NHIN Direct Demo at Redwood Mednet HIE Conference

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[ Link to Photo of Demo at HIE Conference ] [ link to Redwood MedNet Direct Project Pilot Test ]

This wiki page is an archive of the Direct Project Demo at the Redwood Mednet HIE Conference on July 9, 2010 in Santa Rosa, California.


The goals of the demo are to demonstrate the following:
  • Enable providers with various technology choices that promote electronic health information exchange.
  • Demonstrate technology choices and options that "meet the providers where they are" -- in other words technologies that enable optimal alignment with and incremental improvement of providers' business processes.
  • Demonstrate Structural Interoperability among the providers by using common Content packaging.
  • Demonstrate HISP services that enable secure health IT messaging.
  • Investigate potential configurations for HISP in a Box


The following are the list of participants that are actively involved in creation of the demo.
Will Ross
Redwood MedNet
Mark Street
Alliance Medical Center (Redwood MedNet)
Mike Hogarth
UC Davis School of Medicine (Redwood MdNet)
Gary Tiechrow
Mirth Corporation
Will Hartung
Mirth Corporation
Nagesh Bashyam
Harris Corporation
Kim Long
Chris Moyer
John Stanley
Laura Landry
Western Health Information Network (Long Beach)
Ajay Prashar
Physicians Medical Group Santa Cruz
Bill Beighe
Physicians Medical Group Santa Cruz
Sean Nolan
Umesh Madan

Demo Context:

The demo participants, the network topology, the backbone protocol, the different edge protocols and the demonstration scenarios that will be presented are described in the diagram below. (Note, see also Direct Project Convergence Proposal for additional details on the various protocols and HISP services).


The demonstration utilizes three HISPs: Redwood MedNet (RWMN), Santa Cruz HIE (SCHIE) and Western Health Information Network (WHIN, aka Long Beach). In the scenario each participant originates one Direct Project push message. For "bonus points" the Santa Cruz HISP uses a cc of their Direct Project message as an exported CCR to the patient's PHR.

Gordon Fakepatient -- a fake patient, and resident of Mendocino, California, with a HealthVault PHR
Dr. LB -- a Long Beach physician who uses the Long Beach HISP for Direct Project messaging -- Laura Landry
Dr. RM -- a Mendocino physician who uses the Redwood MedNet HISP for Direct Project messaging -- Mike Hogarth, MD
Dr. Bob -- a Santa Cruz physician who uses the Santa Cruz HISP for Direct Project messaging -- Sean Nolan

Long Beach HISP
1. Based on the MedPlus REST prototype code within Quest Diagnostics Care360 web service
2. Enabled a Care360 user to browse and select clinical content from the patient clinical data repository, to assemble the content on the fly into a plain vanilla clinical summary pdf, and then to push that content to a user-entered Direct Project address
3. Due to time and resource constraints, only the REST send capability from Care360 was tested, with no inbound message service

Redwood MedNet HISP
1. Based on the CONNECT gateway SOAP service called from MirthResults clinical messaging application
2. Enabled a MirthResults portal user to view incoming Direct Project messages, and to compose outbound Direct Project messages, where MirthResults is the portal front end to a CONNECT gateway
3. MirthResults received incoming Direct Project SMTP messages at health internet address rm@nhin1.rwmn.org, the Redwood MedNet test environment
4. MirthResults sent outgoing Direct Project SMTP messages

Santa Cruz HISP
1. Microsoft Direct Project SMTP gateway service
2. Outlook received Direct Project SMTP messages from MirthResults
3. Outlook sent Direct Project SMTP messages
4. Able to cc a Direct Project message to patient's PHR account

Scheduled 3:10 PM to 3:30 PM (actual demo ran from 3:20 to 3:45)

Demonstration Script

[presentation screen shows this wiki page]

Introduction to the technology context of this Direct Project bench demonstration. High level overview of the role of Direct Project push messaging as a workflow-appropriate adoption accelerator for health data interoperability services within the larger context of the Nationwide Health Information Network services and the ARRA framework of Meaningful Use measures. Reinforcement of Direct Project messaging as a complementary toolkit to other interoperability efforts, and its important heritage in the pursuit of "simple interop" as a technology breakthrough or tipping point.

