Showing posts with label DirectProject. Show all posts
Showing posts with label DirectProject. Show all posts

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?

Tuesday, October 9, 2012

Direct Transmission in Java : The Go-Cart Version

Over the weekend, John Moehrke wrote this post about View, Download and TRANSMIT, focusing specifically on the Transmit part, and how Direct plays a role.  He notes that Transmit can be implemented without a HISP.  I was curious to see how easy it would be to generate a fully Direct compliant message with as little work as possible in Java.  I've already got an e-mail certificate and key, and I already have John's public key and e-mail address.

So, I want to send him an Direct message.  What do I have to do to make that work?  Fortunately, a good deal of code to support this has already been created in the Direct Bare Metal Project.  You can download the necessary components from Google Code here.  The API Documentation on the Direct Wiki seems to be pretty decent, and if you dig around long enough, eventually, you can find the JavaDoc.

As I read it, what I need to be able to do is first construct a DefaultNHINDAgent, giving it a way to resolve my private certificate and key, and John's public certificate, and a way to understand that John's certificate is one I trust (comes from a Trust Anchor).  For simplicity sake, I'll put my certificate in a key store, John's in a trust store, and the CA issuing John's certificate in Trust Anchor.

The first challenge is finding everything I need.  I'm building a go-cart here.  I don't need (or want) James, Tomcat, and a bunch of other stuff.  This isn't Bare Metal.  It's a Soap box, some twine and bailing wire, and hope that it runs downhill.

What do you need:
  1. agent-1.5.2.jar The Direct Agent Library
  2. direct-common-1.1.1.jar The Direct Comment Library
  3. Apache Commons Logging (General Logging during Message Processing)
  4. Apache Commons IO 
  5. Apache Commons Codec (Base 64 Encoding)
  6. Bouncy Castle SMIME Library (Crypto)  [Release 140 for JDK 1.5]
  7. Bouncy Castle JCE Provider (Crypto) [Release 140 for JDK 1.5]
  8. mail.jar from the Java Mail Library
OK, now, where to get BC 140?  Well, where I got it from was from the version of James that comes with the Bare-Metal non-HISP Java Project.  You can find the necessary libraries in the direct/james/2.3.2/apps/james/SAR-INF/lib folder in this tarball that is in the Direct Google Code Library.  Download the tarball, unzip/tar it, and extract bcmail-jdk15-140.jar and bcprov-jdk15-140.jar to where you are putting the rest of your libraries.

Next, you'll need to follow the instructions to install the JCE (Java Cryptographic Extensions) for whichever JDK you are using.  Download them from here.  Then follow these instructions to install them.

Once you have all of that, you should be good to go.

We're going to do this in five steps.  

1: Configure JavaMail

The first step is to configure JavaMail to send from Google Mail, or another SMTP server you have access to.

Properties properties = new Properties();
properties.put("mail.smtp.host", "smtp.gmail.com");
properties.put("mail.smtp.auth", "true");
properties.setProperty( "mail.smtp.port", "587" );
properties.put("mail.smtp.starttls.enable", "true");
Session session = Session.getDefaultInstance(properties,
  new Authenticator() {
    public PasswordAuthentication getPasswordAuthentication() 
    {
return new PasswordAuthentication("account", "password");
    }  
  }
);

2: Configure the DirectAgent

The next step is to configure an NHINDirectAgent to do all of the work for us.

