New Hampshire Health Information Organization
Meaningful Use Stage II Support
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NHHIO Mission
As healthcare organizations look to transform healthcare by providing better
healthcare, improving the health of their patients, and reducing costs, the
need to more effectively and efficiently coordinate the care of patients has
never been more important.
The electronic transmission of patient health information between health
care providers in a timely, secure, and confidential manner is an important
next step in the evolution of health care delivery in the Granite State.
New Hampshire Health Information Organization
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Meaningful Use is the Building Block for other Clinical
Transformation Initiatives
Transform
Health Care
Access to and
Exchange of
Information
Improved population
health
Enhanced access and
continuity
Data utilized to improve
delivery and outcomes
Data utilized to improve
delivery and outcomes
Patient self
management
Patient engaged,
community resources
Care coordination
Care coordination
Patient centered care
coordination
Patient informed
Evidenced based
medicine
Team based care, case
management
Basic EHR functionality,
structured data
Structured data utilized
Registries for disease
management
Registries to manage
patient populations
Privacy & security
protections
Privacy & security
protections
Privacy & security
protections
Privacy & security
protections
Stage 1 MU
Stage 2 MU
Million Hearts
Utilize
Technology
New Hampshire Health Information Organization
PCMH/ “Stage 3 MU”
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
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Definitions
ONC: Office of the National Coordinator - Oversees the HIE grant and certifies EHRs
DSM: Direct Secure Messaging – Encrypted exchange of information between providers and
organizations without using a centralized repository
HPD: The healthcare provider directory is a “phone book” of providers using DSM
HISP: Health Information Service Provider – Assigns Direct addresses and provides the
network for providers listed in the HPD to utilize DSM.
Direct: A national standard for interoperability using specific email type addresses, defined
message formats and transport protocols
•
XDR-SOAP (optional of ONC certification)
•
SMTP-S/MIME (required for ONC certification)
CCD: Continuity of Care Document – A medical summary of patient information
CCDA: Consolidated Clinical Document Architecture – A standard for message formats under
the Direct protocols
CEHRT: Certified Electronic Health Record Technology
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
© NHHIO. All rights reserved.
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Supported Meaningful Use Objectives
Eligible Professional (EP)
Core: Incorporate clinical lab-test results into Certified EHR Technology (CEHRT) as
structured data.
Core: The EP who transitions their patient to another setting of care or provider of care
or refers their patient to another provider of care should provide a summary care
record for each transition of care or referral.
Menu: Imaging results consisting of the image itself and any explanation or other
accompanying information are accessible through CEHRT.
Menu: Capability to identify and report cancer cases to a public health central cancer
registry in accordance with applicable law and practice.
New Hampshire Health Information Organization
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Supported Meaningful Use Objectives
Eligible Hospital (EH)
Core: Incorporate clinical lab-test results into Certified EHR Technology (CEHRT) as
structured data.
Core: The eligible hospital or CAH who transitions their patient to another setting of
care or provider of care or refers their patient to another provider of care provides a
summary care record for each transition of care or referral.
Core: Capability to submit electronic reportable laboratory results (ELR) to public
health agencies in accordance with applicable law and practice.
Core: Capability to submit electronic syndromic surveillance data to public health
agencies in accordance with applicable law and practice. (AHEDD)
Menu: Imaging results consisting of the image itself and any explanation or other
accompanying information are accessible through CEHRT.
Menu: Provide structured electronic lab results to ambulatory providers
New Hampshire Health Information Organization
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Meaningful Use Objectives – Details Matter
Core EP/EH: The EP/EH who transitions their patient to another setting of care or
provider of care or refers their patient to another provider of care should provide a
summary care record for each transition of care or referral.
 Problem list must use Systematized Nomenclature of Medicine Clinical Terms
(SNOMED CT)
 Review translation requirements between ICD-9/10 and SNOMED
Menu EP: Imaging results consisting of the image itself and any explanation or other
accompanying information are accessible through CEHRT.

