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Provider Directory CoP

Meeting title

Date, 2012
Discussion on the Western
  States Consortium and
   Inter-State Exchange
    Robert Cothren, California Health eQuality
   Institute for Population Health Improvement
Who we are…




              2
Focus…

Investigating the policies, procedures, and
technologies that allow interstate exchange of health
information.




                                                        3
Use Case

Using Direct to exchange clinical information between
providers across state lines for treatment purposes.
• Includes investigation of policies, procedures, and
  technologies.
• “Using Direct” concentrates on a simple use case
  being implemented today.
• “Across state lines” is a more complex version of
  “with unaffiliated providers”.
• “Between providers” and “for treatment purposes”
  places focus on interstate exchange rather than
  patient privacy issues.
                                                        4
Use Case

Using Direct to exchange clinical information between
providers across state lines for treatment purposes.


       Really about scalable trust.
       Two important components…
    1. Establishing a Trust Community.
    2. Discovering how to communicate with others.


                                                        5
Use Case – the Future

Using Direct to exchange clinical information between
providers across state lines for treatment purposes.
  Focus on this use case for now, but we want to
  prepare for the future…
• Use cases beyond Direct.
• Use cases within state lines but between unaffiliated
  organizations.
• Use cases beyond between providers.
• Use cases beyond treatment purposes.

                                                          6
Pilot Scenarios

Using Direct to exchange clinical information between
providers across state lines for treatment purposes.
Scenario 1 The sender knows the Direct address of
           the recipient.
          – Defines a Trust Community of HISPs that conform
            to Eligibility Criteria. (governance task)
          – Creates a Trust Bundle as the identities of
            Qualified Entities. (technology task)
          – Currently underway.




                                                              7
Creating a Trust Community

Moving from today’s       … to tomorrow’s world of
world of point to point     scalable trust.
trust agreements….




                                                     8
Creating a Trust Community
                              Add New Qualified Entity to Trust Community




• Policies for sharing of
                                                                                Trust Bundle                  New Qualified            Existing Qualified
                                  Governance Body          Party State
                                                                                Coordinator                    Entity POC                 Entity POCs

                                                             From “Eval




  information between
                                                             of Qualified
                                                                Entity”




                                                            Requests that




  HISPs.
                                                          Qualified Entity be     Requests Trust                Returns Trust
                                                           added to Trust            Anchor.                  Anchor (via email).
                                                             Community.



                                                                                 Inspects Trust
                                                                                Anchor to verify it




• Eligibility criteria that
                                                                                 meets Eligibility
                                                                                    Criteria.




                                                                                      Issues?           yes     Corrects issues.




  look a little like                                                                    no




  accreditation.
                                                                                Places Trust Anchor
                                                                                    in test HISP.




                                                                                Sends trust anchor
                                                                                                               Places trust anchor
                                                                                 for test HISP (via
                                                                                                              for test HISP in HISP.




• A process for managing
                                                                                      email).




                                                                                 Conducts test of               Conducts test of
                                                                                  Trust Anchor                   Trust Anchor.




  and distributing trust                                                              Issues?         yes       Corrects issues.




  anchors.                                                                              no


                                                                                Adds Trust Anchor
                                                                                 to Trust Bundle.




                                                          Notes successful        Sends notice of
                                                          addition to Trust      addition to Trust
                                                            Community.             Community.




                                                                                 Sends notice that
                                                                                 Trust Bundle has
                                                                                  been updated.

                                                                                                                Retrieves Trust           Retrieves Trust
                                      Notes update to
                                                                                                              Bundle (via FTP) and      Bundle (via FTP) and
                                       Trust Bundle.
                                                                                                                places in HISP.           places in HISP.



                                                                                                                                                               9
So on to the meat…

Using Direct to exchange clinical information between
providers across state lines for treatment purposes.
Scenario 1 The sender knows the Direct address of
           the recipient.

            Not today’s topic.




                                                    10
Question

  We are looking for input, so will be asking questions
  today. A little practice…
• What is your favorite color?

My favorite color is blue.




I don’t like blue all that much.




                                                          11
Context

• Many states are focused on implementing Direct.
• Direct doesn’t require provider directories, but
  directories can facilitate use cases where the sender
  doesn’t know in advance recipients’ addresses and
  other desired information.
• Many solutions include address books or some other
  level of provider directory to serve their participants
  internally.
• However – the ability for participants to query
  directories outside of their HISP/HIE will be needed
  to continue to advance today’s exchange objectives
  and facilitate tomorrow’s.
                                                        12
Pilot Scenarios

Using Direct to exchange clinical information between
providers across state lines for treatment purposes.
Scenario 1 The sender knows the Direct address of
            the recipient.
Scenario 2a The sender does not know the Direct
            address of the recipient.




