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
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Role Call
» Show of hands in audience
– EHR?
– PHR?
– Lab?
– Pharmacy?
– Others
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Proposed Interoperability
Physician’s
Office A
Laboratory
Send Results
Physician’s
Office B
Provider Referral, Receive Labs,
Send Prescription, Provider to Patient
Physician’s
Office C
NHIN/
Internet
Pharmacy
Receive Prescription
Patient
Visit Summary
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Proposed Systems View
Physician’s
Office A
Laboratory
Send Results
Physician’s
Office B
Provider Referral, Receive Labs,
Send Prescription, Provider to Patient
Physician’s
Office C
NHIN/
Internet
Pharmacy
Receive Prescription
Patient
Visit Summary
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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)
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NHIN Today
CONNECT Gateway
HTTP
HTTP
CONNECT Gateway
Adapter
Adapter
NHIN
CONNECT Gateway
CONNECT Gateway
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Other
Other
Gateways
Gateways
HTTP
HTTP
Adapter
HTTP
Adapter
CONNECT Today
Your Health Organization
Locate Patients
Other Health
Organizations
Retrieve
Disclosure
History
Locate Health
Systems/Services
Health
Data
Exchange
Decision
Disclosure
History
NHIN Conventions
Framework for Authorization,
Security, Privacy
External NHIN API
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Internal CONNECT API
Proprietary
Interface
Patient
Identity
Future
Services
Adapter
Publish/Subscribe
to Data Feed
CONNECT Gateway
Locate/Retrieve
Health Documents
Your Existing
Health
Information System
Custom
Interface
Proprietary
Interface
Custom
Interface
•
•
•
•
Master
Patient
Index
Health
Information
Exchange
Policies
Audit Logs
Terminology Mapping
Document Viewers
Clinical Decision Support
Other
Proprietary/Custom Interface
CONNECT Architecture:
Message From NHIN
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CONNECT Architecture:
Message to NHIN
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The Nationwide Health Information Network
Moving 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.
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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?
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CONNECT Tomorrow (Maybe NHIN too)
HTTP
XMPP
XMPP
Adapter
HTTP
CONNECT Gateway
EHR
(XMPP Client)
CONNECT Gateway
Adapter
EHR
(XMPP Client)
NHIN/ Internet
HTTP
XMPP
Other
Other
Gateways
Gateways
XMPP
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HTTP
Lab System
(XMPP Client)
XMPP
Adapter
HTTP
CONNECT Gateway
CONNECT Gateway
Adapter
Rx System
(XMPP Client)
CONNECT Tomorrow (Maybe NHIN too)
XMPP
Alternative
1
HTTP
XMPP
Adapter
HTTP
CONNECT Gateway
EHR
(XMPP Client)
CONNECT Gateway
Adapter
EHR
(XMPP Client)
NHIN/ Internet
HTTP
XMPP
Other
Other
Gateways
Gateways
XMPP
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HTTP
Lab System
(XMPP Client)
XMPP
Adapter
HTTP
CONNECT Gateway
CONNECT Gateway
Adapter
Rx System
(XMPP Client)
CONNECT Tomorrow (Maybe NHIN too)
XMPP
Alternative
2
HTTP
XMPP
Adapter
HTTP
CONNECT Gateway
EHR
(XMPP Client)
CONNECT Gateway
Adapter
EHR
(XMPP Client)
NHIN/ Internet
HTTP
XMPP
Other
Other
Gateways
Gateways
XMPP
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HTTP
Lab System
(XMPP Client)
XMPP
Adapter
HTTP
CONNECT Gateway
CONNECT Gateway
Adapter
Rx System
(XMPP Client)
Suggested Scope and Functionality (What)
» Provider to Provider
» Provider to Patient
» Lab to Provider
» Provider to Pharmacy
» Provider to Agency
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Provider to Provider
» Find Doctor (Doc Talk)
– Doctors share id with each other.
ID
– A provider searches and discovers
a 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.
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??
?
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.
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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.
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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
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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.
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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).
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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).
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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.
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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
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Provider to Pharmacy
» Send electronic prescription
for medications.
» Implement drug-drug, drugallergy, drug-formulary checks.
– Return alerts
– Check formulary
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Rx
Suggested Technical Requirements
»XMPP
»Technical Standards
»Discussion
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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
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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
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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:
–
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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
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
XMPP
– John Smith adds Lab to friend list and requests
“inclusion” into Lab’s friend list (First time only)
XMPP
– Lab uses the XMPP client to send the lab results
to John Smith.
XMPP
– 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.
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Scenario: Provider to Pharmacy
» Scenario
– Physician John Smith sends an order for a
prescription to the corner store pharmacy.
Rx
» Steps in the process
– John Smith authenticates into CONNECT XMPP
server using the XMPP client
XMPP
– John Smith adds the corner store pharmacy to friend
list and requests “inclusion” into pharmacy’s friend
list (First time only)
XMPP
– John Smith uses the XMPP client to send the
prescription to the pharmacy.
Rx
XMPP
– 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.
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Rx
XMPP Scenario Ideas?
» Administrative
Provider inbox
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Suggested Technical Approach (How)
» Provider to Provider
» Provider to Patient
» Lab to Provider
» Provider to Pharmacy
» Provider to Agency
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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?
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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).
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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?
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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
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Timeline
Q3 2010
Task Name
Q1 2011
Q2
2011
Duration
May
EHRI-SIG
Announcement
1 Day
Monthly Con Calls
1 Day
Face to Face
1 Day
Call
1 Day
Call
1 Day
Call
1 Day
Face to Face
1 Day
Call
1 Day
Call
1 Day
Call
1 Day
Face to Face
1 Day
Dry Run
3 Days
Demonstration (TBD)
2 Days
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Q4 2010
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
5/26
5/26
6/2
6/22
7/15
8/24
9/15
10/12
11/15
12/15
1/18
2/1
3/1
Apr
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
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Parting Thoughts
• Did we miss anything?
• We look forward to seeing you in June
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