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Direct message protocol stirs anxiety among exchanges



Does the federally sponsored Direct messaging protocol pose an existential threat to vendors of health information exchange software?

Time will tell, according to the author of a new market research report on health information exchanges. But Direct is definitely producing anxiety among firms selling software that's designed to be used in more complex types of health information exchange—the long-sought “query-and-response” style of information swapping that has yet to achieve widespread adoption through the industry despite extended federal efforts.“They're all on Direct, but the biggest risk is that this could be successful,” said Brian Murphy, the lead analyst in a recent report on HIEs for Chilmark Research, Cambridge, Mass, that looked at 19 vendors of these systems—4medica, Alere ACS, Caradigm, CareEvolution, Cerner, Certify Data Systems, Covisint, dbMotion, GSI Health, Harris Healthcare, HealthUnity, ICA, InterSystems, Medicity, MobileMD, Optum Insight, Orion Health, RelayHealth, and Surescripts Kryptiq.

“They've visiting all their customers and saying, 'We have this Direct, how about it?'” Murphy said. And yet, “There are a handful that are very queasy about Direct, because they've invested so heavily in query-based exchange and this Direct undercuts their value proposition.”

The Direct project was launched by the Office of the National Coordinator for Health Information Technology at HHS in April 2010 to quickly reach industry consensus around a group of standards and implementation specifications to send over the Internet basic, encrypted healthcare messages, such as referral letters or care summaries between providers with already established relationships.

This “peer-to-peer” form of interoperability, which is based on one provider “pushing” a message to another, was developed to provide an alternative to the more robust but far more difficult to achieve query-and-response form of communication. In query-and-response, the location of a patient's medical records may or may not be known to the requesting provider. This latter form of technology had been the primary focus of federal IT promotional efforts through community, regional and state-wide health information exchanges as part of a proposed Nationwide Health Information Network going back to 2004.

With passage of the American Recovery and Reinvestment Act in 2009, however, federal policymakers realized the NwHIN wouldn't be ready in time for providers to achieve widespread interoperability that was mandated to be part of the federal EHR incentive payment program in the ARRA. Payments to hospitals and physicians under the stimulus law began in January 2011.

“The idea (with Direct) was to address some of those shortcomings, something quick and dirty that works,” Murphy said. “It is e-mail and so it comes with all the advantages and disadvantages with e-mail. It does put some pressure on EHR vendors to produce and consume data that is amendable to e-mail. That could take off and could become the path of least resistance for most clinicians. To some extent, that sort of cuts us off from the underlying benefits of software technology. There are a lot of vendors out there that are trying to produce this longitudinal health care record and this could leave them high and dry. The longitudinal record is clearly a superior approach, but it's just very hard to do.”

In his report, Murphy also predicts the coming of what he calls HIE 2.0.

“The world is moving away from fee for service,” Murphy said. “What that future world will look like is still up in the air. But what we're saying, any organization that gets to the future state has to get to 2.0. That will get any record to any clinician at any time on any device and not just the data but functionality that's germane from patients moving around from hospital to clinic, to imaging center to nursing homes all the things outside the four walls of an organization.

“The world is nowhere, not even vaguely, close to putting this (HIE 2.0) together,” said Murphy. “I'm loath to make a specific prediction (as to when it might happen), but I think bits and pieces of HIE 2.0 will be here by next year.

A lot of people will be looking at cross enterprise medication reconciliation,” he said. “Over the course of 12 to 18 months you'll see better solutions. Care coordination, post-acute care, whatever facility they're going to, rehab, nursing homes or just homes, there will be better tools for that over the next couple of years. They'll all be web-based and reasonably supported by hand-held devices,” he said.

Follow Joseph Conn on Twitter: @MHJConn

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