Q&A: Moving from a PCMH to a 'medical neighborhood' via Direct

By Tom Sullivan
02:17 PM

Sharing medical records between different vendors' EHRs is one of the meaningful use Stage 2 measures that some folks would like to see yanked – but not MedAllies' Holly Miller, MD, or John Blair, MD.

In fact, Miller (pictured at left) will be demonstrating how MedAllies does just that this week during ONC’s Direct Implementation and Adoption Summit in Washington, D.C.on Thursday and Friday.

Prior to the summit, Government Health IT spoke with Blair and Miller, CEO and CMO, respectively, of MedAllies, about why that EHR interoperability measure should not only remain in Stage 2, but also be ratcheted-up in Stage 3. They also discussed how the Direct protocol that enables MedAllies' closed-loop referral system is serving as a technological foundation upon which the Hudson Valley, N.Y. area is moving beyond a group of patient-centered medical homes and into what they call patient-centered medical neighborhoods. Each also offered a prediction of what Amazon, eBay or Facebook might one day might be.

Q: What is it you’ll be demonstrating at the ONC event this week?
Essentially, one of the biggest issues in healthcare right now is the fact that as patients go through care transitions, when the clinicians need to take care of the patients in the new environment but do not have information about the patient, it puts the patient at risk and it delays and increases the cost of healthcare. So it makes healthcare inefficient and, of course, creates a dangerous environment. Some examples of this, and I’m a primary care physician, so I’ve sent patients for referrals and when that patient comes back to my office needing to actually ask the patient what the other doctor said because I have no information from the doctor and so for all I know the medications might have changed. I’m flying blind. If I’m unaware the medication changed, I could prescribe something that is dangerous.

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So in the closed-loop referral we’re demonstrating, a patient who has seen their primary care physician gets sent for a consultation with a specialist. The information while the patient is with the primary care physician goes to the specialist, very specific information about what’s needed, what any questions are, critical information about the patient such as their demographic, their medications, their problem lists, allergies and then other information the specialist would need to care for the patient. And then once the patient has seen the specialist, the information about the consultation goes back to the primary care physician.

Q: And the primary care physician gets to keep that information? Or is it a temporary view?
In both cases, the CDA document would be stored in the EHR. So what we’re really excited about, working with various EHR vendors, in this instance with Greenway and NextGen, the information goes from disparate electronic health records through the MedAllies HISP and then is stored in both the electronic health records.

Q: So that’s actual exchange of health information – which might seem a nitpicky point, but this afternoon I was speaking with the executive director of an HIE who said, "exchange is an interesting word right now," because in many cases, say, an ED clinician might be able to view a patient record for a limited time, such as 20 minutes: not an uncommon scenario.
That’s right and there’s a tremendous difference between health information exchange and Direct. Direct is clinician-to-clinician. The model is really what clinicians do every day as patients transition across care environments. And it’s a push model, so I as a primary care physician, if I’m asking a cardiologist to do a consultation, I’m sending the information about that patient that the cardiologist needs to treat the patient.

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So there are certain things that might always get sent, then things specific to the cardiologist, such as tests that I’ve done that pertain to cardiology, or other lab results like an echocardiogram. A dermatologist, they don’t need to see that information, they want a photograph I took of the rash and something along those lines. The other thing that’s an important distinction is that under HIPAA when there’s communications between physicians, consent is not required by the patient, it’s presumed.

Continue reading our interview with Drs. Blair and Miller on the next page...

Q: Exchanging information between different vendors' EHRs at least 10 percent of the time is one of the measures in the NPRM for meaningful use stage 2 that plenty of people are saying should be removed from the final rule. Given this example, what percentage of the time do you exchange records between different vendors EHRs?
Blair (pictured at left): Once this is up and running, and I look at this taking a few years because these networks have to be stood up and there are aspects to deal with around trust fabric, things like that, standards, directories. Once networks are up and running, once the EHR vendors have it in their versions, the functionality with workflow and it’s fairly-well used by the providers, once that happens it will be used in virtually all transitions because providers want to have this information going back and forth. We’re early on with this, we’re a reference implementation, and some of the vendors have started moving into production. Certainly where we see this already going into production, it will be used always on transitions. We’re starting to see the end users look for improvements to functionality they’ve been using for a while to leverage those capabilities. So I don’t think there will be any resistance on the provider side.

Miller: The reason for that is because as doctors adopt electronic health records, that is their clinical workflow. So having the information in a push fashion come into their EHR, doctors have described it as a holy grail of health information technology because it’s absolutely what they’re looking for to have the information in the patient’s EHR before and at the time they’re seeing the patient without having to hunt for it.

Q: So, as someone who is actually swapping medical records between vendors EHRs, do you think it makes sense to keep that measure in meaningful use Stage 2?
We believe it should be in Stage 2. Now, you may want to put provisions in there addressing if there’s not a connectivity opportunity available, but we do not believe it is an overly burdensome lift to have in there. I think that at Stage 3 they may want to markedly increase the threshold of usage, but we don’t think it’s too hard for Stage 2.

One other thing about usage: It’s just like e-prescribing in that as the functionality got better and better and pharmacies got more and more adept at it and the efficiencies started to come around it you’re starting to see the usage now. And providers that use it ubiquitously wouldn’t go back. I think the same thing will happen with this, except this has a stronger impact on clinical care.