CertificateResolver certResolver = 
  new KeyStoreCertificateStore("private.jks", "password", "password");
KeyStoreCertificateStore certResolver2 = 
  new KeyStoreCertificateStore("public.jks", "password", "password");
TrustAnchorResolver trustAnchor = 
  new DefaultTrustAnchorResolver(certResolver2.getAllCertificates());
NHINDAgent agent = 
  new DefaultNHINDAgent("gmail.com", certResolver, certResolver2, trustAnchor);

I've created two files to work with this bit of code.  The first, private.jks contains the certificate and private key I use with my GMAIL Account to sign e-mails.  I got mine here for free.  I also created public.jks which contains the just the certificate for my G-mail account, and the certificates for mine and John Moehrke's e-mail accounts.  If I've ever sent you a signed e-mail, you have that too.  And if John's ever sent you signed e-mail, you also have that.  I exported my signing certificate and key from Outlook in PKCS12 format, and then converted to JKS using this little trick (as it turns out, I still had jetty in the same location).  I used keytool to import the various other certificates that I exported from Outlook into Base64 encoded format.  Oh, and to create public.jks from those files, just use keytool the same way you would to create a trust store.

For what I need, the trust method is this: If I have the certificate's anchor in my list of public keys, then it's trusted.  Otherwise it isn't. I had to dabble a bit with the right way to create the DefaultTrustAnchorResolver, but the code you see is what finally did it for me.

3: Create the Message

The next step is to create the message:

MimeMessage mx = new MimeMessage(session);
mx.addHeader("To", "keith.boone@ge.com");
mx.addHeader("From", "kwboone@gmail.com");
mx.addHeader("Date", new Date().toString());
mx.addHeader("Subject", "Hello");
mx.setText("Hello Again!");

4: Process Message

This step performs certificate resolution, trust resolution, and encryption, according to the Direct protocol.
Message msg = new Message(mx);
OutgoingMessage oMessage = new OutgoingMessage(msg);
OutgoingMessage processedMessage = agent.processOutgoing(oMessage);

5: Send the Message

The last step below grabs the content into a new MimeMessage configured to use the JavaMail session we started with in Step 1, and sends it.

MimeMessage mxo = new MimeMessage(session,
  new ByteArrayInputStream(

    processedMessage.serializeMessage().getBytes("UTF-8")));
Transport.send(mxo);

You'll note a couple of things:
  1. No HISPs were consulted in the construction or transmission of this message.
  2. Certificate lookup was very simple.  A more complex mechanism using LDAP could have been implemented.  You may need to consult with a number of locations to locate recipient certificates.
  3. Trust was also simple.  These are outbound messages only.  So long as they are, and the certificate is signed somewhere along the way by a trust anchor I care about, then it goes.
For John's discussion about what you need for the Transmit portion of VDT, this Go-Cart could use a few more things to soup it up:  A motor (LDAP Certificate lookup), and a Roll-Cage (A little bit better trust model than a certificate from John or I, perhaps just list the common e-mail certificate signer anchors), and away you go.

  -- Keith

P.S.  And the short answer to what I need to do to make that work?  About a day of coding.



Monday, February 6, 2012

When Every Problem is a Nail

When you build a better mouse-trap, the world will beat a path to your door.  But what if there isn't really a need to catch mice, but you've got something that can do that better than anything else?

The Direct Project was originally designed to be an on-ramp to the NwHIN.  But as a result of its success in development of the specification (not necessarily the implementation), it's been billed by some as the solution to all important (in 2011) exchange problems.  We've known for a long time that point-to-point isn't enough (look at the original design of Direct again), and the design of the NwHIN goes beyond that already in a suite of protocols that support both point-to-point and query/response type exchanges.  The HIMSS EHR Association even wrote a white paper (pdf) about how you go from simple, to more fully featured exchange capabilities.

Unfortunately for NwHIN, some of the work that was planned for the last year was held up for several months in 2011 due to a bidding protest (as I mentioned here).  So, what happens when all you have to sell is a mouse-trap?  You pitch the mouse-trap for all you are worth.

State HIE organizations that have been planning for something better than a mouse-trap are told that they must also use mouse-traps, even though a better solution is being developed by them.  I know at least two former interim HIE directors that were asked set aside long-standing plans to use Exchange-compatible technology to first support the Direct Protocol.  Fortunately, both were astute enough to understand the progression from Direct to Exchange and were able to modify their plans to ensure that they had a transition strategy.  That has been the exception rather than the rule, and even that distraction has still been problematic for the informed folks.  Other HIEs that were not as aware disposed of their previous implementation plans in favor of a Direct only solution.

