The Direct Project announced yesterday the next step in their evolution towards creating a simple, scalable way of securely transporting health data from where it is to where it is needed. This is the next incarnation of what was previously named the NHIN Direct, which addressed the smaller-scale (yet very commonplace) needs of getting health data securely from one place to another.
As the Office of the National Coordinator for Health IT (ONC) has spurred the development of a nationwide infrastructure that will eventually allow health data to follow patients wherever they go – across institutions, practices, and geographies – the efforts have diverged into two simultaneous efforts: (1) the Nationwide Health Information Network (NHIN), which has focused on the more complex issues facing institutional data exchange, and sees itself as a network of regional HIEs, and (2) the NHIN Direct (now called the Direct Project), which has addressed smaller-scale data-exchange issues and has been sometimes referred to as the “health Internet.”
The Direct Project is a laudable effort, and has included many different stakeholders, including vendors, e-health collaboratives (many of which are emerging as Health Information Exchanges, or HIEs), and others. According to the newly released overview document, “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.”
These efforts are the next step in the evolution of electronic health interoperability. But how does this fit into the current picture? Is it really something that can or will be adopted by physicians everywhere?
One of the assumptions made in all these efforts is that a Sender of health data and the Receiver of that data are using electronic systems that are different from each other, and don’t really talk to each other. In fact, the Receiver may not have an Electronic Health Record (EHR) at all, and may use mainly faxes and maybe (hopefully secure) email to receive information. Given that this is a very common scenario, we should look at it a little more closely.
Health data exchange involves 3 main elements: (1) you need a transport method, (2) you need a standard message structure, and (3) you need to use standard vocabulary in that message. The Direct Project’s efforts focus currently on the first part: developing a transport method that is secure yet easily usable. The second element (standard message structure), which include standard message types like HL7, CCRs, and CCDs, are important if the data is to go automatically between different electronic systems that can create/consume them – in the “real life” of current practicing physicians, the “standard message structure” is still human-readable text, often as a faxed document. And the third element (standard vocabulary) piggy-backs onto the second one (standard message structure) – even laboratories, for example, that export lab results via a “standardized” HL7 document may not use a standardized vocabulary (a system for identifying a given lab test, like blood sugar, for example), which makes interpreting the “standard message” more challenging still.
Let’s say that the Direct Project is able to define a safe way to get health data from a Sender’s EHR to a Receiver’s office (who doesn’t use an EHR) via secure email. The presumption here is that the message content is human-readable (not an HL7 or CCD), and that the Receiver is able to receive secure email. One still needs a way to make sure that the Receiver’s email address is valid and that some prior form of authentication has happened – the Sender would thus need to authenticate each and every Receiver in such a scenario. This can be sufficiently onerous to create a roadblock to widespread adoption.
Hopefully, the efforts to create a national healthcare Provider Directory will alleviate much of this “look up and authenticate” roadblock. Use of such a Directory will help both the NHIN and also the Direct Project activities. This, however, is still in the formative stages, and it is uncertain when such a service will be available to rank-and-file physicians.
How does this all relate to web-based EHRs like Practice Fusion? A true web-based EHR links all participating users by definition, so that the presumption that each user has a locally-installed silo that is not connected to anyone else is no longer valid. Robust data exchange between Practice Fusion users is an important feature that is currently in the development lab – but the technical issues of sharing data between practices is not a stumbling block. And data sharing between clinicians using the Practice Fusion EHR and enrolled patients using the linked Patient Fusion PHR is already in place – though it is admittedly a product in-evolution with the full power of such a connection yet to be fully developed.
So, does a web-based EHR, which in essence already has an internal “HIE” for its own 50,000+ users and 5,000,000+ patients, need the Direct Project at all? Actually, yes. Although it is relatively easy to exchange data within the Practice Fusion community (and – since it is free and can be signed up on-demand right away – any potential Receiver of information can get an account and receive the shared information without any further setup needed), there will always be the need to exchange data with outside systems.
Hospitals, laboratories, and other medical practices already invested in their own EHR will need a way to send information to Practice Fusion, as well as a way of receiving information out of the system. However, given that a web service is a single point of connection for all the 50,000+ users, the external connection and authentication only need occur once. We have seen this with each lab we have engaged – a single setup (from a technical standpoint) allows access to all users for that lab.
But, regardless of the significant simplification of the connectivity question resulting from a centralized web service, outside connections will still be needed, and will still need to be standards-based. The work of the Direct Project is an important piece of building that base of standards. Its work contributes to the rising tide that lifts all boats, and is welcomed.
Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR
