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How Will Direct Continue to Advance Health Data Exchange?

Supporting more than secure messaging, the Direct protocol has a role to play in making health data exchange more efficient and healthcare interoperability more widespread.

By Kyle Murphy, PhD

- Achieving widespread or true interoperability remains the goal of federal officials, but efficient forms of healthcare interoperability are already in place, thanks in large part to the DirectTrust and its Direct protocol.

Direct standard for health data exchange, healthcare interoperability

The specifications underpinning the health IT standard Direct gained notoriety for their part in enabling the exchange of health information in federal health IT initiatives such as the EHR Incentive Programs and Stage 2 Meaningful Use. However, the use of the Direct for secure messaging has left many with the impression that this health IT standard does little more than support secure email.

As DirectTrust President & CEO David Kibbe, MD, MBA, made clear in a recent interview with HealthITInteroperability.com, the Direct standard can do a whole lot more for improving health data exchange and advancing health IT interoperability. The Direct standard already supports a multitude of real-world use cases and has the potential to work with other emerging health IT standards, such as Fast Healthcare Interoperability Resources (FHIR), to make information sharing more efficiently and equally secure.

HealthITInteroperability.com: What kind of impact is the Direct standard having on heath data exchange?

David Kibbe: Direct exchange and messaging as a transport protocol is a rapidly maturing and at the same time being extended — and there's innovation within the domain of its use and use cases. We have been following some of the metrics reported by the HISPs for three years now.

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This is a network of networks. Each HISP of course is its own network and has customers who are variably health information exchanges, EHRs, sometimes personal health record companies. That network now includes 40 HISPs that are fully accredited and have contracts with over 300 electronic health record vendors that are certified by ONC and they in turn extend Direct exchange to over 60,000 healthcare organizations in the US. We have about 1.3 million endpoint Direct addresses in the provider space right now, and all of those are parties that have been identity verified. The DirectTrust network is seeing about 8 million Direct exchange transactions per month now, or approximately 24 million a quarter. That's the DirectTrust network of networks. It's this cumulative, incremental growth of the use of Direct that's now running those numbers up, and we'll see that steadily increase over time.

HealthITInteroperability.com: Is the understanding of Direct as a secure messaging too narrow?

DK: It is too narrow. It's very convenient to think about the primary use case for Direct exchange being a "secure email message plus an attachment" that goes from you — let's say, a nurse care coordinator  in a hospital — to me, a doctor, or to my organizational address because the patient is being discharged. That primary use case is one that has led to say that it's basically secure email. But actually it's much broader than that. It's a transport protocol which has a lot more capability than simply to be used as a means of person-to-person communication. That's very valuable; that use case is very important. It creates a connection between two people that a fax doesn't do very well electronically.

HealthITInteroperability.com: in what other ways can it be used in health data exchange?

DK: As a transport protocol, we also see information being transported via Direct from server to server, for example, or from server to endpoint person. Health information exchanges all over the country use Direct exchange to send alerts to a medical practice when a patient whom the HIE has received an ADT message about has either been admitted to the hospital or is about to leave the hospital or the emergency room. There's a server that is accepting that inbound ADT within the infrastructure of the health information exchange and that triggers then a message being sent from the server to a doctor's office or to a particular nurse or clinic. It's also possible for devices to have Direct access to an endpoint. A device of any kind could send the information contained in the device's output to a server.

Another example that's also easy to understand: The CDC uses Direct messaging as a means of receiving inbound cancer registry notifications from medical practices and hospitals to its repository. That's the reverse of the HIE example. That's somebody sending a message to that repository which is a server receiving it.

HealthITInteroperability.com: How should the healthcare industry view Direct then?

KB: It's actually better to think of Direct exchange more broadly as a platform for interoperable exchange that is content-neutral. You can send an ADT message. You can send a C-CDA. You can send a PDF file. You can send an image. One of the things we're starting to see: As the healthcare provider organizations start using Direct exchange for that primary use case — care coordination, transitions of care, and so forth — they're starting thinking about using it for moving data from point A to point B for other use cases. That starts to involve the protocol being used in those other ways.

HealthITInteroperability.com: What is the future of Direct use, especially with the push for health data exchange as part of value-based care models?

DK: As more and more parties, not just users of EHRs — long-term care facilities, medical devices, home health services, care coordinators — have Direct addresses, the incentive to use those for that kind of exchange increases as the financial incentives under MACRA are felt by the healthcare provider organizations. The Comprehensive Primary Care Plus is a great example where there is a strong incentive on the part of the participants in those programs to move the data quickly and securely and electronically as opposed to slowly and by paper or fax. The workflow has to be accomplished quickly and Direct is a very, very good way to do it quickly. You push the button and the message is sent and you get a receipt from the receiving party that it has been received. The future of value-base care payment models is one that will be increasing the incentives for those healthcare provider organization to use Direct exchange as opposed to fax.

There's another to bring out: You need to separate the transport protocol from the content. Many of the problems people have had using Direct exchange has really been about content rather than the protocol. For me to use that content, it has to be understandable to me and vice versa. This starts to bring in the issue of workflow, which is really important. Regardless of how you move data from point A to point B or point A to points C, D, E, and F, if there's not a well-defined workflow, then the technology is not being utilized to its highest potential. Once people in those programs for care coordination and transitions of care have decided on the pieces of data they need to receive, they are much better off because now that workflow is more efficient and the expectations about what's going to happen when that information is received are much higher and can be realized.

HealthITInteroperability.com: Are health IT standards such as FHIR a complement to Direct or something the technology could itself make use of?

DK: Both. Any query technology  — any technology that allows you to automate a request for information — is complementary to any technology that allows you to push information. Those are complementary workflows and they're different and they're not necessarily going to be satisfied by any single technology. Direct exchange is going to continue to flourish for those use cases in which the parties are exchanging information. FHIR is going to be exceedingly valuable in those situations in which I as a requester of information can automate a query and send it off to the other electronic health record.

The use case for organization-to-organization of FHIR queries is not the one that is most worked upon now. For the next couple of years, we're going to see primarily single-enterprise FHIR APIs as opposed to interorganizational FHIR queries. As the organization-to-organization use case for FHIR becomes more common and desirable, that's when you're going to see the fundamental trust framework that DirectTrust has built around Direct exchange be leveraged to support FHIR queries. For organization A to make a request of information using FHIR of organization B, there needs to be some basic trust between the two parties. We have a means of allowing organization B to trust organization A bona fides when a request of any kind is sent. You can think of this as a FHIR query being initiated with a Direct exchange trust relationship occurring.

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