Case Analysis 2

Please, write 3 pages 12 point font double spaced
Info 731 – Case Analysis 2
Please review the attached case study and answer following 2 questions using the concepts
covered in the class material.
1) Identify and analyze the risks for MedAllies project for implementing DIRECT exchange
among Hudson Valley providers using EHRs. (Suggestion – Include risk register to frame
your response)
2) One of the biggest challenges during this project was managing multi-vendor and multiprovider organizations team. Please outline & justify your approach in managing the crossorganizational team for the MedAllies project to ensure successful delivery.
Note – if you would like to learn more about the DIRECT exchange, please visit
The response to case analysis questions will be graded for
– Detailed understanding of the MedAllies Direct project & insights from the project
– Originality of opinions and clear expression of the same
– Usage of the weekly class materials from week-1 through week-7
– Referencing concepts from assigned readings
Response Format –
Please record the care analysis response as word document which is at minimum 1 page and
should not exceed 3 pages excluding appendix if any. The text should be in 11 pt font size and 1.5
Submission process –
Please submit the word document through blackboard assignment section.
MedAllies and the Direct Project Support
Secure Exchange of Clinical Information
in EHR Systems
Hudson Valley, NY – Fall 2012
Source – – Health Information Exchange case Studies
MedAlliesWeb Site Disclaimers established in 2001, is located in the Hudson Valley of New York
and specializes in electronic health record (EHR) implementations. They are also a Health
Information Service Provider (HISP), providing the infrastructure to enable secured sharing of
health information among providers.
In 2010, MedAllies joined the Direct Project to help define new protocols for sharing health
information. This effort consisted of approximately 200 volunteer participants from more than 60
private-sector companies and organizations. Through the Direct Project, MedAllies and the other
participants developed consensus standards that support secure exchange of basic clinical
information and public health data. In 2010, the Direct Project selected the Hudson Valley as one
of seven pilot sites to demonstrate health information exchange (HIE) using Direct standards.
MedAllies and the Direct Project
In 2007, MedAllies joined with two other Hudson Valley healthcare organizations — the 5,000-
physician Taconic IPAWeb Site Disclaimers (TIPA) and the community health information
exchange,THINCWeb Site Disclaimers — to form the Hudson Valley InitiativeWeb Site
Disclaimers . Their goal was to improve health care quality through advancements in patient care
delivery models, payment reform, and health IT tools. Through the Hudson Valley Initiative,
MedAllies assisted physicians in implementing EHRs and helped primary care providers become
patient-centered medical homes (PCMH). When MedAllies became one of the Direct pilot sites,
they began working with regional medical centers to implement Direct and establish a strategy to
advance Direct adoption across the Hudson Valley. By that time, the region was ideal for the pilot
because it already had a high concentration of healthcare organizations invested
in PCMH and EHR adoption initiatives.
According to MedAllies, results of a 2012 survey showed that EHR adoption in the Hudson
Valley is 82% and is estimated to reach 93% within the next 12 months.
In this environment of advanced primary care with an increased focus upon care coordination,
physicians were eager to move beyond fax machines and start sharing health information
electronically with each other.
Engaging Providers with EHR Systems and Vendors
MedAllies was met with great enthusiasm and support as they began engaging Hudson Valley
providers to participate in the Direct pilot. Their approach was to focus on the EHRsystems and
build Direct capabilities into the existing clinical environment, requiring only minimal enhancements
to current clinical workflows and EHR functionality in hopes of reducing provider impact.
A. John Blair III, MD, CEO of MedAllies, Inc. and president of TIPA explained: “From day one, we
were focused on the end user and the provider. We said, ‘Okay, we need to figure out a way, using
their current EHR systems, with minimal modifications to workflow, and minimal changes in
functionality, how doctors can leverage their EHRs to transmit these messages.”
To figure this out, MedAllies met with both providers and vendors and asked “How do we make this
work for you?” During these working sessions, they:
• Identified pilot use cases
• Created storyboards to identify key users and functions
• Reviewed EHR functionality and existing workflows
• Determined best practice workflows
This process allowed MedAllies to work with participating vendors to customize EHR functionality
for the pilot. Once these capabilities were built into the EHRs, they then tested sending Direct
messages through the MedAllies HISP. Among other venues, these capabilities were
demonstrated at the 2011 and 2012 HIMSSWeb Site Disclaimers Interoperability showcases.
