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Tuesday, September 16, 2014

In what ways does it make sense to extend DirectProject beyond those already defined by MeaningfulUse?

The question above comes from 20 questions for HealthIT posted over on the HL7 Standards blog. You can probably guess my short answer, which is NO.  What you may not know are my reasons.

The Purpose of Direct

Let's start with the purpose of the Direct Project which you can find in the project overview:
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.
Direct was promoted as being the on-ramp to Health Information Exchange.  As an on-ramp, Direct technically has succeeded.  It is certainly technically possible to use direct to exchange information between providers, or to patients.  In execution, it has pretty much failed to deliver to those expectations.  These challenges aren't technical, they are organizational and related to the Healthcare provider. Until we solve those issues, I don't want to rely on Direct (or anything else) until we have resolved the exchange issues between providers.

We need more than an On-Ramp

We need more than a on-ramp for exchange.  Direct as it stands is a one-way push.  As a push specification, it can only address known, trusted entities.  It cannot deal with exchange with unknown entities, and the developing trust framework does not have any way at present to deal with establishing trust in a near real-time way.  

Another challenge with the Direct Project is that there's no real way to do dynamic almost-real-time queries, and it is NOT ideal for handling other sorts of queries, even though it is feasible.  There is a small group of people who have promoted it for this purpose, but several attempts at creating a consensus body to further develop Direct to support query has not yet succeeded.

Meaningful Innovation

Direct was supposed to resolve a short term problem which, as it turns out is much bigger than the technical issues it was supposed to solve.  At present, there are other innovative activities which are more promising than Direct (e.g., FHIR), which require attention.  I really want to stop trying to catch the train that's already left the station (e.g., the next stage of Meaningful Use), and spend more time on meaningful innovations in Healthcare IT.  

If you had a choice to advance yesterday's compromise solution (and to be sure, Direct was exactly that), or to work on more forward looking forms of Health information exchange, which would you do?