Wednesday, March 7, 2012

Early NPRM Questions

As HIT stakeholders review the Meaningful Use Stage 2 NPRMs in detail, questions about the intent of the language are circulating throughout the industry.

The two most common questions I've heard are related to image display (is it viewing via an EHR, through an EHR, DICOM required etc.) and Healthcare Information Exchange transport standards.

Here's a very thoughtful blog post from David Clunie that summarizes the issues of image viewing in the Stage 2 NPRMs.

Healthcare Information Exchange transport is now required per this provision in the CMS NPRM:

"The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care electronically transmits a summary of care record using certified EHR technology to a recipient with no organizational affiliation and using a different Certified EHR Technology vendor than the sender for more than 10 percent of transitions of care and referrals."

Many are asking what standards and what architecture will be required, since the Standards and Certification NPRM offers a few options.

The HITSC NwHIN Power Team will continue to make recommendations to ONC, but here's my suggestion:

1.  For Push transactions, use SMTP/SMIME between Health Information Services Providers (HISPs) with the option of SOAP for "on ramps" and "off ramps" to EHRs (and PHRs).   For point to point transport between EHRs without a HISP use SOAP.
2.  For Pull transactions, use SOAP per a rewritten NwHIN Exchange implementation guide (eliminate the layering of specifications that refer to standards within standards within standards).   For point to point Pull, consider the kind of simplified Exchange-like SOAP transaction we've implemented between BIDMC and Atrius that does not require a master patient index, record locator service, or  document registry.
3.  If a RESTful implementation guide becomes available for Push or Pull,  consider it.

Over the next 60 days, HITPC and HITSC experts will examine all the ambiguities in both NPRMs.   I'm confident that with public comment and expert review, CMS and ONC will polish the NPRMs into Final Rules that are pure poetry.


Greg Lose said...

Tx for the summary. Why do you think REST is lagging behind SOAP in the specifications ?

Adrian Gropper said...

The combination of Direct, OAuth and DICOM provides a much simpler RESTful solution to imaging MU.

We can treat DICOM files as if they were BlueButton files, and secure them with OAuth to facilitate single-sign-on and enable delegated access for physician-to-physician transfers. EHRs and Provider Portals will have streaming viewers supplemented by download and OAuth options for both the streaming and DICOM versions of a study. Secure Direct emails can be integrated with OAuth to enable a physician or patient to click a link in the Direct message and launch a streaming viewer or DICOM download.