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Direct Secure Messaging for Health Info Exchange
- 1. Direct Secure Messaging A form of secure email for exchanging Protected Health Information Jeff Livesay, Associate Director Michigan Health Information Network November 12, 2014
- 2. Agenda • What is Direct Secure Messaging? • How is Direct Secure Messaging used? • Using Direct for Public Health Reporting – two use cases: • Immunization reporting • Clinical Quality Measures • Using Direct for Care Coordination – three use cases: • Statewide Admission/Discharge/Transfer Notification Service • Statewide Medical Reconciliation Service • Trust Organizations and Trust Bundles: • DirectTrust.org, HISP accreditation, and vendor trust bundles • National Association for Trusted Exchange – consumer trust bundles • Security and Privacy Issues – what if…? • Contractual considerations with HISPs, RHIOs, HIEs and HINs • Introducing MiDiGate™ - Medical Information Direct Gateway • Direct and MiDiGate™ for Public Health Reporting • Direct and MiDiGate™ for Health Information Exchanges • Direct and MiDiGate™ for Health Plans Copyright 2014 - Michigan Health Information Network Shared Services 2
- 3. SMTP Simple Mail Transfer Protocol 3 What is a Direct Secure Message? Direct = secure email Copyright 2014 - Michigan Health Information Network Shared Services
- 4. Direct is required under MU 2 Final Rule • “These transport standards include the two transport specifications developed under the Direct Project6: (1) Applicability Statement for Secure Health Transport7 and (2) External Data Representation (XDR) and Cross- Enterprise Document Media Interchange (XDM) for Direct Messaging8. The Applicability Statement for Secure Health Transport specification describes how electronic health information can be securely transported using simple mail transport protocol (SMTP), Secure/ Multipurpose Internet Mail Extensions (S/MIME), and X.509 certificates. The XDR and XDM for Direct Messaging specification describes the use of XDR” • See: • 6 http://wiki.directproject.org/Documentation+Library • 7http://wiki.directproject.org/Applicability+Statement+for+Secure+Health+ Transport • 8http://wiki.directproject.org/XDR+and+XDM+for+Direct+Messaging Copyright 2014 - Michigan Health Information Network Shared Services 4
- 5. The Direct Project 5 • Simple, secure, scalable, standards-based way to send encrypted information “directly” to known, authenticated, trusted recipients • Messages sent securely between end-points: • person to person • person to system • system to system • system to person http://wiki.directproject.org/Documentation+Library Copyright 2014 - Michigan Health Information Network Shared Services
- 6. Live Not Live Pilot Not implementing Direct Other States and Territories CNMI 6 A National View of Direct Adoption CO NM TX OK UT VT NY PA NC KY MA Copyright 2014 - Michigan Health Information Network Shared Services CA WA NV OR ID AZ MT WY ND SD NE KS MN IA WI MI MO AR LA IL IN MS AL FL GA SC TN OH WV VA NH ME AK AS DC GU HI PR USVI RI CT DE NJ MD Map Legend Marketplace Contractual Hybrid •Marketplace: A state approves Health Information Service Providers (HISPs) based on a set of criteria that allows providers to determine the services and vendors that are right for them. •Contractual: A state has contracted directly with a vendor or vendors to provide HISP services. •Hybrid: A state has contracted directly with a vendor or vendors to provide HISP services and has also set up a marketplace for other HISPs to participate in.
