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* In Tennessee, the
* In New York,
All of these information swaps, and several others now in pilot phases, are propelled by the
Using Direct Project protocols, providers could send clinical messages to one another, regardless of their location or institutional affiliation, without relying on fax machines and sneakernet (i.e., courier service). The information contained in the messages could, when appropriate and correctly formatted, slide directly into an electronic health record, a database, or any other digital receptacle without scanning or transcription.
"We've been toying with this for awhile, but we've been so busy getting EHRs to be something that's clinically usable," Hickman says. "For this to be meaningful, you have to have a critical mass of EHR users in a community. We have that critical mass and [Direct messaging] will be the next thing."
In Hickman's mind, the Albany pilot shows how seamlessly and inexpensively Direct messaging should work if it's executed correctly. "The vendors are the ones who have made the notable investment, because they had to make software changes," he says. "The investment we've made is one we had planned to make already, and it wasn't substantial. It's been mostly just smart people getting together, and doctors showing us what's clinically meaningful to them."
Four EHR vendors are participating-Allscripts, Epic, Greenway, and
The system automatically gathers the information needed for the type of specialist the referral is going to and creates a "package" that is routed using Direct-compliant protocols to MedAllies, which maintains a master directory of Direct addresses for all the physicians in the pilot.
It finds the receiving physician and sends the package to the workflow area of the doctor's EHR.
At that point, the specialist's office staff can open it, schedule the referral visit, and incorporate the patient's data into its EHR.
Once the specialist sees the patient, the system compiles the specialist's report, orders and recommendations and sends that package back through MedAllies to the referring physician, who can add the new information into the patient's record.
"This one set of transactions could markedly improve the quality of care and address a remarkable inefficiency that physicians have tolerated day in and day out, even if they have an EHR," Hickman says, referring to the current reliance on phone, fax, and traditional mail service. "Our physicians get really pumped about it."
To quote the project's own overview, "
Strongly encouraged by the federal government (which requires secure communications in connection with several EHR "meaningful use" criteria), the
"There are lots of ways to do secure exchanges now, but they're not very standardized and they require lots of custom work at each end," says
"The connection should be straightforward for a good programmer," says
Because many aspects of Internet messaging have more than one standard in use, it was vital to narrow things down, says
Though it's still early, there are promising signs.
Most major EHR vendors have representatives on the various
Using Direct Project standards can eliminate the need to create custom interfaces among systems from multiple vendors, says
The pilot in
* Trust issues. How do providers know that the address they're sending to actually belongs to the recipient? And how does the recipient know that the sender is who it appears to be? They can swap contact information "out of band"-that is, independent of the electronic communication, via phone, personal meeting, paper mail, fax, carrier pigeon-or they can use a digital certificate, as secure Web sites do. MedAllies, the HISP for the
* Workflow integration. Ideally, the provider shouldn't have to worry about, or even notice, the inner workings of secure messaging, says
Some observers think vendors will fight attempts to standardize a hitherto proprietary function. The AAFP's Kibbe says they will adopt the Direct protocols begrudgingly. "They'd rather not, because if you and I can talk to each other as easily as we can on a telephone, regardless of who we're buying service from, then its cost has to go down."
Elmore says there will still be plenty of opportunities to innovate. "Any number of things are possible once you have a core transport mechanism," he says. "
The ONC's Fridsma looks forward to the day when providers can send secure messages so routinely that they don't even think about it anymore.
"Most of the things in my office are successful when people stop talking about them."
Direct Project Models a New Kind of
The development process for the
Malec says the
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If you're interested in learning more about the
Delving into the "Reference Implementation Workgroup" section will eventually bring you to software available for download (either Java or C-Sharp). Some in-house time and programmer know-how is needed to make it work, says
Another interesting page is Who's Fueling Direct? (http://directproject.org/content.php?key=getstarted&sub=vendorsupport), a list of vendors, HIEs, and various other parties supporting Direct-compliant messaging. Many of the largest EHR vendors are on the list.
The National E-health Collaborative presented a course on the
Covering new developments in health information technology involves continual déjà vu. Look, X is happening! It happened 10 years ago in (banking, retail, manufacturing-pick one). If it's frustrating for us as reporters, we can only imagine how HIT pros feel.
The nice thing is that when history repeats itself the way it's always doing in HIT, it's easy to predict what will happen next. Everyone knows secure messaging is an essential component of HIT infrastructure. Various vendors and health information exchanges offer it, and some forward-thinking providers have bought it, or developed their own systems. They can send messages to providers on the same system.
Prediction #2: Fax machines will go away when Prediction #1 comes to pass, and not before. It wasn't until the Internet replaced proprietary online services that e-mail made serious inroads on fax. It took awhile because standard e-mail is not secure and secure e-mail is a lot of trouble. Over time, most of the world has learned to live with less-than-secure e-mail because the speed and convenience so dramatically outstrip the risk. (Really, do you care if bandits learn the call-in number for your Monday meeting or obtain copies of the cute cat pictures your cousin sent you?)
Fax still dominates in health care because providers are appropriately risk-averse about personal health information. They can't afford the time and hassle to figure out secure e-mail on their own, and even if they could, there's no point unless other providers are figuring it out, too. Fax is not iron-clad against breaches-you never know who's standing at the other end-but its speed/security trade-off is the current standard. Secure, simple, inexpensive and widely available electronic messaging will change that standard, and 10 years after that, it will be hard to remember that it was ever done any other way.
What's a HISP?
HISPs are often health information exchanges, though they don't have to be. However, Albany Medical Center CIO George Hickman points out that secure messaging is the biggest reliable revenue-generator for HIEs, and he expects most of them to adopt Direct protocols to insure their futures. Ultimately, though, the future may be less localized. "For the sake of the health care dollar, we'd like to see this evolve, and HISPs are scalable to a large geography," he says, observing that e-prescribing is handled almost entirely through a national network, Surescripts.
Check the growing list of HISPs at www.directproject.org to see if any of your current business partners are listed in the HIE/HIO category, because they could potentially be your HISP. "You may have a HISP and not know it," says
What's the Story?
They were selected because they're required capabilities under federal EHR meaningful use criteria and can't be easily met using existing solutions. The top dozen are:
* Primary care provider refers patient to specialist including summary care record
* Primary care provider refers patient to hospital including summary care record
* Specialist sends summary care information back to referring provider
* Hospital sends discharge information to referring provider
* Laboratory sends lab results to ordering provider
* Transaction sender receives delivery receipt
* Provider sends patient health information to the patient
* Hospital sends patient health information to the patient
* Provider sends a clinical summary of an office visit to the patient
* Hospital sends a clinical summary at discharge to the patient
* Provider sends reminder for preventive or follow-up care to the patient
* Primary care provider sends patient immunization data to public health
Various types of public health and quality reporting make up much of the second and third tier of use cases.