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DoD onboarding slides

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DHSM Industry Onboarding Roundtable

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DoD onboarding slides

  1. 1. PEO DHMS February 10, 2016 PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 1 Defense Healthcare Management Systems Industry On‐Boarding Roundtable
  2. 2. PEO DHMS Agenda PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 2 Opening Remarks / Setting the Stage ‐ Mr. Miller 9:00 AM – 9:15 AM Overview of DoD Health Information Exchange and DMIX Program −Ms. Heermann‐Do / Ms. Scanlon 9:15 AM – 9:30 AM Overview of Onboarding Process ‐Ms. Farah‐Stapleton 9:30 AM – 10:10 AM Break Facilitated Discussion of Lessons Learned ‐Dr. Parker 10:30 PM – 12:30 PM Initiatives Underway (JETs) / ONC (HL7Collaboration) ‐Dr. Thompson 12:30 PM – 12:45 PM Closing Remarks/Next Steps ‐Mr. Miller 12:45 PM – 1:00 PM Lunch* / Networking DoD/VA Interagency Program Office (IPO) Town Hall – ONC Health IT Certification Program ‐CAPT Morton 2:00 PM – 3:00 PM
  3. 3. PEO DHMS The Federal Advisory Committee Act (FACA) PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 3 • The purpose of this meeting is solely to exchange information regarding challenges our organizations have encountered in connecting to HIEs and in sharing patient information. We also hope to explore methods participants may have discovered for overcoming those challenges and share best practices. • The Department of Defense is not seeking to obtain the group’s advice or recommendations on agency issues or policies, which could implicate the Federal Advisory Committee Act (FACA).
  4. 4. PEO DHMS Military Health System PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 4
  5. 5. Federal Medical Facilities DoD, VA, HHS PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 6
  6. 6. A Personal Perspective 1980s PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 7 Today
  7. 7. PEO DHMS Overview of DoD Health Information Exchange and DMIX Program PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 8
  8. 8. Relationship of DoD Data Sharing Activities HIE On‐boarding Prioritization PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 9 Business Policy Strategy Functional Requirements Content Technical Implementation Fielding
  9. 9. PEO DHMS Evolution of Data Sharing PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 10 • Clinical Data Repository/Health Data Repository Exchange (CHDR) – Date started: 2003 – Purpose: Two‐way exchange between DoD and VA of actionable outpatient pharmacy medication, allergy, and allergy reaction data for beneficiaries that use both DoD and VA health facilities. • Bidirectional Health Information Exchange (BHIE) Suite – Date started: 2004 – Purpose: Real‐time read‐only viewing of DoD and VA patient clinical data, and data exchange services. • Virtual Lifetime Electronic Record Health Information Exchange (VLER‐HIE) – Date started: 2009 – Purpose: DoD health data exchange with public sector (e.g. SSA) and private sector health care providers. • Joint Legacy Viewer (JLV)‐Health Information Portal (HIP) and Data Exchange Service (DES) – Dates started: 2013 and 2015 – Purpose: Easy access to integrated (DoD, VA, Private Sector ) view of patient information thru JLV‐HIP viewer; DoD data provided to data exchange partners through DES data service. – DoD viewers have been replaced by JLV; data services continues to be sunset thru DES.
