MedAllies and the Direct Project Support Secure Exchange of Clinical Information in EHR Systems

MedAllies established in 2001, is located in the Hudson Valley of New York and specializes in electronic health record (EHR) implementations. They are also a Health Information Service Provider (HISP), providing the infrastructure to enable secured sharing of health information among providers.

In 2010, MedAllies joined the Direct Project to help define new protocols for sharing health information. This effort consisted of approximately 200 volunteer participants from more than 60 private-sector companies and organizations. Through the Direct Project, MedAllies and the other participants developed consensus standards that support secure exchange of basic clinical information and public health data. In 2010, the Direct Project selected the Hudson Valley as one of seven pilot sites to demonstrate health information exchange (HIE) using Direct standards.

In 2007, MedAllies joined with two other Hudson Valley healthcare organizations -- the 5,000-physician Taconic IPA (TIPA) and the community health information exchange, THINC -- to form the Hudson Valley Initiative . Their goal was to improve health care quality through advancements in patient care delivery models, payment reform, and health IT tools. Through the Hudson Valley Initiative, MedAllies assisted physicians in implementing EHRs and helped primary care providers become patient-centered medical homes (PCMH). When MedAllies became one of the Direct pilot sites, they began working with regional medical centers to implement Direct and establish a strategy to advance Direct adoption across the Hudson Valley. By that time, the region was ideal for the pilot because it already had a high concentration of healthcare organizations invested in PCMH and EHR adoption initiatives.

According to MedAllies, results of a 2012 survey showed that EHR adoption in the Hudson Valley is 82% and is estimated to reach 93% within the next 12 months.

In this environment of advanced primary care with an increased focus upon care coordination, physicians were eager to move beyond fax machines and start sharing health information electronically with each other.

MedAllies was met with great enthusiasm and support as they began engaging Hudson Valley providers to participate in the Direct pilot. Their approach was to focus on the EHR systems and build Direct capabilities into the existing clinical environment, requiring only minimal enhancements to current clinical workflows and EHR functionality in hopes of reducing provider impact.

A. John Blair III, MD, CEO of MedAllies, Inc. and president of TIPA explained: “From day one, we were focused on the end user and the provider. We said, ‘Okay, we need to figure out a way, using their current EHR systems, with minimal modifications to workflow, and minimal changes in functionality, how doctors can leverage their EHRs to transmit these messages.”

To figure this out, MedAllies met with both providers and vendors and asked “How do we make this work for you?” During these working sessions, they:

• Identified pilot use cases
• Created storyboards to identify key users and functions
• Reviewed EHR functionality and existing workflows
• Determined best practice workflows

This process allowed MedAllies to work with participating vendors to customize EHR functionality for the pilot. Once these capabilities were built into the EHRs, they then tested sending Direct messages through the MedAllies HISP. Among other venues, these capabilities were demonstrated at the 2011 and 2012 HIMSS Interoperability showcases.

MedAllies has worked with vendors, such as Allscripts, Epic, Greenway, NextGen, and Siemens, to customize EHR functionality and incorporate Direct into existing clinical workflows.

Today, approximately 20 providers and two vendors are participating in the MedAllies Direct pilot. Each of these participants is committed to improving care coordination and care transitions in the Hudson Valley through the use of Direct exchange.

MedAllies evaluated the critical needs in the region when selecting the use cases for their Direct pilot.

“Patients are particularly vulnerable when they are transitioning across care environments, such as being referred from their primary care provider to a specialist for a consultation, or at the time of discharge from the hospital when the patient returns back to the care of the patient’s primary care team. Critical information is required for the next provider to appropriately care for the patient, but today that doesn’t always happen.” - Dr. Holly Miller, Chief Medical Officer of MedAllies

Through discussion with providers, MedAllies determined that there was a need for provider-to-provider communication during transitions of care. Three use cases, which MedAllies believed were critical care transitions, were selected for the Direct pilot. The scenarios included:

1. Upon discharging a patient from an inpatient environment, the hospital sends a discharge summary to the patient’s primary care physician.
2. A primary care physician refers a patient to a specialist (Part 1 of the closed loop referral).
3. After seeing the patient, the specialist returns a care summary back to the primary care physician (Part 2 of the closed loop referral).

MedAllies believed that the Direct project could greatly improve these three transitions of care scenarios. Through the pilot, Hudson Valley physicians would have the ability to send and receive care summaries or discharge summaries immediately after a visit in a secure and efficient manner. The importance of timely discharge and care summaries was in even more demand due to the high level of Patient-Centered Medical Homes (PCMH) in the Hudson Valley.

Dr. Miller offered a scenario showing how Direct supports this type of advanced primary care:

At discharge from the hospital, many of a patient’s medications have been changed. He returns home, where he has all of his medicines—those he had before hospitalization and those he received at discharge. He may be a little confused about which ones he should be taking. Recall about medical information is often poor and inaccurate, especially when the patient may be slightly cognitively impaired, has multiple medical problems and is being treated with numerous medications, or is anxious; research suggests patients retain about half of the information given by health care providers.

With Direct, those medication changes are recorded and a new, reconciled medication list has already arrived at his primary care practice before the patient has even left the hospital. If the patient is deemed a high-risk patient he may have a care manager assigned to him. The care manager can call the patient the same day he returns home, review his medications, tell him which drugs to discard and reinforce which ones he should be taking. The care manager reviewing the updated list with the complex patient can prevent re-hospitalization or adverse events through this simple follow up, armed with the appropriate information regarding the care transition.

