One Nation, One EHR –The Direct Project

The essence of Health Information Exchange (HIE) lies in easily accessible health information to improve the quality of care delivered by the healthcare community. Complicated formats intrinsic to many EHR systems are generally counterproductive to this basic nature of HIEs and can prove to be a hindrance against delivering quality care. So the natural question arises, what can be done to remove such blockades in the inherent design of these EHRs to facilitate their intended requisites? A popular solution proposed to answer this query is to develop a holistic system of sharing health information between healthcare providers and other concerned entities on a national level within the healthcare continuum.

With the expected level of complications in developing such a system, a lot of critics would say that the notion of a national EHR system is far-fetched and would dismiss the idea altogether. Their objection would be justified if we considered the amount of time invested into the development and implementation of health information interoperability throughout the nation and still not attaining the desired results. Not even a single developed country so far has managed to go a hundred percent electronic with their clinical documentation. That being said, we have examples of numerous countries that have successfully devised and kicked off a national EHR system including France, Singapore, Sweden and Germany. These systems have been successfully deployed for quite some time now and are functioning with improved efficiency while acquiring a larger database of patients by the day.


When one ponders over the matter, the ideal solution would be to implement such a system in the United States as well. It wouldn’t matter which hospital you visited or if you switched providers, your private health record would be accessible in a secure format no matter where the point of care is located. Reflect on the example where your physician refers you to another specialist. Imagine if the specialist already had your health information upon your arrival instead of you having to remember your previous tests, medications and diagnoses. Wouldn’t that be much more convenient and helpful as compared to the alternative?

The fact of the matter is that the government is not oblivious to the huge potential which lies in developing such an interface on a national scale. Significant efforts have been made towards achieving such a system. The government’s endeavors came to fruition in March of 2010 when the Direct Project was launched and furthered the struggle to form a robust nationwide health information network. The Direct Project was developed in order to create a secure, simple and scale able platform which is standardized to send/receive authenticated health information to trusted entities over the internet. More than fifty different organizations and 200 participants are currently employing the Direct Project to their benefit. These participants consist of PHR and EHR vendors, system integrators, medical organizations, federal organizations, health IT consultants and many more. We will try to illustrate some implemented instances pertaining to the Direct Project with some examples in this extract.



The Newborn Hearing Screening Program (NBS) in Florida mandates the state’s hospitals to monitor all newborn babies to check for any potential hearing impairment which the infants might be experiencing. This process is carried out in order to make instant interventions in case a problem is detected so that any undesirable effects of hearing loss may be countered. Conventionally, the NBS processing was largely accomplished through fax. This meant that hospitals were required to present screening results to the state and NBS had to provide a compilation of results which were accumulated back to the hospitals through fax. One can imagine the inefficiencies as a consequence of using such an outdated medium. Right now, Florida is employing the Direct Project to make electronic transmissions for NBS and the results have spoken in volumes. The cost incurred for paper during processing has virtually been eliminated along with the hassle of using paper which accompanies it. Furthermore, it has created a sizeable increase in the efficiency of workflows for audiologists and various other professionals conducting the screenings.


The St. Joseph Health System and Redwood MedNet in California are collaborating to implement the Direct Project to enhance care delivery for newborns. Maternity wards inside different facilities will make use of the Direct Project to deliver newborns’ health information to their concerned pediatricians. Moreover, this health information will be transmitted to the patients’ HealthVault accounts as well which will enable parents to view their babies’ health data even prior to their discharge from the hospital. Redwood MedNet takes this even a step further; using the leverage of the Direct Project Redwood MedNet is providing hospitals the capacity to share clinical summaries once patients are discharged from the hospital. This gives hospitals the capability to demonstrate proposed Meaningful Use requirements which direct providers to electronically share care summaries during a patient’s transition from one clinical setting to another.


Guam HIE is tackling several distinct aspects in their implementation of the Direct Project for the Department of Defense (DoD) and the Department of Veterans Affairs (VA). VA and Guam HIE are at present referring VA patients in Guam for mammography by means of the Direct Project. They are looking towards using the resourcefulness of the Direct Project in making all future referrals for VA patients, providing a simple mechanism to expedite test results and imaging results alike. Guam HIE is also planning to employ the Direct Project to exchange military patient information with the Department of Defense as well.

Approximately 30 states across the country have gone live with the Direct Project with numerous others to follow. Providers may now share confidential patient health information electronically to ensure informed referrals and safer care transitions to other care delivery organizations via the Direct Project services presented by the ONC. Unnecessarily spending money on duplicated results is abolished once this innovation is adopted. The Direct Project will undoubtedly prove to be an innovative tool to enhance patient care and become a time saver for both doctors and patients.


The iBlueButton experience – Part II

In terms of usability and simplicity, the iBlueButton is a far cry from its crude predecessors. The information gathered from the conventional Blue Button application is cumbersome to process and often confusing. Therefore, this limited the effectiveness of Blue Button and subsequently proved as a hindrance towards the adoption of this new feature in health IT. Complicated numbers and digits instead of simplistic information put a cap on the true potential on the idea behind the inception of Blue Button. However, through the iBlueButton app the feature is easy to both access and to employ for all. Using the iBlueButton on a mobile device is a totally different experience than that of the traditional Blue Button.