                                                    13
The picture…

• What is Dr. Smith’s Direct address?



                                query
              HISP                           HISP
           (directory)                    (directory)
                               response

          NCHIN, an HIO                     CareAccord,
         operating a HISP                  operating the
         with a directory in              statewide HISP
             California.                  with a directory
                                             in Oregon.




                                                             14
The purpose…

• Test an emerging standard for Directory Services
  query.
• Drive out additional requirements as a result of user
  feedback.
• Address these issues without complications of
  federation.




                                                          15
Who are we talking about?

• For the WSC, and for right now, there is a one-to-one
  correspondence between HISPs and directories.
• This may not always be the case:
  – A HISP may use a third party directory provider.
  – A state may implement a statewide directory for
    multiple HISPs.
  – A HISP may have multiple directories to serve
    multiple geographies.




                                                      16
Pilot Scenarios

Using Direct to exchange clinical information between
providers across state lines for treatment purposes.
Scenario 1 The sender knows the Direct address of
            the recipient..
Scenario 2a The sender does not know the Direct
            address of the recipient.
          – Requires that a HISP use a searchable provider
            directory containing provider demographics.
            (operations task)
          – Defines a standard for Directory Services to query
            a provider directory for a Direct address.
            (technology task)
          – Currently underway.
                                                             17
Concept of Operations

Trivial Case – Message to a local recipient.
  – For most HISPs, this is functionality that exists today.
  – Requires that there be a provider directory populated with
    appropriate demographic information to perform a search.




        NCHIN Directory
       Operated by NCHIN                                1.   Fills out query form.
             HISP                                       5.   Retrieves Direct address.
                                                        6.   Ensures recipient address is appropriate.
       Audit Log   Directory                            7.   Sends message.
                                           Authorized
                                              User
            2. Searches local directory.
            3. Locates matching entry.
            4. Presents match to user.
                                                                                                     18
Concept of Operations

Scenario 2a – Query another HISP.
         Oregon LDS                           LDS = local directory service,
         Operated by                                e.g. operated by a HISP
       CareAccord HISP

      Audit Log        Directory


                  4.    Logs received query.
                  5.    Searches local directory.
                  6.    Locates matching entry.
                  7.    Sends response to NCHIN; logs sent
                        response.

         NCHIN LDS                                                         1.    Fills out query form.
      Operated by NCHIN                                                    10.   Retrieves Direct address.
            HISP                                                           11.   Ensures the recipient address is appropriate.
                                                                           12.   Sends message.
      Audit Log        Directory
                                                             Authorized
                                                                User
           2.     Recognizes recipient not in local directory.
           3.     Sends query to CareAccord LDS; logs sent query.
           8.     Logs received response.
           9.     Presents match to user.                                                                                        19
The standards…

   SOAP: Robust web services standard widely
          accepted for health information exchange.
    HPD: Emerging IHE (LDAP) standard for
          Healthcare Provider Directory data model.
 HPDPlus: Emerging EHR | HIE Interop Workgroup
          recommendation that adds more robust
          organizational elements to HPD.
   DSML: OASIS standard for querying an LDAP
          directory.
     S&I: Guidance on query for individual.

                                                  20
The standards…

   SOAP: Robust web services standard widely
          accepted for health information exchange.
    HPD: Investigating an update to incorporate
          HPDPlus functionality.
 HPDPlus: Commitment of many industry partners,
          plans to adopt / align with IHE
          adjustments to HPD.
   DSML: OASIS standard for querying an LDAP
          directory.
     S&I: Looking for experience of states
          implementing provider directories.
                                                  21
Question

  There is a concern over protection of PII.
• Should directory query be authenticated?

Yes, I want to know who is asking the question.




No, we should keep this simple. It is public information.




                                                            22
Question

  There is a concern over protection of PII.
• Should directory query be authenticated?

• This is a technology question implementing a policy
  decision.
• Currently, WSC approach is to include authentication
  between directory systems using TLS.
 – Note that individuals are NOT authenticated.
 – There is an assumption of system/organizational trust, part
   of “scalable trust”.



                                                                 23
Question

  We have said that we will log a query.
• What information should be logged?
Nothing.



Date and time, querying org, the query.



Date and time, querying org, the query, the response.



                                                        24
Question

  We have said that we will log a query.
• What information should be logged?

• While the technology may be “complicated”, this is
  really a policy question.
• Currently, WSC response is to log all queries and
  responses, but reconsidering responses since they
  include PII.

• Question for thought: What would you do with log
  information?

                                                       25
Pilot Scenarios

Using Direct to exchange clinical information between
providers across state lines for treatment purposes.
Scenario 1 The sender knows the Direct address of the
            recipient.
Scenario 2a The sender does not know the Direct
            address of the recipient.
Scenario 2b The sender does not know the Direct
            address or the HISP of the recipient.



