Micky Tripathi, president and CEO of Massachusetts eHealth Collaborative (MAeHC) [based in Waltham], has been chairman of the HIT Policy Committee Information Exchange Workgroup since the group’s inception a year and half ago. One of the workgroup’s missions is to pursue the use of directories across state HIEs to support provider and patient information exchange, as well as public health reporting. It is one of the first in the country to focus on this particular issue, and as Tripathi explains to HCI ’s Associate Editor Jennifer Prestigiacomo, the group is now weeding through the complexities behind this mammoth project.
Healthcare Informatics: Where did this idea of provider directories come from?
Micky Tripathi: The provider directories issue arose from two different places. One, is the ongoing effort to try to build approaches to get interoperability across the country that’s universally accessible and available to clinicians to help them get to their meaningful use requirements, in particular summary of care exchange, e-prescribing, and lab results delivery. So it was an ongoing effort to create an approach to allow physicians, regardless of where they are in the community, the ability to do those meaningful use transactions. That led to the inception of NHIN [The Nationwide Health and Information Network] Direct [a wiki to promote a set of standards to enable secure health information exchange over the Internet.]
If you have a directed exchange model where I say I’m going to use the Internet electronically to mimic those flows of information that happen in the real world today, I can build it on the current consent and legal framework, which may sound trivial, but it’s actually huge. Privacy is obviously a paramount concern of everyone when we think of health information exchange.
The issue of provider directories comes up because if I’m going to have just a way of sending a secure document or message, what are the core things that I need to have in that system? I need to be able to create the message in my own system, have it addressed, and then have it securely transported, and then have it received on the provider’s end so they can get it to the right person. I need something that will allow me to do that in the same way e-mail does today. If directed exchange doesn’t have that today, then the question is how would I create some kind of directory that at a minimum would enable the routing of information. So, if I’m a hospital and I want to send something to the PCP, like the discharge summary, I’m going to enter that it’s going to reach this particular practice who referred this patient to me. I need to have some sort of directory service to do that. That’s the minimum.
There is a more expansive definition of what a provider directory might be, which is more like a big universal list of all the doctors in the country, and which entities they practice at and perhaps other information like their medical license numbers in whichever states they deliver care in, credentialing information, MPI number from Medicare, their DEA number from a prescribing perspective. You may want to have that type of information to use for a variety of other purposes. One purpose could be a Yellow Pages; if you want to look up a physician and you need to get information to him or her. Another might be for organizations that spend a lot of time creating directories like health plans or credentialing organizations. The Department of Public Health or the state licensing board can use this single directory when they’re trying to identify physicians. So, you can imagine that you could create something that could have multiple uses. That’s the second conception of a provider directory, which is more expansive.
If we’re going to have directed exchange, and NHIN Direct has one particular way of doing that, we’re going to have some type of universal addressing directory service. That was one of the questions handed to our workgroup. The second reason that this was proposed for us to work on is there is now roughly $600 million being distributed to 56 designated entities for health information exchanges. If you look at the original FOA, the funding opportunity announcement, or the PIN, the program information notice, that went up in July, both of those point specifically to providing guidance to the states. A number of states were thinking of provider directories as something that they’ve been given some encouragement from ONC and that they also see value in. [Since there are] 56 states out there—some number whom are going to be spending money on what they’re calling provider directories—and from a government and a tax payer perspective, at a minimum we want to be able to rationalize the approaches so they are systematic and interoperable with other states.
HCI: Will there be separate approaches for these two pieces of this directory project, or will they go hand in hand?
Tripathi: Right now, those are just concepts. We’re just at the beginning of thinking about them. We’re [figuring out] our collective understanding of what are these two things, if they really are two things, and how do we put common definitions on them.
HCI: Will consumers be able to benefit from these directories?
Tripathi: The focus of this is really on providers and how I get clinical information sent securely and with confidence to healthcare organizations that are providing healthcare services. Now, if there is some kind of Yellow Pages functionality that becomes available, I would think that we’d want to make that available to patients, especially if we’re in a world where we’re going to have higher and higher penetration of personal health records and patient portals.
HCI: How is the workgroup recommending the directories should be built? I saw in the slides for one of your meetings approaches ranging from unitary to hybrid?
Tripathi: The architecture depiction you saw in there was really just to get conversation started. It’s a very early stage and not meant to represent real options. It really was to throw some stuff out there, because we’re all in the formative stages of our thinking. One of the things that came from that conversation was a little of this conceptual separation of something that is about network architecture and routing from a technical perspective, versus this other more expansive concept which is more about how do humans us a directory to do a variety of things.
