
then responds to the query in the EDC system providing a reason for any updates to the originalrecord which the system captures in the audit trail. The data manager can then review the
updates and the response and close the query if no further information is required.
17.1.6.2 Future State - query process

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Edit checks built into trial-specific forms and eCRFs in the EHR system can facilitate accurate
and complete data capture; however, it is probable that during the course of a trial, some data
elements will need to be reviewed by the site for clarification, correction, or verification.
As data managers review the data (through manual and/or system-supported validation
processes), they identify missing, incomplete, or potentially discrepant data (e.g. a site reports apatient was prescribed penicillin for a headache). Data queries are generated through the sponsor
system and prepared to the site for clarification/ correction/ verification by the researchcoordinator. The EHR study coordinator accesses and reviews each data query through the EHR
system referencing the EHR data in order to respond to the query. On occasions, the site mayneed to contact the patient if the EHR data is incomplete (e.g., a stop date on a medication). The
coordinator documents clarifications to the data in the EHR system if needed and submits aquery response as well as any data updates to the sponsor system and to the investigator sitearchive. The query response includes a reason for any changes made which is included as part of
the audit trail in the EHR system, sponsor system, and the investigator’s site archive. The data
manager of the sponsor can then review the response and the updates in the sponsor system andclose the query if no further information is required.

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17.2 Actors/ Transactions
Figure 17.2-1 shows the actors directly involved in the Retrieve Form for Data Capture
Integration Profile and the relevant transactions between them. Actors that may be indirectly
involved due to their participation in other profiles are not shown.

 Archive Form [ITI-36]
Form Filler

Retrieve Form [ITI-34]↓

Form Archiver

Retrieve Clarifications[ITI-37] ↓↓ Submit Form [ITI-35]

Form ReceiverForm Manager

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Figure 17.2-1: Retrieve Form for Data Capture Actor Diagram

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Table 17.2-1 lists the transactions for each actor directly involved in the Retrieve Form for Data
Capture Profile. In order to claim support of this Integration Profile, an implementation must
perform the required transactions (labeled “R”). Transactions labeled “O” are optional. A
complete list of options defined by this Integration Profile that the implementations may choose
to support is listed in Section 17.3.
Table 17.2-1: Retrieve Form for Data Capture Integration Profile - Actors andTransactions
ActorsForm Filler

Transactions

Optionality

Section in
Vol. 2Retrieve Form [ITI-34]

R

ITI TF-2b: 3.34

Submit Form [ITI-35]

R

ITI TF-2b: 3.35

Archive Form [ITI-36]

O

ITI TF-2b: 3.36

Retrieve Clarifications [ITI-37]

O

ITI TF-2b: 3.37

Form Manager

Retrieve Form [ITI-34]

R

ITI TF-2b: 3.34

Retrieve Clarifications [ITI-37]

R

ITI TF-2b: 3.37

Form Receiver

Submit Form [ITI-35]

R

ITI TF-2b: 3.35

Form ArchiverArchive Form [ITI-36]

R

ITI TF-2b: 3.36______________________________________________________________________________
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17.2.1 Actors
17.2.1.1 Form Manager

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The Form Manager supplies forms to Form Fillers based upon form retrieval requests. In somecases, the Form Manager may simply return a form from a store of forms, whereas in other cases
the returned form may be selected or even constructed based upon context information suppliedin the form retrieval request. Additionally, forms from a store may be modified based upon
whether or not the Form Filler supplies additional information about a Form Archiver. A FormManager may return a form instance id along with a form in response to a request to retrieve aform.
17.2.1.2 Form Filler

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The Form Filler actor retrieves forms from a Form Manager as and when required. Whenrequesting a form, the Form Filler actor can optionally provide EHR context information by
providing pre-population xml data in the request for use by the Form Manager, as well as
workflow data that may be used to facilitate form selection. A form instance id may be provided
to identify use of previously submitted data.

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The Form Filler may also specify a Form Archiver actor. The Form Archiver actor specified by
the Form Filler is in addition to any Form Archiver actors specified by the Form Manager.
17.2.1.3 Form Receiver
The Form Receiver actor receives and processes completed or partially completed forms instancedata from a Form Filler. Form Receiver processing is out of the scope of the profile.

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17.2.1.4 Form Archiver
The Form Archiver actor receives completed or partially completed forms instance data andstores these for archival purposes.
17.2.2 Transactions
17.2.2.1 Retrieve Form

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The Retrieve Form transaction carries the form identifier from a Form Filler to a Form Manager.
The transaction allows a Form Filler to optionally specify a Form Archiver actor. Additional datacontaining context information as well as workflow information may be supplied with therequest to facilitate the selection and pre-population of the requested form. The value of theassigned form identifier determines the format of the form. Assignment of form identifiers is notprofiled and is assumed to take place as a part of the setup configuration process necessary
between Form Fillers and Form Managers.

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17.2.2.2 Submit Form
The Submit Form transaction allows a Form Filler to submit form instance data to a Form
Receiver actor.
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17.2.2.3 Archive Form
The Archive Form transaction allows a Form Filler to submit form instance data to a Form
Archiver actor.
17.2.2.4 Retrieve Clarifications

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The Retrieve Clarifications transaction allows a Form Filler to request the set of clarifications fora given organization from a Form Manager. The value of the assigned organization identifier
determines the named option format of the clarifications form. Assignment of organization
identifiers is not profiled and is assumed to take place as a part of the setup configuration process
between Form Fillers and Form Managers.

17.3 Retrieve Form for Data Capture Integration Profile Options
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Options that may be selected for this Integration Profile are listed in Table 17.3-1 along with theActors to which they apply. Dependencies between options when applicable are specified innotes.
Table 17.3-1: Actors and Options
Actor

Options

Vol & Section

Form Filler

Archive FormITI TF-2b: 3.36

Data Clarifications

ITI TF-2b: 3.37

XFormsITI TF-1: 17.3.2

XFormsITI TF-1: 17.3.2

Form Manager

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17.3.1 Archive Form Option
The Archive Form option allows a Form Filler to submit, for archival purposes, the form
instance data to a Form Archiver.
17.3.2 Data Clarifications Option

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The Data Clarifications option allows a Form Filler to retrieve clarifications from a FormManager and submit updates to a Form Receiver for data that have been previously submitted.
17.3.3 XForms Option
The XForms option allows Form Fillers and Form Managers to exchange forms in XForms
format. See ITI TF-2b: 3.34.4.1 for constraints that apply to this option.
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17.4 Retrieve Forms for Data Capture Process Flow
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This section describes the process and information flow when a form is retrieved for data captureand subsequently submitted upon partial or full completion. The criteria for determining whether
or not the form is “complete” is outside the scope of this profile.
Five cases are distinguished.

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•

Case 1: This case illustrates a simple, Retrieve Form using a known formID.
The identifier of a form, the formID, is known to the Form Filler, such as may happen
during the registration process for participation in a Clinical Trial. formID values could
also be communicated by publication of form directories or by personal communications.
The method of acquisition of the formID is outside the scope of this profile and is aprecondition for the Retrieve Form request.

4210

The Form Manager and Form Receiver are grouped on the same system functioning as
the form source.
The Form Filler makes a Retrieve Form request to a Form Manager. The Form Manager
either returns the requested form, or an error indicating no form is available. When aform is returned, the Form Filler will subsequently submit the form instance data to a
Form Receiver using the Submit Form transaction. Since the Form Manager and Form
Receiver are grouped, there may be communications between the Form Receiver and theForm Manager, as would be necessary to support partially completed forms, but thesecommunications are internal and are not IHE transactions.

4215

4220

Form Filler

form source
Form Manager

Form Receiver

Retrieve Form [ITI-34]

Submit Form [ITI-35]

Figure 17.4-1: Case 1: Retrieve Form and Submit Form;
Form Manager grouped with Form Receiver

4225

•

Case 2: This case illustrates that a Form Receiver may be standalone (i.e., not groupedwith a Form Manager).

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The identifier of a form, the formID, is known to the Form Filler; there is a grouped FormManager and Form Receiver on one system supporting intermediate form storage, and aseparate Form Receiver on a different system for final storage of form data.
The Form Filler makes a Retrieve Form request to a Form Manager. The Form Manager
either returns the requested form or an error indicating no form is available. When aform is returned, the Form Filler submits partially complete forms to the intermediate
Form Receiver. This partially completed form can be retrieved with another Retrieve
Form request to the Form Manager, and final completed form data can be submitted to
the final storage, standalone, Form Receiver, such as a national data registry. The action
upon submit is controlled by the form, hence the Form Manager is responsible fordefining the post-submit action by selection of, or generation of, the desired action during
the Retrieve Form transaction processing.

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4240

Form Filler

Form Receiver

form source
Form Manager

Form Receiver

Retrieve Form [ITI-34]

Submit Form [ITI-35]

Retrieve Form [ITI-34]

Submit Form [ITI-35]

4245

Figure 17.4-2: Case 2: Retrieve Form, Submit Form;
Form Manager separate from Form Receiver•
4250

Case 3: In this case the Form Filler uses the Archive option.
The Form Filler makes a Retrieve Form request to a Form Manager, specifying thatarchival is necessary to a specific Form Archiver. The Form Manager either returns the______________________________________________________________________________
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requested form or an error indicating no form is available. The Form Manager constructs
the form to perform an archive transaction to the Form Archiver specified in the Form
Filler’s Retrieve Form request. When the form is returned and subsequently submitted,
form instance data is submitted to the Form Receiver and also to the Form Archiver.
4255
Form Filler

form source

Form Archiver

Form Manager Form Receiver
Retrieve Form [ITI-34]

Submit Form [ITI-35]

Archive Form [ITI-36]

Figure 17.4-3: Case 3: Retrieve Form, Submit Form, Archive Form______________________________________________________________________________
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•
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Case 4: This case illustrates one way to use Form design to solve the issue where aformID is not known in advance.
The identifier of a form, the formID, is not known to the Form Filler, but a set of context
value (name, value) pairs is known. A context form where these values could be enteredwould have a formID. Information collected by the instance of a context form would be
used by the Form Manager to determine the appropriate data capture form to return to theForm Filler.
The Form Filler has enough information to request a context form that collects
information that can help the Form Manager determine the actual data capture form. The
Form Filler completes the context form, submits this to the Form Receiver which returns
either new instance data, or a new form.
form source

Form Filler
Use form to submit
Context Informationin order to select theData Capture form

Retrieve Form [ITI-34]

Form Manager
Form Receiver

Submit Form [ITI-35]
Multiplesubmitactions
may takeplace.
Submit Form [ITI-35]
Fill in and submit
the actual Data
Capture Form.

4270

Figure 17.4-4: Case 4: Retrieve Form; Submit Form

•

4275

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4285

Case 5: In this case the Form Filler supports the Data Clarifications option.
The Form Filler makes a Retrieve Clarifications request to a Form Manager. Theinteractions of Form Receiver and Form Manager are outside of the scope of this profile.
An example of a solution for providing clarification information to a Form Manager is togroup the Form Manager with the Form Receiver, as shown in Figures 17.4-5 and 17.4-6.
The request made by the Form Filler contains an organization identifier allowing theForm Manager to return only the set of clarifications relevant to the organization making
the request. The Form Manager returns a form containing the necessary information toallow the site or organization making the request to amend the data as required. These
Retrieve Clarifications requests must be periodically executed by the Form Filler. The
frequency of request is likely based upon some duration as defined or agreed upon by theForm Manager / Form Receiver.
The Form Manager can return either a form containing the data to be modified or a form
containing a list of references to other forms. In the second case, the references are used
to obtain the individual forms using the Retrieve Form transaction. In both cases the data______________________________________________________________________________
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are then modified and submitted to the Form Receiver using the Submit Form transaction.
Submitted data may then be evaluated by the data manager of the sponsor for proper
handling.
4290

The profile does not distinguish between the two responses, the content returned within
the form allows the user of the Form Filler to process the form returned in the appropriatemanner.
Form Filler

Form source
Form Manager Form Receiver

Retrieve Clarifications [ITI-37]

Submit Form [ITI-35]

4295

Figure 17.4-5: Case 5: Form Filler supporting Data Clarifications Option
Form Filler

Form source
Form Manager Form Receiver

Retrieve Clarifications [ITI-37]

Retrieve Form [ITI-34]

Can berepeated

Submit Form [ITI-35]

Figure 17.4-6: Case 5: Form Filler supporting Data Clarifications Option

17.5 Security Considerations
17.5.1 RFD Risk analysis Risk Assessment
4300

The risk analysis for RFD enumerates assets, threats, and mitigations. The complete risk data isstored and available from IHE 5.

5

The risk analysis data may be found at: ftp://ftp.ihe.net/IT_Infrastructure/iheitiyr5-20072008/Technical_Cmte/Profile_Work/RFD/ RFD%20Risk%20Analysis%202007-05-15.xls______________________________________________________________________________
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The purpose of this risk assessment is to notify vendors of some of the risks that they are advised
to consider when implementing RFD actors. For general IHE risks and threats, please see ITI
TF-1: Appendix L. The vendor is also advised that many risks cannot be mitigated by the IHE
profile and instead responsibility for mitigation is transferred to the vendor, and occasionally tothe affinity domains, individual enterprises and implementers. In these instances, IHE fulfills its
responsibility to notify affected parties through the use of the following sections.
17.5.2 Recommendations

4310

The high impact risks include: accuracy errors, mismatch between data and schema, disclosureof trade secrets. This profile includes the mitigations:
M1. If the user notices that the wrong form has been retrieved they will discard the form. Since
Form Retrieval is stateless, a discard of the form shall cause no problems.

4315

M2. When using the XForm option, the XForms model provides for schema validation of thedata model. The XForms plugins responsible for processing and displaying XForms, which areoutside of this profile, are required to validate forms.
M3. TLS may be implemented, so that those affinity domains and enterprises that need privacy
protection and site authentication can use it. (Implementations must provide the TLS, but thedecision to activate it is up to the affinity domain and enterprises.)
M4. Form validations will prevent submission of forms with missing data.

4320

M5. The RFD Archive Form Transaction for saving source data to a trusted third party is an
option that it is available to enterprises.
These mitigations are transferred to Vendors and Clients.

4325

4330

T1. IHE recommends that providers evaluate and review forms as presented before entering dataand submitting. Provider review is an essential part of the forms retrieval and submission
process to ensure data is entered into the correct form and for the correct patient. Vendors are
cautioned not to use RFD for unmediated treatment or diagnosis. A doctor must always intervene
prior to treatment or diagnosis to ensure that errors that may occur in transit are checked by ahuman prior to engaging in any treatment or diagnosis of a patient.
T2. The supported format options allow for basic data validity checks within the form. It is the
responsibility of the forms designers/implementers to take advantage of this to protect against
entry errors, etc.
T3. The need for partially filled forms identifies this as a workflow issue within theorganization(s) supplying the data.
T4. Forms and workflow designers should break forms into sequential step forms if possible.

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T5. Forms Design should facilitate evaluation of workflow and gaps.
T6. Access control and security at the client site are important mitigating factors to potential
disclosures.

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T7. Policy controls are recommended to determine which systems may be used to perform theForm Filler actor.
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T8. Policy controls are recommended to determine which users may fill out forms.
T9. This profile does not require audit logging. An enterprise audit logging process isrecommended to reduce errors and track malicious behavior.
T10. An application feature to support roll back of forms data may be needed.
T11. Notification of the need to clarify data.

4345

T13. Form Managers, Receivers, Archivers must be on well protected systems.
T14. Network and Infrastructure and Systems robustness must be considered, especially forforms applications that are to be used during disasters, epidemics, and other situations where thelocal infrastructure may be significantly disrupted.

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T15. Forms should be designed for high latency, low bandwidth links if they are for applications
that are to be used during disasters, epidemics, and other situations where the local infrastructure
may be significantly disrupted.
T16. Form Fillers should be robust in the face of user error, network failure, and underlying
hardware failures.

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T17. Workflow must be addressed in the requirements gathering phase. Vendors are advised to
discuss investigator workflow with clients.
T18. Vendors are advised to consider the implications of their logging and audit repository
implementation.

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18 Cross-Community Access (XCA) Integration Profile
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4365

The Cross-Community Access profile supports the means to query and retrieve patient relevant
medical data held by other communities. A community is defined as a coupling offacilities/enterprises that have agreed to work together using a common set of policies for the
purpose of sharing clinical information via an established mechanism. Facilities/enterprises may
host any type of healthcare application such as EHR, PHR, etc. A community is identifiable by aglobally unique id called the homeCommunityId. Membership of a facility/enterprise in one
community does not preclude it from being a member in another community. Such communities
may be XDS Affinity Domains which define document sharing using the XDS profile or any
other communities, no matter what their internal sharing structure.

18.1 Actors/ Transactions
4370

Figure 18.1-1 shows the actors directly involved in the XCA Integration Profile and the relevanttransactions between them.
Note: The Document Consumer Actor is shown in Figure 18.1-1 to clarify the responsibility of
the XDS Affinity Domain Option discussed in Section 18.2.

Initiating Community

Responding Community

Registry Stored
Query [ITI-18] ↓Document
Consumer

Retrieve Document
Set [ITI-43] ↓Cross Gateway
Query [ITI-38]
Initiating
Gateway4375

Responding
Gateway
Cross Gateway
Retrieve [ITI-39]


Figure 18.1-1: XCA Actor Diagram

Table 18.1-1 lists the transactions for each actor directly involved in the XCA Profile. In order toclaim support of this Integration Profile, an implementation must perform the required
transactions (labeled “R”). Transactions labeled “O” are optional. A complete list of options______________________________________________________________________________
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defined by this Integration Profile and that implementations may choose to support is listed in
Section 18.2.
Table 18.1-1: XCA Integration Profile - Actors and Transactions
ActorsTransactions

SectionInitiating

Cross Gateway Query [ITI-38]

R

ITI TF-2b: 3.38

Gateway

Cross Gateway Retrieve [ITI-39]

R

ITI TF-2b: 3.39

Registry Stored Query [ITI-18]

O

ITI TF-2a: 3.18

Responding Gateway

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Optionality

Note:

Retrieve Document Set [ITI-43]

O

ITI TF-2b: 3.43

Cross Gateway Query [ITI-38]

R

ITI TF-2b: 3.38

Cross Gateway Retrieve [ITI-39]

R

ITI TF-2b: 3.39

When an Initiating or Responding Gateway is grouped with a Document Consumer, there are additional
requirements. See Section 18.2.3 for a description of grouping.

18.2 XCA Integration Profile Options
4390

Options that may be selected for this Integration Profile are listed in the Table 18.2-1 along with
the Actors to which they apply. Dependencies between options when applicable are specified innotes.
Table 18.2-1: XCA Integration Profile - Actors and Options
Actor

Options

Vol & Section

Initiating Gateway

XDS Affinity Domain Option

ITI TF-1: 18.2.1

Asynchronous Web Services Exchange
Responding Gateway

No options defined

ITI TF-1: 18.2.2--

18.2.1 XDS Affinity Domain Option
Initiating Gateways which support the XDS Affinity Domain Option interact with Document
Consumers within the XDS Affinity Domain served by the Initiating Gateway.
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Initiating Gateway actors which support this option:• shall receive Registry Stored Query [ITI-18] transactions from a local Document Consumer
actor and act on those requests on behalf of the Document Consumer. When receiving a
Registry Stored Query from a local Document Consumer, shall require thehomeCommunityId as an input parameter on relevant queries, and shall specify thehomeCommunityId attribute within its Registry Stored Query responses. See Section 18.3.2
for description of homeCommunityId. Initiating Gateways which support this option shalladjust the patient identifier found in the Registry Stored Query to an appropriate patient
identifier known to the Responding Gateway receiving the Cross Gateway Query. See TF2a:3.18.4.1.3 for details of the processing of the patient identifier.

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•

shall receive Retrieve Document Set [ITI-43] transactions from a local Document Consumer
actor and act on those requests on behalf of the Document Consumer. When receiving a
Retrieve Document Set from a local Document Consumer, shall require thehomeCommunityId as an input parameter.

