Session 2: Approaches to Implementation

4/12/11: 9:00 – 10:30AM

Session Objectives

  • Discuss how states can leverage Directed exchange to address health challenges


  • Gary Christensen, CIO/COO, Rhode Island Quality Institute
  • Christopher M. Henkenius, Program Director, NeHII, Inc.
  • Carol Robinson, Oregon State Coordinator for HIT, Oregon Health Authority


  • Direct is a tool that we want to use when appropriate and when we want to use it in innovative new ways to improve delivery
  • Not all strategies will work the same for different states
  • The Direct project is supposed to be simple and open for coordination. Many organizations (vendors, HIOs, etc.) are involved in developing Direct and are committed to rolling out solutions
  • There are a range of approaches that states can take to implement Direct. Variables that may affect the chosen implementation strategy include geography, demography, and current health exchange environment
    • States will need to find a strategy that fits them and their needs

  • A goal for today is to help states understand what the different Direct tools are and how to leverage them. Different approaches include:
    • Encourage market-based approaches: Direct is a light-weight tool; states can encourage an environment for market-drive solutions
    • Offer a complete set of services: States can also offer a complete set of services, acting as the HISP or developing HISP services
    • Fill in the gaps: State can provide services to underserved communities (i.e. rural providers, etc.), “white space”

  • Key point is that there are many different approaches that states can leverage for Direct. States can mix and match
  • Direct is not a solution, it is not a strategy, it is a tool
  • There are four general HIE strategies: Elevator, Capacity-builder, Orchestrator, and Public Utility. Each of these strategies will necessitate a different usage of Direct.
  • Quick overview of the three panelists that represent different approaches to Direct:
    • Rhode Island: RIQI encouraged market based solution to establish HISPs
    • Nebraska: NeHII offered a set of services to the entire community
    • Oregon: OHA employed a “fill in the gaps” strategy that leveraged their existing regional HIT investments and initiatives

  • Direct is a tool, states have a range of ways to employ this tool. Where along the spectrum will work best for my state’s needs?

Presentation 1, Gary Christensen

  • The approach that RIQI is taking is very much dependent on both the state and RIQI. RIQI is the state-wide HIE, the REC, and a Beacon Community.
  • RIQI uses a collaborative approach that reaches payers, vendors, etc. The goal is to improve the value, quality of healthcare in the state. There are roles for Direct that align with this.
  • Primary-care oriented state: Rhode Island has lots of small practices (over 65 EHR platforms) and the highest percentage per capital of patient-medical homes.
  • Key tenets:
    • #1: RIQI should not be a HISP. RIQI’s goal is to improve health care, not deliver it.
      • RIQI is currently receiving applications from HISPs that are interested in participating in the Rhode Island HIE.

    • All have agreed to operate at a certain level (meet various requirements)
    • #2: If you’re going to choose the market-based approach, you must be HISP-agnostic. There were no assumptions based on which HISP would be selected. This also implied that HISPs will differentiate themselves based on price, services, and more value-added services than the minimum expectations. Thus, physicians can choose which HISP works best for them
    • #3: Be value add (or not). There was no reason for RIQI to get in the middle of the Direct flow and the HISP-provider relationship.
      • RIQI won’t even sign contracts with HISPs; providers will take on this responsibility based on their requirements.

    • #4: RIQI’s role is to educate, facilitate, and enable, but not actually provide the HISP services. RIQI started off as a very small organization and didn’t have the human resources to outreach to all of the physicians. This is the role of the REC, to help doctors get the information that they need to meet
    • #5: RIQI will be offering a service to make “certificates” invisible. RIQI will offer a certificate “product “ that providers can choose to purchase or not.
    • #6: Enable trust. As a trusted third party, RIQI can help to develop the trust community and offer that objective perspective to curious providers. RIQI is just option for a trust anchor for providers, but the goal is to make this as simple as possible for physicians. This is a physician-centric approach.

Presentation 2, Christopher M. Henkenius

  • Nebraska is leveraging an operational state-wide HIO, NeHII, that went live in 02/2009. This is important because it made merging Direct and NeHII a unique challenge. There were many meetings on where to fit Direct in our overall HIE strategy. In the end, there was not a huge amount of Direct information in our plan. Now, however, as NE is looking at financial sustainability and other components, Direct can take the model a step further and allow us find ways to reduce cost to physicians and caregivers that participate in NeHII
  • NeHII background:
    • NeHII is operational with various shared services (e.g. e-prescribing, etc.)
    • Participation from over 1,300 users and a good percentage of patients.
    • The reason why Direct came into play is to address the rural areas.
      • For instance, NE has areas that have only two providers or citizens per square mile. It’s a question of giving the state providers and patients the opportunity of choice.