Has Direct been an HIE killer?  I don't know of any HIE's that have gone under as a result of third party implementation of Direct.  I would imagine that some HIE's would welcome support from third party vendors, and others might have challenges as they still struggle with business models.  The reality here is that no matter what happens, if your HIE business model would be threatened by something as simple as Direct, then you probably need to think more about your approach.

In the last six weeks, some things have settled down quite a bit.  That appears to have been as a result of some well-informed and influential people asking tough questions and making their views known. The new message most recently from ONC has been about Exchange with some references to Direct.  This presentation, presented by Doug Fridsma to the HITSC at their last meeting talks quite a bit about Exchange (see slides 13 to the end), and barely references Direct for example.

Capping it all off, we have this January JAMIA article from Dr. Les Lenert (former CDC Director at the now disbanded NCPHI) and others hammering the ONC for their shift in focus in 2011.  Two months ago, I would have welcomed the article more enthusiastically.  Now, it already seems a bit dated (always a danger in journal publication).  Some of its critiques I have also made myself.  Others are a good deal more political, and I wouldn't touch with a 10-foot-pole (although this might work).

I found a few points to be a bit misleading.  For example, of the billions in funding for EHR and HIE by the article, ONC only got $2B to support grants for HIE, Regional Extension Centers, Workforce and Education, et cetera.  About $500M of HITECH funds went to HIE in any way, with the other large chunk going to expansion of broadband access.  While HITECH didn't say where the ONC $2B went, the writing was pretty much on the wall as to how that was to be divvy'd up. The $20B that CMS has to spend is really about EHR adoption. It COULD do more to support HIE, but not at all directly, only through mandating standards and criteria for use of exchanges and attestations for meaningful use.

The whole mess around the PCAST report hasn't helped, and has been a rather large distraction throughout for just about everyone involved.  There's some good in that report too, (e.g., the Query Health efforts), but frankly, there's also a quite a bit of axe-grinding going on in PCAST.  I even tried my hand on that whetstone.

What I find most disruptive in all of this is how the people making the decisions are disconnected from the people working on the exchanges or the standards.  It's better with the ONC FACA's than it is with other advisory bodies, but I still wish more of the communication was better connected.  Even in the S&I Framework projects, the people doing the work don't get to choose what projects are to be developed, and there are few FACA members involved in the ONC S&I projects that moving forward on the FACA indicated priorities.

Where I'm at with this chatter is done.  It's time to move forward on real Health Information Exchange, let's do it, and stop talking about it.



Tuesday, July 26, 2011

EHRA Web Cast: A Pragmatic Framework for Achieving HIE

A few months ago, the EHRA began a white-paper on HIE standards. This web-cast, open ro all interested parties (EHR Vendors and all others), reviews the results of that work. If you are involved in HIE activities at any level, I urge you to watch.

 

Good afternoon, EHR Association,

 

This Thursday, the Executive Committee and the Standards & Interoperability Workgroup are hosting an EHR Association web cast based on the recently published white paper “Supporting a Robust Health Information Exchange Strategy with a Pragmatic Transport Framework.” Registration details are below.  Please contact any of us with your comments and questions.

 

Carl Dvorak, EHR Association Chair, Epic

Charlie Jarvis, EHR Association Vice Chair, NextGen

Leigh Burchell, Allscripts

Pamela Chapman, e-MDs

Jason Colquitt, Greenway Medical

Mickey McGlynn, Siemens

Rick Reeves, CPSI

Justin Barnes, EHR Association Chair Emeritus, Greenway Medical

Mark Segal, EHR Association Vice Chair Emeritus, GE Healthcare

 

 

 

Thursday, July 28, 2011 10:30 am, Eastern Daylight Time

-------------------------------------------------------

To register for the online event

-------------------------------------------------------

1.    Go to https://himss.webex.com/himss/onstage/g.php?d=926703701&t=a&EA=agorden%40himss.org&ET=1189dea2523c7b96b88e10d5e8bcde1a&ETR=8cd3cd1987ab761bad3478f409bb73b9&RT=MiMxMQ==&p

2.    Click “Register”.

3.    On the registration form, enter your information and then click “Submit”.

 

Once the host approves your registration, you will receive a confirmation email message with instructions on how to join the event.