                                                    26
The picture…

    • What is Dr. Smith’s Direct address?



 CareAccord,                          query                         IPHI, acting on
acting on behalf   State                             State             behalf of
  of Oregon.                                                          California.
                                    response




                                                 response

                                                            query
                            NCHIN, an HIO
                           operating a HISP
                           with a directory in
                                                      HISP
                               California.
                                                                             27
The need for Scenario 2a…

     Oregon LDS
     Operated by
   CareAccord HISP
                                                                                                     Scenario 2a…
  Audit Log        Directory
                                                                                                   • Requires knowledge of each
                                                                                                     HISP in Trust Community.
              4.    Logs received query.
              5.    Searches local directory.
              6.    Locates matching entry.
              7.    Sends response to NCHIN; logs sent
                    response.

     NCHIN LDS
  Operated by NCHIN
        HISP
                                                                      1. Fills out query form.
                                                                      10. Retrieves Direct address.
                                                                                                   • Requires knowledge about
  Audit Log        Directory
                                                         Authorized
                                                            User
                                                                                                     geography or customers
                                                                      11. Ensures the recipient address is appropriate.
                                                                      12. Sends message.


       2.
       3.
       8.
              Recognizes recipient not in local directory.
              Sends query to CareAccord LDS; logs sent query.
              Logs received response.
                                                                                                     served by each HISP.
       9.     Presents match to user.



                                                          Scenario 2a                              • Is not scalable; requires
                                                          leads back to…
                                                                                                     coordinating updates to
                                                                                                     every HISP every time…
                                                                                                     … a new HISP is added, or
                                                                                                     … a HISP changes the
                                                                                                        customers it serves.
                                                                                                                              28
The big picture…

 Where we are headed…

                         California Statewide Provider Directory                   Oregon
SDS = state directory                                                               SDS
      service
                                                    California                                       Nevada
Hides complexity of                                   SDS                                             SDS
federation.

                          NCHIN
                           LDS                                                                                Alaska
                                                                                                               SDS
                                                                                            Hawaii
                                                                                             SDS
                                     SD Beacon
                        RWMN            LDS
                                                          SCHIE
                         LDS                               LDS


                                              IEHIN                LDS = local directory
                                               LDS                       service


                                                                                                                       29
The big picture…

 Where we are headed… Western States

                         California Statewide Provider Directory                   Oregon
SDS = state directory                                                               SDS
      service
                                                    California                                       Nevada
Hides complexity of                                   SDS                                             SDS
federation.

                          NCHIN
                           LDS                                                                                Alaska
                                                                                                               SDS
                                                                                            Hawaii
                                                                                             SDS
                                     SD Beacon
                        RWMN            LDS
                                                          SCHIE
                         LDS                               LDS


                                              IEHIN                LDS = local directory
                                               LDS                       service


                                                                                                                       30
The big picture…

 Where we are headed… California

                         California Statewide Provider Directory                    Oregon
SDS = state directory                                                                SDS
      service
                                                    California                                        Nevada
Hides complexity of                                   SDS                                              SDS
federation.

                          NCHIN
                           LDS                                                                                 Alaska
                                                                                                                SDS
                                                                                             Hawaii
                                                                                              SDS
                                     SD Beacon
                        RWMN            LDS
                                                          SCHIE
                         LDS                               LDS


                                              IEHIN                LDS = local directory
                                               LDS                       service


                                                                                                                        31
The purpose…

• Continue to test an emerging standard for Directory
  Services query.
• Drive out additional requirements as a result of user
  feedback.
• Address federation!




                                                          32
Who are we talking about?

• For the WSC, and for right now, California is
  implementing a federated directory service.
  – There are almost 30 HIOs operating in California,
    with 5 separate HISPs.
  – This complexity should be hidden from the
    provider.
  – The California state node stores no data; all
    directory information is managed by local
    directories.



                                                        33
Pilot Scenarios
Using Direct to exchange clinical information between
providers across state lines for treatment purposes.
Scenario 1 The sender knows the Direct address of the
            recipient.
Scenario 2a The sender does not know the Direct
            address of the recipient.
Scenario 2b The sender does not know the Direct
            address or the HISP of the recipient.
          – Builds on Scenario 2a.
          – Addresses scalability by adding state Directory
            Service and federation.

                                                              34
Concept of Operations

Scenario 2b – Query a state’s Directory Service.
         California SDS               SDS = state directory               Oregon SDS               Acts as an SDS and
      Operated by IPHI/CHeQ                 service                       Operated by              hides federation.
                                                                        CareAccord HISP
       Audit Log
                                                                       Audit Log   Directory

                   4. Logs received query.
                   5. Recognizes recipient not in California.                  7. Logs received query.
                   6. Sends query to Oregon; logs sent query.                  8. Searches statewide directory.
                   11. Logs received response.                                 9. Locates matching entry.
                   12. Forwards response to NCHIN.                             10. Sends response to California; logs
                                                                                   sent response.

