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Tesdngthe

Nadon'sHealthcareInlorlladon

Infrastructure:

NISTPerspecdve

Kevin Brady, Ram D. Srlram, Bettijoyce tide, and Kathleen Roberts

NationalInstituteof Standardsand Technology

The National Institute of Standards and

Technology is enabling the development

of an integrated healthcare information infrastructure by developing test tools and

techniques that will facilitate seamless

exchange of information across the healthcare enterprise.

A

ccording to the Centers for Medicare and Medicaid Services. the USspent nearly $2.6 trillion

on healthcare in 2010. an amount estimated to

nearly double by the end of this decade (www.

cms.Slov).This rate of spending was underscored by

Athenahealth CEOJonathan Bush: "The USspends an

amount equal to 300 percent of India's GNPon healthcare, and India's population isthree times ours" (Fortune,

16Jan. 2012, p. 22). In an attempt to rein in healthcare

costs. the Obama administration. like the preceding Bush

administration. has initiated a major effort to move from

paper-based medical record keeping to electronic health

records (EHRs).These efforts established the Officeofthe

National Coordinator for Health Information Technology

(ONC)and formulated financial incentives forthe nation's

physiciansto use EHRs,whichwUljointly leadto considerable automation in the healthcare Industry.

To take advantage of such automation. Information

generated In the healthcare enterprise must be digitally

encoded with the right semantics. archived for efficient

storage and retrieval. and transported reliably.securely,

50 COMPUTER PublishedbytheIEEEComputerSociety 0018-916V1V$31.0002012 IEEE

and efficiently. without any Information loss. Accordingly,the National Institute of Standards and Technology

has been working closely with ONC;Integrating the

Healthcare Enterprise (IHE;www.lhe.net).anlnitlatlve

by healthcare professionals and Industry to Improve the

way healthcare computer systems share Information;

and other organizations, such as IEEE,to accelerate the

adoption of information technology by US healthcare

enterprises.

NIST.specifically ItsInformation Technology laboratory, isInvolvedInseveral heaJthcare automation activities

focused on developingassociated test methods. protocols;

and specifications. for Interoperabillty. These projects,

which frequently Involve coordination with related or.

ganlzatlons such as IHE.have been devised according to

heaJthcare Information flows.

INFORMATION FLOW IN

HEALTHCARE SERVICES

The healthcare services Industry generates and processes large amounts of complex Information relating

to patient diagnosis. testing, monitoring, treatment. and

health management; billing for healthcare services; and

asset management of healthcare resources. Healthcare

delivery is a collaborative process. with many physicians,

specialists. nursing staff. and technicians from multiple

organizations participating In patient treatment. In addi.

tlon. many external organizations. includinggovernment

agencies, Insurance companies. employers. medical researchers. pharmacists. and even lawyers In malpractice

suits use the resulting healthcare Information.

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The h,ealthcare industry creates and uses different

classesof information. including the following five types:t.2

. detailed medical records of each patient for every

episode of illness or type of heakhcare delivered;

workflow for patient referrals to specialists.' physician

orders for diagnostic tests or procedures. and hospital

admission and discharge;

·detailed administrative records for managing healthcare resources-for example. scheduling patient

appointments. tracking hospital bed utilization, and

inventory management of pharmaceutical supplies:

. bil1ing for healthcare services. healthcare cost control

procedures. and coordination of benefits; and

· research reports. clinical observations. results of new

pharmaceutical clinical trials. and new guidelines,

One category of information flow occurs within the

healthcare services industry and Is characterized as foUows:

. An administrator obtains patient medical history.

employment and socialdata. and health insurance information and enters the data into the patient's chart.

· Anurse records the patient's vital signs. medications.

andchiefcomplaintsfor aparticularvisit.

. Aphysician conducts an examination and writes or

dictates an -encounter note- for subsequent transcription and signoff for inclusion in the chart. An

administrator submits billinginformation identifying

services rendered and the diagnosis codes for use in

insurance claims.