With respect to the resourcefulness of the mobile app Dr Mostashari added, “When I saw my Dad’s information it changed everything. Because for the first time, you hit the provider button, it brings back a list of all his doctors, and their phone numbers and their addresses. I never had that before. Now I can see his medications, diagnoses, ER visits, outpatient visits, procedures, images and labs.”

According to Bettina Expert on, CEO of Humetrix, the iBlueButton is not merely a physician or physician app. It is a mobile communications instrument which links one side of the healthcare equation with the other. Moreover, the iBlueButton grants real-time access to various healthcare resources such as a patient’s essential medical information. With an air of authority Expert on proclaims, “iBlueButton is the mobile embodiment of Blue Button”.  Expert on who is a professor of medicine at the University of California and is invited regularly to the counseling panel on healthcare in the White House also assisted in manufacturing the EHR smart card for the French national health system. As the Apple based application gains traction with the public, Expert on has unveiled that an Android based version of the iBlueButton will be available later this month as well. Additionally, several commercial health plans are going on board with employing Blue Button. This bodes well for Humetrix and the healthcare industry alike.

The amount of information accessible to patients while they are on the go will undoubtedly transform conventional healthcare practices. Instead of calling up various entities, scheduling appointments and waiting in line, one may simply view everything they require on a screen in their pocket while sitting in the comfort of their homes. This rapid access to health information will prove detrimental, especially in emergency situations where every second could be the difference between life and death.  Having the ability to obtain and share medical records at any point of care is the main differentiation from traditional EMRs. The level of convenience to the patients themselves enables them to be more informed and proactive towards personal care as well. Innovation in health IT is finally catching up with our daily lives and providing avenues for continuous improvement in care delivery. Such advances in technology will without question shape the future of healthcare as we know it.


The iBlueButton experience – Part I

During the course of the past few weeks, there has been some commotion and excitement in the healthcare community over the successful introduction of the mobile Blue Button. Many individuals within the industry are familiar with the concept of the Blue Button, however, since half of the clinician populace across the nation has not opted for EHRs, a large percentage of physicians are still oblivious to this common health IT terminology. Essentially, Blue Button is a tool which allows users of electronic medical records to obtain their personal health information via downloading it in various formats on their computers. It was initially designed as a platform to allow American Veterans easy access to their personal health information.

Blue Button has already been used extensively by hospitals throughout the country. Numerous federal agencies such as HHS (Health and Human Services), DOD (Department of Defense) and VA (Veterans Affairs) have applied Blue Button to facilitate their beneficiaries. The most basic format in which Blue Button allows the user to download their personal health information is a text file. By default the file downloaded from this technology is ASCII which is machine readable, meaning that the file may be downloaded in a variety of formats as required, such as text, PDF etc. As mentioned earlier, a Blue Button ASCII file is machine readable, which essentially means it can be parsed (broken down and analyzed) with a straightforward program on any basic computer. The downloaded text file may be accessed on any mobile device or computer without the need for any specific program. These files provide an effortless medium for transmitting health information amongst an assortment of members within the healthcare continuum.

Now, there is a new development in the world of health IT with regards to Blue Button, which is the iBlueButton mobile application. Humetrix is the health IT vendor which is responsible for shaking up the entire industry by introducing this revolutionary technology. Humetrix, a California based organization, revealed its iBlueButton 3.6 physician and consumer apps last October and won the national Blue Button ‘Mash Up’ Challenge. According to Todd Stein, the official spokesperson for Humetrix, thus far no one has been successful in making an application which makes a patient’s complete medical record accessible on their mobile device directly from their provider being solely under the patient’s control. As a result of this remarkable modernization, millions of military veterans and 37 million Medicare patients may now download their Blue Button medical record via their iPad or iPhone.

During a summit convened by the Bipartisan Policy Center in Washington DC, the National Coordinator for Health Information Technology (ONC) Dr. Farzad Mostashari was full of praise for the iBlueButton and its implication within the healthcare community. To quote, Dr Mostashari while sharing a personal story exclaimed that the iBlueButton “opened my eyes”. During a medical emergency pertaining to his father, Dr. Mostashari downloaded his father’s full medical record using the iBlueButton application. Upon obtaining the record, Dr. Mostashari shared it electronically with his father’s doctor who was astonished to see it, as this was unprecedented for him. Pleased with the resourcefulness of this app, Dr. Mostashari comments, “This is patient engagement at its best. This is the future of healthcare. I’m a doctor myself and when I first saw this, it was a real eye opener. I had first tried to download my father’s file from CMS’s Blue Button but it was everything I kind of feared – long, not pretty, it’s got all these codes that you don’t understand, the name of the provider is a number.”



