EPR Primary System Integration

For a deep EPR integration into a primary systems the following usecases should be covered

1. Integrate the strong authentication into the primary system with an IdP (Level 1)
2. Search for patients in the community (Level 2.1)
3. Register a patient from the primary system in the community (Level 2.1)
4. Query and retrieve documents for a patient from the EPR including authorization (Level 2.2)
5. Publish documents for a patient by a healthcare professional (Level 2.2)
6. Providing AuditEvents (Level 2.1)
7. Query and update the Healthcare Professional Directory (HPD) (Level 2.3)
8. OID configuration

The levels of integration are described by eHealth Suisse, see checklist [fr] and [de].

eHealth Suisse has described the different steps with examples [fr], [de].

You find test patients which you can use for publication of documents here.

Please find below additional information relevant for CARA and EPRIK:

1. Integrate the strong authentication into the primary system with and IdP

Authenticate a user at an identity provider certified for the Swiss EPR. Primary systems need to use this transaction to retrieve a IdP assertion. The IdP assertion is required to retrieve the XUA Assertion to be used with EPR transactions. See detailed description here.

See EPRIK example for AuthnRequest and ArtifactResolve.

If you have a test user you can use the IdP Assertion from EPRIK until you have done the IdP integration yourself.

2. Search for patients in the community

This sequence diagram shows the preferred way of managing patient identities. The first case, EPR set in PS is the case where you have already linked your local patient identity to an EPR patient identity and fed your local identifier to the MPI. To get the MPI-PID and the EPR-SPID, you just have to query the MPI with your local identifier (described in section 3.2).

The second case, EPR not set in PS, is the case where you have to reconciliate the patient identities. You can query the MPI for patient demographics (like name, birthdate, gender, etc., described in section 2.2) and manually match demographics. Once that is done, you can feed your patient local identifier to the MPI (described in section 3.1).

2.1 Check if the patient has an EPR based on AHVN13/NAVS

With the PIX V3 query You can use AHVN13/NAVS13 to check if the patient has an EPR (EPR-SPID is returned), and if the patient is already registered in the community (MPI-PID is returned). See example request for patient Gassmann, which returns EPR-SPID and MPI-PID in the id elements. For a test patient who has no EPR (as of 31.3.2023) with AHVN13 7560739410295 no EPR-SPID and MPI-PID is returned, see request. If the the AHVN13 is not found, an Application Error (AE) will be returned. For a test patient who has an EPR but not in CARA int (as of 31.3.2023) with AHVN13 7560520619845 only EPR-SPID is returned, see request.

2.2 Demographics Query

A search for a patient is done via a demographics query. See detailed description here.

EPRIK example request, response. This example search is done on the family name, other demographics query parameters are possible. Please note that Swiss Extension requires that an error is returned if more than 5 matched would be returned. You need to provide creationTime, sender OID and receiver OID in addition to the query parameters in the request. For the communication you need a client certificate but with EPRIK a client certificate is not necessary.

3. Register a patient from the primary system in the community and query the patient community id

3.1 Register local patient Id in the community

Register a patient in a community. Primary systems need to use this transaction to register patient data and then to be able to provide and retrieve documents to the patients EPR. See detailed description here.

EPRIK example request, response. This example registers the local id from the primary system P003 of the patient identity domain 2.16.756.5.30.1.145.1.3 in the MPI. You need to provide creationTime, sender OID and receiver OID in addition to the patient parameters ( EPR-SPID, MPI-ID) in the request. For the communication you need a client certificate, but with EPRIK a client certificate is not necessary.

Danger

Never feed a patient identifier with a domain that is not yours, and especially a domain equal to the configured receiver OID of the plateform. It would make the patient unreachable from PDQ queries.

3.2 Query MPI-PID and EPR-SPID based on local ID

The primary systems needs to query the master patient ID (MPI-ID) for patients to retrieve or provide documents for, based on the local id registered above. See detailed description here.

EPRIK example request, response.