- 7. The Role of DIRECT & EHRs Copyright 2014 - Michigan Health Information Network Shared Services 7
- 8. 8 Dr. Jones Dr. Smith First way to use Direct: Provider-to-Provider messaging Definition HISP Federally-bridged digital security certificate as HISP – Health Information Service Provider trust anchor HISP Copyright 2014 - Michigan Health Information Network Shared Services
- 9. 9 Second way to use Direct: System-to-system messaging From: results@direct.lab.com HISP To: someClinic_lab_results@direct.mihin.org Definition Federally-bridged digital security certificate as HISP – Health Information Service Provider trust anchor HISP Copyright 2014 - Michigan Health Information Network Shared Services
- 10. Public Health Reporting Use Case: Submitting Immunizations Using Direct mcir@direct.mihin.org 10 VACCINATIONS State of Michigan (SOM Data Hub) Standards Gateway Public Health Reporting Copyright 2014 - Michigan Health Information Network Shared Services
- 11. Public Health Use Case: Immunizations via Direct • d o c t o r@d i r e c t . f l o r i d a . o r g • d o c t o r@d i r e c t . o h i o . o r g • d o c t o r@d i r e c t .wi s h s i n . o r g • n u r s e@c o r r e c t i o n s .mi h i n . o r g mcir@direct.mihin.org State of Michigan Data Hub 11 Immunization Registry VPN into State Copyright 2014 - Michigan Health Information Network Shared Services
- 12. Public Health Reporting Use Case: Submitting Immunizations without Direct 12 MDCH Data Hub Data Sharing Organizations Public Health Reporting State-wide Shared Services No Change Required! Copyright 2014 - Michigan Health Information Network Shared Services
- 13. Clinical Quality Measures: The Problem • Meaningful Use (MU) Stage 2 requires Clinical Quality Measurement (CQM) reporting to State Medicaid • Status quo: no standard way to submit CQMs to state agencies • Providers must manually request MU credit • Limited ability to compare quality data within single clinics, within hospitals, across clinics • Solution: Clinical Quality Measure Recovery and Repository (CQMRR) Copyright 2014 - Michigan Health Information Network Shared Services 13
- 14. 14 Eligible Providers Eligible Hospitals CA Hospitals Data Peeler Cypress/DQA SOM Data Warehouse CQM Data Mart (Final) VXU’s Reports, Dashboards, Comparisons, QRD A MDSS MCIR MSSS CQMS@direct.mihin.org Valid QRDA VPN to SOM valid QRDA (CAT I & III) Health Provider Directory Meaningful Use Database Mining, NPI lookup State of Michigan Data Hub QRD A QRD A QRD A Valid QRDA QRD A QRD A Clinical Quality Measure Recovery and Repository QRDA (CAT I & III) QRDA (CAT I & III) TM CATIII@direct.mihin.org Copyright 2014 - Michigan Health Information Network Shared Services
- 15. ADTs / Medication Reconciliation: Care Coordination Use Cases Data Sharing Organization Data Sharing Organization Summary of Care Active Care Relationships Delivery Preference Lookup 1) Hospital sends Medication Reconciliation message 2) Check Active Care Relationships and identify three providers 3) Using the HPD, identify delivery preference for each provider 4) Medication reconciliation is routed to providers based on preferences MNO OSP 15 Animation GMPHO MEDs Copyright 2014 - Michigan Health Information Network Shared Services
- 16. DirectTrust.org: Mission and Goals • A voluntary, self-governing, non-profit trade alliance • Dedicated to the growth of Direct exchange at national scale • Operates under a Cooperative Agreement with ONC to support its work of creating a national network of interoperable Direct exchange services providers. • Establishes policies, interoperability requirements, and business practice requirements Security & Trust Framework EHNAC-DirectTrust Accreditation Program Trust Anchor Bundle Distribution Copyright 2014 - Michigan Health Information Network Shared Services 11/12/2014 16
- 17. DirectTrust Members 17 11/12/2014 17
- 18. Copyright 2014 - Michigan Health Information Network Shared Services 18
- 19. Current DTAAP Accreditation Roster November 10, 2014 • Athenahealth Inc. • Axesson • CareAccord • Cerner Corporation • Covisint • DataMotion Inc. • DigiCert Inc. • EMR Direct • Health Companion Inc. • Hixny Inc. • Infomedtrix LLC • ICC • ICA • Inpriva • IOD Incorporated • Alere Accountable Care Solutions • Applied Research Works, Inc. • Corepoint Health LLC • eClinical Works • Glenwood Systems • Healthunity Corporation • Indiana Health Service • Nitor Group • Orion Health • Pulse Systems Inc. • Qsource • Quest Diagnostics • Shifox LLC • Siemens Medical Solutions USA Inc. • Simplicity Health Systems 19 Fully Accredited and Audited Candidate Status 11/12/2014 • Maxims • Medicity • MedAllies • MHIN • MRO Corporation • NextGen/Mirth • NYeC • Optum • Relay Health • Rochester RHIO • Secure Exchange Solutions Inc. • Surescripts • Truven Health Analytics • Updoxy Copyright 2014 - Michigan Health Information Network Shared Services
