1. Direct Implementation Perspective 0 Mark Bamberg, Vice President Research & Development MEDfx

2. Overview Introduction Secure Content Delivery with DIRECT HIE Architecture Lab result delivery Heterogeneous Labs Multiplexed thru HIE Recommendations 1

3. Introduction - MEDfx 2 Committed member of ONC Standards and Interoperability Framework. Participating member of Transitions of Care Architecture Workgroup. Participating as Workgroup Lead for S&I Framework Transitions of Care Reference Implementation and Pilots Workgroup. Participating member of Direct Reference Implementation and Direct Implementation Geographies Workgroups. Completed Direct Project Pilot unveiled at the HIMSS 2011 ONC Interoperability Showcase with a live demonstration of NwHIN and Direct interoperability.

4. Introduction – MEDfx 3 Developed 1 st integration of an HIO to a government agency to provide CCD documents to SSA automating the disability determination process. Integrated the 2 nd Virtual Lifetime Electronic Record (VLER) community using the NwHIN to connect an HIO to the Veterans Administration (VA) and Department of Defense (DoD). ‘First to CMS via the NHIN’ as a participant in the C-HIEP project enhancing communication and coordination of care across multiple settings. Invited to demonstrate NwHIN integration to members of Congress as part of Health IT Week in Washington, D.C., September 2009.

5. Secure Content Delivery with Direct Lab Order Example 4 HIE/EHR HISP HIE/EHR HISP Lab HIE / EHR Backend HIE / EHR Portal/Client 1.EHR Portal/Client sends lab result query to EHR Backend or HIE via EDGE over secure channel 2.EHR Backend or HIE sends message to HISP using SMTPS on port 465 3.HISP verifies Lab is trusted by verifying the Lab’s certificate can be located and has been digitally signed by a trusted authority (Root Anchor) 4.HISP uses Provider’s Private Key (to sign) and Lab’s Public key (encipher) to create a secure payload encode using S/MIME 5.HISP routes message via SMTP on port 25 to Lab’s HISP 6.Lab HISP verifies Provider is trusted by verifying the Provider’s certificate can be located and has been digitally signed by a trusted authority (Root Anchor) 7.Lab uses its Private key to decipher and Providers public key to verify message signature 8.HISP sends deciphered message to Lab backend 9.HISP sends receipt to Provider SMTP 1 SMTP 2 SMTP 3 LAB HISP LAB HISP

6. Secure Content Delivery with Direct Lab Result Example 5 HIE/EHR HISP HIE/EHR HISP LAB HIE / EHR Backend HIE / EHR Portal/Client 1.Lab sends lab result sends message to Lab HISP using SMTPS on port 465 2.HISP verifies Provider is trusted by verifying the Provider’s certificate can be located and has been digitally signed by a trusted authority (Root Anchor) 3.HISP uses Lab’s Private Key (to sign) and Provider’s Public key (to encipher) to make a secure payload encoded using S/MIME 4.HISP routes message via SMTP on port 25 to Provider’s HISP 5.Provider’s HISP verifies Lab is trusted by verifying the Lab’s certificate can be located and has been digitally signed by a trusted authority (Root Anchor) 6.Provider uses its Private key to decipher and Lab’s public key to verify message signature 7.HISP sends deciphered message to HIE /EHR backend 8.HISP sends receipt to the Lab SMTP 1 SMTP 2 SMTP 3 LAB HISP LAB HISP

7. HIE Architecture Components 6 Clinical UI HIE Service Framework Authorization Store Authorization Store RIM-based CDR Consent Subscription Management Subscription Management Administration Identity Provider Provider Registry Provider Registry Audit Repository Audit Repository MPI NwHIN DIRECT Other EDGE HIE Framework

8. HIE Lab Feeds 7 HIE Service Framework NwHIN DIRECT SSA VA DOD HISP Lab Feeds EDGE Clinical UI EHR Backend EDGE EHR Portal/Client

9. Lab Provider with No DIRECT Capability Traditional Approach – Transport VPN – MLLP – FTP SFTP – Content HL7V2 8 Lab Feeds EDGE

10. Lab Provider with DIRECT Capability SMTP – Patient Context – Message CDA based document container HL7V2 IHE XDS.b profile – Metadata used to construct patient context 9 HISP Lab Feeds

11. EHR with no DIRECT Interface DIRECT to HISP – SMTP – IHE XDS.b profile Conversion to traditional feed CDA contained messages can be converted to HL7V2 10 DIRECT HISP Lab FeedsEHR Backend EDGE HIE Service Framework

12. DIRECT Enabled EHR DIRECT to HISP – SMTP – IHE XDS.b profile 11 HISP Lab FeedsEHR Backend EHR Portal/Client

13. Heterogeneous Labs Multiplexed thru HIE 12 HIE Traditional Lab Feeds Traditional Lab Feeds HIE Portal HISP Traditional Lab Feeds Traditional Lab Feeds Traditional Lab Feeds Traditional Lab Feeds Traditional Lab Feeds Traditional Lab Feeds Traditional Lab Feeds Traditional Lab Feeds Direct enabled Lab Feeds Direct enabled Lab Feeds EDGE HISP EHR Portal HIE Portal

14. HIE Simplifies Complexity 13 Lab 1 Lab 2 Lab 3 EHR 1 EHR 2 EHR 3 Lab 1 Lab 2 Lab 3 EHR 1 EHR 2 EHR 3 HIE O(n 2 )O(n)

15. Recommendations Multiplex Lab Feeds thru HIE – Reduces complexity and cost of developing interfaces – Handles message routing – Automatic transport and content conversion – Ensures lab orders and results delivery Message failures are routed to remediation Utilize EHR Hub Solutions – When an EHR has a Hub solution, the EDGE appliance can connect to the EHR Hub for message routing 14

16. Contact Mark Bamberg Vice President of Research and Development mark.bamberg@medfx.com (401) 965-6626 15