By Mike Miliard
'Growth is continuing, and I expect it to continue, but it does feel that it's been an uphill struggle, at times'
The 2015 Direct Messaging Survey published this week by HIMSS shows growing use and appreciation for the secure, email-like method of data exchange. But there are still challenges to be ironed out – related to technology standards, cost and workflow – before it sees broader acceptance.
The Direct Project, shepherded along by the Office of the National Coordinator for Health IT with collaboration with some 50 or so health IT vendors, went live with pilot projects back in 2011. At the time, then-ONC chief Farzad Mostashari, MD, called it "a new way of doing business."
Billed as a simple, secure, scalable way to transfer clinicial data between two parties, Direct was touted as "the first technology that could really kill the fax in healthcare," as Microsoft engineer Sean Nolan put it.
[See also: Direct messaging comes to 6 state HIEs]
In the years since, the apprach has found favor across healthcare. But perhaps has not spread as far and wide as its creators initially hoped.
"In terms of new technology adoption, it's been pretty fast," says David Kibbe, MD, chief executive officer of Direct Trust, non-profit alliance of 150 or so IT and provider organizations who support Direct message protocols. "If you look at the growth of Direct over the past two years – and it's only been three since it was available as a standard – it's pretty astorunding. We're now up to 40,000 healthcare organizations that are contracted for Direct exchange by one of the HISPs in Direct Trust's network."
There are currently 36 health information service providers enabling Direct, he adds. "That's more than doubled in a year, and it had doubled the year before. The exponential growth is continuing, and I expect it to continue. But it does feel that it's been an uphill struggle, at times. In a fee-for-service world, there isn't a whole lot of incentive to exhange health information. So it's taken a while."
Spearheaded by the HIMSS Interoperability and HIE Committees, the 2015 Direct Messaging Survey polled hospitals, health systems, physician practies, HIEs, HISPs, ACOs, and government officials in 27 states.
The poll found substantial use of Direct in support of care coordination use cases, and broad availability to a provider directory (albeit with "great variability" in the method of access. Participants also reported continued challenges incorporating structured data into the EHR.
The top five reported use cases of Direct were:
- Transitions of care
- ADT notifications
- Patient communication
- Secure email for other purposes
- Consult requests between physicians
The most-cited benefits of the technology included speedier access to information, less paper handing, and more accurate and complete patient information.
Still, there are big roadblocks. Major impediments to Direct implementations includes high cost, disruptions to clinical workflows and the fact that many other providers were not yet ready to connect via Direct.
In a blog post, Mari Greenberger, director of informatics at HIMSS, and committee member Sean Kennedy, HIE director at the Mass eHealth Institute, break down some further numbers from the report:
- 76 percent of respondents reported access to a provider directory, further 64 percent report they can access internal providers from that directory from within their EHR, whereas 52 percent report they can access external providers within their EHR
- 28 percent report their EHR offers an integrated directory, whereas 28 percent report they pull in the directory via web services and 17 percent perform a manual download
- 83 percent of respondents are part of a HISP; 85 percent of HISPs can route information to another HISP
- 85 percent of HIOs are part of a scalable trust network (e.g., DirectTrust, NATE, HealtheWay) and most respondents report it extremely important their HISP is part of such a network
- 51 percent agree that the cost of using Direct is worth the benefit of information exchange
- There remains no standard provider directory format – 14 percent report using LDAP, 14 percent use IHE HPD, 18 percent have no plans to adopt a standard, 18 percent are considering their options, while others use another proprietary standard or simply a relational database.
- Incorporating C-CDA data, identifying trading partners and funding implementations are reported as modestly challenging; completing the directory is reported as prohibitively challenging,
- In the absence of MU, respondents reported the following technical preferences for sending electronic health information: CONNECT (27 percent), SMTP/S-MIME (23 percent), Direct + XDR/XDM (15 percent), SOAP+XDR/XDM (6 percent)
In an interview with Healthcare IT News, Kennedy says he sees much to be encouraged about. In particular, he cites the response to one question. When asked to agree or disagree with the statemen, "I would still use Direct to exchange health information, even if not required to do so because of meaningful use," 59 percent of respondents assented.
"That tells me that there's an interest in Direct as a standard for exchange," he says. "And given that it's one of the lower-denominator exchanges, it really allows most providers to engage in that activity at a low cost."
Still, Kennedy says there's work left to be done.
"There still remains no standard for provider directories," he says. "We saw disparate implementations using LDAP (Lightweight Directory Access Protocol), using HPD (Healthcare Provider Directory), using other non-standard approaches – and then others saying they had no interest in adopting a standard and were just going to go with a relational database. That was pretty interesting to me. There's no compelling standard that's coming to the forefront, and as a result, people are innovating in that space."
There were some positive surprises in the report's numbers, however, says Kennedy.
"I was surprised that 85 percent of HISPs can actually talk to another HISP. We've always talked aboutthe fact that HISP to HISP is an enormous barrier to exchange, and I still think that's a big deal. But the fact is that most have crossed that barrier with at least one other HISP, and in many cases they're able to talk to a number of HISPs."
As for the respondents citing high cost and workflow disruption as two big reason for pessimism with regard for Direct, Kennedy is understanding.
"Trying to unify that workflow is really paramount to adoption," he says. "And getting an inter-organization exchange of messaging integrated into the EHR is definitely something that's proven challenging. It's gotten better over the past couple years – and I think some of the results say that most respondents to the survey could actually access extrenal providers and provider directories from within their own EHR – which was remarkably encouraging."
But costs can be prohibitive – especially for, say, smaller physician practices.
"Direct was envisioned to be a fairly low-cost standard," he says. "But when you take into account the full solution to implement, the cost definitely became prohibitive" for some.
Nonetheless, all told both Kennedy and Kibbe are greatly encouraged by the responses to the survey, and see a bright future for this (relatively) simple and stratightforward piece of the health information exchange equation.
Kibbe says he sees "tipping point" and cites the survey as evidence that standards-based methods such as Direct are now a permanent fixture on the HIE landscape, and will continually gain ground over fax other "one-off" connectivity tools.
"In general, organizations are much better practiced at using HIE, and Direct in many cases," than they were just a couple years ago, says Kennedy. "The market overall is becoming more proficient and has matured. The incentives are certainly there, and we're all sort of learning to collaborate together on this."
HIMSS members can access the full report here.