    • There are also the demands from Medicaid. Nebraska has been working with Medicaid and the VA to figure out how they can all collaborate to meet everyone’s needs.
    • There are also the external demands. Nebraska is working with other states to help them get their exchanges up and running. NeHII collaborating with other states to help them get financially sustainable. With small provider communities, an HIE may not be sustainable.

  • Objectives:
    • Provide value and services to the patient and to the participants

  • Nebraska has a robust exchange with services, but the question of Direct was still perplexing. State had to answer, what is it? What do we do with it? Nebraska realized that they needed to embrace this and had the buy or build discussion. Nebraska analyzed the approaches of other states and finally decided that these services could be provided to providers and become a revenue stream for the HIE entity. This could then reduce the licensure fees for providers. This is still in development, but the model is decided.
  • Nebraska is home to five Fortune 500 companies. Nebraska has collaborated with them in certain areas to decide which areas are important for the HISP to offer. As of today, they feel very confident that they can develop functionality, provide the certificate authority, provide the provider directory, and provide the HISP for the state. State knows that this can be turned into a sustainable process.
  • The goal is to serve as a HISP for NeHII participants, non-NeHII participants, and other states and communities. For those that don’t want to join NeHII, Direct serves as another option to still participate in exchange.

Presentation 3, Carol Robinson

  • Oregon Governor John Kitzhaber has served two terms and is a forward thinker in health. Under his leadership, OR went to CMS and received a waiver to create the Oregon Health Plan, which is a prioritized list of health services for Oregonians who need these services.
    • Governor was re-elected and state plans to return to CMS for another waiver: this time it is to create a payment structure with a global budget for Medicaid services for Coordinated Care Organizations (CCOs - an Oregon-specific version of ACOs), they are ACOs at the next level. State hopes to have an RFP out by early Fall that will award this first for Medicaid, next for all state employees, and then for Medicare.
    • Oregon is in this health reform environment which is unique and involves huge, huge change. For most businesses, in times of massive change, investments slow down. Uncertainty breeds a lack of movement for a time.
    • Because of this, Oregon has not come very far in terms of its regional HIO success. Moving towards this massive change, measuring for outcome as opposed to simply service.

  • This is a time for a simple solution (a foundational solution)and Oregon feels that Direct meets these requirements.
  • State does not have a lot of HIE occurring, state met with its stakeholders and learned that they wanted a lightweight state-approach. State began developing a set of standards and, through rule making, a standard contracting policy and a common consent policy.
  • State thought that it would see a lot more movement. State now is planning to monitor these gaps as much as possible. Because there are many EHR adopters, but low HIE occurring, state realized that it needed to get information moving so quickly as possible. State views Direct as its “on ramp”.
  • The common policy and qualification framework includes trust, secure information, verification, etc. Within this, there are several things we know and some that we don’t. What we know about CCOs and ACOs is that we will need much more sophisticated data aggregation and analysis to be able to achieve payment reform. This is the only way to see if quality is improving and how costs are shifting.
  • We do know, however, that quality will improve even with point-to-point information exchange. This will give providers a base comfort level with exchange and with these methodologies. We know that patients want this type or reform.
  • The Commonwealth Fund released a poll yesterday that showed that 92% of patients want their physicians to have all of their information, all of the time.
  • We don’t know how ACOs and CCOs will organize, who will aggregate that data (i.e., state, community)? What will be the nature of this eventual data repository. Not knowing how fast this environment is going to change, just knowing that the environment is going to change, Oregon knows that it has to do something now, something cost-efficient. The solution in Oregon is Direct.
  • Direct is an on-ramp for providers to help them get to exchange comfort. It’s exchange with training wheels.
  • The foundation of EHR adoption, the highway that will be created with Direct messaging. The “Driver’s Ed” will be provided by the REC, this will be able to accelerate EHR reform and health reform in Oregon.

Question to the panelists: How do I serve my providers in delivering high quality care, if I choose to be that hub?

  • Gary (RI): We should be adding value. We should ask ourselves if getting involved would add value to this scenario or transaction. Let’s facilitate doctors and the market in doing what they do naturally and move better than we could. Let’s make sure that doctors can adopt this.

