PDMP & HITI Solution Planning Workgroup

SessionMay 29, 2014

Transactions Scope

From Via To

1a1b

EHRPharmacy

- In-State PDMP

2a 2b

EHRPharmacy

HIEPh. Int

In-State PDMP

3a3b

EHRPharmacy

Hub In-State PDMP

4 In-State PDMP - Out of State PDMP

5a5b

HIEPh. Intermediary

- Out-of-State PDMP

6 Hub - Out-of-State PDMP

7a7b

HIEPh. Intermediary

Hub In-State PDMP

8 In-State PDMP Hub Out-of-State PDMP

PMP/HITI User Stories with Alternate WorkflowsEHR or Ph. to In-State PMP: 1a: EHR to In-state PMP 1b: Ph. to In-state PMP 2a: EHR to In-state PMP via HIE 2b: Ph. to In-State PMP via HIE 3a: EHR to In-state PMP via Hub 3b: Ph. Intermediary to In-State PMP via HubEHR or Ph. to Out-of-State PMP: 1a+4: EHR to out-of-state PMP via In-state PMP 1b+4: Ph.to out-of-state PMP via In-state PMP 2a+4: EHR to out-of-state PMP via HIE & In-state PMP 2b+4: Ph. to out-of-state PMP via Ph. Int & In-state PMP 2a+5: EHR to out-of-state PMP via HIE 2b+5: Ph. to out-of-state PMP via HIE 3a+4: EHR to out-of-state PMP via Hub & In-State PMP 3b+4: Ph. to out-of-state PMP via Hub & In-State PMP 1a+8: EHR to out-of-state PMP via In-State PMP & Hub 1b+8: Ph. to out-of-state PMP via In-State PMP & Hub 3a+6: EHR to out-of-state PMP via Hub 3b+6: Ph. To out-of-state PMP via Hub

HIE/Pharmacy

Intermediary

In-State PDMP

Out of State PDMP

Hub

EHR or Pharmacy

System1

2

3

42

36

57

7

Hub8 8

Summary of Transactions

Data Flow Transactions Reviewed on 5/15 & 5/22 SPWG

Transaction System - Outbound System Intermediary 1 System Intermediary 2 System Inbound

1a EHR -- -- PDMP

1b Pharmacy IT -- -- PDMP

2a EHR HIE -- PDMP

2b Pharmacy IT Pharm. Int. / Switch -- PDMP

3a EHR -- PDMP Hub PDMPs

2a+7a+6 EHR HIE PDMP Hub PDMPs

Data Flow Transactions To Be Reviewed on 5/29 SPWG

Transaction System - Outbound System Intermediary 1 System Intermediary 2 System Inbound

3b Pharmacy IT PDMP Hub PDMPs

2a + 2b + 7a + 7b + 6

Pharmacy IT Pharm. Int. / Switch orHIE

PDMP Hub PDMPs

Transaction Summary from SPWG 5/15 Items Required for Further Clarification

1a: EHR System to

PDMP (Direct)

• EHRs don’t generally query PDMPs directly• Ohio connectivity model is a direct connection to OARRS via

PMIX• Kansas leverages HIEs and PMPi data hub for all of their

connections• Illinois and Ohio use a direct connection – need further

clarification on standards used

• Jinhee Lee to gather information on transactions occurring in Illinois, Kansas, Indiana – In progress

• Jean Hall to confirm Ohio connectivity model – Complete

2a: EHR System to

PDMP via HIE

• HL7 messaging relatively uncommon in EHRs for PDMP connections

• Kentucky using QRY^T12 as request and DOC^T12 as acknowledgment and response message – CCD structure

• Some states that cannot make interstate connections might have no other option but to use this model

• Washington, Maryland, Maine, Oklahoma use this model• Washington response – PMIX-NIEM is mapped to NCPDP

SCRIPT and responding with NCPDP SCRIPT message• ADT used as trigger in Ohio, Indiana, Illinois, Kansas

• Jean Hall to further clarify what the query/message pairing used to engage EHR system to HIE – Complete

1b: Pharmacy IT System to

PDMP (Direct)

• Transaction 1b is not currently in use• ASAP Web Services standard was developed specifically with

this transaction in mind• NCPDP Medication History might be suitable for this purpose

but is not used currently

• Jean Hall to further clarify standards currently in use – Complete

Transaction Summary from SPWG 5/15 Items Required for Further Clarification

2b: Pharmacy IT System to

PDMP via Pharmacy

Intermediary/ Switch

• NCPDP SCRIPT Medication History is being used today but not for the purposes of querying PDMP data

• Real-time query for claim to be dispensed through switch via Telecommunication standard

• Not yet in use but is possible via claim submission• SureScripts to enable this transaction (Intermediary to

