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EHRI-SIG

EHRI-SIG. Announcement. Introduction. Recent direction to support NHIN Direct Interoperability between providers, patients, labs and pharmacies CONNECT can facilitate the requested information exchange and follow the guidance of the interim final ruling

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EHRI-SIG

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  1. EHRI-SIG Announcement

  2. Introduction • Recent direction to support NHIN Direct • Interoperability between providers, patients, labs and pharmacies • CONNECT can facilitate the requested information exchange and follow the guidance of the interim final ruling • Purpose of the group is to produce an operational example and resolve technical issues between the What we want to do and How we are going to accomplish • We will lead the discussion but our goal is to get input from the group

  3. Role Call • Show of hands in audience • EHR? • PHR? • Lab? • Pharmacy? • Others

  4. Proposed Interoperability Physician’s Office A Laboratory Send Results NHIN/ Internet Physician’s Office B Provider Referral, Receive Labs, Send Prescription, Provider to Patient Pharmacy Receive Prescription Physician’s Office C Patient Visit Summary

  5. Proposed Systems View Physician’s Office A Laboratory Send Results NHIN/ Internet Physician’s Office B Provider Referral, Receive Labs, Send Prescription, Provider to Patient Pharmacy Receive Prescription Physician’s Office C Patient Visit Summary

  6. Extending CONNECT Across the Healthcare Spectrum • CONNECT services need to support organizations across the complexity spectrum. • This includes adding capabilities and services that will implement the use cases involving physicians, specialists, providers, labs etc. • These use cases typically involve point to point exchange of health information via paper mail with trust established via telephone calls or other means. • CONNECT is analyzing various technologies to solve these specific use cases. Two specific areas being researched are: • Use of XMPP (Extensible Messaging and Presence Protocol) • Enhancements to UCF (Universal Client Framework)

  7. NHIN Today HTTP CONNECT Gateway CONNECT Gateway HTTP Adapter Adapter NHIN HTTP CONNECT Gateway HTTP HTTP CONNECT Gateway Other Gateways Other Gateways Adapter Adapter

  8. CONNECT Today Your Health Organization Other Health Organizations Locate Patients Your Existing HealthInformation System Master PatientIndex ProprietaryInterface Patient Identity Locate/RetrieveHealth Documents Health Information HealthData CustomInterface Publish/Subscribe to Data Feed Adapter CONNECT Gateway ExchangePolicies ProprietaryInterface Exchange Decision Retrieve Disclosure History Audit Logs Disclosure History Custom Interface Locate Health Systems/Services NHIN Conventions Framework for Authorization,Security, Privacy • Terminology Mapping • Document Viewers • Clinical Decision Support • Other Future Services Proprietary/Custom Interface Internal CONNECT API External NHIN API

  9. CONNECT Architecture: Message From NHIN

  10. CONNECT Architecture: Message to NHIN

  11. The Nationwide Health Information NetworkMoving U.S. Health IT Forward The NHIN: • Provides the foundation for the exchange of health information that supports meaningful use. • Supports both the local and nationwide exchange of health information. • Offers a trust framework for information sharing. • Includes a common infrastructure necessary for network security and connectivity. • Contains specifications for interoperable services. • Promotes sharing accurate health information.

  12. NHIN Trust Fabric • 2-Way TLS • WS-Security • SAML 2.0 • Digital Signatures • Certificates issued by Entrust • Contractor to NIHN • Must sign DURSA agreement • What is the EHRI trust fabric?

  13. CONNECT Tomorrow (Maybe NHIN too) HTTP HTTP CONNECT Gateway CONNECT Gateway XMPP XMPP Adapter Adapter NHIN/ Internet EHR (XMPP Client) EHR (XMPP Client) HTTP HTTP CONNECT Gateway CONNECT Gateway HTTP XMPP XMPP XMPP Other Gateways Adapter Other Gateways Adapter Lab System (XMPP Client) Rx System (XMPP Client)

  14. CONNECT Tomorrow (Maybe NHIN too) HTTP HTTP CONNECT Gateway CONNECT Gateway Alternative 1 XMPP XMPP Adapter Adapter NHIN/ Internet EHR (XMPP Client) EHR (XMPP Client) HTTP HTTP CONNECT Gateway CONNECT Gateway HTTP XMPP XMPP XMPP Other Gateways Adapter Other Gateways Adapter Lab System (XMPP Client) Rx System (XMPP Client)

  15. CONNECT Tomorrow (Maybe NHIN too) HTTP HTTP CONNECT Gateway CONNECT Gateway Alternative 2 XMPP XMPP Adapter Adapter NHIN/ Internet EHR (XMPP Client) EHR (XMPP Client) HTTP HTTP CONNECT Gateway CONNECT Gateway HTTP XMPP XMPP XMPP Other Gateways Adapter Other Gateways Adapter Lab System (XMPP Client) Rx System (XMPP Client)