4. Query and retrieve documents for a patient from the EPR

This sequence diagram shows the search and retrieval of documents. Searching documents in CARA is described in section 4.2a, searching in other communities is described in section 4.2b. Retrieving a document is described in sections 4.3a and 4.3b, depending on the community. The PIXv3 query is shown as a reminder. For these calls, another mandatory step is the Get X-User Assertion call to get a XUA token from the EPR.

4.1 Authorization

To query and retrieve documents the HCP needs to be authorized based on the IdP token, the patient (resourceID with EPR-SPID), purposeOfUse (NORM, EMER) and role (HCP). See detailed description here.

EPRIK example request, response.

Example STS requests with IdP or EPRIK-httpheader.

4.2a Query documents from the CARA community

Retrieve the document metadata for the documents stored in a patients EPR for the CARA community. See detailed description here.

EPRIK example request, response. For the Query the MPI-ID of the patient needs to be added. This example requests includes the security token necessary. With the EPRIK you can do the user authentication there and reuse the token see. For the communication you need a client certificate but with EPRIK a client certificate is not necessary.

4.2b Query documents from remote communities

To retrieve the document metadata for the documents stored in a patients EPR but registered in remote communities, the initiating gateway has to be called with an IIT-18 query. EPRIK example request, response. Gassmann has an example document in the remote community urn:oid:2.16.756.5.30.1.177.1.0.

4.3a Retrieve documents from the CARA community

To retrieve documents from a patients EPR the IHE XDS.b profile and transactions needs to be used. See detailed description here.

EPRIK example request,response. With EPRIK you can do the user authentication there and reuse the token see. For the communication you need a client certificate but with EPRIK a client certificate is not necessary. You will need to add the HomeCommunityId, RepositoryUniqueId and DocumentUniqueId.

4.3b Retrieve documents from remote communities

To retrieve the documents stored in remote communities, the initiating gateway has to be called with an ITI-43 query with the homeCommunityId added from result 4.2b. EPRIK example request, response.

5. Publish documents for a patient by a healthcare professional

This sequence diagram shows the publication of a document by a healthcare professional.

To provide documents and metadata about the documents the IHE XDS.b profile and transactions needs to be used. See detailed description here.

EPRIK example request,response. With EPRIK you can do the user authentication there and reuse the token see. For the communication you need a client certificate but with EPRIK a client certificate is not necessary. You will need to add metadata for the document.

confidentiality code in metadata

The patient can set the default level of confidentiality to normally accessible , restricted accessible or secret. This need to be taken into account when publishing (sequence diagram). If a publication fails for normally accessible it has to be retried with restricted accessible. It is only possible to publish a document with confidentiality secret if the user has set the default confidentiality code to secret. To test this three different patients have been setup with different confidentiality codes: GASSMANN-IMHOLZ (normally accessible, EPR-SPID: 761337613645876216), SOARES JESUS (restricted accessible, EPR-SPID 761337618424274719) et Ratchawat (secret: EPR-SPID 761337611340275266)

Publication with	normal	restricted	secret
Gassmann (normally accessible)	ok	ok	error
SOARES JESUS (restricted accessible)	error	ok	error
Ratchawat (secret)	error	error	ok

metadata in portal

The portal displays the metadata provided in the publication. The patient name is only visible if it is provided in PID-5 in sourcePatientInfo. example

The institution can be filtered by the portal only if the authorInstitution contains an OID in the XON.10 field.

provide a document with a technical user (TCU)

This sequence diagram shows the publication of a document by a technical user.

Instead of using an authenticated user for publishing documents, the ERP allows to publish documents with a technical user see factsheet in french. You are required to create a client certificate for this technical user and let it register in the HPD. See the developer platform for exact steps.

EPRIK allows you to work with a specific test technical user during integration. You can get the TCU IdP SAML2 assertion from here. This assertion is valid for 10 minutes. With this assertion you can get then the XUA (STS) token for the XDS requests, for the urn:e-health-suisse:principal-id you need to put the GLN to 2000040030829 when using EPRIK's technical user. example

change metadata of existing documents (2.223)

If a document has been added the metadata can be changed with the IHE Restricted Metadata Update Profile (RMU). See an example message here, where the document title is changed. A new ITI-18 query shows the changed title (Line 312). If you are working with a Technical User you would need to store the DocumentEntry including entryUUID during the provide and register transaction, because you cannot read it with ITI-18.

