An Early Look at Direct
WHILE DIRECT IS not expected to be widely available until
2012, how providers will use it is taking shape. Direct Project
coordinator Arien Malec gave a brief overview during a National eHealth Collaborative webinar in March.
Providers will not require special software or hardware to
use Direct, Malec said. Exchanging information will be similar to sending an e-mail.
To get started, a physician would contract with a health information service provider (HISP), such as a local HIE that is
offering Direct as one of its exchange services. Large healthcare organizations could also function as HISPs, facilitating
Direct exchange both within their organizations and with
Direct-enabled providers outside their network. The Direct
Project maintains a list of HISPs on its Web site, http://di-
Once the physician contracts with the HISP, the HISP will
assign the physician a Direct e-mail address. To access the
Direct service, the physician will log on to the HISP’s Direct
gateway via the Internet.
Physicians with a Direct e-mail address can send information securely to any other provider with a Direct e-mail
address—for example, a referring physician could e-mail a
patient referral to a specialist.
Information may be sent only to users with a Direct e-mail
address. Thus the sending physician would have to know
the receiving physician’s Direct e-mail address. Individual
HISPs, or perhaps ONC, may also develop a directory of
Physicians do not need an EHR to use Direct, said Gary
Christensen during the webinar. Christensen, COO and CIO
of Direct pilot site Rhode Island Quality Institute, stressed
that to use Direct physicians required only a computer and
an Internet connection.
However, EHR vendors are developing products that will
come Direct-ready, enabling providers to send structured
health information directly from their EHRs using Continuity
of Care Document standards.
change is a project developed years before ARRA by the federal
government. Like Direct, NwHIN is a set of openly available protocols that lays out standards, services, and policies for secure
health information exchange via the Internet.
Though initially used only by government contractors, recently the exchange platform was expanded to select private healthcare organizations. The larger goal is to allow providers to use
Direct for simple “push” exchanges, and the NwHIN standards
for complex exchanges, such as those that require looking up a
provider to exchange complex health information data—likely
through an HIE.
The State HIE Cooperative Agreement Program was
launched by ONC in March 2010 and has awarded $547 million
to 56 states and territories to develop state-level HIEs. These
state-level HIEs are designed to either coordinate local HIEs or
serve as the main HIE for an area. Interstate exchange between
state-level HIEs is a long-term goal.
Private HIE efforts have also launched, looking to capitalize
on the slow development but high potential. In July 2010, for example, telecom giant Verizon launched the Verizon Health Information Exchange. The system can be used to store, manage,
and transfer health records within one’s own enterprise, community, state, or country, according to Verizon.
Will the Fed and the States Connect?
Though further development of these HIE efforts could lead to
interoperable health information exchange, they are not developing with a clear connection to each other, Frohlich says.
A big question is how the state-level HIEs will connect with
federal ONC-led efforts like the Direct Project and NwHIN.
Several HIEs have been pilot-testing Direct Project specifications with the expectation they will eventually implement Direct into their suite of HIE offerings. As the NwHIN Exchange
expands, many expect state-level HIEs to use those standards
and specifications to exchange information as well, including
exchange among individual state HIEs.
In the State HIE Cooperative Agreement Program, ONC has
strongly encouraged the various state-level HIE developers to
implement Direct and NwHIN Exchange protocols and standards into their HIE models, according to Claudia Williams, di-
In launching meaningful use, ONC
may have taken its eye off HIE
slightly, relying on the industry to
fill in the gaps. —Jonah Frohlich
rector of the state HIE program at ONC. This will better allow
intrastate information exchange, as well as exchange between
other state HIEs.
HIEs in the cooperative agreement program have also been
asked to develop a system that helps providers achieve stage 1
Although the final State HIE Cooperative Agreement Program
grants were announced in March 2010, 17 of 56 state-level HIEs
had yet to receive full funding as of March 2011. This is because
ONC must finalize its strategic and operational plans before issuing the entire grant funding. The first grant installment was for
planning, the second for development.
The process for handing out the full grants has been slowed
because ONC did not want to develop one standard program
for all state-level HIEs to follow. States have different laws and
requirements that affect an HIE’s success. Therefore, ONC allowed each state to formulate a strategy it felt would lead to the
greatest HIE success, Williams says.