* In Rhode Island, some physicians who use EHRs can automatically upload a finished record to currentcare, the state's health information exchange, with the same keystrokes that saved it to the practice's database.
* In Tennessee, the VA Mountain Home Medical Center outsources its mammograms to local health systems. While almost all Veterans Affairs hospitals outsource their mammograms, Mountain Home is the only one sending its referrals and receiving reports back electronically.
* In New York, Albany Medical Center (AMC) has successfully tested a way to securely exchange electronic referrals and discharge summaries among primary care physicians, specialists, and the hospital, with data that flows seamlessly among systems from four different vendors. "It almost feels like they're all using the same EHR," says Albany's CIO George Hickman. The medical center is now exploring how to put the enhanced communications capability into daily use.
All of these information swaps, and several others now in pilot phases, are propelled by the Direct Project: secure electronic mail designed specifically for health care. The idea-simple to describe, less simple to execute, and potentially transformative-is to make HIPAA-compliant, one-to-one Internet-based communication as easy for providers, and as ubiquitous, as regular e-mail.
Using Direct Project protocols, providers could send clinical messages to one another, regardless of their location or institutional affiliation, without relying on fax machines and sneakernet (i.e., courier service). The information contained in the messages could, when appropriate and correctly formatted, slide directly into an electronic health record, a database, or any other digital receptacle without scanning or transcription.
"We've been toying with this for awhile, but we've been so busy getting EHRs to be something that's clinically usable," Hickman says. "For this to be meaningful, you have to have a critical mass of EHR users in a community. We have that critical mass and [Direct messaging] will be the next thing."
In Hickman's mind, the Albany pilot shows how seamlessly and inexpensively Direct messaging should work if it's executed correctly. "The vendors are the ones who have made the notable investment, because they had to make software changes," he says. "The investment we've made is one we had planned to make already, and it wasn't substantial. It's been mostly just smart people getting together, and doctors showing us what's clinically meaningful to them."
Four EHR vendors are participating-Allscripts, Epic, Greenway, and Siemens (AMC's vendor). They've built a capability into their software so that a primary care physician can click a "referral" button in an EHR.
The system automatically gathers the information needed for the type of specialist the referral is going to and creates a "package" that is routed using Direct-compliant protocols to MedAllies, which maintains a master directory of Direct addresses for all the physicians in the pilot.
It finds the receiving physician and sends the package to the workflow area of the doctor's EHR.
At that point, the specialist's office staff can open it, schedule the referral visit, and incorporate the patient's data into its EHR.
Once the specialist sees the patient, the system compiles the specialist's report, orders and recommendations and sends that package back through MedAllies to the referring physician, who can add the new information into the patient's record.
"This one set of transactions could markedly improve the quality of care and address a remarkable inefficiency that physicians have tolerated day in and day out, even if they have an EHR," Hickman says, referring to the current reliance on phone, fax, and traditional mail service. "Our physicians get really pumped about it."
To quote the project's own overview, "The Direct Project specifies a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet."
Strongly encouraged by the federal government (which requires secure communications in connection with several EHR "meaningful use" criteria), the Direct Project launched March 1, 2010, as a collaboration among a coalition of providers, vendors, and state and federal agencies. The idea is to build standardized secure messaging capability into all the pieces of the health care information infrastructure.
"There are lots of ways to do secure exchanges now, but they're not very standardized and they require lots of custom work at each end," says Kevin Larsen, M.D., chief medical information officer for Hennepin County Medical Center. "The idea of the Direct Project is, let's do it one way as a country so we don't have to do that work."
The Direct Project, which began releasing final specifications in March, is an offshoot of the National Health Information Network development. It specifies widely used Internet standards: SMTP, MIME, S/MIME, and x.509 digital signatures. It also utilizes health-care-specific standards such as SOAP that are supported by Integrating the Healthcare Enterprise (IHE), the force behind the Interoperability Showcase featured at annual HIMSS meetings. "That's important because all EHR vendors have been moving to [IHE] standards over the last few years," says Leroy Jones, CIO of MedAllies, Fishkill, N.Y., which is handling the data exchange for the Albany Medical Center Direct Project pilot.
"The connection should be straightforward for a good programmer," says Pat Pope, provider relations coordinator at CareSpark, the Kingsport, Tenn.-based health information exchange that's handling the messages for the VA mammogram referral pilot mentioned earlier.
Because many aspects of Internet messaging have more than one standard in use, it was vital to narrow things down, says Doug Fridsma, M.D., director of the office of standards and interoperability for ONC. "We've heard from the industry that when we put out a standard that says you can do this or that, vendors have to be sure they can do both this and that," he says. The government doesn't want to go too far in specifying how things are done, he adds, but the Direct Project's purpose was to arrive at a consensus that the government can endorse and providers and vendors can embrace with confidence.