Issue Brief:
Electronic Health Information
Transport for Public Health
and Meaningful Use
Developed by the Stage 2 Meaningful Use Public Health Reporting Requirements Task Force
5/6/2013
Issue Brief: Electronic Health Information Transport for Public Health and Meaningful Use
Acknowledgements
This document was developed by the Stage 2 Meaningful Use Public Health Reporting Requirements Task
Force (Task Force), a collaboration between the Centers for Disease Control and Prevention (CDC), national
non-profit public health associations, and public health practitioners from around the country. We would like
to acknowledge the contributions and support provided by the public health associations, public health
agencies, and federal agencies involved in the Task Force. The initial draft of this document was developed by
a subgroup of the Task Force led by Alison Chi and Charlie Ishikawa. We would like to thank the following
individuals for their active participation in the development of this document:
Sundus Adhi, Deloitte Consulting LLP (CDC Contractor)
Noam Arzt, HLN Consulting, LLC
Wendy Blumenthal, Centers for Disease Control and
Prevention (CDC)
Bill Brand, Public Health Informatics Institute (PHII)
Frank Caniglia, Pennsylvania Department of Health
Daniel Chaput, Rhode Island Department of Health
Alison Chi, American Immunization Registry Association
(AIRA) [Transport Subgroup Co-Lead]
Michael Coletta, National Association of County and City
Health Officials (NACCHO)
Laura Conn, Centers for Disease Control and Prevention
(CDC)
Glenn Copeland, Michigan Department of Community
Health
Rebecca Coyle, American Immunization Registry
Association (AIRA)
Jim Daniel, Office of the National Coordinator for Health
Information Technology (ONC)
Hunter Davis, Florida Department of Health
Brook Dupee, New Hampshire Department of Health and
Human Services
Emily Emerson, Minnesota Department of Health
Cathy Fiato, New York State Department of Health
Seth Foldy, Principal, SethFoldy.com Consultant in
preventive health systems and informatics
Nedra Garrett, Centers for Disease Control and Prevention
(CDC)
Sarah Goff, New York State Department of Health
Scott Gordon, Association of State and Territorial Health
Officials (ASTHO)
Janet Hamilton, Council of State and Territorial
Epidemiologists (CSTE)
Gillian Haney, Massachusetts Department of Public Health
Lori Havener, North American Association of Central
Cancer Registries (NAACCR)
Gary Heckert, Delaware Health and Social Services
Michelle Hood, Nebraska Department of Health and
Human Services
Leah Huang, Arkansas Department of Health
Monica Huang, Council of State and Territorial
Epidemiologists (CSTE)
Charlie Ishikawa, International Society for Disease
Surveillance (ISDS) [Transport Subgroup Co-Lead]
Jim Jellison, Public Health Informatics Institute (PHII)
Mark Jensen, Business Computer Applications, Inc. (CDC
Contractor)
Geraldine Johnson, New York State Department of Health
Sandy Jones, Centers for Disease Control and Prevention
(CDC)
Bryant Karras, State of Washington, Department of Health
Janet Kelly, Centers for Disease Control and Prevention
(CDC)
James Kirkwood, Association of State and Territorial
Health Officials (ASTHO)
Micheal Knox, Arkansas Department of Health
Emilie Lamb, North Carolina Division of Public Health
Mike McPherson, Kansas Department of Health and
Environment
Laura Rappleye, Altarum Institute
Anita Samuel, Association of State and Territorial Health
Officials (ASTHO)
Jonathan Schultz, Arkansas Department of Health
Carmen Springer, Alaska Department of Health and Social
Services, Division of Public Health
David Stinchcomb, North American Association of Central
Cancer Registries (NAACCR)
Sanjeev Tandon, Centers for Disease Control and
Prevention (CDC)
Denise Webb, Wisconsin Department of Health Services
Melanie Williams, Texas Department of State Health
Services
Wake Young, Arkansas Department of Health
The Task Force welcomes comments on this document. Please send all comments to
[email protected].
The Task Force reserves the right to modify this document.
Stage 2 Meaningful Use Public Health Reporting Requirements Task Force
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Issue Brief: Electronic Health Information Transport for Public Health and Meaningful Use
Table of Contents
Introduction .............................................................................................................................................. 3
What is transport and why does it matter for Meaningful Use? .............................................................. 3
Transport and Meaningful Use ................................................................................................................. 4
Artifacts and References ........................................................................................................................... 4
APPENDIX .................................................................................................................................................. 6
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Issue Brief: Electronic Health Information Transport for Public Health and Meaningful Use
Introduction
This issue brief explains electronic health information transport and its relevance to Meaningful
Use. An overview of the available transport approaches, priority issues for consideration, and a list
of materials for further reference and learning are also provided.
Figure 1: A graphic depiction of the tasks and flow of information from a source, electronic health record system (EHR-S), to a
receiving public health (PH) system for public health surveillance purposes.
What is transport and why does it matter for Meaningful Use?
Transport, also called transport layer technology or a transport mechanism, physically enable two
separate information systems to securely exchange electronic health data. In a manner of speaking,
it is the necessary medium for sending health data messages from electronic health record systems
(EHR-S) to public health information systems for Meaningful Use. Transport mechanisms
commonly used with health data are listed in Table 1. Secure File Transfer Protocol (SFTP) and
Public Health Information Network Messaging System (PHINMS) are the most common methods
currently used in public health, with web services increasingly being used by immunization
information systems.
Method
Direct
Description
Simple, secure, scalable, standards-based way for participants to “push” encrypted
health information directly to known, trusted recipients over the Internet
HTTPS POST
Common form of transport used by web browsers to send data to web services
/ REST
MLLP
Relatively simple form of message transport over TCP/IP
PHINMS
CDC-developed software for secure public health data exchange
SFTP
Internet standard for point-to-point interactive or “batched” secure file transfer
Web
Service Oriented Architecture-based strategy for enabling two systems to
Services
interoperate securely
Table 1- The most common mechanisms for transport of health data (alphabetical listing).
For additional details on these transport methods, refer to: 1) the references provided in the
Appendix of this document, and 2) the Appendix of the Architectures and Transport Mechanisms
for Health Information Interchange of Clinical EHR Data for Syndromic Surveillance: A Report from
the International Society for Disease Surveillance (ISDS), (November 2012) available at:
http://www.syndromic.org/storage/Architecture_Report_ISDS_Final.pdf
Transport technologies are a required element for system interoperability. They do not describe all
necessary aspects of interoperability, however, since transport mechanisms merely carry data
messages between systems and are indifferent to message content. In addition to the transport
layer, messaged data must be syntactically and semantically interoperable. Data syntax, or the
format and order of data within a message (e.g., HL7), and data semantics or vocabulary (e.g.,
LOINC) must also be synchronized between an EHR-S and public health systems for successful
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Issue Brief: Electronic Health Information Transport for Public Health and Meaningful Use
communication of the information.
Transport and Meaningful Use
Meaningful Use regulations require eligible professionals and hospitals (EPs and EHs) to use the
transport technologies specified by their public health agency1 for sending public health data. While
this flexibility has many benefits for public health, it also creates a need for inter and intra-agency
coordination and clear communication with EPs and EHs. The following recommendations are
offered to guide public health professionals responsible for implementing or coordinating health
information exchange for Meaningful Use through transport related issues.
1. Form a cross-agency task force to organize a coordinated approach to stage 2 readiness and
implementation.
2. Harmonize on transport standards across programs within an agency as much as possible.
This will not only make it easier for your data sources but lower your costs over time (and
enable sharing of expertise, infrastructure, etc.).
3. Consider choosing the transport mechanism that supports the most complex use case
(presumably bi-directional exchange of immunization information) and adopt that across as
many programs as possible.
4. Consider the existing transport mechanism that providers may be using for other (non-public
health) meaningful use related data exchanges and the challenges that providers may encounter
to implement additional transport mechanisms.
5. Consider transport mechanisms offered by third parties, such as a Health Information Exchange
(HIE). An HIE can serve as an intermediary that supports the transport mechanism(s) most
often used in healthcare, and then forwards the data to public health via the transport
mechanisms needed by the various programs.
Artifacts and References
1. Architectures and Transport Mechanisms for Health Information Interchange of Clinical EHR
Data for Syndromic Surveillance: A Report from the International Society for Disease
Surveillance (ISDS) (November 2012).
Various architectures for transporting health data for public health surveillance are assessed in
this ISDS report. The report describes a range of transport mechanisms used by PHAs,
compares strengths and weaknesses, and makes general recommendations regarding health
data transport for syndromic surveillance purposes. Much of the information in the report can
be generalized to other public health interoperability transactions.
Available for download:
http://www.syndromic.org/storage/Architecture_Report_ISDS_Final.pdf
2. Electronic Health Record – Immunization Information System (EHR-IIS) Interoperability
Enhancement Project Transport Layer Protocol Recommendation (May 2011)
The CDC established a panel of subject matter experts to evaluate and analyze currently utilized
industry transport protocols and recommend the most suitable option for EHR-IIS
interoperability. Panel members identified SOAP-based Web Services as the best choice to meet
1
Transport references for the public health objectives from the CMS Stage 2 Meaningful Use Final Rule,
http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf, Pages 54021-54022
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Issue Brief: Electronic Health Information Transport for Public Health and Meaningful Use
the current and future needs of IIS data exchange, with the best chance for broad adoption
across disparate healthcare systems.
Available for download: http://www.cdc.gov/vaccines/programs/iis/interopproj/downloads/ehr-interop-trans-layer-tech-recs.pdf
Additional information and resources available at:
http://www.cdc.gov/vaccines/programs/iis/interop-proj/ehr.html
3. American Immunization Registry Association (AIRA) Transport Layer Webinars
 IIS Transport Layer 101 - Available at:
http://www.immregistries.org/events/2011/10/25/iis-transport-layer-101