MedAllies has worked with vendors, such as Allscripts, Epic, Greenway, NextGen, and
Siemens, to customize EHR functionality and incorporate Direct into existing clinical workflows.
Today, approximately 20 providers and two vendors are participating in the MedAllies Direct pilot.
Each of these participants is committed to improving care coordination and care transitions in the
Hudson Valley through the use of Direct exchange.
Choosing the Use Cases
MedAllies evaluated the critical needs in the region when selecting the use cases for their Direct
“Patients are particularly vulnerable when they are transitioning across care environments, such as
being referred from their primary care provider to a specialist for a consultation, or at the time of
discharge from the hospital when the patient returns back to the care of the patient’s primary care
team. Critical information is required for the next provider to appropriately care for the patient, but
today that doesn’t always happen.” – Dr. Holly Miller, Chief Medical Officer of MedAllies
Through discussion with providers, MedAllies determined that there was a need for provider-toprovider communication during transitions of care. Three use cases, which MedAllies believed
were critical care transitions, were selected for the Direct pilot. The scenarios included:
1. Upon discharging a patient from an inpatient environment, the hospital sends a discharge
summary to the patient’s primary care physician.
2. A primary care physician refers a patient to a specialist (Part 1 of the closed loop referral).
3. After seeing the patient, the specialist returns a care summary back to the primary care
physician (Part 2 of the closed loop referral).
MedAllies believed that the Direct project could greatly improve these three transitions of care
scenarios. Through the pilot, Hudson Valley physicians would have the ability to send and receive
care summaries or discharge summaries immediately after a visit in a secure and efficient manner.
The importance of timely discharge and care summaries was in even more demand due to the high
level of Patient-Centered Medical Homes (PCMH) in the Hudson Valley.
Dr. Miller offered a scenario showing how Direct supports this type of advanced primary care:
At discharge from the hospital, many of a patient’s medications have been changed. He returns
home, where he has all of his medicines—those he had before hospitalization and those he
received at discharge. He may be a little confused about which ones he should be taking. Recall
about medical information is often poor and inaccurate, especially when the patient may be slightly
cognitively impaired, has multiple medical problems and is being treated with numerous
medications, or is anxious; research suggests patients retain about half of the information given by
health care providers.
With Direct, those medication changes are recorded and a new, reconciled medication list has
already arrived at his primary care practice before the patient has even left the hospital. If the
patient is deemed a high-risk patient he may have a care manager assigned to him. The care
manager can call the patient the same day he returns home, review his medications, tell him which
drugs to discard and reinforce which ones he should be taking. The care manager reviewing the
updated list with the complex patient can prevent re-hospitalization or adverse events through this
simple follow up, armed with the appropriate information regarding the care transition.
Direct exchange offers many benefits to both patients and providers:
• Prevents re-hospitalization, adverse events, or even death
• Ensures care team members have the most up-to-date, accurate information about a patient
• Enhances care efficiency
• Helps control health care costs
Implementing Direct in the Hudson Valley
Unlike some Direct pilots that developed a new user interface for Direct exchange, MedAllies
sought to provide Direct functionality within the EHR systems with which physicians were already
interacting. They held working sessions with the EHR vendors to design this Direct functionality,
including messaging capabilities, provider directory functions, and encryption services, and then
worked with them to connect to the MedAllies HISP. Since vendors built this functionality into the
EHR system itself, there was very little to no effect on existing clinical and EHR workflows. As a
result, all participating providers quickly adopted Direct and began exchanging information via the
MedAllies HISP within one to three months.
To foster communication between health systems, MedAllies implemented the full Direct
infrastructure for the pilot, including both the required SMTP backbone and the XD* elective
protocol. For certificates, MedAllies chose to obtain certificates from Certificate Authorities that are
cross-certified with the Federal Bridge Certificate Authority.
The capabilities for each actor participating in MedAllies’ Direct exchange include:
Source Capabilities (EHR)
• Create message payload (most systems use HITSP C32 format).
• Provide basic provider directory services (the Direct addresses for participating providers were
manually loaded into the EHR system).
• Communicate to MedAllies HISP using XDR or S/MIME encrypted IHE-XDM package.
