Thursday, March 6, 2014

A Primer on Meaningful Use and HISPs

The Massachusetts State government offers low cost HIE services including Direct transport to all the stakeholders of the Commonwealth.    Recently. Micky Tripathi wrote this FAQ which is so good that I wanted to share it on my blog.   Feel free to use it with your stakeholders.

1. What is a HISP?
A Health Information Services Provider (HISP) is an organization that manages security and transport for health information exchange among health care entities or individuals using the Direct standard for transport.  There is no specific legal designation for a HISP, nor are HISPs specifically regulated by Meaningful Use certification rules.  The term HISP was coined to describe specific message transport functions that need to be performed to support scaled deployment of the Direct standard in the market.  HISP functions can be performed by existing organizations (such as EHR vendors or hospitals or HIE organizations) or by standalone organizations specializing in HISP services.

HISPs perform two key functions that support scalability of exchange using the Direct standard.

a. Issue security certificates.  HISPs establish trust networks by defining policies for network participation and issuing security certificates tied to a HISP anchor certificate to enforce such policies
b. Issue direct addresses.   HISPs issue direct addresses tied to the HISP anchor certificate in accordance with conventions defined by the Direct standard

2. Do I need to use a certified HISP to attest for Meaningful Use Stage 2?
No, because there is no such thing as a certified HISP.  Meaningful Use certification applies to technology, not to organizations.  In order to attest for Meaningful Use Stage 2, you need perform certain activities using certified EHR technology (CEHRT).  For most EHR users, their EHR is certified for all of the functions that they need.  If it is not, you will need to incorporate specific additional certified technology solutions to fill the remaining gaps.  It doesn’t matter whether that additional technology comes from an EHR company or a HISP company – the only thing that matters is that the technology is certified.

3. Doesn’t DirectTrust certify HISPs?
DirectTrust is a private, non-profit organization that offers voluntarily accreditation of HISPs through its EHNAC DTAAP program.  This private, voluntary accreditation program often gets confused with Federal Meaningful Use certification.  DirectTrust is NOT a Federal certification entity, and its EHNAC DTAAP accreditation process is purely private and voluntary and has no relationship with Meaningful Use Stage 2 attestation or certification requirements.

4. What role does a HISP play in Meaningful Use Stage 2?
A HISP provides specialized network services that connect your EHR to other EHRs that are also using the Direct standard for communications.  You don’t need a HISP in order to create Direct-compliant messages, but you do need to be connected to a HISP in order to send and receive Direct messages with other parties.  Using an email analogy, you may have Microsoft Outlook installed on your computer, but if it isn’t connected to an email network, your emails can’t go anywhere and none can get to you.  Similarly, your CEHRT can send and receive Direct-compliant messages, but those messages won’t go anywhere unless you and those who you are communicating with have valid
Direct addresses and are connected to a secure network that can get the messages safely and reliably from one endpoint to another.  These are the message transport functions that HISPs perform.

There are two Meaningful Use Stage 2 attestation requirements that require Direct transport:

Summary care record for transitions of care (TOC)
Patient ability to view, download, transmit their medical record (VDT)

Most HISPs (including the Mass HIway) do not yet have the ability to connect directly with patients, so they are not able to assist with the VDT requirement.

For the purposes of attestation, the Meaningful Use Stage 2 TOC requirement specifies that you must electronically send a standardized summary care document to another care setting, and that you must have reasonable assurance that the other care setting actually received the document.  The HISP performs the message transport functions to provide you with the assurance that your messages have been delivered to their intended recipients.

In order to attest for the TOC requirement, you need to send CCDA care summaries containing at least problem lists, medications, and medication allergies.  These summaries must be transmitted with your CEHRT using either the SMTP/SMIME or XDR/SOAP protocol.  There is no Federal certification for HISPs, so you can send your message to its intended recipient using any HISP or any number of HISPs, as long as you have assurance that the message will get delivered.  The only certified system that you need to use is the one that creates the Direct-compliant SMTP or XDR message – after that, your message may take any number of “hops” between your EHR and its final destination, and as long as you’re confident that the message will get delivered, you will have completely fulfilled your Meaningful Use Stage 2 attestation requirement.

5. How do I get assurance that my messages are delivered?
Meaningful use attestation requirements do NOT specify how you get assurance of delivery, they specify only that you have taken reasonable steps to be confident of delivery.  The most robust way for you to be assured of message delivery is for your system to receive message disposition notifications (MDNs) for each message sent by your EHR to the intended recipient.  However, not all receiving systems or HISPs can generate MDNs, and not all EHR systems can consume MDNs even if they are returned.

Fortunately, you are not required to receive MDNs in order to be assured of delivery.  Other acceptable methods of assurance are through HISP guarantees of delivery after successful setup testing and/or notification of failure of delivery (like emails) and/or HISP central maintenance of delivery logs that can be made available as needed.

The Mass HIway provides you with assurance of delivery through rigorous setup testing, and maintenance of a central log of delivery successes and failures.  This log is made available to participants as necessary in the event of an audit.  The Mass HIway will also return any MDNs or application-specific responses or acknowledgements generated by receiving endpoints, however, the Mass HIway cannot guarantee that any receiving endpoint will generate notifications, acknowledgements, or responses.

The one exception where delivery notification is available and required is public health.  The Massachusetts Department of Public Health requires that participants receive delivery notifications in order to satisfactorily meet the Meaningful Use Stage 2 public health requirements.  Massachusetts DPH does generate automated acknowledgements, which are sent automatically via the Mass HIway in response to each message successfully received.

