Family physicians have been front-line adopters of electronic health record (EHR) technology for the past decade, so it's no surprise that many FPs are ready, able and willing to push forward with the meaningful use (MU) of those EHRs as directed by CMS and the Office of the National Coordinator for Health IT (ONC).
David Kibbe, M.D.
With stage one of MU well underway and stage two poised to begin early in 2014, AAFP News Now recently sat down with family physician David Kibbe, M.D., of Oriental, N.C., to discuss a key component of stage two -- "direct exchange" of health information.
Kibbe is nationally recognized for his health information technology (IT) expertise. He is the president and CEO of the nonprofit organization DirectTrust and serves as a senior adviser to the AAFP on health IT issues.
Q. How would you define the term "direct exchange" for family physicians?
A. Direct exchange is just like regular e-mail, but with an added layer of security and trust-in-identity operating behind the scenes. This makes direct exchange of messages and attachments suitable for electronic sharing of personal health information. Put simply, this is a way for users of two separate EHR systems to send and receive information securely.
The Health Insurance Portability and Accountability Act requires that the transfer of such information remain confidential at all times and across geographic and health IT vendor boundaries.
- Direct exchange of health information is a key component of meaningful use stage two, which begins in January.
- Direct exchange ensures that the transfer of information is secure and confidential at all times, as called for by the Health Insurance Portability and Accountability Act.
- Direct exchange will be integrated into upgraded electronic health record technology for 2014, and systems must be certified as to this capability.
Q. How is direct exchange different from e-mail?
A. To engage in direct exchange, physicians need a direct e-mail address that looks something like this -- Bob.Jones@Direct.SmithvilleFamilyPractice.org -- that will be provided to them by their EHR vendor or the health information service provider that has partnered with the vendor. Direct e-mail users compose messages, attach files or documents, and send them to known direct addressees just as they would regular e-mail.
The difference is that direct e-mails are encrypted and signed before they go out onto the Internet.
Q. Explain how the direct exchange of health information relates to MU stage two, which is coming in 2014.
A. When used by providers and hospitals to transport and share qualifying clinical content, the combination of that content and direct exchange is now an integral component of MU stage two objectives and measures. For example, if a family physician refers a patient to a (sub)specialist and uses direct exchange to provide a clinical summary to the (sub)specialist, he or she will be able to attest to having met one of the stage two objectives for transitions of care.
Physicians attesting for MU stage one or two in 2014 must use an EHR that is capable of direct exchange and that meets the other certification requirements as directed by the ONC. This will mean a significant software upgrade for most physicians by mid-2014.
Q. What's the difference between health information exchange (HIE) requirements and direct HIE requirements as they relate to MU stage two?
A. MU stage one focused on data collection in EHR technology; stage two is all about exchange of that data. In other words, HIE becomes a verb. Many of the stage two objectives involve moving data and information from the EHR to some destination, such as a public health immunization repository or a cancer registry.
Q. What are the three most important points for physicians to understand when it comes to direct exchange of health information?
A. First, understand that direct exchange will be integrated into upgraded EHR technology for 2014, and EHRs must be certified as to this capability.
Second, physicians will be able to use secure direct exchange for a wide range of data and information communication needs with other physicians, health care professionals, patients and some payers. This can mean a significant reduction in a practice's paper, mail and fax correspondence with commensurate decreases in cost and mishandled care transitions.
Finally, physicians have some say in how their EHR vendors configure the direct exchange services. Costs of services will vary vendor to vendor, so physicians need to communicate with their vendors about these issues.
Q. How important is the patient engagement piece of MU stage two, and how difficult will it be for physicians to comply?
A. Patient engagement is a very important aspect of stage two MU, and it will pose challenges to some physicians in terms of compliance. For one thing, practices must have a Web-based patient portal to comply with "view, download and transmit" requirements. And the portal must be able to send -- via direct exchange -- certain health information documents, such as clinical summaries and visit notes, to patients who request this.
To meet the MU stage two patient engagement objective, patients must be able to view, download and transmit a summary-of-care record provided by the EHR technology to a third party of their choosing, and, importantly, 5 percent of patients must actually do this.
Q. Why should family physicians care about the electronic transfer of health information and secure messaging?
A. Aside from the requirements of stage two MU, family physicians care about continuity and coordination of care for their patients. Electronic messaging makes it easier for critically important health information to follow patients wherever they go in the patient-centered medical home neighborhood.
Q. What steps do physicians need to take now to prepare for MU stage two next year?
A. A couple of aspirin would be useful! Seriously, physicians should have already been preparing their practices for the new objectives and measures of stage two MU and working closely with their EHR vendors to manage the needed new features in their software to meet them. Remember, physicians who are not engaged in MU will face a 1 percent penalty in their Medicare payments starting in January 2015.
Q. What questions should physicians ask their EHR vendors related to direct exchange?
A. Here are several:
- Has the new software version of the EHR for use in 2014 been fully certified for stage two MU, including for compliance with direct exchange?
- When will the new software upgrade be available for installation? (Remember, attestation for three months of stage two MU requires installation of the upgraded software no later than July 2014.)
- Is the EHR's health information service provider accredited by DirectTrust, as required by the ONC, to meet the needed security and trust-in-identity features?
- What will direct integration for both "transitions of care" and for patient "view, download and transmit" measures cost the practice?
- How can physicians find the direct addresses of parties with whom they need to transfer information via direct exchange?
Q. Are there any red flags physicians should be aware of when assessing their own EHR systems and in working with vendors?
A. Indeed there are. One would be a delay in software upgrade installation availability beyond the first quarter of 2014. Another would be the inability of a software vendor to identify dates for both certification and accreditation of the direct exchange components of the upgraded version the practice will be using.
Q. How can the AAFP and other organizations help physicians work through this process?
A. Stage two MU is more complex than was stage one -- and by a long shot. We need to help our members prepare for a smooth transition to their upgraded software and help them avoid attestation problems during the first year of stage two MU, that is, during 2014.
Q. What's the most important takeaway point for family physicians?
A. Expect direct exchange to be part of your EHR's feature set in 2014, and be prepared to use direct exchange to the benefit of your practice and your patients.
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