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How Adoption of Direct in Tennessee Reached a Tipping Point

February 20, 2014
by Gabriel Perna
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June to December, exactly six months, seems like an impossibly short time to accomplish a substantial goal in the world of healthcare informatics.

However, that period of time was exactly how long the folks at the Memphis-based Qsource, a nonprofit consultancy, took to create widespread adoption of Direct technology within the state of Tennessee. Qsource powers the Tennessee Regional Extension Center (tnREC). It was contracted by the Tennessee Office of eHealth Initiatives in September of 2012 to get Direct going in the state.

The Direct Project allows providers to securely message each other electronically and exchange information, which is a required component of Stage 2 of meaningful use under the Health Information Technology for Economic and Clinical Health (HITECH) Act. Over the course of six months, starting in June of last year, tnREC was able to get 4,000 providers in the state on board with Direct and accomplish the benchmarks it had set for itself. In fact, it beat its imposed deadline of January 2014 by a month.

When the contract came in, the leaders at Qsource and tnREC knew getting there would take a lot of hard work. “It was so new,” says Amanda King, tnREC Direct Project manager. “No one in our state was using it. We had to provide education before we could even get people to jump on board to try this new technology.”

Amanda King

Qsource and tnREC rolled out a step-by-step plan to increase adoption. Along with the education mentioned by King, they created incentives for early adopters, marketed the technology, and brought on “anchor” providers who could tip the proverbial scales. Many of these plans were hashed out and developed in a three-month pilot, from February to May of last year, which the organization oversaw.


The pilot, which occurred in Memphis, Chattanooga, and Hickman, gave Qsource a chance to better understand how Direct technology could be utilized statewide. The three locations were chosen because they represented east, west, and middle Tennessee, giving Qsource a foothold in each region of the state. According to Dawn Fitzgerald, the CEO of Qsource, the pilot taught them the most effective use cases for Direct.

“Going through the process of the pilot, one of the big lessons learned was the best use cases for Direct, at least now in its current form, aren’t physician-to-physician communications, but case manager to community case manager to care transitions. Those are the ones that have the most viability in the current construct we have,” Fitzgerald says.

Thus, it was critical for Qsource and tnREC to find out those people within a community that communicated care transitions information on a regular basis. She says it was typically the case or office manager. Utilizing them, she says, was the most effective way to utilize the technology.

Going through the process of the pilot, one of the big lessons learned was the best use cases for Direct, at least now in its current form, aren’t physician-to-physician communications, but case manager to community case manager to care transitions.

The other lesson from the pilot was enabling a community-based approach to garner widespread adoption. Essentially, Fitzgerald says, “You can’t take a shotgun approach.” Qsource recruited community champions to really tip the scales. This was done on a broader level, with “anchor” locations pushing Direct.

Dawn Fitzgerald

“Someone has to raise their hand first in the community, and it needs to be a big somebody. Once you get that hand raised, and start getting people to use and understand it, it rolls down from there in that community. It’s just getting over that first hump,” King says.

HIT Specialists to the Rescue

The “tipping the scales” mentality ended up being integrated into the overall Direct technology rollout. As part of its marketing efforts, Qsource and tnREC established the Health eShare TN provider directory on a website, which King says turned out to be “white pages” for the providers, who could search and see who was using it. They also developed a tool for the website that allowed providers to look at a Google map to see who registered to use Direct.

“The Google map was a great [mechanism to use] when you are telling providers, ‘You need to use this tool, look who has it in your community,’ They can see statewide and pinpoint on map who is using the technology,” King says.

Also established in the pilot, and later used as part of the rollout, were health information technology (HIT) specialists. These specialists, who were staffed by Qsource, worked with the community directly to assist them in using the technology and integrate it into workflow. They educated the providers as well on the incentive requirements, ensuring that the software vendor was an established Direct Trusted Agent Accreditation Program (DTAAP) Health Information Service Providers (HISP) vendor.

This turned out to be more vital than Qsource and tnREC originally figured it would be. Even though the Direct technology is “akin to Gmail,” according to Fitzgerald, someone was needed at the elbow to educate providers on how to integrate it into the workflow and better understand how it could be used to make referrals or send discharge summaries.

No Silver Bullets Seen