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RHEx Pilots Lessons Learned WebEx #8 27 September 2012 Powering Secure, Web-Based Health Data Exchange wiki.siframework.org/RHEx

What is RESTful Health Exchange (RHEx)? Open source, exploratory project to apply Web technologies to demonstrate a simple, secure, standards- based health information exchange –Builds the foundation for patient access to data via the Web and mobile devices, removing barriers to broad electronic health data exchange –Offers a new approach to health data exchange –From moving documents to linking to needed information Sponsored by the Federal Health Architecture (FHA) program in FY12 Continues tradition of Federal partner leadership –Investing in innovative solutions to health IT needs –Sharing results with entire health IT community 3 RHEx informs a path forward on RESTful health data exchange

Outline Overview of RHEx Pilots RHEx Pilot with TATRC RHEx Pilot with HealthInfoNet Lessons Learned Conclusions 4

55 Pilot with TATRC –Goal: Demonstrate simple, secure RESTful health data exchange in two phases –Use Case: Consults/Referral Selected via discussions with Federal Partners –FHA Partner: Steve Steffensen and Ollie Gray, TATRC Telemedicine & Advanced Technology Research Group (TATRC), U.S. Army Medical Research & Materiel Command (MRMC) Pilot with HealthInfoNet –Goal: Investigate use of RESTful approach to populate Maine HIE (HealthInfoNet) Clinical Data Repository –Use Case: Populate single electronic health record for patients in medically underserved areas –FHA Partner: Todd Rogow, HealthInfoNet Develop proof of concept for a World Wide Web model for health data exchange RHEx Pilots

6 Two different RHEx pilots Pilot with TATRC focuses on secure RESTful transport between people Pilot with HealthInfoNet focuses on secure RESTful transport between machines Secure RESTful transport: OpenID Connect for distributed user authentication (person in the loop) Secure RESTful transport: OAuth2 for service to service authentication (machine to machine) Consult/Referral Transport volumes of data to State HIE Clinical Data Repository Pattern Use Case Security Differences in:

7 TATRC PILOT RHEx Pilots Lessons Learned

RHEx Pilot with TATRC Worked with selected federal partners to identify critical capability gaps and select a prototype use case –Consult results are not consistently sent to PCP today, impacting healthcare for Veterans and Service Members Demonstrate secure, RESTful health data exchange in support of Consult/Referral scenario Phase 1: Secure exchange –Implement the secure exchange of health data with Direct secure messaging and OpenID authentication –Develop an OpenID Connect Identity Provider and a simple Web application that will act as the Relying Party Phase 2: Content –Provide a richer set of services by utilizing emerging standards to support secure exchange of data in a granular fashion 8

consult results Sample Consultation/Referral Process 9 PCPPayer consult request Consult results are not consistently sent to PCP resulting in diminished patient care authorized consult request PCP = Primary Care Physician = Paper, Fax, or Consulting Physician

consult results Improving the Consultation/Referral Process 10 PCP Payer consult request authorized consult request PCP = Primary Care Physician RHEx approach allows PCP and Consulting Physician to access and retrieve current, relevant portions of each other’s records when they need them URL-1 = Consult Requests Details URL URL-2 = Consult Results Details URL URL-1 URL-2

Phase 1 Focus 11 PCP = Primary Care Physician Phase 2 Focus URL-3 Links to patient vitals

12 TATRC Pilot Architecture

13 HEALTHINFONET PILOT RHEx Pilots Lessons Learned

Motivation for Pilot with HealthInfoNet Worked with HealthInfoNet to identify how RHEx technology might be applied –Today, patient health data from 26 hospitals and 240 ambulatory practices is moved in near real time to the Clinical Data Repository at HealthInfoNet –However, data is not sent today from smaller organizations who do not have the expertise to support a traditional HL7 interface connection to the HIE –By providing a simple, lightweight, secure method of transferring health data, small practices in underserved areas in Maine will be able to participate in the Maine HIE system –In addition, this work will contribute to the foundation for standard, machine processable formats from providers to Maine HIE for smaller healthcare organizations 14

Goal of RHEx Pilot with HealthInfoNet Demonstrate secure, RESTful health data exchange from a Federally Qualified Health Center (FQHC) to Maine HIE using RHEx 15 Islands Community Medical Services

Health data flow for connected providers in Maine 16 A patient can opt out of the Maine HIE system. 1. Provider sends form to Maine HIE. A patient can refrain from opting out of the Maine HIE system. 3. Maine HIE deletes the patient health data and marks patient as “opted out”. X X X X X X Opted out 2. Flow of patient data from provider to HIE is blocked. X 1. After patient visit is complete, physician updates patient’s record. 3. HL7 message is sent in near real time. 2. EHR system sends message to Maine HIE. Single VPN Interface for healthcare organizations