Larger healthcare institutions might have internal

advisory groups that recommend treatment guidelines(evidence-basedmedicine)to be foUowedby the

healthcare staff to improve healthcare quality.

Asecond category of information flow involves information exchanged between healthcare facilities:

· The physician might prescribe an order for a laboratory or diagnostic imaging test or procedure. referthe

patient to a specialist. or have the patient admitted to

a hospital.In some cases,the physician would include

the patient's relevant clinical history.

· The results of a laboratory test or the report and

images of a diagnostic imaging would subsequently

be sent to the physician.

Upon the patient's discharge from the hospital. the

discharge summary would be sent to the patlent's

physician.

In the third category of information flow. information

Istransmitted between a healthcare facility and external

agencies:

The office administrator submits claims to an insurance agency using the physician-supplied codes for

claims processing. and sometimes seeks benefits authorization forspecialized tteatment for the patient.

· Health insurance agencies might seek additional

justification for tteatment provided to the patient or for a recommended course of tests or treatment.

· Health insurance agencies might provide a list of

preferredmedications(formularies)and other cost

containment measures to healthcare facilities.

. Managedcare organizationsand other payer agencies

might also provide treatment guidelines.

· Lifeinsurance companies mightseeka patient's medical record to evaluate the risk of a policy applicant

or to identify fraud due to a known. but undisclosed.

preexisting medical condition.

The foundation for healthcare

information sharing is the electronic

health record (or electronic medical

record), as it contains all the relevant

patient healthcare data in sharable form.

Clinic nursing staff occasionally might need to report

incidents of certain diseases to public health agencies

and record pediatric immunizations with the appropriate state's vital statistics bureau.

. Medical researchers might seek medical records of

patients with certain profiles for investigations; the

clinic might provide the information (with patient

consent) after removing patient-identifiable data.

Malpractice lawsuits might require a healthcare facility to submit medical records of patients (with profiles

similar to the litigant's) to determine adherence to

standards of practice. .

Finally.accreditingorganizationsin this information

flow category might review patient records to review

operational and quality standards.

ELECTRONIC HEALTH RECORDS

TheEHRor electronic medicalrecord (EMR)Isthe f0undation for healthcare information sharing. as both contain

all the relevant patient healthcare data in sharable form.In

healthcare delivery.the EHRserves integrating functions

similar to a manufacturing biD of materials. Although the

terms EMRand EHRare used interchangeably. ONCmakes

a distinction between these two. as follows (see htttp:/l

www.healthit.gov). EMRs represent digital versions of the

paper charts in a doctor's office. An EMR contains the

medical and tteatment history of the patients in one practice. but the information in EMRs doesn't travel easily out

NOVEMBER1012 51

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Support

services

~

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ECG

monitor

IV

pump

VentIlator

IEEE11073 alnlcal recordkeeping

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hI7book.netllndex.php?title-CDA)are

exemplary In this regard.

HL7.briefly. Is the global authorIty on Interoperablllty standards

for health IT (www.hI7.or~). 5

Such measures would prevent the

loss of Information during data Interchange that couldotherwise occur due

to differences In terms. codes. and related semantics In various healthcare

vocabularies. Byusing ITthat adheres

to HL7.healthcare Institutions could

deal transparently with Information

obtained from external agencies as

well as with Information generated

by In-house healthcare Information

systems. Their applications could perform data mining of patient medical

records forhealthcare qualitymetrics.

Identify patients across populations

for timely medical Interventions. and

check for compliancewith preventiveservice protocols.

Avariety of messaging and Information exchange standards permits

an enterprise to Integrate the various health Information systems and

archive the data as an EHRor EMR

(www.nlst.govlhealthcare/index.cfm).

In addition to HL7.such standards include Digital Imaging and Communications In Medicine (DICOM),IEEE

11073Healthcare Devices and Personal Health Devices.

and others listed by the Healthcare Information and Management Systems SOclety's Integrating the Healthcare

Enterprise Initiative and ANSI'sHealthcare Information

TechnologyStandards Panel.

