Direct Clinical Messaging Surges in Multiple Contexts

by Ken Terry, iHealthBeat Contributing Reporter

A year-and-a-half after the Direct secure clinical messaging protocol emerged upon the scene, it's suddenly attracting a lot of attention across the country.

More than 40 statewide health information exchange entities have implemented or are in the process of implementing Direct, and many of them are contracting with health information service providers to give health care providers the ability to exchange Direct messages. Others are setting up marketplaces for HISPs.

In all, at least 7,000 providers already have signed up with these HISPs. A number of regional HIEs that are not part of the federally funded statewide HIEs also are using Direct in various ways.

Meanwhile, some health IT regional extension centers are encouraging their client practices to adopt Direct, partly as a way to meet the meaningful use criteria for receiving government electronic health record incentives. And there are signs that some health care organizations are starting to use Direct to communicate across their enterprises and even across accountable care organizations.

Background on Direct

The fruit of a private-public collaboration, the Direct Project was unveiled in early 2011. The secure clinical messaging protocol adapts the familiar SMTP Internet protocol to exchange messages between trusted parties. To send a message to another Direct user, a provider must register with a Registration Authority and must hold a digital certificate used for security purposes. To move messages across this parallel version of the Internet, providers require HISPs. These are private companies that, in some cases, are the same firms that provide HIE services.

Direct is compatible with the Nationwide Health Information Network. But, unlike the NwHIN, which can be used to locate and pull patient data from other providers, Direct can be used only to push messages and attachments from one provider to another.

Some observers regard Direct as a primitive, albeit necessary, starting point for heath information exchanges.

Jennifer Covich Bordenick -- CEO of the eHealth Initiative, a longtime promoter of HIEs -- called Direct "a step in the right direction." But, she added, "Direct does not replace HIE. It's too simple, and it doesn't do what we need to get done."

One advantage of Direct, she pointed out, is that physicians don't need an EHR to use it. "It's necessary, especially for these small physician practices that don't have the means to purchase an EHR, even with the incentive programs. Direct really serves a purpose for them," she said.

In fact, some people view Direct messaging, which can transport document attachments, as a fax replacement. In that sense, it requires a lot less change than robust health information exchange, said Kate Berry, president of the National eHealth Collaborative.

"You don't have to change your workflow dramatically to transmit information via a secure message instead of a fax machine," she pointed out.

Why Direct Is Taking Off

That still doesn't explain all of the buzz around Direct. Observers cite the following reasons for the messaging protocol's recent growth.

Direct can help providers meet the Stage 1 and proposed Stage 2 meaningful use criteria. According to a post on the Office of the National Coordinator for Health IT's "Health IT Buzz" blog, providers can use Direct to do public health reporting, receive structured lab results, improve care coordination, do safe and efficient transitions of care, and engage with patients -- all present or future meaningful use requirements.

Direct is jump-starting some regional HIEs by providing a way for providers with EHRs to exchange information with providers who don't have EHRs. Berry said that "it's a gap-filler." In Tennessee, where the entity that was supposed to create a statewide HIE shut down, the state is continuing to promote Direct as a stopgap.

Other HIEs, such as MedAllies in the Taconic Valley of New York State, are using Direct to enable physicians with disparate EHRs, or none, to do "closed-loop referrals" from primary care doctors to specialists and back again. In Cincinnati, a Beacon Community is experimenting with the use of Direct to send discharge summaries from hospitals to primary care physicians.

In addition, health IT consultant Shahid Shah noted that a growing number of health care organizations are starting to use Direct within their enterprises. Shah advises other providers to follow suit.

"You can start using Direct to build your own health information exchange," he said, adding, "I tell CIOs, 'Don't assume that the HIE that has been created for you is actually going to work for you. If you're an ACO, you might have to create your own HIE because the HIE won't do what you need to do.'"

Obstacles to Direct

Not all is sunny in Direct-land, however. For one thing, physicians who have EHRs cannot use Direct to transmit messages from their system unless their vendor has imbedded Direct capability in the application. They still can use Direct to message other providers, but they can't send automatically generated clinical summaries directly from their EHRs to other providers' EHRs.

ONC spokesman Peter Ashkenaz told iHealthBeat that 14 of the more than 400 EHR vendors on the market have embedded Direct to date. However, because EHRs must incorporate Direct to be certified for meaningful use Stage 2 more vendors are expected to add that feature in the near future. "In 18 months, it will probably be an integrated capability for at least the top 15 EHRs," Berry said.

Another barrier to effective use of Direct is that many HISPs are not communicating with one another. According to the guidelines for Direct messaging that ONC recently issued, these HISPs permit data exchange within their boundaries "while not offering mechanisms or supporting policies that enable exchange with other HISPs. Such limitations effectively block providers using different HISPS from exchanging patient information."

Erica Galvez -- community of practice director for ONC's state HIE program -- said that the problem lies not with the technology but with the policies for Direct messaging, which the new guidelines endeavor to straighten out. HISPs have to be confident that other HISPs will route messages to the proper providers, but they don't know much about the other HISPs, she said.

To find out more, she said, "They'd have to reach out to other HISPs. I don't know of a single clearinghouse or a portal that puts out information on HISPs."

Nevertheless, Galvez believes that ONC's guidelines -- which cover technical specifications, business associate agreements, industry standard practices for privacy and security, and other issues -- should help break down the HISP silos if these companies follow them.

Expanding Direct's Horizons

Eventually, Direct will be used to connect providers other than physicians and hospitals. Already, the Florida state health information exchange has gotten a HISP to enroll physician practices, labs, community health centers, skilled nursing facilities and ambulatory surgery centers, Chris Philips, the HIE's technical manager, said at the Healthcare Information and Management Systems Society Conference in February. And ONC recently released an implementation guide for using Direct to report lab results electronically.

Few providers are using Direct to send results or other health care information to patients, but that is also a possibility. Microsoft HealthVault, for example, is giving consumers Direct addresses for free, Galvez noted. Presumably, providers could use this to send health records to a patient's personal health record on HealthVault.

Many other Direct experiments are under way. ONC has a project to test closed-loop referrals from one EHR to another in Beacon Communities. The Kansas Health Information Network has just launched a combination of Direct and query transaction capabilities from the same HISP, which has enrolled 2,000 users.

Direct could even get the NwHIN off the ground. For example, MedVirginia, a statewide health information exchange, already has combined its access to NwHIN with Direct to provide push and pull messaging.

So what appears to be the most elementary form of health information exchange could actually have the biggest effect, at least in the short run. Regardless of how HIEs progress, don't count out Direct.

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