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The Other Talk: EHRs and Advance Medical Directives

Posted on September 11, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

The Other Talk: EHRs and Advance Medical Directives

Most of us who have adult children can remember that awkward talk we had about life’s origins. We thought, whew, that’s done. Alas, there’s yet another talk. This time it’s with those adult children and it’s about you.

This one’s covered in Tim Prosch’s and AARP’s book, The Other Talk. The talk, or more accurately the process is how you want to spend the rest of your life.

The Other Talk

It’s about your money, where and how you’ll live and your medical preferences. It’s just as hard, if not harder, than the old talk because:

  • It’s hard to admit that you won’t be around forever and your independence may start to ebb away.
  • You don’t want to put your kids on the spot with difficult decisions.
  • Your children may be parents coping with their own problems. You don’t want to add to their burdens.
  • You’ve been a source of strength, often financial as well as emotional. That’s hard to give up.

Prosch and AARP want to make it easier on everyone to deal with these issues.

He covers many topics, but for those of us who live in the EHR world one is of significant importance: Medical directives.

Prosch explains directives and simply says you should give them to your doctor. Easier said, etc. Today, that means not only your PCP, but also making sure that hospitalists etc., know what you want. While the Meaningful Use program helps a bit. It’s still going to take some doing.

Medical Directives and EHRs

EHR MU1 recognizes directives’ importance requiring that they be accounted for:

More than 50% of all unique patients 65 years old or older admitted to the eligible hospital’s or CAH’s inpatient department have an indication of an advance directive status recorded.

This means that the EHR has to have the directives. However, MU 1 only goes halfway to what’s needed. It’s what the EHR does with directives that’s unsaid.

If the EHR treats a directive as a miscellaneous document, odds are it won’t be known, let alone followed when needed. To be used effectively, an EHR needs a specific place for directives and they should be readily available. For example, PracticeFusion recently added an advance directives function. That’s not always the case.

Practice Fusion: Advanced Medical Directives

Googling for Directives

To see how about twenty popular EHRs treat directives, I did a Google site search, on the term directive. I got hits for a directives function only from four EHRs:

  • Athenahealthcare
  • Cerner
  • Meditech
  • PracticeFusion

All the others, Allscripts, Amazing Charts, eClinicalWorks, eMDs, McKesson, etc., were no shows. Some listed the MU1 requirement, but didn’t show any particular implementation.

Directives: More Honored in the Breech

This quick Google search shows that the EHR industry, with a few exceptions, doesn’t treat directives with the care they deserve. It should also serve as a personal warning.

If you already have directives or do have that talk with your family, you’ll need to give the directives to your PCP. However, you should also give your family copies and ask them to go over them with your caregivers.

Some day, EHRs may handle medical directives with care, but that day is still far off. Until then, a bit of old school is advisable.

Do We Really Like the JASON Recommendations for Interoperable Health Data?

Posted on August 28, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The health IT community has been abuzz over the past few months about a report released by the Agency for Healthcare Research and Quality. Although the report mostly confirmed thoughts that reformers in the health IT space have been discussing for some time, seeing it aired in an official government capacity was galvanizing. The Office of the National Coordinator has held several forums about the report, known by the acronym JASON, and seems favorably inclined toward its recommendations.

Even though only four months have passed since its publication, we can already get some inkling of how it will fare at the ONC, which is going through major realignment of its own. And to tell the truth, I don’t see much happening with the JASON recommendations. In this article I’ll look at what I see to be its specific goals, and what I’ve heard regarding their implementation:
Read more..

One Physician’s Experience Seeing an Ophthamalogist Pre and Post EHR

Posted on August 27, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I always love to hear doctor’s perspectives on EHR and how they’re impacting their day. You can be certain that they’ll lead with a long list of complaints. Many of the initial complaints are minor things that can be easily resolved with workflow or by a small enhancement by the EHR vendor. Once you get past the initial complaints, then you get to the heart of what they really think about the EHR software. I’ve had this experience hundreds of times and it’s always insightful.

