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Direct Messaging in North Carolina: Current Capabilities & Future Directions

November 4, 2015 Research Triangle Foundation

NCHICA Presents the 7th Thought Leader Forum

Presenters Dennis Andrison, IS Project Lead II, New Hanover Regional

Medical Center

Patty Lewis, Implementation Lead, Coastal Connect HIE

David C. Kibbe, MD, President & CEO, DirectTrust

Moderator Mary McCaskill, Health IT Manager, NC AHEC Program

North Carolina Area Health Education Centers

Direct Messaging • Direct messaging is

basically a secure email system

• The vision of a Direct-enabled healthcare system is to provide a secure healthcare network where all participants are verified and can securely communicate with anyone else within this network. This connectivity will empower clinicians, administrators and systems to securely share information. (http://h22168.www2.hp.com/docs/orion/RS971_Demystifying_DSM_WhitePaper.pdf )

http://h22168.www2.hp.com/docs/orion/RS971_Demystifying_DSM_WhitePaper.pdf

http://h22168.www2.hp.com/docs/orion/RS971_Demystifying_DSM_WhitePaper.pdf

North Carolina Area Health Education Centers North Carolina Area Health Education Centers

http://www.njhitec.org/services/direct/

Direct email address from the NCHIE looks like: [email protected]

http://www.njhitec.org/services/direct/

North Carolina Area Health Education Centers

Direct Messaging • Standard Use Cases

– Referrals between organizations – Discharge summaries sent to PCPs and

patients – Transmit Care Summaries – Secure provider to patient communications


Direct Messaging

Challenges: • Many implementations for each provider • Each EHR is different in the steps needed to

manage Direct within the EHR and in packaging information for sending via direct

• Not all HISPS talk to each other http://www.directtrust.org/member-list/

• No central provider directory

http://www.directtrust.org/member-list/


Best Practices Building a Community… 1. Improve communication- What does our internal team look

like? Who are our external partners? 2. Standardize processes- What does a preferred partner look

like? What does the workflow look like? How do we test Direct Messaging capabilities?

3. Establish accountability- What are the roles involved? What tasks are assigned to each role? What do we do when we encounter a problem?

4. Measure performance- How do we know we are on the right track?

5. Encourage strong care coordination- What resource allocations or policy and procedure changes are necessary?

Direct Messaging in North Carolina

Nov. 4, 2015 Dennis Andrison IS Project Lead II

NHRMC

• Based in Wilmington, NC and serving 7-county region in southeastern North Carolina (Pender, New Hanover, Brunswick, Onslow, Duplin, Columbus, Bladen)

• Regional referral center with: – Level II Trauma Center – Heart Center – Stroke Center – Women's & Children's Hospital – Orthopedic Hospital – Rehabilitation Hospital – Cancer Center – Neonatal, Pediatric and Adult Intensive Care – EMS

• Affiliated with NHRMC Physician Group (200+ providers) and Pender Memorial Hospital

• Teaching hospital affiliated with UNC School of Medicine • Third largest county-owned public hospital in the United States • ~ 550 Physician Staff • Licensed for 769 beds

Why Direct

• Comply with Meaningful Use Stage 2 metric for electronic transfer of SOC (summary of care documents)

• To improve care coordination for our patients

Implementation

• Concluded many surrounding Practices not

ready to electronically send SOC/TOC

• Partnered with local CCHIE

• Approximately three and a half month implementation

Lessons Learned

• NHRMC has two direct domains – Direct.nhrmc.org – Soc.nhrmc.org

• Incoming Direct messages had to be uniquely identified

• Many different ways to send a Direct message

• Testing

12

13

Success

Questions

14

Thank you for your time. [email protected]

910-667-7513

mailto:[email protected]

Direct Messaging in North Carolina

Patty Lewis Implementation Lead Coastal Connect HIE

Coastal Connect Current Footprint

Total Patients Since Inception: 4,051,703

• HIE to HIE Connection • 40 Counties • 84 Data Contributors – acute, ambulatory and commercial lab,

diagnostic center

Regional Interoperability

17

Solution Use Case

COMMUNITY HEALTH RECORD Access to data outside your own network: Reduction in duplicate testing and more timely diagnosis and completion of care plan .