          NCHIN LDS
       Operated by NCHIN                                             1. Fills out query form.
             HISP                                                    15. Retrieves Direct address.
                                                                     16. Ensures recipient address is appropriate.
       Audit Log     Directory                                       17. Sends message.
                                                        Authorized
                                                           User
            2. Recognizes recipient not in local directory.
            3. Sends query to California SDS; logs sent query.
            13. Logs received response.
            14. Presents match to user.                                                                          35
Concept of Operations

Scenario 2b – Query a state’s Directory Service.
         California SDS               SDS = state directory           Oregon LDS               Acts as both an SDS
      Operated by IPHI/CHeQ                 service                   Operated by              and an LDS.
                                                                    CareAccord HISP
       Audit Log
                                                                   Audit Log   Directory

                   4. Logs received query.
                   5. Forwards query to LDS(es); logs sent                 2. Recognizes recipient not in Oregon
                       queries.                                            3. Sends query to California; logs sent
                   10. Logs received response(s).                              query.
                   11. Aggregates response(s).                             13. Logs received response.
                   12. Forwards response(s) to Oregon.                     14. Presents matches to user.

          NCHIN LDS
       Operated by NCHIN                                                    1. Fills out query form.
             HISP                                                           15. Retrieves Direct address.
                                                                            16. Ensures recipient address is
       Audit Log     Directory                                                  appropriate.
                                                                 Authorized 17. Sends message.
                                                                    User
            6.     Logs received query.
            7.     Searches local directory.
            8.     Locates matching entry.
            9.     Sends response to California SDS; logs sent                                              36
                   response.
The standards…

   SOAP: Robust web services standard widely
          accepted for health information exchange.
    HPD: Investigating an update to incorporate
          HPDPlus functionality.
 HPDPlus: Addresses the need for complex
          organizational descriptions within the data
          model; not yet accepted or implemented.
   DSML: Not designed to address federation; one
          query to one directory.
     S&I: Looking for experience of states
          implementing provider directories.
                                                    37
Question

  Federation allows for centralized or distributed policy
  decisions.
• Should the decision to respond be centralized or
  local?

Leave the decision with those responsible for the data.




Users have an expectation, so policy should be uniform.



                                                          38
Question

  Federation allows for centralized or distributed policy
  decisions.
• Should the decision to respond be centralized or
  local?

• For now, WSC is adopting an approach of local
  autonomy. Each state and directory operator should
  be empowered to decide on whether to respond to a
  query.



                                                        39
Question

  We said we should log information about the query.
  DSML does not support federation.
• What do you need to know about “who”?
I need to know the name of the individual.


I need to know the name of the organization (i.e., the HISP).



I need to know the name of the state.


                                                                40
Question

  We said we should log information about the query.
  DSML does not support federation.
• What do you need to know about “who”?

• For now, WSC is passing only the identity of the last
  organization in a query.
  – Oregon knows the query came from California.
  – California knows the query came from NCHIN.
  – NCHIN knows the query came from Dr. Jones.



                                                          41
Question

  DSML does not support federation. You can only have
  one response to a query.
• What do you do if someone errors?
Pass on all the matches there were. Sometimes the Internet fails.


Pass on the matches, but report an error.



I don’t know.


                                                               42
Question

  DSML does not support federation. You can only have
  one response to a query.
• What do you do if someone errors?

• This is a technical issue with user experience
  implications.
• WSC is trying to think of the user.
  – What would the user do with the information?
  – Should errors be only an administrator’s issue?
  – If a user didn’t get the information they expected,
    would they just ask again?
• DSML doesn’t support the answer we like.
                                                          43
Question

  DSML and HPDPlus support querying for members of
  an organization. Directory operators are concerned
  about protecting directory information.
• Should directory queries allow browsing?

No, you need to know enough to get a single response.




Yes, users are expecting to be able to browse a directory.



                                                             44
Question

  DSML and HPDPlus support querying for members of
  an organization. Directory operators are concerned
  about protecting directory information.
• Should directory queries allow browsing?

• Must be controlled by policy.
• WSC decided that browsing should not be allowed.
• The first time a query was placed, the user asked “but
  why can’t I get a list of the members”?
  – Our users have an expectation.
  – If we meet that expectation, we open the door to fishing.
• This is what pilots are for!                                  45
Question

  DSML allows for a rich set of query capabilities.
  Directory operators are concerned about protecting
  directory information.
• Is there a minimum standard for wildcards?

No, we decided that should be left to the directory operators.




Yes, so the users know what to expect.



