Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island

Transcription

1 December 2013 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island State Health Policy Consortium Final Report Prepared for Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services 300 C Street, SW Washington, DC Prepared by Monica Chiarini Tremblay Gloria Deckard Debra VanderMeer Florida International University Michael Shapiro Stephanie Rizk Ross Loomis RTI International 3040 E. Cornwallis Road Research Triangle Park, NC RTI Project Number

2 RTI Project Number Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island State Health Policy Consortium Final Report December 2013 Prepared for Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services 300 C Street, SW Washington, DC Prepared by Monica Chiarini Tremblay Gloria Deckard Debra VanderMeer Florida International University Michael Shapiro Stephanie Rizk Ross Loomis RTI International 3040 E. Cornwallis Road Research Triangle Park, NC RTI International is a trade name of Research Triangle Institute.

3 Contents Section Page 1. Executive Summary Background Use Case Observations Methodology General Findings Benefits of Direct: Examples of Cost Savings and Other Benefits Alabama Overview of Alabama Direct Implementation and Adoption Dyad 1: Case Management (Two Scenarios) Dyad 1, Scenario Dyad 1, Scenario Dyad 2: Monitoring Mental Health Treatment Anticipated Improvements Challenges/Opportunities Florida Overview of Florida Direct Implementation and Adoption Dyad 1: Dermatology Specialty Referral Improvements Challenges/Opportunities Dyad 2: Public School System Referral for Special Needs Children Improvements Challenges/ Opportunities Illinois Overview of Illinois Direct Implementation and Adoption Dyad 1: Adolescent Crisis Assessment Referral for Hospitalization Improvements Challenges/Opportunities iii

4 6.3 Dyad 2: Methadone Treatment Center Refers Clients to Community Health Center for Physical Exam Improvements Challenges/Opportunities Rhode Island Overview of Rhode Island Direct Implementation and Adoption Dyad 1: Primary Care Referrals Dyad 1 (Scenario 1) Dyad 1 (Scenario 2) Improvements Challenges/Opportunities Dyad 2: Coordination and Supervision of Community-Based Behavioral Care Improvements Challenges/Opportunities References R-1 iv

5 Figures Number Page 4-1. Alabama Dyad 1 Pre- and Post-Direct Information Transfers (Scenario 1) Alabama Dyad 1 Pre- and Post-Direct Information Transfers (Scenario 2) Alabama Dyad 2 Pre- and Anticipated Post-Direct Information Transfers Florida Dyad 1 Pre- and Post-Direct Information Transfers Florida Dyad 2 Pre- and Post-Direct Information Transfers Florida Dyad 2 Pre- and Post-Direct Information Transfers Subdiagram Illinois Dyad 1 Pre- and Post-Direct Information Transfers (Scenario 1) Illinois Dyad 2 Pre- and Post-Direct Information Transfers Rhode Island Dyad 1 Pre- and Post- Direct Information Transfers (Scenario 1) Rhode Island Dyad 1 Pre- and Post- Direct Information Transfers (Scenario 2) Rhode Island Dyad 2 Pre- and Post-Direct Information Transfers v

6 Tables Number Page 3-1. Participant Description by State Cost Estimate for Alabama Dyad Cost Estimate for Florida Dyad Cost Estimate for Florida Dyad Cost Estimate for Illinois Dyad Cost Estimate for Rhode island Dyad Adoption Metrics: State of Alabama Participants and Roles of Alabama Dyad 1 Use Case Participants and Roles of Alabama Dyad 2 Use Case Adoption Metrics: State of Florida Participants and Roles of Florida Dyad 1 Use Case Participants and Roles of Florida Dyad 2 Use Case Adoption Metrics: State of Illinois Participants and Roles of Illinois Dyad 1 Use Case Participants and Roles of Illinois Dyad 2 Use Case Adoption Metrics: State of Rhode Island Participants and Roles of Rhode Island Dyad 1 Use Case (Scenario 1) Participants and Roles of Rhode Island Dyad 1 Use Case (Scenario 2) Participants and Roles of Rhode Island Dyad 2 Use Case (Scenario 1) vi