- 20. DataMotion™ Direct Secure, Integrated Messaging for Electronic Health Records • Direct Secure Messaging subscription service • Group and individual address provisioning • EHR integration and/or email client integration • Easy Direct access via web portal login DataMotion is an accredited Health Information Service Provider (HISP) of Direct Secure Messaging*
- 21. Who is NATE? 21 http://nate-trust.org/wp-content/uploads/2014/10/20141105-NBB4C-2014-slides-FINAL.pdf Copyright 2014 - Michigan Health Information Network Shared Services
- 22. NATE PHR Initiative Phase 1 participating actors 22 http://nate-trust.org/wp-content/uploads/2014/10/20141105-NBB4C-2014-slides-FINAL.pdf Copyright 2014 - Michigan Health Information Network Shared Services
- 23. NATE: PHR Incentive Phase 1: examining desired capabilities to inform Phase 2 recommendations 23 http://nate-trust.org/wp-content/uploads/2014/10/20141105-NBB4C-2014-slides-FINAL.pdf Copyright 2014 - Michigan Health Information Network Shared Services
- 24. NATE: Message and Certificate Flow • Some quick definitions: • Digital Certificate: Electronic document used to prove ownership of a public key; includes information about owner's identity and digital signature of entity (“Certificate Authority”) that has verified contents are correct • Public Key: Used to encrypt a message or to verify a digital signature • Private Key: Used to decrypt an encrypted message or create a digital signature • Trust Anchor: An authoritative entity for which trust is assumed and from which a chain of trust is derived • Trust Store: A collection of digital certificates of trust anchors you have chosen to trust
- 25. NATE: Message and Certificate Flow
- 26. NATE: Sender and Recipient Identity • “Level of Assurance” – How well the addressee’s identity is proofed. • NIST LOA level 2 – “in-person” government picture ID • FBCA medium – “in-person” government picture ID and signature attesting to identity • NIST LOA level 3 – “in-person” government picture ID verified independently • Answers the question “How do I know the address really belongs to who claims to own it?” • Traditional LOA mechanisms may be impossible or inappropriate for consumers • Assurance of the owner of a Direct address may be achieved through personal relationships
- 27. NATE: Trust Bundles • “Trust Bundles” are a collection of trust anchor certificates used to populate a trust store • Reduces the need for point-to-point trust relationships: • A use case and set of policies define a Trust Profile • A Trust Bundle identifies the members of a Trust Community that have agreed to voluntarily adopt the Trust Profile • Trust Bundles are published via Direct Project standard
- 28. NATE: Trust Bundles • Since Trust Bundles populate trust stores: • HISPs can load more than one trust bundle; they are not exclusive • Organizations can be part of more than one Trust Community • Organizations can load anchors of individual trusted partners • Both sender and receiver must have Trust Bundle in store (i.e. both be members of at least one common Trust Community or agree to be trusted partners)
- 29. NATE to Administer Blue Button Plus Trust Bundles
- 30. Security and Privacy – what if… • Can a hacker intercepts a Direct Secure Message? • Very difficult but even if this happened, the payload is encrypted so this would not be considered a breach under HIPAA/HITECH • Additionally, a single Direct message likely only has information on one patient – a full breach involves at least 500 patient records – the exposure is minimal • How could someone break into Direct? • Breaking into the data center is almost the only way, but the accreditation process inspects the physical security of the data center • What if a Direct Secure Message is sent to the wrong recipient? • This happens all the time today with faxes – it is no different • If the “wrong recipient” is another health provider, they are a covered entity • If the wrong recipient is not a provider, this is an “accidental disclosure” Corporate Confidential -All Rights Reserved 2014 - Michigan Health Information Network Shared Services 30