When an Initiating Gateway does not support the XDS Affinity Domain option it is expected to
be using non-IHE specified interactions to communicate remote community data to systems
within its local community. These proprietary interactions are not further described within any
IHE profile.
See the relevant transactions for further details regarding the homeCommunityId attribute.
18.2.2 Asynchronous Web Services Exchange Option

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Initiating Gateways which support Asynchronous Web Services Exchange shall support
Asynchronous Web Services Exchange on the Cross Gateway Query [ITI-38] and Cross
Gateway Retrieve [ITI-39] transactions. If the Initiating Gateway supports both the XDS
Affinity Domain Option and the Asynchronous Web Services Option it shall support
Asynchronous Web Services Exchange on the Registry Stored Query [ITI-18] and Retrieve
Document Set [ITI-43] transactions.
18.2.3 Grouping Rules
Grouping with a Document Consumer Actor is used in situations where an Initiating Gateway
and/or Responding Gateway are supporting an XDS Affinity Domain

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When an Initiating Gateway is supporting an XDS Affinity Domain, it can choose to query andretrieve from local actors in addition to remote communities. This is accomplished by grouping
the Initiating Gateway Actor with a Document Consumer Actor. This grouping allows Document
Consumers such as EHR/PHR/etc. systems to query the Initiating Gateway to retrieve document
information and content from both the local XDS Affinity Domain as well as remotecommunities. For details see Section 18.2.3.1. An Initiating Gateway Actor that is not groupedwith a Document Consumer Actor is only able to return results from remote communities, so
local EHR/PHR/etc. systems (Document Consumer Actors) must direct separate query anddocument retrieve transactions internally and externally.
When a Responding Gateway is supporting an XDS Affinity Domain, it may resolve Cross
Gateway Query and Cross Gateway Retrieve Transactions by grouping with a Document
Consumer Actor and using the Registry Stored Query and Retrieve Document Set transactions.
For details see 18.2.3.2
18.2.3.1 Initiating Gateway grouped with Document Consumer

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Initiating Gateways that are grouped with a Document Consumer:• shall support the XDS Affinity Domain option• shall initiate Registry Stored Query [ITI-18] transactions to a local Document Registry toquery local information in response to a received Registry Stored Query [ITI-18] from a local
Document Consumer.
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shall initiate Retrieve Document Set [ITI-43] transactions to a local Document Repository in
response to a received Retrieve Document Set from a local Document Consumer whichcontains a homeCommunityID indicating the local community.

Community A

Document
ConsumerDocument
Registry
Document
Repository

Grouped Actors
RegistryStored Query
ITI-18Retrieve
Document Set
ITI-43

RegistryStored Query
ITI-18Community B
Responding
Gateway

Initiating
Gateway

Cross-Gateway Query ITI-38
Cross-Gateway Retrieve ITI-39

Internal (unspecified
mechanism)

Document
Consumer
Retrieve
Document Set
ITI-43Figure 18.2.3.1-1: Initiating Gateway grouped with Document Consumer

18.2.3.2 Responding Gateway grouped with Document Consumer
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Responding Gateways that are grouped with a Document Consumer:• shall initiate a Registry Stored Query [ITI-18] transaction to a local Document Registry toquery local information in response to a received Cross Gateway Query [ITI-38]. The
Document Registry response must be augmented with the homeCommunityId of the
Responding Gateway’s community prior to returning in the response to the Cross Gateway
Query.
• shall initiate a Retrieve Document Set [ITI-43] transaction to a local Document Repository
to retrieve local information in response to a Cross Gateway Retrieve [ITI-39].
When a Responding Gateway is not grouped with a Document Consumer actor it is expected to
be using non-IHE specified interactions to collect local information in response to a Cross
Gateway Query or Cross Gateway Retrieve. These proprietary interactions are not further
described within any IHE profile.

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Community A
Initiating
Gateway

Community B

Grouped Actors
Responding
Gateway

Cross Gateway Query ITI-38
Cross Gateway Retrieve ITI -39

Internal (unspecified
mechanism)

RegistryStoredQuery ITI18

Document
Consumer
Retrieve
Document Set
ITI-43Document
Registry
Document
Repository

Figure 18.2.3.2-1: Responding Gateway grouped with Document Consumer

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18.3 XCA Process Flow
18.3.1 Use Cases

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Assume within a given domain, such as the State of California, we have several healthcarecommunities (or XDS Affinity Domains or RHIOs). One in Los Angeles is based on IHE-XDS.
One in Sacramento is based on another form of healthcare sharing infrastructure. One in San
Francisco is also based on IHE-XDS. A patient X, who travels frequently, has received
healthcare in each of these communities. Patient X is admitted to a hospital in LA. The attending
physician uses his hospital information system to query across multiple domains for healthcare
information about this patient. Once found, references to patient data outside the local domain
are cached locally for easy future reference.
18.3.2 homeCommunityId defined

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This profile makes use of a homeCommunityId value which is a globally unique identifier for acommunity and is used to obtain the Web Services endpoint of services that provide access todata in that community. Specifically:• It is returned within the response to Cross Gateway Query and Registry Stored Query
transactions to indicate the association of a response element with a community. Document
Consumers process the value in the response as an opaque unique identifier.
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It is an optional parameter to Registry Stored Query requests, not requiring a patient id
parameter, and Retrieve Document Set requests to indicate which community to direct therequest.
It is used by Initiating Gateways to direct requests to the community where the initial data
originated.

18.3.3 Detailed Interactions
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The following diagram presents a high level view of the interactions between actors when both
initiating and responding communities are XDS Affinity Domains i.e. use of the XDS Affinity
Domain option and the Initiating Gateway and Responding Gateway are each grouped with aDocument Consumer. Details on each interaction follow the diagram.

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Community A (Local)
Doc Consumer

Community B (Remote)

Doc Registry

Registry Stored Queryby patient Id

Initiating GW

Patient
Identification
Mapping

Registry Stored Query

Responding GW

Community C (Remote)

Doc Registry

Responding GW

Doc Registry

Query Across Remote Communities A, B and C
Cross-GW Query
Doc Repository
Registry Stored Queryby patient Id
Response includes
homeCommunityId-B
Cross-GW Query
Registry Stored Queryby patient Id

Response includes
homeCommunityId-C

Response includes
homeCommunityId-C,B & A
Reuse a received
HomeCommunityId-C

Use homeCommunityId-C to
get to the Responding
Gateway

Registry Stored Query
byUUID

Refinement Query by UUID to Remote Community C A

Cross-GW Query
Registry Stored Query
UUID

Response includes
homeCommunityId-C

Response includes
homeCommunityId-C
Reuse received
HomeCommunityId-B & C
Retrieve Document Set
with homeCommunityId-B&C

Use HomeCommunityId-C to
get to the Responding
Gateway

Retrieve Documents from Remote Community B and C A
Cross-GW Retrieve
Retrieve Document Set

Use HomeCommunityId-B
to get to Responding
Gateway

Doc Repository
Cross-GW
Retrieve

Retrieve Document Set

Figure 18.3.3-1: XCA Detailed Interactions

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Document Consumer initiates a Registry Stored Query request by patient id – theDocument Consumer initiates the initial transaction by formatting a Registry Stored Queryrequest by patient identifier. The consumer uses PDQ, PIX or some other means to identify
the XDS Affinity Domain patient id, formats that information plus any other query______________________________________________________________________________
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•

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parameters into a Registry Stored Query request and sends this request to an Initiating
Gateway.
Initiating Gateway processes Registry Stored Query by patient id request – The Initiating
Gateway receives a Registry Stored Query by patient id and must determine a) which
Responding Gateways this request should be sent to b) what patient id to use in the Cross
Gateway Queries. Detailed specification of these steps is not in the intended scope of thisprofile. Combination of this profile with other existing profiles (e.g., PIX/PDQ), future
profiles or configuration mechanisms is possible. Please refer to ITI TF-2x: E.10 XCA andPatient Identification Management for possible use of existing profiles PIX and PDQ. For
each Responding Gateway identified, the Initiating Gateway shall update the query with thecorrect patient identifier corresponding to the Responding Gateway’s community andinitiates a Cross Gateway Query transaction to the Responding Gateway. If the Initiating
Gateway is grouped with a Document Consumer it shall also initiate a Registry Stored Queryto the local Document Registry.
Responding Gateway processes Cross Gateway Query by patient id – The Responding
Gateway within an XDS Affinity Domain processes the Cross Gateway Query by usinggrouping as a Document Consumer and initiates a Registry Stored Query to the local
Document Registry. The Responding Gateway shall update the response from the Document
Registry to ensure that the homeCommunityId is specified on every applicable element. Thisupdated response is sent as the response to the Cross Gateway Query.
Initiating Gateway processes Cross Gateway Query by patient id responses – The Initiating
Gateway collects the responses from all Responding Gateways it contacted. For each
response it shall verify homeCommunityId is present in each appropriate element. If theInitiating Gateway initiated a Registry Stored Query to the local Document Registry it shallupdate the response to that transaction to contain the homeCommunityId value associatedwith the local community. Once all responses are received the Initiating Gateway
consolidates all updated response data into one response to the Document Consumer. The
Initiating Gateway shall return to the Document Consumer the same homeCommunityId
attribute values that it received from Responding Gateways.
Document Consumer receives Registry Stored Query by patient id response – The
Document Consumer receives the results of the query from the Initiating Gateway and mustaccount for two unique aspects of the response; namely that a) the homeCommunityId
attribute will be specified and b) the Document Consumer may not be able to map therepository id value directly to the Document Repository. There shall be a common
coding/vocabulary scheme used across all communities. For example, all communities shallhave common privacy consent vocabularies. The Document Consumer shall retain the valuesof the homeCommunityId attribute for future interaction with the Initiating Gateway.
Document Consumer initiates a Registry Stored Query by UUID – Many Registry Stored
Queries do not include patient id as a parameter, but instead require one of the entryUUID or
uniqueID parameters, generically referred to as UUID. Both of these values are returned aspart of the metadata from a query by patient id. The Document Consumer may do a patient
id query to the Initiating Gateway prior to a query by UUID or shall have access to thecorrect homeCommunityId through some other means. In either case the consumer has the______________________________________________________________________________
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•

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•
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•

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•

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•

homeCommunityId attribute and shall specify it as a parameter of the query. The Document
Consumer puts the homeCommunityId and UUID values plus any other query parameters
into a Registry Stored Query request and sends this request to an Initiating Gateway.
Initiating Gateway processes Registry Stored Query by UUID request – The Initiating
Gateway receives a Registry Stored Query by UUID and determines which Responding
Gateway to contact by using the homeCommunityId to obtain the Web Services endpoint of
the Responding Gateway. The process of obtaining the Web Services endpoint is not further
specified in this profile. If the homeCommunityId represents the local community theInitiating Gateway will initiate a Registry Stored Query to the local Document Registry. The
Initiating Gateway shall specify the homeCommunityId in the Cross Gateway Query by
UUID which is associated with the Responding Gateway.
Responding Gateway processes Cross Gateway Query by UUID – The Responding
Gateway within an XDS Affinity Domain processes the Cross Gateway Query by grouping
as a Document Consumer and initiating a Registry Stored Query to the local Document
Registry. The response to the Cross Gateway query shall contain the homeCommunityId of
the responding community. This processing is identical to processing of the Cross Gateway
Query by patient id.
Initiating Gateway receives Cross Gateway Query by UUID response – The processing of a
Cross Gateway Query by UUID response is identical to the processing of a Cross Gateway
Query by patient id response, except there is only one response, so consolidation of responses
is not needed.
Document Consumer receives Registry Stored Query by UUID response – The processingof a Registry Stored Query by UUID response is identical to the processing of a Registry
Stored Query by patient id response.
Document Consumer initiates a Retrieve Document Set – Prior to issuing a Retrieve
Document Set the Document Consumer may issue a Registry Stored Query by patient id to
the Initiating Gateway. The response to the Registry Stored Query by patient id or
subsequent Registry Stored Query by UUID includes a) the document unique ID b) the
repository unique ID c) the homeCommunityId attribute. If the Document Consumer did notissue a Registry Stored Query which returned this information then it shall have acquired theinformation through some other means. The Document Consumer shall specify these threeparameters in its Retrieve Document Set transaction to the Initiating Gateway.
Initiating Gateway processes Retrieve Document Set – The Initiating Gateway determines
which Responding Gateways to contact by using the homeCommunityId to obtain the Web
Services endpoint of the Responding Gateway. If the homeCommunityId represents the local
community the Initiating Gateway will initiate a Retrieve Document Set to a local Document
Repository. The Retrieve Document Set may contain more than one unique
homeCommunityId so the Initiating Gateway shall be capable of initiating requests to morethan one Responding Gateway and consolidating the results. The Initiating Gateway shallspecify the homeCommunityId in the Cross Gateway Retrieve which identifies thecommunity associated with the Responding Gateway.
Responding Gateway processes Cross Gateway Retrieve – The Responding Gateway within
an XDS Affinity Domain processes the Cross Gateway Retrieve by grouping as a Document______________________________________________________________________________
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Consumer and initiating a Retrieve Document Set transaction to the Document Repository
identified by the repository unique ID within the request. If the Cross Gateway Retrieve
requests multiple documents with different repository unique IDs, the Responding Gateway
shall contact multiple Document Repositories and consolidate the responses.

18.4 XCA Security Considerations
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18.4.1 XCA Risk Assessment
The risk analysis for XCA enumerates assets, threats, and mitigations. The complete risk data isstored and maintained in a central location. The complete risk data is stored and available fromIHE 6.

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The purpose of this risk assessment is to notify vendors of some of the risks that they are advised
to consider in implementing XCA actors. For general IHE risks and threats please see ITI TF-1:
Appendix L. The vendor is also advised that many risks cannot be mitigated by the IHE profile
and instead the responsibility for mitigation is transferred to the vendor, and occasionally to the
XDS Affinity Domain and enterprises. In these instances, IHE fulfills its responsibility to notify
affected parties through the following section.
18.4.2 Requirements/Recommendations
The following mitigations shall be implemented by all XCA actors. These mitigations moderate
all high impact risks.
• M1: All actors in XCA shall be grouped with an ATNA Secure Node actor (or Secure
Application) and a CT Time Client actor.
• M2: Document metadata shall include a SHA1 hash of the document content. Applications
shall have the ability to verify the SHA1 hash of the document with the SHA1 hash in themetadata, if corruption detection is requested.
• M3: Document Consumer implementations shall handle overloading through excessive
volume of response data by discontinuing the read on the socket and closing it. The
Initiating and Responding Gateways shall respond to disconnection by discontinuing
processing of responses.
• M4: Document Consumer implementations shall not issue a Registry Stored Query that is notpatient specific, i.e. it shall either supply a patient identifier or a unique document entry
identifier.
• M6: Queries of unknown patient identifiers shall return either zero documents with nofurther information or XDSUnknownPatientId, depending on local policy. This applies topatient identifiers that are properly formatted or improperly formatted. By not using an error
code indicating that the identifier is ill-formatted, you are able to reduce the ability of
applications to fish for data. This applies only to Responding Gateways, if appropriate.
6

The risk analysis data may be found at: ftp://ftp.ihe.net/IT_Infrastructure/iheitiyr5-20072008/Technical_Cmte/Profile_Work/XC/XCARiskAnalysis.xls______________________________________________________________________________
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The following mitigations address the risk of a document being maliciously changed. This
mitigation is optional.
• M5: Documents may be digitally signed using the DSG profile
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The following mitigations are transferred to the vendors, XDS Affinity Domains, andenterprises.
• T1: Backup systems for registry metadata, repository documents, and gateway configuration
are recommended.
• T2: All implementations are recommended to ensure that all received data is propagatedappropriately (i.e. without corruption and complete results) or an error is presented.
• T3: Network protection services are recommended to be sufficient to guard against denial ofservice attacks on all service interfaces.
• T4: A process that reviews audit records and acts on inappropriate actions is recommended.
• T5: It is recommended that service interfaces be implemented with a good design to guard
against corruption and denial of service attacks

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18.4.3 Policy Choices

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Policy choices will not be addressed by this profile. Each community may have different
policies. The profile has been designed with this fact in mind and an understanding of enoughvariety of policies so that any reasonable policy can be implemented without violating the
profile.

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19 Basic Patient Privacy Consents Integration Profile
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The document sharing infrastructure provided by XD* allow for the publication and use ofclinical documents associated with a patient. This profile allows for a Patient Privacy Policy
Domain (e.g., an XDS Affinity Domain to have a number of Patient Privacy Policies that can be
acknowledged (aka consent). This allows for more flexibility to support some patient concerns,
while providing an important and useful dataset to the healthcare provider. Without BPPC, theXDS profile requires that the administrators of an XDS Affinity Domain creates and agrees to asingle document publication and use policy (See ITI TF-1: Appendix L). Such a single XDS
Affinity Domain Policy is enforced in a distributed way through the inherent access controls of
the systems involved in the XDS Affinity Domain.
This profile will use terms consistent with ISO 22600 - Privilege Management and AccessControl (PMAC), but is not restricted to systems that implement PMAC. This profile uses theterm “Patient” to refer to the human-subject of health related data. In this context “Patient” is not
to imply only those subjects under current treatment, this is sometimes referred to as“consumer”. This profile uses the term “Consent” to mean acknowledgement of a privacy policy,
also known as an information access policy. In this context the privacy policy may include
constraints and obligations. The systems involved in XDS are expected to support sufficientAccess Controls to carry out the Policy of the XDS Affinity Domain7.
Healthcare providers utilize many different sets of data to carry out treatment, billing, andnormal operations. This information may include patient demographics, contacts, insurance
information, dietary requirements, general clinical information and sensitive clinical information.
This information may be published (e.g., to XDS, XDR, XDM, PACS) as independent
documents with different sensitivity labels (i.e. confidentialityCode). This mechanism is notunique to BPPC, but is leveraged by privacy and security policies.
Healthcare providers in different functional roles will have different needs to access these
documents. For example, administrators may need to be able to access the patient demographics,
billing and contact documents. Dietary staff will need access to the dietary documents but would
not need access to insurance documents. General care providers will want access to most clinicaldocuments, and direct care providers should have access to all clinical documents. This is an
example of a Patient Privacy Policy that would be given a Patient Privacy Policy Identifier
within a Patient Privacy Policy Domain. When a patient acknowledges this policy, the Patient
Privacy Policy document would refer to the policy by the Patient Privacy Policy Identifier.
This profile provides a mechanism by which an XDS Affinity Domain can create a basic
vocabulary of codes that identify Patient Privacy Domain managed Privacy Policy Identifierswith respect to document sharing. Each Privacy Policy Identifier uniquely identifies a Privacy
Policy which should identify in legal text what the acceptable use, re-disclosure uses, whichfunctional roles may access which document and under which conditions, etc. The administrationof the XDS Affinity Domain will assign each Privacy Policy Identifiers for use within the XDS
7

See the IHE white paper “HIE Security and Privacy through IHE” published on the IHE web site
http://www.ihe.net/Technical_Framework/upload/IHE_ITI_Whitepaper_Security_and_Privacy_2007_07_18.pdf______________________________________________________________________________
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Affinity Domain. Future profiles may include in addition to the legal text, a structured and coded
expression of the consent policy that can be used to support even more dynamic understanding of
the patient's directives (see HL7 and OASIS).

19.1 Basic Patient Privacy Consent Use-Cases
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This section gives examples of some possible patient privacy consent policies and how thesystems publishing documents and using documents might act. This is an informative section andshould not be interpreted as the only way to implement the BPPC profile. Its purpose is to allow
implementers of BPPC to more easily understand the principle of operation of BPPC.
19.1.1 Implied Consent vs. Explicit Consent

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This profile supports both Implied Consent as well as Explicit Consent environments. In order toprovide a profile with global appeal we have supported both environments. In an implied consent
environment it would be normal for a Document Consumer to find no instance of a patient
specific acknowledgement of a privacy consent policy in the XDS Affinity Domain, as capturing
the act of acknowledging a privacy consent policy would not be required. Note: this may also betrue in an Explicit Consent environment, where obtaining the acknowledgement is delayed due to
medical reasons (e.g., emergency).
An XDS Affinity Domain might have a paper document that describes their Privacy Consent
Policy. In our example this Privacy Consent Policy will be given a local XDS Affinity Domain
managed Privacy Policy Identifier (e.g., an OID such as: 9.8.7.6.5.4.3.2.1). The example in
Figure 19.1-1 is ridiculous (i.e., chicken costume) but is provided to emphasize that IHE doesn’t
write these policies, and to make clear that the BPPC profile could be used to enforce any policythat could be written in human readable form, provided that all actors can be configured to
enforce that policy. This example also points out that the content of the policy is human readable______________________________________________________________________________
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text, and that we provide no structured or coded way to interpret. This example policy might look

The patient agrees to share theirhealthcare data to be accessed only
by doctors wearing a chicken
costume.

like:
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Figure 19.1-1 Policy Example

19.1.1.1 Opt-In

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A common structure for sharing clinical documents requires that the patient first acknowledge
that they want this sharing to happen before any documents are actually shared. In this case the
XDS Affinity Domain administrators would write a policy that indicates what should be shared,
when it should be shared, when it can be used, etc. There would also be an overriding XDS
Affinity Domain policy that indicates that no document will be shared until the patient has
explicitly chosen to participate.
19.1.1.2 Opt-Out

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Equally as common is a structure for sharing documents that presumes that when the patientchooses to get care within a care setting, that they are implicitly agreeing to the normal sharingof their documents for treatment purposes. In this environment, there is usually a control thatallows a patient to choose to NOT participate in this sharing. This is commonly referred to as“opt-out”.
In this case the existence an acknowledgement to an opt-out policy would mean that documents
should no longer be shared, and any documents that might appear should not be used. Clearly the
XDS Affinity Domain administrators need to make the actual behavior clear in their policies.
19.1.2 Wet Signature
An XDS Affinity Domain might have the patient acknowledge the consent through ink on paper.
For Example:______________________________________________________________________________
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Sample Consent: by A. Patient. It's OK

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Figure 19-2 Simplistic Consent Example

This acknowledgement is captured according to the XDS Scanned Document Content Profile(XDS-SD), with the additional parameters specified in the BPPC Content Profile also applied.
This is submitted into the XDS Affinity Domain as proof that the patient has acknowledged
policy 9.8.7.6.5.4.3.2.1.
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The following shows this graphically:
XDS Metadata:Consent Document
Ack of 9.8.7.6.5.4.3.2.1

Structured and Coded CDA Header
Patient, Author, Authenticator, Institution,
Time of Service, etc.