However, this time a doctor shared something even more interesting. This was a doctor visiting another doctor as a patient. Rather than put words in his mouth, I’ll just share with you what he shared with me (EHR vendor name excluded since this could apply to many different EHR vendors):

I was in my ophthalmologist today. He is a really nice, busy doctor. He is in group practice and used to run his wing with one long time nurse with no hassles. He could previously see a patient in 10 min finish refraction, move from room to room and breeze through cases jotting what he needed to write down on one clean ophthalmology SOAP note. Since 2011 they have had EHR Vendor A. (because a consultant sold them on it and promised rewards from CMS)

Today, It took them a total of 1.5 hours to get my refraction, eye exam done. The workflow seemed to be in a complete disarray (remember this is an installed cloud based software since 2011, supposed to the be cream of the crap for Ophthalmology). What shocked me the most was that he now has 4 ladies doing inane things with EMR, trying to help him. I can also see why errors can creep in because he was reading out numbers for the assistant/ Nurse to enter into EHR Vendor A. Distraction fatigue, EMR ennui can cause errors of entry. So the cost of running crappy software far exceeds the physical costs / monthly service costs of the product. It amplifies personnel costs. It took the lady 20 minutes to take totally pointless history and do ROS!

I did not tell her I was a physician and she was clicking away to glory. I counted more than 50 clicks before anything of substance was even gathered. Based on the EMR prompts she made me do finger counting and asking me if I can see her face etc..>! I had clearly indicated to her that I just wanted a retinal exam and prescription for glasses because I wanted to buy new lenses and that I had not required change of prescription for glasses in 10 years!

Then I walk out with mydriatic in my eyes…and saw a hazy illusion of one of my ex-patients, a severe schizophrenic waiting for his turn to be checked in. He was talking about meeting Jesus and asked if I have had a “meeting Jesus moment” in my life.. I assured him I just did…

In those 1 hr and 45 min, the good doctor had seen just 4 patients and 6 more were still waiting impatiently on one arse looking irate, checking their iphones and smart watches …spreading anxiety.

I’m always torn on sharing these type of stories. I know that this doesn’t have to be the case since I know many EHR users who don’t have these issues. However, far too many of them do that it’s worth keeping this perspective in mind. Plus, regardless of how efficiently someone has incorporated the MU requirements, it’s had a huge impact on everyone that’s participating.

I guess it’s fair to say that the above ophthamologist doesn’t agree that meaningful use saves a doctor time.

Ten-year Vision from ONC for Health IT Brings in Data Gradually

Posted on August 25, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

This is the summer of reformulation for national U.S. health efforts. In June, the Office of the National Coordinator (ONC) released its 10-year vision for achieving interoperability. The S&I Framework, a cooperative body set up by ONC, recently announced work on the vision’s goals and set up a comment forum. A phone call by the Health IT Standards Committeem (HITSC) on August 20, 2014 also took up the vision statement.

It’s no news to readers of this blog that interoperability is central to delivering better health care, both for individual patients who move from one facility to another and for institutions trying to accumulate the data that can reduce costs and improve treatment. But the state of data exchange among providers, as reported at these meetings, is pretty abysmal. Despite notable advances such as Blue Button and the Direct Project, only a minority of transitions are accompanied by electronic documents.

One can’t entirely blame the technology, because many providers report having data exchange available but using it on only a fraction of their patients. But an intensive study of representative documents generated by EHRs show that they make an uphill climb into a struggle for Everest. A Congressional request for ideas to improve health care has turned up similar complaints about inadequate databases and data exchange.

This is also a critical turning point for government efforts at health reform. The money appropriated by Congress for Meaningful Use is time-limited, and it’s hard to tell how the ONC and CMS can keep up their reform efforts without that considerable bribe to providers. (On the HITSC call, Beth Israel CIO John Halamka advised the callers to think about moving beyond Meaningful Use.) The ONC also has a new National Coordinator, who has announced a major reorganization and “streamlining” of its offices.

Read more..

Rep. Phil Gingrey Comes After Healthcare Interoperability and Epic in House Subcommittee

Posted on July 30, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

On July 17th, the House Energy and Commerce Committee’s subcommittee on Communications and Technology and Health (that’s a mouthful) held a hearing which you can see summarized here. Brought into question were the billions of dollars that have been spent on EHR without requiring that the EHR systems be interoperable.

In the meeting Rep. Phil Gingrey offered this comment, “It may be time for this committee to take a closer look at the practices of vendor companies in this space given the possibility that fraud may be perpetrated against the American taxpayer.”

At least Rep. Gingrey is a former physician, but I think he went way too far when he used the word fraud. I don’t think the fact that many EHR vendors don’t want to share their healthcare data is fraud. I imagine Rep. Gingrey would agree if he dug into the situation as well. However, it is worth discussing if the government should be spending billions of dollars on EHR software that can’t or in more cases won’t share data. Epic was called out specifically since their users have been paid such a huge portion of the EHR incentive money and Epic is notorious for not wanting to share data with other EHR even if Judy likes to claim otherwise.