I will say this, when you think of this more expansive concept of provider directories, the horse is already out of the barn in terms of there being all sorts of directories out there. Hospital systems, health plans, and pharmacies all have large provider directories. There is so many out there. Is there some way we can bring those together in a federated architecture that will build on what’s out there?
The reality of these types of directories is that it’s really hard to keep them accurate because every day physicians move and die, leave the state and enter the state. They change practices all the time. The main challenge is how do I maintain that directory and keep it up-to-date. And how up-to-date does it need to be? Does it need to be real time? Meaning that someone is so dependent on that that if it’s a day wrong then we’re [in trouble]. And you can imagine who would be in that situation—a health plan who does claims transactions. They might be in a position where they can’t tolerate if the [information] is wrong because they’re paying someone based on this transaction. So, this can’t be a day wrong. This has to be in real time, whereas a medical licensing board, they only license once a year. So these are the types of things you think about when you build this as a federated model bringing together these different directories and linking them all up. So, those are all the questions we’re going to get into.
HCI: How is this going to be funded beyond the $600 million stimulus funds being issued?
Tripathi: There’s no answer to that right now, but that is the question we’re trying to answer. If you think about the two conceptions we have now of provider directories. The first one, the network architecture, you can almost imagine that one being self-funded. There are registrars like InterNIC and VeriSign who register domains and users pay them a fee. So, a healthcare registration service can be launched, and it becomes a self funded activity.
The other part is the harder part. If I’m going to think about a Yellow Pages type of directory it’s hard to contemplate how to pay for that on an ongoing basis, who’s going to pay for that, and what is it going to cost upfront to build it and maintain it. In part, that’s why the states and ONC [the Office of the National Coordinator for Health Information Technology] are particularly interested in having the workgroup think about that question. The reason is if there’s some way of creating something universally applicable to all those organizations that build directories, then you could imagine an ongoing service where we can offer it back to providers at a lower cost; so that will sustain it as a service. None of that will happen though unless there is a common data standard, synchronization standard, content standard that says something about the way I enter in information. I think there’s hope for that sustainability.
HCI: What is the workgroup’s general timeline moving forward?
Tripathi: What we want to do is offer a staged set of recommendations. First stage would be key principles and an outline of implementation issues from the states. The key principles are what’s the framework we’re using to even think about this, and then what we as the workgroup agree on how a directory is defined [and what its functionality would be]—all of the high level stuff. So, that is the first stage of recommendations we want to bring to the HIT Policy Committee in October. As a part of the hearing, we’re going to hear from states on what issues they’re facing and what do they want they workgroup to address. So the second report out will be a synthesis of what we hear from the states.
At the next meeting of the policy committee, we’ll provide more detailed recommendations that can be of two flavors: one will be specific standards or certification, even, for that network architecture for routing information. For the second Yellow Pages conception, we were discussing putting out guidelines or best practices to the states about how they might deploy provider directories without there being some statutory or regulatory authority behind it—in part because it’s not clear the government has the authority to do such a thing. And also in part, because it has to be technology, architecture, and organization-neutral, and accessible by a user through whatever technology they have now or in the future.
We’re responding to a sense of urgency that we understand and are hearing from the National Coordinator’s Office and the states. Six hundred million dollars is being approved and distributed as we speak. There are states that are at the precipice of spending a lot of money and they’re asking these questions. They’re saying ‘we don’t want to invest all these dollars until we have a better understanding of how this investment aligns with the regional and national objectives.’ So by October we want to get a firm set of recommendations that can at least provide guidance. Could there be further things beyond that? There absolutely could be, but it’s hard to know right now.
HCI: What do you see as the biggest challenge moving forward?
Tripathi: I think the biggest challenge, with almost all the interoperability issues we face in the country, is that this part of the economy [healthcare] is the most decentralized. It’s an unbelievably fragmented space both on the supply and demand side. What that means is we have healthcare entities that operate like cottage industries where they set their own standards and workflows, and there’s very little standardization of anything. That might be fine in a country the size of Denmark, but in a country as geographically large as this one with the diversity of people and state governments, trying to do anything that is uniform from a technical, organizational, business perspective is unbelievably complex. I don’t necessarily see this as more or less complex than other aspects of interoperability. Everyone already has a lot of investment in their particular approaches, and trying to align those is always hard. They’re understandably resistant to change those ways unless it can be proven that there’s a better way to do it.