  16. Suggested Scope and Functionality (What) • Provider to Provider • Provider to Patient • Lab to Provider • Provider to Pharmacy • Provider to Agency

  17. Provider to Provider • Find Doctor (Doc Talk) • Doctors share id with each other. • A provider searches and discoversa provider online and request a chat. • Order Referral • A provider refers a patient to a provider. • Provider Patient Medical History • A provider exchanges summary of care document with another provider. • Administrative Coordination of Care • An employee of a provider contacts a medical service provider regarding the status of a test, result, procedure or scheduled visit. ID ? ? ?

  18. Provider to Patient • Patient Reminder • A provider sends a patient reminder message to patients by patient preference for preventive/follow up care and receives acknowledgement. • Electronically generate, upon request, a patient reminder list for preventive or follow-up care according to patient preferences based on demographic data, specific conditions, and/or medication list. • Send to PHR • Provide patients with an electronic copy of their health information upon request. • Enable a user to create an electronic copy of a patient’s clinical information, including, at a minimum, diagnostic test results, problem list, medication list, medication allergy list, immunizations, and procedures.

  19. Provider to Patient • Provide patients with a copy of their discharge instructions and procedures at time of discharge.  • Provide clinical summaries for patients for each office visit.

  20. Provider to Patient • Provide clinical summaries to patients that include: diagnostic test results, medication list, medication allergy list, procedures, problem list, and immunizations.  • Update a patient’s record based upon received laboratory test results SUMMARY

  21. Football Game Environment • Primary Actor: Physician • Secondary Actor: Patient • Organization(s): Primary Care Practice (PCP) • Scenario: Contact from Patient while PCP is at a football game • Prerequisites: The physician is taking calls overnight for his primary care practice. While the physician is at the local high school football game, a patient, whom the physician does not know (since the patient normally sees his physician partner), calls for help with “My heart is beating fast.” • Modalities & Form Factor: Patient on telephone; Physician on smartphone • Workflows: The physician answers the phone, listens for the patient's name, and looks up the patient on his device (smartphone). He reviews the data from the CCD, asks the patient some questions based on the data he is seeing, and then verbally tells the patient what to do (for this challenge, no physician data entry is included.

  22. Lake Cottage Environment • Primary Actor: Physician using device • Secondary Actor: Patient on phone • Organization(s): Primary Care Practice • Scenario: Call from Patient while PCP at weekend cottage • Prerequisites: The physician is taking calls overnight for his primary care practice. While the physician is at his weekend cottage on the lake, a patient, whom the physician does not know (since the patient normally sees his physician partner,) calls for help with “My heart is beating fast.” • Modalities & Form Factor: Patient on telephone; Physician both on telephone and netbook computer display. • Workflows: The physician answers the phone, listens for the patient's name, and looks up the patient on his device (netbook computer). He reviews the data from the CCD, asks the patient some questions based on the data being displayed, and then verbally tells the patient what to do (for this challenge, no physician data entry is included; begin the demonstration with physician viewing and then navigating through the Halamka CCD in order to view the detailed data).

  23. Home Study Environment • Primary Actor: Physician using device • Secondary Actor: Patient on phone • Organization(s): Primary Care Practice • Scenario: Call from Patient while PCP in his home study • Prerequisites: The physician is taking calls overnight for his primary care practice. While the physician is in his study at home, a patient (John Halamka), whom the physician does not know (since the patient normally sees his physician partner), calls for help with “My heart is beating fast.” • Modalities & Form Factor: Patient on telephone; Physician both on telephone and full-sized computer display • Workflows: The physician answers the phone, listens for the patient's name, and looks up the patient on his device (full-sized computer display). He reviews the data from the CCD, asks the patient some questions based on the data being displayed, and then verbally tells the patient what to do (for this challenge, no physician data entry is included; begin the demonstration with physician viewing and then navigating through the Halamka CCD in order to view the detailed data).

  24. Lab to Provider • Send laboratory results to provider • Receive clinical laboratory test results • Submit reportable lab results (as required by state or local law) to public health agencies.