St r u c t u r ed Co n t ent wi th c o d ed s ec t i o n s :•Scanned Document details•Privacy Consent details•Policy 9.8.7.6.5.4.3.2.1

Base64 encoded

Figure 19.1.2-1: Graphical representation of consent with wet signature4735

If an XDS Affinity Domain wants to further provide non-repudiation protections it may choose
to apply a digital signature using the IHE-DSG Content Profile to the whole package with theappropriate purpose and signed by an appropriate signing system/person.
19.1.3 Advanced Patient Privacy Consents
An XDS Affinity Domain may have jurisdictional or organizational policies that require support
for more complex patient privacy consent policies. These privacy policies may require that a______________________________________________________________________________
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patient explicitly consent to disclosure of protected or sensitive health information to specificentities. The BPPC profile provides a starting point for implementing these types of privacy
consent policies, but does not explicitly specify how additional information needed to enforce thepolicy would be conveyed. In these cases, the capability of BPPC may not be enough to support
all types of needs. An example of an Advanced Patient Privacy Consent would be when a patientwants to name individuals that can access their documents.

19.2 Creating Patient Privacy Policies
The administrators of the Patient Privacy Policy Domain (e.g., XDS Affinity Domain) will needto develop and publish an overall Policy for the Patient Privacy Policy Domain that clearly
defines the overall appropriate use of the protected resources. This is the subject of ITI TF-1:
Appendix L and is not further defined here.

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Within this Patient Privacy Policy Domain (e.g., XDS Affinity Domain) overall Policy is adefined set of acceptable use Patient Privacy Policies. A Patient Privacy Policy further explainsappropriate use of the protected resources in a way that provides choices to the patient. The
BPPC profile places no requirements on the content of these policies nor the method used todevelop these policies (See ITI TF-1: Appendix P for some guidance on developing thesepolicies). BPPC only assumes that the overall Patient Privacy Policy Domain can be structured
as a set of specific policies (A, B, C, D in the example below), where each one may be used
independently or combined in relationship to publication and access of a specific type(s) of
document.
XDS Affinity Domain Privacy Policy

Policy A

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Policy B

Policy C

Policy D

Figure 19.2-1: Example Patient Privacy Policy Hierarchy

A Patient Privacy Policy will identify who has access to information, and what information isgoverned by the policy (e.g., under what conditions will a document marked as containing
sensitive information be used by a specific type of individual for a specific use). The mechanism
for publishing these policies is not described by this profile. The set of Patient Privacy Policies
written by the Patient Privacy Policy Domain must be able to be implemented by thetechnologies in all of the systems that have access to the domain. This means that the Patient
Privacy Policies must be created with great care to ensure they are enforceable.
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Each Patient Privacy Policy will be given a unique identifier (OID) known as a Patient Privacy
Policy Identifier. This is additionally used when capturing a patient’s acknowledgement of a
specific Patient Privacy Policy resulting in a Patient Privacy Policy Acknowledgement
Document (i.e. an instance of a BPPC document).
Finally, Privacy Consent Policies used within an XDS Affinity Domain will very likely be
different than those used with the XDM or XDR Profiles as these profiles often are used totransfer documents in ad-hoc ways. The patient may provide a consent given to share
information on media to the provider creating the media for specific use, rather than for moregeneral sharing within an XDS Affinity Domain. When transferring information that originatedin an XDS Affinity Domain to media (XDM), the Privacy Consent Policies found in the XDS
Affinity Domain might be changed during the publication process. There are also differences inthe sensitivity that should be considered for consents shared on media or transmitted through
XDR and those shared in an XDS Affinity Domain. See the section Security Considerations laterin this volume for more details.
19.2.1 Summary of the creation and publication of the policies

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1.

The Patient Privacy Policy Domain will write and agree to overall privacy policies (lotsof lawyers involved).

2.

The Patient Privacy Policy Domain will include a small set of Patient Privacy Policies(more lawyers). These are text documents very similar to the privacy consent
documents used today.

3.

Each Patient Privacy Policy will be given an unique identifier (OID) called the Patient
Privacy Policy Identifier

4.

The Policy of the Patient Privacy Policy Domain and all of the Patient Privacy Policies
will be published in some way. It is expected that this will be sufficiently public tosupport local regulation.

5.

When a patient acknowledges a Patient Privacy Policy, a Patient Privacy Policy
Acknowledgement Document will be published with the Patient Privacy Policy
Identifier of the policy that the patient acknowledged.

19.3 Actors/Transactions

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There are two actors in the BPPC profile, the Content Creator and the Content Consumer.
Content is created by a Content Creator and is to be consumed by a Content Consumer. The
sharing or transmission of content or updates from one actor to the other is addressed by the useof appropriate IHE profiles described in the section on Content Bindings with XDS, XDM and
XDR. in PCC TF-2: 4.1, and is out of scope of this profile. A Document Source or a Portable
Media Creator may embody the Content Creator actor. A Document Consumer, a Document
Recipient or a Portable Media Importer may embody the Content Consumer actor.

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Figure 19.3-1: BPPC Actor Diagram

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Table 19.3-1 lists the transactions for each actor directly involved in the BPPC Profile. In orderto claim support of this Integration Profile, an implementation must perform the required
transactions (labeled “R”). Transactions labeled “O” are optional. A complete list of options
defined by this Integration Profile and that implementations may choose to support is listed in
ITI TF-1: 19.4.
Table 19.3-1: BPPC Integration Profile - Actors and Transactions
ActorsTransactions

Optionality

SectionContent Creator

Share Content

R (note 2)

ITI TF-1: 19.4.3

Content Consumer

Share Content

R (note 3)

ITI TF-1: 19.4.4
ITI TF-1: 19.4.5

19.3.1 Grouping
19.3.1.1 Basic Patient Privacy Documents Bindings to XDS, XDR, XDM
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A BPPC Content Creator or Content Consumer can be grouped with appropriate actors from the
XDS, XDM or XDR profiles to exchange Basic Privacy Consent documents. The metadata sentin the document sharing or interchange messages has specific relationships or dependencies(which we call bindings) to the content of the clinical document – a Basic Patient Privacy
Consent document - described in ITI TF-3: 5.1.2 and 5.1.3.
• A BPPC Content Creator shall be grouped with and XDS/XDR Document Source or and
XDM Portable Media Creator.
• A BPPC Content Consumer shall be grouped with an XDS Document Consumer, and XDRDocument Recipient, or an XDM Portable Media Importer.
19.3.1.2 Basic Patient Privacy Grouping with XDS-SD

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The BPPC Content Consumer shall be grouped with a XDS-SD Content Consumer. This meansthat a Content Consumer for BPPC Content must also be able to display XDS-SD content. Thisis required due to the common practice of capturing Wet Signatures.

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19.4 Basic Patient Privacy Consent Profile Options
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Options that may be selected for this Integration Profile are listed in Table 19.4-1 along with the
IHE actors to which they apply.
Table 19.4-1: Basic Patient Privacy Consents - Actors and Options
Actors

OptionSectionContent Creator

Basic Patient Privacy Acknowledgement (note 1)

ITI TF-3: 5.1.2

Basic Patient Privacy Acknowledgement with Scanned
Document

ITI TF-3: 5.1.3

Basic Patient Privacy Acknowledgement View (note 2)

ITI TF-3: 5.1.2

Content Consumer

ITI TF-3: 5.1.3
Note 1: Content Creator shall implement the Basic Patient Privacy Acknowledgement Option, and may choose to
implement the Basic Patient Privacy Acknowledgement with Scanned Document Option

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Note 2: Content Consumer shall implement the Basic Patient Privacy Acknowledgement View Option.

19.4.1 Intentionally Left Blank
19.4.2 Intentionally Left Blank
19.4.3 Basic Patient Privacy Acknowledgement Option
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The Content Creator shall be able to create Patient Privacy Policy Acknowledgement Document
Content as specified in ITI TF-3: 5.2.
A Patient Privacy Policy Acknowledgement Document is a kind of medical document. The
content of a Patient Privacy Policy Acknowledgement Document shall include the effective timeof the acknowledgement and Patient Privacy Policy Domain (e.g., XDS Affinity Domain)
defined coded vocabulary identifying the Patient Privacy Consent Policy Identifier (OID)
acknowledged by the patient. The content of the Patient Privacy Acknowledgement Document
may include a text description of what the patient has acknowledged.
The Patient Privacy Policy Acknowledgement Document may be signed. There are cases, as seenin the use-cases, where the Content Creator would need to be grouped with a DSG Content
Creator. The BPPC profile does not require this grouping. This grouping can be fully specified in
an IHE Integration Statement.
19.4.4 Basic Patient Privacy Acknowledgement with Scanned Document Option

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A Basic Patient Privacy Policy Acknowledgement Document may include a scanned document.
An example of the scanned document could be a wet signature by the patient on the text. The
Content Creator that claims to support Basic Patient Privacy Policy Acknowledgement with
Scanned Document Option shall be able to create a Patient Privacy Policy Acknowledgementwith Scanned Document Content as specified in ITI TF-3: 5.1.3.
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19.4.5 Patient Privacy Acknowledgement View Option
The Content Consumer shall be able to display the Patient Privacy Policy Acknowledgement
Document Content as specified in ITI TF-3: 5.1.2 and ITI TF-3: 5.1.3.
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19.5 Intentionally Left Blank
19.6 BPPC Process Flow in an XDS Affinity Domain
This flow shows how an XDS Affinity Domain would use the BPPC Profile. Only a basic flow
is shown, the profile supports many alternative flows.
19.6.1 Checking for a patient’s acknowledgement of a privacy policy

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An XDS Document Consumer Actor that is enforcing policies registered by BPPC can query an
XDS Affinity Domain for instances of Patient Privacy Policy Acknowledgement Documents thathave been acknowledged by a specific patient. Through the XDS Metadata the Document
Consumer can determine which Patient Privacy Policies have been acknowledged.
Note if the local regulations allow, some XDS Affinity Domains may not publish the consent
documents, so systems should be able to handle the configurations where no Patient Privacy
Acknowledgment Document is in the XDS Affinity Domain for a specific patient (e.g., implied
consent).
Note if the local regulations allow, some patients may have documents shared before informed
consent can be captured. In this case the XDS Affinity Domain policy needs to explain thedefault behavior, that behavior for the absence of a consent document.
19.6.2 Recording a patient’s acknowledgement of a privacy policy
The Content Consumer Actor creates Patient Privacy Policy Acknowledgement Documents withor without a scanned document part. This document records the patient’s acknowledgement of a
specified policy.

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19.6.3 Publishing documents against a consent policy
All documents managed in an XDS Affinity Domain, or transferred using XDM/XDR, arelabeled with a confidentialityCode. The administrators of an XDS Affinity Domain may need todefine a vocabulary and meaning to that vocabulary.

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The XDS or XDR Document Source Actor that supports the Basic Patient Privacy Enforcement
option determines which of the XDS Affinity Domain – Privacy Consent Policies would allow
the documents to be published. In some XDS Affinity domains this may require that the system
check that a patient has indeed acknowledged a specific policy.
The Document Source Actor will set the XDS Metadata – confidentialityCode - to indicate theappropriate sensitivity for use/constraint (determined by the XDS Affinity Domain Policy)______________________________________________________________________________
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The XDS Document Registry validates that each of the confidentialityCode(s) are from theapproved list of confidentialityCode for use within the XDS Affinity Domain.
19.6.4 Using published documents

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When an XDS Document Consumer that supports the Basic Patient Privacy Enforcement option
queries the XDS Affinity Domain it may utilize the confidentialityCode filter in the Registry
Stored Query to restrict the documents returned to those that the Document Consumer canutilize.
The Document Consumer will enforce access controls based on the returned XDS metadataconfidentialityCode, current state of consent acknowledgements, system type, user, context, andany number of other factors that the system is capable of enforcing.

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The Document Consumer may be capable of querying for ‘Approved’ consent acknowledgement
documents and using the resulting XDS Metadata as the list of currently Approved Patient
Privacy Policy Acknowledgement Documents. There is no requirement for the Document
Consumer system to retrieve the Patient Privacy Policy Acknowledgement Document content.

19.7 Security Considerations
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Consents stored in an XDS Affinity Domain are also governed by privacy policies. The content
of a Patient Privacy Policy Acknowledgement Document may itself contain sensitive
information. For example, a terminally ill patient may decide that his prognosis should not beshared with his family members, but that other information may be. Sharing the Patient Privacy
Policy Acknowledgement Document with family members would potentially inform them of anegative prognosis. Thus the confidentialityCode placed on Patient Privacy Policy
Acknowledgement Documents must be appropriately assigned (e.g., most will be assigned thebroadest use confidentialityCode).
However, Patient Privacy Policy Acknowledgement Documents stored in the clear on media(XDM), or transmitted through XDR, should not contain sensitive information. The rationale isthat the receiver of the information must be able to read the consent that was used to share thisinformation in order to understand how they must treat the information with respect to their own
Patient Privacy Policies.
Implementation of Patient Privacy Policies within a healthcare environment has different
considerations and risks than implementing similar access control policies within other nontreatment environments. This is for the simple reason that failing to provide access to critical
healthcare information has the risk of causing serious injury or death to a patient. This risk must
be balanced against the risk of prosecution or lawsuit due to accidental or malicious disclosure ofprivate information. The XDS Affinity Domain should take care in writing their Patient Privacy
Policies to avoid this.
One mitigation strategy that is often adopted in healthcare provides accountability through audit
controls. That is to say that the healthcare providers are trusted not to abuse their access to
private information, but that this is followed up by a policy of monitoring healthcare provider
accesses to private information to ensure that abuse does not occur. This strategy reduces the risk______________________________________________________________________________
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of serious death or injury due to lack of access to critical healthcare information, at the increased
risk of disclosure of private information. This is why the ITI Technical Committee created the
Audit Trail and Node Authentication (ATNA) Integration profile, and furthermore, why thatprofile is a requirement of XDS and related profiles.
Another risk that must be resolved by an affinity domain is how to address the issues of sharing
truly sensitive information in a registry (e.g., psychology documents). One strategy that might berecommended is that truly sensitive data not be shared within the XDS Affinity Domain; directed
communications using XDR or XDM may be more appropriate.

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20 Cross-Enterprise Sharing of Scanned Documents Content
Integration Profile
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A variety of legacy paper, film, electronic and scanner outputted formats are used to store andexchange clinical documents. These formats are not designed for healthcare documentation, andfurthermore, do not have a uniform mechanism to store healthcare metadata associated with the
documents, including patient identifiers, demographics, encounter, order or service information.
The association of structured, healthcare metadata with this kind of document is important tomaintain the integrity of the patient health record as managed by the source system. It isnecessary to provide a mechanism that allows such source metadata to be stored with the
document.
This profile defines how to couple such information, represented within a structured HL7 CDA
R2 header, with a PDF or plaintext formatted document containing clinical information.
Furthermore, this profile defines elements of the CDA R2 header necessary to minimallyannotate these documents. Such header elements include information regarding patient identity,patient demographics, scanner operator identity, scanning technology, scan time as well as best
available authoring information. Portions of CDA R2 header, along with supplemental
document registration information, are then used to populate XDS Document Entry metadata.
The content of this profile is intended for use in XDS, XDR and XDM. Content is created by aContent Creator and is to be consumed by a Content Consumer. The Content Creator can beembodied by a Document Source Actor or a Portable Media Creator, and the Content Consumer
by a Document Consumer, a Document Recipient or a Portable Media Importer. Obligations
imposed on the Content Creator and the Content Consumer by this profile are understood to be
fulfilled by the software that creates the final document for submission and/or consumes profile
conformant documents rather than any particular scanning technology.

20.1 Use Cases
20.1.1 Content Use Cases
Text Chart Notes
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Examples of this content include handwritten, typed or word processed clinical documents
and/or chart notes. These documents are typically multi-page, narrative text. They include
preprinted forms with handwritten responses, printed documents, and typed and/or word
processed documents, and documents saved in various word processing formats. Appropriate
formats are PDF, derived from the word processing format, or plaintext, if the text structure is allthat needs to be conveyed. PDF is desirable because it most faithfully renders word processed
document content and it preserves meaning embodied in non-textual annotations.
Graphs, Charts and/or Line Drawings
Examples of this content include Growth Charts, Fetal Monitoring Graphs. Line drawings suchas those described above are best rendered using PDF versus an image based compression, such______________________________________________________________________________
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as JPEG. However, when computer generated PDFs include lines or lossy compression is not
acceptable for diagnostic purposes, PDF should be used.
Object Character Recognition (OCR) Scanned Documents

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Clinical documents can contain text and annotations that cannot be fully processed by opticalcharacter recognition (OCR). We call attention to the fact that the OCR text content may only
partially represent the document content. These are best supported by converting to PDF format,
which can mix the use of OCR’d text, compressed scanned text, and scanned image areas.
Electronic Documents

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Existing clinical documents that are electronically transmitted or software created (e.g., PDF, or
plaintext) can be considered as actually scanned, previously scanned or virtually scanned before
they are shared. In this context, “actually scanned” refers to electronic documents, newly created
via some scanning technology from legacy paper or film for the purposes of sharing. “Previously
scanned” refers to electronic documents that were previously produced via some scanningtechnology from legacy paper or film, but have existed in their own right for a period of time.
“Virtually Scanned” electronic documents are existing electronic documents not derived fromlegacy paper or film that either are PDF/A or plaintext format or have been converted to one ofthese formats for the purposes of sharing. This content is covered by this profile.
20.1.2 Content Creator Use Cases

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Content is created by a Content Creator. Impact on application function and workflow isimplementation specific and out of scope of this content profile, though we note that they will becompliant with this content profile if they can produce CDA wrapped PDF, CDA wrappedplaintext or both. The following example use case is included to aid in the scoping of this content
profile.

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Legacy Clinic is a small two-physician clinic. They presently store their patient's medical
records on paper. The Clinic is trying to figure out what to do with its paper and word
processing documents as it converts over to an electronic system. They would like to be able
to view the files over their local intranet.

5005

Presently, most records are handwritten on preprinted paper forms that are inserted into
specific sections of the patient's chart. More detailed encounter reports are dictated and sent
to a transcription company that returns them in a word processing format. The medical
records clerk at Legacy Clinic receives these files via e-mail, decrypts them, prints them out,
and adds them to the patient's chart in the correct section.

5010

Over the years, Legacy Clinic has used a number of different transcription companies, andthe documents are stored in a variety of word processing formats. Several years ago, they
began to require that returned documents be in RTF format in an attempt to reduce
frustrations induced by dealing with discrepant word processing formats. Only in some cases
was patient and encounter metadata stored within the word processing document in a regularformat, depending upon the transcription company used at the time. A third party presently
handles labs for the clinic. These are usually returned to the Clinic as printed documents.
The clerk inserts these into the labs section in the patient's chart.
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In the case of Legacy Clinic, the link between the word processing documents and the patient
has been maintained for many of its documents, since the existing manual process maintains
that association, and some of the files also contain the encounter metadata. However, thelink to the specific encounter will need to be reestablished by interpreting the document
content, which will require a great deal of manual effort for some of their documents which
do not have it, and will still require custom handling depending upon the format used to store
this metadata.
Legacy Clinic uses a transcription provider that can generate PDF documents, wrapped in a
CDA Release 2.0 header. These are sent to Legacy Clinic via e-mail. While the same
manual process is used, these documents are now in a format that is ready to be used by their
new EHR system.

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20.1.3 Content Consumer Use Cases
Content is consumed by a Content Consumer. Impact on application function and workflow isimplementation specific and out of scope of this content profile. However, we note that adoptionof this profile will necessitate the Content Consumer, upon document receipt, support theprocessing of both CDA wrapped PDF and CDA wrapped plaintext.

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20.2 Actors/ Transactions

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There are two actors in the XDS-SD profile, the Content Creator and the Content Consumer.
Content is created by a Content Creator and is to be consumed by a Content Consumer. The
sharing or transmission of content from one actor to the other is addressed by the appropriate useof IHE profiles described below, and is out of scope of this profile. A Document Source or a
Portable Media Creator may embody the Content Creator Actor. A Document Consumer, aDocument Recipient or a Portable Media Importer may embody the Content Consumer Actor.
The sharing or transmission of content or updates from one actor to the other is addressed by theuse of appropriate IHE profiles described in the section on Content Bindings with XDS, XDM
and XDR.

