An Unsolicited “Push” of Clinical Health Information to a Known Destination Between Systems

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Federally required	Cost	Test Tool Availability
Standard	SOAP-Based Secure Transport Requirements Traceability Matrix (RTM) version 1.0 specification	Final	Production	Yes	Free	Yes
Standard	Direct (Applicability Statement for Secure Health Transport v1.2)	Final	Production	Yes	Free	Yes
Standard	HL7 Fast Healthcare Interoperability Resources (FHIR), DSTU 2	Balloted Draft	Pilot	No	Free	No
Implementation Specification	eHealth Exchange Specification: Messaging Platform	Final	Production	No	Free	Yes
Implementation Specification	eHealth Exchange Specification: Authorization Framework	Final	Production	No	Free	Yes
Implementation Specification	eHealth Exchange Specification: Document Submission	Final	Production	No	Free	Yes
Implementation Specification	IHE-XDR (Cross-Enterprise Document Reliable Interchange)	Final	Production	No	Free	Yes
Emerging Standard	HL7 Fast Healthcare Interoperability Resources (FHIR) STU3	Final	Production	No	Free	No

Limitations, Dependencies, and Preconditions for Consideration	Applicable Value Set(s) and Starter Set(s)
The IHE-XDR implementation specification is based upon the underlying standards: SOAP v2, and OASIS ebXML Registry Services 3.0 The NwHIN Specification: Authorization Framework implementation specification is based upon the underlying standards: SAML v1.2, XSPAv1.0, and WS-1.1. “Direct” standard is based upon the underlying standard: Simple Mail Transfer Protocol (SMTP) RFC 5321 and for security uses Secure/Multipurpose Internet Mail Extensions (S/MIME) Version 3.2 Message Specification, RFC 5751. For Direct, interoperability may be dependent on the establishment of “trust” between two parties and may vary based on the trust community(ies) to which parties belong. The leading trust communities to enable communication amongst the most users include DirectTrust (for provider messaging and consumer-mediated exchange) and NATE (for consumer-mediated exchange). The reference to FHIR for this interoperability need is in relation to the transport services that are conformant to the “RESTful FHIR API” Note that the maturity level of FHIR resources may vary. The FHIR Maturity Model and each of the levels is described on the HL7 wiki. See Direct, FHIR, and IHE projects in the Interoperability Proving Ground.	Secure Communication – create a secure channel for client-to-server and server-to-server communication. Secure Message Router – securely route and enforce policy on inbound and outbound messages without interruption of delivery. Authentication Enforcer – centralized authentication processes. Authorization Enforcer – specifies access control policies . Credential Tokenizer – encapsulate credentials as a security token for reuse (e.g., – SAML, Kerberos). Assertion Builder – define processing logic for identity, authorization and attribute statements. User Role – identifies the role asserted by the individual initiating the transaction. Security Labeling – the health information is labeled with security metadata necessary for access control by the end user. Purpose of Use - Identifies the purpose for the transaction.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Value Set(s) and Starter Set(s)

The IHE-XDR implementation specification is based upon the underlying standards: SOAP v2, and OASIS ebXML Registry Services 3.0
The NwHIN Specification: Authorization Framework implementation specification is based upon the underlying standards: SAML v1.2, XSPAv1.0, and WS-1.1.
“Direct” standard is based upon the underlying standard: Simple Mail Transfer Protocol (SMTP) RFC 5321 and for security uses Secure/Multipurpose Internet Mail Extensions (S/MIME) Version 3.2 Message Specification, RFC 5751.
For Direct, interoperability may be dependent on the establishment of “trust” between two parties and may vary based on the trust community(ies) to which parties belong. The leading trust communities to enable communication amongst the most users include DirectTrust (for provider messaging and consumer-mediated exchange) and NATE (for consumer-mediated exchange).
The reference to FHIR for this interoperability need is in relation to the transport services that are conformant to the “RESTful FHIR API”
Note that the maturity level of FHIR resources may vary. The FHIR Maturity Model and each of the levels is described on the HL7 wiki.
See Direct, FHIR, and IHE projects in the Interoperability Proving Ground.

Secure Communication – create a secure channel for client-to-server and server-to-server communication.
Secure Message Router – securely route and enforce policy on inbound and outbound messages without interruption of delivery.
Authentication Enforcer – centralized authentication processes.
Authorization Enforcer – specifies access control policies .
Credential Tokenizer – encapsulate credentials as a security token for reuse (e.g., – SAML, Kerberos).
Assertion Builder – define processing logic for identity, authorization and attribute statements.
User Role – identifies the role asserted by the individual initiating the transaction.
Security Labeling – the health information is labeled with security metadata necessary for access control by the end user.
Purpose of Use - Identifies the purpose for the transaction.

Comment

Submitted by juliemaas on 2017-11-20

Use of Direct for System-to-System Communication

There are many systems in the field today that have Direct-enabled endpoints in use to send or accept data for automated workflows at the system level. This model is most commonly used in care coordination, public health, and related applications. We see a lot of continued growth in the number of organizations joining Direct networks to take advantage of the system-to-system transmission enabled by Direct. Adoption Level of 1 understates this use and I encourage ONC to increase the stated Adoption Level to 2 or 3.

Julie Maas

CEO, EMR Direct