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3 Key Pieces to the Interoperability Puzzle: #2 Directed Exchange
The ability to send important health information to other providers is essential to effective care coordination. Directed exchange provides the means to do so securely and efficiently.
Health data exchange between providers is key to ensuring that patients receive the most appropriate care possible based on the best available information.
Over the last decade, directed exchange has become a dominant form of secure information sharing by enabling data exchange with a specific recipient in mind.
Whereas query-based exchange supports the “pull” component of information sharing in healthcare, directed exchange enables the “push” of health data from one provider to another.
In the second installment of our series focused on the elements of an effective interoperability strategy, we focus on directed exchange and its fundamental role in provider-directed sharing of information to improve patient care.
THE RISE OF DIRECTED EXCHANGE
The Office of the National Coordinator defines the term as the “ability to send and receive secure information electronically between care providers to support coordinated care.” The technology resembles secure email but is a unique form of data transport for providers to send clinical information electronically “in an encrypted, secure, and reliable way” with other known and trusted healthcare professionals.
And that last part is important to recognize. The sender is transmitting information (e.g., laboratory orders and result, patient referrals, discharge summaries) to a specific recipient.
The widespread adoption of directed exchange is primarily the result of federal regulation that mandated the use of the Direct Standard as part of health IT certification supporting the EHR Incentive Programs. Direct remains an integral part of ONC’s most recent edition of health IT certification criteria, the 2015 Edition, and likely into the future to support federal requirements for transitions of care.
The standard emerged from the Direct Project, a public-private initiative launched in 2010 to develop a standard for sending health information that enjoyed the support of ONC and its parent agency, the Department of Health & Human Services (HHS). At the most basic level, two specifications primarily comprise the Direct Standard.
The first is Applicability Statement for Secure Health Transport v1.2, which uses Simple Mail Transfer Protocol (SMTP) for message transmission, S/MIME (Secure/Multipurpose Internet Mail Extensions) for encryption, and X.509 certificates to secure a connection and validate users.
External Data Representation (XDR) and Cross-Enterprise Document Media Interchange (XDM) together represent the second set of specifications, which are IHE profiles used for document interchange over a reliable messaging system.
All that work sets the table for Direct messaging, today’s predominant mode for exchanging health data between providers outside of faxing.
According to DirectTrust, the association that supports health data exchange using the Direct standard, the use of directed exchange based on Direct continues to grow. In 2019, more than 811 million messages were sent and received using DirectTrust addresses, a twofold increase over 2018. Between 2014 and 2019, a total of 1.4 billion exchange transactions took place.
DirectTrust addresses also increased to 2.2 million in 2019, a 24-percent increase over the previous year. The number of organizations served by DirectTrust’s accredited health information service providers (HISP) increased from 138,000 to 238,000.
HISPs, however, aren’t the sole domain of DirectTrust. These accredited network service operators can be run by EHR companies, state and regional health information exchanges, and private service providers. Responsible for provisioning Direct addresses, HISPs play a central role in the adoption and use of Direct secure messaging because having an address is necessary to receive health information using this interoperability service.
The responsibility for obtaining a Direct address falls to healthcare organizations and providers, so the latter must work with their technology or data exchange partners to be able to make use of the service. Many leading EHR technologies support Direct messaging.
However, providers outside of large health systems and physician groups are not digitized, lacking access to Direct messaging capabilities embedded in many EHR systems. As a result, they must look to alternatives. Fortunately, standalone or web-based solutions are available to enable participation in directed exchange.
The inability to get these services up and running creates limitations in terms of who can participate in directed exchange. Additionally, access to a robust directory of Direct addresses depends on HISPs taking steps to connect to other HISPs. Otherwise, end users are limited to exchanging within a single network.
FORTHCOMING CHANGES TO DIRECTED EXCHANGE
With the release of Interoperability and Patient Access final rule, the Centers for Medicare & Medicaid Services will require as a Condition of participation (CoP) that hospitals send admission, discharge, and/or transfer event notifications "to another healthcare facility or to another community provider or practitioner." The policy will go into effect six months following the publishing of the rule in the Federal Register.
ADT notifications will grow in importance and require healthcare organizations to ensure their health IT systems, namely the EHR, is capable of receiving these notifications, which are necessary for informing providers to connect promptly with patients for follow-up care. These messages rely on an HL7 standard (2.5.1 or later) and use Direct as the "most prominent option for transport," according to the Interoperability Standards Advisory. Health information networks across the country have made these messages a core part of their services, but now the onus is being shifted to hospitals themselves.
With providers wanting more information about their patients — especially in the era of risk-based care models — directed exchange can prove to be a powerful tool for engaging with patients following a hospitalization or major health episode and making necessary interventions to avoid future complications. Therefore, clinical and IT leaders must work to ensure this form of health data exchange is a core component of their organization’s interoperability strategy.
Directed exchange is an effective means of pushing information from provider to provider, but like query-based exchange it is only one part of the interoperability puzzle. In the next installment of this series, we will consider how emerging forms of technology can tie query-based and directed exchange into a unified and effective service for providers and advance interoperability across the healthcare ecosystem.
See the other articles in this series, 3 Key Pieces to the Interoperability Puzzle:
3 Key Pieces to the Interoperability Puzzle: #1 Query Based Exchange
3 Key Pieces to the Interoperability Puzzle: #3 Query-Based Exchange + Directed Exchange