6. Is the Mass HIway a HISP?
Yes.  The MA HIway is a trust community that issues security certificates and Direct addresses to eligible participants and provides Direct-compliant message transport services for its participants.

7. Is the Mass HIway certified as an EHR module for Meaningful Use Stage 2?
No, the Mass HIway is not certified as an EHR module for Meaningful Use Stage 2.  Most providers will not require the Mass HIway to be certified in order to use it to help fulfill their Meaningful Use Stage 2 attestation requirements.  (See discussion above in FAQ on HISP roles.)  As long as your CEHRT delivers a Direct-compliant SMTP or XDR message to the Mass HIway (either to the LAND appliance or directly to the central site), you do not need the Mass HIway to be certified.

If your CEHRT does not send a Direct-compliant SMTP or XDR message to the Mass HIway (for example, if you are sending messages to the LAND appliance in a format other than SMTP or XDR), then you will need to change your interface to send Direct-compliant SMTP or XDR to the Mass HIway (including the LAND appliance) in order to count any of these transactions for Meaningful Use Stage 2 TOC requirements.

Even though you do not need the Mass HIway to be certified for Meaningful Stage 2 in most cases, you will still need to have assurance of delivery of messages sent over the Mass HIway to meet your Stage 2 TOC attestation requirements.  The Mass HIway provides this assurance by delivery after successful setup testing.

8. Must I be connected to the Mass HIway in order to attest for Meaningful Use Stage 2?
Yes, you need to be connected to the Mass HIway in order to meet the Meaningful Use Stage 2 public health requirements for immunization and cancer registries, and syndromic surveillance.  The Massachusetts Department of Public Health will accept public health transactions only through the Mass HIway.  Thus, though there is no Federal requirement that you be connected to the Mass HIway for Meaningful Use Stage 2, you will not be able to meet core public health requirements for Meaningful Use Stage 2 without being connected to the Mass HIway.

You do not need to be connected to the Mass HIway in order to meet the Meaningful Use Stage 2 TOC requirement.  However, over 100 providers and payers are already live on the Mass HIway HISP.  Thus, connecting to the Mass HIway will likely make it easier for you to meet your TOC requirements because you will be immediately connected with many of the providers you share patients with.

9. The Meaningful Use Stage 2 rules refer to the eHealth Exchange – is that the same as the Mass HIway?

No.  The eHealth Exchange is a health information exchange network comprising federal agencies and other large non-federal organizations.  The Mass HIway is not connected with the eHealth Exchange in any way.

10. Do I have to be connected to the eHealth Exchange in order to meet my Meaningful Use Stage 2 attestation requirements?

Absolutely not.  While the Meaningful Use Stage 2 rules do allow special dispensation for eHealth Exchange members, few providers will attest using this mechanism.  No Massachusetts providers or payers are currently members of the eHealth Exchange.

11. Who are the other HISPs in Massachusetts, and can I join any HISP that I want?
There are a wide variety of HISPs operating in the Commonwealth.  Whether you join any particular HISP depends on a number of factors.  The biggest factor is which HISPs your EHR vendor allows you to join.  Some vendors require that you use a specific HISP (either their own or the one they are integrated with), while other vendors (such as Meditech and Epic) allow the provider to choose which HISP they would like to connect to.  CMS and ONC do not require that you use any particular HISP for meaningful use, but in practice, your EHR vendor will dictate which HISP options are available to you.

If your vendor allows you to choose which HISP to connect to, you can connect directly to the Mass HIway HISP.  If your vendor requires that you use their designated HISP, you will have to connect to the Mass HIway through their HISP, as long as their HISP is connected to the Mass HIway.
Please contact the Mass HIway ( if you have any questions about your connection options.

12. Is the Mass HIway part of DirectTrust?
No, the Mass HIway is currently not a member of DirectTrust.  DirectTrust is a voluntary private non-profit collaborative that is helping HISPs to connect with each other.  The Mass HIway is connecting directly with the major HISPs operating in the Massachusetts market.  The Mass HIway may join DirectTrust at some point in the future if it provides additional value to participants.  Providers, EHRs, or HISPs do NOT need to be part of DirectTrust in order to meet their Meaningful Use Stage 2 certification and attestation requirements.

13. If I’m in another HISP, can I still be on the Mass HIway?
Yes.  You can connect to the Mass HIway even if you are a member of another HISP.   The Mass HIway is actively connecting with the major HISPs operating in the Massachusetts market so that messages can be sent between HISPs.  You do still have to join the Mass HIway by signing a participation agreement even if you are in another HISP.  As a member of another HISP, you will pay whatever fees are charged by your local HISP and your Mass HIway fees will be waived.  Once you have joined the Mass HIway, your local HISP will configure your system to enable access to the Mass HIway network.  Your local HISP will still provide you with your security certificate and your Direct address, but you will be able to send and receive messages over the Mass HIway network.

Below is a current list of HISPs that are expected to be connected to the Mass HIway.  The HISP market is evolving rapidly so more HISPs will be added as demand grows.  Please contact the Mass HIway ( if you would like to discuss your connection options.

HISP Live date
eClinicalWorks April 2014
Surescripts April 2014
eLINC/SES April 2014
Allscripts/MedAllies TBD
Athenahealth TBD
Wellport/Alere TBD


  1. For VDT, View and Download do not require Direct Transport. Only the Transmit portion of VDT requires Direct.

  2. "but in practice, your EHR vendor will dictate which HISP options are available to you."

    This looks like more silo's and control being given to the EHR vendors again. Shouldn't there be a requirement that this is an open choice?

    Jeff Brandt