5040

Figure 20.2-1 shows the actors directly involved in the Scanned Documents Content Integration
Profile and the relevant transactions between them. Other actors that may be indirectly involved
due to their participation in other profiles are not necessarily shown.

5045

Figure 20.2-1: Scanned Documents Actor Diagram______________________________________________________________________________
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20.3 Scanned Documents Content Integration Profile Options
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Options for Scanned Documents leverage those in the Patient Care Coordination (PCC)
Technical Framework (TF). Options that may be selected for this Integration Profile are listed in
the Table 20.3-1 along with the Actors to which they apply. Dependencies between options
when applicable are specified in notes.
Table 20.3-1: XDS-SD - Actors and Options
Actor

Options

Content Creator

No options defined

Vol & Section

Content Consumer

View Option1

PCC TF- 2: 34.0.1

Document Import Option1

PCC TF-2: 34.0.2--

Note 1: The Actor shall support at least one of these options.

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20.4 Scanned Documents Bindings to XDS, XDR, XDM
Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content
Consumer sharing function of this profile. A Content Creator or Content Consumer may begrouped with appropriate actors from the XDS, XDM or XDR profiles to exchange the content
described therein. The metadata sent in the document sharing or interchange messages has
specific relationships or dependencies (which we call bindings) to the content of the clinicaldocument described in the content profile. The Patient Care Coordination Technical Framework(PCC-TF) defines the bindings to use when grouping the Content Creator of this Profile withactors from the IHE ITI XDS, XDM or XDR Integration Profiles. See PCC TF-2:4.

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20.5 Scanned Documents Content Process Flow
This profile assumes the following sequence of events in creation of an XDS-SD document.

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1.

A legacy paper document is scanned and a PDF/A is rendered. Alternatively, anelectronic document is converted, if necessary, to PDF/A or plaintext format (see ITI
TF-3: 5.2.1 and 5.2.1.1).

2.

Software, conformant to this profile and most likely with the aid of user input (e.g. toprovide document title, confidentiality code, original author), renders the CDA R2
header pertaining to the PDF or plaintext produced. The document is wrapped and the
XDS-SD document is completed (see ITI TF-3: 5.2.3).

3.

XDS metadata is produced from data contained in the CDA header and supplemental
information (see ITI TF-3: 5.2.2).

4.

The completed XDS-SD document and corresponding metadata is sent via the Provide
a Register Document Set Transaction [ITI-15] or [ITI-41] of XDS/XDR, or theDistribute Document Set on Media Transaction [ITI-32] of XDM.

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21 reserved5080______________________________________________________________________________
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22 Document-based Referral Request Integration Profile (DRR)
This profile has been retired in favor of use of the Cross-Enterprise Document Workflow (XDW)Profile.

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23 Patient Identifier Cross-referencing HL7 V3 (PIXV3)The Patient Identifier Cross-referencing HL7 V3 Integration Profile (PIXV3) is targeted atcross-enterprise Patient Identifier Cross-reference Domains (as defined in ITI TF-1: 5) as well as
healthcare enterprises with developed IT infrastructure. The discussion in ITI TF-1: 5 fully
applies here, with the obvious adjustments to the referenced transactions.

Patient
Identifier
Domain C

Patient Identifier
Cross-referenceManager

Patient
Identity
Feed HL7 V3Patient
Identity Feed
HL7 V3

PIX V3UpdateNotification

Patient Identity
SourceInternal
Domaintransactions

Patient Identifier
Cross-reference Domain

Patient Identity Feed HL7
V3, PIXV3 Query & PIXV3
Update Notification

Patient Identity
SourceInternal
Domaintransactions

Patient Identifier
Cross-reference
ConsumerOther
IHE Actor

Other
IHE Actor

Patient Identifier
Domain A

PIXV3
UpdateNotification

Patient Identifier
Cross-reference
Consumer
Patient Identifier
Domain B

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Figure 23-1: Process Flow with Patient Identifier Cross-referencing HL7 V3

23.1 Actors/Transactions
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The actors in this profile are the same as the actors defined in the PIX profile (ITI TF-1: 5.1).
Figure 23.1-1 shows the actors directly involved in the Patient Identifier Cross-referencing HL7
V3 Integration Profile and the relevant transactions between them. Other actors that may be
indirectly involved due to their participation in other related profiles are not shown.

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Patient Identifier
Cross-reference
Consumer

Patient Identity Source

Patient Identity Feed HL7 V3 [ITI-44]↓↓ PIXV3 Query [ITI-45]↑ PIXV3 Update Notification [ITI-46]

Patient Identifier Crossreference Manager

Figure 23.1-1 Patient Identifier Cross-referencing HL7 V3 Actor Diagram

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Table 23.1-1 lists the transactions for each actor directly involved in the Patient Identifier Crossreferencing Profile. In order to claim support of this Integration Profile, an implementation must
perform the required transactions (labeled “R”). Transactions labeled “O” are optional. A
complete list of options defined by this Integration Profile and that implementations may choose
to support is listed in the ITI TF-1: 23.2.

5105
Table 23.1-1: Patient Identifier Cross-referencing HL7 V3 Integration Profile - Actors andTransactions
ActorsTransactions

Optionality

SectionPatient Identity Source

Patient Identity Feed HL7 V3[ITI-44]

R

ITI TF-2b: 3.44

Patient Identifier Crossreference Consumer

PIXV3 Query[ITI-45]

R

ITI TF-2b: 3.45

PIXV3 Update Notification [ITI-46]

O

ITI TF-2b: 3.46

Patient Identifier Crossreference Manager

Patient Identity Feed HL7 V3[ITI-44]

R

ITI TF-2b: 3.44

PIXV3 Query[ITI-45]

R

ITI TF-2b: 3.45

PIXV3 Update Notification[ITI-46]

R

ITI TF-2b: 3.46

The transactions in this profile directly correspond to the transactions used in the PIX profile (ITI
TF-1: 5) and provide the identical functionality. Table 23.1-2 describes this correspondence.
5110
Table 23.1-2: Transactions Correspondence between the PIX and PIXV3 profiles
Transactions in PIX

Section in
VolumeTransactions in PIXV3

SectionPatient Identity Feed [ITI-8]

ITI TF-2a: 3.8

Patient Identity Feed HL7 V3[ITI-44]

ITI TF-2b: 3.44

PIX Query[ITI-9]

ITI TF-2a: 3.9

PIXV3 Query[ITI-45]

ITI TF-2b: 3.45

PIX Update Notification [ITI-10]

ITI TF-2a: 3.10

PIXV3 Update Notification [ITI-46]

ITI TF-2b: 3.46______________________________________________________________________________
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23.2 Patient Identifier Cross-referencing HL7 V3 Integration Profile
Options
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Options that may be selected for this Integration Profile are listed in the Table 23.2-1 along with
the Actors to which they apply. Dependencies between options when applicable are specified innotes.
Table 23.2-1: Patient Identifier Cross-referencing HL7 V3 - Actors and Options
Actor

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Options

Vol & Section

Patient Identity Source

Pediatric Demographics

Patient Identifier Cross-reference Manager

Pediatric Demographics

Patient Identifier Cross-reference Consumer

PIXV3 Update Notification Transaction

ITI TF-2b: 3.46

23.2.1 Pediatric Demographics
The experience of immunization registries and other public health population databases has
shown that matching and linking patient records from different sources for the same individual
person in environments with large proportions of pediatric records requires additional
demographic data.

5125

5130

In particular, distinguishing records for children who are twins, triplets, etc. – that is, avoiding
false positive matches - may be difficult because much of the demographic data for the two
individuals matches. For instance, twin children may have identical last names, parents,
addresses, and dates of birth; their first names may be very similar, possibly differing by only
one letter. It can be very difficult for a computer or even a human being to determine in thissituation whether the slight first name difference points to two distinct individuals or just atypographical error in one of the records. Additional information is extremely helpful in making
this determination.
Pediatric Demographics makes use of the following six additional demographic fields to aid
record matching in databases with many pediatric records.

5135
Field

Reason for inclusion

Value

Mother’s Maiden
Name

Any information about the mother is
helpful in making a match

Helps create true positive matches

Patient Home
TelephoneA telecom helps match into the righthousehold

Helps create true positive matches

Patient Multiple Birth
Indicator

Indicates this person is a multiple –twin, triplet, etc.

Helps avoid false positive matches ofmultiplesPatient Birth OrderDistinguishes among those multiples.

Helps avoid false positive matches ofmultiples______________________________________________________________________________
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Field
Last Update
Date/Time, Last
Update Facility

Reason for inclusion
These fields, although not strictly
demographic, can effectively substitutewhen multiple birth indicator and birthorder are not collected. They indirectly
provide visit information. Provider
visits on the same day may likely
indicate two children brought to adoctor together.

Value
Helps avoid false positive matches ofmultiplesPatient Identity Source actors which support the Pediatric Demographics option are required tosupport the Patient Identity Management [ITI-30] transaction and shall provide values, whenavailable, for the fields identified as Pediatric Demographics fields.
5140

Patient Identifier Cross-reference Manager actors which support the Pediatric Demographics
option are required to support the Patient Identity Management [ITI-30] transaction, and if values
for one or more of the Pediatric Demographics fields are specified in the Patient Identity
Management [ITI-30], they shall be considered as part of the matching algorithm of the PIXManager.

5145

Pediatric Demographics are defined as all of the following:• Mother’s Maiden Name
• Patient Home Telephone• Patient Multiple Birth Indicator• Patient Birth Order• Last Update Date/Time• Last Update Facility

5150

23.3 Patient Identifier Cross-referencing HL7 V3 Integration Profile
Process Flows
5155

Sections ITI TF-1: 5.3.1 and ITI TF-1: 5.3.2 describe use cases that this profile addresses.
Figures 5.3-1 and 5.3-2 also apply with the changes to the corresponding PIXV3 transactions as
specified in table 23.1-2.

23.4 Relationship between the PIXV3 Integration Profile and eMPIThe discussion in ITI TF-1: 5.4 fully applies to this profile.

23.5 Patient Identifier Communication Requirement
5160

The patient identifier in HL7 V3 messages is represented by the II data type. This data type has
two components: a root, and an extension. For compatibility with the use of patient identifiers in
profiles using HL7 V2 messages, and with the specification of the patient identifier in the XDS
profile, the patient identifier SHALL be represented as a root and an extension, where the root is______________________________________________________________________________
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an appropriately assigned OID. The direct correspondence between the II data type and the HL7
Version 2.5 CX data type (used in field PID-3) is shown in ITI TF-2x: Appendix R.

23.6 Security Considerations
The implementer of this profile is advised that many risks cannot be mitigated by the IHE profile
and instead the responsibility for mitigation is transferred to the vendor, and occasionally to theoperational environment.
5170

5175

5180

In order to address identified security risks:• All actors in PIXV3 should be grouped with a Consistent Time (CT) Profile - Time Client
actor. This grouping will assure that all systems have a consistent time clock to assure a
consistent timestamp for audit logging.
• All actors in PIXV3 should be grouped with an Audit Trail and Node Authentication(ATNA) profile - Secure Node actor or ATNA Secure Application actor. This grouping willassure that only highly trusted systems can communicate and that all changes are recorded in
the audit log.
• All actors in PIXV3 should be grouped with an XUA X-Service User or X-Service Provider
actor as appropriate. This grouping will enable service side access control and more detailed
audit logging.
• All actors in PIXV3 should be grouped with the appropriate actor from the Enterprise User
Authentication (EUA) profile to enable single sign-on inside an enterprise by facilitating one
name per user for participating devices and software.

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24 Patient Demographics Query HL7 V3 (PDQV3)
5185

The Patient Demographics Query HL7 V3 Integration Profile (PDQV3) provides ways for
multiple distributed applications to query a patient information server for a list of patients, basedon user-defined search criteria, and retrieve a patient’s demographic information directly into theapplication. The discussion and use cases in ITI TF-1: 8 fully apply here, with the obvious
adjustments to the referenced transactions.

5190

24.1 Actors/Transactions
The actors in this profile are the same as the actors defined in the PDQ profile (ITI TF-1: 8.1).
Table 24.1-1: Patient Demographics Query HL7 V3 Integration Profile - Actors andTransactions
ActorsTransactions

Optionality

SectionPatient Demographics Consumer

Patient Demographics Query HL7 V3R

ITI TF-2b: 3.47

Patient Demographics Supplier

Patient Demographics Query HL7 V3R

ITI TF-2b: 3.47

5195
The transaction in this profile directly corresponds to one of the transactions used in the PDQ
profile (ITI TF-1: 8) and provide the identical functionality. Table 24.1-2 describes thiscorrespondence. Note that unlike the PDQ profile there is no transaction which corresponds to
the Patient Demographics and Visit query (ITI-22).
5200
Table 24.1-2: Transactions Correspondence between the PDQ and PDQV3 profiles
Transactions in PDQ

Section in
VolumeTransactions in PDQV3Patient Demographics Query [ITI21]

ITI TF-2: 3.21

Patient Demographics Query HL7 V3 [ITI47]

Section in
VolumeITI TF-2b:
3.47

24.2 Patient Demographics Query HL7 V3 Integration Profile Options
5205

Options that may be selected for this Integration Profile are listed in the Table 24.2-1 along with
the Actors to which they apply. Dependencies between options when applicable are specified innotes.
Table 24.2-1: Patient Demographics Query HL7 V3 - Actors and Options
Actor

Options

Vol & Section

Patient Demographics Consumer

Continuation Option

ITI TF-1: 24.2.2

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Actor

Options

Vol & Section

Patient Demographics SupplierContinuation Option

ITI TF-1: 24.2.2

Pediatric Demographics

5210

Support of continuations is described in transaction ITI-47. This option allows the Patient
Demographics Consumer to get the full set of responses in several increments, as opposed to in
one single response.
24.2.1 Continuation

5215

Support of continuations is described in transaction ITI-47. This option allows the Patient
Demographics Consumer to get the full set of responses in several increments, as opposed to in
one single response.
24.2.2 Pediatric Demographics Option

5220

5225

5230

The experience of immunization registries and other public health population databases has
shown that matching and linking patient records from different sources for the same individual
person in environments with large proportions of pediatric records requires additional
demographic data.
In particular, distinguishing records for children who are twins, triplets, etc. – that is, avoiding
false positive matches - may be difficult because much of the demographic data for the two
individuals matches. For instance, twin children may have identical last names, parents,
addresses, and dates of birth; their first names may be very similar, possibly differing by only
one letter. It can be very difficult for a computer or even a human being to determine in thissituation whether the slight first name difference points to two distinct individuals or just atypographical error in one of the records. Additional information is extremely helpful in making
this determination.
Pediatric Demographics makes use of the following six additional demographic fields to aid
record matching in databases with many pediatric records.
Field

Reason for inclusion

Value

Mother’s Maiden
Name

Any information about the mother is
helpful in making a match

Helps create true positive matches

Patient Home
TelephoneA telecom helps match into the righthousehold

Helps create true positive matches

Patient Multiple Birth
Indicator

Indicates this person is a multiple –twin, triplet, etc.

Helps avoid false positive matches ofmultiplesPatient Birth OrderDistinguishes among those multiples.

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Field
Last Update
Date/Time, Last
Update Facility

Reason for inclusion
These fields, although not strictly
demographic, can effectively substitutewhen multiple birth indicator and birthorder are not collected. They indirectly
provide visit information. Provider
visits on the same day may likely
indicate two children brought to adoctor together.

Value
Helps avoid false positive matches ofmultiples

5235

Patient Identity Source actors which support the Pediatric Demographics option are required tosupport the Patient Identity Management [ITI-30] transaction and shall provide values, whenavailable, for the fields identified as Pediatric Demographics fields.

5240

Patient Identifier Cross-reference Manager actors which support the Pediatric Demographics
option are required to support the Patient Identity Management [ITI-30] transaction, and if values
for one or more of the Pediatric Demographics fields are specified in the Patient Identity
Management [ITI-30], they shall be considered as part of the matching algorithm of the PIXManager.

5245

Pediatric Demographics are defined as all of the following:• Mother’s Maiden Name
• Patient Home Telephone• Patient Multiple Birth Indicator• Patient Birth Order• Last Update Date/Time• Last Update Facility

24.3 Patient Demographics Query HL7 V3 Process Flow
5250

ITI TF-1: 8.3 describes use cases that this profile addresses. Figure 8.3-1 also applies to thisprofile with the changes to the corresponding PDQV3 transactions as specified in Table 24.1-2,
and omitting transaction ITI-22, which has no correspondence in this profile.
24.3.1 Combined Use of PDQV3 with other IHE Workflow Profiles

5255

In addition to the discussion in ITI TF-1: 8.3.1, the use of web services as the transport in thetransactions in this profile makes it well suited in cases where other web services-based profiles
are used, like XDS.b and PIXV3.
24.3.2 Supplier Data Configuration

5260

The Patient Demographics Supplier provides demographics information about possible matches
to the parameters of the query. As described in ITI TF-2x: Appendix M, while it is possible forthe supplier to have demographics information from multiple domains, only a single set of
demographics shall be returned by the supplier.
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If the supplier holds information for a single Patient ID domain, it shall provide thedemographics information from that domain. In the case where the supplier holds demographics
information from multiple Patient ID domains, the determination of which set of information to
return must be based on the ID values for the Receiver’s Device and Organization classes of thequery transmission wrapper (the equivalent of MSH-5 and MSH-6 in the HL7 Version 2.5
corresponding message).

24.4 Intentionally left blank
24.5 Security Considerations
5270

5275

5280

5285

The implementer of this profile is advised that many risks cannot be mitigated by the IHE profile
and instead the responsibility for mitigation is transferred to the vendor, and occasionally to theoperational environment.
In order to address identified security risks:• All actors in PDQV3 should be grouped with a Consistent Time (CT) Profile - Time Client
actor. This grouping will assure that all systems have a consistent time clock to assure a
consistent timestamp for audit logging.
• All actors in PDQV3 should be grouped with an Audit Trail and Node Authentication(ATNA) profile - Secure Node actor or ATNA Secure Application actor. This grouping willassure that only highly trusted systems can communicate and that all changes are recorded in
the audit log.
• All actors in PDQV3 should be grouped with an XUA X-Service User or X-Service Provider
actor as appropriate. This grouping will enable service side access control and more detailed
audit logging.
• All actors in PDQV3 should be grouped with the appropriate actor from the Enterprise User
Authentication (EUA) profile to enable single sign-on inside an enterprise by facilitating one
name per user for participating devices and software.

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25 Multi-Patient Queries (MPQ)5290

The Multi-Patient Queries profile defines a mechanism to enable aggregated queries to a
Document Registry based on certain criteria needed by areas related to data analysis, such as
quality accreditation of health care practitioners or health care facilities, clinical research trial
data collection or population health monitoring.

25.1 Actors/ Transactions
5295

Figure 25.1-1 shows the actors directly involved in the MPQ Integration Profile in a solely XDS
Affinity Domain and the relevant transactions between them. Other actors that may be indirectly
involved due to their participation in other related profiles, etc. are not necessarily shown.

Multi-Patient Stored Query[ITI-51] ←Document Registry

Document Consumer

5300

5305

Figure 25.1-1: Multi-Patient Queries Actor Diagram

5310

5315

Table 25.1-1 lists the transactions for each actor directly involved in the Multi-Patient Query
Profile. In order to claim support of this Integration Profile, an implementation must perform therequired transactions (labeled “R”). Transactions labeled “O” are optional. A complete list of
options defined by this Integration Profile and that implementations may choose to support islisted in ITI TF-1: 25.2.
Table 25.1-1: Multi-Patient Queries Integration Profile - Actors and Transactions
ActorsTransactions

Optionality

Section in
Vol. 2Document Registry

Multi-Patient Stored Query [ITI-51]

R

ITI TF-2b: 3.51

Document Consumer

Multi-Patient Stored Query [ITI-51]

R

ITI TF-2b: 3.51______________________________________________________________________________
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25.2 Multi-Patient Query Integration Profile Options
Options that may be selected for this Integration Profile are listed in Table 25.2-1 along with theActors to which they apply. Dependencies between options when applicable are specified innotes.
5320

Table 25.2-1: MPQ - Actors and Options
Actor

Options

Vol & Section

Document Registry

Asynchronous
Web Services
Exchange

ITI TF-1: 25.2.2

Document Consumer

Asynchronous
Web Services
Exchange

ITI TF-1: 25.2.2

25.2.2 Asynchronous Web Services Exchange Option

5325

5330

Actors that support this option shall support the following:
1. Document Consumer Actor shall support Asynchronous Web Services Exchange for theMulti-Patient Stored Query [ITI-51] transaction
2. Document Registry Actor shall support Asynchronous Web Services Exchange for the MultiPatient Stored Query [ITI-51] transaction
Use of Synchronous or Asynchronous Web Services Exchange is dictated by the individual
install environment and policies. Refer to section ITI TF-2x: V.5 Synchronous andAsynchronous Web Services Exchange for an explanation of Asynchronous Web Services
Exchange.

