An Overview Presentation

Table of Contents

• What is the Direct Project?...................................................................... 4-6 • Origin and Oversight of the Direct Project…………………………………………… 7-10

– Origin of the Direct Project………………………………………………………………………………………………………. 8 – Relationship to the Department of Health & Human Services…………………………………………………..9 – Current Oversight for the Direct Project…………………………………………………………………………………. 10

• Components of the Direct Project………………………………………………………11-20 – What Does the Direct Project Do?................................................................................................12 – Construct of E-mail Addresses………………………………………………………………………………………………...13 – Certificates………………………………………………………………………………………………………………………………14 – Direct Messages……………………………………………………………………………………………………………………… 15 – Message Transport and Delivery…………………………………………………………………………………………….. 16 – An Abstract Model of the Direct Project…………………………………………………………………………………. 17 – The Direct Project: Industry Drivers and Assumptions………………………………………………………. 18-19 – What the Direct Project is Not…………………………………………………………………………………………… 20-21

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Table of Contents

• Deployment of the Direct Project……………………………………………………… 22-27 – Pilot Projects…………………………………………………………………………………………………………………….. 23-24 – Dominion Medical Associates and MedVirginia……………………………………………………………………… 25 – Other Deployments…………………………………………………………………………………………………………………26 – High-Level Project Timeline……………………………………………………………………………………………………. 27

• Technical Overview of the Direct Project…………………………………………… 28-30 – Transaction Model…………………………………………………………………………………………………………………..29 – Technical Overview Flowchart………………………………………………………………………………………………… 30

• The Future of the Direct Project…………………………………………………………….. 31 • For More Information……………………………………………………………………………..32 • Bibliography……………………………………………………………………………………… 33-34

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What is the Direct Project?

