Direct Messaging. February 28, 2014

Direct Messaging February 28, 2014

2 Agenda Direct 101 (p. 3) o o o o o o Definition Safeguarding PHI Identifying the need for Direct Solution to achieving MU2 Measures Direct Use Cases Basic Direct workflow Direct 201 (p. 17) o o o Obtaining Direct for your organization How can your RHIO help? Questions for your EHR vendor o Direct workflow 201 Direct 301 (p.28) o o HISP Security certification provisions o Workflow 301 Frequently Asked Questions (p. 31)

DIRECT 101 3

What is Direct Messaging? Direct: specifies a simple, secure, scalable, standards-based mechanism that enables participants to send encrypted health information directly to known, trusted recipients over the Internet. Simply put, Direct virtualizes clinical data across healthcare organizations using disparate EHRs. 4

How is PHI Safeguarded in Direct Communication? There are policy and technology guidelines to guarantee the safety of Protected Health Information (PHI) in Direct messaging Policy o Supports various policy frameworks that might exist across organizations o Ensures information is kept confidential during transit o The sender is responsible for making the determination that it is clinically and legally appropriate to send the information to the receiver o Clinician-to-Clinician communication does not require consent Technology o Enables message handling trust between participants o Verifies the identity of a sender when information is sent and received o The sender and receiver have ensured that their choice of technology is authorized to handle PHI according to law and policy. Source: http://wiki.directproject.org/direct+project+security+overview 5

Why is Direct Communication Needed? o A Transition of Care (TOC) is when a patient moves from one care setting to another Hospital to home PCP to Specialist and back o Patients frequently transition across care environments o Physician to physician TOC communication is sub-optimal (1) Hospital Discharge 1st Post discharge PCP visit ~ 75% no information about the hospitalization (2/3) PCP to Specialist and back PCPs report sending information 70% of time; specialists report receiving the information 35% of the time Specialists report sending a report 81% of the time; PCPs report receiving it 62% of the time 25%-50% of referring physicians did not know if patients had seen a specialist 1. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8):831-41. 2. O Malley, A.S., Reschovsky, J.D. (2011) Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med, 171 (1), 56-65. 3. Mehrotra, A., Forrest, C.B., Lin, C.Y. (2011). Dropping the Baton: Specialty Referrals in the United States. The Milbank Quarterly, 89 (1), 39-68. 6

Frequent Transitions of Care The typical PCP has to coordinate care with 229 other physicians working in 117 practices (Pham et. al., Ann Int Med. 2009) Average Medicare patient sees seven different physicians and fills upwards of 20 prescriptions per year (Partnership for Solutions, Johns Hopkins Univ. 2002) Among the elderly, on average two referrals are made per person per year (Shea et al. Health Service Research, 1999 ) In the nonelderly population, about one in three patients each year is referred to a specialist (Forrest, Majeed, et al. BMJ 2002) Visits to specialists constitute more than half of outpatient physician visits in the United States (Machlin and Carper, AHRQ, 2007) Copyright, 2013, TIPA/HVI, Not for Distribution Source: Holly Miller, MD, not to be used without express permission

Adverse Events Frequent TOC with poor communication results in adverse events 8

Most Frequent Adverse Events (AE) Most frequently occurring AE Medication errors Most frequent category of root causes for serious AE Ineffective communication Most vulnerable parts of a process The hand offs * *Greenes, R. (2007). Clinical Decision Support: The Road Ahead. New York, NY: Elsevier, Inc. 9

Referral Communication Deficits Consulting Specialists o 68% of specialists reported that they received no information from the PCP prior to specific referral visits o 38% of these said that this information would have been helpful PCP o 4 weeks after specific referral visits, 25% of PCPs had still not received any information from specialists J Gen Intern Med. 2000 Sep;15(9):626-31. Communication breakdown in the outpatient referral process. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW.Source Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA

Direct Messaging and Meaningful Use Stage 2 You Are Almost Here Stage 3 Improved Outcomes Improved Quality of Care Stage 1 Advanced Clinical Processes Data Capture and Sharing 11

MU2- Core Objective (Measure 12 of 16)- Hospitals MU2- Core Objective (Measure 15 of 17)- Providers Objective: The eligible hospital who transitions their patient to another setting of care provides a summary care record for each transition of care Measure 1 Measure 2 The eligible hospital or CAH that transitions or refers their patient to another setting of care of provider of care provides a summary of care record for more than 50 percent of transition of care and referrals 10% of all transitions of care must transmitted either a) electronically via a CEHRT technology or b) where the recipient receives the summary of record via exchange facilitated by an organization that is an exchange participant or in a manner consistent with the ONC guidelines for the nationwide health information network. 12

Solution to Achieving MU2 Measures Direct is specifically designed to allow electronic exchanges of summary of care records o The capability is built directly into your MU2 certified EHR o Direct enables information exchange across disparate EHR vendors helping you achieve MU2 requirements EHR A Direct EHR B 13