The other discussion I’ve seen coming out related to this is the idea of de-certifying EHR vendors who don’t share data. I’m not sure the legality of this since the EHR certification went through the rule making process. Although, I imagine Congress could pass something to change what’s required with EHR certification. I’ve suggested that making interoperability the focus of EHR certification and the EHR incentive money is exactly what should be done. Although, I don’t have faith that the government could make the EHR Certification meaningful and so I’d rather see it gone. Just attach the money to what you want done.

I have wondered if a third party might be the right way to get vendors on board with EHR data sharing. I’d avoid the term certification, but some sort of tool that reports and promotes those EHR vendors who share data would be really valuable. It’s a tricky tight rope to walk though with a challenging business model until you build your credibility.

Tom Giannulli, CMIO at Kareo, offers an additional insight, “The problem of data isolationism is that it’s practiced by both the vendor and the enterprise. Both need to have clear incentives and disincentives to promote sharing.” It’s a great point. The EHR vendors aren’t the only problem when it comes to not sharing health data. The healthcare organizations themselves have been part of the problem as well. Although, I see that starting to change. If they don’t change, it seems the government’s ready to step in and make them change.

The Impact of Meaningful Use on EHR Development

Posted on July 22, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been getting a really strong response to my post calling for EHR vendors to expand their definition of customer service. Although, the title doesn’t do the post justice since I also talk about the impact of meaningful use on EHR development. Many of the readers of EMR and HIPAA (and if you don’t read EMR and HIPAA you should go subscribe to the emails now) have highlighted some important points I wanted to share with a broader audience.

First, Peggy Salvatore provides this insight about the impact of billions of dollars of EHR incentive money:

Almost 15 years ago, I wrote material for Intel (the computer chip company) based on research they were doing on physician workflow to make EHRs more usable. It was one of the early efforts to tackle this issue. I mention this to say that a lot of spade work has been done in this field but (in my humble opinion) government regulation has gotten in the way of software businesses trying to build electronic patient record products that work for the end users. Experience has shown time and again that customers will drive product improvements, and the same is true in the healthcare industry as in all others. The government has wasted tens of billions of dollars requiring systems be installed to meet timelines that were not realistic given the budgets and time available, or, to this point, to install products that were not really ready for prime time. Let the customers – in this case – the providers and the patients – drive development and you will end up with products that solve problems, not create them.

Brenden Holt, CEO of Holt Systems, offers this startling commentary on the EHR industry:

To me it is more clear. EHR Vendors, large and small and all points in between are currently working on the support nightmare (R&D and Direct Support) of Meaningful Use. It is the same when CCHIT was coming out, and not much different then the 100′s, if not 1000′s, of current copy cat products, all in one way or another a copy of the master Logician (GE).

Innovation does not bring in customers in the current environment. Government Adherence and more importantly relationships (Marketing and Sales) accomplish this. That is to say products need to be improved upon, but only to the extent of meeting the Government Regulatory Demands and the demands of the Large Organizations that are buying these things in bulk.

Innovation is available, but more then likely will take some time, as will thinking of how we document patient care as a whole, which is antequated methodology.

So as a CEO of a software company, one in the sea of many, I will say, innovation will happen when the phones get off the hook form highly demanding end users who want to make sure the MU is met and a Government Final Ruling that will get Government out of Development. Government is a terrible manufacture of innovation. One other major issue is that the end users don’t really want to pay for the innovation, if the EHR is working they are happy with the LOB application. That in and off itself is a issue, new features don’t translate to higher fees, the opposite is the case, less features in a Free Package can be much more attractive as both meet the basic LOB requirements.

We are the US, as much as the rest of the world tries, inguinity is what makes us great, our leading export, but in this vertical it is all but dead.

Catherine Huddle offered this insight about MU not just derailing EHR development innovation, but also possibly making things worse:

As for MU, as an EHR vendor I would agree that it and related government programs such as PQRS and PCMH have significantly derailed most other product development. Not only was Stage 2 a development “hog” but it brought in required changes that are often unnatural in a practice’s workflow and overly complicated.

MU has changed the goal from delivering what providers need to finding the best way to deliver MU to make it easiest for the providers and other staff – while still trying to make other improvements to the EHR. Unless the government repeals MU and the Medicare penalties the winning EHRs will be the ones that make MU as easy as possible.