Figure 1 Illustrates the classes of clinical Information

and some of the standards that link these classes to a full

EHR.Specifically. HL7messaging standards allow disparate healthcare information systems to communicate

with each other. Version 2.x. although the most common

implementation. islikelyto be superseded by version 3.0,

which uses an object-oriented approach. Independent

healthcare institutions can submit orders and referrals

via HL7for healthcare services for their patients. DICOM

standards enable the interchange of Information between

imaging systems and facilitate remote access for physicians at their clinic.

With standards-based Integration of information systems and authenticated remote access to reports and

images. physicians can review radiologists' reports and

diagnostic images for use in patient counseling. One concern with the current standards, however, is that they

deal only with syntactic issues. Thus, due to the disparate

Figure 1. Standards that link to an electronic health record. (Source: US

Congress. OffIce ofTechnology Assessment. BrInging HeaithcG1eOnline:Th~

Rot. of infotmotIon Technologiu, OTA-rrc-624, USGovernment PrInting Office.

Washington. D.c..1995.)

of the practice. EHRsdo all those things. and more. EHRs

focus on the patient's total health. goingbeyond standard

clinical data collected In the provider's office and Include

a broader view on a patient's care. EHRsare designed to

reach out beyond the health organization that originally

collects and compilesthe Information.

Although large healthcare Institutions have significant

Investments In EHR-based computer systems. it Is estimated that only a small percentage of USsmall practices

use an EHRsystem In their dally practice (www.aafp.o~,4

In most healthcare settings-especially small cllnlcspaper-based records and fax-based communications are

stili the norm. Recent Incentive programs Issued by the

Centers for Medicareand MedicaidServices.however.are

accelerating EHRadoption by both small and large practices (www.cms.~v/ehrincentivepr~rams).

The adoption ofstandards for Information interchange

will help to Integrate disparate healthcare systems. However. rather than being geared simply to support human

readability ofmedical reports. healthcare data Integration

Implementations should Incorporate the formalism and

details necessary for proper computer Interpretability of

such Information. The formalism and details contained

within NIST'sHealth Level Seven International's (HL7's)

Clinical Document Architecture (CDA)standard (http://

52 COMPUTER

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nature of the medical terminology in various EHRs(it Is

common fordifferentEHRsto

use different terminology to

represent the same concept).

it isincreasingly important to

develop tools and techniques

forsemantic Interoperabllity.

C JavaAPIs:=:>

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I HL7communicationJ

HEALTH IT TESTING

AT NIST

NIST'sInformation Technology Laboratory (for

brevity. we use -NIST" to

denote this laboratory from

here on) Iscollaborating with

industry. healthcare informatics-related standards

organizations. consortia.

and government agencies to

build tools and prototypes to

advance the adoption of IT

within heaJthcare systems. NISTresearchers are carrying

on several activities in particular:

Figure 2. NISTHL7toolkit Infrastructure.

Collaborating with HL7 to help ensure that HL7

messaging and EHRsystems' conformance can be

defined and measured at an appropriate level.

Providing technical leadership on IHE projects.

specifically for cross-enterprise document sharing

and patient care devices.

. Providing technical leadership to build a common

Web-based tool set that integrates testing tools

and activities of various standards development

organizations. consortia. and other organizations:

also. providing technical leadership on the development. selection. and implementation of security

specifications for securely communicating health

information.

· Collaborating with ONCto achieve a Nationwide

Health Information Network(NwHIN)and developing

several test procedures for -meaningful use: According to ONC."meaningful use Isthe set of standards

defined by the Centers for Medicare and Medicaid

Services (CMS)Incentive Programs that governs the

use of electronic health records and allows eligible

providers and hospitals to earn incentive payments

by meeting specific criteria:

· Collaborating with the Centers for Medicare and

MedicaidServicesto provide guidance on the Health

Insurance Portabilityand AccountabilityActSecurity

Rule.