 

-------------------------------------------------------

For assistance

-------------------------------------------------------

You can contact Angie Gorden at:

agorden@himss.org

 


Wednesday, February 2, 2011

Direct Project Implementations Take Flight

Direct Project Implementations Take Flight
By Rich Elmore and Paul Tuten

The Direct Project has taken off, with the first-in-the-nation production use of the Direct Project for secure direct clinical messaging.
Arien Malec, ONC’s Direct Project Coordinator, announced today that pilots in Minnesota and Rhode Island are now live with the Direct Project:
  • VisionShare has enabled Hennepin County Medical Center to send immunization information to the Minnesota Department of Health.  Testing of immunization (or syndromic surveillance) communication to a public health agency is a requirement for Meaningful Use incentives.  
  • Rhode Island Quality Institute has implemented provider-to-provider health information exchange supporting Meaningful Use objectives with Dr. Al Puerini and members of the Rhode Island Primary Care Physicians Corporation.
And innovative and high-value pilot projects in New York, Tennessee and California are scheduled to go live later this month.  
Also announced:

Hennepin County Medical Center (HCMC), Minnesota’s premier Level 1 Adult and Pediatric Trauma Center, has been successfully sending immunization records to the Minnesota Department of Health (MDH). "This first-in-the-nation Direct Project for clinical exchange is an important milestone for Minnesota and a key step toward the seamless electronic movement of information to improve care and public health," said James Golden PhD, Minnesota’s State Government HIT Coordinator. Recognizing Minnesota's leadership in delivering high-quality, cost-effective healthcare, U.S. Senator Amy Klobuchar said that “this is the type of innovation that can help strengthen our health care system by reducing waste and improving quality. We need to continue to improve our health care system by continuing to integrate information technology to better serve patients and providers.”  VisionShare, a company headquartered in Minneapolis, serves as the health information services provider (HISP) connecting HCMC to the Minnesota Department of Health. In its role as a HISP, VisionShare will expand this pilot project to additional providers and other states, including the Oklahoma State Department of Health, which has already committed to participation in the program.

The Rhode Island Quality Institute (RIQI), the only organization in the nation to be awarded the Health Information Exchange, Regional Extension Center, and Beacon Community grants has delivered a Direct Project pilot project with two primary goals:

  1. To demonstrate simple, direct provider-to-provider data exchange between PCPs and specialists as a key component of Stage 1 Meaningful Use.
  2. To leverage Direct Project messaging as a means to seamlessly feed clinical information from practice-based EHRs to the state-wide HIE, currentcare, integrating patient data across provider settings and during transitions of care
“This recognition shows that Rhode Island continues to be a nationwide leader in improving health care with better information technology," said Senator Sheldon Whitehouse. "Health care providers communicating with each other in a secure and cost-efficient way helps patients get better sooner with less hassle and confusion.”

“The Direct Project is a giant step forward in improving communication between primary care providers, specialists, hospitals, laboratories and health information exchanges”, according to Dr. Albert Puerini Jr., President and CEO at Polaris Medical Management and Rhode Island Primary Care Physicians.   “The Direct Project’s ability to seamlessly transmit relevant healthcare information greatly enhances the quality of care that is delivered, while also creating much needed efficiencies within our healthcare system.”
Discussing RIQI’s collaborative approach to health IT, Laura Adams, President and CEO of RIQI said “Direct allows the Quality Institute to be on the cutting edge – providing health information exchange via currentcare, delivering the efficient rollout of technology through the Regional Extension Center, and enabling and measuring real patient outcome improvements in our Beacon Community.” Throughout the Pilot, RIQI has worked with a number of key partners, including Arcadia Solutions (program manager and systems integrator), Inpriva’s Health Information Service Provider  solution that supports the security, trust, and Rhode Island-specific consent laws, InterSystems, and Polaris Medical Management’s EpiChart.

