openemr/Documentation/Direct_Messaging_README.txt

Direct Messaging with OpenEMR and EMR Direct phiMail(R)
Version 1.3, 19 Jul 2014

A. Purpose: To provide a secure method from within OpenEMR for sending/receiving 
protected health information to/from another Direct address using the Direct Project 
messaging standard, as a step toward the goal of satisfying the three MU2 criteria 
requiring the use of Direct messaging.  (For general information about Direct messaging, 
see http://www.emrdirect.com/about-directed-exchange-and-secure-direct-messaging.html)

B. IMPORTANT:  Please be aware of the following limitations when using the OpenEMR 
Direct Messaging features with PHI in a production environment:

1. the current code only supports a single shared "group" Direct Address for each OpenEMR 
installation. Note that this model is fully compliant with the Direct Project 
requirements for Direct messaging, but we may add additional models in the future 
should we determine that doing so would provide a higher degree of interoperability for 
OpenEMR users.

2. the current code only sends the CCR or CCD XML data that is already available in OpenEMR; 
these files as currently generated by existing OpenEMR code do not meet the requirements 
of the MU2 criteria, and the current CCD files do not pass strict CDA validation tests.

C. Problems Solved:

1. Patient-initiated transmission of clinical data from the Report section of the Patient 
Portal interface.

2. Provider-initiated transmission of clinical data from the Report section of the Patient 
pane in the main OpenEMR interface.

3. Log all data transmissions including date/time, patient, and whether transmission 
was initiated by the patient through the Patient Portal or by an OpenEMR user through the 
main interface.

4. Receive Direct messages from other sources.

D. How it Works:
Once configured, OpenEMR will interface with a phiMail Direct messaging server to complete the
required message transactions. The phiMail platform is described on the EMR Direct website, 
http://www.emrdirect.com and http://www.emrdirect.com/phimail-faq.html.

E. What you need before enabling Direct Messaging in OpenEMR:

1. Test Mode: Developers may request a complimentary test address at 
https://www.emrdirect.com/subscribe-developer  
Access to a sandbox server is available for testing and development purposes.

2. Production Mode: Healthcare provider users should begin by signing up for a production 
Direct messaging account with EMR Direct by registering at https://www.emrdirect.com/subscribe

Subscribers will receive the username, password, and server address information with which to 
configure OpenEMR.  

F. How to enable the Direct Messaging Features in OpenEMR:
Setup of phiMail Direct messaging Service is done in the Administration::Globals::Connectors 
tab

1. Check the "Enable phiMail Direct Messaging Service" checkbox.

2. Enter the Server Address, Username, and Password provided to you. The server address
will be of the form "ssl://servername.example.com:32541" - replace the hostname and port
with the values provided to you by EMR Direct. The Username is your Direct Address. Do not 
enter the server URL into your browser address bar, as this will not work.

3. Specify the OpenEMR user who will receive notification of new incoming Direct messages. 
Enter their OpenEMR username in the notification user field.

4. Specify the interval for automatic message checking; we suggest 5 or 10 minutes as a
starting point, but installations processing a large number of Direct messages may want a 
shorter interval. To disable automatic message checking through OpenEMR's background service
manager, set the interval to 0 (zero). Disabling automatic checking would be appropriate 
if message checking is managed through another mechanism, such as a system cron job.

5. Optionally check "phiMail Allow CCD Send" and/or "phiMail Allow CCR Send" to enable
the Transmit feature for these data types. If you do not select at least one of these,
OpenEMR will operate in a receive-only mode.

6. Click the "Save" button.

7. Confirm that a valid Notification Email Address is set in the Administration::
Globals::Notifications tab to receive error notifications from the Direct Messaging service.

8. Install the EMR Direct trust anchor certificate.  

Note: This is *not* your Direct certificate; it is the trust anchor for the SSL 
certificate issued to our servers, and is used only to validate the SSL certificate 
presented by the phiMail server on the other side of OpenEMR's connection.  Your Direct private
key and certificate are managed by the phiMail Server and are not installed in OpenEMR.
Your Direct certificate is made availabe for your review by EMR Direct, but you will not
need to install it anywhere.

For added security, the trust anchor for the phiMail Server should be installed in the OpenEMR 
installation tree at:

[installation_root]/sites/[site_id]/documents/phimail_server_pem/phimail_server.pem

This phimail_server_pem directory and its contents should be readable by the the 
webserver process, but only writable by trusted local users. The certificate file 
itself must be PEM encoded. You can identify a PEM encoded certificate file because 
it begins with the text "-----BEGIN CERTIFICATE-----". Although OpenEMR will connect 
to phiMail servers without installing this certificate, this is a required configuration 
step for all production  accounts to ensure that you are connecting to the correct 
server. You can obtain the correct certificate at the following URLs:

  a. Test accounts: http://certs.emrdirect.com/EMRDirectTestCA.crt
     Important: Don't forget to rename the file to phimail_server.pem and install it
     in the correct directory.

  b. Production accounts: https://www.phicert.com/certs/phiCertDirectRootCA.crt
     Important: The production root must be converted to PEM format as follows:
     $ openssl x509 -in phiCertDirectRootCA.crt -inform DER -out phimail_server.pem
     Don't forget to install phimail_server.pem in the correct directory. As an added
     security measure, please call us to confirm the thumbprint on this certificate.

