Successful Electronic Information Exchange through Direct Pilot Implementation with Cerner and the Lewis and Clark Information Exchange (LACIE)

The Lewis and Clark Information Exchange (LACIE) Direct pilot was initiated by the Cerner Corporation in conjunction with LACIE and Heartland Health. Cerner, whose headquarters is located in Kansas City, Missouri, saw the pilot as an opportunity to help a local organization address many of the operational challenges they were facing with traditional fax communications.

• Heartland Health: Heartland Health is an integrated health delivery system that includes the Heartland Regional Medical Center , Heartland Clinic , Heartland Foundation and Community Health Improvement Solutions . Heartland Health operates across 21 counties in northwest Missouri, northeast Kansas, and southeast Nebraska. Their vision for the future of healthcare is a patient-centered, fully integrated regional health delivery system inclusive of all payers and providers. To achieve this, they have committed to making their business and clinical workflows more efficient with health information technology, including Direct. Heartland Regional Medical Center, an acute care facility in St. Joseph, Missouri, was the leading participant in the pilot. As an anchor in their community, they were in a position to promote new ideas and implement better ways of connecting healthcare providers. They were also a Cerner client, and they leveraged this existing partnership to facilitate a successful Direct rollout.
• Lewis and Clark Information Exchange: Heartland Regional Medical Center is connected to LACIE, a wholly-owned subsidiary of Heartland Health. LACIE is a fully operational, multiple-state HIE which uses Direct to enable secure exchange of patient data across disparate systems within the Midwest. LACIE assisted in the recruiting of pilot participants and was an active participant in Directed exchange during the pilot.
• Cerner Corporation: The Cerner Corporation builds and offers an array of information software, professional services, medical device integration, remote hosting, and employer health and wellness services. Cerner is making system advancements that support evidence-based clinical decisions, prevent medical errors and empower patients in their care. Cerner has been a committed member of Direct Project since its inception March, 2010. Together with the over 60 other companies and organizations involved in the Direct Project, Cerner has helped to identify and evolve the standards and services at the heart of Direct that support secure, directed exchange of health information in support of Meaningful Use. Cerner plays a lead role in the development of the Direct Project community's open source Java-based software reference implementation and continues to actively participate in Direct Project's advancement. In 2010, the Direct Project selected multiple pilot sites across the country in order to test the Direct standards. In February 2011, the LACIE Direct pilot kicked off, with Cerner providing HISP services.

Cerner and LACIE approached the Heartland Regional Medical Center in 2010 with the specific use case of replacing outbound fax processes with Direct. Their goal was to improve hospital operations and reduce staff support costs. Once Heartland signed on for the pilot, they worked with Cerner to identify additional local participants.

Today, three primary care offices, one specialist office, Heartland Regional Medical Center, and the Lewis and Clark Information Exchange (LACIE) are participating in the pilot.

Cerner’s strategy for the pilot was to start small and stay local. They selected pilot participants that were located within one hour of their headquarters in Kansas City, Missouri. Using this strategy, they were able to control scope and support participants throughout the pilot.

Heartland Regional Medical Center, LACIE, and Cerner were strategic in selecting additional pilot participants. They looked at the various providers working with Heartland Regional Medical Center and considered several factors, including who had high volume communication channels and high staff support costs. They also identified providers whose operations would be most improved with Direct. In addition, LACIE identified use cases within their own organization which involved routine administrative communications with their provider member organizations that were being conducted via telephone communications.

LACIE and Cerner worked collaboratively with the pilot organizations to understand their current state and to determine the impact Direct would have on their workflows. Upon review of the possibilities, the group identified five initial end-points that were delivering clinical documents (such as discharge summaries, lab results, and radiology reports) via fax. These, along with the administrative scenarios mentioned above, were selected as Direct use cases for the pilot.

Andy Heeren of the Cerner Corporation describes one of the pilot use cases in more detail:

“The participating specialist office was experiencing increased staffing costs due to time-consuming fax support processes. Staff was responsible for manually sorting and routing all fax communications to the proper physicians in this paper-based office. This was wasting time and resources. By introducing Direct, staff members supporting each of the physicians were given Direct addresses and access to a webmail client. There, they could retrieve those messages electronically and securely for the intended provider, eliminating the need to manually sort those communications and saving them precious time.”

Similarly, the other pilot Direct use cases were implemented with a focus on improving office operations by reducing support costs and enhancing business processes.

To roll out the pilot, Cerner had to work within two very different clinical environments; one with a Direct-enabled EHR and one without. Heartland Regional Medical Center was using a Direct-enabled EHR (Cerner Millennium®) before the pilot. To implement Direct, Cerner leveraged existing Cerner Millennium functionality to connect Heartland to the pilot HISP. The other, smaller pilot participants were not using a Direct-enabled EHR system. As a result, Cerner developed application programming interfaces (APIs) along with a simple, web-based email client to connect these participants to the HISP.

