Introduction MaxMD is pleased to provide the Pennsylvania ehealth Partnership Authority (Authority) the Business and Technical Requirements report under the Lab Grant pilot project. We have demonstrated a solution that provides the Commonwealth with a repeatable and scalable approach that expands and enhances the delivery of electronic lab results using the DIRECT protocol throughout the Commonwealth. The MaxMD lab pilot team executed project to automate the creation of structured lab result messages. The result messages from participating lab systems will be sent via DIRECT to the receiving provider EHR. These messages will have been automatically processed by the provider s EHR. The provider is able to view the message within their EHR interface without manual intervention. The MaxMD team leveraged existing software and integration components, as well as creating new software products that will be available to other provider practices, rather than relying on proprietary interfaces. The majority of the pilot tasks concentrated on configuring existing components including: MaxMD HISP Services LIS HL7 Results Delivery HealtheTrax receipt of lab results and transformation to delivery requirements from Penn State Hershey Pathology, Milton Hershey School Health Center, and the VNA Delivery of lab results via MaxMD to Penn State Hershey Pathology, Milton Hershey School Health Center, and the VNA via DIRECT protocol Business and Technical Description of Commercial Systems The scope of the technical solution is further described below. MaxMD The MaxMD HISP will use a dedicated DIRECT email account for each LIS. This account will also serve as the service end-point for the entire system. There will be dedicated DIRECT email accounts for every participating provider, but these will be used for messages outside the stream of lab data coming from the lab vendor. HealtheTrax Integration Platform The integration between the LIS and MaxMD HISP will be provided by Dynamed Solutions, LLC. The LIS service provisioning process begins with the opening of an HL7 channel between the each LIS and HealtheTrax. The LIS will deliver HL7 lab results to an SFTP secure directory in the HealtheTrax platform. HealtheTrax will retrieve the LIS 1
message from the SFTP folder, convert it to the format required by each provider, and pass the message to an SFTP folder on the outbound channel, depending on the destination provider. A routine has been written to call the MaxMD SMTP protocol, to ensure that all DIRECT protocols are followed, and the message is not security-compromised at any point in the process. HealtheTrax will have a MaxMD secure DIRECT account that will provision the appropriate certificates and keys required to meet DIRECT requirements. Dynamed will route the lab feed via their HealtheTrax Integration Platform. The LIS integration module will deliver a standard format message, including all components of the lab message (FROM address, TO address, subject line, body, and attachment(s)) in a defined message. Then the mail server will locate the address and corresponding public key and the message will be delivered. The provider side will consume the re-formatted message utilizing the DIRECT protocol. In most cases, HealtheTrax will be delivering two versions of the lab result message: 1) The first message(s) in a human-readable PDF format. 2) The second message(s) in a machine-readable electronic version that can be automatically consumed into the patient record within the EMR. Within its database, HealtheTrax will record details regarding the type and time of message received, when it was delivered to MaxMD, and when confirmation of delivery is received from MaxMD. Additionally, the channels within HealtheTrax will be pre-configured with user-defined filters to determine if the presence of a new message in the SFTP folder warrants delivery to MaxMD and ultimately the provider. MaxMD Integration and Edge Protocols The HealtheTrax Integration Platform will utilize MaxMD SMTP protocol to access participating email accounts automatically. MaxMD has developed an Edge Protocol application that allows various EMR vendors to use to integrate the registration, directory services, DIRECT transport/receipt and alert notifications from the MaxMD HISP into local applications. The integrated applications (HealtheTrax and providers EMR) have complete control over the integration approach, taking advantage of the MaxMD secure computing platform. HealtheTrax has an outbound channel configured to call MaxMD s SMTP protocol to allow all DIRECT-required services to be utilized from end-to-end during message transport. The service only needs to provide a secure e-mail address to identify a mailbox. All required MDN notifications are handled through MaxMD s existing DIRECT protocols. The lab pilot workflow is depicted in the following diagrams. Diagram 1, Business Workflow, describes the solution s operational workflow and Diagram 2, Technical Workflow, describes the technical operational workflow. 2
The general operational workflow is depicted on Diagram 1. Diagram 1, Business Workflow Diagram 2, Technical Workflow 3
MaxMD Msg Delivery Status Laboratory Clinical Event SFTP Lab Result Msg ACK/NAK Htrax Error Msg HealtheTrax Integration Platform SMTP PDF/CCD/ ASTM HL7 Lab Result MaxMD Msg Delivery Status MaxMD DIRECT Encrypted Lab Result Msg Delivery Status Recipient In-Box EMR Internal Transport EMR Lab Result Format Engine Participant Registration Repository Interface Engine Data Validation PDF/CCD Transformation Engine Provider/Lab Lookup Lab Test Code/LOINC Lookup Encryption Engine Bi-Directional Msg Confirmations Client-side (EMR) Conversion Engine Lab Result Msg Receipt Confirmation
Project Delivery Process and Methodology Solution Workflow: The lab pilot solution includes the following steps: 1. Dynamed s HealtheTrax module receives LIS generated HL7 formatted lab results via a SFTP connection and transforms them into both human readable PDF files and HL7 formatted files containing associated LOINC codes. HealtheTrax sets the recipient direct address and drops the resulting files into a predefined server folder. 2. Dynamed s HealtheTrax module invokes SMTP to send the transformed lab results to the appropriate Provider as a MaxMD DIRECT message with attachments. 3. The MaxMD DIRECT message is digitally signed by private key of the Sender and encrypted by the public key of the Recipient (Provider) according to the DIRECT specification. 4. MaxMD invokes SMTP the DIRECT message s attachment(s) into a predefined shared folder accessible by the Provider s EHR system. 5. MaxMD DIRECT module generates a machine readable MDN which is returned to the Sender for processing. The MDN conforms to the Applicability Statement for Secure Health Transport requirement under which the HISP should notify or indicate back to the Sending system successful delivery of lab results to the destination. 6. The attachment(s) is retrieved from the shared folder and processed by the P rovider s EHR system within the provider existing workflow. There are minimal modifications to the provider s EMR workflow. The pilot relies on existing EMR capabilities. The MaxMD team orchestrated the testing and complete associated documentation for the successful generation and delivery of 150 results per participating provider office. These results include at least 10 distinct patients and 10 distinct lab tests. The MaxMD team worked with the lab to determine which providers order from that lab most frequently (in terms of number of tests ordered) and map the LOINCs for the tests that constitute 60% of all tests ordered. The MaxMD team is submitting test plans and results that document successful generation and delivery of 150 results per participating provider office. These results include at least 10 distinct 1
patients and at least 10 distinct lab tests. 2