Direct exchange offers many benefits to both patients and providers:

• Prevents re-hospitalization, adverse events, or even death
• Ensures care team members have the most up-to-date, accurate information about a patient
• Enhances care efficiency
• Helps control health care costs

Unlike some Direct pilots that developed a new user interface for Direct exchange, MedAllies sought to provide Direct functionality within the EHR systems with which physicians were already interacting. They held working sessions with the EHR vendors to design this Direct functionality, including messaging capabilities, provider directory functions, and encryption services, and then worked with them to connect to the MedAllies HISP. Since vendors built this functionality into the EHR system itself, there was very little to no effect on existing clinical and EHR workflows. As a result, all participating providers quickly adopted Direct and began exchanging information via the MedAllies HISP within one to three months.

To foster communication between health systems, MedAllies implemented the full Direct infrastructure for the pilot, including both the required SMTP backbone and the XD* elective protocol. For certificates, MedAllies chose to obtain certificates from Certificate Authorities that are cross-certified with the Federal Bridge Certificate Authority.

Source Capabilities (EHR)

• Create message payload (most systems use HITSP C32 format).

• Provide basic provider directory services (the Direct addresses for participating providers were manually loaded into the EHR system).

• Communicate to MedAllies HISP using XDR or S/MIME encrypted IHE-XDM package.

HISP Capabilities

• Integration of Direct address lookup with CONNECT HL7 v3 based architecture - Integrating vendors can obtain Direct addresses from MedAllies HISP using PIX or PDQ transactions (HL7 v3).

• Inter-conversion (Step-up/Step-down) between SMTP and XDR message/XDM package for delivery based on destination capabilities (i.e. can send to destinations that support just Direct S/MIME& SMTP, or just support XDR/XDM as transport mechanisms.

Destination Capabilities (EHR)

• Receive and decrypt Direct message using XDR or SMTP client (S/MIME Encrypted XDM package).

• Ingest the HITSP C32 document (or other payload attached to the message) and incorporate in the clinical workflow.

One challenge that MedAllies faced in implementing the pilot was that most out-of-the-box EHRs do not have built-in Direct capabilities. In some cases, even though modules existed to foster communication with other providers (such as referral templates), no capability had been included to leverage this functionality for Direct messaging. MedAllies had to work with vendors to design and build such solutions for the pilot.

MedAllies explained that additional functionality, such as filtering and integration capabilities, are very important, but also lacking in some EHRs. Physicians would like the ability to use filters to limit the amount of information extracted from the EHR prior to sending a message. This ensures that the receiving provider only gets the clinically relevant details of a visit, or in clinical terms: the pertinent positives and negatives. Physicians would also like the ability to select discrete data received through Direct and integrate it into a patient’s record within their EHR. The ability to customize Direct messages and incoming data enhances current clinical provider-to-provider communication. Ultimately, it allows providers to offer better care to patients across care transitions because they are accessing the most relevant and current information on the patient.

MedAllies noted that participating EHR vendors were extremely responsive to provider’s requests and are eager to incorporate more Direct functionality into their systems. They recognize that this work is an important step to facilitate the exchange of health information.

Due to their EHR-centric approach, MedAllies succeeded in implementing a Direct pilot in the Hudson Valley that required minimal changes to clinical workflows. Another benefit of this approach was that it required little user training, as providers were already trained on their EHR systems, and the introduction of Direct messaging did not significantly alter the current provider/end-user roles and responsibilities. With this approach, MedAllies received an overwhelming response from Hudson Valley providers.

“Direct is the holy grail of consultative medicine – being able to effortlessly transmit information back and forth. This is a home run. It’s different from other methods of communicating, such as email or fax, because it is coming right into my EHR, the focal point of all of my clinical workflow and communication.” – Ferdinand J. Venditti, Jr., MD

Since the pilot kicked off, MedAllies has seen a dramatic increase in demand from providers who want to participate in the pilot. Now when MedAllies goes to organizations they work with, providers are asking when they will be able to start using Direct.

Also as a result of the pilot, EHR vendors have been extremely responsive to requests to incorporate more Direct functionality into their systems. As more clinicians adopt Direct and additional Meaningful Use requirements are released, MedAllies expects to see more EHR development supporting Direct. Ultimately, this will help EHR vendors deliver more user-friendly systems and maintain a competitive edge in the marketplace.

• Having executive sponsors speak optimistically about Direct and obtaining end user buy-in were critical aspects in developing the pilot. To obtain this buy-in, MedAllies focused on incorporating Direct into participating organization’s key functions and workflows.
• Providers were more willing to adopt Direct if it required minimal change and effort on their end.

“Direct is not just about technology, it’s about supporting the clinician to best manage their patients. Taking end users’ needs into consideration will ultimately result in greater adoption of Direct.” – Dr. Holly Miller

While the technology advances associated with Direct are apparent, MedAllies aims to have more discrete data on Direct messaging utilization and corresponding outcomes as the pilot progresses. The hope is that these metrics will clearly show that Direct is both improving patient care and increasing office efficiency in the Hudson Valley.

Additionally, MedAllies expects new implementation sites to appear as pilot EHR vendors advance and distribute their Direct capabilities. As they expand, their focus will remain on closed loop referral use cases and discharge notifications.

1. The Direct Project
2. The Hudson Valley Initiative Overview [PDF - 1.5 KB]
3. Issue Brief: Beyond Babel MedAllies Direct Project [PDF - 3.68 KB]
4. Issue Brief: Not So Elusive--MedAllies Direct advances interoperability [PDF - 399 KB]