In the last few years, Direct -- the crowd-sourced encrypted email standard for sending patient data, also known at various times as National Health Information Network (NHIN) Direct and later as the Direct Project -- has evolved from a vague-but-interesting idea to an emerging means of secure, HIPAA-compliant physician-to-physician messaging around which a tech infrastructure is evolving. An online replacement for the fax, if you will.
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As physicians and their electronic health record (EHR) vendors begin to grasp Direct's utility and apply it to the health information exchange (HIE) requirements of meaningful use stage 2, the question arises: Can Direct be a long-lived standard for smaller physician offices to facilitate HIE, or will it ultimately fall short because accountable care organizations and other programs requiring quality reporting will need more granular, structured information? Probably the latter, said health IT leaders discussing that question at the State HIT Connect conference in Washington, D.C.
But the combination of Direct HIE and an ONC-certified EHR will be enough to satisfy meaningful use requirements.
"The best HIE is invisible," said Lee Stevens, ONC program manager for the state HIE program. "It will just be there, it'll work, and it will support the improvement of health care." He went on to explain that Direct protocols were designed to replace fax machines and also to rapidly get physicians compliant with meaningful use rules -- but not necessarily to feed data into the complex analytics systems driving quality improvement.
Direct emerged two years ago starting with the idea that ONC wanted to give the maximum number of physicians a simple way of complying with meaningful use. Stevens said that while ONC didn't know what later stages of meaningful use would look like, it seemed to the agency that basic, secure email protocols would satisfy meaningful use's emerging HIE requirements enough to get physicians their incentive checks.
With data-driven programs from Medicare and commercial payers emerging since those early stages of meaningful use, Direct has shown its limitations. Stevens said he's heard discussion around how Direct could be made more complex, but he's convinced it can't be expanded enough to be considered "ideal" for HIE -- specifically, providing structured data for queryable exchange. Ultimately, such HIE will be done through current and future variants of Clinical Document Architecture (CDA) standards under development.
What Direct does, though, is give certain providers -- for example, rural docs unable to connect to a major HIE for now -- a means to attest for meaningful use and exchange patient data electronically. "There are also providers who don't want to jump in with both feet and really go in with a large-scale system," Stevens said. "They might feel a little bit more comfortable emailing a couple of records around first."
Lorie Mayer, Arizona state Medicaid HIT coordinator who also oversees the state's HIE, said the various agencies and public-private entities building her state's network for moving patient data has focused on "more robust" HIE than Direct can provide.
Lee StevensONC program manager
Still, there are providers who want to do less ambitious HIE, i.e. less structured and detailed than CDA. Erecting a network that can handle both, she said, has proven to be a time-consuming project. Teaching physicians about their options has proven even more so. Time isn't an asset they have, though: Mayer and her colleagues have to get it done in 14 months, when their federal grant cycle ends.
"Our work is really getting ourselves organized to be able to do both Direct and robust HIE … and to provide education and outreach to [help] providers to understand that they have options, which many of them might not have understood that they had."
That’s not such an easy job to explain to physicians in a state where a more basic technology obstacle is in the way: 15%-20% of physicians are older than 55 years old, and many of them are debating whether to adopt EHR systems or retire, making the decision about Direct vs. CDA for patient data exchange a moot point.
Technology-savvy physicians, however, see value in Direct for passing off between each other simple but crucial reports concerning patients they have in common, she said. And so does Mayer herself, who sees Direct as a transitory standard between paper and the more complex HIE of coming years.
"The question is," Mayer wondered, "is it going to get us where we need to be for [National Quality Forum] efforts, for all the bigger data initiatives? I don't see that it will. But in the meantime we do have to help providers learn how to adopt, as well as evolve, as well as to give them a degree of comfort that this can work, that it's stable, that it can help them in their day-to-day practice [and] that it's an investment in getting some time back."
Vendors keen to embrace Direct standards
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Get the latest news on Direct at Health IT Exchange