Source: http://wiki.directproject.org/Direct+Project+FAQ

Set of Standards Set of Policies Set of Services

~~~~~~~~~~~~~~~~~~~~ To facilitate a simple,

secure, encrypted, scalable transport of health

information between authorized care providers

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Sources: (1) http://wiki.directproject.org/Direct+Project+FAQ; (2) The Direct Project Overview, 10/11/10; p.10.

Standards-based health information exchange

that supports Core Stage 1 and 2 Meaningful Use

Measures

Purpose of the Direct Project: • Provide an expedient means to fulfill Stage 1 and 2 Meaningful Use requirements

• However, Direct may not function as a long-term solution for participants

• Serve as an integral component of a broader national strategy to have an interconnected health system through the eHealth Exchange (formerly the Nationwide Health Information Network, or NwHIN)

• Can be implemented by any two participants or organizations, or a community, without a central governance structure.

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What is the Direct Project?

Source: http://wiki.directproject.org/User+Stories

1) Primary Care Provider (PCP) refers patient to specialist, including summary care card

2) PCP refers patient to hospital, including summary care card

3) Specialist sends summary care information back to referring provider

4) Hospital sends discharge information to referring provider

5) Laboratory sends lab results to ordering provider

6) Transaction sender receives delivery receipt

7) Provider sends patient information to patient

8) Hospital sends patient information to patient

9) Provider sends a clinical summary of an office visit to patient

10) Hospital sends a clinical summary at discharge to patient

11) Provider sends reminder for preventative or follow-up care to patient

12) PCP sends patient immunization data to public health

Today

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What Use Cases are covered by the Direct Project?

Standards-based health information exchange

that supports Core Stage 1 Meaningful Use Measures

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Origin and Oversight of the Direct Project

Initiated by: Office of the National Coordinator (ONC) under the Department of Health & Human Services

Launched: March 2010

Purpose: Evaluates applicability of specification recommendations from the Direct Project for inclusion in the eHealth Exchange (formerly NwHIN) and related software such as CONNECT

Source: The Direct Project Overview, 10/11/10; p.11. 8

Origin of the Direct Project

Make specification recommendations to ONC

HIT Standards Committee (HITSC) Oversight for technology standards used in the Direct Project

HIT Policy Committee (HITPC) Oversight for policies used in the Direct Project

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Relationship to the Department of Health & Human Services

Involved in The Direct Project =

Sources: http://wiki.directproject.org/implementation+Group+Committed+Organizations 10

Current Oversight for the Direct Project

• EHR and PHR vendors • Medical organizations • Systems integrators • Integrated Delivery Networks (IDNs) • Federal agencies

• State and regional health information organizations

• Organizations that provide health information exchange capabilities

• Health IT consultants

Participants Include:

Direct stakeholder members come from across the healthcare IT industry to make up the Implementation Group Committed Organizations. Members belong to at least one of the following workgroups under the Direct Project:

Implementation Group (70+ organizations, 200+ participants)

Best Practices Implementation Geographies Communications Reference

Implementation

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Components of the Direct Project

• Each participant will receive an e-mail address.

• This is a “push” approach of moving relevant patient information.

• Leverages Internet standards for e-mail communication.

• Reduces paper-based documents or data as well as faxes with patient information.

• Circumvents mail as mode of sharing patient information.

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What Does the Direct Project Do?

r.franks@direct.cardiodocs.org

Endpoint Domain

Direct Address

Source: Presentation, Direct Boot Camp. Anatomy of Direct., ONCHIT, April 12, 2011, slide 8.

Note: 1.This address can only be used for health information exchange. 2.An individual may have multiple Direct addresses.

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Construct of E-mail Addresses

Source: Presentation, Direct Boot Camp. Anatomy of Direct., ONCHIT, April 12, 2011, slide s 9-11.

• Certificates are issued by Trust Anchors

• Trust Anchors are Certificate Authorities (CAs)

• Certificates are issued to parties that agree to abide by policies set and/or enforced by the Trust Anchor

Adheres to X.509v3 digital certificate

standards

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Certificates

• Each Direct address must have one Digital Certificate

• Certificates are tied to address or domain

• Certificates securely transmit and receive information

r.franks@direct.cardiodocs.org

Source: Presentation, Direct Boot Camp. Anatomy of Direct., ONCHIT, April 12, 2011, slide 12. 15

Direct Messages

• RFC 5322

• Contains headers

• Contains contents (text plus attachments, etc.)

• Contains security information (i.e., signatures, certificate information, as applicable)

Direct messages are e-mail messages • HL7 lab results

• CCD, CCR

• PDF, TIFF

• Text and other human-readable representations

• IHE XDM specifications

Can be structured or unstructured

Mechanism: Simple Mail Transport Protocol (SMTP)

Why SMTP? 1) Supports environments that have minimal capabilities

in terms of using web services

2) Generates detailed metadata

3) Allows for more advanced interoperability

Source: Presentation, Direct Boot Camp. Anatomy of Direct., ONCHIT, April 12, 2011, slide 13. 16

Message Transport and Delivery

HISP = Health Information Services Provider

Source: The Direct Project Overview, 10/11/10; p.7. 17

An Abstract Model of the Direct Project

The Direct Project: Industry Drivers and Assumptions

Industry Drivers include the need to: • Engage in direct, point-to-point electronic communication

between and among providers, consumers and public health.

• Identify a vehicle to support achieving Meaningful Use Stage 1 and 2.