                                                                 46
Question

  DSML allows for a rich set of query capabilities.
  Directory operators are concerned about protecting
  directory information.
• Is there a minimum standard for wildcards?

• This is really a policy decision.
• For now, WSC has not established any requirements
  for minimum data in the query.




                                                       47
Question

  HPD and HPDPlus are complex. They may not be
  uniformly populated. End users need to be able to
  decide whether they can use the address.
• Is there a minimum standard for data that must be
  included in a response?
No, any information is useful and the user is smart enough.



Yes, directory operators to create good directories.



                                                              48
Question

  HPD and HPDPlus are complex. They may not be
  uniformly populated. End users need to be able to
  decide whether they can use the address.
• Is there a minimum standard for data that must be
  included in a response?

• This is really a policy decision.
• For now, WSC has not established any requirements
  for minimum data in the response.



                                                      49
Challenges

1. Single vendor implementation.
  – Few are implementing HPD, HPDPlus, and/or DSML.
  – Exploring Directory Services testing with another vendor.
  – Participating in national conversations to harmonize query
    standards.
2. User experience design.
  – Many things are possible…
3. Policy implications of technical design decisions.
  – There is an (unfortunate) opportunity for technology to
    drive policy.

  This is hard!
                                                                 50
Timeline

                 1-Nov-12            6-Dec-12              15-Jan-13                    4-Mar-13
             Launch Scenario 1   Launch Scenario 2a    Launch Scenario 2b    HIMSS Interoperability Showcase




1 October 2012                                                                                          31 March 2013
                                              6-Dec-12 - 15-Jan-13
                                                 Learn & Refine


                                                           6-Dec-12 - 28-Feb-13
                                                               Scenario 2


                                                 1-Nov-12 - 28-Feb-13
                                                     Scenario 1




                                               Stay tuned!
                                                                                                                  51
Q&A




      Questions?




                   52
Next Steps and Closing Remarks

• Suggestions for meeting topics and speakers can be
  sent to Sarah Gornto at sgornto@deloitte.com
• Thank you!




                                                       53

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Provider Directory CoP Meeting

