Miller: And nursing homes, the spectrum of care. That’s the other reason we do think it’s so important to keep the measure in Stage 2. When patients don’t have information flowing at the time of transitions of care, it is dangerous for them. This is a safeguard that dramatically enhances care as well as decreasing costs. Having the ability to access this information will prevent re-hospitalization in many cases, it will prevent additional unnecessary visits and it will avoid duplicate testing. It’s critical for enhanced patient care.

Q: Dr. Blair, you said Direct plays a large role in this transformation from patient-centered medical home to medical neighborhood. What are the other factors?
Blair: Technology is certainly not the only piece of the medical home. We believe IT is a necessary ingredient, but think that much of the medical home is transformation by retraining practices for team-based care, patient-centeredness, a lot of other techniques, open access, etc. I would say that the EHR technically is to the medical home as Direct is technically to the medical neighborhood. We deal with SMTP, S/MIME, and we also deal with SOAP. Our EHRs are mostly connected to our HISP through the ISA protocols and SOAP, but if we move beyond that to another HISP we invoke SMTP. We can go directly on the SMTP also, but we support both of those. You have to be able to step up and step down between those standards.

Q: The folks at ONC essentially say that you can use Direct, Connect, Exchange or when appropriate you can use industry standards instead if that works for you.
Blair: We do support CCD and access for viewing. That is separate and distinct from our Direct effort. In Direct, it is only the SOAP, SMTP or S/MIME that we support. And everybody connected to us is that way.

Q: At HIMSS12, Doug Fridsma told me he envisions the underlying NwHIN protocols – those of course being Direct, Connect, Exchange, et al. – laying the foundation for the next Amazon, eBay or Facebook, only for healthcare. What’s your best guess for what that might one day be?
Blair: The way I see Direct playing out, ultimately, is that I believe there will probably be national networks. I think that the EHR vendors will be connected to one, maybe several of what are sanctioned or validated networks and those will, in turn, be connected to each other. So de facto if you are connected to a validated entity or network, to use the new vernacular in the RFI, you should be able to connect with any provider also connected to that network. And even though these may be national networks and 90 percent of your communication may be local, you’re still doing it between a network that is national. I don’t think that will happen tomorrow, but I think in time that’s how this will play out. So I see it very much like the wireless network, where the EHRs are like the iPhone or Blackberry or whatever at the edge, and the network just becomes a commodity.

[Related: ONC to stand up NwHIN-Exchange as non-profit HIE in October.]

In my mind, if Direct is working right, doctors want to communicate with other doctors, they can just do that. They have no idea there’s Direct or anything like that, just as hardly any of them know about the connectivity for e-prescribing, they’re just using their system. If this is done right, they will just be able to interoperate or communicate with other providers and it will be an additional functionality in their electronic health record. The connectivity wire, I’m hoping, gets worked out between EHR vendors and those of us that want to be HISPs, and the providers just ask for the functionality to be turned on.

Q: Dr. Miller, would you care to take a crack at that same question?
Miller: My hope for the future is that there is a place for de-identified aggregated data, to be able to accumulate data, to really start to think in terms of public health reporting but beyond that to do analysis that would result in personalized medicine. And I think all doctors dream about this where they might have enough information over millions of individuals about behavioral data, outcomes data, clinical data, and potentially even genetic data. So when a patient is in front of me, I would be able to not start with a random protocol of "Okay, I’ve diagnosed with hypertension and I’m going to start with a diuretic and then if that doesn’t work I’m going to go to a beta blocker and if that doesn’t work, I’ll try the next medication," but to really know that given the data we have that’s been analyzed and given the patient’s profile, I know that this medication would actually have the greatest efficacy and the lowest side effect profile. So I hope that at some point, we can have aggregated de-identified data so that analysis can happen. I think in terms of Direct we need this now and we need this for patient care. It will dramatically enhance patient safety, efficiency, cost of care, and across care transition.