Access to Acute Care Setting Documents – including ED: Community Practices have a full picture of acute setting care to provide appropriate follow up • Reduction in requests for documents to hospital HIM departments Clinical Inbox – results delivery

NOTIFY Alerting Unaffiliated Providers: Notifications are sent for emergency room and inpatient admissions and discharges for their patient population • Allowing for appropriate/timely follow up and in some cases intervention

during ED encounter

Alerting Hospital Care Team Members (non-provider): ER and other Case Managers are receiving readmission alerts on top utilizers

iNEXX Care Coordination Acute to Ambulatory: Electronic scheduling of ambulatory follow up appointment prior to discharge

NHRMC Community Dashboard

Community Health Record Utilization

.

In September, transition of care was supported for 5,076 unique patients!

0

1000

2000

3000

4000

5000

6000

Logins Unique Patients Accessed

From Sept 15 to Oct 15 – CCHIE Direct Secure 80 practices/ 6444 transition of care or referral documents Direct Trust 34 providers/ 780 messages As practices get their Direct Trust set up – CCHIE numbers will decline

Batish Family Medicine, Leland, NC [email protected] Dr. Weckel, Burgaw, NC [email protected] Wilmington Access for Teens, (WHAT), Wilmington, NC [email protected] Coastal Internal Medicine, Wilmington, NC Coastal.internal.medicine@direct.coastalinternal.nextgenshare.com [email protected] [email protected] Orthowilmington, Wilmington, Leland, Jacksonville, Supply, Southport, Sunset Beach, NC [email protected]




mailto:Coastal.internal.medicine@direct.coastalinternal.nextgenshare.com




Patient MCOne-One Zzzztest

Date of birth January 1, 1901

Sex Female

Race

Ethnicity

Contact info Primary Home: UNK WILMINGTON, NC 28401, USA Tel: +1-000-000-0000

Patient IDs 12294425 1.2.840.114350.1.13.298.2.7.5.737384.775029

Document Id 1.2.840.114350.1.13.298.2.7.8.688883.255988

Document Created: October 28, 2014, 13:43:14 -0400 Performer (primary care provider)

Author Epic - Version 7.9

Contact info

Encounter Id 207939056 1.2.840.114350.1.13.298.2.7.3.698084.8

Encounter Date at October 28, 2014

Encounter Location id: 14800 1.2.840.114350.1.13.298.2.7.2.688879

Document maintained by

New Hanover Regional Medical Center

Contact info 2131 S. 17th. St. Wilmington, NC 28401 Tel: +1-910-343-2498

Continuity of Care Document Table of Contents •Reason for Referral •Encounter Details •Active Allergies - as of 10/28/2014 •Medications - as of 10/28/2014 •Active Problems - as of 10/28/2014 •Social History - as of 10/28/2014 •Plan of Care •Procedures •Results •Visit Diagnoses

Interoperability Value

www.DirectTrust.org 1101 Connecticut Ave NW, Washington, DC 20036

David C. Kibbe, MD, MBA President and CEO, DirectTrust

Senior Advisor, AAFP November 4, 2015

http://www.directtrust.org/


Mission and Goals: DirectTrust

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DirectTrust.org, Inc. (DirectTrust) is a voluntary, self-governing, non-profit trade alliance of 150 organizations dedicated to the growth of Direct exchange at national scale, through the establishment of policies, interoperability requirements, and business practice requirements. DirectTrust operated under a two-year Cooperative Agreement with ONC, 2013-15, to support its work of creating a national network of interoperable Direct exchange services providers.

Security & Trust Framework

EHNAC-DirectTrust Accreditation Programs

Trust Anchor Bundle And Network Services



DirectTrust Network of Networks For Secure, Interoperable Exchange



About DirectTrust

• DirectTrust is a non-profit national industry alliance of 155 organizations that is actively supporting Direct exchange through policy setting, accreditation, trust anchor distribution, and outreach activities. DirectTrust is an outgrowth of the Direct Project and supports the “triple aim” set by ONC and HHS: improvement of the health care experience; improvement in the care of populations; and reduction in the cost of care.

• The ONC is establishing governance mechanisms for health information exchange

over the nationwide health information network, Nhwin, in part through a 2 year Cooperative Agreement with DirectTrust.

• The Stage 2 MU objectives require eligible providers engage in health information exchange via standards, used in a manner consistent with these governance mechanisms, including the use of certified EHR technology capable of sending and receiving Direct messages and attachments.