What is the Value-Add of Direct? Provides critical patient information at TOC consistent with established provider EHR workflow Enhanced clinical communication anticipated to decrease adverse events and greatly improve healthcare delivery and integration Patients can receive sensitive information securely directly from their provider There are no geographical or technological boundaries for providers to exchange messages 14

Direct Workflow: Hospital Discharge For all transitions or referrals, at least two providers and settings must be involved in a specific patient s care. Discharge Note to PCP Direct Hospital Primary Care 15

Direct Workflow: Closed Loop Consultation For all transitions or referrals, at least two providers and settings must be involved in a specific patient s care. PCP sends referral to specialist Direct Primary Care Specialist sends continuity of care document back to PCP once patient has been seen Specialist

DIRECT 201 17

Step 1 Consult with your RHIO to discuss connecting your organization on the direct network o Direct becomes truly useful when groups of partners are online Step 2- contact your EHR vendor How Do I Get Direct For My Organization? o Organization must specify that they re looking for MU Stage 2 version that is Direct capable o Ask about when EHR vendor will schedule your site for an upgrade to Direct capable version. National initiative=long upgrade queues. o Find out for yourself if your EHR vendor has received certification for a MU2 version (Direct-ready) : http://oncchpl.force.com/ehrcert?q=chpl Step 3 Fully understand the pricing to enable Direct for your organization as well as the workflow implications 18

Step 1: How Can My RHIO Help? Your RHIO plays a pivotal role in implementing Direct The local RHIO offers a number of Direct options through various vendors (the NYeC Direct solution [aka the NYeC HISP], Surescripts, Mirth, etc.) NYeC offers a capability for EHRs to connect to its Direct network NYeC Direct services are available for RHIOs to offer to their members 19

NYeC Integrations Vendor Vendor Product Product Version Status Etransmedia Direct Care Coordinator v1.0 COMPLETED Siemens Soarian v3.2 COMPLETED Epic Care Everywhere/CareElsewhere v2012 COMPLETED Meditech Meditech v6.x COMPLETED NextGen NextGen Ambulatory v5.8 COMPLETED Mirth Mirth Mail N/A COMPLETED Meditech Magic and Client Server products v5.x COMPLETED Meditech LSS N/A COMPLETED Cerner Cerner HISP N/A COMPLETED Surescripts Surescripts HISP N/A COMPLETED Athenaheatlh Athenahealth N/A COMPLETED ManaHealth For a full list of vendors and organizations, Portal please visit: http://oncchpl.force.com/ehrcert?q=chpl TBD IN PROCESS 20

RHIO Direct Availability Status to Date RHIO EHR Based Option Availability Non-EHR Option Availability Bronx ehnli HealtheConnections (HeC) HEALTHeLINK (HeL) Healthix In vendor selection stage NYeC HISP Available - requires pricing/contract agreements RHIO recommends using the EMR's secure messaging functionality and/or the integrated use of HeC's HISP service. Dependent on EMR's capability and/or if using HeC HISP, it's available now. NYeC HISP Available - requires pricing/contract agreements NYeC HISP Available - requires pricing/contract agreements Not available HeC's HISP service Mirth Mail is part of the Mirth HIE solution. Not available Direct Enabled Clinical Inbox N/A Available to all HeC Participants N/A Q4 2014 21

RHIO Direct Availability Status to Date RHIO EHR Based Option Availability Non-EHR Option Availability HIXNY Interboro Rochester STHL THINC NYeC HISP, SureScripts, Other Available - requires pricing/contract agreements NYeC HISP Available - requires pricing/contract agreements Rochester RHIO HISP Available to particpants at no charge NYeC HISP Available - requires pricing/contract agreements NYeC HISP Available - requires pricing/contract agreements HIXNY HISP Available - requires pricing/contra ct agreements. Direct Enabled Clinical Q4 2014 Inbox Direct Enabled Clinical Inbox Direct Enabled Clinical Inbox Direct Enabled Clinical Inbox Available to participants at no charge Q4 2014 Q4 2014 22

Step 2: What do I ask my EHR vendor before the upgrade? When will the upgraded EHR version be available for my organization? What technology requirements should be in place before you upgrade? What is the timeframe required to transition from existing version to new? Is the new version Direct enabled? Find out yourself: http://oncchpl.force.com/ehrcert?q=chpl What are the training requirements for the EHR implementation upgrade? What are the reporting capabilities built into the EHR that help me calculate MU2 measures? 23

Step 2: What do I ask my EHR vendor before the upgrade? Ensure that the EHR (or the organization) has a plan to accurately calculate the ToC Measure #2 Numerator & Denominator Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP or eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) was the transferring or referring provider. Numerator: The number of transitions of care and referrals in the denominator where a summary of care record was a) electronically transmitted using CEHRT to a recipient or b) where the recipient receives the summary of care record via exchange facilitated by an organization that is an ehealth Exchange participant. The organization can be a third-party or the sender s own organization. Source: ONC Webinar: Understanding Meaningful Use (MU) Stage 2 Transitions of Care (TOC) Measure 2 Calculation: Focus on Query-based Exchange (Jan 17, 2014) 24