Federal Government Perspective
Aneesh Chopra at the Roundtable on Federal Government Engagement in Standards on January 25, 2011 said "I am pleased to report today... the very first Direct specification email message occurred between a county public hospital in Minnesota called Hennepin County and the state Health Department on the issue of a patients immunization record, which is a requirement as part of our meaningful use framework, supported by a commercial vendor called VisionShare".  Speaking of the collaborative nature of the unique public/private collaboration of the Direct Project, he said "This voluntary process has turned this around and in fourteen months [from the time a physician first raised the need to the HIT Standards Committee] the idea is real. And dozens and dozens of vendors will have this service widely deployed across 2011."

On the Runway
Several other Direct Project implementations are scheduled for take-off later this month.  New York, Tennessee and California are among the states where Direct Project will be enabling directed health information exchange among a wide variety of participants.  And later this year, look for Connecticut and Texas to join their ranks.  

New York
MedAllies, a Health Information Service Provider (HISP), will launch a Direct Project pilot to demonstrate the delivery of critical clinical information across transition of care settings in a “push” fashion that supports existing clinical workflows in the Hudson Valley of New York. MedAllies will implement the full Direct Project infrastructure, including both the required SMTP backbone, as well as support for the XDR elective protocol. MedAllies is working with many stakeholders, including EHR vendors Allscripts, eClinicalWorks, Epic, Greenway, NextGen and Siemens, and clinicians in both ambulatory and hospital settings.
The three initial use cases include:
· Primary care provider refers patient to specialist including summary care record
· Specialist sends summary care information back to referring provider
· Hospital sends discharge information to primary care provider
Technical integration with leading EHR and Hospital Information System vendors is underway with pilot exchange alpha sites beginning to go live in Q1 2011.

Tennessee
In this project, CareSpark, a non-profit regional health information exchange supported by the Tennessee State HIE, and the U.S. Department of Veterans Affairs (VA) seek to demonstrate Direct Project-based health information exchange between a federal agency and providers in a private-sector HIE. The main focus will be on facilitating an improved process for exchanging referrals and consultation reports between VA providers and private-sector providers in east Tennessee and southwest Virginia. It will demonstrate two Direct Project user stories: Primary care referral to specialist and Specialist sends summary care information back to referring provider. Text-based mammography interpretation reports will be exchanged utilizing source code made available from the Direct Project workgroups. The project scope will also demonstrate the routing of mammography referrals from the VA to the private sector provider. It is also the intent of the participants that this project once fully vetted could be expanded to additional VA sites. The pilot will exchange information between two different Health Information Service Providers (HISPs) - the VA and CareSpark, respectively.

California
Redwood MedNet provides health information exchange services in rural Northern California. The Redwood MedNet Direct Project pilot has one goal: to deploy directed secure messaging for production data delivery in support of meaningful use measures. Three meaningful use messaging patterns are in development.
  1. Receipt of Structured Lab Results
  2. Immunization Reporting
  3. Sharing Patient Care Summaries Across Unaffiliated Organizations (including both referral to a specialist and discharge summary to a patient centered medical home)
The project will establish a standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients. As an HIE in a rural area, participants in the Redwood MedNet directed messaging project will include small practices, community clinics and small hospitals, as well as the State immunization registry. The discharge summary may also incorporate use of a patient controlled health record (PCHR).

