Monday, November 29, 2010

The Direct Project - Where We Are Today

This article originally appeared in The Health Care Blog and O'Reilly Radar. by Brian Ahier, Rich Elmore and David C. Kibbe The Direct Project announced today the completion of its open-source connectivity-enabling software and the start of a series of... read the rest.

I have copied highlights below, but please note that CareSpark will be piloting the standards used by the Direct project to demonstrate our ability to be a Health Information Service Provider (HISP) communicating to the Veterans Administration.  Carespark (Tennesee) will be linking the VA with private clinics providing health services to veterans.  This is of particular interest to me as my father and mother-in-law locally receive health care benefits from the VA. In addition, I have multiple family members across TN and the state of Tennessee has over 500,000 veterans with over 1 million dependents who will eventually benefit when the pilots move into production in the future.  

The Direct Project announced today the completion of its open-source connectivity-enabling software and the start of a series of pilots that will be demonstrating directed secure messaging for healthcare stakeholders over the internet. 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.

Also announced:
  • A new name - The Direct Project was previously known as NHIN Direct 
  • An NHIN University course(The Direct Project - Where We Are Today), to be presented  by Arien Malec, November 29 at 1PM ET, sponsored by the National eHealth Collaborative
  • An extensive list of HIt vendors (20+) that have announced plans to leverage the Direct Project for message transport in connection with their solutions and services.  
  • Presentations at the HIT Standards Committee on Tuesday, November 30 where three or more vendors will be announcing their support for the Direct Project. 
  • A thorough documentation library including a Direct Project Overview 
  • Best practice guidance for directed messaging based on the policy work of the Privacy and Security Tiger team
  • A new website at
  • A new hashtag #directproject for following the Direct Project on twitter.
What is The Direct Project?
Today, communication of health information among providers and patients is most often achieved by sending paper through the mail or via fax. The Direct Project seeks to benefit patients and providers by improving the transport of health information, making it faster, more secure, and less expensive. The Direct Project will facilitate “direct” communication patterns with an eye toward approaching more advanced levels of interoperability than simple paper can provide.

The Direct Project provides for universal boundaryless addressing to other Direct Project
participants using a health internet “email-like” address.

The Direct Project focuses on the technical standards and services necessary to securely transport content from point A to point B and does not specify the actual content exchanged.  When The Direct Project is used by providers to transport and share qualifying clinical content, the combination of content and The Direct Project-specified transport standards may satisfy some Stage 1 Meaningful Use requirements. For example, a primary care physician who is referring a patient to a specialist can use The Direct Project to send a clinical summary of that patient to the specialist and to receive a summary of the consultation.

How might the Direct Project be Used?

2009-10 Congress and agencies of the federal government have created regulations that require physicians and hospitals participating in the ARRA/HITECH incentives awarded for meaningful use of EHR technology to:
  • send messages and data to each other for referral and care coordination purposes;
  • send alerts and reminders for preventive care to their patients;
  • send patients clinical summaries of their visit and of their health information
  • receive lab results from labs
  • send immunization and syndromic surveillance data to public health agencies
  • integrate with HIT vendor systems
There are already organizations that have announced the establishment of national clinical exchange networks, including integration with the Direct Project. States and HIO’s will need to decide how best to provide Direct Project services to their constituents, whether by partnering with existing exchange networks or incorporating direct messaging into the services they provide.
The Direct Project Implementation
The Direct Project is organizing real-world pilots to demonstrate health information exchange using The Direct Project standards and services. Six pilots are ramping up including:

Rhode Island Quality Institute, Redwood MedNet and MedAllies will be sending Continuity of Care
Documents to other providers for referrals and transitions of care. Visionshare will be linking to
immunization registries. Carespark (Tennesee) will be linking the VA with private clinics providing health services to veterans. And Connecticut’s Medical Professional Services, an IPA, will be
linking Middlesex Hospital with primary care providers.