Step 2: What do I ask my EHR vendor before the upgrade? Two 2014 Edition EHR certification criteria: 170.314(b)(1) : Transitions of care receive, display, and incorporate transition of care/referral summaries. 170.314(b)(2) : Transitions of care create and transmit transition of care/referral summaries. 25

Step 2: What do I ask my EHR vendor before the upgrade? To pass certification: My EHR technology developer must demonstrate that its EHR technology can: My EHR technology developer can also voluntarily demonstrate that its EHR technology can: 1) Create a CCDA with required MU data 2) Send the CCDA according to Direct 1) Send according to Direct + XDR/XDM 2) Send according to SOAP + XDR/XDM I must have EHR technology that s been certified to: 1) Create a CCDA with required MU data 2) Send the CCDA according to Direct To demonstrate Meaningful Use ToC Measure #2: I may electronically send a CCDA in following ways for it to count: 1) Send ( push ) a CCDA via my CEHRT using Direct 2) Send ( push )/Respond to query with a CCDA via my CEHRT using SOAP + XDR/XDM (if certified) 3) Send ( push ) to/respond to query via an ehealth Exchange participant (or under certain circumstances and HIO/HIE) with a CCDA created by my CEHRT Source: ONC Webinar: Understanding Meaningful Use (MU) Stage 2 Transitions of Care (TOC) Measure 2 Calculation: Focus on Query-based Exchange (Jan 17, 2014)

Direct Workflow- 201 Technical Upgrade to MU2/ Direct Enabled version EHR connectivity to Direct network or enabling Direct capability within EHR Direct EHR B ORG EHR A DIRECT EHR C (1) Contractual (2) RHIO (3) Cost $(1)+$(2) +$(4) = $? OR $(1)+(3)+$(4) = $? # of Direct Addresses # of Direct Addresses (1) Cost to upgrade to EHR with Direct capability (2) Cost to join Direct vendor (3) Cost to obtain Direct via RHIO (4) Other recurring charges (per user fee, per message fee, etc.) 27

DIRECT 301 28

A HISP is in charge of performing a number of services required for the exchange of health information. These services may be handled by a third party or by the sender/receiver. o Provider Direct Addresses (looks like an e-mail address) o Route encrypted messages What is a Health Information Service Provider (HISP)? o Arrange for identify verification org and individual o Arrange for digital certificate issuance management o Maintain integrity of trust and security framework o Stay current with federal policies and regulations 29

Direct Trust: HISP-to-HISP Communications IT S ALL ABOUT TRUST! o Supports the creation of best practices to which Direct HISPs and Direct Health Identity Providers (CAs and RAs) would agree in the context of a given community of Direct users/subscribers. To ensure the sender and receiver of PHI are who they who they say they are means connecting to an Accredited HISP is important (EHNAC.org) Decreases the risk of sending or receiving PHI to the wrong person Basic trust is inherent in the design of Direct via a robust accreditation process There are no technical constraints that prohibit HISPs from recognizing and sending data to Direct participants getting services from other accredited HISPs. 30

Digital Security Issuance Registration Authority (RA) o Collects information for the purpose of verifying the identity of an individual or organization (i.e., identity proofing) o Produces certificate requests based on gathered attributes Certificate Authority (CA) o Digitally signs certificate requests o Issues digital certificate that ties a public key to the gathered attributes EHNAC Certification o Promotes standards-based accreditation for HISPs 31

Peeling the Direct Onion HISP to HISP connectivity allows for the ecosystem to connect Other HISP EHR B ORG TLS/Mutual Auth Connection between EHR and HISP EHR A DIRECT (Health Information Services Provider aka HISP) Provider Directory A Provider Directory is maintained at the HISP level EHR C Provider Org or the RHIO can establish a trusted agent relationship with the RA to perform the tasks RHIO Registration Authority (RA) Responsible for ensuring that users are adequately vetted 32

Frequently Asked Questions 33

Frequently Asked Questions Direct address- what does it actually look like? o Looks like an email address John.Smith@direct.healthfacility.org How many Direct addresses can I have? o An individual may have multiple Direct addresses based on their affiliations What does a Direct address domain look like? o Direct domain addresses can be provided by the HISP vendor or an organization may decide to purchase their own domain. How does New York ehealth Collaborative (NYeC) interact with other HISPs? o NYeC uses MedAllies as its software platform, which has tested with and can connect to any Accredited HISPs. 34

Frequently Asked Questions (Contd) If a provider is part of a directory, but a corresponding physician/practice does not have an EHR, can they still securely send messages? o There are several non-ehr or portal based Direct solutions available in the market that can be utilized by organizations that don t have EHRs. If the provider is not in the provider directory but has a direct address of their own, could I still send a message to this provider? o Yes- the EHR has a capability where the Direct address can be manually entered/imported before the message is transmitted. 35

Questions 36

Presenters Sudipto Srivastava Senior Director Product Marketing and Strategic Planning New York ehealth Collaborative ssrivastava@nyehealth.org Irina Vinokur Training and Implementation Manager New York ehealth Collaborative (NYeC) ivinokur@nyehealth.org 37