Health data flow for Islands Community Medical Services in RHEx pilot 17 A patient can opt out of the Maine HIE system. 1. Provider sends form sent to Maine HIE. A patient can refrain from opting out of the Maine HIE system. 3. Maine HIE deletes the patient health data and marks patient as “opted out”. X X X X X X Opted out 2. Flow of patient data from provider to HIE is blocked. X 1. After patient visit is complete, physician updates patient’s record. 3. C32 document is encrypted and sent in near real time to Maine HIE using HTTPS POST over the Web. 2. EHR system automatically generates a patient’s C32 and places it in a file directory for transport. Opting out process is same as for connected providers. Islands Community Medical Services

HealthInfoNet Pilot Architecture Islands Community Medical Services Shared File System EHR Trigger EHR Environment OAuth2 TLS RHEx Client HL7 v2 messages OAuth2 Server Maine HIE DMZ RHEx Endpoint Integration Engine Clinical Data Repository C32 Processing Queue OAuth2 Client Database OAuth2 Client Database Translation C32s C32 18 EHR System EHR System greenC32s Translation to HL7 v2

19 LESSONS LEARNED AND CONCLUSIONS RHEx Pilots Lessons Learned

Lessons Learned, 1 of 2 Collaboration with TATRC and HealthInfoNet has been outstanding REST architectural style applies to multiple patterns of use –Person to person –Machine to machine –Can be leveraged to securely transport different types of documents/messages Use of REST aids in troubleshooting integration problems –Easier to inspect network traffic –Most network transactions can be tested via web browser sessions REST is not a magic bullet - integration issues still occur –e.g., Issues with clocks being out of sync 20

Lessons Learned, 2 of 2 Use of OAuth and OpenID Connect work well as identity and authentication solutions greenC32 format useful for standardizing input to HIE Clinical Data Repository, but standardization tool still needs to be configured to handle different vendor C32s RHEx could be a solution for pushing large volumes of data in support of health information exchange EHR automated trigger capability requires licensing by some EHR vendors (cost could be prohibitive for small independent providers) 21

Conclusions RHEx project has explored secure, Web-based health data exchange, building the foundation for future advances in health care –Allows providers and patients to exchange health data securely over the World Wide Web –Building foundation for secure access via mobile devices Concepts were tested in pilots with TATRC and HealthInfoNet Lessons learned can be applied in future initiatives –e.g., Automating Blue Button Initiative (ABBI) 22 RHEx is informing a path forward for the future of health data exchange

Discussion 23

BACKUP CHARTS RHEx Pilots Lessons Learned 24

25 Sending A Referral AHLTA via PAWS AHLTA via PAWS Dynamic Document Service Dynamic Document Service PCP System Authentication Service Authentication Service OpenID RHEx Endpoint OAuth Test Data OpenID Provider OpenID Provider Consult 2. Direct message with referral link is sent. 6. User authenticates. Direct Gateway Direct Gateway Direct Gateway 1. PCP creates referral. 5. User redirected to OpenID Provider for authentication. 7. User redirected back to URL. 8. Referral viewed by user. 4. User accesses link 3. User receives message. PCP

RHEx TATRC Pilot Phase 2 Model Vision 26 greenC32 Patient Procedures Allergies Medications Lab Results Vital Signs PCP EHR Consulting Provider EHR

Approach to Content Organization, 1 of 2 27 Abstract Content Model Diagram Supports coarse documents OData could be implemented as a Section Feed Supports hierarchy of patient data Describes content available and resource URIs URIs can point to DICOM images or granular patient data, such as allergy or medication

Approach to Content Organization, 2 of 2 28 Course Grained Link Example Granular Content Link Example

HTTP POST Community Medical Services/1234/c32?token=e2FzZHNkOiAicG9k… Technical data flow in RHEx pilot, 1 of 2 Islands Community Medical Services Shared File System EHR Trigger EHR Environment OAuth2 TLS RHEx Client 1. After patient visit is complete, physician updates patient’s record in EHR system. 2. EHR system trigger is used to move C32 document to shared file system. 3. RHEx Client detects the update and invokes OAuth2 workflow. 4. OAuth2 Server authenticates client and secure transport is established. HL7 v2 messages OAuth2 Server Maine HIE DMZ RHEx Endpoint Integration Engine Clinical Data Repository C32 Processing Queue OAuth2 Client Database OAuth2 Client Database Translation C32s C32 5. C32 document is encrypted and moved to the RHEx endpoint over the Web using HTTPS POST. 29 EHR System EHR System greenC32s Translation to HL7 v2

HTTP POST Community Medical Services/1234/c32?token=e2FzZHNkOiAicG9k… Technical data flow in RHEx pilot, 2 of 2 Islands Community Medical Services Shared File System EHR Trigger EHR Environment OAuth2 TLS RHEx Client HL7 v2 messages OAuth2 Server Maine HIE DMZ RHEx Endpoint Integration Engine Clinical Data Repository C32 Processing Queue Translation C32s Token Store Token Store 6. RHEx endpoint moves the C32 to a processing queue within the Maine HIE firewall, where it is decrypted. 7. C32 document is processed by the queue, translated into greenC32 and sent to Integration Engine. 8. Orion sends HL7 message to Clinical Data Repository. 30 EHR System EHR System greenC32s Translation to HL7 v2