7 1. EXECUTIVE SUMMARY The Direct Project establishes a simple, secure, scalable, standards-based way of sending authenticated, encrypted health information directly to known, trusted recipients over the Internet. Based on secure protocols, Direct provides a simple, direct, point-to-point transmission of information (i.e., ) and uses widely available technology. This report presents eight Use Case dyads and ten scenarios from diverse health and social service provider organizations in varying stages of Direct exchange adoption and implementation. All of the dyads preferred Direct to paper-based exchange by fax or personal transport, and all noted increased confidence in security (i.e., assurance of vetted recipient), efficiency (i.e., elimination of phone tag and repeated fax), and completeness of documentation through attachment of files rather than incomplete fax transmissions. Only minor challenges to adoption and implementation were noted, and no participants were dissatisfied with using Direct. Rather, participants anticipated increased use and benefits as Direct networks expand through further adoption. Many described a personal commitment to assist their state in furthering adoption by recruiting more participants through individual contact and through presentations at professional meetings. Key findings through observation of live Use Cases demonstrate: Ease of adoption, implementation, and use, including the following features: minimal change in staff workflow to transmit protected health information (PHI), minimal financial costs and technical investment, ease of use, and usefulness for internal as well as external communication of PHI. Immediate benefits include: improvement in coordination and delivery of care, transmission of PHI that is more efficient and timely, assurance that correct recipient receives PHI, guarantee that complete documentation is received, ease of adoption into health records, and ability to electronically exchange information for providers who do not have an electronic health record (EHR). Direct makes an important contribution to the Health Information Technology for Economic and Clinical Health (HITECH) Act goal of improving quality and efficiency of care through the interchange of PHI across diverse entities within communities, states, and across the nation. The Direct Project brings benefits to both organizations and providers with minimal staff or financial costs in terms of adoption, implementation, and ongoing use. 1-1

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9 2. BACKGROUND The Direct Project was initiated in March 2010 to create specifications for a simple, secure, scalable, standards-based way of sending authenticated, encrypted health information directly to known, trusted recipients over the Internet (the Direct Project wiki, 2013). Based on secure protocols, Direct provides a simple, direct, point-to-point transmission of information (i.e., ) and uses widely available technology. Similar to the exchange of fax or paper documents, Direct is based on a push of content from a sender to a receiver, and its technical specifications assure secure transport, validate the identity of the sender and receiver, and ensure the authenticity and integrity of the content. Therefore, common or prenegotiated master patient identifiers between sender and receiver are not required. Direct provides a secure alternative to faxing while minimizing changes to current workflow processes and, generally, transmits PHI more efficiently, although it promises more than replacement of fax transmissions. The technology standards and services can be incorporated into electronic health records (EHRs), individual EHR modules, or offered through a health information service provider (HISP). EHRs must incorporate Direct on or before January 2014 to be certified for Meaningful Use Stage 2. Thus, Direct can enable eligible providers to meet Meaningful Use and obtain the corresponding reimbursements. Direct also allows electronic exchange of information for providers who do not have an EHR. Jennifer Covich Bordenick, CEO of the ehealth Initiative, noted that Direct is necessary, especially for small physician practices that do not have the means to purchase an EHR, even with incentive programs (Terry, 2012a). Indeed, a number of health information exchanges (HIEs) have used Direct to jump-start online information exchange among providers, many of whom do not have EHRs (Terry, 2012b). The success of Direct can be gauged partially by its growth and partially by the Use Cases documenting its value. Within a year of Direct s launch in March 2010, pilot programs were launched in Rhode Island and Minnesota in February 2011 (Healthit.gov, 2013). Other pilot programs followed in New York, Tennessee, California, Connecticut, Missouri, and Oregon to demonstrate the effectiveness of Direct in sharing health information. As of 2013, all but two states had implemented or were in the process of implementing Direct (ONC, 2013) Direct benefits patients and providers by speeding the transport of PHI, making it more secure and less expensive (the Direct Project wiki, 2013). These benefits contribute to the expansion of Direct in both the number of participants and transactions. The utility of Direct is expanding as public health and social service agencies adopt this service to ease the transmission of PHI to align with Health Information Portability and Accountability Ace (HIPAA) and Family Education Rights and Privacy Act (FERPA) guidelines. Direct contributes to the HITECH Act goal of improving quality and efficiency of care through the interchange of PHI across diverse entities within communities, states and across the nation. 2-1

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11 3. USE CASE OBSERVATIONS This report presents eight Use Case observations from diverse organizations that demonstrate the expansion of Direct to a broader community of providers with distinct, some unique, uses of the services. The organizations vary in types as well as in the stage of adoption. Observations of the workability of Direct in physician offices, health departments, behavioral health, and other health care and social service agencies focused on the ease of adoption as well as information flow among diverse providers. These live Use Cases or scenarios detail how end users interact with Direct services in four states and discuss the benefits and challenges to the adoption, implementation, and use of Direct. The objective of the Use Case observations is to illustrate current scenarios that describe how data are shared across trusted entities through the use of Direct. As part of the Use Case development process, the team designed a framework for performing a basic set of observations for dyads of Direct users within each state and developed a methodology to systematically describe the varying uses of and end-user interaction with Direct. The observational methodology provided a consistent, systematic collection of information about the use of Direct and validated the observation activities and reliability across observers. Initially, the focus for our Use Case observations was to include only observations similar to the Use Cases documented in the Direct Project s User Stories (the Direct Project wiki, 2013). However, as the Office of the National Coordinator for Health Information Technology (ONC) identified states willing to participate and explored the options available, the focus was broadened to allow for the unique participants in each state to provide additional utilization stories beyond those already recognized. 3.1 Methodology ONC identified four states, Alabama, Florida, Illinois, and Rhode Island, as the initial sites for observations, and agreement from the State-Designated Entities (SDE) was obtained before the research team initially contacted them. The team began by communicating with each state HIE coordinator. After providing an overview of the purpose for our study and the observation process, we requested that the state HIE coordinator identify two sets of two providers ( dyads ) who currently exchange PHI and would be willing to participate by allowing us to observe a round-trip (closed-loop) exchange with one another. At that time, we also requested copies of state policy and procedure documents for our comparative content analysis. In a second conversation we sought to clarify our review of the policies and procedures and to expand understanding of the Direct initiative within the state. Table 3-1 summarizes the dyads identified for each state. 3-1

