Transitions of Care Go Digital

Healthcare leaders are finding value in Direct messaging, but transferring information remains a challenge.

This article appears in the May 2014 issue of HealthLeaders magazine.

Still too often in healthcare, transition of care information chases caregivers. Patients often don't possess it or fail to bring it with them to subsequent encounters. Unanswered phone calls pile up in voice mailboxes, and faxes sometimes fruitlessly pursue physicians and specialists moving from practice to practice. The burden imposed upon staff and doctors alike is widely cited as one of the reasons healthcare costs continue to rise and gaps in care persist.

But with many providers facing deadlines to implement meaningful use Stage 2 this year, and the availability of a series of technologies including the Direct protocol, that is starting to change.

"Prior to Direct, what was happening was the case manager in the hospital would make a phone call," says Laurene Vamprine, CIO of Erlanger Health System, a five-hospital health system with more than 800 beds in the Chattanooga, Tenn., region.

"It ends up being this phone tag thing, back and forth," Vamprine says. "With protected health information, you can't leave the information in voice mail. You can't send it through regular email, so it becomes difficult to actually go ahead and tell the other person what you need to have done on a specific patient."

In October 2012, Vamprine heard about a new form of health information exchange being adopted by a coalition of public agencies in southeast Tennessee that would employ the Direct protocol to connect acute care hospitals with health coaches.

"Instead of coaches having to go to the hospital to pick up discharge papers or wait for a fax to come from the hospital, it can be transmitted immediately and securely through email," says Thomas E. Preston, assistant director for the Southeast Tennessee Area Agency on Aging and Disability in Chattanooga. "Also, the same transmission can be sent to several different people or several different locations that have a Direct account at the same time, instead of sending out three different faxes to three different people at three different places."

Preston says the agency's health coaches are able to check their Direct mail from wherever they are—on their phone, laptop, or tablet, "not having to wait until they get back to the office to pick up a fax to do it."

The value of secure messaging is one that consumers have understood and enjoyed for years in areas outside of healthcare. Yet, its integration into healthcare has been bumpy, and the experience in southeast Tennessee provides one example why.

For hospitals such as Erlanger, sending and receiving such Direct messages as currently configured does not yet count this year toward the meaningful use Stage 2 requirement that hospitals provide a summary of care record using electronic transmission for more than 10% of transitions of care and referrals.

"One of the things we're having to evaluate is, is there a way to tie that into the electronic medical record capabilities to generate something out of the EMR through that protocol," Vamprine says.

"I'm not sure that forcing that work that the health coaches are doing through the EMR is really the best way to do that," she says. "Sometimes you can make a process less efficient by forcing it through a technology or a technology process that really doesn't meet workflow."

When a health coach is talking to a patient by phone and hears something, or is visiting the patient and sees something, and the coach needs to quickly send an email, Vamprine says it's not going to be most convenient to do that by logging into an electronic health record software system.

As for the Stage 2 requirement of doing such communications within Erlanger's Siemens-based EHR software, "the industry as a whole is reaching this bolus where we're driving all these meaningful use requirements and functionality with our EMRs and forcing people to do them, but it's creating a tremendous amount of work effort for the clinicians that is not conducive to efficiency in the workflow," Vamprine says. "It's creating additional work, slowing them down, and impacting their productivity, and increasing costs to the organization. I believe that's temporary, but temporary for how long depends on when can we move into the next phase of this and really begin to reap some of the benefit of what we're seeing."

Meaningful use Stage 2 is an ambitious step forward in care coordination. Most "payloads" of Direct secure messages are structured as consolidated clinical document architecture (CCDA) documents, allowing transitions of care around problem lists, medications, allergies, and lab results and more to be shared upon discharge or referral between caregivers.

"It's the ability to package key data into a report that has codes inside to help computers decipher what each thing means, and then send it off to where your next care will be, or to your personal health record," says Joseph Schneider, MD, vice president, chief medical information officer, and medical director of clinical information of Baylor Scott & White Health, a 46-hospital system based in Dallas, with more than 500 patient care sites, 36,000 employees, as well as 6,000 affiliated physicians. "I really do see that this might eventually be the way that things will be done, rather than the health information exchange databanks at, say, a state or a regional level."

