Across the Border of Interoperability

Note: This is part two of a two-part series on Direct messaging published by iHealthBeat. The first article focused on the decision of a large electronic health record vendor, eClinicalWorks, to negotiate one-off agreements with health information service providers, rather than to use the DirectTrust HISP network.

Some electronic health record vendors are creating challenges for providers by restricting the kinds of Direct messages their customers can receive or making it hard to open their attachments.

According to several sources, Epic Systems, the largest EHR company in the U.S., permits its users to receive only Direct messages that have clinical data architecture (CDA) attachments. These are care summaries in a particular format that must be used when providers exchange health information at transitions of care for the purpose of demonstrating meaningful use. The meaningful use Stage 2 rules require providers to exchange online care summaries in at least 10% of transitions, such as hospital discharges and referrals to specialists.

David Kibbe, president and CEO of DirectTrustThe main problem with Epic's approach, health information service providers (HISPs) and health care providers say, is that there are plenty of occasions when physicians need to send simple messages to other doctors about a patient they're both caring for. Clinicians might also want to exchange documents other than a care summary, such as an X-ray image or a PDF report.

Epic's restriction on the kind of Direct messages its users can receive "was a conscious development decision," Alan Swenson, a technical coordinator at Epic, wrote in a July 29 email to West Coast HISP, HIE and provider executives. "We only allow Direct messages where a valid CDA document is attached."

In a follow-up to his first email, Swenson wrote, "Our implementation [of Direct] at Epic has primarily been driven by what needed to be done in order to help the Epic community satisfy the requirements of meaningful use Stage 2. MU2 [Meaningful use Stage 2] requires CDAs, so we only send and we expect to receive CDAs."

Commenting on the emails, David Kibbe, president and CEO of DirectTrust, told iHealthBeat, "Swenson, and Epic by association, appear to be disregarding the concerns of parties who have legitimate reasons to exchange information with Epic customers, using Direct in its intended role as a general purpose technology for secure messaging with attachments." 

When asked about Epic's approach, Office of the National Coordinator of Health IT spokesperson Peter Ashkenaz said, "What is required for EHR certification is a baseline, and we hope that developers will offer EHR technology that will include other enhancements and go beyond the baseline to support their customer needs."

Multiple Vendors Are Doing It

Andy Heeren -- director of network IP for Cerner, a large EHR vendor that operates its own HISP -- and Chad Peterson -- technology manager for the North Dakota Health Information Network, a statewide health information exchange -- confirmed that Epic users are having the problems with Direct messaging described above.

"If you send an unstructured message to them, their EHR simply rejects it," Peterson said. "If you had a question about a [Continuity of Care Document] that you just received at your long-term-care facility and wanted to reply to the message, they wouldn't accept that reply." In addition, he said, the sender would not be informed that the message had not gone through.

Heeren said that other EHR vendors besides Epic are doing the same thing, although he wouldn't name them. "Some vendors have chosen to optimize just one use case for Direct, namely the attestation to meaningful use. So they require messages to have a CCDA attachment in order to be accepted. Not only does this exclude messages without attachments, but also messages bearing PDFs, images, and so on. Multiple vendors have these problems, but Cerner isn't one of them."

Epic Responds

Even if Epic is not alone in this approach, its huge reach gives it more influence in health care than any other health IT vendor.

Epic President Carl Dvorak, recently told a panel of the Health IT Policy Committee, which advises ONC, that Epic has taken a leadership role in increasing interoperability. Among other things, he said Epic has built 12,000 interfaces with 600 systems from other vendors, including 26 EHR suppliers. He added that Epic customers exchange 480,000 C-CDA documents per month with users of other EHRs.

Dvorak minimized the importance of Direct messaging in his remarks to the Policy Committee's panel. "It's clearly better than nothing," he said, but it doesn't help providers locate patient information during unplanned episodes of care, such as visits to the emergency department.