Connecticut
Medical Professional Services (MPS) is a clinically-integrated, multi-specialty IPA in Connecticut with approximately 400 physician members. Along with several partners, MPS is working to demonstrate successful exchange of laboratory results back to the ordering provider and exchange of referral information and summary care information between providers, a local hospital (Middlesex) and a multi-site FQHC (Community Health Center, Inc.). Electronic exchange of data is a challenge in this setting because of the diversity of MPS physician practices, EHRs and HIT tools in place.
The goal set for this pilot is to enable MPS physicians to receive lab results back from Middlesex Hospital and Quest Diagnostics, to exchange referrals with Middlesex Hospital, and to exchange referrals and summary care information among MPS primary care and specialty physicians. Results and referral information will be exposed through MedPlus, eClinicalWorks, Covisint, or through a secured e-mail client. In addition, physicians will have the ability to securely send lab results and care summaries to their patients via Microsoft’s portal.

Texas
A broad set of stakeholders in South Texas are planning to use Direct to improve the health status of persons in South Texas with diabetes, including gestational diabetes. Participants come from the medical community (CHRISTUS Health, the Health Information Network of South Texas, the Driscoll Children’s Health Plan, Corpus Christi Medical Center, Public Health Department, Nueces County Medical Society), community-based social service organizations, colleges, and employers (the Coastal Bend Diabetes Community Collaborative, The Salvation Army, the United Way, and others). The main goal for this project is to connect the OB-GYNs, pediatricians, hospitals, and the State of Texas’ Newborn registry so they can share information (referrals, lab results, discharge summaries) in real time with their care teams to improve patient outcomes. Additionally, the project participants hope to provide patients with better information so that they may better manage their chronic diseases. This will be accomplished using Direct by enabling the following use cases:
  1. Physician to physician referral
  2. Physician to hospital referral
  3. Hospital to physician lab results reporting
  4. Hospital or physician to state newborn registry
What is the Direct Project?
Today, direct communication of health information from a care provider to another healthcare stakeholder is most often achieved by sending paper through the mail or via fax. ONC’s Direct Project (formerly NHIN Direct) benefits providers and patients by improving the direct transport of structured and unstructured health information, making it secure, fast, inexpensive and, for some applications, interoperable.  Using Direct Project addresses, a care provider can send and receive important clinical information, connecting to other healthcare stakeholders across the country.
For more information, see the Direct Project website and keep up with the latest on Twitter at #DirectProject.  
Also, at noon (EST) on February 2, hear about the Direct Project from Dr. David Blumenthal, National Coordinator for Health IT, Aneesh Chopra – U.S. Chief Technology Officer, Mark Briggs – CEO VisionShare, Glen Tullman – CEO Allscripts, Sean Nolan – Distinguished Engineer and Chief Architect Microsoft Health Solutions Group, Dr. Al Puerini Jr. – President and CEO Polaris Medical Management and Rhode Island Primary Care Physicians, Doug Fridsma - ONC Director, Office of Interoperability and Standards and Arien Malec - ONC Direct Project Coordinator.
The Authors
Rich Elmore serves as the Direct Project Communication Workgroup leader and Vice President, Strategic Initiatives at Allscripts.  Paul Tuten participates as the Direct Project Implementation Geographies Workgroup Leader and is Vice President, Product Strategy and Management at VisionShare.


Monday, November 29, 2010

Healthcare Messages Over the Internet: The DirectProject

An announcement regarding the Direct Project...

Healthcare Messages Over the Internet: The Direct Project
November 29, 2010

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 1 PM 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 web site at DirectProject.org
  • A new hashtag #directproject for following the Direct Project on twitter.
The Direct Project is the collaborative and voluntary work of a group of healthcare stakeholders representing more than 50 provider, state, HIE and HIT vendor organizations.  Over 200 participants have contributed to the project.  It’s rapid progress, transparency, and community consensus approach have established it as a model of how to drive innovation at a national level.

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
Each capability can be enabled with point-to-point secure e-mail or in a more integrated manner as HIT vendors and public health agencies enable communication with the Direct Project.