· Participating in the ONCFederalAdvisoryCommittee

on Health Information Technology Standards Com-

~1cat\0r6 and~es

~

Websenices:

Message Messagegeneration

maker Messagevalidation

[§] I

3R1-party

validation applications

andtesting enviJonmenlS 1~E~

.i~~

~ va:tIon 0

Webapplications:

!HEPIX/PDQ

IHEPCD

MUEHR-+PH

MUImmunilatlon-+ PH

NHINPIX/PDQ

«HIT labmessages

Messagegenera1Ion

Messagevalidation

mlttee and associated working groups to pursue these

efforts. Working groups Include HL7.IEEE 11073. the

National Council for Prescription Drug Programs. and

the American Telemedlclne Association.

Following are several NISTprojects. at various stages of

completion. that have resulted from these activities.

HL7testing toolkit

AsFigure2 shows. NISTIsbuilding a toolkit for testing

HL7message Interfaces based on message profiles. The

toolkit'sfoundation Isa set ofJavaAPlsand a testing framework that supports activities such as automated message

generation. message validation. and use case testing. Developers can use the toolkit to build tools or Webservices.

or they can incorporate itinto third.party applicationsand

testing environments.

NISThas applied the toolkit to develop numerous tools

for creating messages. cross.referenclng patient identity.

and formulating EHRqueries. The toolkit's main focus is

on HL7version2.although developershave recently added

capabilities to the toolkit to support version 3 validation.

Tools are delivered as stand.aIone applications. Web services. and Webapplications.

The HL7(version 2)standard. around which we have

based the toolkit. is a specification for moving clinical

and administrative Information between heaJthcare applications. In the US.90 percent of hospitals use the HL7

standard. Its adoption in other care settings such as out.

patient and long-term care facilities or telemedlcine Is

necessary to ensure that organizations can reap the benefits of widespread electronic communication. However.

NOVEMBER2012 53

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the cost-restrictive nature of managing an HL7system to

achieve Interoperabillty Is a concern forwidespread adoption In these other settings.

When originally developed. the HL7standard was designedto accommodate the many diverse processeswithin

the healthcare Industry. Although a universal design was

necessary to gain broad Industry support. the Initialdesign

resulted In a standard that could not be sufficiently constrained to provide a single and consistent Interpretation.

which prohibited plug-and-play Installations. Consequently. systems were difficult to implement and debug.

resulting In undue costs.

Tohelp alleviate this shortcoming. HL7Introduced the

concept of message profiles. Amessage profile is a subset

of the HL7messaging standard that constricts message

definition so that itspecificallystates a message's optional

constructs and processing rules. However.IfEHRvendors

do not followthe profile rules. Interoperabillty problems

wUlpersist. Conformancetesting is essential NISTis developing testing tools to ensure that vendors apply message

profiles as intended to fulfillthe promise of Interoperable

healthcare systems.

Legislation calls for the voluntary

certification of health information

technology to encourage more

widespread adoption of interoperable

health IT.

Clinical Document Architecture validation

The HL7version :3Clinical Document Architecture (CDA)

is an XML-based markup standard Intended to specify the

encoding. structure. and semantics of clinical docUments

for exchange. and is not Itself a document type. CDAwas

developed using the HL7 development framework. which

is based on the HL7Reference Information Model. NIST-in

collaboration with IHE's Patient Care Coordination (PCe>

domain. the Quality. Research and Public Health domain.

and HL7-ls working on a series of testing tools for promoting CDA'sadoption by vendors and users of healthcare

information systems.

The toolkit can validate documents from legacy Health

Information Technology Standards Panel (www.hltsp.olJO

work. the IHE PCC domain documents. and HL7 documents. The toolkit also Includes sample documents of

syntactically correct XML files for most document types.

