With eight pilot programs under way, and nearly three dozen vendors signed on, the Direct Project -- the federal effort to set standards for health information exchange (HIE) that meet Stage 1 meaningful use requirements -- is gathering momentum quickly. (Some may know the Direct Project by its former name, Nationwide Health Information Network, or NHIN, Direct.)
MedAllies Inc., the health information service provider that built the platform for the Hudson Valley Health Information Exchange in upstate New York, sees the value of using Direct Project standards to share consultations, referrals and discharge information among primary care physicians, specialists and hospital care managers.
Such information sharing doesn't just eliminate unnecessary or duplicate medical tests, said Dr. Holly Miller, MedAllies' chief medical officer. Putting additional patient data into physicians' hands electronically also reduces medical errors and relieves patients of the burden of relaying diagnoses, discharge notes and prescriptions to all the doctors they see.
"It gives the opportunity to really support transition of care so that the patient is no longer responsible," Miller said, adding that one doctor referred to the concept as "the holy grail of medicine."
Direct Project a means to interoperability, not interop itself
The first Direct Project pilot programs went live in early February at the Hennepin County (Minn.) Medical Center, which is sending immunization data to the Minnesota Department of Health; and at the Rhode Island Quality Institute, which has enabled provider-to-provider data exchange and made it possible to push data to the statewide HIE organization.
Those two pilots, along with MedAllies' Hudson Valley exchange and several others, were on display at the Interoperability Showcase during the Healthcare Information and Management Systems Society's HIMSS 2011 conference in February.
Those pilots came online about 10 months after the Direct Project's initial conception, Dr. Doug Fridsma, the director of standards and interoperability for the Office of the National Coordinator for Health IT (ONC), said in an interview at HIMSS 2011. Such fast-paced adoption was possible, he said, because the Direct Project offers a "low-cost, simple and scalable mechanism" for HIE.
The project does not, however, offer interoperability in and of itself. As the Direct Project overview puts it, the HIE standard is only one of three key components of interoperability. The others are the structure and format (a Continuity of Care Document [CCD] or a Continuity of Care Record, for example) of the information and the medical vocabulary (SNOMED CT, for example) it uses.
For Dr. A. John Blair, MedAllies' CEO, this assessment fits. "First and foremost," he said, Direct Project is "about provider communication about patient care. This allows the important information to move." The Direct Project's ultimate goal is to establish a nationwide health information network, but Blair cautioned against seeing the standard as a panacea: "We don't want to get carried away that this will solve all problems."
Fridsma agreed: "If people apply this solution to a different problem, they may not find the amount of value that others do." However, he added, "We have been able to demonstrate that it's successful."
For example, Hudson Valley physicians are exchanging standard data sets, such as problem lists and allergy lists, as well as more specific, structured data, such as echocardiograms and other lab results, Blair noted.
This data arrives in the inbox of a user's electronic health record (EHR) system, so the health information exchange process remains consistent with current clinical workflows, MedAllies' Miller noted. In addition, the data arrives "in seconds," so specialists can review it before a patient arrives. "Where there is that level of follow-up, this kind of care will support patients," she added.
'Straightforward' specs enable quick health information exchange
Data can arrive in seconds because the Direct Project specifications are "straightforward" and were easily baked into EHR systems' referral, consultation and discharge-notification modules, Blair said.
It gives the opportunity to really support transition of care so that the patient is no longer responsible.
Dr. Holly Miller, chief medical officer, MedAllies Inc.
Data is packaged using the Secure Multi-Purpose Internet Mail Extensions, or S/MIME, method. The X.509 digital signature standard handles endpoint authentication, and messages are routed using the Simple Mail Transfer Protocol.
There is no data repository -- information simply goes from one endpoint (the sender) to another (the receiver), noted Tom Wagner, chief technology officer for MedPlus Inc., which is owned by Quest Diagnostics Inc. and supports the Direct Project protocols in its Care360 EHR system. Finally, in accordance with meaningful use requirements, data is sent in a human-readable form: a CCD or a PDF file, for example.
These standards are not new, Wagner said. "We just tried to put them together in a simple, meaningful and secure way."
By and large, the health IT vendors supporting the Direct Project are incorporating this technology into their regularly scheduled updates or patches. Compared to the upgrades they are releasing to support meaningful use requirements, adding support for Direct Project standards is relatively minor, MedAllies' Blair said.
For example, Care360's commercial release incorporating Direct Project protocols came in January. With that iteration, Care360 users can send data to a patient's Microsoft HealthVault account.
"We can make this available to every physician on the network" of 165,000 Care360 users, Wagner said. "It will be a good test of the Direct Project platform and how we can get [information] out there."
Microsoft, for its part, sees the Direct Project as a way to take an incremental approach to health information exchange, said Nate McLemore, general manager of business development and policy for the company's Health Solutions Group.
The benefit of the Direct Project is that it has been embraced by the ONC and, at the same time, is easy to implement, McLemore said.
"Those two things, moving together, will make it happen," McLemore said. "We're very hopeful that it'll start to get the data moving."
Fridsma agreed. "If you've got something that people feel an ownership about -- that solves a really important problem and it does it in a simple way -- adoption becomes much easier as a result," he said.
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