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See: http://www.healthit.gov/buzz-blog/health-information-exchange-2/onc-partners-health-information-exchange-governance-entities and also http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/directtrust-builds-transparency-confidence-direct-exchange).


http://www.healthit.gov/buzz-blog/health-information-exchange-2/onc-partners-health-information-exchange-governance-entities

http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/directtrust-builds-transparency-confidence-direct-exchange/

www.DirectTrust.org 1101 Connecticut Ave NW, Washington, DC 20036 32

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DirectTrust’s membership has doubled in the last year and a half.



DirectTrust’s membership has doubled in less than a year.



Stage 2 MU focus is on exchange



Things have been moving very, very fast

April 2010 Direct Project launched Goal: simple, secure, scalable, standards-based way to send health data over the Internet

April 2011 Applicability

Statement published

“Rules of the Road” Workgroup started

HIEs charged w/ Direct

Feb 2013 EHNAC-DirectTrust

accreditation program starts

Stage 2 MU program to require Direct in all EHRs by 2014

Sept 2015 DirectTrust HISPs

provide service to >48,000 HCOs and provision over 1 million

Direct email addresses

Direct = secure, identity validated, vendor/app neutral messaging + content

May 2012 DirectTrust

incorporated as non-profit trade alliance, 501(6)(c)


www.DirectTrust.org 1101 Connecticut Ave NW, Washington, DC 20036 36 36

Health Information Service Provider (HISP)

Healthcare Organization (HCO)

Identity vetting at a specific level of Assurance, LoA.

Certificate Authority (CA)

Certificate Validation Service

X.509 Certificate

Issuance Service

Revocation Services

Certificate Signing Services

Registration Authority (RA)

Compile/Validate Identity and Trust Documentation

The CA and RA enforce the

policies specified in the DirectTrust

and FBCA Certificate Policy

(CP).

Credential issued on the basis of RA’s Identity vetting at specific LoA..

HCO Direct

Addressees

Basic services for user: DNS discovery; encryption; certificate signing and validation; send/receive MDNs; provide HISP-side of edge protocol connection compliance with Direct standard,

The HISP enforces the policies specified in the

DirectTrust HISP Policy (HP), and MUST use accredited RA

and CA.

The HCO relies on HISP, CA, and RA as accredited trusted agents, and bears ultimate

responsibility for HIPAA privacy and security.

NOTE: Three separate roles and responsibilities from “trusted agents” combine to enable Direct exchange

1. 2.

3.



[email protected] (has been identity vetted, has X.509 Digital certificate bound to address.)

[email protected] (has been identity vetted, has X.509 Digital certificate bound to address.)

Exchange between HISPs requires active use of the Direct protocols for secure Internet email exchange

37

EHR EHR

encryption

identity validation





Health care organizations served by DirectTrust HISPs

667 1,460 3,336

5,627

28,148

35,657

39,751

46,797

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q3 2014 Q4 2014 Q1 2015 Q3 2015

Health care organizations served by DirectTrust HISPs

38



Number of Trusted Direct Addresses

8724 45,300 73,922

182,279

428,105

663,321

752,496

998,313

0

200000

400000

600000

800000

1000000

1200000

Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q3 2014 Q4 2014 Q1 2015 Q3 2015

Number of Trusted Direct Addresses

39



Direct Exchange Growth

122,842 2,195,433 2,567,110 3,938,346

7,746,375

22,959,139 27,316,438

57,247,435

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q3 2014 Q4 2014 Q1 2015 Q3 2015

Number of Send and Receive Direct Transactions to/from Trusted Endpoints

40

Increase of 30 million transactions from Q1-Q3 2015



Interoperability Matrix

41

DirectTrust Accredited Bundle Interoperability Benchmarking Results as of 10/2/2015

Health Companion

iShare Medical

MedAllies

CernerData

MotionEMR

DirectICA

MaxMD

McKesson/Relay

MROSure-

scriptsUpdox

NY eHlth Collab

Cozeva MHIN Axesson Inpriva Nitor Glenwood Systems SES Medicity

Athena-health

CareAccord

CernerMobileMD

eClinicalDirect

IODRocheste

r RHIOOrion Health

NextGen (Mirth)

Truven Health Anltcs

Covisint OptumHealthU

nityHIXNY Shifox

Disp Support

(respond)

Interop Score

Interop % Sep. Certs (Send)

Sep. Certs (Reply)