Either incorporation of the image or an indication that the image is available
in another technology and a link to that image
Menu EH: Provide structured electronic lab results to ambulatory providers


Must use Logical Observation Identifiers Names and Codes (LOINC)
Lab must be HL7 v2.5.1
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
© NHHIO. All rights reserved.
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Meaningful Use Objectives – Not Supported (Today)
Core EP: Provide patients the ability to view online, download and transmit their health
information within four business days of the information being available to the EP.
Core EH: Provide patients the ability to view online, download, and transmit
information about a hospital admission.
Core EP: Use secure electronic messaging to communicate with patients on relevant
health information.
RSA 332-I:3 Use and Disclosure of Protected Health Information; Health Information
Exchange:
“Only a health care provider, for purposes of treatment, may have access to protected
health information transmitted through the health information organization.”
http://www.gencourt.state.nh.us/legislation/2014/SB0229.html
New Hampshire Health Information Organization
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Meaningful Use Objectives – Not Supported (Today)
Menu EP: Capability to submit electronic syndromic surveillance data to public health
agencies except where prohibited, and in accordance with applicable law and practice.
Menu EP: Capability to identify and report specific cases to a specialized registry
(other than a cancer registry), in accordance with applicable law and practice.
Core EP: Capability to submit electronic data to immunization registries in accordance
with applicable law and practice.
Core EH: Capability to submit electronic data to immunization registries in accordance
with applicable law and practice.
What are my requirements for Public Health Meaningful Use reporting?
Currently the New Hampshire Department of Health and Human Services has the ability
to accept electronic surveillance data from Eligible Hospitals (EH’s) only.
http://www.recnh.org/public-health/
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
© NHHIO. All rights reserved.
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What is Direct?
The Direct Project establishes standards and documentation to support simple
scenarios of pushing data from where it is to where it's needed, in a way that will
support more sophisticated interoperability in the future.
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Message Formats and Transport Protocols
Providing summaries of care, and the ability for patients to view, download and
transmit their medical information requires data to be sent using Direct.
CCDA care summaries must contain at least problem lists, medications, and
medication allergies.
SMTP-S/MIME (required for ONC certification)
 Sends CCDA as an email attachment
 Provides ability for text component in the message
XDR-SOAP (optional of ONC certification)
 Directly sends CCDA to recipient with text component
Like any email product, both require a secure network to transport:
 Health Information Service Provider (HISP)
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
© NHHIO. All rights reserved.
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Health Information Service Provider (HISP)
An organization that manages security and transport for health information
exchange among health care entities or individuals using the Direct standard for
transport.
There is no specific legal designation for a HISP, nor are HISPs specifically
regulated by Meaningful Use certification rules.
Functions can be performed by existing organizations (such as EHR vendors or
HIE organizations) or by standalone organizations specializing in HISP services.
HISPs perform two key functions that support scalability of exchange using the
Direct standard.
•
Issue security certificates. HISPs establish trust networks by defining
policies for network participation and issuing security certificates tied to a
HISP anchor certificate to enforce such policies
•
Issue direct addresses. HISPs issue direct addresses tied to the HISP
anchor certificate in accordance with conventions defined by the Direct
standard
New Hampshire Health Information Organization
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HISP Connections
Direct messages are delivered using a To: and a From: Direct email address
available through a Healthcare Provider Directory (HPD)
Information generally travels within a HISP, or between HISPs depending on the
intended recipient