  25. Provider to Agency • Submit reportable lab results to public health agencies. • Provider to Agency • Reportable Agency (State Public Health, Federal Health, others) – Nationwide Data Collection example

  26. Provider to Pharmacy • Send electronic prescription for medications. • Implement drug-drug, drug-allergy, drug-formulary checks. • Return alerts • Check formulary Rx

  27. Suggested Technical Requirements • XMPP • Technical Standards • Discussion

  28. Why XMPP ? • Complements the existing CONNECT Technology stack • Provides a Real Time Collaboration platform • Presence Detection • Ability to establish trust by creating buddy lists and groups • Provides ability to chat in real time • Provides ability to transfer files securely between 2 end points • Provides Secure Authentication with existing Directories • Provides Service Discovery capability • Supports federation which enables communication with other organizations and entities that are established to be trusted • Protocol is built to transfer XML between 2 end points • Sample applications that use XMPP • Instant Messaging, Group Chat, VOIP, Media streaming, social networking sites like Facebook, Google Talk

  29. XMPP Authentication and Presence Detection • Each entity contains an account in their own XMPP server • Contact/Friend Lists • Presence detection shared with those in contact list. • Once both entities agree to share information – presence is shared for both parties

  30. Scenario: Provider to Provider • Scenario • Specialist provider John Smith would like to share a document with the primary care physician, Jane Doe about a patient they are currently treating. • Steps in the process • John Smith authenticates into CONNECT XMPP server using the XMPP client • John Smith adds Jane Doe to friend list and requests “inclusion” into Jane Doe’s friend list (First time only) • John Smith uses the XMPP client to send a document to Jane Doe. • Jane Doe’s XMPP server receives the document and holds it. • Jane Doe logs into the XMPP server using the XMPP client and receives the document. • Additional Note: • Using XMPP – John Smith could also detect the presence of Jane Doe. But even if Jane Doe is not on, the XMPP server can hold the document until Jane Doe logs in. XMPP XMPP XMPP

  31. Scenario: Lab to Provider • Scenario • Physician John Smith has submitted a patient specimen to a lab. The lab completes the lab work and sends the results to the physician. • Steps in the process • John Smith authenticates into CONNECT XMPP server using the XMPP client • John Smith adds Lab to friend list and requests “inclusion” into Lab’s friend list (First time only) • Lab uses the XMPP client to send the lab results to John Smith. • John Smith’s XMPP server receives the lab results and holds them. • John Smith logs into the XMPP server using the XMPP client and receives the lab results. XMPP XMPP XMPP

  32. Scenario: Provider to Pharmacy • Scenario • Physician John Smith sends an order for a prescription to the corner store pharmacy. • Steps in the process • John Smith authenticates into CONNECT XMPP server using the XMPP client • John Smith adds the corner store pharmacy to friend list and requests “inclusion” into pharmacy’s friend list (First time only) • John Smith uses the XMPP client to send the prescription to the pharmacy. • The pharmacy’s XMPP server receives the prescription order and holds them. • The pharmacist logs into the XMPP server using the XMPP client and receives the pharmacy order. Rx XMPP XMPP Rx Rx XMPP

  33. XMPP Scenario Ideas? • Administrative Provider inbox

  34. Suggested Technical Approach (How) • Provider to Provider • Provider to Patient • Lab to Provider • Provider to Pharmacy • Provider to Agency

  35. Discussion • Enhance the Gateway with XMPP protocol and services • Each attaching system implements XMPP Client (Possibly use Universal Client Framework) • EHR • Lab • Rx • Other • Need to decide • Type of messages • Text messages • HL7 messages • Documents (C??) • Reuse of NHIN services – repurposed under XMPP? • How to establish accounts/credentials of individuals within XMPP server • Other issues?

  36. Target Standards • HL7 2.X and/or Webservices • Patient Summary Record (HL7 CDA R2 CCD Level 2 or ASTM CCR) • Problem List (ICD–9–CM, ICD-10-CM or SNOMED CT) • Medication List (RxNorm) • Medication Allergy List (UNII) • Procedures (ICD–9–CM or CPT–4), (ICD–10–PCS or CPT–4). • Vital Signs (CDA template) • Units of Measure (UCUM) • Lab Orders and Results (LOINC) • Drug Formulary Check (NCPDP Formulary & Benefits Standard 1.0). • Electronic Prescribing (NCPDP SCRIPT 8.1 and NCPDP SCRIPT 10.6).

  37. Notional Solution Ideas • Easy • Text Messages • Not So Easy • HL7 2.X for obvious stuff (Lab, Consult) • HL7 mapping to web service (HL7 formats to drive gateway functionality) • Wrapper XMPP with HL7 message format • Hard • Web Services • What are the options we should consider?

  38. CONNECT Support • What would you like the CONNECT Team to provide? • Drive Standard(s) definition and requirements • Infrastructure • Gateways • XMPP Servers • API(s) • HL7 Specification/Definition

  39. Timeline

  40. Governance • Les and Greg will be Co-Chairs • Select two industry Co-Chairs, possibly more • Email gregory.fairnak@hhs.gov if interested • Connect Co-Chairs will be selected and announced at the June meeting • Scribe wanted

  41. Parting Thoughts • Did we miss anything? • We look forward to seeing you in June

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