EHR Implementers

EHR Implementers - eCR Exchange and Transport

Overview

When implementing electronic case reporting (eCR), electronic health record (EHR) companies must plan for secure technical connectivity with the Association of Public Health Laboratories (APHL) Informatics Messaging Services (AIMS) platform. Multiple technical transport options are available, and the approach may depend on policy, network membership, and client needs.

This page details the steps that should be taken when an EHR, on behalf of their client healthcare organization (HCO), is ready to establish a connection with the AIMS platform.

Connectivity Options for eCR

Connecting to the AIMS platform can occur using one or more of the following methods:

• Direct Secure Messaging or XDR through the eHealth Exchange HUB
• A Health Information Exchange (HIE) or Health Information Network (HIN)
• A TEFCA Qualified Health Information Network (QHIN)

Note: The approach used may depend on policy and membership status.

Prior to establishing connectivity on behalf of an HCO, the EHR vendor should ensure the following: 

• eICR Creation & Validation: Can generate and validate Electronic Initial Case Reports (eICRs) against eICR standards using the AIMS Online Validator. See EHR Implementers – Conduct Testing for more information.
• Enable & Test eICR Triggering: Use the Electronic Reporting and Surveillance Distribution (eRSD) with HCO test eICRs to ensure that triggering is properly implemented. See EHR Implementers - EHR Triggering for more information.
• Reportability Response Handling: Be able to receive, process, and route a test Reportability Response (RR) to EHR system administrators and, when appropriate, to the patient chart or provider of care. See EHR Implementers - Reportability Response Receipt & Use for more information.

If a HCO is connecting via a HIE or HIN, the designated HIE or HIN should contact the eCR Support Team to ensure that their connection to the AIMS platform is in place. 

Secure Transport Options

There are two secure transport options for eCR connections:   

1. Direct Secure Messaging 

Direct Secure Messaging provides secure transport for the sending and receiving of encrypted health information using The Direct Standard® via a “push” interoperability mechanism from the sender to the AIMS platform.

Administered by: DirectTrust (external link)

Specifications: Connecting with Direct Secure Messaging involves the use of the specifications outlined on the Direct Project Applicability Statement for Secure Health Transport wiki (external link).

2. XDR (ITI-41) specification using the eHealth Exchange HUB

XDR ITI-41 is the other common industry standard for “push” information exchange. The XDR ITI-41 specification is a slightly more constrained version of XDR that makes it more consistently usable.

Specification: XDR (ITI-41) specification (file download) 

1. Direct Secure Messaging

Technical Prerequisites to Establish Connection

EHRs should develop documentation that outlines prerequisites and configuration steps for HCOs. Below are a few technical prerequisites for a HCO to connect using Direct Secure Messaging: 

• Create a Direct testing address registered on either the “Accredited Trust Bundle (external link)” or the “Interoperability Testing Bundle (external link).” If the EHR company has implemented eCR in multiple other settings, it may be possible to bypass the testing connection, but, otherwise, its use is strongly encouraged.  
• Establish a Direct production address registered on the “Accredited Trust Bundle (external link).”  
• Identify the HCO through one of the options below. 
  • Option 1 -The Direct address sending to AIMS has a domain that identifies the sending HCO (e.g., abc@UniqueName.org). 
  • Option 2 -The Direct message is sent as an XDM attachment with the Author Institution metadata field consistently populated in the attached metadata.xml file. 

HCOs Health Information Service Provider (HISP) representative will be able to confirm the DirectTrust registration status of their addresses.  

Steps for Establishing a Connection

Once all EHR setup and configuration tasks are complete—including successful generation of a test eICR—the EHR vendor may initiate testing their connectivity with the AIMS platform on behalf of their HCO. During this process, the EHR vendor may need to coordinate with the HCO’s Health Information Service Provider (HISP) to support secure transport. 

1. Contact HISP.  HCOs should reach out to their HISP to confirm they have the latest certificates on their test environment and determine if the Direct address they will be using for testing is on the Interoperability Testing Bundle or the Production Accredited Trust Bundle.    
2. Send test eICR. Trigger and send a test eICR using a test patient that has fully populated demographic information. Only send synthetic test data. Do not send Protected Health Information (PHI) during these tests.  
   • If the HCOs test address is on the Interoperability Testing Bundle, synthetic test data should be sent to ecr-interop-noroute-test@direct.interop.aimsplatform.org. 
   • If the HCOs test address is on the Production Accredited Trust Bundle, synthetic test data should be sent to ecr-prod-noroute-test@direct.aimsplatform.org. 
3. Ensure Reportability Response (RR) is received. Once the test eICR is sent, the AIMS eCR platform will automatically send an RR message back to the sending Direct address upon receipt.  
   • If an RR is not received, HCOs should verify their configuration to rule out the most common issues found below.  
     • Confirm the eICR was generated and sent. 
     • Confirm the eICR made it to the HCOs HISP.  
     • Confirm the eICR was attached to a Direct Secure Message.  
     • Confirm the receipt of a successful Message Disposition Notification (MDN) response from AIMS.  
     • Confirm the patient-matching configurations allow for matching the RR to an existing patient.  
4. Confirm Success. Inform the eCR Support Team by creating a ticket through our service desk customer portal. In the subject line, include the name of the HCO and “Direct SMTP in TEST.” Communicate in the message that a test eICR was sent via Direct. Include the time and date of the message, the Direct address, and note if the RR was successfully received. If the RR was not received, include the troubleshooting steps completed.  

2. XDR (ITI-41)

Technical Prerequisites to Establish Connection

EHRs should develop documentation that outlines prerequisites and configuration steps for HCOs. Below are a few technical prerequisites for a HCO to connect using XDR (ITI-41) specification via eHealth Exchange: 

• Establish a Health Level Seven International (HL7) Object Identifier (OID) for both their production and testing environments.  
• Establish a XDR (ITI-41) endpoint URL for both the HCOs production and testing environments. If their EHR company has implemented eCR in multiple other settings, it may be possible to bypass the testing connection, but, otherwise, its use is strongly encouraged.

Establish trusted certificates with a chain for mutual authentication.  

Steps for Establishing a Connection 

Once all EHR setup and configuration tasks are complete—including successful generation of a test eICR—the EHR vendor may initiate testing their connectivity with the AIMS platform on behalf of their HCO. During this process, the EHR vendor may need to coordinate with the HCO’s Health Information Service Provider (HISP) to support secure transport. 

1. Inform the eCR Support Team by creating a ticket through our service desk customer portal. In the subject line, include the name of the HCO and “XDR (ITI-41) Connection Request.” In the message, include information for any technical point(s) of contact.  
2. The eCR Support Team will reach out with further onboarding instructions.  

What to do after a connection is established

Testing

After a test connection for eCR has been established, test eICRs can then be validated and processed, and a RR will be returned to the HCO. HCOs should not send real patient data to the test address. Proper testing will require the exchange of data for synthetic patients (test patients with no personal health information); however, test patient data should resemble production patient data as much as possible.  

Validation

When using the test environment, the test eICRs and RRs will be routed through test channels to appropriate PHAs to validate those pathways.

Production Use

When in production, "reportable" and "may be reportable" RRs should be attached to the patient chart or directed to the appropriate provider/support staff work queue, and all RRs should be reviewed by system administrators for errors and warnings. See Healthcare –Conduct Testing for additional context on testing.