  • 2. Discussion on the Western States Consortium and Inter-State Exchange Robert Cothren, California Health eQuality Institute for Population Health Improvement
  • 4. Focus… Investigating the policies, procedures, and technologies that allow interstate exchange of health information. 3
  • 5. Use Case Using Direct to exchange clinical information between providers across state lines for treatment purposes. • Includes investigation of policies, procedures, and technologies. • “Using Direct” concentrates on a simple use case being implemented today. • “Across state lines” is a more complex version of “with unaffiliated providers”. • “Between providers” and “for treatment purposes” places focus on interstate exchange rather than patient privacy issues. 4
  • 6. Use Case Using Direct to exchange clinical information between providers across state lines for treatment purposes. Really about scalable trust. Two important components… 1. Establishing a Trust Community. 2. Discovering how to communicate with others. 5
  • 7. Use Case – the Future Using Direct to exchange clinical information between providers across state lines for treatment purposes. Focus on this use case for now, but we want to prepare for the future… • Use cases beyond Direct. • Use cases within state lines but between unaffiliated organizations. • Use cases beyond between providers. • Use cases beyond treatment purposes. 6
  • 8. Pilot Scenarios Using Direct to exchange clinical information between providers across state lines for treatment purposes. Scenario 1 The sender knows the Direct address of the recipient. – Defines a Trust Community of HISPs that conform to Eligibility Criteria. (governance task) – Creates a Trust Bundle as the identities of Qualified Entities. (technology task) – Currently underway. 7
  • 9. Creating a Trust Community Moving from today’s … to tomorrow’s world of world of point to point scalable trust. trust agreements…. 8
  • 10. Creating a Trust Community Add New Qualified Entity to Trust Community • Policies for sharing of Trust Bundle New Qualified Existing Qualified Governance Body Party State Coordinator Entity POC Entity POCs From “Eval information between of Qualified Entity” Requests that HISPs. Qualified Entity be Requests Trust Returns Trust added to Trust Anchor. Anchor (via email). Community. Inspects Trust Anchor to verify it • Eligibility criteria that meets Eligibility Criteria. Issues? yes Corrects issues. look a little like no accreditation. Places Trust Anchor in test HISP. Sends trust anchor Places trust anchor for test HISP (via for test HISP in HISP. • A process for managing email). Conducts test of Conducts test of Trust Anchor Trust Anchor. and distributing trust Issues? yes Corrects issues. anchors. no Adds Trust Anchor to Trust Bundle. Notes successful Sends notice of addition to Trust addition to Trust Community. Community. Sends notice that Trust Bundle has been updated. Retrieves Trust Retrieves Trust Notes update to Bundle (via FTP) and Bundle (via FTP) and Trust Bundle. places in HISP. places in HISP. 9
  • 11. So on to the meat… Using Direct to exchange clinical information between providers across state lines for treatment purposes. Scenario 1 The sender knows the Direct address of the recipient. Not today’s topic. 10
  • 12. Question We are looking for input, so will be asking questions today. A little practice… • What is your favorite color? My favorite color is blue. I don’t like blue all that much. 11
  • 13. Context • Many states are focused on implementing Direct. • Direct doesn’t require provider directories, but directories can facilitate use cases where the sender doesn’t know in advance recipients’ addresses and other desired information. • Many solutions include address books or some other level of provider directory to serve their participants internally. • However – the ability for participants to query directories outside of their HISP/HIE will be needed to continue to advance today’s exchange objectives and facilitate tomorrow’s. 12
  • 14. Pilot Scenarios Using Direct to exchange clinical information between providers across state lines for treatment purposes. Scenario 1 The sender knows the Direct address of the recipient. Scenario 2a The sender does not know the Direct address of the recipient. 13
  • 15. The picture… • What is Dr. Smith’s Direct address? query HISP HISP (directory) (directory) response NCHIN, an HIO CareAccord, operating a HISP operating the with a directory in statewide HISP California. with a directory in Oregon. 14
  • 16. The purpose… • Test an emerging standard for Directory Services query. • Drive out additional requirements as a result of user feedback. • Address these issues without complications of federation. 15
  • 17. Who are we talking about? • For the WSC, and for right now, there is a one-to-one correspondence between HISPs and directories. • This may not always be the case: – A HISP may use a third party directory provider. – A state may implement a statewide directory for multiple HISPs. – A HISP may have multiple directories to serve multiple geographies. 16
  • 18. Pilot Scenarios Using Direct to exchange clinical information between providers across state lines for treatment purposes. Scenario 1 The sender knows the Direct address of the recipient.. Scenario 2a The sender does not know the Direct address of the recipient. – Requires that a HISP use a searchable provider directory containing provider demographics. (operations task) – Defines a standard for Directory Services to query a provider directory for a Direct address. (technology task) – Currently underway. 17
  • 19. Concept of Operations Trivial Case – Message to a local recipient. – For most HISPs, this is functionality that exists today. – Requires that there be a provider directory populated with appropriate demographic information to perform a search. NCHIN Directory Operated by NCHIN 1. Fills out query form. HISP 5. Retrieves Direct address. 6. Ensures recipient address is appropriate. Audit Log Directory 7. Sends message. Authorized User 2. Searches local directory. 3. Locates matching entry. 4. Presents match to user. 18