Meeting meaningful use Stage 2 this year means submitting a 90-day attestation of compliance with the Centers for Medicare & Medicaid Services. That 90-day period will vary depending upon health system and practice, and applies only to those eligible providers who attested for meaningful use Stage 1 in 2011 or 2012, leaving those who attested last year or this year to attest in future years.

At Baylor Scott & White, some physician practices will attest in July, August, and September. Hospitals will attest starting in October. At least one Direct message must travel between one vendor make of EHR and another. For those lacking such diversity, CMS has set up a test server that will randomly receive a provider's test Direct message.

At Baylor Scott & White, diverse EHR technology is a given. The organization's central Texas division runs Epic software, and its north Texas division runs Allscripts and GE EHR software, Schneider says.

"We're trying to set things so that they happen, I'll call it, automagically," Schneider says. "At the end of the visit, what we want to have is to whom should this information be sent, and build that right into the EMR, so that when the visit is closed or the discharge takes place, that it automatically goes out to those people."

However, Schneider concedes that for now, sending CCDAs using Direct will probably involve hiring personnel in order for the organization to achieve its required meaningful use numbers. "On the receiving side, as a hospital, it actually is even more interesting, because we'll be receiving Direct messages from all over the country, potentially," he says. "Routing those becomes a huge challenge, and so initially what I'm envisioning is that the same person that I'm using to help send things out would also be monitoring the inbound queue, and then looking at each one of those and then figuring out sort of where these go."

The capability to send and receive Direct messages also lays the groundwork for a nearly endless flow of secure electronic exchanges of health information not only between providers, but also between providers and health information exchanges, public health departments, and other government agencies concerned with everything from disease control to medical research—and in the process, allows physicians to remain autonomous.

In northeastern Massachusetts, the 225 physicians in the Whittier IPA will be able to use Direct to transmit secure patient information to the statewide health information exchange, says Joe Heyman, MD, CMIO of Whittier IPA, as well as a gynecologist running his own solo practice.

"Regardless of what network we happened to be associated with, we didn't want to be forced into just using that network," Heyman says. "Just in our little area there are four different contracting networks for hospitals and doctors. There's Steward Healthcare, Partners Healthcare, Beth Israel Deaconess Medical Cooperative, and Leahy Healthcare.

"Patients, when they go to see us as doctors, they have absolutely no idea that we're in one health network or another. They just go to the doctor, and we wanted to be able to see everything that happened to that patient, regardless of which network they were seeing at the time. We wanted the physicians who were in many different networks to be able to look at the entire picture for every patient. So the whole thing is centered on the patient."

Whittier IPA has also contracted with Alere to develop a health information exchange for its service area. The exchange, called Wellport, will issue Direct addresses to IPA physicians and act as a health information service provider, or HISP.

From the patient record on the Wellport HIE, Whittier IPA physicians by the end of 2014 will be able to pull anything off that health information exchange, such as a lab report, progress note from a physician, or a hospital discharge summary, and send it to whoever needs to receive it, Heyman says.

The role of HISPs throughout the meaningful use Stage 2 program is to provide identity verification via a chain of trust. Such a chain requires each HISP to enter into a set of legal agreements with other HISPs via certifying organizations such as DirectTrust or others. In this way, secure messages can eventually find their way to any provider participating in such a chain of trust.

As 2014 progresses, providers say the pricing of Direct messaging services will be determined largely by market forces. Some HISPs are being operated by EHR software vendors, others by HIE technology vendors, and still others operated by state health information exchanges. Some hope to charge by transaction, particularly with hospitals, or by number of Direct addresses provided, particularly with physicians.

Some providers think all Direct services will eventually be free or virtually so. "There will be significant resistance to having to pay for this in the early stages," Schneider says. "While the benefit to many of us is clear, I already have my fax machine and it works quite fine, thank you very much, and while eventually this might be able to replace it, for a while I have to have a fax machine, a phone line, and a person there. If you add costs to my cost structure, again, speaking as a small practice physician here, I'm not terribly happy to do that."

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This article appears in the May 2014 issue of HealthLeaders magazine.