The NwHIN testing team also uses this toolkit at IHE Connectathons (multivendor testing events held worldwide)

to check for meaningful use (MU) and for patient Identity

to validate documents being exchanged. Users access the

tool via a webpage form where they upload their XMLfile

or through a SOAP-based Web service to automatically

54 COMPUTER

load and validate from external applications. NISThas

future plans to expand the toolkit to support the Quality

ReportingDocumentArchltecture'sQualityReportingand

e-Measuresformal

Meaningful-use Stage 1 test method

The US Health Information Technology for Economic and Clinical Health (HITECH)Act. enacted as

part of the 2009 American Recovery and Reinvestment

Act. emphasizes the need for the US to begin using

EHRs.To encourage more widespread adoption of Interoperable health IT. the legislation calls for ONC.In

consultation with NIST.to establish a program forthe voluntary certification of health IT as being In compliance

with applicablecriteria to meet defined MUrequirements.

MUwill be Implemented In three stages: Stage I In 2011.

Stage 2 In 2013. and Stage :3In 2015. Further details of

these stages can be obtained at www.healthlt.gov.Physicians will receive federal financial Incentives depending

on how well they conform to criteria described In rules

associated with each stage.

Under the health IT certification program. ONCauthorized testing organizations use the NISTtest method

and conformance tools to evaluate EHRsoftware and

systems so that doctors' offices. hospitals. and other

healthcare providers can have confidence In the systems

they purchase. In collaboration with ONC.NISThas developed the necessary functional and conformance testing

requirements. test cases. and test tools In support ofStage

1ofthe MUhealth ITcertificationprogram and Iscurrently

working on the other two stages.

In August2010.NISTpublished an ONC-approvedtest

method (encompassingtest procedures. data. and tools)for

testing EHRsystemsto.meet MUStage 1certificationcriteria and standards. During the test method's development.

NISTcollaborated with ONCto ensure that the relevant

standards and certification criteria were consistent and

effectivelyrepresented within the test procedures. The approved NIST-developedtest method evaluates EHRsystem

components such as electronic prescribing of patient prescriptionsto pharmacies. submission of laboratory results

to the Centers for Disease Control and Prevention (COC).

how pediatric doctors plot and display growth charts of

patients. and how vendors control access so that only authorized users can retrieve Information.

The followingtoolsfor MUStage 1testing are complete

and available from NIST(weare working on Stage 2 tools.

which should be available In a fewmonths):

. Stage I Test Method (http://healthcare.nlst.jlovluse

testlnjlleffectlve_requlrements.html). This method

defines the approved version 1.1test procedures that

Authorized Testing and Certification Bodies(ATCBs)

use in the health ITcertification program.

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· Reportable Lab Results and Immunizations (http://healthcare.nist.S[ov:8080/

HL7V2MuValidation20t1).With this HL7

v2 test tool. ATCBscan assess the certification criteria for doctors to use in

submitting immunizations and reporting lab results to the CDC.

· Clinical Document Architecture (CDA)

Validation (http://hit-testinS[.nist.S[Ov/cdavalidation/mu.htmn. NIST provides an

HL7 Continuity of Care Document (CCD)

validation tool designed specifically to

support MU Stage 1 testing.

.

imaging

center

Hospital A

\

/a~~ ~

Admin ~ According to ONC. more than 2.500 EHR

products for ambulatory care and more than

800 products for in-patient care are currently

certified for MUStage 1 (http://oncchp1.force.

com/ehrcertlCHPLHome; a product is not necessarily a complete EHR-see ONC's website

for definition of a product). All products can

be traced back to NlST-developed test procedures and tools.

HospItal B

Figure 3. Cross-enterprlse document sharing (XDS).Healthcan! professionals within a community can use XDSto access a plltlent's dlnlcal

Information regardless of where It Islocated.

Cross-enterprise document sharing

NISTisworking with industry to develop a standardsbased registry infrastructure that will allow healthcare

professionals to find and access all pertinent patient dlnical information regardless ofthe healthcare organization

that creates and manages the documents. Additionally.