While there’s plenty to be pessimistic about what’s happened with EHR, I’m still optimistic that we’ve passed through the meaningful use waters and that the future will bring forth opportunity for EHR development innovation. I’m hopeful (although not 100% certain) that the people in Washington have seen the toll that meaningful use has paid on the industry and they’ll lighten the load so that EHR vendors can start listening to end users instead of regulators.

Meaningful Use Stage 2 Saves Doctors’ Time

Posted on July 21, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I recently saw an older document from an EHR vendor that outlined some reasons why a doctor should take part in meaningful use stage 2. They suggested that meaningful use stage 2 would save our healthcare system money, save doctors’ and hospitals’ time and save lives.

All of these are noble goals worthy of consideration. If meaningful use could achieve this triple aim, then I think every doctor and healthcare organization would happily hop on this new triple aim. Let’s look at each and see how meaningful use stage 2 is doing with this meaningful use stage 2 triple aim:

Save Our Healthcare System Money – This one is interesting because many of the doctors I talk to are afraid that this is exactly what’s going to happen with meaningful use stage 2. They’re deeply afraid that meaningful use is really a way for the government to get access to a physician’s data so that they can pay the physician less. You have to remember that if we save the healthcare system money that means that some organization is going to get paid less.

While I think that the fear these doctors portray is a little overstated, it is true that the government wants the data to be able to pay people using that data. One could argue that a doctor doing good work has nothing to fear and it’s only the crooks that are over billing for their services are the ones that have to worry. Although, we know that data isn’t perfect and there will be collateral damage. I would just argue that the government doesn’t know what to even do with the data right now. So, we won’t see this change happen in the near future. We’ll see if they can achieve this goal long term.

Save Doctors’ and Hospitals’ Time – This suggestion is so ridiculous that I had to make it the title of the post. What I think is possible is that EHR adoption can save an organization time, but I think we need to be careful substituting EHR adoption with meaningful use. Sure, the EHR incentive money has pushed EHR adoption forward, but any time savings that has come from EHR adoption has been lost to the meaningful use check boxes that are required.

Save Lives – Once again, with this one you have to balance the idea of EHR adoption against meaningful use adoption. However, I am hopeful that things like clinical decision support, ePrescribing (ie. legible prescriptions) and a myriad of other things can save some people’s lives. This is hard to quantify, track and measure and so I don’t think we really know. I think there are anecdotal stories of times where care was improved and even lives saved because of something in an EHR. Certainly there’s also some evidence that EHRs can make care worse. Although, I think that is usually just as anecdotal as the lives saved. For now, I’d say this is a bit of a wash, but long term I like the potential of what EHRs can do to save lives. Although, I’m not sure that MU will be the basis for the lives saved.

Comical Patient Portal Discussion

Posted on July 14, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve long been interested in how offices communicate their use of an EHR and patient portal to their patients. Long time readers might remember this EMR Under Construction sign that one office used.

I had a doctor send me this email exchange which isn’t necessarily a great suggestion for a practice, but it does illustrate many physicians view of what’s happening with EHR and patient portals:
Comical Patient Portal Comments
I’ll call back to Carl Bergman’s post asking “Has EHR Become a Bad Brand?” I think many doctors consider the EHR and patient portal as one thing. Of course they’re not always the same, but emails like this illustrate how the patient portal and EHR brand are doing…not so well. Although, my guess is that meaningful use has an even worse image in the eyes of doctors.

Safety Issues Remain Long After EMR Rollout

Posted on June 24, 2014 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @annezieger on Twitter.

The following is a bit depressing, but shouldn’t come as a surprise. A new study published in the Journal of the American Medical Informatics Association has concluded that patient safety issues relate to EMR rollouts continue long after the EMR has been implemented, according to a report in iHealthBeat.

Now, it’s worth noting that the study focused solely on the Veterans Health Administration’s EMR, which doubtless has quirks of its own. That being said, the analysis is worth a look.

To do the study, researchers used the Veterans Health Administration’s Informatics Patient Safety Office, which has tracked EMR safety issues since the VA’s EMR was implemented in 1999.  Researchers chose 100 closed patient safety investigations related to the EMR that took place between August 2009 and May 2013, which covered 344 incidents.

Researchers analyzed not only safety problems related to EMR technology, but also human operational factors such as workflow demands, organizational guidelines and user behavior, according to a BMJ release.

After reviewing the data, researchers found that 74 events related to safety problems with EMR technology, including false alarms, computer glitches and system failures. They also discovered problems with “hidden dependencies,” situation which a change in one part of the EMR system inadvertently changed important aspects in another part of the system.

The data also suggested that 25 other events were related to the unsafe use of technology, including mistakes in interpreting screens or human input errors.