Arien’s follow up question: If a primary care physician is using a highly-structured CCD and is using this to refer to a specialist, how can the specialist or the public health entity get access to the data?

  • Gary (RI): We have a parallel path of using Direct in a separate flow and collecting data information from an EHR and put it into a repository. This is what doctors do naturally, keep records on their patients. These are two very different use cases. The first is the on-ramp, this easy way for providers to get used to exchange. This is what we are building into Direct: workflow training so that doctors will realize how useful this will be. Agree, it’s really a use case function issue.
  • Christopher (NE): The Direct use case is more direct, more straightforward and is communication from one provider to another. You need both of these cases, both of these functionalities for success. This is why Nebraska wanted to be involved in the HISP process, so that they could drive the process and have all of these functions under the same roof.
  • Carol (OR): My point is that we know that quality, health information exchange will happen in communities, but the rural white space in OR is quite extensive. It’s a broad and very diverse state, both geographically and culturally. Getting these providers hooked into a HISP is incredibly important. The landscape of the way that Direct could be used is very rich, in terms of pilot opportunities. OR wants to learn more about what MN is doing with its provider directory, and looking at long-term care communities, and coordinated care. Coordinated care is about information flowing and thinking about how providers can collaborate and work together.
  • Gary (RI): When I talk about the value-add of point-to-point, there’s a lot that we could do through our centralized HIE community as long as they are connected. The goal is to get providers connected in the first place, then these capabilities can be added. The connectivity is already there thanks to Direct and point-to-point. There’s an infrastructure capability that, once in place, can foment many exciting ideas for how it can be used.

Arien: If providers can’t do the basics, they aren’t prepared to do the more advanced services. Has NeHII seen the evolution of this natural history?

  • Christopher (NE): Absolutely, one of the decisions that our board made early on was to develop the initial adoption and training bases for physicians. Then we can take physicians to the next step, to using immunization registries, and other advanced capabilities. We still have physicians, especially in the rural areas, who don’t want an EHR. There’s only one hospital in the entire region. Getting them connected provides value for them and value for us.

Arien: What’s your dialogue with the less willing organizations and how does this play out with your overall Direct strategies?

  • Gary (RI): I think our role will be enabling folks to make use of this tool, making sure they know how to plug in, that nothing is set-up that is “vanilla”. For that question, I’d try to be as helpful as possible and bring up the other possibilities that connection can bring. At the end of the day, we can provide that infrastructure that lets a hospital jump in quickly. Beyond that, though, not a lot.
  • Christopher (NE): We have an advantage in that we are leveraging our robust, operational HIE. But we’re not stopping there, we’re adding in new functionalities (E.g., CPOE, Provider Directory, etc.) The more that we can bring in, the more problems that we can solve. This makes it more beneficial and helps us move forward. Some hospitals really like this, some just want to do Direct, and we support them with that and continue to facilitate the conversation in case they have new issues. We try to add as many services and as many functionalities as possible.
  • Carol (OR): This is walking the balance beam between supporting and competing with regional HIOs. This balance can be very narrow. OR will not be providing a great deal of additional functionalities and services unless the demand is there from those communities. If a particular functionality is available at a point in time, then that option is open.
    What is government’s role in this huge market change? We received this grant to basically seed HIE. We got money for this “driver’s ed.” Providers will get incentives to get EHRs in their offices. The role of government is to facilitate and support and this is where our involvement in Direct comes in. We think that this is a high use as well as the trust services, the provider directory, and secure messaging. There’s more that can be done with the data that would be very useful, but we aren’t going to go there unless there is demand in our marketplace.

Arien: What about for those who have it all taken care of?

  • Gary (RI): Direct won’t help everyone at the same level; these services won’t help everyone at the same level. If we aren’t delivering value, they shouldn’t purchase our services. The next question would be: Do they need this additional information about the patient? Being the only HIE in RI, RIQI has a unique data set that they can offer stakeholders. If physicians are fully wired and don’t need this, we can still find other practices. For the most part, however, when the physicians begin to see what we are providing, they become interested.
  • Christopher (NE): It’s all about providing value. We need to provide services that will meet their needs. There are a lot of different organizations that aren’t currently seeing the value, but we are starting to convince them that this can meet their needs (or at least get their attention). If they haven’t provided value, they consider whether there are additional services and either move forward or not. Some say yes, some don’t.
  • Carol (OR): The Portland metro area is moving towards 100% adoption of the Epic solution--Care Everywhere. This was a coordinated effort. In that environment, I’m not sure what we can provide. Will they want much more? That said, they will still have to abide by our rules. In other communities, there will be a need. There is also the need for HIO-to-HIO functionality. We hope that Direct can provide that service, at least initially. If they don’t need it, that’s okay. The overall goal is providing value.
  • Gary (RI): Payment reform will make a big difference here. A platform-specific tool will lock you into a certain system and Direct can help with this.
  • Carol (OR): The 2010 State HIE PIN (July 6, 2010) contained guidance that grantees make available to every provider at least one mechanism to participate in HIE.