Health Companion Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Sept Jul Sept Jul Sept Jul Jul Jul Jul Jul Sept Jul Jul Jul Jul Aug Sept Aug Jul, 6 33 97%iShare Medical Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Sept Sept Sept Jul Sept Jul Jul Jul Jul Sept Jul Jul Jul Jul Sept Jul Sept Jul Sept 33 97% Sept

MedAllies Jun Jul Jul Jun Jul Jun Jul Jul Jun Jul Jun Jul Jun Jun Jun Jun Jul Jul Jul Jul Jul Jun Jun Jul Jul Jun Jul Jul Jul Jul Aug Sept Jun Jul, 9 33 97%Cerner Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jul Jun Jun Jun Jun Jun Jul Jun Jun Jun Jun Aug Jul Jun Jun Jun Jun Jul Jul Jun Jun Sept 32 94% Aug

Data Motion Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Apr Jun Jun Jul Jun Aug Jul Jun Jun Jun Jun Aug Apr Jul Jun Sept, 16,17 32 94%EMR Direct Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jul Jun Jun Jun Jun Aug Jun Jun Jun Jun Jun Jul Jun Jun Jun Sept 32 94% Aug Aug

ICA Jun Jun Jul Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jul Jun Jul Jun Jun Jul Jul Jul Jul,19 Aug Sept 32 94%MaxMD Jul Jul Jul Jul Jul Jul Jul Aug Jul Jul Jul Sept Jul Sept Jul Aug Jul Apr Aug Jul Jun Jul Sept Sept Jul Jul Jul Jul Jul Jul Apr Sept Sept 32 94% Aug Sept

McKesson/Relay Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Aug Jul Jul Jul Jul Jul Aug Jul Jul Jul Jul Jul Jul Jul Aug Jul Aug,9,17,22,20 32 94%MRO Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Aug Jul Jul Jul Jul Jul Jul Jul Jul Sept 32 94%

Sure-scripts Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Aug Jun Jun Jul Sept Jun Aug Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Aug Jun Sept Aug Sept 32 94%Updox Jun Jun Jun Jun Jun Jun Jun Jun Aug Jun Jun Jun Jun Jun Jun Aug Jun Aug Aug Jun Jun Jun Aug Aug Jun Jun Jun Jun Aug Aug Jun Sept,13 Aug Sept 32 94%

NY eHlth Collab Jun Jul Jul Aug Jul Jul Jul Jul Jul Jul Aug Jun Aug Aug Aug Jul Jul Jun Aug Jun Jun Aug Jul Jul Sept Jul Aug Aug Sept Aug Aug Sept,12,9 31 91%Cozeva Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Sept,13 Jul Jun Jun Jun Jun Sept,13 Jul Jun Jun Jun Jun Jul Jul Jun Sept Oct,13 Aug 30 88%MHIN Aug Aug Aug Aug Sept Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Sept Aug Aug Sept Aug Aug Sept, 2 Aug Aug Sept, 9 30 88%

Axesson Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Sept Jul Jul Jul Jul Jul Jul Jul Aug 28 82%Inpriva Jul Jun Jun Jun Jun Jul Jun Jun Jun Jul Jun Jun Jun Jun Jun Jul Jun Jul Jun Jul Jun Jun Jun Jun Jun Jun Jun Jun Sept,9,12,23,24 28 82%Nitor Jul Sept Jul Jun Jun Jun Jun Jul Jul Jul Jun Jun Jul Jun Jul Jul Jun Sept, 2 Jun Aug Jul Jun Aug Jul Jul Jul Jul Aug Sept, 2 Jul Sept, 14 28 82%

Glenwood Systems Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Oct Sept Sept Sept Sept Sept Aug Sept 9,22 27 79%SES Jun Jul Jun Jun Aug,13 Jun Jun Sept Jun Jun Jul Jun Jun Jun Sept Jul Jun Jun Sept Jun Jun Sept Aug 2,13 Jun Jul Sept Sept Sept Jul,13 Aug,13 Sept,13 Sept,13 Aug Sept,16,17,22 27 79%

Medicity Oct, 2 Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct, 2 Oct Oct Oct Oct, 2 Oct, 2 Oct Oct Oct Oct Sept Oct,1,2 Sept Aug, 16 26 76%Athena-health Jul Jul Jul Jul Aug Jul Jul Aug Jul Jul Jul Jul Jul Sept Jul Jul Jul Jun Jul Sept Jul Jul Aug Jul Jul,6,9 24 71%

