half of a provider. This translation is handled in transformation
adapters within the CareSpark message router, centralizing the
complex software algorithms that are required by nonstandard
This approach is standards-based at the core, so as participants’ systems upgrade and evolve and their level of support for
Direct and other exchange standards matures, CareSpark need
only modify that participant’s connection, not the connections
within the rest of the network.
Using Direct, the VA medical
center and CareSpark providers
transmit orders and reports
securely over the Internet.
The Direct Use Case with the VA
As its first Direct use case, CareSpark is using the Direct Project
specifications to facilitate information exchange between the
Department of Veterans Affairs and participating providers in
the CareSpark network. The VA and CareSpark are utilizing the
open-source, Direct gateway code that the Direct Project team
members have written and contributed.
The exchange centers on veteran patients who require service from providers outside the VA. In this instance, the local
VA medical center, the James. H. Quillen VA Medical Center
(VAMC), refers all mammography work out from its women’s
health center to private sector providers.
Before this project, the VA would fax or have patients hand
carry mammogram orders to the radiology provider. After the
study was done, the radiologist transcribed the report, and it
was faxed (or hand carried) back to the VA. The whole process
was clumsy at best, insecure and inefficient, and clearly did not
integrate well into the VA’s advanced health IT systems.
Now with Direct, both VA and CareSpark providers have the
ability to securely transmit messages between their electronic
health records. Following the mammogram use case, the VA
physician writes a mammography order for the external provider. The order is routed through the VA’s systems to its Direct
gateway. The gateway takes the order, transforms it to a standard
format, encrypts it, and routes it over to the destination radiology group at CareSpark.
This routing occurs using the Internet’s predominant standard
mail transport protocol (SMTP), but since the message content
is encrypted, it is secured from prying eyes.
CareSpark receives the order within its Direct gateway. The
message is decrypted (which includes a process to verify the
identity of the message sender) and routed through CareSpark’s
clinician portal technology to the receiving radiologist. Currently the order is presented in a portal application displaying
in an inbound orders queue, but in the near future CareSpark
expects to connect directly to the provider’s system and deliver
the order without the manual portal step.
The VA patient arrives at the radiologist and has the mammography study done. The reading result is created with the usual
information (findings, impression, and recommendations) via
normal procedures within the radiology group. In fact, they
have little awareness that Direct is used in the order and result
The radiologist’s system transmits the result in a typical HL7
observational result message to CareSpark. Upon receipt, the
CareSpark portal delivers the result to the ordering physician.
The routing path for any physician with a VA address is via CareSpark’s Direct gateway.
Following the same process in reverse, the result is standardized, encrypted, and routed to the VA via secure SMTP. The VA
receives the message, decrypts it, verifies the identity of the
sender (in this case CareSpark), and routes the result to the ordering physician through its own internal systems.
By the end of the process, a set of electronic messages have
crossed organizational boundaries, physical locations, and
radically different domains with the ability to fully integrate into
EHRs. The paper chase has been removed and now data from
mammograms can enjoy the same benefits and usefulness as
other “internal” data within the patient’s record.
Today this exchange exists merely as a demonstration, but given CareSpark’s production deployment of the Direct gateway,
the plan is for the VA and other providers within its region to
enable Direct-based exchange within the year.
Direct Projects Ahead
Based on the enthusiasm generated over the VA demonstration
project, CareSpark is looking at a number of other exchanges
that have been simplified with Direct. Any participating provider wishing to participate in a Direct project will require only a
Direct Project–compatible e-mail address, such as Dr.Voigt@Di-
rect.CareSpark.com, or ABCRadiology@Direct.CareSpark.com.
CareSpark has gathered input from local providers, and likely
next areas for deployment of Direct functions include patient-to-provider messaging, broader lab result delivery, and immunization reporting.
Direct will always be a message sent from one known provider
to another known provider without sharing the message with
other participants, while Exchange will allow clinical data to be
held and accessed through queries at the time that information
CareSpark is watching to see how the Direct Project evolves
and in particular how it will play out with the Nationwide Health
Information Network Exchange specifications—another key exchange capability within CareSpark’s services. CareSpark expects that both Direct and Exchange will be required as cross-community HIE becomes more ubiquitous and robust. ¢
Chris Voigt is cochair of CareSpark’s Technology Committee and vice president of corporate development at MobileMD. Susan O. Torzewski is EMPI
administrator for CareSpark, where she has coordinated development of
health information control policies as well as those for privacy and security.