  10. 10. PM DMIX Data Sharing Implementation PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 11
  11. 11. DoD On‐Boarding PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 12
  12. 12. PEO DHMS Bottom Line • Health data sharing systems are not “plug and play” • DoD must do an extensive amount of work to bring on a partner • Connecting to multiple point‐ to ‐ point partners is unsustainable What can organizations in the middle do, to alleviate the burden between health data exchange users ? PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 13
  13. 13. PEO DHMS PPT Template Distribution A: Approved for PublicRelease DEC2014 DHMS Generic Requirements for Data Exchange DoD Implementation for eHx Participation Other (s) Governance SignedDURSA Patient Matching PDWS Record Locating CDR Connection CONNECT Gateway Viewer JLV‐HIP Data Service DES Clinical Content of Documents C32/C62/CCDA Consent Opt‐In/Opt‐Outprocess Testing eHx and Partner Informal and Formal Testing 14 Key Considerations for Data Sharing
  14. 14. On‐Boarding: DoD Sites and eHx Partners #1 DoDActivities • Provide access to JLV‐HIP • Provide trainingmaterials • Communicate across the enterprise #3: Activities to connect to the eHealth Exchange • Sequoia Onboarding Process • DURSA Participation Agreement • Testing and Certification #2 DoD on‐boarding activities with each exchange partner PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 15 • Identify ports, endpoints • Complete testing • Assess results and refine system
  15. 15. PEO DHMS DoD Onboarding Process and Timelines PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 16 Recent Examples The process for DoD on‐boarding of an external partner includes the following steps and examples of timelines: Organization Initial Contact Testing ( Informal & Formal) Go‐live in Production ~ Time Steps 1‐8 Steps 4‐8 HIE 1 3/4/2015 3/31/2015 4/3/2015 4/4/ 2015 1 month 5 days HIE 2 3/10/2015 5/21/15 6/5/2015 6/19/2015 4 months 1 month HIE 3 5/6/2015 10/29/2015 11/12/2015 12/2/2015 7 months 1 month HIE 4 3/26/2015 3/31/2015 3/31/2015 5 days 1 day HIE 5 4/14/2015 8/4/2015 8/13/2015 10/23/2015 (Pending) 10 months 1 week (staged) 1. InitialContact 2. Introductory Meeting & Questionnaire 3. Technical Meeting (If Needed) 1. Informal Testing 2. Formal Testing 3. Onboarding to DoD 1. Production Testing 2. Go Live in Production
  16. 16. PEO DHMS Partner Integration Questionnaire PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 17 # Question Answer 1 What, if any, gateway technology are you using? 2 What specification (2010 vs. 2011) exchange will you be supporting? 3 What message exchange will you supporting (C32, C62, CCDA)? Which version of the message (e.g. C32 version 2.5)? 4 Which data domains/modules will you be publishing? 5 When will you be able to provide sample XML documents, rendered view of those documents or a stylesheet, and xPath listing? 6 What is your test environment OID and end points? Are they in test UDDI? 7 What is your production environment OID and end points? When will you be registering them in production UDDI 8 Which ports will you be using for exchange ? Will you be using TLS or SSL? 9 What personal and demographic traits will your organization send to the DOD for Patient Discovery? 10 What workflow does your system follow (e.g. DoD PD/QD/RD process is executed in one step)? 11 Are you supporting opt in/out functionality? 12 What is your anticipated Healtheway certification date? 13 What is your anticipated go live date? 14 What other partners are you going through the onboarding process with?
  17. 17. PEO DHMS Partner Integration Questionnaire PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 18 # Question Answer 11 Are you supporting opt in/out functionality? 12 What is your anticipated Healtheway certification date? 13 What is your anticipated go live date? 14 What other partners are you going through the onboarding process with? 15 Do you currently have valid eHealth Exchange Entrust certifications? 16 Do your endpoints match the endpoints registered in the test UDDI prior to JPT events? 17 What are the names and addresses of your treatment facilities (hospitals, clinics,etc.)? 18 What are you doing in regards to ICD‐10? How do you define ICD‐10 compliance? 19 Do you send batch jobs or pre‐fetch data? Do you have a batch jobs/pre‐ fetch schedule? 20 What is the consent strategy for your state? 21 What is your charging policy for testing and exchange?