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25.3 MPQ Process Flow
5335

This section describes the process and information flow when a Document Consumer will query
an Document Registry.

Document Consum er

Document Registry

Multi-PatientStored Query

5340

Figure 25.3-1: Basic Process Flow in Multi-Patient Queries Profile5345

25.4 Use Cases
25.4.1 Multi-Patient Query used in Public Health
Current Situation
5350

5355

5360

The emergency department at Hospital A is treating patient B for certain symptoms, which areindicative of a reportable condition (such as A1H1), according to already established guidelines
from an official public health agency. The symptoms mandate the use of a pre-determined value
set for the XDS metadata eventCodeList. This can be a combination of the eventCodeList andobservation such as “influenza” and “possible A1H1”. Hospital A sends any type of document
capturing this information such as a Discharge Summary, an ED Encounter Summary (EDES),
or in a larger sense any document intended for this purpose, using an XDS.b Provide andRegister transaction to the local XDS repository, as well as a report to the appropriate publichealth agency P, using mechanisms which are outside the scope of this supplement.
After reviewing the report, the public health agency P determines that a review of recent
patients’ encounters with similar symptoms is necessary. Unfortunately, the XDS Document
Registry only accepts patient specific queries, as currently defined in the Stored Query
transaction. The public health agency P needs to obtain a list of patients with the appropriate
symptoms from the healthcare providers.
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Hospital A queries the local Document Registry for other Document Entries containing the same
event code. Since it is not possible to query for multiple patients in one operation, a query is
initiated for each patient known to the Document Registry. This is very time consuming and may
not be very accurate.
Desirable Situation

5370

5375

5380

The emergency department at Hospital A is treating patient B for certain symptoms, which areindicative of a reportable condition (such as A1H1), according to already established guidelines
from an official public health agency. The symptoms mandate the use of a pre-determined value
set for the XDS metadata eventCodeList. This can be a combination of the eventCodeList andobservation such as “influenza” and “possible A1H1”. Hospital A sends any type of document
capturing this information such as a Discharge Summary, an ED Encounter Summary (EDES),
or in a larger sense any document intended for this purpose, using an XDS.b Provide andRegister transaction to the local XDS repository, as well as a report to the appropriate publichealth agency P, using mechanisms which are outside the scope of this supplement.
After reviewing the report, the public health agency P determines that a review of recent
patients’ encounters with similar symptoms is necessary. Using Multi-Patient Queries, the healthcare provider is able to provide in a timely and accurate fashion all the documents with thehaving the same pre-determined value in the eventCodeList XDS metadata to the public healthagency P. The public health agency is able to initiate an appropriate response and hence tocontain a possible outbreak of the A1H1.
25.4.1.1 Post-factual and semi-real time reporting

5385

5390

5395

There are needs to aggregate data so that a pattern can emerge, but the patients’ identities neednot to be known. For example, CDC (The Center for Disease Control and Prevention) or the
InVS in France would like to know how many case of A1H1 are present at a national level at one
point in time. In this case, there is no need to identify the patient, and unless other data isnecessary to establish a trend (such as age, for example); an aggregated query on the metadata
eventCodeList is sufficient using the ObjectRefs query. In this case irreversible
pseudonymization or annonymization can be used since the data is employed statistically togenerate a trend. This is the simplest case of implementing policies regarding security andprivacy.
There are other cases where statistical analysis in semi-real time is desired, such as an aggregatedquery at a district level to do profiling by region in times of an influenza epidemic. Again, this isa situation where the patient’s identity is not needed, but the number of cases and perhaps certain
parameters such as the date. In order to be able to perform the aggregated queries, there has tobe a minimum data set as per HIPAA recommendations.
25.4.1.2 Detailed queries

5400

If more scrutiny is needed, such as in patient safety (reporting to FDA a patient safety issue
concerning medications, medical equipment malfunction, or surgical procedures), or population
health monitoring such as the real-time control of an outbreak), detailed queries can be used.
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If in the Stored Query the LeafClass are specified the metadata of the document or of the folder(including the document ID and Repository ID) is returned. According to policies, these
metadata can be pseudonymized or not.
5405

For the multi-patient queries for detailed use, depending on the need, the policies regarding
patient’s privacy are different.
25.4.2 Technical Use Cases

5410

The output of a Multi-Patient Query can be in one of two forms: a list of opaque identifiers, eachidentifying a matching document (assuming that the query targets Document Entries and not
Folders or Submission Sets); or full metadata where all details known in metadata are returned.
25.4.2.1 Opaque Identifiers

5415

Opaque identifiers, known in XDS as ObjectRefs, are useful to: discover the number of matches
in the registry and then possibly to later retrieve the full metadata for the matching registry
content. Applications that need only statistics (counts) can count the returned identifiers. Notethat these identifiers represent documents (for example) that match the query and not patients. A
single patient could have multiple matching documents.
25.4.2.2 Full Metadata

5420

A Multi-Patient Query can return full metadata, known as LeafClass in XDS. This metadata
includes Patient Ids and patient demographics from potentially multiple patients so it is difficult
to protect yet must be protected. Because of this sensitivity this type of return result would likely
be only allowed by very highly trusted systems and thus this query is likely not to be available aswidely as others.

25.5 Security Considerations
5425

5430

5435

This profile applies the same ATNA grouping to protect against the typical XDS identified risks.
This profile may be grouped with XUA to further provide authentication of the user of the result.
The new security and privacy considerations arise because this profile allows for a single queryto result in multiple patients XDS metadata to be returned in one transaction. Although the XDS
metadata is not high grade health data it is still identifiable health information and thus needs tobe protected. The combination of multiple patient’s protected information in the same result
results in a more difficult task to assure that the intended recipient has all the authorizations
necessary for the intended use. In classical XDS queries the query request/response isconstrained to a single patient and therefore the access control decision can be done across thewhole transaction.
This profile allows for two different types of return result. The ObjectRef result can be used tolimit the exposure as this result will return only opaque identifiers of the matching documents. It
is expected that this result would be more widely allowed. The Document Consumer can stillobtain the full metadata but must use the classic XDS queries on an object-by-object basis thus
allowing for transactions that are constrained to a single patient. This additional set of______________________________________________________________________________
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5440

transactions to retrieve the metadata may be unnecessary when the system doing the query is
authorized to use the LeafClass response. For example when the querying system is known as asystem that will protect the information to the same degree. Where it is known that this querying
system will apply the appropriate access control prior to ultimate use or disclosure.

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26 reserved5445______________________________________________________________________________
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Appendix A: Actor Descriptions
5450

Actors are information systems or components of information systems that produce, manage, or
act on information associated with operational activities in the enterprise. The following aredefinitions of actors used in the IHE IT Infrastructure Integration Profiles:
Audit Repository– This actor provides a repository for audit events. IHE does not specify
what analysis and reporting features should be implemented for an audit repository.
Client Authentication Agent – Provides local management of user authentication.

5455

Context Manager – This actor serves as a broker for the communication between two or more
context participant actors (either Patient Context Participant or User Context Participant). It
supports the passing of the user and patient subjects.
Display – A system that can request specific information or documents from an Information
Source and display them.

5460

Document Source - The Document Source Actor is the producer and publisher of documents. It
is responsible for sending documents to a Document Repository Actor. It also supplies metadata
to the Document Repository Actor for subsequent registration of the documents with theDocument Registry Actor.
Document Consumer - The Document Consumer Actor queries for document metadata meetingcertain criteria, and may retrieve selected documents.

5465

5470

5475

Document Recipient: This actor receives a set of documents sent by another actor. Typicallythis document set will be made available to the intended recipient who will choose to either view
it or integrate it into a Health Record.
Document Registry - The Document Registry Actor maintains metadata about each registereddocument in a document entry. This includes a link to the Document in the Repository where it
is stored. The Document Registry responds to queries from Document Consumer actors about
documents meeting specific criteria. It also enforces some healthcare specific technical policies
at the time of document registration.
Document Repository - The Document Repository is responsible for both the persistent storageof these documents as well as for their registration with the appropriate Document Registry. It
assigns a URI to documents for subsequent retrieval by a Document Consumer.
DNS Server – This actor has authoritative location information.
Form Filler: the actor responsible for retrieving a form from a Form Manager, and forsubmitting form instance data to a Form Receiver. The Form Filler may optionally be
responsible for retrieving clarifications information from a Form Manager.

5480

Form Manager: the actor that supplies a form based upon a request that supplies a form
identification. The Form Manager also supplies clarification information.
Form Receiver: the actor that receives form instance data.
Form Archiver: the actor responsible for receiving form instance data for archival purposes.
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Initiating Gateway - supports all outgoing inter-community communications.
5485

Information Source – A system that responds to requests for specific information or documents
and returns ready for presentation information to be displays on the requesting actor.
Kerberos Authentication Server – Provides central authentication of enterprise users.
Kerberized Server – Receives user authentication information for further use by the service that
contains this actor

5490

5495

Patient Context Participant – This actor participates in a shared context environment by bothsetting the patient context and responding to context changes as communicated by the Context
Manager Actor. This actor shall respond to all patient context changes. This actor shall set thepatient context, if the application containing this actor has patient selection capability.
Patient Demographics Consumer – A system that uses demographic information provided by
the Patient Demographics Supplier about a patient.
Patient Demographics Supplier – A system responsible for adding, updating and maintaining
demographics about a patient, and additional information such as related persons (primary
caregiver, guarantor, next of kin, etc.). It supplies new and updated information to the Patient
Demographics Consumer.

5500

Patient Encounter Source – A system responsible for adding, updating and maintaining
encounter information about a patient. It supplies new and updated information to the Patient
Encounter Consumer.
Patient Encounter Consumer – A system that uses patient encounter information provided by
the Patient Encounter Source about a patient.

5505

5510

5515

Patient Identifier Cross-reference Consumer – This actor allows a system in a Patient
Identifier Domain to determine the identification of a patient in a different Patient Identifier
Domain by using the services of a Patient Identifier Cross-Reference Manager Actor.
Patient Identifier Cross-reference Manager – Serves a well-defined set of Patient Identifier
Domains. Based on information provided in each Patient Identifier Domain by a Patient
Identification Source Actor, it manages the cross-referencing of patient identifiers across Patient
Identifier Domains.
Patient Identity Source – - The Patient Identity Source Actor is a provider of unique identifier
for each patient and maintains a collection of identity traits. Each Patient Identifier Domain
requires this Actor to assign patient identities and to notify other Actors (e.g., a Patient Identifier
Cross-reference Manager or a Document Registry Actor) of all events related to patient
identification (creation, update, merge, etc.).
Personnel White Pages Consumer – This actor has a use for information that can be found in
the Personnel White Pages Directory.

5520

Personnel White Pages Directory – This actor has authoritative Personnel White Pages
information on the human workforce members of the enterprise.

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Portable Media Creator: This actor assembles the content of the media and writes it to thephysical medium. A priori this document set is extracted from an Electronic Healthcare Record(EHR) or a Personal Health Record (PHR) system.
5525

Portable Media Importer: This actor reads and displays the information contained on the
media, allows the user to select information, and store any or all of the elements. Typically thisdocument will be integrated into an Electronic Healthcare Record (EHR) or Personal Health
Record (PHR) and can then process the instances.
Responding Gateway – supports all incoming inter-community communications.

5530

5535

Secure Application - This actor is a subset of Secure Node where the security capabilities (userauthentication, secure communications, security audit recording, and security policy
enforcement) are required to cover the product (e.g., Web Applications) identified in the IHE
Integration Statement and not necessarily the whole node.
Secure Node – The presence of this actor on a system means that all of the other actors and othernon-IHE software comply with the IHE rules for user authentication, secure communications,security audit recording and security policies.
Time Client – Establishes time synchronization with one or more Time Servers using the NTP
protocol and either the NTP or SNTP algorithms. Maintains the local computer system clock
synchronization with UTC based on synchronization with the Time Servers.

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Time Server – Provides NTP time services to Time Clients. It is either directly synchronized toa UTC master clock (e.g., satellite time signal) or is synchronized by being grouped with a Time
Client to other Time Server(s).
User Context Participant - Receives notification of user context changes and follows them forthe application that contains it.
X-Service Provider - System providing a service that needs an X-User Assertion.

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X-Service User - System making a services request of an X-Service Provider.

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Appendix B: Transaction Descriptions
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Transactions are interactions between actors that transfer the required information throughstandards-based messages. The following are brief descriptions of the transactions defined by
IHE.
1.

Maintain Time: NTP transactions used to maintain time synchronization.

2.

Get User Authentication: The Client Authentication Agent requests user
authentication from the Kerberos Authentication Server. When the user isauthenticated, the Kerberos Authentication Server returns a Ticket Granting Ticket(TGT) to optimize future activity.

3.

Get Service Ticket: Obtain a ticket using Kerberos protocol for use with a service.

4.

Kerberized Communication: The Kerberized Communication transaction is an aspectof the connection between a local client and a remote server.

5.

Join Context: Allows a Context Participant Actor to locate and establish
communication with the Context Manager Actor.

6.

Change Context: Includes all messages required to initiate and finalize a context
change transaction:• Initiation of a context change request from the instigating participant actor• Delivery of survey results to instigating actor and display of associated replies• Communication of context change decision to the Context Manager Actor

7.

Leave Context: Allows Context Participant Actor to notify the Context manager Actor
that it is breaking off communication.

8.

Patient Identity Feed: Allows a Patient Identity Source Actor to notify a Patient
Identifier Cross-Reference Manager Actor of all events related to patient identification(creation, update, merge, etc.).

9.

PIX Query: This transaction allows a Patient Identifier Cross-reference Consumer tofind out the identification of a patient in different Patient Identifier Domains by using
the services of a Patient Identifier Cross-reference Manager Actor.

10.

PIX Update Notification: Allows a Patient Identifier Cross-reference Consumer to be
notified by the Patient Identifier Cross-reference Manager Actor of changes to theidentification of all patients in Patient Identifier Domains the Consumer is interested in.

11.

Retrieve Specific Information for Display: A request issued by a display system forspecific information related to a patient returned in a ready for presentation information
format.

12.

Retrieve Document for Display: A display system requests an instance of a uniquely
identified persistent document under custodianship by an information source andreceives its content ready for presentation.

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13.

Follow Context: Accounts for all messages required to propagate a context change toa responding participant actor:• Survey of all other Context Participant Actors by the Context Manager Actor
and display by the instigating Participant Actor of any associated replies• Notification of context change result from the Context manager Actor to theContext Participant Actors• Retrieval of the context data by the Context Participant Actors

14.

Intentionally Left Blank

15.

Intentionally Left Blank

16.

Intentionally Left Blank

17.

Intentionally Left Blank

18.

Registry Stored Query: The Registry Stored Query transaction is issued by theDocument Consumer Actor on behalf of a care provider (EHR-CR) to a Document
Registry. The Document Registry Actor searches the registry to locate documents thatmeet the provider’s specified query criteria. It will return a list of document entries that
contain metadata found to meet the specified criteria including the locations andidentifier of each corresponding document in one or more Document Repositories.

19.

Node Authentication: This transaction is embedded within all network
communications activity. All DICOM, HL7, and HTML connections shall comply
with the IHE specification for bi-directional authentication and authorization ofcommunications of Protected Healthcare Information (PHI). IHE does not specify how
other protocols that transfer PHI shall perform bi-directional authentication andauthorization, but requires that other protocols perform such authentication andauthorization.

20.

Record Audit Event: The delivery of an audit event description from any secure node
to the Audit Repository.

21.

Patient Demographics Query: Look up and return patient demographic information ina single patient demographics source, based upon matches with full or partial
demographic information entered by the user.

22.

Patient Demographics and Visit Query: Look up and return patient demographic andvisit information in a single patient demographics source, based upon matches with fullor partial demographic/visit information entered by the user.

23.

Find Personnel White Pages: This transaction will find the LDAP Directory byquerying the DNS.

24.

Query Personnel White Pages: This transaction provides for read-only access to the
Personnel White Pages directory.

25.

reserved for Send Notification

26.

reserved for Receive Notifications

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27.

reserved for Send Acknowledgement28.

reserved for Receive Acknowledgement

29.

reserved for Cross Enterprise User Authentication

30.

Patient Identity Management – The Patient Demographics Supplier registers or
updates a patient and forwards the demographic information (i.e., all information
directly related to the patient, such as ID, address, next of kin, guarantor, etc.) to othersystems implementing the Patient Demographics Consumer Actor.

31.

Patient Encounter Management – The Patient Encounter Supplier registers or
updates an encounter (inpatient, outpatient, pre-admit, etc.) and forwards theinformation to other systems implementing the Patient Encounter Consumer Actor.
This information will include the patient’s location and care providers for a particular(usually current) encounter.

32.

Distribute Document Set on Media - A source actor (Portable Media Creator) writes a
set of documents on an interchange media. The media is physically transported toanother actor (Portable Media Importer) which then imports the document set, or sent
as a ZIP attachment via Email. The media can also be provided to a patient or areferring physician for web-based viewing.

33.

placeholder

34.

Retrieve Form This transaction retrieves the requested form from a Form Manager.

35.

Submit Form This transaction submits form instance data, in XML format, to a Form
Receiver.

36.

Archive Form This transaction supplies the form instance data, in XML format, to a
Form Archiver.

37.

Retrieve Clarifications This transaction retrieves a set of clarifications from a FormManager.

38.

Cross Gateway Query – send a query from one community to another in order to
identify where healthcare information satisfying specific restraints is located.

39.

Cross Gateway Retrieve – request the retrieval of a specific set of healthcare
information (a document or documents) from a remote location.

40.

Provide X-User Assertion - This transaction provides a trustable user assertion fromthe service user to the service provider

41.

Provide and Register Document Set-b - A Document Source actor initiates theProvide and Register Document Set-b transaction. For each document in the submitted
set, the Document Source actor provides both the documents as an opaque octet stream
and the corresponding metadata to the Document Repository. The Document
Repository is responsible to persistently store these documents, and to register them inthe Document Registry using the Register Document Set-b transaction by forwarding
the document metadata received from the Document Source actor.

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42.

Register Document Set-b - A Document Repository actor initiates the Register
Document Set-b transaction. This transaction allows a Document Repository Actor toregister one or more documents in a Document Registry, by supplying metadata about
each document to be registered. This document metadata will be used to create XDS
Submission Set, XDS Document, and potentially XDS Folder Entries in the registry.
The Document Registry actor ensures that document metadata is valid before allowing
documents to be registered. If one or more documents fail the metadata validation, theRegister Document Set-b transaction fails as a whole.

43.

Retrieve Document Set - A Document Consumer actor initiates the Retrieve
Document Set transaction. The Document Repository will return the set of documentsthat was specified by the Document Consumer.

44.

Patient Identity Feed HL7 V3 - Allows a Patient Identity Source Actor to notify aPatient Identifier Cross-Reference Manager Actor of all events related to patient
identification (creation, update, merge, etc.) using HL7 V3.

45.

PIX V3 Query – Using HL7 V3, this transaction allows a Patient Identifier Crossreference Consumer to find out the identification of a patient in different Patient
Identifier Domains by using the services of a Patient Identifier Cross-referenceManager Actor.

46.

PIX V3 Update Notification – Using HL7 V3, this allows a Patient Identifier Crossreference Consumer to be notified by the Patient Identifier Cross-reference Manager
Actor of changes to the identification of all patients in Patient Identifier Domains theConsumer is interested in.

47.

Patient Demographics Query HL7 V3 – Using HL7 V3, look up and return patient
demographic information in a single patient demographics source, based upon matcheswith full or partial demographic information entered by the user.

48.

placeholder

49.

placeholder

50.

Multi-Patient Stored Query - A Document Consumer actor issues a Multi-PatientStored Query to a Document Registry to locate documents that meet the user’s
specified query criteria. The Document Registry returns a list of document entries
pertaining to multiple patients found to meet the specified criteria, including thelocations and identifier of each corresponding document in one or more Document
Repository.