Miller: And once the doctors start using Direct they wouldn’t go back to a non-push method like faxing because they see the value immediately. The other thing in terms of Stage 2 and Direct and these transitions of care is that our experience is the vendors are working hard right now, they see the value, that the doctors are interested in this, and they’re trying to develop products that meet those clinical needs – and I find that incredibly exciting. The vendors we’re in contact with, those participating very actively in the S&I framework around this topic, transitions of care, are exceedingly interested in making sure their product has clinical functionality clinicians need.

[Related: Hudson Valley care managers reduce readmissions in pilot program.]

This is actually a quote from Dr. Blair, but it’s my favorite description that we have a tremendous concentration of patient-centered medical homes here in the Hudson Valley and we feel strongly that Direct is going to really create a patient-centered medical community.

Q: Is that starting to happen?
It’s definitely starting in our community. We’re moving from the patient-centered medical home to the patient-centered medical neighborhood. I can’t claim that Direct is the catalyst for that, there are lot of other efforts in the Hudson Valley but Direct is front-and-center in our discussions of technical solutions for transitions between in-patient and ambulatory and between ambulatory settings with a closed-loop referral. That’s what Direct is doing for us. We’re looking at Direct in moving form the medical home to the medical neighborhood and connecting primary care and specialty hospital, ambulatory and long-term care.

Continue reading our interview with Drs. Blair and Miller on the final page...

Miller: And nursing homes, the spectrum of care. That’s the other reason we do think it’s so important to keep the measure in Stage 2. When patients don’t have information flowing at the time of transitions of care, it is dangerous for them. This is a safeguard that dramatically enhances care as well as decreasing costs. Having the ability to access this information will prevent re-hospitalization in many cases, it will prevent additional unnecessary visits and it will avoid duplicate testing. It’s critical for enhanced patient care.

Q: Dr. Blair, you said Direct plays a large role in this transformation from patient-centered medical home to medical neighborhood. What are the other factors?
Technology is certainly not the only piece of the medical home. We believe IT is a necessary ingredient, but think that much of the medical home is transformation by retraining practices for team-based care, patient-centeredness, a lot of other techniques, open access, etc. I would say that the EHR technically is to the medical home as Direct is technically to the medical neighborhood. We deal with SMTP, S/MIME, and we also deal with SOAP. Our EHRs are mostly connected to our HISP through the ISA protocols and SOAP, but if we move beyond that to another HISP we invoke SMTP. We can go directly on the SMTP also, but we support both of those. You have to be able to step up and step down between those standards.

Q: The folks at ONC essentially say that you can use Direct, Connect, Exchange or when appropriate you can use industry standards instead if that works for you.
We do support CCD and access for viewing. That is separate and distinct from our Direct effort. In Direct, it is only the SOAP, SMTP or S/MIME that we support. And everybody connected to us is that way.

Q: At HIMSS12, Doug Fridsma told me he envisions the underlying NwHIN protocols – those of course being Direct, Connect, Exchange, et al. – laying the foundation for the next Amazon, eBay or Facebook, only for healthcare. What’s your best guess for what that might one day be?
The way I see Direct playing out, ultimately, is that I believe there will probably be national networks. I think that the EHR vendors will be connected to one, maybe several of what are sanctioned or validated networks and those will, in turn, be connected to each other. So de facto if you are connected to a validated entity or network, to use the new vernacular in the RFI, you should be able to connect with any provider also connected to that network. And even though these may be national networks and 90 percent of your communication may be local, you’re still doing it between a network that is national. I don’t think that will happen tomorrow, but I think in time that’s how this will play out. So I see it very much like the wireless network, where the EHRs are like the iPhone or Blackberry or whatever at the edge, and the network just becomes a commodity.

[Related: ONC to stand up NwHIN-Exchange as non-profit HIE in October.]

In my mind, if Direct is working right, doctors want to communicate with other doctors, they can just do that. They have no idea there’s Direct or anything like that, just as hardly any of them know about the connectivity for e-prescribing, they’re just using their system. If this is done right, they will just be able to interoperate or communicate with other providers and it will be an additional functionality in their electronic health record. The connectivity wire, I’m hoping, gets worked out between EHR vendors and those of us that want to be HISPs, and the providers just ask for the functionality to be turned on.

Q: Dr. Miller, would you care to take a crack at that same question?
My hope for the future is that there is a place for de-identified aggregated data, to be able to accumulate data, to really start to think in terms of public health reporting but beyond that to do analysis that would result in personalized medicine. And I think all doctors dream about this where they might have enough information over millions of individuals about behavioral data, outcomes data, clinical data, and potentially even genetic data. So when a patient is in front of me, I would be able to not start with a random protocol of "Okay, I’ve diagnosed with hypertension and I’m going to start with a diuretic and then if that doesn’t work I’m going to go to a beta blocker and if that doesn’t work, I’ll try the next medication," but to really know that given the data we have that’s been analyzed and given the patient’s profile, I know that this medication would actually have the greatest efficacy and the lowest side effect profile. So I hope that at some point, we can have aggregated de-identified data so that analysis can happen. I think in terms of Direct we need this now and we need this for patient care. It will dramatically enhance patient safety, efficiency, cost of care, and across care transition.