Direct pilots: E-mail piece easy, integration takes work

By Mary Mosquera
11:48 AM
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With a number of Direct Project pilots popping up around the country, healthcare providers who want to have the capability to perform simple exchanges can take heart that this is one technology that is straightforward to use, even if it isn't quite "plug-and-play."

The Direct Project is an effort of the Office of the National Coordinator for Health IT to extend health information exchange to individual physicians and small practices who have limited resources and technology assets to meet requirements for meaningful use of electronic health records (EHRs).

It has been designed to "get the simplest, most practical, irreducible level of workable interoperability available as an option," Dr. David Blumenthal, the national health IT coordinator, has said.

Direct is one of the options for sharing information and is a first step onto the escalator for exchange for meaningful use. For many physicians, their electronic health record vendor will incorporate the Direct protocols into their system. Physicians who have established Direct, thus far at least, have reported that implementation was "relatively smooth."

And actually using it is simple, said Dr. Ferdinand Venditti, a cardiologist and vice dean of clinical affairs and medical professor at Albany Medical College, Albany, N.Y.

Open up a Continuity of Care document, put in the summary patient information and send it to the physician you want it to go to, he said. It goes through the Internet using the Direct protocol and populates the recipient's EHR system, where the information, such as lab results, can come into a task list area. The physician is notified about the Direct message and can decide where to put it.

Venditti is participating in a pilot in New York's Hudson Valley, in which MedAllies, a health information service provider (HISP), delivers clinical information across transitions of care setting with 16 providers at eight sites.

Because numerous primary care physicians send him patients, Venditti needs point-to-point exchange, much like fax and phone have produced.

"It goes right into the record electronically. There is no faxing, dealing with paper, remembering to put the paper in front of me. It's right there in the record," he told Government Health IT on March 31. "That is going to be 80 percent of how we shuffle information around."

Integrating information from the secure message into the clinical practice operations, however, may take more effort, according to those who have used Direct.

The healthcare provider or organization and its systems may have a greater role when it comes to workflow, said Dr. John Halamka, chief information officer of Harvard Medical School and Beth Israel Deaconess Medical Center.

"In my experience implementing Direct, it wasn't the issue of Direct. It was the fact that I deliver 2 million emails through a secure complex infrastructure through a secure firewall and antivirus and spam filters and appliances and now will move Direct into that complex infrastructure. Gluing Direct into that complex infrastructure is not totally plug and play," he said at a March 29 meeting of the Health IT Standards Committee.

But that's the nature of the corporate email system, Halamaka added.

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Venditti said the amount of effort in workflow and who gets tasked is variable, depending on how the physician and office operate. If the information is about a new patient, it goes to a reconciler who initiates a record. Then the information from the CCD flows to that record and the physician is alerted.

If Venditti already shares and treats the patient, the EHR system knows where to put the summary information. But he chooses to have that information flow first to his secretary, who determines if a patient needs to have an appointment scheduled.

"It's like her opening my mail. Then she puts it into different folders for me to deal with. It mimics the [paper] workflow but in a much more efficient, streamlined manner. Vendors have the ability to route the information package different ways," he said.

Direct went live in February with its first pilots in operation in Minnesota and Rhode Island. Since then, pilots have started exchanging information in New York, Maryland, Missouri, Virginia and the District of Columbia, said Arien Malec, coordinator for the Direct Project.

A physician or small practice may ask their EHR provider how it uses Direct or look to health information service providers (HISPs) that can offer some of the routing services.

"Providers who currently don't have EHRs will want to look for either state-based, nationwide-based or local HISPs that offer simple, secure Web-based Direct gateways or Websites that provide basic web capabilities for continuity of care and referrals," Malec said in a March 21 online presentation sponsored by the National eHealth Collaborative.

"The answer will depend on where you are geographically," he said, "and where you are in the technology life cycle."