There are a handful of ways care providers can choose to interface, or connect, to external health organizations, be they a member of the local medical community or an official health information exchange (HIE) organization. Formal HIEs are gaining steam thanks to maturity and providers’ motivation to meet Meaningful Use Stage 2 requirements, but the active process of exchanging health information – the verb, not the noun – has been the goal since the HITECHAs a part of the America Recovery and Reinvestment Act (ARRA) of 2009, Health Information Technology for Economic and Clinical Health (HITECH) refers to the portion of the ARRA that is used to increase the use of Electronic Health Records (EHR) by ph... More act pushed the industry into the modern world via electronic health records.

So how, exactly, do health organizations send health records to an external organization? Since “by hiring a professional” doesn’t really provide you with any real knowledge, let’s examine a handful of HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (ANSI) to author consensus-based standards representing a board view from healthcare system stakeholders. HL7 has compiled a collection of message form... More message transport methods most commonly used by our customers and throughout the health industry. Each method has pros and cons, which will be explored.

Because there are several different methods currently in use, I’ll present the methods in a timeline layout, of sorts, beginning with VPN and ending with Direct messaging, which is the direction the industry is headed.

But, first things first: if you’re going to connect externally, be sure that you’re doing so using designated standards in a “meaningful” way. Meaningful Use Stage 2 rules state that disparate vendor data must become more compatible and require applications to transmit clinical data using a common content and vocabulary, such as Consolidated CDA or, more specifically, CCD over the Internet using methods such as Web Services and Direct Project (more on these below).

The rules also state that CCD or Consolidated CDA documents received from an outside entity must be actionable, meaning they need to be integrated into the EHRElectronic Health Record (EHR), as defined in Defining Key Health Information Technology Terms (The National Alliance for Health Information Technology, April 28, 2008): An electronic record of health-related information on an individual that conform... More system after receipt.

Now, let’s explore the common methods of health information exchange:


FTP stands for File Transfer Protocol. It is a standard network protocol used to transfer files from one host to another over a network, such as the Internet. FTP is built on a client-server architecture. It can be secured by SSLSSL (Secure Sockets Layer) is a cryptologic protocol for securing communications over a network. The successor to SSL is TLS. See also: TLS (FTPs) or SSH (sFTP) technologies. 

Pros: Great for large batch files. Other workflows allow data to accumulate and to be sent at intervals.  There are options to ensure that the data you’re sending and receiving is encrypted and secure.

Cons: Batch processing of data is typically required for data transported over FTP. The receiving organization must import received data and have an application in place to process the batch. This is not a real-time solution.

TCP/IPTransmission Control Protocol/Internet Protocol (TCP/IP) is a low-level communications protocol used to connect hosts on the Internet or a network. TCP/IP connections are established between clients and servers via sockets. TCP/IP is stream-oriented ... More over VPN

This low-level communications protocol is used to connect hosts on the Internet or a network. TCP/IP connections are established between clients and servers via sockets. TCP/IP is stream-oriented, meaning it deposits data in one end and they show up at the other end.  In order for a TCP/IP connection to be secured for external communications, it is wrapped in a VPN tunnel.

Pros: A real-time connection. Rather than rely on batch processing as in a FTP connection, data is automatically transmitted to the receiving organization as it is processed. TCP/IP has traditionally been the go-to data communication method used by hospitals when they need a live, direct connection to their provider community. This is because the hospital can utilize the same protocol they are using within their facility and securely extend it outside the facility using VPN. VPN connections, however, can be time consuming to set up and costly to maintain.

Cons: Creating TCP/IP over VPN interfaces to external organizations can be an obstacle because the HL7 message must be negotiated between EHR systems produced by different vendors.  

Web ServicesWeb services are a standardized way of integrating applications. Using open standards, businesses can communicate without in-depth knowledge of one another’s systems, beyond the communication protocol. Because all communication is XML-based, web se... More

Web Services is communication between electronic devices that can be securely exposed over the Internet. Web Services makes it easier to communicate health data between disparate organizations, regardless of the operating system or software in use.