Encryption maintained throughout transport

Root trust certificates can be shared in “trust bundle” between HISPs

HISPs can become members of Direct Trust
 Voluntary private non-profit collaborative
 Rigorous “accreditation” process to ensure security and
participant identification process
 Certificates placed in “trust bundle”
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
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Transmitting Summary of Care Record
The EP/EH who transitions or refers their patient to another setting of care or
provider of care provides a summary of care record electronically for more
than 10 percent of such transitions and referrals
1. Use of the transport standard capability required for certification:,
(SMTP/SMIME) using their CEHRT’s “Direct” capability (natively or
combined with an intermediary) – 3rd Party HISP or NHHIO
2. Use of the SOAP-based optional transport standard capability permitted
for certification: transmit summary care records using their CEHRT’s
“SOAP-based” capability (natively or combined with an intermediary) –
NHHIO Direct
3. Use of CEHRT to create a summary care record in accordance with the
required standard and the electronic transmission is accomplished
through the use of an eHealth Exchange participant who enables the
electronic transmission of the summary care record to its intended
recipient. - Currently not utilized in NH
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What is the eHealth Exchange?
Group of federal agencies and non-federal organizations that came together
under a common mission and purpose to improve patient care, streamline
disability benefit claims, and improve public health reporting through secure,
trusted, and interoperable health information exchange.
Membership with the eHealth Exchange is not a Meaningful Use requirement.
New Hampshire Health Information Organization
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What Receipt Acknowledgement is Required?
Meaningful use attestation requirements do NOT specify how you get assurance of
delivery, they specify only that you have taken reasonable steps to be confident of
delivery.
The most robust way for you to be assured of message delivery is for your system
to receive message disposition notifications (MDNs) for each message sent by your
EHR to the intended recipient. However, not all receiving systems or HISPs can
generate MDNs, and not all EHR systems can consume MDNs even if they are
delivered.
Fortunately, you are not required to receive MDNs in order to be assured of
delivery.
Other acceptable methods of assurance are through HISP guarantees of delivery
after successful setup testing, for example, or exception notification of failure of
delivery (like emails).
NHHIO HISP participants will be able to receive audit logs of transmission status
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
© NHHIO. All rights reserved.
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3rd Party HISP Connections
New Hampshire Health Information Organization
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DSM Direct – XDR (NHHIO HISP)
Pending ONC
2014 Certification
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
© NHHIO. All rights reserved.
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NHHIO Architecture and HISP Services
CHAN
Health
Centers
Public
Health
(DHHS)
VNA /
Homecare
Inter-state / HISP
communications
ASCC
NH Statewide Network – “Backbone”
Phase I:
Node
addressing
Security
Provider
addressing
Audit
• Direct Secure Messaging
(DSM)
Relationship Listing Service (EMPI)
• Inter-state / HISP
gateway
Provider
Practices
NH
Hospital
Hospital
MD
MD
MD
MD
Behavioral
Health
Diagnostic
testing
Long-term
care
SNFs
MD
New Hampshire Health Information Organization
Phase II:
• Relationship Listing
Service (RLS) –
Electronic Master Person
Index (EMPI)
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Electronic Health Record (EHR) Integration
DSM
NHHIO Trust
Network
Basic Direct Secure Messaging
• Web-based access
• Email client access
Web
Managed Direct Secure Messaging
• Client-deployed hardware device
(LAND Appliance)
• Monitored by OH Managed
Services
HPD
DSM
Connect
Direct Secure Messaging with
EHR System integration
• Encrypted S/MIME access
• HISP-HISP Capability
• Encrypted XDR access
CERT
MSG
DSM
Direct
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
© NHHIO. All rights reserved.
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What about Results Delivery?
NHHIO supports Direct Secure Messaging but is “payload agnostic” and can
support other types of data transport using the Direct protocols to advance
better Care Coordination and reporting requirements
Public Health Reporting:

AHEDD / ELR from hospitals (HL7 v2.5.1)
 Utilizes DSM Connect Device to encrypt and deliver
 Naming Convention Change or Send Documents format (XML)

Cancer Registry
 Will accept CCDA cancer registry reports
Laboratory and Radiology Results:

Requires use of XDR packaging
 DSM Connect Device
 EHR Direct sending/receiving capabilities (if XDR/SOAP
Certified)
New Hampshire Health Information Organization
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Agenda
Definition of Terms
Supported Meaningful Use Objectives
Unsupported Meaningful Use Objectives
What is Direct?
Health Information Service Provider (HISP)
Transmitting Summary of Care Record
New Hampshire HISP Connections
NHHIO Connection Options and Services
HL7 Results Delivery
Resources and Questions
New Hampshire Health Information Organization
© NHHIO. All rights reserved.
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NHHIO Resources
www.nhhio.org
Project Contact Information
125 Airport Road, Concord, NH 03301
Office. (603) 219-0184
Fax. (603) 218-6126
www.NHHIO.org
Jeff Loughlin
c: (508) 326-3944
o: (781) 434-7751
jloughlin@maehc.org
Jackie Baldaro
c: (339) 223-0888
o: (781) 434-7553
jbaldaro@maehc.org
New Hampshire Health Information Organization
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