How DirectTrust Managed Direct Secure Messaging During COVID-19

Communication between providers is crucial when it comes to patient data exchange, which is why health information exchanges across the country are always aiming to enhance provider-to-provider communication by way of direct secure messaging.

Direct secure messaging, which was launched in 2010 by the Office of the National Coordinator for Health Information Technology (ONC), provides a basic exchange or push messaging system without the need for an EHR or health IT infrastructure other than an internet connection.

“It allows the 2.5 million connected parties in our network to send messages to any other connected party,” Scott Stuewe, president and CEO of DirectTrust, said to EHRIntelligence. “It was built as a simple mechanism for interoperability that doesn't take a lot of effort to deploy. The system is easy to deploy, it carries virtually any payload, and the user doesn’t have to do anything but know the recipients’ direct address to send them a message.”

While many expected direct secure messaging to soar at the start of the COVID-19 pandemic, the beginning of the year actually saw a massive 13 percent decrease in messages from Q1 2019 to Q1 2020, before executing a record number of transactions at the end of the year.

“There was work happening with the Association of Public Health Laboratories, an organization that put up a single direct address to receive messages that are called Electronic Initial Case Reporting,” Stuewe explained. “eCR messages were being piloted in 2019 and providers began to send them before COVID-19 hit.”

“But in 2020, APHL managed to ramp this up really quickly because they added thousands of new users,” Stuewe continued. “Providers sent 22 million transactions to APHL and they forwarded it to the CDC and the respective state departments.”

Once APHL would route the message to a jurisdiction, it would send a descriptive message back to the sender to let her know how APHL routed the message and to whom the message was sent.

“Because APHL mostly does a routing job, they have to send those kinds of test results,” Stuewe continued. “The messages need to be sent to both the state where the incident occurred and to the state where the patient lives, which might be two different states.”

Then there is another use case, Stuewe said, which took place in Arkansas.

“They use direct messaging to communicate the COVID positive patients to all of the primary care providers in the State of Arkansas,” he explained. “Every day at 5:00 PM, they send reports to every primary care physician to tell them who all their COVID positive patients are based on lab results that come into the Arkansas shared platform, which the state health department operates.”

Looking back at 2020, Stuewe said he was excited about the opportunity to get the data where it needs to go.

“Most of the health departments are not very well-heeled from a technology standpoint,” Stuewe said. “They don't have a lot of technology, and direct messaging is a very low-cost mechanism for them to communicate with folks who want to send them messages.”

Stuewe referred to the lower number of direct exchange transactions during that time as a “canary in a coal mine; a lack of communication among providers as the result of the dramatic falloff in appointments.”

Once the first wave subsided and providers adapted to patient care during a pandemic, referrals and common procedures, such as non-emergency healthcare, slowly went back to normal.

In fact, DirectTrust announced in February 2020 that it surpassed 2 billion direct secure messages since it began tracking the statistic in 2014. This milestone was powered by a record-breaking 265 million patient data exchange transactions during 4Q 2020 and 719 million overall transactions in 2020.

“Notably, it took five and a half years for the number of direct secure messages exchanged to reach one billion, and just 18 months to surpass two billion,” Stuewe said. “This milestone illustrates interoperability of electronic health information is here and continuing to gain traction as a means to facilitate better coordinated patient care.”

Looking forward to 2021, Stuewe and his team are working on a notification implementation guide. This would fulfill a CMS condition of participation that will require all hospitals to send outbound event notifications by May 2021.

“This is already having a positive impact on our traffic,” Stuewe said. “But once this happens in a big way in May, the issue is actually that people are going to start worrying about being able to tell what the messages are about. Right now, we have many message types being sent across our network. But when users receive them, they can't easily see what they're about right away.”

“Particularly, if a user is using an EHR system, when she receives that message, she’d like to have it route to the right person, activate the right workflow, or otherwise sent to an entirely different department. Now, we're getting an opportunity to see context established for these messages for notifications, so that receivers will be able to route them appropriately.”

Stuewe said the implementation guide should be ready any day now. It should set the stage for DirectTrust to send context on nearly every message in the network, which ultimately intends to make every message more usable, he concluded.

“The biggest thing for us to learn this year is as the transaction volume ramps up, what we're finding is an awful lot of the transactions that are happening now are not having the value they could have if they could just get routed to the right person at the EHR system. That's the big thing we're focused on right now.”