PDMP) in the future

• Lynne Gilbertson to verify if standards are currently being used (Nebraska) – Complete

Transaction Summary from SPWG 5/22 Items Required for Further Clarification

3a: EHR System to

PDMP via Hub

• Ohio, Kansas use PMIX to connect to PMPi data hub• PMP Gateway will be used in the future to

centralize translations, where endpoints can communicate with gateway

• EHR provides translation from HL7 (V2/ADT?) to PMIX in Kansas pilots

• Hub functions as aggregator, depending on arrangements

• Clay Rogers and Jeff McGonigal to verify translation/EHR generating PMIX request

2a + 7a + 6: EHR System to HIE to Hub to

PDMP

• Indiana and North Dakota provides translation to PMIX from the HIE to the Hub

• HIE translates using NCPDP SCRIPT with PMIX wrapper for Hub

• SureScripts: SCRIPT (predominantly) and HL7 (Emdeon does not support) used to connect to SureScripts for medication history (EHR Intermediary),

• Does not connect to a PDMP• Ohio EHR systems (NARxCheck used as interface, does

not “go through” hub) PDMP (does not use HIE or PMPi)

• ADT used as trigger to send query to PDMP through NARxCheck• PMIX used from NARxCheck to PDMP

• Jinhee Lee to verify how Indiana performs translation from HIE to Hub

• Danna Droz and Chad Garner to confirm third party software functionality of NARxCheck via NABP – NARxCheck uses ADT feed and directly connects to OARRs system, which uses PMIX

• NARxCheck does not act as a hub but may get information from PMPi (does not go through interconnect directly)

• What type of message is being sent from NARxCheck

Summary of Current Standards Landscape

• What we know:– Several states utilize the EHR HIE PDMP transaction

• Some states that cannot make interstate connections might have no other option but to use this model

– PMIX-NIEM is the standard used for the Hub to PDMP transaction• Translation from HL7 messaging to PMIX must occur prior to Hub

to PDMP transaction– Thus, translations can occur from the EHR system to the HIE, the HIE

to the Hub, the EHR system to the Hub, or the HIE to the PDMP– HL7 ADT is used as a trigger in several states– Currently, EHR systems and Pharmacy IT systems do not generally

query the PDMP directly• ASAP Web Services standard was developed specifically for this purpose

Current In-State HIT Integrated System Workflows

Current In-State Pharmacy Workflow (Hub)

In-State PDMP

Request

Response

Legend

?

Translation? PMIX

PMIX

Transaction 3b – Not Effective Workflow? Currently Active?

PDMP HubPharmacy

System

Notes:• Hub to PDMP available for use but is not currently in

production• Pharmacy system to hub not currently in use

• May be used in the future; under development• AI: Alex/Divya to follow up with more information• What standards these transactions are based on?• Ohio to possibly pilot for pharm chain to go through hub

(one of 16 states that is a part of SAHMSA grant)

Translation?

Current Interstate HIT System Workflow

Current Interstate Pharmacy Workflow

HIEIn-State PDMP

Request

Response

Legend

NCPDP SCRIPT

Third Party SoftwarePMIX Wrappers

PMIX-NIEM

PDMP Hub

PMIX-NIEM

XML

PMIX-NIEM

PMIX-NIEMXML

Pharmacy System

Pharmacy Int. /

SwitchOut-of-State PDMP

NCPDP SCRIPT

?

?

Transaction 2a + 2b + 7a + 7b + 6

Notes:• Not currently in use but Pharmacy IT System may be able to go through

intermediary in the future• Pharmacy workflow using medication history could be a future use case –

PDMP checking on a claim vs. query of history

Questions to be answered:

1. Differences in pharmacy and clinician workflows / data systems and expectations in PDMP data transmitted?

2. How do we define intermediaries and their relationships to Health IT systems?3. What components of PDMP report are extracted for decision support?4. Can EHR and Pharmacy IT systems handle the proposed standards (in the context

of PDMP systems)?5. What standard(s) fit into message and workflow configuration per transaction

type?6. Are transactions collapsible in terms of capability of leveraging same standard?7. Are all transactions necessary?8. What is the relative cost associated with the proposed solutions?9. How do we define an aggregator? (collection of response from different PDMPs

back to recipient)10. Parking lot item: Differences in care settings - Ambulatory vs. Acute; In-hospital

pharmacies vs. retail pharmacies. Are different standards needed for different EHR systems?

