According to DirectTrust, an association that accredits HISPs, 50% of U.S. Healthcare providers have access to Direct secure messaging via 36 health information service providers (HISPs). However, EHR vendors are complicating physicians' ability to exchange Direct messages.
One example is eClinicalWorks, an EHR vendor, which negotiates agreements between its HISP and other HISPs to allow information to be exchange. However, this makes it difficult for providers to exchange Direct messages with their customers. For a small rural hospital like Harrison Memorial, this makes it impossible to improve care coordination and meet meaningful use stage 2 requirements. Furthermore, eClinicalWorks will not allow any other HISP to serve its clients. Harrison Memorial does not want to switch to another HISP because the Kentucky health information exchange pays the fee for Informatics Corporation of America (ICA) on behalf of the hospital. ICA does have a scheduled meeting with eClinicalWorks to work on the issue. eClinicalWorks CEO, Girish Navani, claims that he does not understand why ICA will not work with his firm's HISP. There is some speculation that eClinicalWorks is reluctant to sign the DirectTrust agreement because it plans to charge other HISPs for exchanging Direct messages, which DirectTrust does not allow. However, eClinicalWorks' HISP does not charge its customers for Direct messages, unlike other HISPs, because it does not want to impose an additional financial burden on them. Navani also estimates that joining DirectTrust may cost $150-$300 per physician each year. President and CEO of DirectTrust, David Kibbe, refutes this statement by saying that Navani is misinformed about the cost, and that they cost of identity proofing is usually less than $20.
Andy Heeren, director of network Intellectual Property for Cerner and a board member of DirectTrust, noted that the DirectTrust accreditation process is designed to be a cost-effective alternative to having every HISP negotiate with each other separately. DirectTrust allows its clients to take advantage of Direct messaging without contracts or delays. It essentially simplifies the process of linking HISPs together. One major issue for DirectTrust, however, is the inability of smaller HISPs to join because of the high membership fees. Some experts argue in favor of the concept of multiple HISP accreditors, which Heeren does not disagree with, as long as they maintain "equivalent privacy and security controls."
Another company that is presenting an issue in the HISP field is Epic Systems, the largest EHR company in the U.S. Epic only allows its users to receive Direct messages that have clinical data architecture (CDA) attachments. CDA attachments are care summaries that have a specific format and are used when providers exchange health information for the purpose of demonstrating meaningful use. Meaningful use stage 2 requires providers to exchange online care summaries in at least 10% of transitions (such as hospital discharges and referrals to specialties). However, Epic's limitation restricts a physician from sending simple messages to another physician, who is caring for the same patient. Physicians may also want to send other documents such as an X-ray or PDF report. If there is an unstructured Direct message sent via Epic's system, their EHR will reject it. Epic says it is doing what is required to satisfy the stipulations of meaningful use stage 2. When questioned about Epic's stance, the Office of the National Coordinator of IT stated, "We hope that developers will offer EHR technology that will include other enhancements and go beyond the baseline to support their customer needs." Epic President, Carl Dvorak, claims that initially Direct was aimed at obtaining C-CDA capabilities, but as of May Epic added support to receive plain text messages and PDFs.
Summary by Caroline Smith
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