All told, 70% of the investigations had found at least two reasons for each problem.

Commonly found safety issues included data transmission between different parts of the EMR system, problems related to software upgrades and EMR information display issues (the most commonly identified  problem), iHealthBeat noted.

After digging into this data, researchers recommended that healthcare organizations should build “a robust infrastructure to monitor and learn from” EMRs, because EMR-related safety concerns have complicated social and technical origins. They stressed that this infrastructure is valuable not only for providers with newly installed EMRs, but also for those with EMRs said that in place for a while, as both convey significant safety concerns.

They concede, however, that building such an infrastructure could prove quite difficult at this time, with organizations struggling with meaningful use compliance and the transition from ICD-9 to ICD-10.

However, the takeaway from this is that providers probably need to put safety monitoring — for both human and technical factors — closer to the top of their list of concerns. It stands to reason that both newly-installed and mature EMR implementations should face points of failure such as those described in the study, and they should not be ignored. (In the meantime, here’s one research effort going on which might be worth exploring.)

What Does Direct Messaging Look Like for MU2?

Posted on June 11, 2014 I Written By

Julie Maas is Founder and CEO of EMR Direct, a HISP (Health Information Service Provider) whose mission is to simplify interoperability in healthcare through the use of Direct messaging EHR integration and other applications. EMR Direct works with a large developer community to enable Direct for MU2 and other workflows using a custom, rapid-integration API that's part of the phiMail Direct Messaging platform. Julie is passionate about improving quality of care and software user experience, and manages ongoing interoperability testing within DirectTrust. Find Julie on Twitter @JulieWMaas.

I’m often asked what EHR integrations of Direct are supposed to look like.  In the simplest sense, I liken it to a Share button and suggest that such a button—typically labeled “Transmit”—be placed in context near the CCDA that’s the target of the transmit action, or in a workflow-friendly spot on a patient record screen.

Send a CCD Using Direct Messaging

Send CCD using Direct in OpenEMR

The receive side is similarly intuitive: the practice classifies how their incoming records are managed today and we map that process to one or more Direct addresses.  If we get stuck, I ask, “What is the workflow for faxes today–how many fax numbers are there, and how are they allocated?”  This usually helps clear things up:  as a starting point, a Direct address can be assigned to replace each fax endpoint.

The address structure raises an important question, because it is tightly tied to the Direct messaging user interface.  Should there be a Direct address for every EHR user?  Provider?  Department? Organization?  A separate address for the patient portal?  A patient portal that spans multiple provider organizations? One for every patient?

The rules around counting Direct messages for Transitions of Care (ToC) attestation do not require each provider to have their own Direct address, as long as the EHR can count transactions correctly for attestation.  As far as meaningful use is concerned, any reasonable address assignment method should be acceptable in ToC use cases (check the rules themselves, for full details).  Here are some examples.

records@orthodocs.ehrco-example.com is clearly an address that could be shared by multiple users, though it could be used by just one person, and might be used for both transitions of care and patient portal transmit.

janesmith@orthodocs.hisp-example.com could also be dual-purpose.  Jane might be the only authorized user of this address, or this address may be managed by a group of people at her practice that does not necessarily even include Jane.  Alternatively, this address could be used for Jane’s ToC transactions, while a patientportal@someother.domain-example.com address could be used for patient portal transmit.

So, any of the options proposed above are possible conventions for assigning Direct addresses.  Also, a patient does not need their own Direct address to Transmit from as part of the View, Download, Transmit measure (170.314(e)(1)), but might have their own address to transmit to.  Note that adding a little extra data can elevate a View, Download, Transmit implementation to BlueButton+ status.

It makes sense for patients and providers to have their own Direct addresses if they are using Direct for Secure Messaging – 170.314(e)(3) – for which Direct is an optional solution.  Or, if patients have their own Personal Health Record (PHR) and Direct address, Direct is a great way to deliver data to the PHR.  Incidentally, there are free services such as Microsoft HealthVault and many others that issue patient Direct addresses.

Direct addresses are nearly indistinguishable from regular email addresses, but a word of caution: Direct is incompatible with regular email, and has additional requirements beyond traditional S/MIME.  Although it’s not a requirement, you’ll often find the word “direct” somewhere in the domain part of a Direct address, to help distinguish a regular email address from a Direct address.

Now that you know what Direct is, and what Direct Messaging and Direct addresses look like, I’m sure you’ll start noticing Direct popping up in more and more places.  So, be a not-so-early adopter and go get yourself a Direct address!