G. Debugging background connections to the server.

You may review the connection activity to the server by Selecting Administration::Other::Logs,
selecting "direct-message" in the "Name of events:" drop-down menu, and clicking "[Refresh]".
If the background service is succesfully connecting, you will see "message check completed"
events in the log as well as any message related entries (see below for instructions to
view more detailed message related status information). If you see no entries, make sure that
the background service is enabled (See F.4 above). If you see "could not connect to server"
entries, each entry will also contain an error code:

  C1: phiMail is disabled in the global configuration. Fix: enable.
  C2: the phiMail server URL entered in the global configuration is invalid. Fix: Confirm
      the URL has been entered correctly. It should be of the form 
      "ssl://server.example.com:32541".
  C3: unable to create stream context. Fix: Usually this is because the server certificate 
      file installed in F.8 above is not the correct certificate or is in the wrong format.
  C4: failed to open connection. Fix: Confirm you Internet service and local DNS servers are
      online and your firewall is not blocking connections to the phiMail Server.

H. Checking the status and history of the Direct Messaging Service in OpenEMR:
Administrators may view the status of the service by Selecting Reports::Services::Background 
Services from the main OpenEMR left navigation bar. The "View Log" link on this page or 
Reports::Services::Direct Message Log will open the messaging history log showing each message 
sent or received and the current status of that message (Received, Sent, Delivery Confirmed, 
or Failed).

I. Note of message status messages: Receiving message status updates requires that Direct message
checking be enabled. When receiving messages, the phiMail back-end is fully compliant with the 
Direct messaging protocols to notify the sender and provide final delivery confirmation, but 
please note that  many other Direct providers do not yet support these features. If a message 
is sent to a recipient using one of these other systems, OpenEMR probably won't ever receive a 
final delivery confirmation for that message.

J. How to use the Direct Messaging Features in OpenEMR:

1. Sending:
When the phiMail Direct Messaging service is enabled, an additional "Transmit" button will
appear in the Continuity of Care Record (CCR) and/or Continuity of Care Document (CCD) block 
of the Reports section in both the Patient Portal and the Patient pane of the main provider 
interface. 

To transmit a CCR or CCD, first click the "Transmit" button. This will open a small dialog 
immediately below the button with a form field to enter the intended recipient's Direct Address. 
Clicking "Transmit" again will hide the dialog.

A Direct Address should have the same form as a regular email address, e.g. 
jonesclinic@direct.example.com. Enter the address in the field and click the "Send" button 
immediately to the right of the field. Only a single recipient may be specified in the field.
The Send button will be temporarily disabled while OpenEMR is communicating with the phiMail 
server. This will only work for properly-configured Direct addresses. Attempts to send to a 
regular email address or Direct address outside of our test mode "trust sandbox" will fail
during testing. Production accounts have wide interoperability with other Direct service
providers. Should you encounter a trust community with which OpenEMR does not interoperate,
please let us know at support@emrdirect.com.

OpenEMR will then display a status message immediately below the Address field, the 
success or failure of the message transmission, or an error message. If the message is
successfully submitted to the server, the Address field will be cleared to prevent accidental
re-transmission. If multiple recipients are required, the next recipient can now be entered.

If you receive an error message, it will be followed by an error code. For a discussion
of error codes beginning with the letter "C" please see section G above. Error codes
beginning with "EC" are listed here:

  EC 1: phiMail disabled in global configuration. Fix: enable.
  EC 4: authentication failure. Fix: The Username and Password entered in the
        global configuration must be corrected.
  EC 5: request to add text failed. Fix: Confirm total message length < 5MB.
  EC 6: problem sending the text. Fix: Confirm your local network connectivity is stable.
  EC 7: request to add clinical document failed. Fix: see EC 5.
  EC 8: problem sending the clinical document. Fix: see EC 6.

2. Receiving:
When the phiMail Direct Messaging service is enabled, and message checking is enabled either 
through the background services manager of another mechanism, OpenEMR will automatically process 
message status updates and new messages. Status updates will be reflected immediately in the 
Direct Messaging log. Additionally, if a "Failed" notification is received for a previously sent 
message, a regular email message will be generated to the Notification Email Address specified 
in the Notifications tab of the Global Settings panel (accessed by selecting Administration::
Globals from the main left navigation menu).

New Direct messages will be processed as follows. A new "Patient Note" will be generated and 
sent to the phiMail notification user specified in the Connectors tab of the Global settings. 
The patient note will contain information about the message, including any text at the beginning 
of the message from the sender. Any attachments (and any non-text content) will be automatically 
converted to separate OpenEMR Documents, which will be referenced in the new Patient Note.  
The Documents and the Patient Note are initially created without an assigned patient. 

At this time, the envisioned workflow is that the notification user will review the message text
and any included Documents to determine which patient the content belongs to and will then set the 
patient using the existing Patient Note interface for choosing a patient. Once the patient is sent, 
the Patient Note can be forwarded to another provider or staff member as appropriate using the 
existing forwarding mechanism for Patient Notes. The unassigned Documents can be viewed by Selecting 
Miscellaneous::New Documents from the main left navigation menu, which opens a Documents list. Once 
the specified document is opened, the user can optionally categorize the document and, when 
appropriate, assign the document to a specific patient using the "Move to Patient #" feature in the 
Documents interface.


Trademark Notice: phiMail is a registered trademark of EMR Direct.

Copyright (c) 2013-2014 EMR Direct.