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Appendix C: IHE Integration Statements
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IHE Integration Statements are documents prepared and published by vendors to describe theconformance of their products with the IHE Technical Framework. They identify the specific
IHE capabilities a given product supports in terms of IHE actors and integration profiles(described in ITI TF-1:2).
Users familiar with these concepts can use Integration Statements to determine what level ofintegration a vendor asserts a product supports with complementary systems and what clinicaland operational benefits such integration might provide. Integration Statements are intended to
be used in conjunction with statements of conformance to specific standards (e.g., HL7, IETF,
DICOM, W3C, etc.).
IHE provides a process for vendors to test their implementations of IHE actors and integration
profiles. The IHE testing process, culminating in a multi-party interactive testing event called theConnect-a-thon, provides vendors with valuable feedback and provides a baseline indication of
the conformance of their implementations. The process is not intended to independently evaluate,
or ensure, product compliance. In publishing the results of the Connect-a-thon and facilitating
access to vendors’ IHE Integration Statements, IHE and its sponsoring organizations are in no
way attesting to the accuracy or validity of any vendor’s IHE Integration Statements or any otherclaims by vendors regarding their products.
IMPORTANT -- PLEASE NOTE: Vendors have sole responsibility for the accuracy andvalidity of their IHE Integration Statements. Vendors’ Integration Statements are madeavailable through IHE simply for consideration by parties seeking information about the
integration capabilities of particular products. IHE and its sponsoring organizations have notevaluated or approved any IHE Integration Statement or any related product, and IHE and its
sponsoring organizations shall have no liability or responsibility to any party for any claims or
damages, whether direct, indirect, incidental or consequential, including but not limited tobusiness interruption and loss of revenue, arising from any use of, or reliance upon, any IHE
Integration Statement.

C.1 Structure and Content of an IHE Integration Statement
An IHE Integration Statement for a product shall include:

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1.

The Vendor Name

2.

The Product Name (as used in the commercial context) to which the IHE Integration
Statement applies.

3.

The Product Version to which the IHE Integration Statement applies.

4.

A publication date and optionally a revision designation for the IHE Integration
Statement.

5.

The following statement: “This product implements all transactions required in the IHE
Technical Framework to support the IHE Integration Profiles, Actors and Options listed
below:”______________________________________________________________________________
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A list of IHE Integration Profiles supported by the product and, for each Integration
Profile, a list of IHE Actors supported. For each integration profile/actor combination,
one or more of the options defined in the IHE Technical Framework may also be stated.
Profiles, Actors and Options shall use the names defined by the IHE Technical
Framework Volume I. (Note: The vendor may also elect to indicate the version numberof the Technical Framework referenced for each Integration Profile.)

Note that implementation of the integration profile implies implementation of all required
transactions for an actor as well as selected options.
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The statement shall also include references and/or internet links to the following information:
1.

Specific internet address (or universal resource locator [URL]) where the vendor’sIntegration Statements are posted

2.

URL where the vendor’s standards conformance statements (e.g., HL7, DICOM, etc.)
relevant to the IHE transactions implemented by the product are posted.

3.

URL of the IHE Initiative’s web page for general IHE information http://www.ihe.net/.

An IHE Integration Statement is not intended to promote or advertise aspects of a product notdirectly related to its implementation of IHE capabilities.

C.2 Format of an IHE Integration Statement
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Each Integration Statement shall follow the format shown below. Vendors may add a cover page
and any necessary additional information in accordance with their product documentation
policies.
IHE Integration Statement
VendorDate

Product Name

Any Medical Systems Co.

12 Oct 2003
VersionIntegrateRecord

V2.3

This product implements all transactions required in the IHE Technical Framework to support the IHE Integration Profiles,
Actors and Options listed below:
Integration Profiles Implemented

Actors Implemented

Options
Implemented

Retrieve Information for Display

Information Source

noneEnterprise User Authentication

Kerberized Server

none

Patient Identity Cross-referencing

Patient Identifier Cross-reference Consumer

PIX Update
Notification

Internet address for vendor’s IHE information:www.anymedicalsystemsco.com/ihe

Links to Standards Conformance Statements for the Implementation
HL7

www.anymedicalsystemsco.com/hl7
Links to general information on IHE

North America: www.ihe.net

In Europe: www.ihe-europe.org

In Japan: www.jira-net.or.jp/ihe-j______________________________________________________________________________
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Appendix D: User Authentication Techniques - Passwords,
Biometrics, and Tokens
Authentication techniques are based on one or more of three factors: Something you know,
something you are, or something you have. There are many different authentication techniques in
use today. The technologies supporting these techniques are not well standardized. There are also
excellent security reasons to avoid specifying any single set of technologies for authentication
use.

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The Kerberos protocol was originally defined to work with any user authentication technique.
Kerberos has been shown to support a wide variety of authentication technologies. These include
various forms of tokens and biometric technologies. Specific implementations of thesetechnologies often include proprietary components. There is often a pair of proprietarycomponents added – one at the user workstation and a matching component at the authentication
server. Once the user authentication is complete, the subsequent Kerberos transactions are the
same.

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These extensions are not yet standardized. The IHE specification for the use of Kerberos does
not prevent the use of these extensions at a specific site, nor does it ensure that the extensions
will work.

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The Kerberos system specified for the Enterprise User Authentication utilizes a challenge
response system together with a username and password system to authenticate the user. The
minimal support of passwords provides a standardized baseline for the IHE “Enterprise User
Authentication”. Kerberos enables enforcement of a central password policy which facilitatesstronger passwords. Such password policies are beyond the scope of IHE. Kerberos does notprevent the use of weak passwords. The password strength policy must be chosen and enforcedby the site security administration.

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Appendix E: Cross Profile Considerations
E.1 Combined use of RID, EUA and PIX Integration Profiles

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When used alone, the Retrieve Information for Display Integration Profile assumes that thePatient Identifier Domain is the same for both the Display and the Information Source Actors.
Furthermore, any user authentication on the Information Source is not addressed explicitly. This
Appendix discusses combination of the Retrieve Information for Display Integration Profile withother IHE Integration Profiles to address these two problems.
When used in conjunction with the Patient Identifier Cross-referencing Integration Profile,
implementations of the Retrieve Information for Display Integration Profile shall take into
account that the Information Source Actor may need to map Patient IDs from different identifier
domains to the one used in its own domain. The combined use of these Integration Profiles isachieved by grouping the Information Source and the Patient Identifier Cross-reference
Consumer Actors. This is depicted in Figure E-1.
Similarly, the Information Source Actor may perform certain access control functions based on
the requesting user authentication performed by the actors implementing the Enterprise User
Authentication Integration Profile. The combined use of these Integration Profiles is achieved bygrouping the Display Actor with the Client Authentication Agent Actor and the Information
Source Actor with the Kerberized Server Actor. This is also shown in Figure E-1.

Patient Identifier
Cross-ReferenceManager

Display

Retrieve Specific Info for Display
Retrieve Document for Display

ClientAuthentication
Agent

Patient Identifier
Cross-reference
Consumer
Information
SourceKerberized
ServerKerberos
Authentication
Server
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Figure E-1: Combined use of actors implementing multiple Integration Profiles______________________________________________________________________________
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E.2 XDS Integration with RID
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The RID Retrieve Document for Display transaction [ITI-12] is compatible with the XDS.a
Retrieve Document transaction [ITI-17]. Thus, an RID Information Source implementing theRetrieve Document for Display transaction can be used to implement the XDS.a Retrieve
Document transaction. In this instance, the RID Information Source must be a Secure Node [seeATNA].
RID is not compatible with XDS.b Retrieve Document Set transaction.

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E. 3 XDS Integration with PIX
All Patient IDs managed in the XDS transactions (either in XAD-Pid Domain or in an EHR-CR
Domain) shall include the related Patient Domain ID (OID of the Assigning Authority)
associated with the patient ID. It is recommended that this unambiguous patient identification be
used with Patient IDs within the Documents also.

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Because XDS is Document content neutral, there is no verification by the XDS Repository that
the Patient IDs included inside the documents are consistent with the patient IDs managed by theRegistry in the document entry related to that document.

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Identity Source

Patient Identity Feed

Patient Identity Feed
Dm=XAD, Pid=Px

PIX Manager

PIX Manager

XDS Document
Registry

Dm=C, Pid=Pc
Dm=XAD, Pid=Px

Dm=XAD
Pid=PxXDS Document
SourcePIX IdConsu
mer

XDS Submission Set
Dm=XAD
Pid=Px

Dm=C
Pid=PcXDS
Doc

Dm=D2, Pid=Pd
Dm=XAD, Pid=Px

XDS Doc Entry
Dm=XAD
Pid=CPx
Provide &Register

XDS Document
Repository
XDS Doc

Patient
Identification
Domain C

Query

XDS Document
Consumer
Dm=XAD
Pid=PxPIX Id
Consu
mer
Dm=D2
Pid=PdPatient
Identification
Domain D2

Patient
Identification
Domain XAD

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Figure E.3-1: XDS Affinity Domain with patient ID cross-referencing with IHE PIXManagers

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Figure C.6-1 depicts an example of an XDS Affinity Domain with a Patient Identifier Domain(called XAD) and two EHR-CRs where the cross-referencing is performed by Patient Identifier
Cross Referencing Managers internal to both the Document Source and the Document Consumer
Domains (called C and D2 respectively).

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A Document Source may choose to perform the cross-referencing of its own patient IDs in thatof the XAD-Pid Domain by leveraging the IHE PIX Integration Profile (See Figure). The Patient
ID Feed Transaction from the XAD Patient ID Source may be used to provide input to thePatient Identifier Cross-Referencing Manager used by the Document Source. The PIX manager
may either be internal to the EHR-CRs or be shared across the XDS Affinity Domain.

E.4 XDS Integration with PWP
The XDS Document Source Actor in the XDS Integration Profile may choose to utilize the PWP
Query Personnel White Pages [ITI-24] transaction to obtain information needed to fill the______________________________________________________________________________
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authorPerson and legalAuthenticatorName fields for the Register Document Set – b [ITI-42] andProvide & Register Document Set – b [ITI-41] transactions.
The Personnel White Pages transaction defines, in ITI TF2a: 3.24.4.1.2.3.1, a “cn” attribute with“lang-x-ihe” that contains the information in the HL7 XCN (extended composite ID number andname for persons) format for personal information. These fields are optional in the PWP
Integration Profile. A care delivery organization may choose to populate these fields in their
Personnel White Pages Directory and utilize the ITI-24 transaction to support its XDS activities.
This is not a required dependency, but is a possible reason to group a Document Source Actor
with a Personnel White Pages Consumer Actor.
The PWP Integration Profile only provides the personnel information. Organizational
information must be obtained via other means, e.g., extending the LDAP directory withorganizational objects.

E.5 XDS Integration with PDQ

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The Patient Demographics Query (PDQ) Integration Profile may be used in conjunction with the
XDS Integration Profile to provide a lookup for XDS Affinity Domain Patient Identifiers to XDS
Document Consumer and Document Source Actor. In this case a Patient Demographics Supplier
Actor needs to be grouped with the XDS Patient Identifier Source Actor on one hand, and on theother hand a Patient Demographics Consumer Actor needs to be grouped with the Document
Source/Consumer where one may want to query based on local patient traits and obtain a picklist of candidate Patient Ids in the XAD Patient Identifier Domain. This offers a simpler
solution that the use of the PIX Integration Profile.

E.6 XDM Integration with XDS, Content Integration Profiles, PIX, andDSG
The XDM Profile does not constrain the document types or purposes. Content Integration
Profiles may impose such constraints.

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The XDM Profile does not address the issue of patient reconciliation. The PIX and PDQ
functionality might be available to a Portable Media Importer, but the XDM Profile does not
require it. If there is no PIX or PDQ available to the Portable Media Importer, some othermethod for performing the necessary coercion of patient identifiers must be provided. Thismight be manual for Portable Media Importers that are intended for very small sites.
The Cross-enterprise Document Media Interchange (XDM) Integration Profile may be used inconjunction with the DSG Integration Profile to provide for the digital signature of the
documents content and of the XDS metadata.

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E. 7 XDM/XDR Distinction
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Both XDR and XDM describe the exchange of a set of patients’ documents. They are relevant insituations where XDS is not yet implemented or available at one of the participatingorganizations or where point-to-point (versus sharing through a registry) interaction is desired.
XDM is applicable in situations where the information receiver is an individual who will
manually interpret or examine the data and associated documents. XDM allows for one exchange
which contains documents relating to multiple patients and can be used in situations where no
continuous networking capability is available on one or both of the participating healthcare
providers.
XDR is applicable in situation where the information exchanged is going to an automatedapplication or robust system capable of automated storage or process of documents relative to
one patient. XDR requires continuous networking capability between the healthcare providers
exchanging data.

E.8 XDR Integration with XDS, Content Integration Profiles, PIX, andDSG
E.8.1 XDR Integration with XDS
The XDR profile and the XDS profile are both similar and complementary.
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Both profiles are document content neutral, conveying documents without modification andmanaging the same set of metadata. They both enable a Document Source to transmit a set of
documents to another IHE Actor, using a HTTP based on-line mode or a SMTP based off-line
mode.
But they do differ in some important ways. XDS is a centralized profile with “servers” (Registry
and possibly Repository) and “clients” (Source and Consumer). XDR is more symmetrical(Source and Recipient).
If the Document Source and the Document Recipient belong to the same Affinity Domain, themetadata shall respect the rules defined for this Affinity Domain (patientId, assigning Authority,
encoding schemes…).

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In case the actors are not all part of the same Affinity Domain, the following options should beconsidered:• If the Document Source is sending the Document Set to a Document Repository while
sending it to the Document Recipient(s) at the same “time” (consequent network on-line
messages), then the rules defined in the Affinity Domain which includes the Document
Source and the Document Repository shall be used.
• In the other cases:______________________________________________________________________________
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Note: it is highly recommended to define such “mutual agreement”

•

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If the Document Source and the Document Recipient(s) have agreed on the rules to use(for example using a “regional patientId” accessible through a PIX compliant server),then these rules shall be used.
If not, the rules available on the Document Source side will be used, and so, theDocument Recipient has to transpose the patientId and the codes to follow its local rules.

The Cross-enterprise Document Reliable Interchange (XDR) Integration Profile may be used inconjunction with the XDS Integration Profile to provide both a cross-enterprise sharing
capability and a targeted sending of a set of documents to one or more specific receivers. This is
illustrated in the figure below, when the Document Source Actor supports both the XDS and theXDR Integration Profiles.

Figure E.6-1: Associated XDS, XDR, and XDM Profiles

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E.8.2 XDR Integration with XDS Content Integration Profiles

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The Cross-enterprise Document Reliable Interchange (XDR) Integration Profile is intended to be
used in conjunction with any number of XDS Content Integration Profiles to provide aninteroperable specification for the content of the documents interchanged. Any XDS Content
Integration Profile such a XDS-SD for scanned documents (See IT Infrastructure Technical
Framework) or XDS-MS for medical summaries (See Patient Care Coordination Technical
Framework) are examples of document content Integration Profiles that may be integrated alongwith XDR. One should note that although these Content Integration Profiles are called XDSScan or XDS-MS, the use of the XDS in their name does not imply that their use is restricted to
XDS. It is equally intended for XDR, for point-to-point interchange.
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E.8.3 XDR Integration with PIXThe Cross-enterprise Document Reliable Interchange (XDR) Integration Profile may be used inconjunction with the PIX Integration Profile to provide the cross-referencing or linkage of thepatient identifier used by the Document Source with that of the Document Receiver. This
Integrated use requires the grouping of the XDR Document Source and of the XDR Document
Receiver with a PIX Patient Identity Source, so that the PIX Manager is fed with the patient
identities in the Document Source and the Document Receiver identification domains. In
addition, the Document Recipient shall be grouped with a PIX Patient Identifier Consumer
Actor, so that when a patient Identifier is received in the XDS Document Metadata of the XDRProvide and Register Document Set transaction, it may invoke the services of the PIX Manager
Actor to cross-reference the received patient identifier to a patient identifier of the Document
Recipient Identification Domain.

E.9 XCA Integration with XDS and non-XDS communities

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This section is informative and suggests some potential configurations that may be used by acommunity. The following types of community are described:• An XDS Affinity Domain• A non-XDS Affinity Domain• A collection of XDS Affinity Domains• A collection of non-XDS Affinity Domains• An XDS Affinity Domain with a “transparent” Gateway
E.9.1 An XDS Affinity Domain
In the example below, the responding community is an XDS Affinity Domain which is served bya Responding Gateway.
Responding Community

Initiating Community

Registry Stored
Query ↓

Document
ConsumerDocument
Registry

Document
Repository↑ Registry
Stored Query

Retrieve
Document Set ↓ Registry
Stored Query

Document
Registry

Cross Gateway
Query Initiating
Gateway

Responding Gateway
Cross Gateway
Retrieve ↓ Retrieve
Document Set↓ Retrieve
Document Set

Document
Repository

Figure E.9.1-1: XDS Affinity Domain______________________________________________________________________________
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E.9.2 A Non-XDS Affinity Domain

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In the example below, the responding community is served by a Responding Gateway.
However, within this community, there is no XDS Document Registry or Repositories. A
proprietary mechanism is used by the Responding Gateway to gather data for the response to the
Cross Gateway Query and Cross Gateway Retrieve transactions.

Responding Community

Initiating Community

Registry Stored
Query ↓

Document
Consumer

Retrieve
Document Set ↓ Registry
Stored Query

Document
Registry

Cross Gateway
Query Initiating
Gateway

Responding Gateway
Cross Gateway
Retrieve ↓ Retrieve
Document Set

Document
Repository

Figure E.9.2-1: Non-XDS Affinity Domain

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E.9.3 A Collection of XDS Affinity Domains (informative)
In the example below, one Responding Gateway is serving two communities. Each one of thesecommunities is an XDS Affinity Domain served by its own Responding Gateway; these two
Responding Gateways are hidden from the initiating community.

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This example is informative only. This profile does not specifically support this configurationand does not address all the considerations of such a configuration.

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Responding Community↑ Reg Stored

Query

Initiating Community

Document
Registry

Responding
Gateway

Document
Consumer↓ Retrieve
Doc SetDocument

Repository

Cross Gateway
Query Initiating
Gateway

Document
Registry

Cross Gateway
Retrieve Responding
Gateway

Responding Community
Document
Repository↑ Reg Stored

Query

Document
Registry

Responding Gateway↓ Retrieve
Doc SetDocument

Repository

Figure E.9.3-1: Collection of XDS Affinity Domains

E.9.4 A Collection of Non-XDS Affinity Domains (informative)
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In the example below, one Responding Gateway is serving two communities. Each one of thesecommunities is a non-XDS Affinity Domain served by its own Responding Gateway; these two
Responding Gateways are hidden from the initiating Community.
This example is informative only. This profile does not specifically support this configurationand does not address all the considerations of such a configuration.

Responding Community

Initiating Community
Responding Gateway

Document
Consumer
Cross
Gateway Query
Document
Registry

Initiating
Gateway

Cross Gateway
Retrieve Responding
Gateway

Responding Community
Document
Repository

Responding Gateway

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Figure E.9.4-1: Collection of Non-XDS Affinity Domains______________________________________________________________________________
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E.9.5 An XDS Affinity Domain with a “Transparent” XCA Gateway (informative)

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In the example below, the initiating community is an XDS Affinity Domain where the Initiating
Gateway is grouped with the XDS Affinity Domain Document Registry. Thus the Document
Consumer interacts with one system to retrieve both local and non-local data. This is called“transparent Gateway” as the Document Consumers do not see the cross-domain communication
explicitly, but it is hidden by the Domain Registry and a Proxy Repository. Configuration would
be needed to instruct the Document Consumer to interact with the Initiating Gateway when anon-local repository identifier was found in the metadata. In this way the Document Consumer
interacts with the Initiating Gateway as a Proxy repository.
This diagram also shows a Responding Gateway grouped with a Document Registry.
This example is informative only. This profile does not specifically support this configurationand does not address all the considerations of such a configuration

Receiving Community

Initiating Community
Registry Stored
Query ↓

Document
Consumer
Cross Gateway
Query Retrieve
Document Set ↓Document
Registry

Initiating
Gateway

Document
Repository

Cross Gateway
Retrieve Responding
Gateway↓ Retrieve
Document Set

Document
Registry

Document
Repository

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Figure E.9.5-1: An XDS Affinity Domain with a “Transparent” XCA Gateway

E.10 XCA and Patient Identification Management
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This section describes two models for resolving the patient identity in a cross-community
exchange environment. As the XCA profile is not intended to address patient identification
management, it is therefore necessary to combine XCA with appropriate identification
management Integration Profiles. This section is informative and describes only two possible
ways to resolve patient identification relying on the existing two IHE Integration Profiles in thisdomain, Patient Identifier Cross-Referencing (PIX) and Patient Demographics Query (PDQ).
The description in this section is only at a high level and more details (not covered here) arenecessary for implementation of these models. Other models for patient identification exist andwill not be described in this section. Future work by the IHE IT Infrastructure Technicalcommittee may support more sophisticated approaches.
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E.10.1 Patient Identification using PIX
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The following diagram describes a mechanism for managing patient identities where there is
topmost PIX which cross references between communities A, B and C. This diagram assumes
that a Responding or Initiating Gateway for each community interacts in order to drive a patient
identity feed to the topmost PIX. The diagram does not include processing on the remotecommunities (B and C) to respond to the query request. The topmost PIX is not defined in thisexample, but can be assumed to be a PIX Manager, or equivalent, which is accessible to allcommunities.