HISP Capabilities
• Integration of Direct address lookup with CONNECT HL7 v3 based architecture – Integrating
vendors can obtain Direct addresses from MedAllies HISP using PIX or PDQ transactions (HL7
• Inter-conversion (Step-up/Step-down) between SMTP and XDR message/XDM package for
delivery based on destination capabilities (i.e. can send to destinations that support just Direct
S/MIME& SMTP, or just support XDR/XDM as transport mechanisms.
Destination Capabilities (EHR)
• Receive and decrypt Direct message using XDR or SMTP client (S/MIME Encrypted XDM
• Ingest the HITSP C32 document (or other payload attached to the message) and incorporate in the
clinical workflow.
One challenge that MedAllies faced in implementing the pilot was that most out-of-the-box EHRs
do not have built-in Direct capabilities. In some cases, even though modules existed to foster
communication with other providers (such as referral templates), no capability had been included to
leverage this functionality for Direct messaging. MedAllies had to work with vendors to design and
build such solutions for the pilot.
MedAllies explained that additional functionality, such as filtering and integration capabilities, are
very important, but also lacking in some EHRs. Physicians would like the ability to use filters to limit
the amount of information extracted from the EHR prior to sending a message. This ensures that
the receiving provider only gets the clinically relevant details of a visit, or in clinical terms: the
pertinent positives and negatives. Physicians would also like the ability to select discrete data
received through Direct and integrate it into a patient’s record within their EHR. The ability to
customize Direct messages and incoming data enhances current clinical provider-to-provider
communication. Ultimately, it allows providers to offer better care to patients across care transitions
because they are accessing the most relevant and current information on the patient.
MedAllies noted that participating EHR vendors were extremely responsive to provider’s requests
and are eager to incorporate more Direct functionality into their systems. They recognize that this
work is an important step to facilitate the exchange of health information.
Successes of Direct Functionality in EHR Systems
Due to their EHR-centric approach, MedAllies succeeded in implementing a Direct pilot in the
Hudson Valley that required minimal changes to clinical workflows. Another benefit of this
approach was that it required little user training, as providers were already trained on their EHR
systems, and the introduction of Direct messaging did not significantly alter the current
provider/end-user roles and responsibilities. With this approach, MedAllies received an
overwhelming response from Hudson Valley providers.
“Direct is the holy grail of consultative medicine – being able to effortlessly transmit information
back and forth. This is a home run. It’s different from other methods of communicating, such as
email or fax, because it is coming right into my EHR, the focal point of all of my clinical workflow
and communication.” – Ferdinand J. Venditti, Jr., MD
Since the pilot kicked off, MedAllies has seen a dramatic increase in demand from providers who
want to participate in the pilot. Now when MedAllies goes to organizations they work with, providers
are asking when they will be able to start using Direct.
Also as a result of the pilot, EHR vendors have been extremely responsive to requests to
incorporate more Direct functionality into their systems. As more clinicians adopt Direct and
additional Meaningful Use requirements are released, MedAllies expects to see more EHR
development supporting Direct. Ultimately, this will help EHR vendors deliver more user-friendly
systems and maintain a competitive edge in the marketplace.
Lessons Learned
o Having executive sponsors speak optimistically about Direct and obtaining end user buy-in were
critical aspects in developing the pilot. To obtain this buy-in, MedAllies focused on incorporating
Direct into participating organization’s key functions and workflows.
o Providers were more willing to adopt Direct if it required minimal change and effort on their end.
“Direct is not just about technology, it’s about supporting the clinician to best manage their
patients. Taking end users’ needs into consideration will ultimately result in greater adoption of
Direct.” – Dr. Holly Miller
Next Steps
While the technology advances associated with Direct are apparent, MedAllies aims to have more
discrete data on Direct messaging utilization and corresponding outcomes as the pilot progresses.
The hope is that these metrics will clearly show that Direct is both improving patient care and
increasing office efficiency in the Hudson Valley.
Additionally, MedAllies expects new implementation sites to appear as pilot EHR vendors advance
and distribute their Direct capabilities. As they expand, their focus will remain on closed loop
referral use cases and discharge notifications.
1. The Direct ProjectWeb Site Disclaimers
2. The Hudson Valley Initiative OverviewWeb Site Disclaimers [PDF – 1.5 KB]
3. Issue Brief: Beyond Babel MedAllies Direct ProjectWeb Site Disclaimers [PDF – 3.68 KB]
4. Issue Brief: Not So Elusive–MedAllies Direct advances interoperabilityWeb Site

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