Connectivity among providers is facilitated by Health Information Service Providers (HISP). HISP describes both a function (the management of security and transport for directed exchange) and an organizational model (an organization that performs HISP functions on behalf of the sending or receiving organization or individual).
Best Practices
The Direct Project is bound by a set of policies that have been recommended to the HIT Policy Committee (HITPC) or are being examined by the HITPC’s Privacy and Security Tiger Team for directed messaging. Within this context, the Direct Project has developed best practice guidance for secure communication of health data among health care participants who already know and trust each other. The Direct Project assumes that the Sender is responsible for several minimum requirements before sending data, including the collection of patient consent. These requirements may or may not be handled in an electronic health record, but they are handled nonetheless, even when sharing information today via paper or fax. For example, a sender may call to ask whether a fax was sent to the correct fax number and was received by the intended provider. The following best practices provide context for the Direct Project standards and services:
  • The Sender has obtained the patient’s consent to send the information to the Receiver.
  • The Sender and Receiver ensure that the patient’s privacy preferences are being honored.
  • The Sender of a Direct Project transmission has determined that it is clinically and legally appropriate to send the information to the Receiver.
  • The Sender has determined that the Receiver’s address is correct.
  • The Sender has communicated to the receiver, perhaps out-of-band, the purpose for  exchanging the information.
  • The Sender and Receiver do not require common or pre-negotiated patient identifiers. Similar to the exchange of fax or paper documents, there is no expectation that a received message will be automatically matched to a patient or automatically filed in an EHR.
  • The communication will be performed in a secure, encrypted, and reliable way, as described in the detailed The Direct Project technical specifications.
  • When the HISP is a separate entity from the sending or receiving organization, best practice guidance for the HISP has been developed for privacy, security and transparency.
The demonstrations will likely take place early next year at the HIMSS Annual Conference in Orlando

What is a Unicorn?

When I was much younger and extending into my early 20’s, I loved the concept of and collected Unicorns. While I still love the concept of Unicorns, I no longer collect them, so you can imagine my surprise to hear from one of the CareSpark stakeholders that I was leading and helping to build the region’s Unicorn
During the last CareSpark Board meeting, a CIO from one of the hospital systems in the region mentioned that he could share his vision of a Unicorn to support the needs of his providers for Health information exchange (HIE). He went onto mention that an HIE is like a Unicorn…we all know what we think one should look like, but who’s to say my unicorn looks like your unicorn. What does your Unicorn look like?  
I would like to think my Unicorn would be golden and sparkly…something like this…  
“Now I will believe that there are unicorns…” William Shakespeare – The Tempest

As the common fare of little girls' fantasies, the origin in histories becomes quite ironic. In thinking about this blog topic, I thought it was interesting to correlate that the Unicorn is known for the healing power in it’s horn.  A fabulous beast born of man’s imagination, the unicorn form and function are as variable as the minds and religions of mankind;  but whatever its shape – and it has been described as an ox, ram, goat, bull, antelope, wild ass, horse,  rhinoceros, serpent or fish, - a one-horned beast was always a symbol of supreme power.

In the west, the unicorn was first mentioned in 398 BC by Ctesias, a Greek physician and historian of Persia and India.  He traveled to the Persian court and remained there working as a physician for 17 years under two rulers.  

Why did they go away, do you think? "Who knows? Times change –especially in health care today. Would you call this age a good one for unicorns?"  

For those of you who may not be aware yet, I stepped in as Interim CEO for CareSpark on September 30, 2010. One of my deliverables during my tenure will be to develop a sustainable business plan and I have spent the past several weeks helping to shepherd and lead CareSpark toward the evolution necessary to sustain them into the future and reduce the dependency on federal funding. 

Out of the 234 HIEs surveyed by the eHealth Initiative for 2010 only 18 are operational, not dependent on federal funding, and have broken even through operational revenue only. To date, CareSpark has been dependent on federal funding business plan will begin to wean them from the dependencies over the next several years with the support of the community and state.

In addition to the Carespark business plan, I have the pleasure of working with the State of TN and the state designated entity (HIP TN) to develop their sustainability plan and roll out the backbone connecting the various HIEs across the state beginning in 2011. 


At the beginning of this week, after the Thanksgiving holidays, I have much to give thanks for reflecting back over the past two years of business after starting Serendipity Health. I am doing what I set out to do and am working full time to help improve the quality of health care in my region and across the state. CareSpark has always had a place in my heart having followed the standards based approach for building the HIE which now has 33 signed data sharing agreements from providers in the region. Over the coming years, I look forward to working with health care provides to deploy connected health care, thus providing actionable information at the point of care.As the cartoon below depicts, I am pleading for all providers to give generously!