Session 11: Moving into the Future: Direct and the NwHIN
4/13/11: 3:30 --5:00PM

Session Objectives
● Discuss how Direct fits into NwHIN
● Arien Malec, Coordinator, Direct Project, ONC
● Mark Bamberg, VP Research & Development, MEDfx

Presentation 1, Arien Malec, ONC
● HIE is not a one size fits all scenario. It is not one hammer that pounds all nails. At scale, we will see different kinds of exchange being used for different purposes.
● In PCMH, getting the provider in the loop of care is a value and asset in that care transition.
● When a patient’s care is fragmented across multiple delivery systems and when there is intelligence built into repository, this is bridge to more sophisticated HIE
● What is the NwHIN?
○ What we are aiming at is a true nationwide health information network that uses the internet to transport care. Every form of HIE should be part of NwHIN. It should all use standards, policies, etc. in a trust framework. This aims to be the superset of all HIE.
● What scenarios will the NwHIN address?
○ Each scenario requires a different tool. At scale, each scenario uses a subset of these different tools.
○ Direct, and Direct with value-added intermediaries, work in scenarios where physicians are pushing information in a one-to-one fashion
○ If a patient moves, etc. and treating physicians needs more information, the you probably need need more complex exchange
○ Even more complex when you are creating a longitudinal patient record across the community and across care settings
○ There are sets of standards that are applicable for different aspects of HIE.
○ When Direct is needed:
- Directed exchange
- Directed exchange with value-added intermediaries
- Can be useful in more advanced exchange
- When information is not needed right now, push can be effective for more advanced exchange
● ADT trigger, push something back = this is a common scenario. Lots of HIOs work like this. But this is not the only way.
○ Real-time query/retrieve - might want to do a pull.... Query/Retrieve for Docs/Patient Discovery
○ Having a range of tools is a good thing
● Direct can be used to enable a variety of different use cases:
○ One way exchange
- Referral (provider to provider)
- Lab results report (lab to provider)
Public health report (lab to ELR or provider to IIS)
○ Two way (two pushes - look like query/retrieve that are really two pushes) The kinds of cases where this makes sense include:
- #1: Providers can do it already and its a simple add
- #2: Actual workflow is asynchronous and time delayed
- Not right when data is needed “just in time”
- Use cases include:
● Hospital admit/discharge
● Immunization request
● Closed loop referral
● Medical home update
● When can other tools address more robust use cases?
○ How does a NwHIN query for information?
- Step 1: Patient Discovery
● Can skip if you have already synched up MPIs (know there the patient is)
● Ask the place you are asking if they know the patient
● Example: Virtual Lifetime Record (VLR) between DOD and VA
- Step 2: Query for Documents
● Asking for document
- Step 3: Retrieve Documents
● Get the documents
● Scalability of Direct
○ NwHIN governance is critical to scalability to Direct.
○ Technology for Direct is simple. Hard part is access to certificate and scalable trust.
○ Need to get nationwide governance
○ Getting lists of trust anchors across multiple HISPs
○ Establish standardized mechanisms for issuing certificates
- Following same policies in terms of identify management, authentication, etc. across trust anchors
○ Over time, we need standards for interoperable directories for look-up

Presentation 2, Mark Bamberg, MEDfx
● Importance of invention
○ The Thomas Edison machine shop was the vehicle for creating inventions for Thomas Edison’s company
- Led by the “Insomnia squad” (behind the scenes).
● They could create inventions faster and better than anyone else, and would race to the patent office before competitors
● Direct and open source CONNECT are like this
● Compete and collaborate at the same time
● How did MEDfx get involved with Direct?
○ Joined in Sep 2011
○ Joined the reference implementation and implementation geographies workgroups
○ Initiated a PCMH pilot in the Virginia region, involving:
- MEDfx
- Verizon
- MedVirginia
- Dominion Medical Associates
● Involvement with CONNECT, supporting multiple CONNECT projects:
○ SSA Disability Claims Use Case
- MedVirginia provides C32 to SSA via the NwHIN
- Proprietary NwHIN Gateway
- July 2009 MEDfx integrates MedViriginia with CONNECT 2.0
- Supports
● SubjectDiscovery
● DocQuery
● DocRetreive
- MedVirginia submits C83 to CMS for Patient Discharge Events
- Upgrades to CONNECT 2.4
- July 2010 MedVirginia goes into production
- Supports
● Patient Discovery
● DocQuery
● DocRetrieve
● XDS.b
○ Provide and Register Document Set
○ Retrieve Document
○ Virtual Lifetime Electronic Record (VLER)
- MedVirginia provides full NwHIN support to VA and DoD
- Supports SSA, VA and Dod with single CONNECT instance
- Adds Centra as subordinate HIE through MedVirginia
● CONNECT 2.0 Deployment
○ CONNECT was NwHIN Gateway
○ Supported:
- Subject Discovery
- Document Query
- Document Retrieve
● CONNECT 2.4 Deployment
○ Similar configuration
○ Added additional providers of document sharing
○ Added CMS CHIEP use cases
● Local integration
○ Collaborative effort
○ Dominion is a portal.
○ Two HISPs (Dominion and MedVA)
- Provided by Verizon using their certificate authority
○ Satisfies PCMH referral use case
○ Portal users had full access to the NwHIN
● Target architecture
○ Full support for Oracle HTB
○ Includes Oracle RIM
○ Lifescape (replaces legacy portal)
● Capabilities
○ Documents available via CONNECT
○ Ability to shred Documents into CDR via Direct
○ Ability to share Direct Sourced Documents
○ Ability to share C32 with content from structured Direct Sourced Documents
○ Low overhead installation
○ Scalable
● Demo
○ PCMH - phone calls are made to patients; patient may indicate low medication. Normal action would be a phone call to PCP to let them know. With connected portal (connected to NwHIN), managed care nurse can sends a note to PCP (information found on Virtual Lifetime Electronic Record). Real-time NwHIN transactions:
- Patient Discovery
- Query for Documents
- Retrieve Documents

FAQ Session
● Content standards and transport standards are separate issues, but we need to match up content to transport. Different providers will use different transport mechanisms. Having a transport registry would be helpful.
○ Mark: As the transports become more than 2, or 3, or 4. It becomes easier to scale.
● Dave Perry (NM): What is the HL7 v3.0 RIM and how does it relate to Oracle database?
○ Database is called Oracle database used for clinical data repository.
● Claudia: A lot of folks have in mind a phased strategy in the next year. Focus on those directed use cases. But have in mind a way to build out capabilities over time. More robust requirements. Starting out with an MPI/RLS, etc. I would like to hear key considerations on how states are thinking about phasing this. How have the last few days influenced your strategy?