Replace a document

To replace a document, the same ITI-41 transaction is used as for the publication of a new document, with the addition of a specific Association element that shows which document is to be replaced:

<rim:Association associationType="urn:ihe:iti:2007:AssociationType:RPLC"
                 sourceObject="urn:uuid:fa9b4f10-3ea1-436f-a988-ebbb8a2cfffc"
                 targetObject="urn:uuid:42fbb7ad-fe7a-4585-95c6-15d91a476c40"
                 id="(a unique id)"/>

EPRIK example request,response.

Using entryUUIDs

Warning

The documents entryUUIDs may change at any time: if the metadata changes (through an ITI-92 transaction, or if the patient changes the confidentiality level), or if the document is replaced, a new entryUUID will be generated.

To change the metadata of a document, or to replace it with a new document, the entryUUID of the currently approved DocumentEntry is required, and may be different from the submitted entryUUID in the original publication. In some cases, it may prove impossible to retrieve the right entryUUID. In those cases, the help from CARA's administrators can be requested, or the document may be republished as a new document.

To retrieve the currently approved entryUUID of a document that has not been replaced, if a healthcare professional is logged in, the ITI-18 search can be used with the document unique ID. If a technical user is logged in, there is no possibility. Depending on the configured confidentiality levels, the document may not be returned in the search.

To retrieve the currently approved entryUUID of a document that has been replaced, the ITI-18 GetRelatedDocuments search can be used to retrieve the document that replaced the original document. A loop may be needed, if the document has been replaced multiple times.

6. Providing AuditEvents

Each IHE Transaction has AuditEvent requirements. This is described for each transaction (see example for ITI-45 here or in eprik). This AuditEvents need to be registered in the community. With EVSClient you can validate if the content of the AuditMessages is correct. See for sending message via syslog protocol also guidance about not using BOM in IHE 3.20.4.1.2 Message Semantics.

The specifications for generating the audit messages are given in the following documents:

1. DICOM PS3.15 A.5: the foundation of audit messages.
2. IHE profile for each transaction: in the section 'Security Considerations' of each transaction, you'll find IHE requirements.
3. EPDV-EDI Annex 5 Complement 1: there are some Swiss requirements too. §1.5.2 describes generic requirements and §1.6.4.3.5.1 describes requirements for transactions that use a SAML assertion (XUA).

EPD-by-example has some examples of audit messages.

7. Query and modify the Healthcare Professional Directory (HPD)

The HPD is an LDAP directory, and interactions with it are wrapped in DSMLv2 objects. It contains three different objects: professionals (ou=HCProfessional), organizations (ou=HCRegulatedOrganization) and relationship between them (ou=Relationship).

7.1 Query entries

With the ITI-58 transaction, you can query the Healthcare Professional Directory (HPD) for the entries you are interested in. You can query entries with LDAP filters on LDAP attributes and select the attributes to return. Example, request.

7.2 Add an entry

With the ITI-59 transaction, you can add an entry to the HPD with an addRequest. Example, request.

7.3 Modify an entry

With the ITI-59 transaction, you can update an entry in the HPD with a modifyRequest. Example, request.

7.4 Delete an entry

With the ITI-59 transaction, you can delete an entry from the HPD with a delRequest. Example, request.

8. OID Configuration

Parameter	Integration	Production
MPI OID Patient	2.16.756.5.30.1.191.1.0.2.1	2.16.756.5.30.1.191.3.0.2.1
HL7 v3 Receiver Device ID	2.16.756.5.30.1.191.1.0.12.1.101.2	2.16.756.5.30.1.191.3.0.12.1.101.2
Repository unique ID	2.16.756.5.30.1.191.1.0.12.1.101.31