DHSM Industry Onboarding Roundtable

1. PEO DHMS
February 10, 2016
PEO DHMS
DHMS PPT Template
DEC2014
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Defense Healthcare
Management Systems
Industry On‐Boarding Roundtable

2. PEO DHMS
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

3. PEO DHMS
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).

4. PEO DHMS
Military Health System
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5. Federal Medical Facilities
DoD, VA, HHS
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6. A Personal Perspective
1980s
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Today

7. PEO DHMS
Overview of DoD Health Information
Exchange and DMIX Program
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8. Relationship of DoD Data Sharing Activities
HIE On‐boarding
Prioritization
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Business
Policy
Strategy
Functional
Requirements
Content
Technical
Implementation
Fielding

9. PEO DHMS
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.

10. PM DMIX Data Sharing Implementation
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11. DoD On‐Boarding
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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 ?
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13. PEO
DHMS PPT Template Distribution A: Approved for PublicRelease
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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. 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
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• Identify ports, endpoints
• Complete testing
• Assess results and refine system

15. PEO DHMS
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 3/31/2015
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. PEO DHMS
Partner Integration Questionnaire
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DHMS PPT Template
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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 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. PEO DHMS
Partner Integration Questionnaire
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DHMS PPT Template
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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?

18. DoD Informal/Formal Testing
Test Scenarios + Test Data
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# 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. PEO DHMS
Onboarding Standards
Example 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 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. Lessons Learned Discussion
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21. PEO DHMS
Lessons Learned
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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. PEO DHMS
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

23. PEO DHMS
Lessons Learned (continued)
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DHMS PPT Template
DEC2014
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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. PEO DHMS
Lessons Learned (continued)
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DHMS PPT Template
DEC2014
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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. PEO DHMS
6DEC2014
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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. PEO DHMS
Lessons Learned (continued)
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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. PEO DHMS
Required and Optional Modules
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DHMS PPT Template
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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. Initiatives Underway
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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
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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
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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
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32. Discussion
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