CareAccord Jul Jul Jul,13 Jul Jul Jul Jul Jul Aug,13 Jul Jul Jul Jul Jul Jul Jul Jul Jul Sept Sept Jul Jul,2 Aug,13 Jul, 13 Jul Jul Jul Jul Jul Jul,1,13 Aug2,13, Jul,13 Sept 24 71%CernerMobileMD Aug Aug Aug Aug Aug Aug Aug Sept Aug Aug Aug Aug Aug Sept Sept Sept,13 Aug Sept Aug Aug Aug Aug Sept Aug Aug Sept, 16,17,24 24 71% Sept

eClinicalDirect Jun Jul Jul Jul Jul Jul, 18 Jul Aug Jul Aug Jun Jul, 2 Jun Jul Jul Jun Aug Jun Jul Jun Jul Jul Jul Jul Jul Sept 17, 20,9,23 24 71%IOD Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul, 9 24 71%

Rochester RHIO Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Jan Sept,13 Sept Sept,13 Jan Sept Sept Sept Sept,13 Sept Sept Sept Jan Sept Sept,13 Jul, 15 23 68%Orion Health Aug Sept Aug Aug Sept,13 Aug Aug Aug Sept,13 Aug Aug Aug Aug Aug Aug Aug Sept Aug Sept,13 Aug Aug Sept,13 Sept,13 Aug Aug Aug Sept,13 Sept,13 Sept 21 62%

NextGen (Mirth) Aug,2 Aug,2 Aug Aug Aug Aug Aug Aug Aug,13 Aug Aug Aug Aug Aug Jan Aug Aug Aug Sept Aug,13 Aug Aug Aug Aug Aug,2 Sept Aug,2 Aug,13 Jan Aug,13 Sept 20 59%Truven Health Anltcs Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Sept 22,17 10 29%

Covisint Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Aug, 12,16 9 26%Optum Aug Aug,9,20 1 3%

HealthUnity Sept, 16,12,25 0 0%HIXNY Sept 17,16,22,23 0 0%Shifox Sept, 14 0 0%

Interop Testing Bundle (Test PKI)

Accredited Bundle Results Summary

Sender



HIMSS Survey shows Direct exchange now mainstream

Current market view of the usage, value and future of Direct Messaging

Themes from the survey results: • substantial use of Direct in support of care coordination use cases, • broad availability to a provider directory but great variability in the method of

access, • continued challenges incorporating structured data into the EHR, • extensive membership [of provider organizations] in a HISP, • some knowledge of the availability of Direct messaging among the clinician

community, and • that most participating organizations support Direct as the method choice for

exchanging data.

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http://blog.himss.org/2015/06/22/current-market-view-of-the-usage-value-and-future-of-direct-messaging/





http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemNumber=42810

http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemNumber=42810


Contact Information

David C. Kibbe MD, President and CEO DirectTrust.org [email protected] [email protected] [email protected] 913.205.7968






Short lexicon of terms

Health Information Service Provider, HISP An entity or service providing its subscribers Direct accounts, addresses and secure, encrypted exchange of messages between users within the same domain, and also with users in different domains, that is, who are subscribers of different HISPs. It is typically also the responsibility for a HISP to arrange for its subscribers’ identity proofing and verification (the Registration Authority function) and for its subscribers’ digital certificate issuance and management (the Certificate Authority function). HISPs may be organized along several different business models. For example, an EHR technology vendor may operate a HISP internally for its customers. A so-called “full service” HISP may operate a stand alone business, and partner with several EHRs as well as offer its Direct services through a web portal or other set of tools and devices.



Short lexicon of terms Direct Project A public-private sector initiative sponsored and run by ONC whose aim was to create a simple, secure, and open standard for transport of messages and attachments between health care participants over the Internet, regardless of end-user technology. Direct Standard The outcome of the Direct Project. A set of protocols and specifications, along with a security and trust architecture, for simple, secure, inter-vendor communications over the Internet for use by health care professionals and patients. Direct Message Exchange Use or deployment by individuals or entities of health information exchange utilizing the Direct standard. Also sometimes referred to as Directed “push” exchange, Direct exchange. Direct User or Subscriber An organization or an individual that participates in sending and receiving messages and attachments using technology equipped to do so, e.g. an EHR or a web portal, via the Direct standard, and who has the authority to do so.


Questions?