NIST is collaborating on the IHE project on CrossEnterprise Document Sharing (XDS).Specifically. NIST

is a primary author of the XDSstandards-based specification. As Figure :3shows. healthcare professionals

can use XDSto manage document sharing betWeen any

healthcare enterprise. from a private physlcian's office

to an acute care in-patient facility and personal health

record systems.

Sharing ismanaged through document repositoriesand

a document registry to create a longitudinal patient Information record within a given dlnlcal domain. These are

distinct entities with separate responsibilities.Adocument

repository stores documents In a transparent. secure. reliable.and persistent manner and can respond to document

retrievalrequests. Adocument registry stores Information

aboutthose documentssothat the documentsofInterestfor

a patient's care can be easilyfound.selected.and retrieved

irrespectiveofthe repositorywhere theyare actuallystored

Usingdocument registriesto share dinical information

Intraorganlzatlonally presents unique chailenges: data

Interoperability and Interchange. for example. requires

standardized metadata. interfaces.and formats;moreover.

the technology must support strict adherence to security

and privacy policies related to healthcare information.

NISThas developed a reference Implementation for

the XDSspecification and a Web-based test suite. allowing vendors to determine conformance to the XDS

profile. Vendors also use.the test suite as an early stage

tool for interoperability testing. The reference Implementation is available as IHEopen source. an open source

project hosted on Source Forge (http://Iheos.sourceforge.

net). The NISTtest suite Is available at http://ihexds.

nistS[ov.

Medical device communication testing

In a typical intensive care unit. a patient might be connected to one or more vital-sign monitors. receive fluids

through multiple Infusion pumps. and be supported by a

ventilator. Each of these medical devices can capture volumes of data. which is available multiple times per second.

on a per-patient basis. Today. these devices do not communicate and have little or no plug-and-play interoperability.

Medical device interoperability raises several issues:

· Manually captured data Is labor intensive. recorded

Infrequently. and prone to human error.

Expensive custom connectivity equipment might be

used only for patients with acute needs.

· Detection of patient problems such as adverse drug

events Is hindered due to the inability to collect realtime data from multiple devices.

· Vendors Intending to communicate data betWeen devices must develop specialized interfaces for each

device.

NOVEMBER2011 55

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The ISOnEEE11073(x73)Healthcare Devicesand Personal Health DevicesWorking Groups are defining a set

of standards to enable medical devices to Interoperate

and electronically capture and process data. These workIng groups are collaborating with the IHEPatient Care

Device Domain to develop a framework for Integrating

medical device data Into an EHR.

NISTIs actively developing medical device communication test methodologies and tools to enable consistent

and correct communication between medical devicesand

devlce-gatewaysacrossthe healthcare enterprise.Thiswork

IsIntendedto providestandards-based. rigorousvalidation

of medical device communication through conformance

leading to Interoperablllty.Rigoroustesting Is essential to

achieve multlvendor and enterprise-wide Interoperablllty.

and Itmust be predicated on sufficientlyspecifiedmedical

deviceand enterprise-communlcation standards. TheNIST

software test tools aim to meet the X73-deflned requirements as well as the enterprise/electronic health record

leveldefined In the HL7messaging standard

Electronic health information exchange

that follows patients across providers

regardless of geographical boundaries

greatly improves the clinical decisionmaking process.

A related tool Is the ICSGenerator (http://hlt-testlng.

nlst.gov/medlcaldevlcesllndex.html). which facilitates

creation of vendor conformance statements that would

be applicable to testing a particular X73 device. With

the ICSGenerator.users can easily develop and produce

Implementation conformance statements. Users such

as medical device vendors. manufacturers. and clinical

engineers can execute the tool to produce statements that

disclose details of a specific Implementation and specify

the features providedby a particular medical device-that

Is. a device profile. Medical device vendors can compare

deviceImplementationconformance statements based on.

and required by. the x73 standards and use them across

device Interfacesto help overcome the semantic Interoperability problem.