Introduction of the organizations contributing staff time to this demo: Redwood MedNet, Santa Cruz HIE, Western Health Information Network, MedPlus, Mirth Corporation, Harris Corporation and Microsoft.

Shows schematic diagram to illustrate the three Direct Project push messages in the demonstration.

Recognition that this Direct Project workbench demonstration is intended to illustrate capabilities. This is not a reference implementation; those are planned for the fourth quarter of 2010.

Introduction to the clinical scenario in this Direct Project demonstration. Gordon Fakepatient is a 72 year old retired banker and resident of Mendocino with a history of COPD, coronary artery disease, and hypertension. Because of his complex medical problems, Mr. Fakepatient subscribes to a PHR service, and diligently keeps his PHR updated. After each office visit his primary care physician (Dr. R.M.) forwards a patient summary CCD to Mr. Fakepatient's PHR.

[presentation screen transferred to Dr. L.B. Care360 desktop]

Mr. Fakepatient was visiting his daughter in Long Beach, California. One morning he had onset of chest pain and shortness of breath. 911 was called and he was transported to Long Beach Memorial Hospital in stable condition with persistent chest pain and elevated blood pressure of 200/105. His initial ECG showed tachycardia of 100, LVH, and lateral T-wave inversions. Cardiac markers were negative twice over several hours and his chest Xray was unrevealing. Mr. Fakepatient volunteered that last week he had some right leg swelling. Dr. L.B. obtained a CT angiogram which showed a medium sized right pulmonary embolism. He was admitted for further treatment of his PE and his poorly controlled hypertension.

During his hospital stay, Mr. Fakepatient is started on low molecular weight heparin for his acute PE. The next day Coumadin is also started. Over the next two days, his blood pressure improves with adjustments to his blood pressure medication. He is discharged on Tinzaparin 12,000 Units daily and Coumadin 2.5mg per day. He is instructed to follow up with his primary care physician in Mendocino, who will assume management of his anti-coagulation. On discharge Dr. L.B. forwards a care summary document, including the serial daily INRs and Coumadin doses given while he was in the hospital, to Dr. R.M., the primary care physician in Mendocino for Mr. Fakepatient.

- - - - - - - -
Send Direct Project message originated from Long Beach HISP
1. Dr. L.B. uses the RESTful interface on Quest Diagnostics Care360
2. Navigates to "Compose NHIN Direct Message"
3. Enters health internet email address rm@nhin1.rwmn.org
4. Enters patient name (Gordon Fakepatient) to access clinical document repository
5. Selects content to attach to Direct Project message
6. Fills out "Reason for Disclosure"
7. Sends to Dr. R.M. at Redwood MedNet HISP
- - - - - - - -

[presentation screen transferred to Dr. R.M. desktop]

Two days after discharge from Long Beach, Mr. Fakepatient arrives at the office of Dr. R.M., his Mendocino primary care physician, for follow up care. Dr. R.M. reviews the encounter summary received from Dr. L.B. as an incoming clinical message.

- - - - - - - -
Receive Direct Project message originated from Long Beach HISP
1. Dr. R.M. uses the Redwood MedNet MirthResults clinical messaging portal
2. From the "Messages" menu select "Inbox"
3. From the "Inbox" select the incoming Direct Project message from Dr. L.B. regarding Mr. Fakepatient
4. Open message and select attachment
5. View attachment as pdf in separate window
- - - - - - - -

Dr. R.M. continues Mr. Fakepatient on tinzaparin while adjusting the Coumadin. After several days, the tinzaparin is discontinued once he has been therapeutic on Coumadin. The plan is to treat Mr. Fakepatient with Coumadin for 6 months. Dr. R.M. forwards an updated patient summary CCD to Mr. Fakepatient's PHR, including a current medication summary and treatment plan.

