David Kibbe, M.D., CEO of DirectTrust and longtime policy adviser to the American Academy of Family Physicians, talks with SearchHealthIT about the near- and far-term prospects for Direct exchange, particularly in light of the apparent weakening of federal meaningful use rules and deadlines incentivizing the adoption of electronic health records. With a small, part-time staff, Kibbe's Washington, D.C.-based nonprofit is making clear progress in furthering adoption of the Direct standard for secure, private healthcare information exchange. While some health IT thought leaders might feel robust EHR-to-EHR data exchange is the gold standard, Kibbe points out that, yes, Direct has its place in healthcare and it's a far cry better than faxes and emails, which it replaces.
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This is a two-part Q&A. Read the second part.
Explain to our readers new to DirectTrust what it is, and how it works.
David Kibbe: DirectTrust is a voluntary, self-governing, nonprofit trade alliance. It is dedicated to the growth and adoption of Direct exchange, at a national scale, primarily for the establishment of policies, interoperability and business practices that support the encryption, trust and identity aspects of Direct exchange. DirectTrust has approximately 140 members now. It has grown very rapidly from its incorporation in 2012. Now it supports a network of approximately 30 health Internet service providers that are providing Direct exchange to a broad and diverse group of customers including electronic health record [vendors] and their customers, health information exchanges, health plans and federal agencies.
So who's using DirectTrust now? About how many users do you have?
Kibbe: DirectTrust supports service providers who are providing Direct exchange, largely driven by stage 2 meaningful use requirements that transitions of care be electronically supported. Right now DirectTrust members are supporting the delivery of care by approximately 6,000 organizations, including medical practices. Those numbers have been doubling every three months for a year.
About how many physicians have been using Direct exchange in the U.S.?
David Kibbe, M.D.CEO, DirectTrust
Kibbe: It's unclear exactly how many are using it. We do know out of the 250,000 addresses that have been provisioned and supplied, probably about 75,000 of those are physicians and nurses. We're still early in stage 2 meaningful use. As you know, there has been a hiatus declared, a delay. Some healthcare organizations do not have to use meaningful use, and therefore do not have to use meaningful use in 2014. Nonetheless, the use of Direct exchange for transitions of care document exchange is growing on a daily basis.
Here's a devil's advocate question. Isn't Direct exchange just a replacement for faxes?
Kibbe: We certainly hope it is a replacement on a national scale for fax, e-fax, and for mail and for phone communication. One of the problems with faxes is they're not secure. But another problem that is more substantial is they're not as dependable as electronic messages. They are routinely delivered late, or to the wrong entity, and of course they are paper. So it somewhat defeats the purpose of having an electronic health record if in order to move information from an EHR, you have to print it out, scan it and print it by fax.
How is DirectTrust funded?
Kibbe: DirectTrust is funded by its membership dues, which are on a sliding scale. So a small nonprofit membership is considerably less than for a large organization or large corporation. We operate under a two-year cooperative relationship with ONC [Office of National Coordinator for Health Information Technology]. In the first year, which was March 2013 to March 2014, we received $285,000, which was approximately half of our operating budget for that time. This next March 14 to March 15, we are receiving approximately $50,000 more, which is currently less than 10% of our operating budget.
Do you guys have a paid staff? Do you receive a salary? [According to DirectTrust's most recent publicly available tax return, the organization paid out $80,245 in contractor fees in 2012.]
Kibbe: I receive a salary as a contracted part-time employee. I have an administrative staff that is also contracted. We currently have a staff that is about three and a half to four people. Nobody is full-time. All the people who work for DirectTrust are contracted.
What do you do in your other life, your other world?
Kibbe: I work part-time for the American Academy of Family Physicians. I have worked there either part-time or full-time for the last 11 years. My involvement with DirectTrust came directly as a result of the AAFP's support for this interoperability standard. AAFP members as a group have been among the very highest users of EHR and have been so even before the meaningful use program. The fact that these EHRs have been unable to exchange information with each other has been a real problem for the patients that are at home and physicians in primary care. It's been my good fortune to be working for an organization that supports [health data] interoperability 100%.
You've received grant money from ONC. So how does this fit into ONC's world view of health information exchange?
Kibbe: That would be a great question to put to ONC. ONC has, of course, supported interoperability of EHR in a variety of ways through their funding of health information exchanges, but it's also the case that the stage 2 meaningful use objectives and measures, which come from CMS, and the standards and support that are offered by ONC require interoperability of health information exchange for transitions of care and for patient engagement in 2014. It's very much the case that ONC wants this level of interoperability to become ubiquitous. And as Farzad Mostashari, the previous director of ONC, has said many times, Direct exchange should be ubiquitous, affordable and easy to use.
So which meaningful use criteria does Direct exchange help a physician attest to?
Kibbe: There are two very specific areas in which Direct comes into play. The first is in the requirements for transitions of care. Meaningful use requires that 50% of all referrals in transitions of care must be electronically transmitted, and 10% of those must occur via Direct exchange or acceptable substitutes in certain cases. The same thing is true for hospital systems where they're required to have a certain percentage of their referrals be electronically transmitted. And although Direct exchange is not the only way to meet these requirements, because EHRs certified in the 2014 period must be Direct enabled, it's a convenient and easy way to fulfill those requirements. The second area is in viewing downloaded transcripts of patients. There's a requirement that patients be enabled by the provider -- using a certified EHR -- to view, download and transmit to a third party of the patient's choosing, a summary of the patient's clinical care. That must be done electronically as well a certain percentage of the time. So there again, Direct is not required to be used for that purpose, but EHRs must be able to send messages via Direct. Therefore, the EHRs are being used for that purpose.
Next stage of meaningful use still up in the air
Two healthcare executives share why stage 2 and Direct exchange are intertwined
DirectTrust gets funding from ONC for interoperability work