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Cross-Community Id X-ref
Community A (Local)

Community B (Remote)Initiating GW

Doc Consumer
Patient Id Source

Responding GW

TopmostPIX Mgr

Patient Id X-Ref
Consumer

Patient Id X-Ref
ConsumerCommunity C (Remote)Responding GW
Patient Id X-Ref
Consumer

Patient Id Source from Communities A, B and C to X-ref
Patient Id Feed A1
Patient Id Feed – A1

Patient Id Feed-B5
Patient Id Feed-C9

Identifier Mapping in Queries Across Communities
Registry Stored Query (A1)
Patient Identification
Mapping

PIX Query-A1
A1=B5 or C9Cross-GW Query (C9)

Cross-GW Query (B5)
Registry Stored Query
Consolidated Response

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Figure E.10.1-1: Patient Identification using PIX

E.10.2 Patient Identification using PDQ

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The following diagram describes one approach to patient identification in a cross-community
exchange where there is no entity which can cross reference between local and remote
identifiers. Note that interactions among entities in remote communities (B & C) are not detailed
in this diagram.

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Community B (Remote)Community A (Local)
Doc Consumer

Initiating GW

Responding GW

Patient Demographics Consumer

Community C (Remote)Responding GW

Patient Demographics Source

Patient Demographics Source

Demographics in Community A mapped to Patient Id in B and C
Registry Stored Query (A1)PDQ Query
Traits=C9

Patient Identification
Mapping
PDQ Query
Traits=B5

Query to Communities B and C with their Patient ID
Cross-GW Query (C9)

Cross-GW Query (B5)
Registry Stored Query
Consolidated Response

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Figure E.10.2-1: Patient Identification using PDQ

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This diagram present a basic approach relying on the existing IHE Patient Demographics Query(PDQ) Integration Profile by the Initiating and Responding Gateways, where the Responding
Gateway respond to queries with patient demographics traits for potential patients in thecommunity it serves, thus allowing Initiating Gateways to obtain the patient Id to use in the
Cross Gateway Query. The result of this transaction would be a) zero, indicating the patient does
not have records at that community b) one, indicating the gateway was able to uniquely identify
the patient c) multiple, indicating the Responding Gateway was not able to uniquely identify thepatient. In the case of a) or b) the transaction is complete and does not require humanintervention. If multiple results are returned this requires human intervention to resolve.

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This approach requires a significant number of policy decisions to be in place, coordinated withprivacy consent in cross-community environment that are well beyond the scope of the combined
use of PDQ and XCA presented in Figure E.10.2-1. In addition, the integration of a large numberof communities with a large number of non overlapping patient populations is likely to require
addressing significant scaling issues in allowing Responding Gateways to process the requests
for identity resolution.
Future IHE work in this area may offer more sophisticated integration profiles that could be
combined with XCA.

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Appendix F: Request to Standards Development Organizations
This Appendix is blank.

Appendix G: Security Considerations
G.1 Cross Profile Considerations
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IHE compliant systems usually process private healthcare information. This is subject to national
privacy regulations, and possibly other state and contractual requirements. The IHE
Infrastructure profiles do not fully define the security mechanisms necessary to protect thisinformation. The Enterprise User Authentication profile provides one component of this solution.
IHE assumes that actors will be installed on nodes with the following characteristics:• Each node has a security policy and procedure that applies to its operation.
This is assumed to be part of the healthcare enterprise security policy.
• Any user (human, or application process) external to the node boundaries is submitted to anaccess control procedure in which the user/application will be authenticated.
• All required audit trail events are captured and recorded.
The profiles in this framework assume the following environment:• Physical Security Environment• The equipment is assumed to be located in a physically protected and actively monitoredarea. This is normally the case with modality equipment because of other patient safety,
privacy, and operational concerns. Similarly, the HIS systems and various archives arenormally protected. Equipment like PACS workstations is sometimes placed in
unprotected areas, but it is usually located where hospital staff monitors and limit access.
It assumes that the threat of equipment modification is protected against by means of thephysical security mechanisms.
• The network equipment that connects the computers is also assumed to be physicallyprotected against unauthorized connections and unauthorized modifications. In thetreatment areas of most hospitals the network equipment is in ceilings, cableways, lockedcabinets, and other protected areas. There is usually staff present to monitor that no
unauthorized activity is taking place.
• Local procedures and operations will be in place to ensure that the physical security
assumptions are valid for other areas of the hospital, such as administrative offices, that
may be at greater risk.
• Remote locations, especially home offices, are not physically protected. Other means will
be used to provide equivalent protection. This may include the use of technology such as
VPN connections or HTTPS encryption. Use of encryption or VPN is not a complete
replacement for physical security but may be part of an overall protection system.

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•
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The home computer that is used for both personal and professional purposes is difficult toprotect. It will be protected from inadvertent modification by malicious software or its
use will be prohibited.
Network Security Environment• In addition to the physical security of the network, there will be protection against
network access by unsupervised systems. This is typically provided by mechanisms suchas firewalls and VPNs.
•

The threat profile is assumed to be:• Accidental and inadvertent misuse• Individual abuse for personal gain, malice, revenge, or curiosity. The abusers are
assumed to have only limited access to the underlying systems and software. They are notexpert at the internal structure of the systems.
• Random untargeted abuse, such as from an Internet hacker.
The threat profile also assumes that the following threats are either not present or otherwise
protected.
• Individual abuse by a system administrator, system developer, or other expert.
• Military or hostile government action• Organized criminal attack

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IHE addresses only those security requirements related to IT systems within the scope of IHE
healthcare applications. It does not address security requirements for defending against network
attacks, virus infection, etc.

6105

IHE does not mandate the use of encryption because the performance impact of current
encryption algorithms is excessive. Most hospital networks provide adequate security throughphysical and procedural mechanisms. The additional performance penalty for encryption is notjustified for these networks. The profiles permit the use of encryption so that it can be used aspart of an overall security plan.

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Appendix H: Intentionally Left Blank
Appendix I: Intentionally Left Blank______________________________________________________________________________
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Appendix J: Content and Format of XDS Documents

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The XDS Integration Profile purposely leaves a number of policies up to the XDS Affinity
Domain to decide, including the structure and format of the content of XDS Documents to beshared, the mapping of content metadata into the XDS Document Registry, the coding of XDS
Document metadata, the events that trigger an XDS Submission Request, and the policies
concerning the use of XDS Folders to facilitate sharing.
It is important to recognize that until sufficient experience has been gained in cross-enterprise
document sharing, it is not possible to establish common or even best practices in the use of the
XDS Integration Profile. IHE has therefore chosen to abstain to make recommendations in these
topics at this time.

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IHE also recognizes that there will be a need for content-oriented integration profiles to be usedin cooperation with this Integration Profile. It is expected that in the future the various IHE
Domains (Patient Care Coordination, Cardiology, Laboratory, Radiology, IT Infrastructure, etc.)
will produce IHE Integration Profiles refining the use of XDS within the domain. These various
content-oriented integration profiles may rely on XDS, but would further constrain the forms of
documents to be shared, or the uses of XDS features such as Folders and Submission Sets, etcetera.
Content Neutrality

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6135

XDS is content neutral. It neither prescribes nor prohibits the format, content, structure or
representation of documents that can be retrieved from an XDS Document Repository. For the
XDS Integration Profile to have immediate value to an XDS Affinity Domain, it must be able toadapt to the documents that are present and available from its members. Thus, prohibitions oncontent would only serve to limit the utility and adoption of the XDS Integration Profile.
Similarly, XDS Affinity Domains must be able to adapt to emerging standards, which cannot beenumerated in any list of prescribed content formats.
IHE strongly recommends that XDS Affinity Domains adopt rules that require documents tocomply with widely accepted standards where possible (e.g., HL7 CDA, CEN ENV 13606,
ASTM CCR, and DICOM Composite Object).
Document Headers and Metadata

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Because XDS is content neutral, XDS cannot validate metadata contained within the body of an
XDS document against the metadata supplied to the XDS Document Registry. XDS Affinity
shall therefore select content where IHE has defined Integration Profiles, or until that point, the
XDS Affinity Domains shall carefully define how the attributes in the XDS Document Registry
are filled.
Metadata and the Patient Record

6145

Although metadata in the document header may be duplicated in the XDS Document Registry,
the XDS Document Registry metadata has a particular role in term of being part of the legal
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Document Repositories where documents reside. Furthermore, XDS does not provide fortransactions to “sign” or legally authenticate the content of an XDS Submission Set (See IHE
Document Digital Signature Content Profile- DSG), although it offers the ability to track its
author, if the XDS Affinity Domain so desires to enforce it. The contents of XDS Folders aretracked, through the Submission Sets that contributed to placing document references in folders.
However, the existence of document metadata in the registry and the potential medical acts
involved in creating an XDS Submission Set or XDS Folder may make the contents of the XDS
Document Registry part of the patient’s legal medical record. It will be up to individual XDS
Affinity Domains to decide how to address the issues involved with these clinical acts and toresolve them in accord with common sense, acceptable medical practices, and local regulations.

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Appendix K: XDS Concept Details
K.1 XDS Document Concept
An XDS Document is the smallest unit of information that may be provided to a Document
Repository Actor and be registered as an entry in the Document Registry Actor.

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6170

An XDS Document is a composition of clinical information that contains observations andservices for the purpose of exchange with the following characteristics: Persistence, Stewardship,
Potential for Authentication, and Wholeness. These characteristics are defined in the HL7
Clinical Document Architecture Release 1 specification.
An XDS Document may be human and/or application readable. In either cases, it shall comply
with a published standard defining its structure, content and encoding. IHE intends to define
content-oriented Integration Profiles relying on such content standards to be used in conjunction
with XDS.
Furthermore:
1. When submitted for sharing, an XDS Document shall be provided to the Document
Repository Actor as an octet stream with an associated MIME type.

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2. When retrieved through the Retrieve Document transaction, an XDS Document shall beunchanged from the octet stream that was submitted (full fidelity repository).
Note:

An XDS Document may be a MIME multipart document (e.g., an HL7 CDA as its first part followed byattachments as files). The first part of the multi-part contains the primary part of the document, other parts are
direct attachments to the primary part. The Document Repository handles this multi-part data set as an “opaqueentity”. The Document Repository does not need to analyze or process its multi-part structure nor the content ofany parts in the context of the XDS Integration Profile.

Note:

An XDS Document may be retrieved using alternate methods using document specific retrieval methods. Such
optional capabilities are not provided in the current specification of XDS, but are possibly candidates for addition
as future options this Integration Profile.

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6190

3. An XDS Document shall be associated with metadata defined by the Document Source.
This metadata information shall be placed by the XDS Registry Actor in an XDS
Document Entry, and is used for query purposes by XDS Consumer Actors.
4. The XDS Integration Profile manages XDS Documents as a single unit of information, it
does not provide mechanisms to access portions of an XDS Document. Only theDocument Sources or Document Consumers have access to the internal information of
the XDS Document.
5. An XDS Document is globally uniquely identified, so that no two XDS Documents withdifferent content shall bear the same Unique Identifier. This identifier is unique across all
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from different domains, or exchange of XDS Documents between Clinical Affinity
Domains, if so desired.

6200

6. The XDS Document Registry Actor shall maintain a single document entry for each XDS
Document stored in a Document Repository Actor. Duplicate copies of the same XDS
Document (with the same unique identifier) may be stored and registered. Registration of
an XDS Document with the same unique identifier but a different content is rejected.

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7. This Integration Profile specifies the metadata required for each XDS document
registered in the Document Registry. It is the responsibility of the Document Source toensure that the XDS Document metadata reflects the actual content of the associated
XDS Document. Neither the Document Repository nor the Document Registry checks
this consistency.
8. The Document Source maintains the following responsibilities over the XDS Documents
it has registered:a. It has rights to change the status of any of these Documents from “approved” to“deprecated” or to delete them outright.

6210

b. It has rights to submit an XDS Document with a “Parent Relationship” of
replacement (“RPLC”) for one of its previously submitted document 8.
XDS Affinity Domains should have policies and procedures to provide patient access tothese operations where necessary. For example, in certain regions, patients may request
the removal of documents from the EHR-LR. The Registry and Repositories
implementations should be ready to support these local operations although there are no
IHE transactions defined at this time.

6215

K.2 Concept of an XDS Affinity Domain
6220

An XDS Affinity Domain is made of a well-defined set of Document Repositories andDocument Consumers that have agreed to share the clinical documents. An XDS Affinity
Domain has a number of properties defined:
1. An XDS Affinity Domain does not deliver care. Only the EHR-CRs belonging to an
XDS Affinity Domain as Document Sources and Consumers do.
2. An XDS Affinity Domain is managed by a single Document Registry Actor.
Note: A distributed registry approach will be considered as a future and separate Integration Profile. For Document Source
and Document Consumer Actors, the perception of a single Document Registry Actor hides the complexity of a
distributed registry.

6225

8

For example, in DICOM, where the document identity does not change even though its internal patient
metadata may have been updated, the Document Source would submit an updated DICOM Document as areplacement for the existing one.

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3. It includes any number of Document Repository Actors (a distributed configuration is thedefault, however, a centralized configuration with a grouped Registry/Repository is also
supported).
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4. It contains an explicit list of Document Consumer and Document Repository actors thatparticipate in document sharing. The addition of a Document Repository or Document
Consumer Actor is an administrative task that requires involvement of authorities
maintaining the Registry and Repositories.
5. There is a chain of trust established between the users (healthcare staff) in each EHR-CR
and the XDS Affinity Domain.
6. Document Repositories and Document Consumers may belong to more than one XDS
Affinity Domain and share the same or different documents. This is an implementation
strategy and will not be further described.

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7. The XDS Affinity Domain supports a primary Patient Identification Domain that is usedby the Document Source and Consumers to communicate with the Document Registry.
When Document Sources and Consumers in the XDS Affinity Domain belong todifferent Patient Identifier Registration Domains, the Document Source and Consumers
must cross-reference their own Patient Identifier Registration Domains to that of theRegistry. They may use the IHE Patient Identifier Cross-referencing Integration Profile,the IHE Patient Demographics Query Integration Profile or other XDS Affinity Domain
specific mechanisms for cross-referencing (See ITI TF-2x: E.3 and E.5).
8. A Document Source may only contribute documents with Document Codes and HealthFacility Codes that draw from a Vocabulary Value Set that is approved by the XDS
Affinity Domain.

6250

K.3 Other Principles of XDS
The XDS Integration Profile has been designed with the following limitations and principles:

6255

1. A Document may contain references to other documents in its content which are notunder the management of the XDS Document Registry. Such references may beavailable to the EHR-CR that registered the document that includes the reference. It isbeyond the scope of XDS to provide access to such documents internal to the EHR-CR.
2. The XDS Repositories are not expected to perform any processing or translations on
document content. Processing and translation are the responsibility of a Source EHR-CR
or Consumer EHR-CR. The analysis, cross-document combination and presentation of
document content are outside the scope of the XDS Integration Profile and its actors.

6260

3. The custodianship for the clinical information contained in a registered document
remains with the Source Actor of the EHR-CR. The EHR-LR offers only a “sharedspace” under the responsibility of each contributing EHR-CR. Through XDS,
replacement or deletion of documents in the EHR-LR may only be initiated by thecorresponding EHR-CR Source.
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4. When an XDS Document that has already been registered in the XDS Registry of an
XDS Affinity Domain is resubmitted as if it was a new XDS Document with the same
Document Unique identifier, this “duplicate submission” is detected by the Repository
and/or Registry based on the fact that the XDS Document Unique Identifier already exists
in a Document Entry. The submission request to which that resubmitted Document
belongs shall be rejected in the case where the identifiers match but the actual content
differs (detected by use of a hash key computed by the Document Repository at the timeof submission).

K.4 Document Identification

6280

In order to reduce the number of unique identifiers associated with an XDS Document, theglobally unique Document Id assigned by the document source and the unique XDS Document
Id used by the Repository are the same. It is strongly recommended to limit the use of theDocument Entry UUID created per ebRS in order to reference the document entry forreferencing internally to the encoding of the IHE transactions operations, and to encourage theuse of the globally unique Document Id for all external operations (e.g., links maintained in databases internal to the Document source Actor, links within documents, etc.).

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The XDS Document Entry includes two separate attributes: an XDSDocument.uniqueId and
XDSDocument.repositoryUniqueId. The Document Unique ID is a location independent
identifier. As the result of XDS Document migration from one XDS Document Repository toanother one within an XDS Affinity Domain, the repositoryUniqueId would be changed, but not
the Document unique ID.

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K.5 Example of Document Relationship
id = "1.2.345.678910.123"

replaceappendid = "1.2.345.678910.456"
relationship = "APND"
parent id = "1.2.345.678910.123"

id = "1.2.345.678910.266"
relationship = "RPLC"
parent id = "1.2.345.678910.123"

replaceappendid = "1.2.345.678910.224"
relationship = "RPLC"
parent id = "1.2.345.678910.456"

id = "1.2.345.678910.557"
relationship = "APND"
parent id = "1.2.345.678910.456"

replace

id = "1.2.345.678910.448"
relationship = "RPLC"
parent id = "1.2.345.678910.266"
Adapted from HL7 CDA Release 2

Figure K.5-1: Example of Document Relationships______________________________________________________________________________
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These relationships are illustrated in the above figure. Typical scenarios are a simple replacement(e.g., XDSDocument.id "1.2.345.678910.266" replacing XDSDocument.id"1.2.345.678910.123") and a simple addendum (e.g., XDSDocument.id "1.2.345.678910.456"
appends XDSDocument.id "1.2.345.678910.123"). More complex scenarios that might be
anticipated include:6295

1. Replacement of an addendum (e.g., XDSDocument.id "1.2.345.678910.224" replaces
XDSDocument.id "1.2.345.678910.456", which itself is an addendum to
XDSDocument.id "1.2.345.678910.123") - expected behavior would be to render the
replacement as the addendum (e.g., render XDSDocument.id "1.2.345.678910.224" asthe addendum to XDSDocument.id "1.2.345.678910.123");6300

2. Addendum to a replaced document (e.g., XDSDocument.id "1.2.345.678910.456"
appends XDSDocument.id "1.2.345.678910.123", which has been replaced by
XDSDocument.id "1.2.345.678910.266") - expected behavior would be to render theaddendum along with the replacement (e.g., render XDSDocument.id"1.2.345.678910.456" as an addendum to XDSDocument.id "1.2.345.678910.266").

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Appendix L: XDS Affinity Domain Definition Checklist

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The concept of an XDS Affinity Domain is defined in ITI TF-1:10 and ITI TF-1: Appendix K.
ITI TF-1: Appendix L originally provided an informative checklist for the key policies that need
to be addressed in order to deploy an EHR-LR document sharing environment for an XDS
Affinity Domain. However, it was recognized that this checklist was incomplete as it did not deal
with many necessary XDS Affinity Domain deployment issues. In order to address theseshortcomings, a new “Template for XDS Affinity Domain Deployment Planning” White Paper
has been created:
http://www.ihe.net/Technical_Framework/index.cfm#IT

6315

It takes the form of a template rather than a checklist because it acts more as an outline for all theissues that should be considered, rather than a checklist to be used to verify the correctness of aparticular implementation. This new template can be used when defining policies for either anindividual XDS Affinity Domain, or multiple XDS Affinity Domains within a particular nation
or region.

6320

Here is a summary of the topics defined in the new “Template for XDS Affinity Domain
Deployment Planning”:• Organizational Rules• Structure, Roles, Transparency, Legal Considerations and Enforcement• Operational Rules• Service Level Agreements, Daily Governance, Configuration Management, Data
Retention, Archive, and Backup, and Disaster Recovery• Membership Rules• Acceptance, Types of Membership, Membership Policies• Connectivity to the XDS Affinity Domain from External Systems• System Architecture• Global Architecture, Affinity Domain Actors, Transaction Support• Terminology and Content• Refinement of Metadata and Content Attribute Use• Patient Privacy and Consent• Access and Use, Patient consent, and Override Guidelines• Technical Security• Authorization, Role Management, User/Role Authentication, Node Authentication,
Certificates Management, Information Access Security, Information Integrity, Updates, andMaintenance Policies, Secure Audit Trails, Consistent Time, Audit Checks, and Risk analysis

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Appendix M: Cross-Enterprise Document Sharing and IHE Roadmap

6345

The IHE Cross-Enterprise Document Sharing Integration Profile is part of a family of IHE
Integration Profiles grouped in a number of domain-specific Technical Frameworks Patient Care
Coordination, Cardiology, Laboratory, Radiology, IT Infrastructure, etc.). XDS is a central
foundation for Cross-Enterprise interoperability that may be combined with a number of theexisting IHE Integration Profiles (See ITI TF-1: Appendix E). However a number of new IHE
Integration Profiles need to be developed, pending the availability of the relevant base standards.

M.1 Document Content Integration Profiles for XDS
6350

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It is expected that the various IHE Domains (Cardiology, Laboratory, Radiology, IT
Infrastructure, etc.) will produce new IHE Integration Profiles addressing the content of the
documents that need to be shared. These various “content-oriented” Integration Profiles will relyon the XDS Integration Profile for managing the registration, discovery and access processes in acommon manner.
Such an effort is underway with the IHE Patient Care Coordination Domain for medicalsummaries used in referrals and discharge summaries and other document types. See
www.ihe.net.