Conformance test tools can use device profiles In conjunction with messages to and from devicesto determine

standards conformance and validity.The ValldatePDUtool

can determine notonly the correctness ofthe x73message.

bUtalso the message's compliance to a user-deflnedprofile

(derived via the ICSGeneratortool).ValidatePDUprovides

basic syntax. structure. and low-levelsemantic checking

for one or more captured messages. BothValidatePDUand

ICSGeneratoruse the electronic representation of the x73

standards Informationmodel that NISTresearchers Imple56 COMPUTER

mented In an XMLschema. These tools (and Information

model) are publicly available (http://hlt-testlng.nlst.gov/

medlcaldevlcesllndex.html).Medical device test message

generation Is also possible to facilitate future manager!

agent conformance test scenarios.

IHE CONNECTATHONS

Each year. the IHEsponsors Connectathons In North

America. Europe. and Asia to promote InteroperabllIty among IHEprofile Implementations (www.lhe.net/

connectathon). The Connectathons are cross-vendor

structured testing events where developers of health Information systems can compare their Implementations with

those of other vendors. The goal Isto promote the adoption ofstandards-based Interoperablllty solutions defined

by IHEIn commercially availablehealthcare ITsystems.

The 2012North American Connectathon held In Chicago. Illinois. featured more than 160 systems from 117

participating organizations. which performed and verified more than 3.500 successful tests of IHEIntegration

profiles. Ninety percent of the applications demonstrated

at the Connectathon used the NISTtest tools. Participants and monitors use NISTtooling In cross-enterprise

document sharing. patient Identity and queries. patient

care devices. and CDAvalidation to compare them against

the IHEprofiles.

Interest In the Connectathons and NIST tooling to

support them has been growing: at the 2012 event.IHE

Korea and IHEJapan began using NISTtooling with IHE

Australia to learn how to use the technology for their

respective Connectathons.

NWHIN TESTING

NwHINis a set of standards. services. and policies

that enable secure health Information exchange over the

Internet. NwHINIs not a physical network but rather is

a foundation for the communication of health Information across diverse entities and communities around the

country. Electronic health information exchange that

followspatientsacross providersregardlessof geographical

boundaries greatly Improvesthe clinlcal-declsion-maklng

process by providing clinicians with updated. relevant.

and accessiblepatient data (http://nwhin.siframework.or'IV

NwHlN+BasicsJ

These standards. services.and policiesenhance patient

care quality and evolvecare coordination by helpingmove

current paper-based medical records to an electronic process forsecurely storing and sharing EHRs.NISThas been

involved in the testing process for .on-boarding; the process by whichan organizationjoins the NationwideHealth

InformationNetworkExchange.which verifiesthat Itcomplies with NwHIN-supportedspecifications. On-boarding

includesverifyingan organization'seligibilityforparticipation (must be a federal agency or ONCcontractor). that Its

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gateway complies with the NwHIN specifications. and that

it can exchange Information.

NwHIN uses an existing set of NISTtools with modifications based on the NwHIN specifications (http://hit-testinJ(.

nlst.gov:I2080Ixdstools2nwhin). The tools Include XDS.

Cross-Community Patient Discovery Query and Retrieve

(XCPD).Patient Identity Cross Reference. Patient Discovery

Query. and a CDAvalidator. These tools help to automate

the on-boarding process and allow potential participants

to completely test their gateways at the NISTwebsite before

they start on-boarding. The NwHIN network might playa

larger role In meaningful use testing in Stage 2.

