Direct and the Nationwide Health Information Network

Session 11

April 13, 2011

Agenda• What is the Nationwide Health Information Network?

– What health information exchange scenarios will the Nationwide Health Information Network help address?

– What are the tools in the Nationwide Health Information Network toolkit?– How does Direct fit into the Nationwide Health Information Network toolkit?

• What are the clinical Use Cases for health information exchange?– How can Direct be used to enable a variety of use cases?– How can other tools address more complex use cases?

• How will Direct work at scale?

• MEDfx Presentation: Integrating Direct and CONNECT– Mark Bamberg, VP Research and Development, MEDfx

• Q&A

• Poll2

3

What is the Nationwide Health Information Network?• A set of policies, standards and

services that enable the Internet to be used for secure and meaningful exchange of health information to improve health and health care.

• Enables a variety of health information exchange scenarios – from less complex to very robust

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What scenarios will the Nationwide Health Information Network help address?

• Each health information exchange scenario requires a different “tool” from the Nationwide Health Information Network “toolkit”; e.g., Direct, Exchange, etc.

• Each tool must be used in conjunction with a coherent set of: – Standards– Services– Policies– Trust Fabric

DirectedExchange

Directed Exchange with Value-Added Intermediaries

Longitudinal data access across settings of care within a community

Cross-Community Access

Scenarios

Less Complex

Very Robust

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What are the tools in the Nationwide Health Information Network toolkit?

DirectedExchange

Directed Exchange with Value-Added Intermediaries

Longitudinal data access across settings of care within a community

Cross-Community Access

Less Complex

Very Robust

Scenarios Tools

Direct

Query for Documents

Document Submission*

Patient Discovery

Retrieve Documents

* Not currently in Nationwide Health Information Network toolkit

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How does Direct fit into the Nationwide Health Information Network toolkit?

The Direct Project provides HIEs with a low cost way to enable simple push messaging to their healthcare constituents

The Direct Project doesn’t replace other ways information is exchanged electronically today, but it might augment them

The Direct Project supports speedy adoption and simple use cases (e.g., provider referrals), but other methods of exchange might be better suited for other scenarios (e.g., real-time population health statistics)

The Direct Project was designed to coexist gracefully with existing protocols for data exchange, e.g., web services, client-server, etc.

The Direct Project seeks to replace slow, inconvenient, and expensive methods of exchange (e.g., paper and fax) and provide a future path to advanced interoperability.

Though not technically incorporated yet, Direct Project specifications are expected to be incorporated into the NwHIN specifications

Health information exchange:a puzzle with many pieces

Cross-Community Access Directed

Exchange

Longitudinal Data Access across a

CommunityDirected Exchange with

Valued-Added Intermediaries

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How can Direct be used to enable a variety of use cases?

Exchange Mechanism

Use Case Sequence of Direct Messages

One-way Directed Exchange

Simple Referral • Provider Provider: Clinical Summary

Lab Results Report • Lab Provider: Lab Results Report

Public Health Report from Labs

• Lab ELR System: Reportable Lab Test Results

Public Health Report from Providers

• Provider IIS: Reportable Disease Diagnoses

Two-way Directed Exchange

Hospital Admit/Discharge

• Hospital Primary Care: ADT Notification• Primary Care Hospital: Clinical Summary

Immunization Request

• EHR HISP/IIS: ADT Notification• HISP/IIS EHR: Updated Immunization

Closed Loop Referral • PCP Specialist: CCD/CCR• Specialist PCP: Updated CCD/CCR

Medical Home Update

• Medical Home EHR: Longitudinal Record Update• HIE Medical Home: Gap in Care, Updated Record

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How can other tools address more complex use cases?Tools Sequence of Actions

Patient Discovery • Initiating Gateway Responding Gateway: Request to indicate whether the community has knowledge of a patient matching a set of demographic criteria

• Responding Gateway Initiating Gateway: patients with matching demographics known by the responding community

Query for Documents

• Initiating Gateway Responding Gateway: request for document communities associated with a particular patient 

• Responding Gateway Initiating Gateway: communities with documents associated with that patient

Retrieve Documents

• Initiating Gateway Responding Gateway: request to a community for documents  associated with a particular patient 

• Responding Gateway Initiating Gateway: documents associated with that patient

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How will Direct work at scale?• Scalable Trust:

– Standards-based certificates

– Policies for issuance of certificates

• Scalable Directories: – DNS-based Directories at first

– Interoperable statewide directories with certificate lookup next

• Upcoming S&I Framework initiatives targeted at both of these topics

MEDfx Presentation

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Presentation Goals

• Involvement with Direct• Involvement with CONNECT• Evolution of the Direct / CONNECT integration• How the integrated solution works

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Involvement with Direct

• MEDfx involved from beginning in CONNECTathons• Joined Direct in September 2011

– Implementation Group– Reference Implementation WG– Implementation Geographies WG

• Provided Install for Java Bare Metal Direct Reference Implementation• Initiates Direct Project Pilot for Virginia Region

– MEDfx, Verizon, MedVirginia, and Dominion– Supports Referral to Patient Centered Medical Home– Integrated support with Lifescape Portal

• Demonstrates Direct / CONNECT solution at HIMSS 2011

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Involvement with CONNECT• SSA Disability Claims Use Case

– MedVirginia provides C32 to SSA via the NwHIN• Proprietary NwHIN Gateway

– July 2009 MEDfx integrates MedViriginia with CONNECT 2.0– Supports

• SubjectDiscovery• DocQuery• DocRetreive

• CHIEP– MedVirginia submits C83 to CMS for Patient Discharge Events– Upgrades to CONNECT 2.4– July 2010 MedVirgina goes into production– Supports

• Patient Discovery• DocQuery• DocRetrieve• XDS.b

– Provide and Register Document Set– Retrieve Document

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Involvement with CONNECT cont.• Virtual Lifetime Electronic Record (VLER)

– MedVirginia provides full NwHIN support to VA and DoD– Supports SSA, VA and Dod with single CONNECT instance– Adds Centra as subordinate HIE through MedVirginia

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CONNECT 2.0 Deployment

MedVirginiaPortal

HTTPS

Solution 1 CONNECTSSANwHIN

Subject DiscoveryDocument Query

Document Retrieve

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CONNECT 2.4 Deployment

MedVirginiaPortal

HTTPS

Solution 1 CONNECTSSA NwHIN

Patient DiscoveryDocument Query

Document Retrieve

VA

DoD

CMSXDS.b

Provide And Register Document Set

Review Document

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Legacy IntegrationSMTPMedVirginia

HISP

MedVirginiaPortal

SMTPS SSL

HTTPS

DominionHISP

DominionPortal

SMTPS SSL

HTTPS

Interchange

Lifescape

Solution 1

CONNECTfx

Interchange

Lifescape

Solution 1

DOD

VA

SSA

NwHIN

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Target ArchitectureSMTP

HISP 1

MedVirginiaSolution2

Portal

SMTPS SSL

HTTPS

HISP 2

VerizonLifescape

Portal

SMTPS SSL

HTTPS

Interchange

Lifescape

Oracle HTBOracle OHMPI

CONNECTfx

Interchange

Lifescape

DOD

VA

SSA

NwHIN

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Capabilities

• RIM HL7v3 CDR• Documents available via CONNECT• Ability to shred Documents into CDR via Direct• Ability to share Direct Sourced Documents• Ability to share C32 with content from structured

Direct Sourced Documents• Low overhead installation • Scalable

Q&A

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Poll