Web Services Description Language (WSDLA WSDL is an XML-based document for locating and describing a web service. WSDLs contain the identifying information and configuration data for a web service. An application developer will produce a WSDL to make it easier to configure the user’s ap... More) is an XML-based language that provides the framework to send messages electronically over the Internet. XML messages that follow the SOAPSOAP (Simple Object Access Protocol) is a web services protocol used heavily in healthcare to implement IHE profiles. SOAP is an enterprise standard that is typically used by business applications to exchange information across the enterprise. See... More standard for secure communications is the most common Web Services standard used in healthcare.

Pros: By using this method with an integration engine, organizations can securely exchange large amounts of data over the Internet and integrate received data into their application environment without the need for scripting. Web Services is highly interoperable and allows for real-time query-based updates based on designated trigger events for updating to one or more HIEHealth Information Exchange (HIE) focuses on the mobilization of healthcare information electronically across organizations within a region or community. HIE provides the capability to electronically move clinical information between disparate health... More using industry-standard methods, such as IHEIntegrating the Healthcare Enterprise (IHE) is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. Visit the IHE website. Synonyms: Integrating the Healthcare Enterprise profiles. Because Web Services allows data transmission regardless of the vendor or workflow, it has been proven to be the ideal communication method for connecting remote providers and applications across an HIE network. 

Cons: The utilization of Web Services for transporting patient data is still limited in use in healthcare IT.  Not all vendor applications provide robust and intuitive support for Web Services. There is also a learning curve for healthcare IT personnel.

Direct Messaging

Direct messaging is a government-sponsored initiative to promote the secure communication of patient health information. To do this, Direct uses the SMTP protocol as its communication backbone. This has led many in the industry to refer to the standard as “secure e-mail.” However, Direct has the potential to be much more than just traditional e-mail.

Pros: The Direct protocol is an ideal substitute for VPNs. Patient health data can be sent securely, sent on demand, and sent using the SMTP protocol. The HL7 message payload can be parsed and sent and received automatically. Using SMTP as the backbone, applications can share data using Direct without any human intervention, much in the same way that Web Services or TCP/IP using VPNs might be utilized. Secure SMTP transfer is easy to implement, while maintaining scalability.

Direct has the capability to handle a variety of data formats, including all the standard healthcare formats. Computer–to-computer sharing of patient health information is simplified by XDM packaging. All of the metadata for the content, such as CCDContinuity of Care Document (CCD) The HL7 CCD is the result of a collaborative effort between the Health Level Seven and American Society for Testing Materials (ASTM) to “harmonize” the data format between ASTM’s Continuity of Care Record (CCR)... More/CDAClinical Document Architecture (CDA) HL7 CDA uses XML for encoding of the documents and breaks down the document in generic, unnamed, and non-templated sections. Documents can include discharge summaries, progress notes, history and physical reports,... More, CCRContinuity of Care Record (CCR) is an XML-based standard for the movement of “documents” between clinical applications. Furthermore, it responds to the need to organize and make transportable a set of basic information about a patient’s health ... More, HL7 V2, DICOMDigital Imaging and Communications in Medicine (DICOM) is a common format for image storage. It allows for handling, storing, printing, and transmitting information in medical imaging. Visit DICOM website. Synonyms: Digital Imaging and Communicati... More, etc., is defined in a metadata file. This allows the receiving system to decide rather simply how to process the content.

In addition, content can be displayed without the need to parse apart the document. Take for instance the very simple prospect of displaying a CCD document. Without metadata, even when the document is in an XML format (such as CCD/CDA or CCR), the receiving application would still need to "look inside" the content before it can decide how to render the contents. But with XDMCross-enterprise Document Media Interchange (XDM) – What itss used for: According to IHE, XDM transfers documents and metadata using CDs, USB memory or email attachments. This profile supports environments with minimal capabilities in terms of usin... More metadata available, the application can do that, and a lot more decision making about how to process the content, without ever looking inside. This allows for a much simpler processing path.

Cons: Direct messaging and Web Services are the health information exchange methods of the future, both for their ease of use and external, real-time interoperability. However, Direct messaging is constrained in that it is a push-based form of communication.  It cannot query for documents in the same way Web Services can.

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