Will Direct Project Cripple HIEs?

The Office of the National Coordinator for Health IT says its Direct Project can help healthcare practitioners nationwide quickly gain IT interoperability. So why aren't you jumping on board?

Paul Cerrato, Contributor

August 9, 2011

4 Min Read

The biggest complaint I hear from clinicians about health information exchanges (HIEs) is that they provide too much information. Practitioners hesitate to sign up because they worry that revealing details about their patient population will put them at a competitive disadvantage. "If you wouldn't ask Macy's to share its customer database with JCPenney, why ask me to reveal my patient database to the doctor down the road?"

If that's your concern, why not take advantage of the ONC's Direct Project, a government initiative that offers healthcare providers a way to directly and securely communicate with one another online, even in the absence of an HIE?

This year, several pilot projects are taking advantage of the technology, including one involving Hennepin County Medical Center in Minnesota and another with the Rhode Island Quality Institute. Hennepin is using Direct Project to push immunization records to the Minnesota Department of Health. In Rhode Island, primary care physicians are using the system to send patient information to specialists, and to send EHR-based data to the statewide HIE.

The program offers a secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted parties over the Internet. How does it accomplish this feat in the absence of a full-fledged HIE? Direct Project has enlisted several IT vendors, including Allscripts, Epic, NextGen, and GE Healthcare. For example, hospitals and medical practices that use any one of their EHR products need only follow the procedures outlined by the ONC to get their system to talk with an EHR in another facility via a Direct Project hookup.

To take advantage of the government service, a healthcare facility needs to be able to send and receive secure emails--some as simple as a primary care physician consulting with a specialist, others as complex as sharing a full set of patient records, including lab data, large medical image files, and nursing notes through compatible EHR products.

Keep in mind, however, that Direct Project focuses on the transport of health information. On its own, it doesn't create interoperability.

As explained in the ONC's overview document, in order for systems to interoperate, the IT department must determine 1) how the systems will send and receive messages, 2) the structure and format of the exchanged content (e.g., a Continuity of Care Document), and 3) what terms or language the systems will use within their content (e.g., SNOMED Clinical Terminology). Direct Project provides only the first of these three components.

Understanding The Why And How

Why sign up? One advantage of using Direct Project's point-to-point link is that it can help satisfy Stage 1 Meaningful Use objectives for healthcare providers. And depending on your needs, the service can be used in conjunction with certified comprehensive EHRs, individual EHR modules, personal health records, a simple email client, or a Web browser.

The next logical question is: How do I connect? A detailed explanation of the technical specs are provided on the ONC's Direct Project site, but essentially, there are four requirements:

-- Use MIME to package the message content.

-- Use S/MIME encryption and signatures to ensure confidentiality and integrity of the content.

-- Authenticate the sender and receiver with X.509 digital certificates.

-- Route the messages via SMTP.

The System's Weaknesses

As I mentioned earlier, Direct Project is a push system. It won't let clinicians pull data from other sources. So if, for example, you have an unconscious patient in the ED and you're trying to find out if he or she has a medical record elsewhere, you can't pull such data from a regional HIE or other source.

Some HIE proponents also worry that Direct Project could fragment progress toward widespread HIE interoperability by encouraging clinicians to postpone enrollment in a full-scale information exchange. However, a major goal of ONC is to get most healthcare providers to eventually participate in its mega-HIE, the Nationwide Health Information Network (NHIN), which links federal health-related agencies such as the VA, Social Security Administration, Centers for Medicare and Medicaid Services, and the Beacon Communities. ONC thinks of the Direct Project as only a steppingstone on the way to full implementation of NHIN.

Signing on to Direct Project seems like a no-brainer, so what are you waiting for? If you aren't using the program, why not? If you are, what are its strengths and weaknesses? Email me at [email protected]. We'd like to get a conversation going.

Find out how health IT leaders are dealing with the industry's pain points, from allowing unfettered patient data access to sharing electronic records. Also in the new, all-digital issue of InformationWeek Healthcare: There needs to be better e-communication between technologists and clinicians. Download the issue now. (Free registration required.)

About the Author(s)

Paul Cerrato


Paul Cerrato has worked as a healthcare editor and writer for 30 years, including for InformationWeek Healthcare, Contemporary OBGYN, RN magazine and Advancing OBGYN, published by the Yale University School of Medicine. He has been extensively published in business and medical literature, including Business and Health and the Journal of the American Medical Association. He has also lectured at Columbia University's College of Physicians and Surgeons and Westchester Medical Center.

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