- 31. Contractual Considerations • Is the HISP vendor already accredited by EHNAC-DTAAP or in the process and if the latter, by what date certain do they expect to be accredited? • Does the HISP support all forms of Direct, not just person-to-person? • Does the vendor also provide RA and CA or partner? • Does the vendor provide a good End-User License Agreement • Is the HISP client a full-featured browser/PDA-based client? • Does the HISP support Single Sign-On and Identity Federation? • What are *all* of the costs (yes, there can be hidden costs)? • Cost to stand up your instance of the HISP? Annual maintenance? • Cost per account per year, in both low and high volumes? • Can you provision your own accounts or does HISP vendor have fee? • Are there Application Programming Interfaces (APIs) for integration with your existing ecosystem? Can you use these or only the vendor? • What kind of provider directory is included/supported? • How much storage is included per account? • How much does additional storage cost? • What is the maximum file size for attachments? Corporate Confidential -All Rights Reserved 2014 - Michigan Health Information Network Shared Services 31
- 32. Medical Information Direct Gateway: MiDiGate™ for Public Health Reporting 32 Medical Information Direct GatewayTM MiDiGateTM for Public Health & QRDA Cat III ccdas@direct.mihin.org TM MiDiGate SOM Data Warehouse VPN to SOM ADT-Subscribers adts@direct.mihin.org Meaningful Use Reporting labs@direct.mihin.org immunizations@direct.mihin.org CQM Data Mart Medicaid ADT Repository MCDR MDSS MCIR MSSS A T E Outbound G I M I D M I D I G Inbound A T E cqms@direct.mihin.org QRDA CAT III QRDA Meaningful Use Database MU Credit deaths@direct.mihin.org QRDA Copyright 2013 – MiHIN – Corporate Confidential – Proprietary Patent Pending Labs Patients Hospitals Physicians HIEs Other States Correctional Facility Any provider organization EDRS MDCH Data Hub Direct Email Convention Examples Using MiDiGate & Health Provider Directory Inbox labs@direct.mihin.org immunizations@direct.mihin.org deaths@direct.mihin.org birthdefects@direct.mihin.org cqms@direct.mihin.org adts@direct.mihin.org fostercarehealth@direct.mihin.org ccdas@direct.mihin.org Destination(s) . Reportable Labs to MDSS Michigan Care Improvement Registry Electronic Death Registry System Chronic Disease Registry SOM Data Warehouse Vital statistics Foster Kids Registry Chronic Condition Registry Description Lab Results Immunizations Death notices Birth defect notices Clinical Quality Measures Admit, Discharge, Transfer Foster kids care summaries Consolidated Clinical Document Architecture Copyright 2014 - Michigan Health Information Network Shared Services
- 33. MidiGate™ for HIEs 33 MDCH Data Hub HIE QO/VQO Michigan Direct GatewayTM QRDA Cat III ccdas@direct.hieqo.org TM MiDiGate adts@direct.hieqo.org MiDiGateTM for HIE QOs and VQOs labs@direct.hieqo.org immunizations@direct.hieqo.org CQM Data Mart Medicaid ADT Repository MSSS MCIR MDSS SOM Data Warehouse VPN to SOM A T E Outbound G I M I D M I D I G Inbound A T E cqms@direct.hieqo.org QRDA CAT III MU Credit Meaningful Use Database deaths@direct.hieqo.org QRDA MiHIN VPN to MiHIN Copyright 2013 – MiHIN – Corporate Confidential – Proprietary Patent Pending Labs Patients Hospitals Physicians HIEs Correctional Facility Any provider organization EDRS MCDR VPN to HIE/QO/VQO HIE Repository Other States Direct Email Convention Examples Using MiDiGate & Health Provider Directory Inbox labs@direct.hieqo.org deaths@direct.hieqo.org immunizations@direct.hieqo.org usecasename@direct.hieqo.org birthdefects@direct.hieqo.org cqms@direct.hieqo.org adts@direct.hieqo.org fostercarehealth@direct.hieqo.org ccdas@direct.hieqo.org Destination(s) . Reportable Labs to MDSS Electronic Death Registry System Michigan Care Improvement Registry Registry for that use case Chronic Condition Registry SOM Data Warehouse Vital Statistics Foster Kids Registry Chronic Disease Registry Description Lab Results Death Notices Immunizations Use Case Specific Birth Defect Notices Clinical Quality Measures Admit, Discharge, Transfer Foster Kids Care Summaries Consolidated Clinical Document Architecture Copyright 2014 - Michigan Health Information Network Shared Services
