Slides from some of the various presentations at the Direct Project boot camp for state level health information exchange planning

1. Direct Project Boot Camp Chicago, Illinois

2. What is Direct? A project to create the set ofstandardsand services that, with a policy framework, enable simple, directed, routed, scalable transport over the Internet to be used for secure and meaningful exchange between known participants in support of meaningful use 2

3. Secure Internet-based Direct Communications Direct Project specifies a simple, secure, scalable, standards-based way for participants to send encrypted health information directly to known, trusted recipients over the Internet. h.elthie@direct.ahospital.org b.wells@direct.aclinic.org Simple.Connects healthcare stakeholders through universal addressing using simple push of information. Secure. Users can easily verify messages are complete and not tampered with in travel. Scalable. Enables Internet scale with no need for central network authority. Standards-based. Built on common Internet standards for secure e-mail communication.

4. Why Direct? When current methods of health information exchange are inadequate: Communication of health information among providers and patients still mainly relies on mail or fax Slow, inconvenient, expensive Health information and history is lost or hard to find in paper charts Current forms of electronic communication may not be secure Encryption features of off-the-shelf e-mail clients not often used in healthcare communications today Physicians need to transport and share clinical content electronically in order to satisfy Stage 1 Meaningful Use requirements. Need to meet physicians where they are now Direct will be one of the communication methods in the Nationwide Health Information Network Sources: http://www.flickr.com/photos/dougww/922328173/ http://www.flickr.com/photos/greenlagirl/154148230/sizes/o/ http://www.flickr.com/photos/kenjonbro/3418425029/sizes/m/

5. Who is Direct? (as of November 2010) The Direct Project represents over 50 organizations and over 200 participants. Members participate in the Implementation Group and one or more of 6 workgroups. Implementation Group (50+ organizations, 200+ participants) Security and Trust Communications Documentation and Testing Implementation Geographies Reference Implementation Best Practices

6. What do you need to enable Direct? Direct Addresses Security & Trust Services Direct Messages Message Transport & Delivery

7. Direct Addresses Direct Addresses are used to route information Look like email addresses Used only for health information exchange b.wells@direct.aclinic.org An individual may have multiple Direct addresses Domain Endpoint Direct Address

8. Security & Trust: Certificates Each Direct Address must have at least one digital certificate associated with it in order to securely transmit and receive health information Certificate may be tied to either the specific Direct Address or the Domain that is part of that address X.509v3 digital certificate standards By using certificates to securely transmit and receive information… The Sender has a strong mathematical certainty that only the Receiver or explicitly authorized delegates can view the message The Receiver has a strong mathematical certainty that only the Sender sent the message Both Sender and Receiver have confidence that nothing happened to the message in transit (e.g., tampering, disclosure, etc.)

9. Security & Trust: Certificate Discovery Certificate discovery must occur prior to a Direct message being sent in order to fulfill the encryption functions of the S/MIME format Discovery based on existing Internet protocols Existing specifications exist for discovery via DNS Address-bound certificates must be associated with a Direct-formatted address Organization-bound certificates are stored under the Health Domain Name If DNS is not supported, an alternate method must be offered

11. Trust Anchors are Certificate Authorities (CAs)

13. Message Transport & Delivery Direct specifies Simple Mail Transport Protocol (SMTP) as its primary mechanism for delivering healthcare content from a sender to a receiver This choice supports environments that have minimal capabilities in terms of using Web Services and generating detailed metadataand allows for more advanced interoperability

14. Direct Project Compliance Compliance is defined in the Applicability Statement for Secure Health Transport Core set of requirements for using SMTP, S/MIME, and X509 certificates in an interoperable way However, it’s recognized that communities may use other standards or proprietary mechanisms internally Will generally have Direct-compliant gateways that implement the Applicability specification while harmonizing local standards/mechanisms to Direct-equivalents XDR and XDM for Direct Messaging specifies such a solution when using IHE XDR for local transport

15. SOAP, IHE and XD* Conversions While SMTP is the primary delivery method for Direct, some healthcare environments have existing SOAP-based Web Services that provide detailed metadata and have adopted a family of IHE profiles SOAP – format for exchanging structured information, based on XML for message format XDR and XDM for Direct Messaging XDR – supports a direct push model using Web Services transport XDM – supports a direct push model with SMTP as a transport option, among several XD* Conversion Enables interoperability between Direct participants who may be using SOAP+XDR, SMTP+XDM, or SMTP+MIME

18. SMTP+XDM (RFC5322+XDM)

20. HIE Strategy should drive the approach to implementing Direct Orchestrator Elevator Public Utility Capacity-Builder $ $ Rapid facilitation of directed exchange capabilities to support Stage 1 MU Develops and bolsters local exchange capabilities Connects local exchange activities with thin layer of statewide infrastructure Directly connects providers into centralized HIE solution Direct Approach #1: Market-based solns Direct Approach #3: Fill in the gaps Direct Approach #3: Fill in the gaps Direct Approach #2: Offer complete svcs Direct Approach #2: Offer complete svcs Individual States may adopt multiple strategies

21. User InterfacesOverview of Options Email Client S/MIME Encryption is popularly supported Downloadable Plug-in for Direct Web Portal (or Webmail) Web Portal can be set up by HISP or HIE Webmail with plugin for Direct EHR Module that enables Direct messaging Message generated and sent by EHR without intermediate steps @ EHR Individual communities are likely to include instances of all user interfaces, depending on provider preferences and choices in the local market

22. User InterfacesPros and Cons EHR @

23. Deployment ModelsOverview of Options 20 Encryption at Client Client does encryption/decryption locally Capabilities built into the EHR Relies on HISP for routing Encryption at HISPs HISP provides encryption/decryption HISP provides routing Client interacts through EHR, Email, or Portal Direct and XDR (optional) Some HIEs use the IHE XDR profile for push workflows This deployment model enables compatibility with the Direct Project DestHISP Src Dest DestHISP SrcHISP Src Dest HISP Src Dest Individual communities likely to employ all deployment models, depending on provider preferences and local EHR choices. States need to enable HISPs regardless.

24. Deployment ModelsPros and Cons Threat Models for these deployments (including “Direct to/from XDR”) available at: http://wiki.directproject.org/Threat+Models