Is Direct the Rodney Dangerfield of Interoperability?

Sept. 7, 2015
Several years ago, when the Office of the National Coordinator put its weight behind the Direct protocol as a way for providers to exchange information, some people working in the health information exchange space were concerned that it was a short-term distraction rather than a long-term solution. But for many, that impression has changed.

Several years ago, when the Office of the National Coordinator put its weight behind the Direct protocol as a way for providers to exchange information, some people working in the health information exchange space were concerned that it was a short-term distraction rather than a long-term solution.

In 2013 some HIE execs expressed the belief that Direct was being promoted to help people meet Meaningful Use numbers, but that focusing on Direct exchange would come at the expense of participation in the startup and sustainability of organizations working on broader query and exchange infrastructure.

There was also concern about how long it would take to get the project off the ground. Speaking at the eHealth Initiative Annual Conference in Washington, D.C., in February 2015, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, referenced Direct when talking about the introduction of FHIR and APIs to the marketplace. “We saw with Direct what happens when you throw something top-down on the market when no ecosystem already exists,” he said. “It is just now getting traction. That’s not anyone’s fault. It just takes time to develop.”

But I think there are plenty of signs that Direct is taking hold as providers find it increasingly fits their business and care coordination needs, and the HIE organizations are playing key roles in its dissemination. For instance, at a recent ONC panel session, John Blair III, M.D., CEO of MedAllies, which facilitates provider adoption of health IT, described the work his organization has done to connect practices using the Direct protocol. “We are running a national network, bringing on 100 provider organizations a week. MedAllies has connected more than 3,500 ambulatory groups, 300 hospitals, and close to 60,000 providers.

He stressed that the uptake has followed from a use case. The business model is driven by the patient centered medical home and advanced primary-care networks. “We have incorporated Direct to meet transition-of-care needs,” Blair said. “When it become clinically relevant, adoption becomes a non-issue. It needs to be driven by clinical interest, and there need to be financial incentives to make it work. Ultimately it is driven by a reimbursement model that rewards coordination of care.”

I often read through the online newsletters of HIE organizations around the country, and from their updates it is clear that the numbers of Direct users is steadily increasing.

For instance, in July 2015, the West Virginia Health Information Network (WVHIN) noted that while it continues to make strides in connecting more providers to its query-based network, WVDirect, the WVHIN’s secure clinical messaging system, has seen its growth continue in each month that passes. As of July, WVDirect has over 1,100 individual users representing over three hundred organizations.

 “Over the past eight to ten months, we’ve seen the usage of WVDirect increase” stated Phil Weikle WVHIN COO, said in the newsletter. “We know that a good portion of this usage was driven by providers utilizing WVDirect to help their facility meet the Transitions of Care requirement under the Meaningful Use Stage 2 guidelines. However, we believe that more providers are seeing the benefit of using direct messaging beyond the need to meet the Meaningful Use requirements and have integrated WVDirect into their daily workflow to improve the quality of care they provide” added Weikle.

 “We have heard from providers that the use of WVDirect has allowed them to provide better care to their patients. This is because they are able to communicate with other providers in near real time, so that they can get the referrals and information needed, but also because secure messaging systems, like WVDirect can be integrated into workflows very easily” said David Partsch, WVHIN CIO, in the newsletter article.

And the more experience HIE organizations and providers have, the more they can customize and develop solutions around Direct. Provider directory services continue to expand, and standards for provider directories are advancing. For instance, the Alaska eHealth Network recently noted in a newsletter that it had successfully on-boarded over 200 organizations and over 2,000 users.

“In addition our DirectTrust certification enables AeHN the ability to share our health provider directory with organizations who are also DirectTrust certified, enabling better communication between providers, consumers and systems.”

In its online newsletter, MetroChicago HIE describes how it is planning to bring its members a “revolutionary” way to manage their clinical communications. Its DirectRoute allows every physician, department and hospital with a Direct address to set up a personalized message routing profile, empowering each end user to decide how they want to receive clinical information from their colleagues, whether inside their EHR, on a web portal or on a mobile device. MetroChicago HIE notes that as the flow of data increases, so does the providers’ need to effectively manage incoming data within their preferred workflow. MetroChicago HIE said it recognized the need for busy healthcare providers to control their messages through a centralized, easy-to-use profile.

Recently the HIMSS Interoperability and HIE Committees conducted a nationwide survey on Direct messaging. With 75 responses representing 27 states, the 2015 Direct Messaging Survey found substantial use of Direct in support of care coordination use cases. “Use of Direct to enable HIE has been a bumpy ride and while variability exists in the market, the message should be that HIE is growing, the market is maturing and we are all learning how to better collaborate with our community partners,” according to the survey report. “The inter-organizational exchange of information in support of improved patient care is challenging, but from the feedback in this survey the cost is worth the benefit.”

Are there health IT execs who still think of Direct as more of a distraction than one of many valuable interoperability tools?

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