  18. 18. DoD Informal/Formal Testing Test Scenarios + Test Data PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 19 # TestScenario 1 Initiate a PD, DQ, DR for DoD Opted In Patient 2 Initiate a PD, DQ, DR for DoD Opted Out Patient 3 Initiate a PD, DQ, DR for Partner Opted In Patient 4 Initiate a PD, DQ, DR for Partner Opted Out Patient 5 Initiate a PD, DQ, DR for a patient with no clinical data 6 Initiate a PD, DQ, DR for a non‐matching patient • Each scenario is tested for inbound and outbound requests – Inbound: External Partner requests information from the DoD – Outbound: DoD requests information from the External Partner • Use testpatients – EDIPN, Lastname, Firstname, DOB, SSN, Gender, Phone, Address_Street1, City, State, Zip, Country – Provided to joint partners for testing wit DoD
  19. 19. PEO DHMS Onboarding Standards Example for the eHealth Exchange PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 20  Specifications ‐ The 2010 and 2011 specifications lay out the standards on transport and exchange for patient discovery, document query, and document retrieve. o 2010 Specification o 2011 Specification (MU2) *The DoD can support both (2010 and 2011 exchanges)  Document Types – HITSP and HL7 define the documents below for exchange o C32 CCD‐ Patient Health Summary o CCDA CCD ‐ Patient Health Summary (MU2) o HITSP C62 Unstructured Documents – (Radiology Reports, Encounter Notes, etc.) *The DoD only requests C32s or CCDAs, but can send any of the three document types  Document Origination o Dynamically Created – One document created dynamically through on‐the‐fly database queries o Static Documents – Multiple documents returned for single clinical events (i.e., encounter admissions) *The DoD can support both dynamic and static documents
  20. 20. Lessons Learned Discussion PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 21
  21. 21. PEO DHMS Lessons Learned PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 22 Observation Resolution Specification Ambiguity The specifications contain ambiguity and this has resulted different interpretations. Enforcement of the specs is inconsistent. Recommend dedicated SME (s) to adjudicate/enforce partner interpretation disputes. Some partners have implemented pre‐fetch and there is no regulation or visibility around this functionality. Exploring when/how often external partners are pre‐fetching data, so performance impacts to non‐requesting partner is minimized. New partners have trouble following specifications due to lack of both experience and SMEs. Assist as needed.
  22. 22. PEO DHMS Lessons Learned (continued) PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 23 Observation Resolution Specification Ambiguity The specifications require the implementation of an older IHE exchange specification from 2009. Most new partners do not realize this and make implementation decisions using the most current IHE spec. Recommended that the specifications to be used are clearly communicated. Partial Success is the DoD response to external partners when an error (incorrect XML data, connectivity issue, etc.) occurs when retrieving a patient’s records. This was requested so that DoD does not give partners the impression that all of the records were appropriately available through the exchange. The HIE partner made a code change to handle the partial success condition. Other partners are unable to handle partial success. Thus, if DoD responds with partial success, several partners will not be able to retrieve DoD CCDA
  23. 23. PEO DHMS Lessons Learned (continued) PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 24 Observation Resolution Patient Matching Some partners were sending fake SSNs across the exchange which causes patient matching issues. Sending fake SSNs is also not allowed by the DURSA. DoD PDWS enacted a more stringent probabilistic matching algorithm. DoD implemented code changes, including the ability to send more patient traits to PDWS for more accurate patient matching. Content A partner requested a change to distinguish a C32 CCD from a CCDA CCD using a specific format code. Per the exchange specifications, this format code is optional and was not required. DoD added a format code to message response. There are various CCDA validators but a gold standard, identifying which validator(s) are appropriate for implementation, hasn’t been identified. DoD has been utilizing as a validator, but is willing to adopt whichever validator(s) are endorsed by the community.
  24. 24. PEO DHMS Lessons Learned (continued) PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 25 Observation Resolution Testing All partners are not auto‐refreshing endpoints with the published UDDI in TEST and Production. There is no enforcement of UDDI refreshment. Communicate to partners to use the test UDDI as first option. If this is not feasible, UDDI entry should be communicated to all partners. Partners have problems staging test data in TEST and PROD . Coordinated with partners in advance of any testing. For PROD, all smoke tests are performed with known patients that have shared data between DoD and the external partner. A partner completed informal and formal testing with staged documents, resulting in passing testing but not being able to exchange data. No resolution – awaiting partner to finish configuring systems so that actual exchange from the partner to DoD can occur. The current suite of integrated certification tests do not guarantee a partner has implemented their system per the specifications in order to exchange with real partners. Recommended to enforcing authority that they expand/provide more detailed test cases for testing. DoD will contribute to the success of this effort.
