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July 20, 2011
by Mark Hagland
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The Federal Direct Project Offers One More Option, Though a Supplementary One, to HIE-Based Clinical Communications


The federal Direct Project may be a viable interim solution that can enhance clinician-to-clinician communications as HIEs continue to be developed.

Phoning and faxing healthcare data and information, especially patient records, are so last-century, but the healthcare industry still hasn't yet fully turbocharged the information superhighway towards health information exchanges (HIEs) and the Nationwide Health Information Network. The question is, what are the possible interim solutions to speeding clinician-to-clinician communications? The energy behind that question seems to be fueling progress on a federal initiative called the Direct Project (, which is evolving forward among healthcare IT leaders on the provider and vendor sides, and fueling some technical and process collaboration could enhance such communications even as more complex HIE infrastructures continue to be developed.

As the project's website explains it, “The Direct Project specifies a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet.” That mission statement encapsulates both the potentialities and limitations of Direct. Industry experts, and those involved in the demonstration project's development work, agree on one thing: while Direct could provide a very positive communications channel for clinicians around patient information, it will not-nor is it intended to-replace HIEs, or any other large communications superstructures. Instead, for a variety of relatively simple purposes-referring physicians sending their patient visit notes to specialists; clinical laboratories sending lab results to ordering providers; hospitals sending patient record information to their patients; primary care physicians sending patient immunization data to public health authorities, and so on-Direct will be helping to facilitate electronic communication that now in most cases still relies on faxing and other old-fashioned methods of transport, without the need for complex new data infrastructures.

Direct may also knock down barriers of skepticism and avoidance on the part of physicians in private practice, when it comes to participating in communication arrangements with other providers; just ask James Pollowitz, M.D., and Simeon Schwartz, M.D.


James Pollowitz, M.D.
James Pollowitz, M.D.

Earlier this spring, Pollowitz, an allergist and a member of the three-allergist Allergy and Asthma Associates of Westchester, in Scarsdale, a suburb of New York City, participated in the pilot phase of the Direct Project through his EHR vendor, the Carrollton, Ga.-based Greenway Medical. Meanwhile, Schwartz, who is president of the Westmed Medical group, a 200-plus multispecialty group practice in Purchase, N.Y., also a Westchester County community, worked, alongside other physicians in his group, with their vendor, the Chalfont St. Giles, U.K.-based GE Healthcare, and the Beaverton, Ore.-based Kryptiq, to create the foundation for a messaging capability that will encompass e-prescribing activity.


Mark Segal, Ph.D.
Mark Segal, Ph.D.

In the case of Allergy and Asthma Associates of Westchester, Pollowitz explains that “They basically created a module in the 2011 version of Greenway that allows you to export certain documents from within the EHR. There is an import feature, too, that I didn't have access to” as part of the initial pilot, he adds. The export capability, which was scheduled to go live about at the time of publication of this article, is something that Pollowitz says he is very much looking forward to taking advantage of. “Clearly, being able to get information, including hospital records, online in real-time, is incredibly important, and we've had that ability for about two years,” he says. “Added to that, being able to copy and paste within the EHR and to export information appropriately, will be a big advance,” he adds.

In the case of the Westmed Medical Group, Schwartz says that, “From my understanding, virtually everything is in place already” in order to go live very soon with Direct-channeled communications.” The first phase, which people are talking about now, is a push methodology, which allows me to do a consult, and send a consult-to-consult letter, and if the recipient is on the system, the document is immediately available to them. In the future,” he says, “I hope I can ultimately pull down the documents I need, from others.”

Schwartz adds that he sees another strong benefit in the use of the Direct channel going forward. “We don't like regional health information exchanges,” he says, “and our patients in general have indicated to us that they are not comfortable having their data stored in the ether, out of our control. We have patients who want to validate every transaction as it happens. They want to give consent at the point of service.” Use of Direct will allow Schwartz and his colleagues to accommodate such patient preferences, he emphasizes.


For development experts at the four vendor companies that have participated in the initial demonstration project (Greenway, and the Chicago-based Allscripts, the Malvern, Pa.-based Siemens, and the Horsham, Pa.-based NextGen, all led by the Chicago-based Health Information and Management Systems Society (HIMSS)), there were inevitable complications, but also progress in collaborating in the use of evolving industry-wide standards. Tone Southerland, senior applications manager at Greenway, reports that, “For part of the demonstration project, we worked directly with NextGen, sending them a message, and having them send it back to us,” for proof of concept. Technically, says Southerland, the demonstration project work was “pretty straightforward,” but it did also engender a multi-sided dialogue, among providers, including MedAllies, the New York HIE heavily involved in the demonstration project, and vendors, over which standards to rely on for development work. Two standards so far have been involved-the general SMTP messaging standard, and the option XDR standard, which provides document type neutrality in the handling of PDF and other electronic documents.

Jane Metzger
Jane Metzger

Says Mark Segal, Ph.D., vice president of government and industry affairs at GE Healthcare, “Direct will be usable, and perhaps almost optimal, in certain use cases. One can think of it as replacing a lot of the communication that’s taking place right now by fax. And it can do the structured clinical summaries, CCDs, though it’s not limited to that. What I think that Direct can do,” he says, “is to enable more people, particularly small-scale providers, to interact quickly, and build the demand for more robust exchange, which I would expect will increase over time.”

Meanwhile, Bob Barker, manager, interoperability and standards, at NextGen, notes that “The Direct Project had a different twist to it, and that was not just to develop an implementation package, so to speak, but also to change standards as needed, and to come up with an implementation guide that all vendors working on the project could work together on. In that sense, “ he says, “it was much deeper than the typical projects I’d been involved with.”

Barker says that “It was positive to come together as colleagues, not just as competitors, to come up with a set of solutions, even as the scope of the project expanded to include providers not currently live with their own EHRs, and even as he and his colleagues addressed the challenge of integrating the Direct messaging capability into their own EHR solution's capabilities.


One industry expert who has a very even-handed view of all this is Jane Metzger, principal researcher in the Waltham, Mass.-based Global Institute for Emerging Health Care Practices at the Falls Church, Va.-based CSC. “I think this is an important first step,” says Metzger. “When you watch the painfully slow progress with EHRs, you realize that ‘the perfect’ is the enemy of immediate forward progress. This is very reality-based, because it doesn't assume that senders and receivers have sophisticated EHRs, though they will someday,” she says.

Metzger concludes by saying that “The other thing that's really interesting about it is that there's been a lot of difficulty building the infrastructure for HIE, because it involves this big global business model; whereas this sort-of-push model [involved in Direct] has a very clear business model. It's information that an individual provider definitely feels is going to have value in a patient care context.”

Healthcare Informatics 2011 August;28(8):14-30

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