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. 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 validation tool
  • Have used the Electronic Reporting and Surveillance Distribution (eRSD), and the healthcare provider test eICRs to ensure that triggering is properly implemented
  • 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
  • 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 is in place. The following specifications generally apply whether you are using the eHealth Exchange or a direct connection.

For eCR connections, eCR provides 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).

  1. NwHIN XDR

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. eCR currently uses NwHIN CONNECT Gateway software to accomplish this exchange.

In general, Direct is a better choice for small healthcare provider organizations, as it minimizes the custom integration your healthcare provider site may need to do. NwHIN XDR is also available, but generally takes more technical support on the healthcare provider side to conform to the NwHIN XDR specification.

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 connection Direct SMTP?

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

   Step 1 - Open a ticket by sending an email to 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 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 connection NwHIN XDR?

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

   Step 1 - Open a ticket by sending an email to 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 connection?

Now that you’ve established a test connection for eCR, any eICR documents delivered will be processed and an 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 non-actual 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 an 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.