- 34. MiDiGate™ for Health Plans 34 Medical Information Direct GatewayTM Quality & PQRS Reporting ccdas@direct.[healthplan].org TM MiDiGate adts@direct.[healthplan].org MiDiGateTM for Health Plans labs@direct.[healthplan].org Quality A T E Outbound G I M I D M I D I G Inbound A T E cqms@direct.[healthplan].org QRDA authorizations@direct.[healthplan].org Labs Patients Hospitals Physicians HIEs Other States Any provider organization QRDA VPN Revenue Management Incentive Hospital Contract Health Plan Data Warehouse Provider Relations MyEmail@direct.[healthplan].org Pharmacy Utilization Management Care Management Analytics Fraud Copyright 2013 – MiHIN – Corporate Confidential – Proprietary Patent Pending Correctional Facility Direct Email Convention Examples Using MiDiGate & Health Provider Directory Destination Examples Care Manager, Incentive Utilization Management Pharmacy, Care Manager, Incentive Hospital Contracts, Provider Relations Quality, Revenue Management Care Manager, Utilization Manager Other Qualified Organization Inbox labs@direct.[healthplan].org authorizations@direct.[healthplan].org meds@direct.[healthplan].org custom@direct.[healthplan].org cqms@direct.[healthplan].org adts@direct.[healthplan].org ccdas@direct.[healthplan].org Description Lab Results Authorizations Medication Notices Any PHI type message Clinical Quality Measures Admit, Discharge, Transfer Consolidated Clinical Document Architecture Copyright 2014 - Michigan Health Information Network Shared Services
- 35. Questions? Jeff Livesay Associate Director livesay@mihin.org Copyright 2014 - Michigan Health Information Network Shared Services 35
- 36. References • http://wiki.directproject.org/Documentation+Library • http://wiki.directproject.org/Applicability+Statement+for+Secure+Health+Tran Copyright 2014 - Michigan Health Information Network Shared Services 36 sport • http://wiki.directproject.org/XDR+and+XDM+for+Direct+Messaging • www.directtrust.org • www.nate-trust.org
Notas do Editor
- DT addressing many issues and growing strong
- Membership expanding rapidly
- Accreditation has industry acceptance
- DataMotion™ SecureMail is a powerful, yet simple desktop solution that secures sensitive email and file attachments from accidental exposure and data theft, while ensuring regulation compliance. DataMotion™ SecureMail Gateway safeguards sensitive email messages by automatically scanning all of your company’s email for compliance, and applying policy-based secure mail encryption. DataMotion™ SecureMail Automation automatically encrypts high volume email communications to keep workflows compliant with industry regulations so your reputation and customers’ privacy are protected. DataMotion™ SecureMail for Salesforce enables any user of Salesforce.com Enterprise Edition to send and track secure emails and file attachments from inside the Salesforce application. DataMotion™ Direct enables healthcare providers, patients, business associates and clinical systems to securely send and receive protected health information (PHI) in conformance with EHR MU2 guidelines. DataMotion™ SecureContact enables customers to initiate a secure email with file transfer from your website through a “Contact Us” button, by simply typing a message, attaching files and clicking ‘Submit’. DataMotion™ SecureContact.me allows your email recipients to initiate a secure message and file transfer to you using an embedded link that is easily embedded in your email signature profile. DataMotion™ Secure eForms provides a powerful tool for your customers and partners to securely submit information for automatic integration into back end systems to web-enable offline workflows. DataMotion™ Secure File Transfer enables employees to easily send files up to 2GB securely, to anyone, anywhere, anytime, with full visibility into all files sent – keeping your organization in compliance.
- Sender creates a Message to be transmitted via Direct Sending HISP verifies it can send message to the Receiving HISP (Trust Anchors check) Sending HISP will sign the message with its private key Sending HISP will encrypt the message with the Receiver’s public key Sending HISP sends the message Receiving HISP verifies it can receive the message from the Sending HISP (Trust Anchors check) Receiving HISP receives the message. Receiving HISP decrypts the message using the Receiver’s private key Receiving HISP verifies the signature of the message using the Senders public key. Receiving HISP provides an MDN to the Sending HISP Receiving HISP delivers the message to the receiver Receiver reads the message.