Arien: Where are you on Ross’ spectrum on knowing what are the questions that you need to ask participants?

  • Gary (RI): A lot of it has to do with organizational energy. Some organizations have different capabilities in answering these questions.
  • Chris (NE): What is my strategic plan and how does this fit in my strategic plan. You need to get value to get participants. Don’t try and do 700 different things at the same time.
  • Carol (OR): It’s going to be hard to only have HIE be related to cost efficiencies. There are too many variables. I worry less about proving the value as opposed to keeping it simple and communicating it effectively. How will we keep our message simple? Our core services currently take up three pages, but we need this in a brochure for providers.

Audience FAQs:

  • Question for Gary, RI: Illinois is interested in a similar model to RI. We are thinking of providing a portal for providers and offering a comparison and collect the provider’s Direct email address at that point.
    • Gary (RI): We let the HISPs compete on the value of their interfaces. W don’t want to get in the way. What we are doing with the REC is creating vendor marketplaces to provide comparisons. tThese apples-to -apples views may help providers to choose. We’re not going to put a layer in between us and the providers and the HISPs, because we don’t think we add any value to that.
      • I’m thinking more that providers could sign up through the portal for different HISPs. Gary agrees that this is a part of their model. This makes things easier and cheaper to facilitate transactions.

  • Dave Perry (NM): Did Gary (RI) say that RIQI was populating their HIE using Direct? I thought it was more of a manual transfer? How does it populate an HIE?
    • Gary (RI): We’ve worked with EHR vendors to put a line of code in their system. This develops a Direct message to the state’s mailbox with a CCD attached. This is a simple transport idea, but we absorb it as data, not just a CCD document. HIEs are good at that.

  • Bill Bayhee (CA): We have a mature HIE. My question is about HISP-to-HISP communication, how is a doctor connected to one HISP going to connect to another HISP.
    • Gary (RI): The short answer is that there are requirements to be a HISP, this is one of them. The second has to do with this concept of trust. As part of setting up your Direct account, you will have to indicate who you trust. There are many options here. I don’t have to think about how HISPs share data, I only know that that is their requirement.

  • Doug Arnold (CT): In most markets we’re seeing a heterogeneous uptake of EHRs, and many physicians don’t have them yet. The OR market is atypical. Some of the vendors have not embraced Direct at all. How can we deal with this viewpoint?
    • Chris (NE): The value that we provide within NeHII is we get them up and running on the exchange. It does two things, it brings physicians on and forces all the physicians to collaborate. Thus, when a vendor doesn’t want participate, they are avoided. We have sued our physicians to help us with these conversations. We use the medical organizations and go as groups to talk to them. Having physicians engaged as the focal point is a unique advantage.
    • Carol (OR): The thing about being proprietary, it’s not with the times. Data is not going to be proprietary any more. Look at the ACO proposed rule for Medicare: providers won’t get paid in the same way if they don’t share data. It will change in different ways, but it will change.
    • Gary (RI): I’d also argue that these EHR vendors aren’t needed for point to point exchange. If doctors see the value of using Direct, I think a smart EHR vendor will hear the doctors discuss what is valuable and what needs to be adjusted. I’m letting this play out.

  • For Chris and Carol: How are you addressing the needs of the small rural hospitals in your approach to Direct?
    • Carol (OR): We aren’t yet, but we hope to soon. Many of these smaller hospitals are associated with larger systems, sometimes across state borders. This will make interstate policies and interstate repositories important issues. Making this as easy as possible to get them started is also important.
    • Chris (NE): We’ve talked to the critical access hospitals, there is a distinct value of critical access hospitals in the rural parts of the states. They can refer and get the patients back to their community as quickly as possible.

  • Russ Leftwich (TN): You mentioned value several times; we need to educate providers about the value that is offered. When I started as a physician in the 80s, it was a clinical term. Now it’s an insurance term. Providers know that it’s important to exchange information, it’s just not happening.