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PEO DHMS February 10, 2016 PEO DHMS DHMS PPT Template DEC 2014 Distribution A: Approved for Public Release 1 Defense Healthcare Management Systems Industry On‐Boarding Roundtable

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PEO DHMSFebruary 10, 2016

PEO DHMSDHMS PPT Template DEC 2014

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Defense Healthcare Management Systems

Industry On Boarding‐ Roundtable

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Agenda

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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

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The Federal Advisory Committee Act (FACA)

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• 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).

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Military Health System

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Federal Medical FacilitiesDoD, VA, HHS

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A Personal Perspective

1980s

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Today

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Overview of DoD Health Information Exchange and DMIX Program

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Relationship of DoD Data Sharing Activities

HIE On‐boarding Prioritization

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BusinessPolicy

Strategy

FunctionalRequirement

s Content

TechnicalImplementation

Fielding

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Evolution of Data Sharing

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• 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.

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PM DMIX Data Sharing Implementation

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DoD On‐Boarding

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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 ‐ pointpartners is unsustainable

What can organizations in the middle do, to alleviate the burden between health data exchange users ?

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Generic Requirements for Data Exchange

DoD Implementation for eHx Participation Other (s)

Governance Signed DURSA

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 Out‐ ‐ process

Testing eHx and Partner Informal and Formal Testing 14

Key Considerations for Data Sharing

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On Boarding:‐ DoD Sites and eHx Partners

#1 DoD Activities• Provide access to JLV HIP‐• Provide training materials• 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

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• Identify ports, endpoints• Complete testing• Assess results and refine system

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DoD Onboarding Process and Timelines

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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 3/31/20154/3/2015

4/4/ 2015 1 month5 days

HIE 2 3/10/2015 5/21/156/5/2015

6/19/2015 4 months1 month

HIE 3 5/6/2015 10/29/201511/12/2015

12/2/2015 7 months1 month

HIE 4 3/26/2015 3/31/2015 3/31/2015 5 days1 day

HIE 5 4/14/2015 8/4/20158/13/2015

10/23/2015(Pending)

10 months1 week (staged)

1. Initial Contact2. Introductory Meeting & Questionnaire3. Technical Meeting (If Needed)

1. Informal Testing2. Formal Testing3. Onboarding to DoD

1. Production Testing2. Go Live in Production

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Partner Integration Questionnaire

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# 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 UDDI8 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 theDOD for Patient Discovery?

10 What workflow does your system follow (e.g. DoD PD/QD/RD process isexecuted 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?

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Partner Integration Questionnaire

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# 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?

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DoD Informal/Formal TestingTest Scenarios + Test Data

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# Test Scenario

1 Initiate a PD, DQ, DR for DoD Opted In Patient2 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 Patient5 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 test patients– EDIPN, Lastname, Firstname, DOB, SSN, Gender, Phone, Address_Street1, City, State, Zip, Country– Provided to joint partners for testing wit DoD

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Onboarding StandardsExample for the eHealth Exchange

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Specifications The 2010 and 2011 specifications ‐ lay out the standards on transport and exchange for patient discovery, document query, and document retrieve.o 2010 Specificationo 2011 Specification (MU2)*The DoD can support both (2010 and 2011 exchanges)

Document Types – HITSP and HL7 define the documents below for exchangeo C32 CCD ‐ Patient Health Summaryo 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 Originationo Dynamically Created – One document created dynamically through on the fly ‐ ‐

database querieso Static Documents – Multiple documents returned for single clinical events (i.e.,

encounter admissions)*The DoD can support both dynamic and static documents

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Lessons Learned Discussion

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Lessons Learned

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Observation Resolution

Specification AmbiguityThe 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.

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Lessons Learned (continued)

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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

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Lessons Learned (continued)

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Observation Resolution

Patient MatchingSome 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.

ContentA 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.

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Lessons Learned (continued)

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Observation Resolution

TestingAll 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.

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Lessons Learned (continued)Observation Resolution

ConsentEach 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 ModelsSome 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 includesquestions on charging to test, up front.‐

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Lessons Learned (continued)

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Observation ResolutionPrioritizationSeveral 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.

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Required and Optional Modules

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Modules for CCD Summary Report HITSP C32 CCD‐ Format* C CDA ‐ CCD Format**Comprehensive C32 and CCDAPerson Information Required RequiredLanguage Spoken Optional OptionalSupport Required (if known) OptionalHealth Providers Optional OptionalInformation Source Required RequiredAllergies Optional RequiredMedications Optional RequiredProblem List Optional RequiredProcedures (List of surgeries) (History of Procedures) Optional RequiredDiagnostic Results (Lab and Diagnostic) Optional RequiredAdvance Directives Optional OptionalEncounters Optional OptionalFamily History Optional OptionalFunctional Status Optional OptionalImmunizations Optional OptionalMedical Equipment Optional OptionalPayers/Health Insurance Optional OptionalPlan of Care Optional OptionalSocial History Optional OptionalVital Signs Optional OptionalSources:*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

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Initiatives Underway

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Health Interoperability and Exchange Alliance (HIEA)To synchronize standards, services, policies, and personnel to achieve

interoperability between the DoD, VA and their partners

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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 TestingTest DoD/VA FHIR based ‐ interoperability

and security

FHIR DevelopmentCollaborate on FHIR profiles and

extensions

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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

potential solutions• 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

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Discussion

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