12 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island Table 3-1. Participant Description by State State Participant 1 Description Participant 2 Description Use Case Alabama Dyad 1 Case management organization State dept. of public health Medicaid case management: Monitoring and auditing chronic care. Coordinating transportation and delivery of medical supplies. Alabama Dyad 2 State/regional mental health association Mental health provider Managing placement and treatment transitions of clients in a 5-county region. Notifications and status updates sent to state department of mental health. Florida Dyad 1 Dermatologist Dermatologist surgery specialist Specialist referral of patient to specialist for advanced surgical treatment. Record of treatment sent back to referring specialist. Florida Dyad 2 Children s social service agency School system Exchange of PHI between a social service agency and county school system to transition students with special needs. Illinois Dyad 1 Methadone clinic Community health center Methadone treatment center refers clients for physical examination and establishment of dosage amounts. Health center sends authorization to treat; exam and lab results sent back. Illinois Dyad 2 Social services agency Behavioral health acute care facility Community-based crisis assessment creates referral to adolescent psychiatric unit. Discharge summary returned for follow-up care. Rhode Island Dyad 1 Primary care physician practice Behavioral health provider Primary care provider (PCP) refers a patient to a behavioral health provider. Behavioral health provider sends back acknowledgement of receipt of referral, acknowledgement when patient first seen for treatment and, if requested, status updates on treatment. Hospital sends admission, transfer, and discharge alerts to PCP. Rhode Island Dyad 2 Community behavioral health organization Communitybased behavioral health provider Community behavioral health center communicates with community-based providers who are geographically dispersed across their catchment area for case management and supervision. Once the dyads were identified in each state, we employed the following process to develop each Use Case (a copy of the Guideline for Use Case Development is provided in Appendix A): 1. Pre-observation discussion: 1 hour by teleconference, recorded and professionally transcribed. Discussion about the decision to participate in Direct and the use of any other electronic exchange within the office. Obtain description of workflow for protected information exchange prior to Direct. 3-2

13 Section 3 Use Case Observations 2. Creation of draft pre-direct workflow diagram. 3. Scheduled 1-hour in-person observation. Validate pre-direct workflow model. Discuss impact of Direct on workflow processes. Observe post-direct workflow of a two-way exchange: When possible, we attempted to be in both offices to observe the workflow of sending and receiving a secured message. If the participants were already exchanging information, we preferred that they exchange real data. If not, a sample Continuity of Care Document (CCD) was available to use as test data. 4. Create draft of post-direct workflow diagram. 5. Post-observation discussion: 1 hour by teleconference, recorded and professionally transcribed to validate observations and final workflow models. Our general presentation of the Use Cases employs simplified workflow diagrams. Appendix B includes the extensive workflow diagrams that follow Unified Modeling Language (UML) guidelines to represent discrete units of interaction among people (humans) and systems (computers configured with software). The diagrams in Appendix B describe these interactions as UML Activity Models (Object Management Group, 2011). 3.2 General Findings Seven out of eight use cases demonstrated that Direct improves efficiency. Most participants were in the early stages of adoption of Direct and were excited about current uses as well as anticipating increased use as the pool of participants expands. All participants preferred Direct to paper-based exchange by fax or personal transport and noted increased confidence in security (i.e., assurance of vetted recipient), efficiency (i.e., eliminating phone tag and repeated faxes), and completeness of documentation through attachment of files rather than incomplete fax transmissions. Many described a personal commitment to assist their state in furthering adoption by recruiting more participants through individual contact and through presentations at professional meetings. If satisfying the needs of end users is the acid test for measuring the utility of valued goals in HIE (Acker et al., 2007), the Use Case participants in this study validate the utility and usefulness of Direct. Although each Use Case dyad is unique, all but one participant demonstrated that the adoption of Direct can improve the efficiency of the organization without creating difficulties or disrupting the workflow within the organization. The one exception was a paper-based organization that had to add a workflow step to scan documents prior to sending the attachments via Direct. Despite this additional step, the efficiency of PHI exchange between the two organizations in the dyad was improved. In addition, this organization corroborates the use of Direct for practices without an EHR. 3-3