• Improve coordination of care.

• Ensure patient safety.

• Create an economical solution especially for small-size providers to achieve Meaningful Use Stage 1 and 2..

• Develop an early, practical and accessible option for HIE.

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The Direct Project: Industry Drivers and Assumptions

Assumptions: • Policies for the Direct Project will be generated by the eHealth

Exchange in collaboration with the EHR/HIE Interoperability Workgroup (IWG).

• Policies will not be decided within the Direct Project.

• It will conform to applicable federal and state laws, including but not limited to those related to the security and privacy of protected health information.

• Sender has obtained patient’s consent to send the information to the receiver. (Privacy is maintained.)

• Sender of the message has determined it is clinically and legally appropriate to forward information to receiver.

• Sender has determined that the receiver’s address is correct.

• Sender has communicated to the receiver as to the purpose of communication.

• Sender and receiver do not require common or pre-negotiated patient identifiers.

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Source: (1) The Direct Project Overview, 10/11/10; p.5; and (2) Presentation: An Overview of NHIN Direct, 04/15/10.

• It does not address complex health situations such as an unconscious patient that presents to an emergency department.

• It does not create interoperability for its participants.

• There is no function to “pull” information forward or into existing Electronic Health Records (EHRs).

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What the Direct Project Is Not

Potential users of the Direct Project must be aware that it has certain limitations.

Review of these limitations will ensure that user expectations are set correctly.

What the Direct Project Is Not

Source: (1) The Direct Project Overview, 10/11/10; p.5. and (2) Presentation: An Overview of NHIN Direct, 04/15/10.

• It will not compete with or replace the eHealth Exchange.

• It will not disrupt the current development of the eHealth Exchange.

• It will not require providers, Health Information Organizations (HIOs) or eHealth Exchange nodes to be either eHealth Exchange or Direct Project.

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Potential users of the Direct Project must be aware that it has certain limitations.

Review of these limitations will ensure that user expectations are set correctly.

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Deployment of the Direct Project

Pilot Projects

Launch to Pilot Projects: Less than 1 year

Initial Pilot Projects: February 2, 2011

Pilot Participants: Minnesota and Rhode Island

Subsequent Pilot Participants: California, Connecticut, New York, Oklahoma, Tennessee and Texas

Source: The Direct Project Brochure, 49098452 23

The Rhode Island Quality Institute (RIQI): 1) Improve patient care when patients are referred to specialists by

demonstrating simple, direct provider-to-provider data

2) Leverage Direct Project messaging as a means to securely feed clinical information, with patient consent from practice-based EHRs to the state-wide HIE

3) Improve quality by detecting gaps in care and making sure the full record is available to all care providers

Source: The Direct Project Brochure, 49098452. 24

Pilot Projects

Minnesota: Hennepin County Medical Center (HCMC), a Level 1 Adult and Pediatric Trauma Center, has been sending immunization records to the Minnesota Department of Health (MDH).

Dominion Medical Associates • Independent, minority physician practice located in Richmond VA

• Traditionally paper-based practice that is now moving toward EHR

MedVirginia • CenVaNet and MedVirginia working with practice to help it achieve

recognition as a Level 3 NCQA Patient-Centered Medical Home

Objectives of The Direct Project Initiative: • Utilize Direct Project standards and transactions to facilitate the referral process. • Improve care management and coordination services for identified high risk chronic

disease populations, including diabetes.

Source: Presentation, Direct Boot Camp. Anatomy of Direct., ONCHIT, April 12, 2011, slide 34. 25

Dominion Medical Associates and MedVirginia

Additional Information: (1) http://www.wiki.directproject.org/Implementation+Geographies; (2) http://directproject.org/content.php?key=pilots 26

Other Deployments

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High-Level Project Timeline

28

Technical Overview of the Direct Project

Source: http://wiki.directproject.org/Intersection+with+Exchange 29

Transaction Model

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Technical Overview Flowchart

Source: http://wiki.directproject.org

1) Provider or hospital reports quality measures to CMS. 2) Provider or hospital reports quality measures to

State. 3) Laboratory reports for some specific conditions are

reported to Public Health. 4) Hospital or provider sends chief complaints data to

Public Health. 5) Provider or hospital sends update to regional or

national quality register. 6) Pharmacist sends medication therapy management

consult to Primary Care Provider (PCP). 7) A patient-designated caregiver monitors and

coordinates care among three domains. 8) A provider EHR orders a test. 9) A patient sends a message to the provider.

Priority 2 1) Transaction sender receives read receipt. 2) State public health agency reports Public Health data

to Centers for Disease Control (CDC).

Priority 3

Source: http://wiki.directproject.org/User+Stories

After the initial release of transactions for The Direct

Project, Priority 2 and 3 transactions have been

defined for future releases.

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The Future of the Direct Project

wiki.directproject.org

32

For More Information

Bibliography

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Reference Web Sites The Direct Project http://wiki.directproject.org

Presentations Direct Boot Camp. Anatomy of Direct. ONCHIT Day 3. April 12, 2011. Direct Boot Camp. Approaches to Implementation. ONCHIT, April 12, 2011 Fridsma, Doug. An Overview of NHIN Direct, ONC. April 15, 2010. The Direct Project Overview. February, 2011.

Documents The Direct Project Brochure, 49098452. The Direct Process Overview (document), October 11, 2010.

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Bibliography