How will the Direct Project affect states and Health Information Exchanges?
States that are receiving federal funding to enable message exchange are being asked by the ONC to facilitate Stage 1 Meaningful Use information exchange.  The Direct Project may serve as a key enabler of directed messaging for all states and Health Information Exchanges.  Even states that have some level of health information exchange capability need to address areas that are currently uncovered by a regional or local Health Information Organization (HIO).

As state plans seek to address a means to fill the gaps in exchange capability coverage, the Direct Project may provide a bridge to enabling the basic exchange requirements for Stage 1 Meaningful Use. The Direct Project does not obviate the need for state planning for HIE, neither does it undercut the business case for HIOs. More robust services can be layered over simple directed messaging that will provide value to exchange participants.
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.

The Reference Implementation
To help the Direct Project implementers, an open source reference implementation of the Direct Project standards and services has been developed under the guidance of the Direct Project. To ensure the broadest possible participation, the reference implementation has been implemented in two flavors:  Java and .Net.  

The HISP
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.
What it isn’t
The Direct Project is not targeted at complex scenarios, such as an unconscious patient who is brought by ambulance to an Emergency Department. In the unconscious patient scenario, a provider in the ED must “search and discover” whether this patient has records available from any accessible clinical source.  This type of broad query is not a simple and direct and therefore requires a more robust set of health information exchange tools and services that The Direct Project does not provide.
The Direct Project in Context of the Nationwide Health Information Network
The Direct Project is an integral component in a broader national strategy to have an interconnected health system through a Nationwide Health Information Network (NHIN). The NHIN is “a set of standards, services and policies that enable secure health information exchange over the Internet. The NHIN will provide a foundation for the exchange of health IT across diverse entities, within communities and across the country, helping to achieve the goals of the HITECH Act.”
The authors:
Brian Ahier is chairman of the State of Oregon’s Health Information Technology Oversight Council Technology Workgroup.  Rich Elmore is Vice President, Strategic Initiatives at Allscripts.  David C. Kibbe is a family physician, senior advisor to American Academy of Family Physicians and co-founder of the Clinical Groupware Collaborative.

Wednesday, November 17, 2010

NHIN 203 - An Update on The DirectProject

Crossed my desk a few minutes ago ...










NHIN 203 – An Update on The Direct Project
Join National eHealth Collaborative (NeHC) on Monday, November 29, 2010 for NHIN 203 – The Direct Project: Where We Are Today. This NHIN University class will feature Arien Malec, Coordinator of The Direct Project, and will offer stakeholders an in-depth look at the journey of the Direct Project, from its inception to its current position in the health information exchange space and on to its future direction. NHIN 203 students will learn how Direct, launched less than one year ago, has grown to include 200 participants and 50 organizations in its collaborative effort to “develop specifications for a secure, scalable, standards-based way to send encrypted health information directly to known, trusted recipients over the Internet.”

NHIN 203 – The Direct Project: Where We Are Today
DATE: Thursday, November 29, 2010  (add to your calendar)           TIME: 1:00 – 2:30 pm ET
FACULTY: 
  • Arien Malec – Coordinator, The Direct Project
WEBINAR:  http://nationalehealth.us1.list-manage.com/track/click?u=aea4a31fd49de738553683cb4&id=d78c5cd742&e=7f799d00de

AUDIOCONFERENCE:  (866) 699-3239 or (408) 792-6300
(Please join the event with a computer system first and follow the audio instructions on the screen.)

ACCESS/EVENT CODE: 668 619 540

ATTENDEE ID: You will receive this number when you join the event first with a computer connection.
READ THE NHIN 203 COURSE DESCRIPTION AND LEARNING OBJECTIVES

Review the full Fall Semester Course Catalog: www.NationaleHealth.org/NHIN-U

Did you miss any of the NHIN University 2010 Spring Semester?
Recordings and transcripts are available here.