ehri-sig

EHRI-SIG

Announcement

1

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

2

Role Call

»Show of hands in audience

– EHR?

– PHR?

– Lab?

– Pharmacy?

– Others

3

Proposed Interoperability

4

NHIN/Internet NHIN/

Internet

Send Results

Receive Prescription

Visit Summary

Laboratory

Pharmacy

Patient

Provider Referral, Receive Labs,Send Prescription, Provider to Patient

Physician’s Office A

Physician’s Office B

Physician’s Office C

Proposed Systems View

5

NHIN/Internet NHIN/

Internet

Send Results

Receive Prescription

Visit Summary

Laboratory

Pharmacy

Patient

Provider Referral, Receive Labs,Send Prescription, Provider to Patient

Physician’s Office A

Physician’s Office B

Physician’s Office C

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)

6

NHIN Today

7

CONNECT GatewayCONNECT Gateway

AdapterAdapter


AdapterAdapter

CONNECT Gateway CONNECT Gateway

AdapterAdapter


AdapterAdapterOther

GatewaysOther

Gateways

Other Gateways

Other Gateways

HT

TP

HT

TP

HT

TP

HT

TP

HT

TP

HT

TP

HT

TP

HT

TPHTTPHTTP

NHINNHIN

Ada

pter

Your Health Organization

Future Services

• Terminology Mapping• Document Viewers• Clinical Decision Support• Other

Patient Identity

HealthData

Exchange Decision

Disclosure History

NHIN ConventionsFramework for Authorization,

Security, Privacy

Locate/RetrieveHealth Documents

Publish/Subscribeto Data Feed

Your Existing Health

Information System

Health Information

Health Information

Audit LogsAudit Logs

ExchangePolicies

ExchangePolicies

Master PatientIndex

Master PatientIndex

ProprietaryInterface

CustomInterface

ProprietaryInterface

CustomInterface

CO

NN

EC

T G

atew

ay

Locate Patients

Locate HealthSystems/Services

Other Health

Organizations Retrieve Disclosure

History

Proprietary/Custom InterfaceExternal NHIN API Internal CONNECT API

CONNECT Today

8

CONNECT Architecture: Message From NHIN

9

CONNECT Architecture: Message to NHIN

10

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.

11

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?

12

CONNECT Tomorrow (Maybe NHIN too)

13

Rx System(XMPP Client)


Lab System(XMPP Client)Lab System

(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)


AdapterAdapter


AdapterAdapter


AdapterAdapter


AdapterAdapterOther

GatewaysOther

Gateways

Other Gateways

Other Gateways

NHIN/ InternetNHIN/ Internet

HT

TP

HT

TP

HT

TP

HT

TP HT

TP

HT

TP

HTTPHTTP

HT

TP

HT

TP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XMPPXMPP


14




(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)


AdapterAdapter


AdapterAdapter


AdapterAdapter


AdapterAdapterOther

GatewaysOther

Gateways

Other Gateways

Other Gateways


HT

TP

HT

TP

HT

TP

HT

TP HT

TP

HT

TP

HTTPHTTP

HT

TP

HT

TP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XMPPXMPP

Alternative 1

Alternative 1


15




(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)

EHR(XMPP Client)


AdapterAdapter


AdapterAdapter


AdapterAdapter


AdapterAdapterOther

GatewaysOther

Gateways

Other Gateways

Other Gateways


HT

TP

HT

TP

HT

TP

HT

TP HT

TP

HT

TP

HTTPHTTP

HT

TP

HT

TP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XM

PP

XMPPXMPP

Alternative 2

Alternative 2

Suggested Scope and Functionality (What)

»Provider to Provider

»Provider to Patient

»Lab to Provider

»Provider to Pharmacy

»Provider to Agency

16

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.

17

ID

???

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.

18

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.

19

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

20

SUMMARY

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.

21

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).

22

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).

23

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.

24

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

25

Provider to Pharmacy

»Send electronic prescription for medications.

» Implement drug-drug, drug-allergy, drug-formulary checks.

– Return alerts

– Check formulary

26

Rx

Suggested Technical Requirements

»XMPP

»Technical Standards

»Discussion

27

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

28

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

29

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.

30

XMPP

XMPP

XMPP

XMPP

XMPP

XMPP

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.



– 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.

31

XMPP

XMPP

XMPP

XMPP

XMPP

XMPP

Scenario: Provider to Pharmacy

» Scenario

– Physician John Smith sends an order for a prescription to the corner store pharmacy.



– 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.

32

RxRx

XMPP

XMPP

XMPP

XMPP

XMPP

XMPP

RxRx

RxRx

XMPP Scenario Ideas?

33

» Administrative Provider inbox

Suggested Technical Approach (How)

»Provider to Provider

»Provider to Patient

»Lab to Provider

»Provider to Pharmacy

»Provider to Agency

34

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?

35

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).

36

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?

37

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

38

Timeline

39

Task Name Duration

Q3 2010 Q4 2010 Q1 2011 Q2 2011

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

EHRI-SIG Announcement

1 Day 5/26

Monthly Con Calls 1 Day 5/26

Face to Face 1 Day 6/2

Call 1 Day 6/22

Call 1 Day 7/15

Call 1 Day 8/24


Call 1 Day 10/12

Call 1 Day 11/15

Call 1 Day 12/15


Dry Run 3 Days 2/1

Demonstration (TBD) 2 Days 3/1

Governance

»Les and Greg will be Co-Chairs

»Select two industry Co-Chairs, possibly more

– Email [email protected] if interested

– Connect Co-Chairs will be selected and announced at the June meeting

»Scribe wanted

40

Parting Thoughts

• Did we miss anything?

• We look forward to seeing you in June

41

ehri-sig

Documents

provider provider

provider searches

medical service provider

accurate health information

information sharing

order referrala provider

nhin directinteroperability

forwardthe nhin