EHR Implementers

EHR Implementers - eCR Exchange and Transport

Exchange and Transport Options for eCR

What follows are the steps that should be taken when you are ready to establish a connection with the Association of Public Health Laboratories (APHL) Informatics Messaging Services (AIMS) platform using eHealth Exchange, Commonwell, Carequality, or Direct. At this point, you should: 

  • Have an electronic health record (EHR) that can create electronic initial case reports (eICRs) that validate successfully against the online AIMS Validator.

  • Have used the Electronic Reporting and Surveillance Distribution (eRSD) with healthcare organization test eICRs to ensure that triggering is properly implemented (For details, see EHR Implementers - EHR Triggering page).

  • Be able to receive a test Reportability Response (RR), process it, and route it to EHR system administrators and, when appropriate, to the patient’s chart or the provider of care (For details, see EHR Implementers - Reportability Response Receipt & Use page).

  • Have communicated your intent to start electronic case reporting (eCR) to your public health agency (PHA). 

If, on the basis of your policy/network membership determinations, you intend to use a Health Information Exchange (HIE) or Health Information Network (HIN) to connect, you may need the HIE to contact the eCR Support Team to ensure that their connection to the AIMS platform is in place. 

 For eCR connections, there are two secure transport options:   

 1. Direct SMTP 

Direct Simple Mail Transfer Protocol (SMTP) provides secure transport for the sending and receiving of encrypted health information. It is administered by DirectTrust (external link), a nonprofit health care industry alliance. Connecting with Direct involves the use of the specifications outlined on the Direct Project Applicability Statement for Secure Health Transport wiki (external link). 

 2. NwHIN XDR using the eHealth Exchange HUB 

IHE XDR (Cross Enterprise Document Reliable Interchange) is the other common industry specification for “push” information exchange. The NwHIN XDR specification (file download) is a slightly more constrained version of XDR that makes it more consistently usable.  

Technical Prerequisites to Establish Connection

There are a few technical prerequisites to establishing either connection: 

   Direct SMTP Technical Prerequisites: 

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

   NwHIN XDR Technical Prerequisites: 

  • A Health Level Seven International (HL7) Object Identifier (OID) for both your production and testing environments. 
  • NwHIN XDR endpoint URL for both your production and testing environments. If the EHR vendor has implemented eCR in multiple other settings, it may be possible to bypass the testing connection, but, otherwise, we strongly encourage its use. 
  • Trusted certificates with a chain for mutual authentication. 

How to establish connection with Direct SMTP

Follow the below steps to establish a Direct SMTP connection for eCR: 

Once all electronic health record (EHR) setup and configuration tasks are complete, including the ability to trigger a test eICR, you can now test your connectivity with the AIMS eCR Platform. During this process you may need to work with your Health Information Service Provider (HISP). 

  1. Contact your HISP:  Reach out to your HISP to confirm you have the latest certificates on your test environment and determine whether the Direct Address you will be using for testing is on the Interoperability Testing Bundle or the Production Accredited Trust Bundle.   
  2. Send test message: Trigger and send a test eICR using a test patient that has fully populated demographic information. 

Only send test data, no Protected Health Information (PHI) during these tests 

  • If your test address is on the Interoperability Testing Bundle send to test@aimsplatform.sandbox.dmhisp.com.
  • If your test address is on the Production Accredited Trust Bundle send to demo@direct.aimsplatform.com.
  1. Confirm Reportability Response (RR) Receipt: Once you send the test eICR, the AIMS eCR platform will automatically send a RR message back to the sending Direct address upon receipt. 

  • If you do not receive a Reportability Response back, confirm your configuration to rule out the most common issues found below. 

    • Confirm the eICR was generated and sent.
    • Confirm the eICR made it to your HISP. 
    • Confirm the eICR was attached to a Direct Message. 
    • Confirm you received a successful Message Disposition Notification (MDN) response from AIMS. 
    • Confirm your patient matching configurations allow for matching the RR to an existing patient. 
  1. Confirm Success: Open a ticket by sending an email to informatics.support@aphl.org, with the subject line: eCR - [your healthcare organization name] - Direct SMTP in TEST. Inform the eCR Support Team that you sent a test eICR via Direct, include the time and date of the message, your Direct address, and note if you successfully received the RR back. If you did not receive the RR, include the troubleshooting steps completed prior to opening a ticket. 