14 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island Adoption of Direct proved to be beneficial for exchange of information within organizations and systems as well as across separate organizations, providers, and agencies. Though our observations focused on interorganizational exchange, many participants stated that communicating within their organization via Direct improved security and efficiency and, thereby, the care process. Adoption and implementation of Direct provides efficiencies in transmission of PHI with minimal change in workflow, financial, or technical investment. The Use Cases demonstrate that adoption and implementation of Direct to transport PHI does not radically change workflow and requires minimal financial and technical investment for physicians and other providers. Organizations did not track the exact financial costs, in part, because of the ease of switching from fax to Direct without substantial financial investment. No office was required to purchase new or additional technology, obtain Internet access, or significantly change staff assignments or work processes. Two Use Cases were unique in reducing costs in staff time due to prior in-person delivery of records between the entities; however, the exact costs and time were not monitored. In accompanying tables for each Use Case, we present the benefits and challenges mentioned in discussions while observing the use of Direct. No participants expressed dissatisfaction with adoption and implementation. The one functionality described as a future benefit yet to be obtained is the direct integration of information from Direct into EHRs. Currently, for the participants in our study, sharing across organizations requires the participants to add documents to the EHR, typically in PDF format. The integration of Direct with EHRs depends on the interoperability standards and technical vocabularies established by vendors, which are not addressed by Direct standards. However, the requirement for EHR vendors to integrate Direct to be certified for Stage 2 Meaningful Use is reason for optimism. Although uses of Direct include physician and clinical provider communication, responsibility for transport of PHI documents generally resides with staff as it does in existing models using fax and regular mail. Thus, an advantage of Direct is that electronic transmission provides more efficient, timely access to clinical data for physicians while existing clinical work patterns are not changed. 3.3 Benefits of Direct: Examples of Cost Savings and Other Benefits Most of the sites observed during the course of this study reported benefits that were attributable to the implementation of Direct. While broad generalization is difficult due to the size and scope of the project, some of the health care practices being observed were able to extrapolate from these preliminary results to estimate the potential benefit they would derive from full implementation of Direct. Note that these estimates are drawn from practices that displayed significant differences and were in varying stages of incorporating Direct into their workflows. The estimates are minimum amounts and can be expected to increase with the addition of more exchange partners. For example, at the site in Alabama, 3-4

15 Section 3 Use Case Observations the number of staff using Direct represented only 20% of potential users. Increasing this depends in part on adoption of Direct by the practices with which they exchange health information. Consequently, the research team often heard anecdotal reports of efforts by staff in the study sites encouraging their exchange partners to adopt Direct. Table 3-2. Cost Estimate for Alabama Dyad 1 Cost Savings Parameter Frequency Time Cost Savings Estimated Yearly Savings Eliminate upload of documents to ADPH 35 patients by nursing/month hours (.125/patient) $206.46/ month $2,478 Eliminate upload of documents to ADPH 17.5 patients by receptionist/month hours (.125/patient) $46.40/ month $557 Total Monthly Total Yearly $ $3,035 Table 3-3. Cost Estimate for Florida Dyad 1 Cost Savings Parameter Frequency Time Cost Savings Estimated Yearly Savings Personal pick-up of referral documents 2.5 times/week 1.25 hours (.5 hrs./pick up) $26.61/week $1,384 Table 3-4. Cost Estimate for Florida Dyad 2 Cost Savings Parameter Frequency Time Cost Savings Estimated Yearly Savings Avoidance of telephone tag 125 children/month hours (4 5 min/call) $560/month $6,720 Eliminate sensitive document hand delivery 125 children/month hours $420/month $5,040 Total Monthly Total Yearly $980 $11,

16 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island Table 3-5. Cost Estimate for Illinois Dyad 1 Cost Savings Parameter Frequency Time Cost Savings Eliminate patient chart hand delivery Estimated Yearly Savings 1 trip/week 1.5 hours $28.32/week $1,472 Cost Savings Parameter Frequency Miles Cost Savings Estimated Yearly Savings Travel costs 1 trip 11/week $6 $312 Total Weekly Total Yearly $34.62 $1,784 Table 3-6. Cost Estimate for Rhode island Dyad 1 Cost Savings Parameter Frequency Time Cost Savings Estimated Yearly Savings Avoidance of telephone tag 5.5 patients/week.733 hours (8 min./patient) $16.87/week $878 Beyond estimated cost savings, the sites offered other insights into how the use of Direct had benefitted their practice. The Florida dermatology surgery practice manager explained how photographic images were king in dermatology (i.e., fundamental to the diagnosis and treatment of dermatological conditions), and that Direct made it simple to share these images with referring practices. The site quality manager in Alabama pointed out that Direct did not alter the quality of patient care while decreasing the amount of time staff spent collecting required information. Extra hours staff spent in the past collecting required information was no longer needed when using Direct, thus the net benefit must include improved professional job satisfaction. Other advantages of Direct that were cited included getting patient information in a predictable and timely manner, which is important in order to avoid unneeded hospitalization of patients because crucial health data is unavailable. From the provider or medical support staff perspective, Direct enables asynchronous and secure communication, allowing those staff to share and access information at the time most effective for workflow and individual schedules. The primary obstacle to increased use of Direct is the absence of more pervasive use of Direct among health information trading partners. Because of the number of benefits of using Direct that accrue to practice managers, practice managers may be an important resource for the promotion of Direct, and promotion efforts should focus on practice management professional organizations and meetings. 3-6

