In February 2011, two pilots of a new standard for sending health information securely over the Internet were launched. The pilots -- one in Minnesota and one in Rhode Island -- are the first tests of the Direct Project, an HHS initiative designed to simplify the exchange of information within the health care industry.
The most noteworthy aspect of this initiative is how quickly it happened. These initial pilots are taking place less than a year after the Direct Project was started.
The project represents an unusual experiment in accelerating the creation of the Nationwide Health Information Network. The project has demonstrated how rapidly a "lightweight" open process can yield useful results compared with typical government-sponsored IT development projects.
Development of NHIN began at HHS in 2005. It was intended to provide a robust, comprehensive electronic infrastructure for sharing health-related information among multiple agencies.
The NHIN project grew out of a realization that a great deal of time and effort had been invested in developing standards for the format and structure of medical information (such as the data in health records), but relatively little attention had been paid to how this information could be shared by different parties.
According to Brian Behlendorf -- who served as an adviser to HHS on the Direct Project (and now is the chief technology officer of the World Economic Forum) -- it was as if the creators of the Internet had focused all of their attention on deciding whether HTML or PDF was the best standard for presenting information online but neglected to establish a communications standard like the URL ("uniform resource locater"), the simple address scheme that is the key to allowing information to be easily found anywhere on the World Wide Web.
Development of NHIN was well funded, but it was carried out in a traditional governmental process -- specifications and parameters for the project were carefully defined in advance, a request for proposals was issued and a contractor was selected to carry out the work.
In an effort to increase the usefulness of NHIN, the government decided to use an open-source model for development of the software. This approach did expand participation in the project: an open-source community began to grow around the effort, and several private companies built applications to extend the functionality of NHIN. However, the effort also had significant limitations.
Development was done in Java, an open-source tool that is powerful but relatively difficult to learn. Some parties criticized the effort as being too broad and trying to accomplish too much at one time. Further, actually using NHIN Connect would require a relatively high degree of trust because (much like the Web) information placed in the system would be available to any other party who requested it, an arrangement that was potentially at odds with stringent HIPAA standards designed to protect the privacy of sensitive medical information.
Enter the Direct Project
In response to an HHS advisory panel recommendation, a decision was made in late 2009 to pursue an alternative approach that would be faster and less complicated to implement because it was more limited in scope. This new project, known initially as NHIN Direct, would be more like an e-mail service that allows two parties to directly exchange information between themselves (rather than making it publicly available), which simplified the issue of trust. In addition, the development process for this alternative would be much less structured.
HHS agreed to try using an "organic" process that involved inviting all interested parties to participate. The project leader agreed to serve as the "orchestrator" of an open development process ("air traffic controller"), rather than as a contractor responsible for writing the software. Since funding for the project would end in 2011, the goal was to have a working prototype completed by the end of 2010.
The Direct Project, as it came to be known, was built around:
A weekly conference call open to all interested parties was set up to identify issues needing attention and keep everyone informed of the project's progress. Notes from the calls were published on the wiki, where a continuously updated list of current tasks and their status also was available.
When the project was officially launched in March 2010, the expectation was that it would attract perhaps a dozen outside participants. However, within a few months, more than 60 organizations -- including both major software and health care IT companies, as well as much smaller firms -- had gotten involved.
Over the next 11 months, the project progressed from initial discussion of the goals of the project to the development of a model to the creation of a set of prototypes to the launch of the first pilot implementations.
Farzad Mostashari, deputy national coordinator for programs and policies in the Office of the National Coordinator for Health IT, describes the Direct Project as "an amazing accomplishment." According to Mostashari, one reason the project has been able to move so swiftly is that participants consciously avoided protracted debates about ideal solutions in favor of rapid prototype development and refinement.
For example, participants initially proposed three different "flavors" of messaging standards on which the project should be based. Rather than spending time arguing about the pros and cons of these different approaches, three teams were given 90 days to come up with working prototypes of their favored approach. After a "bake off" that tested the three alternatives, the participants quickly reached a consensus on which approach to adopt and then moved on to the next stage. Despite fears that the losers would "take their balls home" and quit the project, none did. They all stayed with the effort.
Benefits of the Direct Project
The Direct Project is not intended to replace the larger NHIN effort, but rather to serve as a complement to it. For example, the Department of Veterans Affairs is working on integrating the functionality of Direct into its implementation of NHIN Connect.
One of the most immediate benefits of the Direct Project is that it will provide a practical way for health care providers to meet the criterion for the meaningful use program that calls for them to demonstrate the ability to share data with others. Another benefit is that parties who have participated in development of the standard are more inclined to make use of it, thereby facilitating the process of actual adoption.
According to Aneesh Chopra, U.S. chief technology officer, the Direct Project represents a promising new approach that "brings the principles of start-up into government policymaking." It also has served to demonstrate the real benefits of an open, collaborative development process as an alternative to the slower, more structured methods that have been typical of government-funded IT-development projects.
Author's note: This article is based on a section of a forthcoming report, titled Solving the Dilbert Paradox, to be published by the Aspen Institute.