T

he creation of an Integrated heaithcare information

infrastructure depends on all parties involvedconsumers. healthcare professionals. researchers.

and insurers-having systems. tools. and Information

that are complete. correct, secure. and Interoperable.Until

we achieve a full-scale interoperabillty of software systems in the heaithcare enterprise. we will not realize the

full benefits of using Information technology In healthcare. Achievingtrue Interoperabillty would require that

three tightly Integrated activities must succeed:standards

development. implementation support (including Implementation guidance and precertificatlon testing). and

comprehensive conformance and Interoperability testing.Thus. true Interoperability testing cannot be achieved

without having the right standards. Implemented In the

right way. and tested-both for syntax and semanticsto the right requirements. NIST will continue the

research and development activities required to support

and test a fully Integrated and Interoperable healthcare

enterprise. [I

Acknowledgments

Project leads for the various projects Include Robert Snelick

(HL7V2 Testing Toolkit). Ken Gebhart (Meaningful Use).Bill

Majurski (Cross-Enterprise Document Sharing).John GarguIlo

(Medical Device Interoperability). Andrew McCaffrey (CDA

validation). and Gavin O'Brlen (NwHIN).Usa Carnahan Initiated the testing projects during her term as the leader of the

health ITconformance testing program; Mary Laamanen and

Sandra MartInez also contributed efforts In CDAand Medical

Devices. respectively. We appreciate the Input from Steven J.

fenves and Usa Carnahan on this article.

References

1. C. Bock et aL,HealIhazre Stra/qJic FocusAmz:Qinical1nformatics. NIST Intemal Report 7263. Nat1 Inst. of Standards

and Technology. Washington. D.C~ 2005.

2. NatIonal Research CouncIL For the Record: l'rot«ting Electronic Health lnj'omrizlion. National Academies Press. 1997.

3. M.Ramalah et al~ "Workflowand Electronic Health

Records In Small MedicalPractices,"AHIMI1'sOnline

Research).. Perspectives in Health Infonrurtion ManJIgernent. 2012.

4. S.R.Raoetal~ "Electronic Health Records in Small Physician Practices: Availability.Use. and Perceived Benefits,"

). Am. MtdiaIlinjormatics Assoc..voL 18. no. 3. 2011. pp.

271-275.

5. T. Benson. Principles of Health Interoperability: &7 and

SNOMED.Springer. 2010.

Kevin IJroaq is InteroperabUity Group leader, Systems and

Software Division.I'!formation 7echnology Laboratory. Nationalinstitute of Standards and Technology. His research

interests include health i'!formation technology. smart

healthcare. and cyberphysical systems. Brady received an

MS in computer science from the George Washington University. Contact him at kevin bral{v(jJmistgov.

Ram D. Srlnnn is chief of the Systems and Software

Division. Information Technology Laboratory. NationalInstitute of Standards and Technology. His research interests

include distributed design. artificiJJlintelligence. and smart

networked systems and societies. Sriram received a PhD

in civil engineering from Carnegie Mellon University. He

is a senior member ofl£EE. afeUow of ASME and MAS.

and a life member of AMI and ACM. Contact him at ram.

sriram@nist.qov.

BettfIoyce Li4e is the health ITprogram manager. I'!formation 7«hnology Laboratory. National Institute of Standards

and Technology. Her research interests include health

i'!formation technology. evaluated scientific data. and collaborations on cuttfng-edge RliD. Lide received an MS in

chemistry. information technology. and managementfrom

the American University. She is a member of the American

Chemical Society. Contact her at b]lide@nistgov.

Kathleen Roberts is associate director for federal and industrial relations. Information Technology Laboratory.

National Institute of Standards and Technology. Roberts

received an MS in computer science from the George Washington University. Contact her at Kathleen.Roberts(il)nist

~.

The Identification of certain commercial software systems in this article does not Imply recommendation or

endorsement by NIST nor does It Imply that the products Identified are necessarily the best avai1abIe for the

purpose. Further. any opinions. findings. conclusions.

or recommendations expressed In this material are

those of the authors and do not necessarily reflect the

views of NIST or any other supporting US government

or corporate organizations.

.. Selected CS.rtldes .nd columns .vall.ble

L!lIJ for free.t http://ComputingNow.computer.org.

NOVEMBEllOl1 57

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