17 4. ALABAMA 4.1 Overview of Alabama Direct Implementation and Adoption The state of Alabama has implemented Direct through the state HIE system, One Health Record, and provides an authoritative participant directory. The One Health Record Web portal is available to registered providers for sending and receiving records point-to-point consistent with national Direct standards. The dyads identified for observation in Alabama focused on organizations that had recently joined the network (less than 1 2 months of participation), and thus, demonstrated the ease of adoption and early success. Participants expressed confidence in the system and positive anticipation of expanded connections and uses. Dyad 1 has experienced more efficient and timely case management referral and follow-up and is experimenting with using Alabama Summary Findings Direct to manage the transportation requests for More efficient and timely case clients and delivery of medical supplies, e.g., management referral and follow-up glucose test strips. Dyad 2 was just getting off the ground by sending test messages between various treatment agencies and for notifications with the state Department of Mental Health. Table 4-1 provides the first quarter 2013 numbers for adoption and transaction numbers for Direct (ONC, 2013) Table 4-1. Adoption Metrics: State of Alabama Adoption Metrics Number Number of clinical and administrative staff enabled for Direct exchange 484 Number of organizations actively participating in Direct 43 Number of ambulatory entities actively participating in Direct 1 Number of acute care hospitals actively participating in Direct 1 Number of nonhospital clinical laboratories actively participating in Direct 0 Other health care organizations actively participating in Direct exchange 25 Number of transactions Dyad 1: Case Management (Two Scenarios) Dyad 1 provides two Use Case scenarios that are linked to case management for chronic care patients. The participants use Direct to monitor and audit the provision of care and are 4-1

18 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island also incorporating Direct in the provision of transportation and delivery of medical supplies to these same clients. The participants and their roles are described in Table 4-2. Table 4-2. Participants and Roles of Alabama Dyad 1 Use Case Participant Private case management organization with contract for Medicaid case management services (A) State Department of Public Health (B) Role Provides case management for Medicaid clients and coordinates with Department of Public Health to follow up with clients not receiving indicated care (Scenario 1). The transportation coordinator also incorporates Direct client assistance in arranging client transportation and/or delivery of needed medical supplies (Scenario 2). Case managers follow up on referrals and assure appropriate care is provided (Scenario 1). They also interact to arrange transportation of clients and/or delivery of medical supplies to clients (Scenario 2) Dyad 1, Scenario 1 Use Case: Private case management contractor reviews care provided to Medicaid clients, primary those with chronic conditions, within a Medicaid patient medical electronic data exchange to ensure patients are receiving appropriate care. Referrals are sent to case managers at the State Department of Public Health to follow-up. Follow-up is monitored and audited. Highlights of Direct Use: Direct is used in conjunction with Alabama Medicaid patient medical electronic data exchange demonstrating the potential of interactions between the push approach of Direct with the pull approach from a centralized medical record system. A single Direct replaces a tedious loop of phone-tag that could last several hours or days for referrals as well as audits. Case managers immediately have more detailed and current information, which improves the timeliness of their follow-up and coordination with clients. This Use Case describes the referral and follow-up process for Medicaid clients in eastern Alabama. Figure 4-1 illustrates this scenario. The private case management organization (A) uses the Medicaid patient medical electronic data exchange to identify patients who are not receiving recommended medical care as indicated by their medical histories and diagnoses. The case management organization (A) notifies the supervisors and contacts the appropriate case manager (B) with patient information that details follow-up needs. The case manager (B) follows up with clients and 4-2