IIS Transport Layer 201 - Available at:
http://www.immregistries.org/events/2012/03/08/iis-transport-layer-201
4. “How To” guides available on the AIRA website
 Dddd Accessing a SOAP/XML Web Service Using Visual C# - Available at:
http://www.immregistries.org/resources/howto.html

Creating an XML Web Service Using Visual C# - Available at:
http://www.immregistries.org/resources/HowToWebService02.html
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Issue Brief: Electronic Health Information Transport for Public Health and Meaningful Use
APPENDIX
Additional Transport Related References

Secure File Transfer Protocol (SFTP) - http://en.wikipedia.org/wiki/SSH_file_transfer_protocol

Public Health Information Network Messaging System (PHINMS) http://www.cdc.gov/phin/tools/PHINms/index.html

Simple Object Access Protocol (SOAP) - http://www.w3.org/TR/2000/NOTE-SOAP-20000508/

Extensible Markup Language (XML) - http://en.wikipedia.org/wiki/XML

Minimal Lower Layer Protocol (MLLP) - http://en.wikipedia.org/wiki/Health_Level_7#MLLP

Hypertext Transfer Protocol Secure (HTTPS) - http://en.wikipedia.org/wiki/HTTP_Secure

HTTPS POST - http://en.wikipedia.org/wiki/HTTP_POST

Representational State Transfer (REST) - http://en.wikipedia.org/wiki/REST

Direct - http://www.healthit.gov/policy-researchers-implementers/direct-project

Web Services - http://www.w3.org/TR/ws-arch/
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