Asked to comment on the difficulties some providers have had in sending Direct messages to Epic users, Dvorak in an email to iHealthBeat wrote, "Epic can receive a variety of messages through the Direct Protocol standard, and health care organizations that use Epic are successfully receiving these messages now. For example, St. Joseph’s Hospital Health Center in New York receives PDFs from other EHR systems."

He added, "When we first released support for Direct, we chose to get C-CDA capabilities to our customers right away. At that time, the software accepted only certain messages (C-CDA, CDA/CCD and CCR documents). In May of this year, we added support to receive plain text messages, PDFs and CDA-wrapped PDFs. The Epic system can receive each of those types as standalone messages or with other attachments."

According to Dvorak, Epic customers can configure their systems to receive only certain kinds of Direct messages. He said, "For example, a health system might decide it only wants to receive structured data."

But that doesn't explain why HISP and HIE executives across the country say that Epic customers are still unable to receive non-CCD-A-bearing Direct messages. It also doesn't explain Swenson's emails, which are dated July 29, two months after Epic says it made its Direct update available to its client base.

Other Direct Issues

GE's Centricity EHR has a different but no less curious problem: At some user sites, it accepts only Direct messages with the address all in caps. This might be considered silly, but senders who are unaware of this wrinkle might send a message with a header in a different format and they won't even be informed when the message doesn't go through.

Peterson cited a Mayo Clinic ambulatory site that uses GE Centricity. Some North Dakota HIE participants wanted to send Direct messages to the Mayo Clinic from a different EHR. The North Dakota doctors knew about the all-caps requirement. But Orion, the HISP that the HIE uses, was automatically changing the addresses to lower case, and the messages were being rejected. Now the HIE is trying to straighten things out.

A GE Healthcare spokesperson acknowledged that the Mayo Clinic has had a problem with the Direct address format and said that it is being fixed. She added that Mayo was the only GE customer that has had such a problem.

Other EHR vendors have made it difficult to open attachments to Direct messages because of a misinterpretation of the government's Direct messaging criteria, Heeren said.

Certification for meaningful use requires that EHRs be able to exchange Direct messages with a conventional CCD-A attachment, he said. But in addition, they're allowed to send attachments in XDM metadata wrappers that count toward the meaningful use requirement. Unfortunately, some vendors have made the latter their only communication option. Other EHRs can't necessarily unzip those files, because they're not required to do that for certification. They can receive the messages, but the attachments have to be manually unzipped.

Will Direct Survive?

As this two-part series has shown, Direct messaging is going through growing pains.

Yet Heeren argued that the challenges are predominantly content-based and have nothing to do with the Direct protocol itself, which is mostly working well. Meanwhile, he noted that many EHR vendors have implemented Direct capabilities in the field and that there has been tremendous growth in Direct messaging.

Providers served by DirectTrust HISPs have exchanged 7.7 million Direct messages since the beginning of this year, according to the association.

There are questions, however, about whether Direct messaging will outlast the meaningful use program.

Girish Navani, CEO of eClinicalWorks, said he believes that Direct messaging should be free, because he doubts doctors will pay for it after they collect their last government checks. If most HISPs continue to charge providers for their services, he doubts Direct will survive in the long term.

The other issue is whether EHR vendors will allow Direct to take hold by making it easy to use and available for exchanging data with all providers who have Direct addresses. If Direct ever replaces faxes and allows widespread point-to-point interoperability, it will become part of clinicians' daily workflow. But if vendors don't allow that to happen, another tool for increasing interoperability might be lost.

Meanwhile, Martha Sullivan -- CIO of Harrison Memorial Hospital in Cynthiana, Ky., which has been unable to Direct-message with its doctors -- said she's still seeking "a permanent solution for bidirectional exchange of Direct messaging through our HISP, which is ICA, and eClinicalWorks."

Referring to the alternative of using a Web portal that ONC suggested to her hospital, she declared, "We are not looking for a temporary solution, but a solution that brings together the interoperability that is needed within health care. We still feel held hostage at the border."