19 Section 4 Alabama enters follow-up information into the data exchange system. The case management organization (A) audits the follow-up through the data exchange system. If the audit identifies concerns, the case management organization (A) communicates with the case manager supervisor (B) to discuss audit findings or needed follow-up. Figure 4-1. Alabama Dyad 1 Pre- and Post-Direct Information Transfers (Scenario 1) Participant A sends follow-up case referrals to Participant B. Participant B receives follow-up referral, follows up with client, and records activity in statewide system. Participant A audits followup cases in statewide system and sends out audit reports for incomplete follow-up cases. Pre-Direct Step 1 Phone calls (one to several) to reach case manager for detail follow-up needs. Step 2 Receives information and records on paper client names and needed follow-up. Completes follow-up and records in statewide system. Step 3 Audits system and drops off paper copy of audit report to the case manager s supervisor and may also make multiple phone attempts to follow up. Post-Direct Step 1 Step 2 Direct detailing client follow-up needs sent to supervisor and case manager one click, one attempt. Detailed information received via Direct . Completes follow-up and records in statewide system. Step 3 Direct to supervisor and case manager to detail any incomplete cases. Time Savings Improvements The adoption of Direct allows the Medicaid case management and Department of Public Health supervisors and case managers to communicate asynchronously, which eliminates phone tag and numerous phone calls. Although the time saved cannot be precisely calculated (because phone tag consumes varying amounts of time), the participants believe they saved hours of time; and synchronous connection time may have stretched these hours across several days. For this case study, cost savings for one exchange partner were estimated at approximately $3,035 (see Table 3-2). 4-3

20 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island In addition, the patient data exchange system allows the care to be documented, and then audited, without additional communications back and forth between the organizations. Additional communication is only required if the audit identifies concerns. The complementary approaches allow more timely and improved coordination of care. The participants believe that the result will be improved quality of care and health status. Participants noted that Direct is as easy as a click. The adoption and implementation were as easy as a regular system and, the similarity to regular virtually eliminated any learning curve. Direct allows case managers to be informed of referrals more quickly and with more detailed information. Anticipated future uses include Direct communication with physicians outside the Department of Public Health. Challenges/Opportunities Direct is new and case managers are not in the habit of checking the Direct system for . Currently, an is sent through a non-secure system alerting users to check their Direct account. Direct does not currently allow sharing of large files. With large files, the case management organization must separate the larger file into smaller files and send each of the smaller files in separate Direct s. Participants want to send group s and/or forward Direct s, for instance, allowing one to be sent to the case manager with a cc to the supervisor Dyad 1, Scenario 2 Case managers from the Department of Public Health (Participant B) send a request for transportation to the transportation coordinator of the private Medicaid case management organization (Participant A), who then coordinates the details for client pickup/drop-off or the delivery of medical supplies, e.g., glucose test strips. Highlights of Direct Use A single Direct replaces a tedious loop of fax and phone-tag that may consume hours of time. This Use Case describes the coordination of transportation for clients and/or the delivery of needed medical supplies. Before Direct was adopted, Department of Public Health case managers faxed a request to the transportation coordinator who would make the arrangements and then spend time making attempts to call the case manager with the details. After Direct adoption, the requests are currently still faxed; however, the transportation coordinator can now use Direct to send the details to the case manager thereby eliminating the inefficiency of numerous phone calls to connect. Figure 4-2 depicts an overview of this process. 4-4

21 Section 4 Alabama Figure 4-2. Alabama Dyad 1 Pre- and Post-Direct Information Transfers (Scenario 2) Participant B sends request for client or supplies transportation to Participant A. Participant A makes arrangements and sends details to Participant B. Participant B notifies client of delivery or transportation details. Location A provides transportation or delivery. Pre-Direct Step 1 Case manager faxes request for transportation or delivery of medical supplies to Participant A. Step 2 Transportation coordinator makes arrangements and then makes phone calls until he/she reaches case manager. Step 3 Case manager notifies client of specific transportation details.. Step 4 Transportation coordinator ensures transportation or delivery as agreed. Post-Direct Step 1 Step 2 No Change Transportation coordinator makes arrangements and then logs into Direct and sends details to case manager. Step 3 No Change. Step 4 No Change. Time Savings Improvements The adoption of Direct allows the transportation coordinator to communicate arrangement details for pickup of clients or delivery of medical supplies to case managers asynchronously, which eliminates phone tag and numerous phone calls. Although the time saved cannot be accurately estimated (because phone tag consumes varying amounts of time), the participants believe they saved hours of time. In addition, the secure provides an accurate record of the details. These details were sometimes lost and/or misunderstood and/or incorrectly noted when the telephone was used. Challenges/Opportunities The use of Direct is so recent that two s must currently be sent: the Direct with the information and a non-secure alerting the case manager to access Direct. 4-5