Clinical documents are created within Heartland’s EHR, and the Remote Report Distribution module within the EHR has the ability to automatically fax a copy of these documents to appropriate clinicians for review. To implement Direct, Cerner improved this module, allowing documents to be packaged as PDF or RTF documents and sent as an attachment via a Direct message instead of a fax transmission. They activated this service for the pilot use cases, allowing Heartland providers to seamlessly introduce Direct into their clinical workflows. This integrated approach resulted in easier adoption and more transparency for providers.

The other participants, who did not have a Direct-enabled EHR, utilized Cerner’s standalone web-based email client (Cerner Direct Inbox) which allowed participants to retrieve and route Direct messages. As part of this solution, individual users within each organization were assigned Direct addresses.

Cerner serves as the certificate authority (CA) and registration authority (RA) for the pilot. They are responsible for validating each participating organizations’ identity and then issuing organizational-level certificates. Each participating organization then assigns authorization for individuals to conduct Directed exchange according to their existing policies and procedures covered under HIPAA.

To train staff participating in the pilot, a Cerner representative held on-site train-the-trainer sessions. Cerner reported that while this was an effective strategy for the Heartland Health Direct pilot, it may not be a scalable model for larger pilots in which educational materials and consulting services may be more effective training tools. To build participant’s confidence in Direct, Cerner also offered a software configuration where providers could choose to receive messages by both fax and Direct. Many providers turned off the fax capability shortly after they began using Direct.

Cerner and LACIE initially faced challenges securing pilot participants outside of the Heartland Regional Medical Center. These specific organizations were hesitant to adopt Direct as they already had fax solutions integrated into their current clinical workflows.

Cerner found that introducing Direct was a challenge for those organizations in which the process did not easily integrate into the provider’s workflow. Unlike Heartland Regional Medical Center who had a seamless transition to Direct, many of the participants had to add or change steps in their clinical workflows to begin using Direct. One long-term care facility that originally participated in the pilot found that logging into a separate application to retrieve Direct messages didn’t work in their practice. They removed themselves from the pilot early on and returned to receiving faxes within their EHR workflow. While a few organizations declined to participate in the pilot, Cerner found that some were willing to take these extra steps of logging into a separate application in order to send Direct messages.

Cerner noted that overcoming these challenges with adoption is a broader industry challenge. As more and more vendors embed Direct within the EHR workflows that providers and their support staff are accustomed to, they will ultimately see greater Direct adoption rates.

“We set out to highlight that use of Direct could be an enabler toward more meaningful and safe information exchange amongst members of our community, regardless of where those participants were along their technology roadmap. We believe we did that, and Direct continues to be an integral part of our interoperability strategy moving forward.” - Jeff Bloemker, Executive Director of LACIE

Through the LACIE pilot, traditional fax and telephone communications were successfully replaced with electronic information exchange in six healthcare organizations. Some of the uncertainty with fax machines was also eliminated by implementing read receipts. While these are optional in the Direct specifications, they provided tremendous value to pilot participants because they now received better feedback as to the status of their communications. Additional efficiencies and security measures such as these greatly contributed to participants’ confidence in Direct.

The pilot participants also noted that implementing Direct:

• Increased security (vs. fax).
• Enhanced workflows (vs. paper).
• Reduced support effort/costs.
• Offered the potential for lowered long distance charges.

Cerner identified three key lessons learned from the LACIE Direct pilot:

1. Early Adoption is Challenging
   • Not everyone has Direct-enabled endpoints.
   • Providers want to send everything via Direct, but today that is not possible. A combination of Direct and fax is necessary in some cases.
2. Value is in the Workflow Impacts
   • Some EHRs have embedded fax receipt /processing within their workflows, which makes it more convenient to continue using fax.
   • Having the ability to embed Direct into workflows that providers are familiar with is key to obtaining user buy-in.
3. Education is Necessary
   • Providing some level of Direct education to providers is an immediate need and challenge, and is a first step that should not be overlooked. Industry organizations, such as DirectTrust.org, could be leveraged to assist with this.

Cerner successfully implemented Direct messaging capabilities between Heartland Regional Medical Center and affiliated community providers. The ability to communicate securely and efficiently resulted in reduced staff support costs and improved business processes in several of the participating organizations.

Today, Cerner continues to develop Direct functionality within Cerner Millennium. As of August 2012, they have incorporated Directed exchange into the Cerner Millennium solution, which includes two-way messaging using inbox messaging tool capabilities. Based on the successes at Heartland Regional Medical Center and others, such as Torrance Memorial Medical Center (Torrance, CA), Cerner has already begun to roll this out to their other clients across the U.S., With these upgrades, Heartland Regional Medical Center and others will benefit from deeper integration of Direct standards into their workflows and will have the ability to communicate externally with other trusted HISPs, not just affiliated entities. Additionally, in anticipation of Meaningful Use Stage 2 objectives, Cerner has already introduced referral and transitions of care use cases and solutions into a similar pilot project.

1. The Direct Project
2. Cerner and the Direct Project