- 12 -

Controlled Substance History Report, Integration Architecture Drivers

TO: Easy, timely, consistent access to reliable

PDMP data

FROM: Pervasive challenges to access data

within clinical workflows

As-Is Architecture

Segmented conceptual framework for data exchange

Varying solution practices

Varying state requirements and source ownership (e.g., authorization, authentication protocols)

Flexible interstate data sharing and intermediaries facilitating open data exchange for authorized users

Constraints on cost for Δ in source data architecture

Constraints on ease of implementation of foreign standards in established functional models/frameworks

To-Be Design Principles

Congruent data / message formats across integration sites

Compatible with established PMIX-NIEM architecture

Ability to support various front-end capabilities

Ability to integrate within existing technical systems and evolve to support regulatory/technology changes

Health Information Exchanges

Data harmonization and structuring of a data integration layer

Interstate Data sharing Hubs

Continuous improvement of real

time reporting

Vis

ion

Arc

hit

ectu

reD

rive

rs

Controlled Substance History Information Needs

- 13 -

Integrated PDMP Data Exchange ArchitectureSolution Plan - Multi -Level Standards

State PDMPs

EHR EMR

Use

r In

terf

ace

(Pre

sen

tati

on

)H

ealt

h I

T /

Cli

nic

al

Dat

abas

esD

ata

Har

mo

niz

atio

nS

ou

rce

Sys

tem

s

Recommendation/Notes

Pharmacy IT

Out of scope - however…User access modes important to consider in standards selection. Modules within ambulatory and enterprise in-patient EHRs vary. Where would the interface be most effective?

Define a comprehensive query-response strategy aligned to both EHRs and Pharmacy IT systems compatible with state PDMP architecture/regulations and intermediary capabilities/infrastructure.

Defined standards architecture based on source data framework: PMIX-NIEM.

Metadata transformations, routing

PDMP Med History Architecture

Pharm. Int / HIEs

Establish standard data models and an approach for data harmonization; achieve standard and consistent data in this layer for query-response while addressing the source system layer in parallel. Translations are essential for compatible standards to interoperate.

Hubs

Translation / Transformation

ePrescribingCDS PMS FunctionsMed History/ Reconciliation

Internal Med Orders

HIE/PDMPs (Nebraska)

Other Medication History Sources

(eg. PBMs)

Data Extraction / Transformation

HL7 SCRIPT

SCRIPT ASAP PMIX

PMIX

Solution Plan Review

Solution Plan

Review Proposed Solutions

Appendix

Context Diagram

HIE/Pharmacy

Intermediary

In-State PDMP

Out of State PDMP

Hub

EHR or Pharmacy

System1

2

3

4

2

6

57

7

Hub8 8

3

16

= In Scope

System Transaction-Relationship Flow

System Relationships: Transactions

1. EHR to In-State PDMP2. EHR to HIE3. EHR to PDMP Hub4. EHR to Ph Int./Switch5. Ph IT to In-State PDMP6. Ph IT to Ph Int./Switch 7. Ph IT to PDMP Hub8. Ph IT to HIE9. HIE to PDMP Hub10. HIE to In-State PDMP11. HIE to Out-of-State PDMP12. PDMP Hub to In-State PDMP13. PDMP Hub to Out-of-State PDMP14. In-State PDMP to Out-of-State PDMP

Known

To Confirm

Legend

Current In-State EHR Workflow (Direct)

EHR SystemIn-State PDMP

PMIX?

Request

Response

Legend

Transaction 1a

Current In-State EHR Workflow (HIE)

EHR System HIE In-State PDMP

Request

Response

Legend

HL7 OBXXML Report

NCPDP SCRIPT

HL7 ADT feedsNCPDP SCRIPT

HL7 A04NCPDP SCRIPT with PMIX

WrappersThird Party Software

XML ResponseNCPDP SCRIPT with

PMIX Wrapper

Transaction 2a

Current In-State Pharmacy Workflow (Direct)

Pharmacy IT System

In-State PDMP

Request

Response

Legend

Transaction 1b

Current In-State Pharmacy Workflow (Pharmacy Int. / Switch)

Pharmacy System

Pharmacy Intermediary

/ Switch

In-State PDMP

Request

Response

Legend

NCPDP SCRIPT (Medication History)

NCPDP SCRIPT (Medication History)

?

?

Transaction 2b

Current In-State EHR Workflow (Hub)

EHR SystemIn-State PDMP

Request

Response

Legend

?

PMIX ?

?

Transaction 3a – Not Effective Workflow? Currently Active?

PDMP Hub

Current Interstate EHR Workflow

EHR System HIEIn-State PDMP

Request

Response

Legend

NCPDP SCRIPT (Medication

History)

Third Party SoftwarePMIX-NIEM

Out-of-State PDMP

PMIX-NIEM

PDMP Hub

PMIX-NIEM

XML

PMIX-NIEM

PMIX-NIEMXML

Transaction 2a + 7a + 6