by: Rick Edwards, Director, Integration Strategy, Iatric Systems, Inc and Stacey Lee, MS, Workflow Redesign and HER Implementation Specialist.
Looking back over the last several decades, it appears that healthcare in the US has had a lack of interest and incentives surrounding interoperability. For clinics and hospitals – are we still worried that health information exchange (HIE) will make it easier for patients to switch to our competitors? We could deduce that many healthcare IT vendors have lacked the motivation to properly support interoperability standards. For these healthcare IT vendors – do we still claim that we are interoperable, yet we only provide tools in order to import data into our EHR system while intentionally charging extra for functionality designed to export data?
The “time has come for us to be more explicit about standards,” said ONC Chief Karen DeSalvo, MD, in a January 30 press conference introducing ONC’s interoperability roadmap (Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Draft Version 1.0), which outlines the steps that will enable hospitals, providers, patients, etc. to securely send, receive, find, and use a standard national common clinical data by the end of 2017.
Using other interoperability standards – such as those contained in the Direct Project, Integrating the Healthcare Enterprise (IHE) profiles, and eHealth Exchange – for health information exchange, can enable public and private sector stakeholders to achieve nationwide interoperability in the near, medium and long term.
Standards Use Case Success
The Direct Project was launched in March 2010 as a part of the Nationwide Health Information Network (NwHIN), which is now referred to as the eHealth Exchange. The eHealth Exchange, which began as an ONC nationwide health information network program in 2007, is now operated by Healtheway, a non-profit, public-private collaborative. The eHealth Exchange enables its participants exchange under a common trust (Data Use and Reciprocal Support Agreement – DURSA) and interoperability framework.
Direct is a simple, scalable, secure, and standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the public Internet. The capabilities and values of the Direct Project (and the use of Direct along with applicable IHE profiles for advanced complex queries) have been demonstrated at the HIMSS Interoperability ShowcaseTM event since 2011.
The Kansas Health Information Network (KHIN) is a provider-led, government organization that takes state wide responsibility for health information exchange. KHIN’s Executive Director, Laura McCrary Ed.D in her presentation at the HIMSS HIE Roundtable in October 2014, shared with the HIE community their success story of using Direct secure messaging for Transitions of Care (TOC), in order to meet the requirements of Meaningful Use (MU) Stage 2. Since using Direct, a return on investment was achieved and core tenets of MU Stage 2 were met – patient engagement was improved and risks for HIPAA violations were mitigated. KHIN was also the first statewide HIE in the United States to use Direct to populate the Center for Disease Control’s BioSense program, sharing aggregated patient data to enable public health agencies to be better prepared and to coordinate responses to potential public health incidents and threats.
MedAllies, a Health Information Service Provider (HISP), has partnered with regional HIEs in the state of New York to use Direct in a pilot project focused on “critical” transitions of care, as well as closed loop referral use cases, and discharge notifications. This HISP has demonstrated that their EHR-centric approach succeeded in implementing Direct in a manner that required minimal changes to clinical workflows and current provider/end-user roles and responsibilities.
Standards for Nationwide HIE Interoperability
Direct enables health information exchange via its push method to exchange data between healthcare participants. Any two participants, without the need for a central governance structure, can implement the Direct standard and services. Direct can also coexist with other HIE services and data exchange methods, based on existing eHealth Exchange (formerly NwHIN) standards and services.
Implementing Direct can be as simple as a point-to-point health information exchange based on SMTP/SMIME (Secure/Multipurpose Internet Mail Extension) protocol. In order to send a Direct message to another participant, the sender will need the recipient’s Direct address and the recipient’s public key (digital certificate); the recipient will receive the Direct message into their Direct address and will decrypt the message using their private key (digital certificate). Direct addresses and related services, such as the necessary encryption, trust verification, and privacy /security mechanisms, can be provided by entities called Healthcare Information Service Providers or HISPs.
Using the Direct Project, integrated with a provider’s EHR system, can make clinical workflow more efficient for providers. It will enable a provider to use their EHR system as part of normal daily workflows, while creating, packaging, and sending patient care information for delivery across the eHealth Exchange to another provider, public health agency, etc. The ideal use case also includes the integration of this clinical workflow with a patient portal or personal health record (PHR) application in order to empower and facilitate patient engagement. Some EHR systems on the market can support some or all of these capabilities. We encourage you to request your EHR vendor to evaluate the feasibility of supporting these functionalities, by either participating in eHealth Exchange and/or working with a HIE vendor.
Commercial products, such as Microsoft HealthVault, are already offering Direct addresses to the public via their PHR application software. Blue Button+ offers an even more integrated solution and approach, as it enables EHR/HIE software to securely and continuously receive clinical data, on behalf of a patient, from data sources using Direct.
- Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap – Draft v1.0
- MedAllies and the Direct Project Support Secure Exchange of Clinical Information in EHR Systems
- Direct User Stories
- HIE Toolkit-Direct Guide-National Rural Health Resource Center
- eHealth Exchange Data Use and Reciprocal Support Agreement (DURSA)
- eHealth Exchange Onboarding Overview
- Blue Button+ Implementation GuideKHIN Executive Director, Laura McCrary Ed.D’s presentation for HIMSS HIE round table meeting in Oct, 2014
- Direct is the First Meaningful Step toward Full Interoperability (a HIMSS13 whitepaper)
- 2013 HIMSS HIE Presentation – eHealth Exchange and CONNECT