1. DIRECT TRANSPORT FOR QH 10/18-19 F2F NOTES (SPN)

2. NwHIN Direct = Email for Healthcare Add “just enough” technology to email to create a safe and usable environment Include providers and patients Provide an incremental path to evolve from…. – unstructured to structured data (attachments) – simple mail to integrated EHRs (inbox -> clinical task list) – manual to automated workflows (referrals@mypractice.com)referrals@mypractice.com And integrate seamlessly with the existing NwHIN/IHE constructs

3. MIME support for QH envelope Request – Body text: human-readable notes – Attachment: text/xml+queryhealth-query – Attachment: query payload Response – Body text: human-readable notes – Attachment: text/xml+queryhealth-response – Attachment: response data (text/csv?) Encrypted & Signed

4. Direct “Trust Circles” = “Query Networks” Need to be able to take advantage of “trust where we can find it” … individual, regional, organizational, someday national But demand convenience of a single email address / infrastructure Solution = enable participation in multiple “trust circles” as demonstrated by possession of certificates from multiple CAs HITPC still working on global trust CCF Cleveland CCF Toronto CCF Abu Dhabi University Hospital CCF Trust Circle Ohio HIE Trust Circle

5. Query Lifecycle 1.Requestor optionally uses a query builder user interface to create a query and submits it to their dedicated orchestrator. 2.The orchestrator determines at what time and frequency the query should run (one time, monthly, etc.) and submits the query when appropriate to its requestor agent. 3.Requestor agent submits the query over the Internet to each participating organization’s responder agent and awaits responses. Responder agents may provide a number of services: additional authorization, manual review, etc. 4.The responder agent calculates site results using the appropriate data sources. 5.The responder agent returns site results to the appropriate requestor agent. 6.The requestor agent returns site results to the aggregator that combines site results into combined results 7.The aggregator makes interim and final results available to the requestor. Requestor Agent Responder Agent Responder Agent Query Builder UX Aggregator Source Data Authorized Requestor 1a 1b 4 5 6 3 Responder “1”Responder “N” … Orchestrator 2 7 Note: All communication between Requestors and Responders are asynchronous.

6. Configuration Web Service Windows SMTP Service (Gateway) SMTP Event Sinks Security Agent SQL Configuration Web/Console UI DNS Responder “Real” SMTP Server Inbound, Outbound SMTP Msgs Email Clients MX, CERT Requests Human Admin Automated Admin XDD Gateway Inbound, Outbound XDD Msgs SMTP File DropPickup XDD Clients.NET R EFERENCE I MPLEMENTATION C OMPONENTS Query Health Agents and Computation engines

7. Direct-based QH Data Flow 1.Requestor uses a standard email client or research software to send a Direct query to a known address, e.g., queries@cdc.gov 2.Using standard COTS email list software, the distributor forwards the request to nodes that have agreed to respond. Certificates enforce “query network” security. 3.Each response node replies with a Direct message containing query results 4.Requestor aggregates responses as needed, either automatically or manually Direct HISP COTS / open source mailing list software Email Client or other research software Direct HISP … EHR or other data source EHR or other data source Requestor Distributor Responder 1Responder N 12 3 4

8. Advantages of NwHIN/Direct for QH Transport Asynchronous by design (with built-in acknowledgement) Secure / Proofable Supportive of multiple “query networks” by config Native support for multiple “query types” Reference implementations already have extensibility hooks to call into computation engines Infrastructure used to support basic messaging scenarios is 100% reusable for Query Health. No capital investment required, no new firewall rules, no new technology for IT. Bonus: supports “plain old email client” submission and receipt of QH queries if desired.