22 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island The request for transportation or medical supplies is still transmitted by fax. The organization would like to develop an electronic form for the requests to be sent through Direct for further efficiencies. However, they also need to be able to forward or cc s simultaneously. Participants want to send group s and/or forward Direct s. If the transportation coordinator was on vacation or ill, no one would receive the request. In the current process, someone else in the office can access the faxes from the fax machine and ensure that the requests are handled. 4.3 Dyad 2: Monitoring Mental Health Treatment This Use Case illustrates the monitoring of treatment of clients who are supervised by the state Department of Mental Health (DMH) within a five-county area in southern Alabama. A regional mental health center manages treatment and transfers to varying levels of treatment facilities and provides status updates to the DMH. The adoption of Direct for this Use Case was still in progress at the time of observation and the organizations had been registered with One Health Record for less than a month. Although we summarize the current pre-direct processes and the expected use of Direct, exchange of messages was still in the testing phase of implementation; therefore, the benefits, improvements, and challenges/opportunities are anticipated rather than currently realized. The participants and their roles are described in Table 4-3. Table 4-3. Participants and Roles of Alabama Dyad 2 Use Case Participant Role Local mental health center (A) Receives notification from court system and evaluates client to determine initial level of treatment center. Manages the treatment of mental health services that often includes transitioning through various levels of facilities in alignment with client progress. Notifies the state Department of Mental Health of all client transfers between facilities. Intermediate mental health facility (B) State Department of Mental Health (DMH) (C) not observed Receives referral and treatment records. Treats patient. Send treatment records to new facility for patients transferred to next level of treatment. Receives notification of all client transfers between facilities. 4-6

23 Anticipated Benefits of Direct Use: Section 4 Alabama Lengthy forms and records accompanying client transitions to treatment centers will be easily entered into system records, which will eliminate paper records (that can be 60 pages or more). Data will no longer need to be reentered into electronic records (date will be replaced with an attachment). Notifications to DMH will more be efficient. The transmission of PHI will improve. This Use Case describes the coordination of care to individuals who, by court order, are placed in DMH care. A local mental health center (A) evaluates initially, then continues to oversee treatment and assist in transferring patients between facilities as client progresses (B). The regional liaison to the state (A) notifies the DMH (C) of client status and all facility transfers. Figure 4-3 summarizes this Use Case. Figure 4-3. Alabama Dyad 2 Pre- and Anticipated Post-Direct Information Transfers Participant A sends referral to Participant B and notification to Participant C. Participant B receives referral and treats patient. Participant A notifies Participant C. Location B transfers or discharges patient from system. Participant A notifies Participant C of patient status. Pre-Direct Step 1 Phone calls to reach appropriate individuals and faxing of records to Communication to Participant B. Phone calls and fax to notify Participant C. Step 2 Participant B receives lengthy paper record via fax. Participant C receives notification of patient status. Step 3 Participant B either phones and faxes transfer or discharges. Participant A notifies Participant C by phone and/or fax. Post-Direct Step 1 Step 2 Step 3 Time Savings All referrals, transfers, and treatment records sent via Direct to Participant B. Participant A notifies Participant C via Direct. Participant B receives referral and treatment records via Direct and attaches it to electronic recorded. Participant A notifies Participant C via Direct Participant B uses Direct for transfer or discharge communications. Participant A notifies Participant C via Direct. 4-7

24 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island Anticipated Improvements The adoption of Direct should reduce the use of paper and toner because treatment records in behavioral health settings are typical very long. In addition, the use of Direct should improve the accuracy and completeness of records sent. Electronic files will eliminate mishaps with paper jams and multiple fax pages, which can result in incomplete records that must then be retransmitted, incurring the expense of staff time, paper, and toner Challenges/Opportunities The connection with the state DMH has not yet been successful because the liaison responsible for sending notifications has been unable to find intended recipients in the service s directory. Direct is not yet integrated into workflow, which creates the need for phone or nonsecure to alert recipients of need to check Direct. 4-8

25 5. FLORIDA 5.1 Overview of Florida Direct Implementation and Adoption The state of Florida has implemented the Direct messaging service (Direct Secure Messaging) for sending records point-to-point consistent with national Direct standards as a component of Florida HIE. The secure messaging service is accessed through a central portal and includes an authoritative participant directory. The dyads identified for observation in Florida demonstrate the functionality of Direct for physician referral of patients for specialized care in alignment with the Direct Project s User Stories plus its functionality beyond traditional health care scenarios. Direct provides a unique service for social service agencies and school systems that require client/student PHI as well as other types of information that are protected by FERPA guidelines. Table 5-1 provides the first quarter 2013 adoption and transaction numbers for Direct (ONC, 2013). Florida Summary Findings Saves printing and transportation costs Provides functionality beyond traditional health care scenarios Table 5-1. Adoption Metrics: State of Florida Adoption Metrics Number Number of clinical and administrative staff enabled for Direct exchange 2,727 Number of organizations actively participating in Direct 468 Number of ambulatory entities actively participating in Direct 64 Number of acute care hospitals actively participating in Direct 4 Number of nonhospital clinical laboratories actively participating in Direct 0 Other health care organizations actively participating in Direct exchange 30 Number of transactions 3, Dyad 1: Dermatology Specialty Referral Use Case: A patient is referred for specialized skin cancer surgery between two dermatology practices. The participants and their roles are described in Table