EMR adoption and Meaningful Use

As the rate of EMR adoption grows across the country, physicians are beginning to express doubt regarding their ability in meeting the latest interoperability benchmarks.  According to a study, approximately fifty percent of hospital administrators across the U.S felt that their hospitals were ready to meet the set forth in Meaningful Use stage 1 requirements. However, the remaining fifty percent were uncertain about the readiness of their organizations to comply with the latest CMS guidelines.

While the American Recovery and Reinvestment Act (ARRA) was a clear attempt to lure practices into early adoption of an EMR system, it also initially created new revenue opportunities for IT vendors. These vendors now face a greater challenge because the second stage of Meaningful Use will require providers to actually perform the tasks that they merely needed the capability for in Stage 1. Most vendors assured their clients of their system’s compliance with stage 1, but stage 2 requires much more from these systems than many providers anticipated. Hence, industry experts suggest that doctors should start their stage 2 preparations right away, as they will require help from their staff, patients, hospitals and most importantly their EMR vendors in order to comply with stage 2.

Providers should initiate their practice evaluation process by assessing what they already have and what they need to purchase or upgrade. On one hand, it is encouraging to see the number of practices endorsing electronic documentation rising consistently. However on the other hand, a rush to adopt electronic medical records has led to unwarranted side effects, namely lack of training and poor quality of implementation. The eventual result of such incomplete implementation is that providers are unable to achieve the level of productivity and efficiency which can be expected from the usage of EMR technology, while this can also have a negative impact on the quality of patient care.

Meaningful Use stage 1 is currently under way, while stage 2 starts in January, 2014. Physicians will be required to adopt EHR technology and comply with the meaningful use criteria by October, 2014 or the payments they receive from Medicare will be reduced in 2015. Patient Portals are a major part of the stage 2 requirements and physicians will have to determine whether their current system has the functionality for patients like secure messaging, access to health information, lab results, ability to request prescription refills etc. Stage 2 will also be focusing on the exchange of health information to enhance care coordination along with information security and privacy. Providers will need to determine which regional; state or private health information exchanges will be involved in clinical data sharing.

Providers may have received incentives for stage 1 Meaningful Use compliance, but later stages will require greater commitment than initially anticipated by many. As a conclusion, it is evident that now is the time for action and providers must immediately direct their efforts towards the acquisition, implementation and utilization of an EMR solution, one that will consistently comply with any updates in the Meaningful Use requirements over the next few years.



EMR Implementation – The Expert Advice (Part 1)

With the government’s initiative to take healthcare into the new era of technology, practices of all sizes are vying to make the transition from paper to electronic documentation. For any practice seeking to make this conversion, a thorough analysis of their operations is required in order to assess how the implementation of an EMR solution should begin. Various operational aspects of the physician’s office have to be factored in prior to the beginning of the EMR implementation phase. Ray Parker, an EMR implementation specialist at a major health IT organization, gives us his take on the subject matter explaining the approach that practitioners should take in order to ensure a smooth execution of the system within their offices.

First and foremost, general practitioners and specialists alike have to identify the specific needs of their practices, while fully comprehending the reasons for conversion from paper to electronic medical records or a switch to a different EMR vendor. They have to ask whether they are looking to expedite documentation and reporting, and whether their existing solution inadequately equipped to handle these needs. Regardless of the motives driving physicians towards adoption, their eventual goal may well be common i.e. complying with Meaningful Use measures. If they are conforming to the standards set by CMS, the practice efficiency and expedition of operational processes is expected to improve by leaps and bounds. A significant determinant while finalizing your selection of the vendor should be the qualifications of the vendor organization (with special emphasis on the quality certifications) and subsequently judging the capability of the vendor in terms of meeting your practice requisites.

During the process of ascertaining the clinical and administrative requirements of the practice, some fundamental questions need to be answered and communicated with your vendor. For instance, how many clinicians are based within the practice, the workflows they follow, how many staff members need access to the system and what will be the corresponding training requirements etc? The practice has to be prepared beforehand to convey the entirety of its needs to their chosen service provider preceding a demo of the vendor system. For example a practice might want to stop getting paper faxes and want to receive their faxes electronically instead, or a practice may want to opt for an electronic lab interface with a local lab company. To help the vendor understand specific practice requirements, it’s very helpful to ensure that providers share their existing clinical data templates and specialty specific workflows before scheduling a demo with the vendor.

With respect to implementation, it’s of utmost significance that communication between physicians and vendors is crystal clear regarding data preservation requirements of the practice. Keeping into mind the legal ramifications of maintaining historical data (which varies from state to state), a provider has to aptly determine how much data has to kept and migrated. The vendor must be able to meet these necessities or propose appropriate alternatives to avoid unwarranted outcomes. Size and nature of their data plays a huge role at this stage, as clinical and billing data from older/outdated EMRs is very tedious to extract and even more complex to migrate. Apart from the data requisites of the practice, the clinician should also communicate any specific hardware requirements with their vendor. This provides an opportunity to the vendor to deal with any hardware compatibility problems that may arise at a later stage.