M.2 Cross-Enterprise Dynamic Information Sharing
6360

The management of dynamic information (non-document-oriented) such as allergy lists,
medication lists, problem lists, etc. is not addressed by XDS. However, a means to access thisinformation in a structured form and to manage updates to such dynamic clinical information is acandidate for a specific Integration Profile.

M.3 Collaborative Workflow Process Management
6365

There is a wide array of shared care delivery collaborative processes such as the placing andtracking of orders (e.g., drug prescriptions, radiology orders, etc.) for which XDS provides only apartial solution (the creation of the patient record with the resulting persistent artifacts). XDS
offers a critical infrastructure for ePrescribing and eReferral in that it can ensure that the various
providers share access to orders, prescriptions, dispensations, and results. The means tointeroperate on the command/control part of these collaborative workflow processes is acandidate for specific Integration Profiles in the future.

6370

M.4 Security and Privacy Management

6375

The operation of any XDS Affinity Domain will require that a proper security model be put inplace. It is expected that a range of security models should be possible. Although the XDS
Integration Profile is not intended to include nor require any specific security model, it isrequired that XDS implementers group XDS Actors with actors from the IHE Audit Trail andNode Authentication and will need an Access Control capability that operates in such a cross______________________________________________________________________________
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enterprise environment. Specific IHE Integration Profiles complementary to XDS are available(e.g., Cross-Enterprise User Authentication, Document Digital Signature, etc.).

M.5 Federation of XDS Affinity Domains
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XDS is an effective means to establish XDS Affinity Domains that include care deliveryorganizations at any level, local, regional or national. However, the establishment of
independent but consistently XDS Affinity Domains will call for their federation, as patients
expect their records to follow them as they move from region to region, or country to country.
IHE foresees a need for transferring information from one XDS Affinity Domain to another, or
to allow access from one XDS Affinity Domain to documents managed in other XDS Affinity
Domains. XDS has been designed with this extension in mind. The Cross-Community Access(XCA) Integration Profile that complements XDS provides this function.

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Appendix N: Intentionally Left Blank
6390

Appendix O: Intentionally Left Blank
Appendix P: Privacy Access Policies (Informative)
6395

6400

6405

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6415

This Appendix provides information about when consent could be automated and consequently
when BPPC could be used. Privacy consent can be summarized as: "I agree on my personal data
being disclosed to someone under specific conditions".
Conditions are based on various factor(s) for example:• type of person the data is disclosed to;• type of data disclosed;• type of access (normal access, emergency access...);• security level in which the disclosure takes place (weak authentication vs. strong
authentication);• type of purpose for which the data is disclosed;• timeframe (period of validity of the consent, window of disclosure...);
BPPC could be used when conditions can be described with a limited number of factors andwhen the factors can be defined and be easily interpreted by a Document Consumer
implementing the Basic Patient Privacy Enforcement Option.
The XDS Affinity Domain Privacy Consent Policies could result in various actions, for example:• limitation of the display of the existence of specific documents to the users of a
Document Consumer• limitation of the access to specific documents by the users of a Document Consumer• display of a warning note (either concerning this access or to inform that further
disclosure is not allowed, limited to some defined population, needed further consent...)• collection of new consent (oral consent, patient authentication, electronically signed
consent, paper consent...)______________________________________________________________________________
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P.1 Consents in a sensitivity labeled and role based access control
environment
6420

One possible implementation may have a collection of policies and sensitivity markers thatwould form an access control matrix. An example simple access control matrix is shown in thetable below.

Administrative Staff

Mediated by
Direct Care Provider

Dietary Staff

X

X

General Care Provider

X

X

X

Direct Care Provider

X

X

X

X

X

Emergency Care Provider

X

X

X

X

X

Researcher

X

Patient or Legal Representative

6425

Research Information

Sensitive Clinical
Information

X

General Clinical
Information

X

Dietary Restrictions

Functional Role

Administrative
Information

Sensitivity

Billing Information

Table P-1: Sample Access Control Policies

X

X

X

X

X

Each instance of the matrix results in a single Patient Privacy Policy. This vocabulary must thenbe configured in the XDS Affinity Domain. Thus configuring each application in the XDS
Affinity Domain to recognize for each Patient Privacy Policy identified, and which sensitivity(confidentialityCode); what types of accesses are allowed. Using the example above, the Patient
Privacy Policy might look like.
Table P-2: Patient Privacy Policies When Expressed by Document Sensitivity
Privacy Consent Policy

Description

Billing Information

May be accessed by administrative staff and the patient or their legal representative.

Administrative Information

May be accessed by administrative or dietary staff or general, direct or emergency careproviders, the patient or their legal representative.

Dietary Restrictions

May be accessed by dietary staff, general, direct or emergency care providers, the patient or
their legal representative.

General ClinicalMay be accessed by general, direct or emergency care providers, the patient or their legal______________________________________________________________________________
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Privacy Consent Policy

Description

Information

representative.

Sensitive Information

May be accessed by direct or emergency care providers, the patient or their legal representative.

Research Information

May be accessed by researchers.

Mediated by Direct Care
ProviderMay be accessed by direct or emergency care providers.

6430
Other divisions of the access control matrix are possible, so long as a Patient Privacy Policy
covers each layout of the matrix.

6435

The following list of references is provided as good references to understand the terms andconcepts presented here. These references are not required by this profile.
• ISO/TS 21298 "Health informatics – Functional and structural roles".
• ISO/TS 22600 "Health Informatics – Privilege Management and Access Controls".
• CEN prEN 13606-4 "Health informatics — Electronic health record communication — Part
4: Security requirements and distribution rules"

P.3 Possible checklist for implementations
6440

6445

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6455

General (before anything else)• Granularity of confidentiality implementation:• Granularity of document: all documents, document type, each document.
• Granularity of user: all users, user type, each type.
• Depth of confidentiality implementation:• Is the existence (metadata) about a document that can't be read by the user shown in a listof available documents for this patient?
• Is the user informed there are / might be not shown documents and how much?
• Is there the possibility to manage different depth of confidentiality depending on users or
document type?
• How to identify users, documents and policy?
• Does confidentiality management spread through further use (once the document isdownloaded by a user)
While implementing• Definition of default codes depending on site / hardware, document type, author, patient...
• Implementing options:• possibility of a list to choose from and how the list is constituted (out of all the possible
value, out of the value acknowledged by patient...)______________________________________________________________________________
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•

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possibility to change default codes prior to publication
possibility to use different format depending on the confidentiality policy (only nondownloadable image, pdf, word...)Later modification of policy (possible directly when requesting a document or have to bevalidated before)••

Prior to publication• What elements should be checked before publication:• existence of a policy• existence of the policy used
• existence of a consent for that policy• What additional information should be given (general consent policy, patient's specificconsent policy...?)
Prior to allowing access to a document• What elements should be checked before publication:• accessing user role
• existence of the policy used vs. accessing user
• Specific accesses and impact on confidentiality policy:• emergency (specific policy, short cut of confidentiality policy...)• break glass• What additional information should be given (general consent policy, patient' specificconsent policy...)P.4 Potential obligations
6480

Possible things that the BPPC policies might include are not fully known at this time. The
following is a list that has been discovered through use by researchers, health informationexchanges, and vendors. The following are some thoughts of things that might be orchestrated by
BPPC Policies.
General6485

1. Is the existence (metadata) about a document that can't be read by the user shown in a listof available documents for this patient
2. Map local role codes into some Affinity Domain defined role codes
Prior to implementation

6490

3. the specific Document Source is configured with one site specific “normal” code to
publish all of that Document Source documents against. For example an automatic bloodpressure device being used by one specific patient.
4. prompt user for the code to apply to the document (drop-down-list)______________________________________________________________________________
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5. document-type based codes
Prior to publication
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6. validate that the code to be published against has been acknowledged
7. support for a XDS Affinity Domain Patient Privacy Policy that forbids the publication
and/or use of documents in the XDS Affinity Domain (aka Opt-Out).
Prior to allowing access to a document
8. should documents with unrecognized codes be shown?

6500

9. prompt the user with some site defined text "do you really want to do this?"
10. allow the user to review the base consent policy
11. allow the user to review the patient's specific Patient Privacy Policy Acknowledgement
Documents
12. allow the user to override a consent block (break-glass)6505

13. require that a new consent be acquired from the patient before using the documents in the
XDS Affinity Domain
14. support for a XDS Affinity Domain Patient Privacy Policy that forbids the publication
and/or use of documents in the XDS Affinity Domain (aka Opt-Out).
15. validate that the code on the document has been acknowledged6510

16. confidentialityCode that would indicate that the Document can only be viewed, it cannot
be incorporated or copied.
17. use of this document shall result in an ATNA emergency access audit event

P.5 Dynamic Use Models
6515

It has also been suggested that documents should simply be published with the expected codes,
and that only on use of a document that ALL current Patient Privacy Policy Acknowledgements
are evaluated against with the code on the document. In this way revocation is more dynamic.

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6520

Actor: An entity within a use case diagram that can perform an action within a use case diagram.
Possible actions are creation or consumption of a message
ADT: Admit, Discharge & Transfer.

6525

6530

6535

6540

6545

Care Delivery Organization: A Care Delivery Organization refers to a broad variety ofhealthcare facilities: private practice, nursing home, ambulatory clinic, acute care in-patient
facility, hospitals etc.
CCOW: ANSI certified technology neutral specification for the Health Level Seven Context
Management Architecture (CMA). This architecture enables multiple applications to be
automatically coordinated and synchronized in clinically meaningful ways at the point of use.
The architecture specified in this document establishes the basis for bringing interoperability
among healthcare applications to point-of-use devices, such as a personal computer that serves asa clinical desktop.
Community: A community is defined as a coupling of facilities/enterprises that have agreed towork together using a common set of policies for the purpose of sharing clinical information via
an established mechanism. Facilities/enterprises may host any type of healthcare applicationsuch as EHR, PHR, etc. A community is identifiable by a globally unique id called thehomeCommunityId. Membership of a facility/enterprise in one community does not preclude it
from being a member in another community. Such communities may be XDS Affinity Domains
which define document sharing using the XDS profile or any other communities, no matter what
their internal sharing structure.
Confidentiality Code: A value from the value-set that indicates the sensitivity and/or
confidentiality of an object (e.g., Document). This may be from the HL7 defined vocabulary or
extension defined in the Security/Privacy Domain. The Confidentiality Code is used during
access control to indicate the type of object as viewed by the security and/or privacy policies.
Context Management Registry: An HTTP technology specific service defined by the HL7
Context Management “CCOW” Standard to locate an instance of a context manager servicing a
specific desktop.
Context Session: A collection of participant applications that are sharing context on one or more
subjects.
CDA: Clinical Document Architecture (specified by HL7).

6550

CT: Consistent Time Integration Profile.
XDS Affinity Domain: A group of healthcare enterprises that have agreed to work together
using a common set of policies and which share a common infrastructure of repositories and aregistry.

6555

Directory: A book containing the names and residences of the inhabitants of any place, or ofclasses of them; an address book; as, a business directory.
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EHR-CR: An EHR-CR or Care-delivery Record abstracts the patient information managed by
the IT system or set of systems of a Care Delivery Organization, which may support a broad
variety of healthcare facilities: private practice, nursing home, ambulatory clinic, acute care inpatient facility, etc.
6560

EHR-LR: The documents shared by the EHR-CR and tracked by the Registry form aLongitudinal Record for the patients that received care among the EHR-CRs of the XDS Affinity
Domain. This is known as the EHR-LR.
eMPI: Enterprise Master Patient Index.

6565

Encounter: An interaction between a patient and care provider(s) for the purpose of providing
healthcare-related service(s). Healthcare services include health assessment.
Examples: outpatient visit to multiple departments, home health support (including physicaltherapy), inpatient hospital stay, emergency room visit, field visit (e.g., traffic accident), officevisit, occupational therapy, telephone call.
EUA: Enterprise User Authentication Integration Profile.

6570

Expected Actions: Actions which should occur as the result of a trigger event.
Globally Unique Identifier (GUID): An identifier of an entity, such as persistent document,that has been generated by an algorithm guaranteeing its global uniqueness.
HIMSS: Healthcare Information and Management Systems Society.
HIS: Hospital Information System.

6575

homeCommunityId: A globally unique identifier for a community. It is used in XCA to obtain
the Web Services endpoint of services that provide access to data in that community.
IETF: Internet Engineering Task Force
IHE: Integrating the Healthcare Enterprise.

6580

6585

inetOrgPerson: The inetOrgPerson [RFC 2798] object class is a general purpose object classthat holds attributes about people. The attributes it holds were chosen to accommodate
information requirements found in typical Internet and Intranet directory service deployments.
The inetOrgPerson object class is designed to be used within directory services based on the
LDAP v3 [RFC 2251] and the X.500 family of protocols, and it should be useful in othercontexts as well.
Interaction Diagram: A diagram that depicts data flow and sequencing of events.
IT: Information Technology.
JPEG: Joint Photographic Experts Group.
KDC: Key Distribution Center (the Kerberos server that issues Ticket Granting Tickets andservice tickets. See RFC1510).

6590

LDAP: Lightweight Directory Access Protocol is designed to provide access to directories
supporting the X.500 models, while not incurring the resource requirements of the X.500
Directory Access Protocol (DAP). This protocol is specifically targeted at management______________________________________________________________________________
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6595

applications and browser applications that provide read/write interactive access to directories.
When used with a directory supporting the X.500 protocols, it is intended to be a complement to
the X.500 DAP.

6600

Local Authentication: In the ATNA profile the term “local authentication” means that the user
identification, authentication, and authorization method is chosen by the local systemadministration and does not necessarily comply with any IHE profile. It may be a local
username password system, a secure token system, or any other system that is considered
acceptable by the local security administration.
Movement: An event describing a change of the situation of the patient in the context of theencounter. This concept encompasses changes such as transfers of patient location, change ofpatient class, new attending doctor, new consulting doctor, new encounter starting, encounterclosing, etc. The concept of Movement is a superset of the concept of “Transfer”.

6605

MPI: Master Patient Index.
MRN: Medicare Record Number.
NEMA: National Electrical Manufacturers Association.

6610

NTP: Network Time Protocol. This is the standard Internet protocol for synchronizing computer
clocks. The web site http://www.ntp.org provides extensive background documentation at the
introductory and expert level on how to synchronize computers.
OID: Object Identifier. (See also 'Globally Unique Identifier’).
PACS: Picture Archive and Communication System.

6615

6620

Patient: (When used in the context of ATNA) RFC 3881 defines the means of identifying theperson who is a patient. The patient information in audit event records corresponds to theinformation available to identify a patient at the time the audit record was generated, and does
not reflect later updates (e.g., patient reconciliation).
PatientID: (When used in the context of ATNA) A free text that holds the system-internalpatient identifier being unique within that system domain. The patient identifier domain is thatassigned to the system that generated the audit event record. The patient information in audit
event records corresponds to the information available to identify a patient at the time the audit
record was generated, and does not reflect later updates (e.g., patient reconciliation).

6625

Patient Identifier Cross-reference Domain: Consists of a set of Patient Identifier Domains
known and managed by a Patient Identifier Cross-reference Manager Actor. The Patient
Identifier Cross-reference Manager Actor is responsible for providing lists of “alias” identifiers
from different Patient Identifier Domains.

6630

Patient Identifier Domain: A single system or a set of interconnected systems that all share acommon identification scheme for patients. Such a scheme includes: (1) a single identifierissuing authority, (2) an assignment process of an identifier to a patient, (3) a permanent recordof issued patient identifiers with associated traits, and (4) a maintenance process over time. The
goal of Patient Identification is to reduce errors.
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Patient Mapping Agent: The CCOW defined component that provides for the mapping ofpatient identifiers across disparate patient identity domains.

6635

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6645

Patient Privacy Policy Acknowledgement Document: A document that follows the BPPC
Content Profile and captures the act of the patient acknowledging a specific Patient Privacy
Policy Domain defined Patient Privacy Policy.
Patient Privacy Policy: A Patient Privacy Policy further explains appropriate use ofdata/documents in a way that provides choices to the patient. The BPPC Profile places norequirements on the content of these policies nor the method used to develop these policies (SeeITI TF-1: Appendix P for some guidance on developing these policies). A Patient Privacy Policy
will identify who has access to information, and what information is governed by the policy(e.g., under what conditions will a document be marked as containing that type of information).
The Patient Privacy Policy may be a consent policy, dissent policy, authorization policy, etc.
Patient Privacy Policy Identifier: A Patient Privacy Policy Domain assigned identifier (OID)
that uniquely identifies the Affinity Domain: Patient Privacy Policy. There is one unique
identifier (OID) for each Privacy Policy within the Patient Privacy Policy Domain.
Patient Privacy Policy Domain: The Domain for which the Patient Privacy Policies apply.
When using XDS this would likely be equivalent to the XDS Affinity Domain.
Patient Subject: The PSA defined subject that supports sharing the currently selected patient
identifier amongst disparate applications running on the desktop.

6650

PDF: Portable Document Format.

6655

Personnel White Pages: Information on human workforce members within the authority of the
PWP directory. This information has broad use among many clinical and non-clinicalapplications across the healthcare enterprise. The information can be used to enhance the clinicalworkflow (contact information), enhance the user interface (user friendly names and titles), andensure identity.
PIX: Patient Identifier Cross-referencing Integration Profile.
PMA: Patient Mapping Agent component as defined by CCOW.

6660

Principal: An end user, an application, a machine, or any other type of entity that may act as arequester in a transaction. A principal is typically represented in a transaction with a digital
identity and the principal may have multiple valid digital identities to use with different
transactions
Process Flow Diagram: A graphical illustration of the flow of processes and interactions among
the actors involved in a particular example.
PSA: Patient-Synchronized Applications Integration Profile.

6665

RID: Retrieve Information for Display Integration Profile.
RIS: Radiology Information System.
Role: The actions of an actor in a use case.
RSNA: Radiological Society of North America.
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Scope: A brief description of the transaction.
6670

Secure Domain: A network, hardware systems, secure nodes, and physical environment for
which a single set of security policies is defined and enforced for access to its addressable
objects.
Secure Node: A network-addressable system that conforms to a secure domain’s access policies
and management. A secure node often supports IHE actors.

6675

SNTP: Simple Network Time Protocol. This is a reduced accuracy version of NTP. The protocol
fields are the same, but the data values and algorithms used are greatly reduced accuracy so thatit can be implemented on limited capacity systems.
Submission Set: A set of XDS documents registered together to a Document Repository
concerning information related to one care event of a single patient, provided by an EHR system.

6680

SUID: The Study Instance UID from a DICOM SOP instance, or collection of SOP instances.
TGT: Ticket Granting Ticket. The initial credentials that verify that the user has beenauthenticated. It is used to avoid repeated user authentication events and as a token to request
access to services.

6685

Trigger Event: An event such as the reception of a message or completion of a process, whichcauses another action to occur.
UID: Unique Identifier (See also Globally Unique Identifier).
Universal ID: Unique identifier over time within the UID type. Each UID must belong to one of
specifically enumerated species. Universal ID must follow syntactic rules of its scheme.
Use Case: A graphical depiction of the actors and operation of a system.

6690

Username: A sequence of characters, different from a password, that is used as identificationand is required when logging on to a multi-user computer system, LAN, bulletin board system,or online service. Also called user ID, or uid.
User Assertion: A set of claims about an authenticated principal (user, application, system...)that is issued by an identity provider

6695

User Subject: The PSA defined subject that supports sharing the user identity of the currently
logged in to the applications on the desktop.
UTC: Universal Coordinated Time. This is the replacement for GMT. It defines a referencetime base that is internationally recognized and supported.
Wet Signature: Ink on paper signature.

6700

X-Assertion Provider: This is a SAML Identity Provider (IDP) or WS-Trust Security Token
Service (STS), and is not further specified by IHE.
XDS Affinity Domain Policy: XDS Affinity Domain Policy that clearly defines the appropriate
uses of the XDS Affinity Domain. Within this policy is a defined set of acceptable use Privacy
Consent Policies that are published and understood.
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XDS Document: An XDS Document is the smallest unit of information that may be provided toa Document Repository and registered in a Document Registry. An XDS Document may containsimple text, formatted text (e.g., HL7 CDA Release 1), images (e.g., DICOM) or structured andvocabulary coded clinical information (e.g., CDA Release 2, CCR), or may be made up of a
mixture of the above types of content.

6710

XDS Folder: An XDS Folder allows document sources to group the documents they submit withother related documents. What constitutes a Folder and the vocabulary associated with thespecific Folders used by an EHR-CR is decided by an agreement between the care deliveryorganization members of an XDS Affinity Domain.
XUA: Cross-Enterprise User Assertion Integration Profile______________________________________________________________________________
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