26 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island Table 5-2. Participants and Roles of Florida Dyad 1 Use Case Participant Role Dermatology practice (A) 1. Practice determines need to refer patient for specialized surgery, prepares referral documents, arranges delivery to Participant B. 2. Once patient receives treatment from Participant B, administrative staff receives treatment record and updates the EHR. Dermatology surgeon (B) 1. Physician receives referral documents from Participant A. 2. Physician treats patient and updates the EHR accordingly. 3. Administrative staff delivers the treatment record to Participant A. Highlights of Direct Use Benefits: Initiating a referral and receiving the treatment report are performed more efficiently in digital form and do not require printing and/or photocopying records. Fewer resources are used for printing. Staff time is saved no need to hand-carry referral documents, eliminating transportation time. Direct exchange provides greater security than hand-carry transfer of documents. This Use Case illustrates the referral of a patient for specialized skin cancer surgery between two dermatology practices. The referring dermatology practice (Participant A) prepares a package of all referral documents for Participant B. Once surgical treatment and follow-up are concluded, Participant B delivers treatment record to Participant A. Figure 5-1 depicts an overview of this process in three steps Improvements Initiating a referral and receiving the treatment report are performed more efficiently through a digital exchange using Direct. Prior to Direct, the referral process required printing for transport of hard copy (paper records) to Participant B and scanning the returned treatment report into the patient record. The use of Direct is saving significant staff time (less scanning and printing) and supplies (paper, ink). Second, prior to Direct referral, documents between Participant A and Participant B had been transported and hand-carried by staff from Participant B (in both directions) which took considerable staff time. After Direct, the hand-carry process is no longer required and resulting in time savings for both offices. The use of Direct provides a more secure, reliable, and efficient method than taking documents from one building to another. For this case study, cost savings for one exchange partner were estimated at approximately $1,384 (see Table 3-3). 5-2

27 Section 5 Florida Figure 5-1. Florida Dyad 1 Pre- and Post-Direct Information Transfers Participant A creates referral with medical care, demographics, pathology, and images for Participant B. Participant B receives referral, treats patient, and sends a record of treatment to Participant A. Participant A receives treatment record. Pre-Direct Step 1 Administrative staff prints paper referral and attachments from EHR for in-person pickup by staff from Participant B. Step 2 Administrative staff scans referral documents into the EHR. After patient is treated, administrative staff prints the record and hand delivers Step 3 Treatment record is received and recorded in EHR. Post-Direct Step 1 Step 2 Step 3 Time Savings Administrative staff exports referral and attachments from EHR to PDF and attaches to Direct to Participant B. Administrative staff imports referral documents into patient EHR record. Administrative staff creates Direct message to transmit treatment report. No Change Challenges/Opportunities A larger network of subscribers is needed because the current number is limited; therefore, benefits and improvements are limited. The ability for full integration of Direct with EHRs integration of Direct with practice EHRs would significantly improve the practice s workflow. Direct is currently not available to certain nonclinical agencies and organizations that use PHI. More benefit could be gained with an extended network. 5-3

28 Use Cases Demonstrating the Utilization of Direct in Four States: Alabama, Florida, Illinois, Rhode Island 5.3 Dyad 2: Public School System Referral for Special Needs Children This Use Case from Southwest Florida focuses on exchange of PHI between a social service agency that provides early intervention for special needs children and the county school system. The participants and their roles are described in Table 5-3. Table 5-3. Participants and Roles of Florida Dyad 2 Use Case Participant Social service agency that provides early intervention for special needs children (A) County school system (B) Role Transfers a child s records to the school system Assess the child s eligibility for services Highlights of Direct Use: Direct assures timely receipt of documents impacting eligibility for services. Direct is a huge-timer saver as it eliminates the need to repeatedly fax requests and play phone tag to obtain documents needed to qualify a child for special education. This improvement in communication has a major impact because a strict deadline for receipt of documents is imposed by the child s third birthday. If delays are encountered due to phone tag or incomplete faxes, the child s eligibility for the Individual Education Plan (IEP) program may be in jeopardy The availability of documents in digital format allows easy searching, sorting, and other digital manipulation that is not possible with paper-based documents. Removing the use of fax ensures that the correct person receives PHI for children requiring special services. Direct eliminates the need for an individual to personally deliver sensitive information. The school system can directly upload information into the IEP system rather than having to scan it first. This Use Case from Southwest Florida illustrates how Direct can be used beyond health care systems to communicate with other agencies and organizations that require PHI and transmit other protected information. The Use Case observation focused on exchange between a social service agency that provides early intervention for special needs children and the county school system. As an early intervention provider, Participant A serves children only to age 3, when a child is referred to the school system for an IEP. The two participants exchange documents needed to establish eligibility for IEP services. 5-4