Two months later, while visiting his brother in Santa Cruz, Mr. Fakepatient experiences significant back pain. He recalls helping his brother move a refrigerator into the garage the day prior. Mr. Fakepatient has a history of chronic back pain. A five hour drive away from his primary care provider, Mr. Fakepatient presents that morning at the Steamers Lane Urgent Care in Santa Cruz. During patient check in, Mr. Fakepatient is given the Direct Project address of Dr. Bob at Steamers Lane clinic as an optional part of the new patient clipboard process. He then phones Dr. R.M.'s office in Mendocino and asks for an encounter summary to be sent as a Direct Project message to Dr. Bob at Steamers Lane Urgent Care in Santa Cruz.

- - - - - - - -
Send Direct Project message originated from Redwood MedNet HISP
1. Dr. R.M. uses the Redwood MedNet clinical messaging portal
2. From MirthResults open Mr. Fakepatient's records
2. Select "clinical documents" tab
3. Open patient summary document from most recent episode of care
4. Select "send in message" from portal navigation panel
5. Enter health internet address for Dr. Bob (bob@nhind.hsgincubator.com)
6. Send to Dr. Bob at Santa Cruz HISP
- - - - - - - -

[presentation screen transferred to Dr. Bob desktop]

Mr. Fakepatient enters the exam room at Steamers Lane Urgent Care clinic. Prior to the exam, Dr. Bob receives a summary of care record from Dr. R.M., who is Mr. Fakepatient's primary care physician in Mendocino. The summary of care document details Mr. Fakepatient's most recent visit to Dr. R.M., which was two months prior.

- - - - - - - -
Receive Direct Project message originated from Redwood MedNet HISP
1. Dr. Bob uses Outlook to receive Direct Project message
2. Open Outlook
3. Use inbox to select patient summary message from Dr. R.M. at Redwood MedNet HISP
4. View pdf attachment to Direct Project message
- - - - - - - -

After a physical exam is negative except for significant back spasms, Dr. Bob, the urgent care physician, decides to recommend three days of valium with 600mg of Motrin three times a day along with bed rest until the pain improves. However, reviewing Mr. Fakepatient's medication list Dr. Bob notes that Mr. Fakepatient is on Coumadin, so and forgoes the Motrin in favor of Tylenol. Dr. Bob recommends that Mr. Fakepatient see his primary care provider in Mendocino for an INR and follow up visit within four days. Dr. Bob forwards an encounter summary to Dr. R.M. in Mendocino, with a cc to Mr. Fakepatient's PHR.

- - - - - - - -
Send Direct Project message originated from Santa Cruz HISP
1. Dr. Bob uses Outlook to send Direct Project message
2. Open Outlook
3. Create new message
4. Address to rm@nhin1.rwmn.org
5. cc to Gordon Fakepatient PHR account
7. Attach encounter summary
8. Send Direct Project message
- - - - - - - -

- - - - - - - -
Receive Direct Project message in PHR
1. Log into HealthVault PHR account for Gordon Fakepatient
2. View CCR encounter summary document sent by Dr. Bob at Santa Cruz HIE
- - - - - - - -

Four days later Dr. R.M. sees Mr. Fakepatient in Mendocino, who reviews his recent treatment. The INR is stable and his back pain is now largely resolved. Mr. Fakepatient is removed from valium and tylenol, and continues his usual coumadin dose. He will see Dr. R.M. in a month. Br. R.M. forwards an encounter summary to Mr. Fakepatient's PHR.

Sean closes presentation by contextualizing what we have done: a bench demo with newly developed prototype security tools to secure a federated SMTP backbone, with the demonstration of all three protocols in the current Direct Project production pipeline: REST, SOAP and SMTP. And that this was all put together in four weeks.

Design Information:

The page Redwood Demo Design Information contains more details regarding the design of the Demo and the various subsystems.

Location, Schedule and Collaboration Information:

For conference calls please use the following dial in # 1-866-633-8804 and the following passcode # 9357. The conference calls are held daily at 7:00 EST or 4pm PST.

For Collaboration, real-time discussions, ideas, questions, comments, suggestions etc. please subscribe to the wiki page and feel free to post a discussion topic.

Task Assignments and Status:

The following is an initial list of the tasks that need to be completed for the demo:

Initial Tasklist

Notes from 6_16_2010