  25. 25. PEO DHMS 6DEC2014 PEO DHMS DHMS PPT Template Distribution A: Approved for PublicRelease Lessons Learned (continued) Observation Resolution Consent Each state has different consent laws for sharing patient health information. The DoD has encountered issues in testing and production with opt‐in states . At one DoD site, the DoD system attempted to retrieve files for a live patient; however, the system timed out in the process. Since there were no error codes in the log for this DQ request, it appeared that there was a problem with the connection between the DoD system and the HIE. If a patient served by that HIE has not opted‐in, DoD will receive a “no documents” response . Some partners have stricter opt in/out consent policies. DoD spent countless hours troubleshooting because DoD patients with known partner data were not viewable in DoD. The exchange partner indicated different levels/forms of patient consent which can either apply per DoD facility or DoD enterprise‐wide. Analyzing the known limitations of external partners to exchange due to state policy/guidelines. Make part of the DoD on‐ boarding questions. Charging Models Some HIEs’ vendors have tried to charge DoD and their clients for Joint Partner Testing and connection. Appropriate charging models should be consistently applied and enforced between health data exchange partners. DoD has paused on‐ boarding this partner until a legal recommendation is provided by DHA. In the interim, the DoD on‐boarding process includes questions on charging to test, up‐front. 2
  26. 26. PEO DHMS Lessons Learned (continued) PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 27 Observation Resolution Prioritization Several prospective partners have indicated that DoD is not a priority for on‐ boarding. On‐going. Elevating the matter to DoD leadership and partner leadership for resolution.
  27. 27. PEO DHMS Required and Optional Modules PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 28 Modules for CCD Summary Report HITSP C32‐CCD Format* C‐CDA CCD Format** Comprehensive C32 and CCDA Person Information Required Required LanguageSpoken Optional Optional Support Required (if known) Optional HealthProviders Optional Optional InformationSource Required Required Allergies Optional Required Medications Optional Required Problem List Optional Required Procedures (List of surgeries) (History of Procedures) Optional Required Diagnostic Results (Lab and Diagnostic) Optional Required AdvanceDirectives Optional Optional Encounters Optional Optional Family History Optional Optional Functional Status Optional Optional Immunizations Optional Optional Medical Equipment Optional Optional Payers/Health Insurance Optional Optional Plan ofCare Optional Optional Social History Optional Optional VitalSigns Optional Optional Sources: *HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component / HITSP C32 v2.5 by Care Management and Health Records Domain Technical Committee, July 8, 2009. **Implementation Guide for CDA Release 2.0 Consolidated CDA Templates by Health Level Seven (HL7), Integrating the Healthcare Environment (IHE), the Health Story Project, December 2011
  28. 28. Initiatives Underway PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 29
  29. 29. PEO DHMS Template Distribution A: Approved for PublicRelease Health Interoperability and Exchange Alliance (HIEA) To synchronize standards, services, policies, and personnel to achieve interoperability between the DoD, VA and their partners DHMSPPT DEC2014 30
  30. 30. Fast Healthcare Interoperability Resources (FHIR) Proving Ground Practice Data Exchange • Load a sample server with test data conforming to DoD/VA Profile and access through UI Client Validate • Validate server through testing tools (test data, test harness) to determine server compliance Develop FHIR Profiles Test Interoperability • Round‐tripping and merging, re‐querying after patient data is integrated with native system • Tailor or extend existing harmonized profiles for DoD‐VA use cases • Cover all data elements identified by IPO FHIR Testing Test DoD/VA FHIR‐based interoperability and security FHIR Development Collaborate on FHIR profiles and extensions PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 31
  31. 31. Improve C‐CDA Deployment Research • Capture problem areas with the deployment of C-CDA, including inconsistencies and ambiguities with standards • Identify implementation issues specific to the DoD and VA, as well as external government agencies and private sector • Delineate inconsistencies and ambiguities in standards during C-CDA deployment • Address issues related to new revision releases Submission of Priority Issues • Catalog and assess key C-CDA issues based on recurrence • Submit prioritized list of outstanding C-CDA issues for adjudication by HL7 Solution • Plan for adjudication of issues by HL7 • Collaborate with HL7 on potentialsolutions • Develop proposals for resolving outstanding top issues • Minimize level of customization required for future C-CDA exchanges Purpose: To identify problem areas with the deployment of C‐CDA and propose solutions to inform ONC and other Standards Development Organizations (SDOs) as appropriate, such as HL7 Work Groups. Aggregate Analyze Prioritize Propose Resolve In August 2015, C-CDA 2.1 was published to address compatibility issues between different C-CDA releases. • Adds compatibility guidance for creation of R1.1 instances and new documents not automatically supported by R1.1 receiver • DoD/VA IPO led HL7 project team – facilitation, design development, comment adjudication, and publication • Adopted in ONC 2015 Final Rule for Meaningful Use Stage 3 C‐CDA 2.1 PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 32
  32. 32. Discussion PEO DHMS DHMS PPT Template DEC2014 Distribution A: Approved for PublicRelease 33

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