  • 20. Concept of Operations Scenario 2a – Query another HISP. Oregon LDS LDS = local directory service, Operated by e.g. operated by a HISP CareAccord HISP Audit Log Directory 4. Logs received query. 5. Searches local directory. 6. Locates matching entry. 7. Sends response to NCHIN; logs sent response. NCHIN LDS 1. Fills out query form. Operated by NCHIN 10. Retrieves Direct address. HISP 11. Ensures the recipient address is appropriate. 12. Sends message. Audit Log Directory Authorized User 2. Recognizes recipient not in local directory. 3. Sends query to CareAccord LDS; logs sent query. 8. Logs received response. 9. Presents match to user. 19
  • 21. The standards… SOAP: Robust web services standard widely accepted for health information exchange. HPD: Emerging IHE (LDAP) standard for Healthcare Provider Directory data model. HPDPlus: Emerging EHR | HIE Interop Workgroup recommendation that adds more robust organizational elements to HPD. DSML: OASIS standard for querying an LDAP directory. S&I: Guidance on query for individual. 20
  • 22. The standards… SOAP: Robust web services standard widely accepted for health information exchange. HPD: Investigating an update to incorporate HPDPlus functionality. HPDPlus: Commitment of many industry partners, plans to adopt / align with IHE adjustments to HPD. DSML: OASIS standard for querying an LDAP directory. S&I: Looking for experience of states implementing provider directories. 21
  • 23. Question There is a concern over protection of PII. • Should directory query be authenticated? Yes, I want to know who is asking the question. No, we should keep this simple. It is public information. 22
  • 24. Question There is a concern over protection of PII. • Should directory query be authenticated? • This is a technology question implementing a policy decision. • Currently, WSC approach is to include authentication between directory systems using TLS. – Note that individuals are NOT authenticated. – There is an assumption of system/organizational trust, part of “scalable trust”. 23
  • 25. Question We have said that we will log a query. • What information should be logged? Nothing. Date and time, querying org, the query. Date and time, querying org, the query, the response. 24
  • 26. Question We have said that we will log a query. • What information should be logged? • While the technology may be “complicated”, this is really a policy question. • Currently, WSC response is to log all queries and responses, but reconsidering responses since they include PII. • Question for thought: What would you do with log information? 25
  • 27. Pilot Scenarios Using Direct to exchange clinical information between providers across state lines for treatment purposes. Scenario 1 The sender knows the Direct address of the recipient. Scenario 2a The sender does not know the Direct address of the recipient. Scenario 2b The sender does not know the Direct address or the HISP of the recipient. 26
  • 28. The picture… • What is Dr. Smith’s Direct address? CareAccord, query IPHI, acting on acting on behalf State State behalf of of Oregon. California. response response query NCHIN, an HIO operating a HISP with a directory in HISP California. 27
  • 29. The need for Scenario 2a… Oregon LDS Operated by CareAccord HISP Scenario 2a… Audit Log Directory • Requires knowledge of each HISP in Trust Community. 4. Logs received query. 5. Searches local directory. 6. Locates matching entry. 7. Sends response to NCHIN; logs sent response. NCHIN LDS Operated by NCHIN HISP 1. Fills out query form. 10. Retrieves Direct address. • Requires knowledge about Audit Log Directory Authorized User geography or customers 11. Ensures the recipient address is appropriate. 12. Sends message. 2. 3. 8. Recognizes recipient not in local directory. Sends query to CareAccord LDS; logs sent query. Logs received response. served by each HISP. 9. Presents match to user. Scenario 2a • Is not scalable; requires leads back to… coordinating updates to every HISP every time… … a new HISP is added, or … a HISP changes the customers it serves. 28
  • 30. The big picture… Where we are headed… California Statewide Provider Directory Oregon SDS = state directory SDS service California Nevada Hides complexity of SDS SDS federation. NCHIN LDS Alaska SDS Hawaii SDS SD Beacon RWMN LDS SCHIE LDS LDS IEHIN LDS = local directory LDS service 29
  • 31. The big picture… Where we are headed… Western States California Statewide Provider Directory Oregon SDS = state directory SDS service California Nevada Hides complexity of SDS SDS federation. NCHIN LDS Alaska SDS Hawaii SDS SD Beacon RWMN LDS SCHIE LDS LDS IEHIN LDS = local directory LDS service 30
  • 32. The big picture… Where we are headed… California California Statewide Provider Directory Oregon SDS = state directory SDS service California Nevada Hides complexity of SDS SDS federation. NCHIN LDS Alaska SDS Hawaii SDS SD Beacon RWMN LDS SCHIE LDS LDS IEHIN LDS = local directory LDS service 31
  • 33. The purpose… • Continue to test an emerging standard for Directory Services query. • Drive out additional requirements as a result of user feedback. • Address federation! 32
  • 34. Who are we talking about? • For the WSC, and for right now, California is implementing a federated directory service. – There are almost 30 HIOs operating in California, with 5 separate HISPs. – This complexity should be hidden from the provider. – The California state node stores no data; all directory information is managed by local directories. 33
  • 35. Pilot Scenarios Using Direct to exchange clinical information between providers across state lines for treatment purposes. Scenario 1 The sender knows the Direct address of the recipient. Scenario 2a The sender does not know the Direct address of the recipient. Scenario 2b The sender does not know the Direct address or the HISP of the recipient. – Builds on Scenario 2a. – Addresses scalability by adding state Directory Service and federation. 34
  • 36. Concept of Operations Scenario 2b – Query a state’s Directory Service. California SDS SDS = state directory Oregon SDS Acts as an SDS and Operated by IPHI/CHeQ service Operated by hides federation. CareAccord HISP Audit Log Audit Log Directory 4. Logs received query. 5. Recognizes recipient not in California. 7. Logs received query. 6. Sends query to Oregon; logs sent query. 8. Searches statewide directory. 11. Logs received response. 9. Locates matching entry. 12. Forwards response to NCHIN. 10. Sends response to California; logs sent response. NCHIN LDS Operated by NCHIN 1. Fills out query form. HISP 15. Retrieves Direct address. 16. Ensures recipient address is appropriate. Audit Log Directory 17. Sends message. Authorized User 2. Recognizes recipient not in local directory. 3. Sends query to California SDS; logs sent query. 13. Logs received response. 14. Presents match to user. 35