 How to establish a connection with NwHIN XDR

Follow the below steps to establish a NwHIN XDR connection for eCR:  

  1. Open a ticket by sending an email to informatics.support@aphl.org with the subject line: eCR - [your healthcare organization name] - NwHIN XDR Connection Request. Include your technical point(s) of contact information. 
  2. You will be contacted by the eCR Support team with further instructions. 

What to do after establishing connection

Now that you’ve established a test connection for eCR, any eICR documents delivered will be processed and a RR returned as would happen in the production environment. Please do not, however, send actual patient data to the test address. Proper testing will require that data for synthetic patients (test patients with no real personal health information) be exchanged, and that this test patient data should resemble production patient data as much as possible. 

Test eICRs will be validated, run through the Reportable Conditions Knowledge Management System (RCKMS) decision support, and a RR will be returned, which should help finalize your testing. When using the test environment, the test eICRs and RRs will be transmitted via a test channel to appropriate PHAs to validate those pathways as well.  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.

Additional context on testing is available on the Healthcare –Conduct Testing page.

What are the technical prerequisites to establishing connection?

There are a few technical prerequisites to establishing either connection:

Direct SMTP Technical Prerequisites:

Your Health Information Service Provider (HISP) will be able to confirm the DirectTrust registration status of your addresses.

NwHIN XDR Technical Prerequisites:

  • A Health Level Seven International (HL7) Object Identifier (OID) for both your production and testing environments.

  • NwHIN XDR endpoint URL for both your production and testing environments. If the EHR vendor has implemented eCR in multiple other settings, it may be possible to bypass the testing connection, but, otherwise, we strongly encourage its use.

  • Trusted certificates with a chain for mutual authentication.

How to establish a connection with Direct SMTP?

Follow the below steps to establish a Direct SMTP connection for eCR:

   Step 1 - Open a ticket by sending an email to informatics.support@aphl.org informing the eCR Support Team that you sent the Hello World message via Direct.  Include your technical contact information and sending address. Make the subject line: eCR - [your healthcare organization name] - Direct SMTP Connection Request (example: “eCR - ABC Hospital - Direct SMTP Connection Request”).

   Step 2 - Send a Hello World message from your Direct testing address to demo@direct.aimsplatform.com. Be sure the subject line is: eCR - [your healthcare organization name] and “Hello World” (example: “eCR - ABC Hospital - Hello World”).

   Step 3 - Once the initial Hello World message is received, the eCR platform will send a Hello World message back to the provided Direct address and request confirmation that it was received.

How to establish a connection with NwHIN XDR?

Follow the below steps to establish a Direct SMTP connection for eCR: 

   Step 1 - Open a ticket by sending an email to informatics.support@aphl.org with the subject line: eCR - [your healthcare organization name] - NwHIN XDR Connection Request (example: “eCR - ABC Hospital - NwHIN XDR Connection Request”). Include the following information:

  • Technical point(s) of contact information

  • HL7 OID for both your production and testing environments

  • NwHIN XDR endpoint URL for both your production and testing environments

  • Trusted certificates with a chain for mutual authentication

   Step 2 - You will be contacted by the eCR Support team with further instructions.

What to do after establishing a connection?

Now that you’ve established a test connection for eCR, any eICR documents delivered will be processed and a RR returned as it would in the production environment. Please do not, however, send actual patient data to the test address. Proper testing will require that data for synthetic patients (test patients) be exchanged, and that this test patient data should resemble actual patient data as much as possible.

Test eICRs will be validated, run through the Reportable Conditions Knowledge Management System (RCKMS) decision support, and a RR will be returned, which should help finalize your testing. When using the test environment, the test eICRs and RRs will be transmitted via a test channel to appropriate PHAs to validate those pathways as well. 

If you are the first provider site in a jurisdiction that seeks to go live with eCR, it will be important, first, that the PHA's surveillance systems are ready to receive eICRs in this way.