The First Approved HISP comes to Arizona

Arizona Health-e Connection recently announced the selection of the first health information service provider (HISP) for Arizona. This is exciting news because this is the first step that will enable use of the Direct Project specification. Direct enables secure exchange of health information using a "push" type mechanism much like email. Unlike typical email secure transmission utilizes encryption of messages through use of cryptographic protocols that are powered by digital certificates. The protocols are very similar to online banking and online purchasing services over the Internet, two examples with which we are all familiar. The HISP is needed to provision health care providers with special health care email addresses and provide and manage the digital certificates. The digital certificates are issued by a certificate authority and are needed for trusted identification of the endpoints of the information exchange pair as well as for use in the encryption/decryption process. The selected vendor, GSI Health will also offer a provider directory (needed to obtain health email addresses and digital certificate information needed to communicate with others) and a web portal (software as a service) to enable participation in HIE for those who use EHRs where Direct is not included as a native service and even those for clinicians without EHRs. The basic service is very affordable at $45 annually for the digital certificate and $15 monthly for HIE access using the available portal. Check out the GSI web site for fees associated with EHR interfaces.

The benefits of using Direct are several. Information exchange using interoperable standards facilitate continuity of care, especially when transitions of care are needed and different providers are involved. Examples are discharge of a patient from a hospital with subsequent care by the primary care physician/clinician (PCP), referral from a PCP to a specialist, and transfer of a patient from an inpatient facility to a long term care setting. Other uses include reporting of clinical quality measures, communication with disease registries, public health reporting, and syndromic surveillance. Educated readers will note that many of these tasks are required in Meaningful Use Stage 1 or are included in the two Notices of Proposed Rule Making (NPRM) for Meaningful Use Stage 2. Some have criticized the Direct Project for not having all the bells and whistles of more robust information. Nevertheless, it is a potential game-changer for freeing up the flow of clinical information between authorized clinicians. Now let's review some of the barriers to use of Direct.

Probably the most significant barrier is the resistance to sharing information. Many clinicians and health organizations view patient data as a personal possession. They refuse to consider that the data belongs to the patient and that sharing of data is essential to provide the best possible medical care. Another barrier is that we are at a point where the technology for information exchange is not wide-spread. Think of the similar problem faced by early adopters of the fax machine. For electronic information exchange to make sense, we must of trusted partners who are willing to exchange information and have the necessary technology to do so. The greater the number of partners, the greater the value of the capability. The workflows to incorporate Direct in routine clinical care need to be developed and promulgated. Most vendors do not support Direct natively in their EHR systems. This will need to change in the next two years, unless a major change is made to the NPRM to preclude the proposed standards for interoperability and EHR certification, including the prescription for information transport via Direct. Many EHR vendors also need to work harder to enable preparation of summary documents (CCD) that facilitate transmission of essential clinical information between clinicians (in stage 2 this will need to comply with the consolidated CDA standard.) Finally, many state public health agencies are not prepared for the changing rules and will need to move forward rapidly to enable receipt of information from clinicians via Direct.

These are exciting times. Rapidly changing technology will eventually enable clinicians to provide higher quality medical care for reduced cost. Finally, it is important to remember that Direct is just one hammer in an arsenal of tools that will be available to help achieve the health care goals of the US.