While Direct messaging has had a circuitous path into health information exchange, Nemours is already using the protocol to meet the 10 percent threshold for sending electronic summary care records when transitioning patients to other care settings under meaningful use.

Nemours has Direct messaging integrated with its EHR and also contracts with a separate HISP – health information services provider – which senior manager of strategic process implementation Alex Koster likened to "a telecom company for Direct messaging," during a National Health IT Week webinar on Wednesday.  

In Nemours' case, the HISP is Surescripts, but others include DataMotion MedAllies, Medicity, Orion, RelayHealth and many more.

"Once we have that in place, it allows us to generate Direct secure messaging addresses for all the physicians, nurse practitioners and others in our system," Koster added. "And also to create, if we wanted departmental address, such as an endocrinology address or a hospital-level address as well."

That function, he said, is embedded in Nemours' EMR, and routes messages as part of the system's communication and ordering workflows.

"As a large subspecialty and specialty pediatric system we receive many more messages than we send," Koster pointed out. "We have been receiving messages from a variety of different sources, and we've identified message types that come into our system using the Direct messaging framework."

Among them:

1. Inpatient and ED discharge notifications. "We are the primary care physician of record, and one of our patients goes to a hospital that's not ours. If they have updated their provider directory, they know when they discharge that patient to send us information about the hospital stay via a CCD," he said."

2. Referrals from primary care sites. "Most of them have explored Direct messaging through their local EHRs. They select Nemours – whether it's just our generic address or the address of one of our doctors – from their directories. And they're able to send us referrals directly, using this mechanism."

3. Post-visit notes to PCPs from specialists who come from other health systems. "And also from retail clinics such as CVS," Koster added. "When one of our patients goes to a CVS, they send us a post-visit note via Direct and that goes into our system."

4. Immunization notifications from organizations such as Walgreen's. "Those are coming int our EMR via Direct.

5. Medication renewal reminders from groups such as ExpressScripts

6. Medication adherence notices. "I won't say we've gotten many of these, but where there has been some discussion between patients and a pharmacy on a medication regimen; we've gotten a clinical note, via Direct, where a patient has admitted they haven't followed up with the fact that they've discontinued their medication regimen."

7. Drug substitution notices.

8. Some patient generated messages. "One of the requirements for functionality with patient portals is that they have to have the capability for the patient to transmit using this avenue as well," Koster said. "We have had patients who are relocating from other areas of the country and are coming under our care, sending us their own care summaries."

Nemours analyzes which doctors are transitioning patients to specialists or other facilities, for example.  

"We then reach out to those organizations to see how we can enable this electronic transmission, so they have easy access through our communication workflow, our ordering workflow, to select that common referral partner and that (continuity of care document) will go out electronically,” Koster said.

What’s more, Koster added that staff at Nemours has been "making sure, as we've been working with different primary care sites, to capture the Direct address for the physicians or practices, in a way that will be readily available."

That way, when a patient is discharged from a Nemours hospitals and is managed by a referring physician for whom a Direct address is noted, "they will automatically get a discharge summary," he said. "That is also happening from our urgent care."

How Direct got where it is today
When it was first unveiled as a new vehicle for health information exchange back in 2011, Direct messaging was described as "a classic, fantastic, soon-to-be-legendary example of how the public and private sectors can come together in a collaborative, entrepreneurial explosion of mojo to improve and advance healthcare in America."

The secure, scalable, email-like messaging system was touted by one of its architects as "the first technology that could really kill the fax in healthcare." 

[Also: Direct messaging finding its stride despite hurdles]

More than five years later, the hype has abated a bit. Direct messaging has spread somewhat as reliable and cost-effective way for physicians, clinicians and even patients to exchange data, but it still hasn't quite caught on to the extent some – not least government agencies like ONC, which initially convened the who's-who of private-sector IT vendors to helped develop its specs – had hoped.

As David Kibbe, MD, CEO of Direct Trust, which accredits and supports its protocols, told Healthcare IT News in 2015: Direct's use has grown, but it has also, at times, felt like "an uphill struggle."

According to HIMSS' 2015 Direct Messaging Survey, Direct is broadly available and substantially put to work for certain use cases. But many respondents reported difficulties incorporating the messaging with theirs EHRs – while also citing cost, workflow integration challenges and a lack of other Direct-enabled providers as barriers to wider use.

But Direct offers a familiar and intuitive way to exchange information about admissions, discharges and transfers; enables easy consultations between physicians and other clinical staff; offers new avenues for patient communication and much more.

It's also, not insignificantly, a key way to comply with the health information exchange requirements of Stage 2 meaningful use.

More than meaningful use compliance
While Nemours has achieved success in complying with meaningful use, Koster has additional future plans for the protocol.

"If organizations take the stance that this is really all about checking a meaningful use box, it might limit the imagination or creativity that could be applied enhancing their patient experience," said Koster.

Koster recommended taking an approach that technology and tools can be applied to make a better patient experience as well as improving treatment and outcomes.

"We're very much interested in seeing how we can streamline and remove paper from our workflows," he said. "That's part of the reason why we will actually accept referrals that come in via Direct – rather than saying, 'No, send us Direct so we can meet meaningful use, but also fax it to us.' We're trying to eliminate that duplication. I'm not going to say it's been smooth, or perfect, but it's working most of the time and when it doesn't work we're able to follow up and figure out why."

Helpful advice for planning to purchase a population health platform:

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