  • 37. Concept of Operations Scenario 2b – Query a state’s Directory Service. California SDS SDS = state directory Oregon LDS Acts as both an SDS Operated by IPHI/CHeQ service Operated by and an LDS. CareAccord HISP Audit Log Audit Log Directory 4. Logs received query. 5. Forwards query to LDS(es); logs sent 2. Recognizes recipient not in Oregon queries. 3. Sends query to California; logs sent 10. Logs received response(s). query. 11. Aggregates response(s). 13. Logs received response. 12. Forwards response(s) to Oregon. 14. Presents matches to user. NCHIN LDS Operated by NCHIN 1. Fills out query form. HISP 15. Retrieves Direct address. 16. Ensures recipient address is Audit Log Directory appropriate. Authorized 17. Sends message. User 6. Logs received query. 7. Searches local directory. 8. Locates matching entry. 9. Sends response to California SDS; logs sent 36 response.
  • 38. The standards… SOAP: Robust web services standard widely accepted for health information exchange. HPD: Investigating an update to incorporate HPDPlus functionality. HPDPlus: Addresses the need for complex organizational descriptions within the data model; not yet accepted or implemented. DSML: Not designed to address federation; one query to one directory. S&I: Looking for experience of states implementing provider directories. 37
  • 39. Question Federation allows for centralized or distributed policy decisions. • Should the decision to respond be centralized or local? Leave the decision with those responsible for the data. Users have an expectation, so policy should be uniform. 38
  • 40. Question Federation allows for centralized or distributed policy decisions. • Should the decision to respond be centralized or local? • For now, WSC is adopting an approach of local autonomy. Each state and directory operator should be empowered to decide on whether to respond to a query. 39
  • 41. Question We said we should log information about the query. DSML does not support federation. • What do you need to know about “who”? I need to know the name of the individual. I need to know the name of the organization (i.e., the HISP). I need to know the name of the state. 40
  • 42. Question We said we should log information about the query. DSML does not support federation. • What do you need to know about “who”? • For now, WSC is passing only the identity of the last organization in a query. – Oregon knows the query came from California. – California knows the query came from NCHIN. – NCHIN knows the query came from Dr. Jones. 41
  • 43. Question DSML does not support federation. You can only have one response to a query. • What do you do if someone errors? Pass on all the matches there were. Sometimes the Internet fails. Pass on the matches, but report an error. I don’t know. 42
  • 44. Question DSML does not support federation. You can only have one response to a query. • What do you do if someone errors? • This is a technical issue with user experience implications. • WSC is trying to think of the user. – What would the user do with the information? – Should errors be only an administrator’s issue? – If a user didn’t get the information they expected, would they just ask again? • DSML doesn’t support the answer we like. 43
  • 45. Question DSML and HPDPlus support querying for members of an organization. Directory operators are concerned about protecting directory information. • Should directory queries allow browsing? No, you need to know enough to get a single response. Yes, users are expecting to be able to browse a directory. 44
  • 46. Question DSML and HPDPlus support querying for members of an organization. Directory operators are concerned about protecting directory information. • Should directory queries allow browsing? • Must be controlled by policy. • WSC decided that browsing should not be allowed. • The first time a query was placed, the user asked “but why can’t I get a list of the members”? – Our users have an expectation. – If we meet that expectation, we open the door to fishing. • This is what pilots are for! 45
  • 47. Question DSML allows for a rich set of query capabilities. Directory operators are concerned about protecting directory information. • Is there a minimum standard for wildcards? No, we decided that should be left to the directory operators. Yes, so the users know what to expect. 46
  • 48. Question DSML allows for a rich set of query capabilities. Directory operators are concerned about protecting directory information. • Is there a minimum standard for wildcards? • This is really a policy decision. • For now, WSC has not established any requirements for minimum data in the query. 47
  • 49. Question HPD and HPDPlus are complex. They may not be uniformly populated. End users need to be able to decide whether they can use the address. • Is there a minimum standard for data that must be included in a response? No, any information is useful and the user is smart enough. Yes, directory operators to create good directories. 48
  • 50. Question HPD and HPDPlus are complex. They may not be uniformly populated. End users need to be able to decide whether they can use the address. • Is there a minimum standard for data that must be included in a response? • This is really a policy decision. • For now, WSC has not established any requirements for minimum data in the response. 49
  • 51. Challenges 1. Single vendor implementation. – Few are implementing HPD, HPDPlus, and/or DSML. – Exploring Directory Services testing with another vendor. – Participating in national conversations to harmonize query standards. 2. User experience design. – Many things are possible… 3. Policy implications of technical design decisions. – There is an (unfortunate) opportunity for technology to drive policy. This is hard! 50
  • 52. Timeline 1-Nov-12 6-Dec-12 15-Jan-13 4-Mar-13 Launch Scenario 1 Launch Scenario 2a Launch Scenario 2b HIMSS Interoperability Showcase 1 October 2012 31 March 2013 6-Dec-12 - 15-Jan-13 Learn & Refine 6-Dec-12 - 28-Feb-13 Scenario 2 1-Nov-12 - 28-Feb-13 Scenario 1 Stay tuned! 51
  • 53. Q&A Questions? 52
  • 54. Next Steps and Closing Remarks • Suggestions for meeting topics and speakers can be sent to Sarah Gornto at sgornto@deloitte.com • Thank you! 53