July 13, 2011
Direct Project - It's Not Just About Email
The Direct Project “seeks to benefit patients and providers by improving the transport of health information, making it faster, more secure and less expensive.” This is the fifth post in a series detailing Cerner’s participation in this project.
The power of Direct Project as a transport protocol
The standard Direct Project tagline is "it's easy ... it's just email." When most people think of email, they likely visualize notes being passed between users, an inbox containing rows of read and unread messages, a folder for sent items, a place to deposit spam, message preview, etc. Essentially, an email application such as Microsoft Outlook or Gmail. While certainly a valuable application workflow to layer on top of the Direct Project, equating the output of the Direct Project to an email application does it a disservice and underestimates its potential.
The power of Direct is its universal addressing scheme, simple mail transfer protocol (SMTP) as its time-tested transport mechanism, and its use of a standard message container with multipurpose internet mail extension (MIME) messages.
In fact, we believe that targeted uses of Direct Project as a transport protocol embedded in existing workflows will be a very strong driver of its adoption. To support this, look no further than the approaches the Direct Project pilots that are shooting with “live bullets” have taken. Each is focused on a specific use case and automates (read: human not using an email application) at least one side of the transaction.
Cerner Direct's pilot with LACIE and Heartland Regional Medical Center
Pilot Goal: Target replacement of clinical data exchange scenarios today, which are primarily conducted via fax or phone call.
As described in a previous post, we developed an adaptor to the Cerner Millennium Remote Report Distributions (RRD) that delivers reports as attachments via the Cerner Direct health information service provider (HISP). There is zero change in the end user's workflow in Millennium. Reports are generated in several ways including custom scripts triggered automatically by some event or a variety of Millennium solutions including Clinical Reporting XR. The report is in a human-readable format so the destination client could be anything. For the pilot, the destination client is the Cerner Direct inbox. With wider adoption of the Direct Project, the destination client could easily be an electronic health record (EHR) Queue Management Solution or inbox.
Ability's pilot with the Minnesota Department of Health and Hennepin County Medical Center
Pilot Goal: To demonstrate the feasibility of using the Direct Project communication protocols, security model, and addressing mechanism to securely submit immunization data from providers into a state immunization information system.
Unlike the Cerner Direct Project pilot, which focused on the source, the key to this pilot is the destination. The Minnesota Department of Health worked with Ability to enable their Immunization Registry, the Minnesota Immunization Information Connection (MIIC), through the Direct Project. To take advantage of previous investment, Ability provided a transformation adaptor between the Ability HISP and MIIC that transforms the MIME message to an HL7 message and delivers it via Public Health Information Network Messaging System (PHINMS).
Any Direct Project-enabled client that can submit immunization data understood by the adaptor could submit immunization data to MIIC. For the pilot, Ability provided a stand-alone immunization data entry solution for Hennepin County Medical Center.
Rhode Island Quality Institute's (RIQI) pilot
Pilot Goal: To demonstrate the feasibility of leveraging the Direct Project as a vehicle for feeding clinical information from practice-based EHRs to the statewide health information exchange (HIE), currentcare.
A recent article in Government Health IT does a great job of describing the use case:
A doctor in Rhode Island, per his daily routine, has just updated and closed a patient’s chart in the practice’s electronic health record. As he punches up the next record or heads to the exam room, a routine of another sort is underway between the EHR and the state’s health information exchange database.
The EHR signals the HIE network to send what amounts to a self-addressed envelope, attaches the record and automatically moves the message to a gateway that applies the patient’s pre-set consents to share information fully or with limitations. Then it’s on to the HIE, which detaches the record, breaks it into discrete data, checks for and eliminates elements previously entered in the database and uploads the rest.
No interfaces were built between the two points of exchange. Instead, it’s a direct, uncomplicated, but securely conducted event.
In this case, both the source and destination "clients" are automated processes. The data sent from EpiChart is not meant to be human-readable. It is designed to be processed by currentcare and automatically added to the HIE data repository.
Did you notice that an inbox was only used once between the six edge clients in these pilots? Although that percentage (less than 20 percent) is much lower than we see with regular email, there are examples of creative uses of regular email that focus on the transport service. Anyone use their Gmail account as a personal file server?
The possibilities are endless. Don't shortchange the Direct Project by thinking an email client is required on the sending and/or receiving end of a transaction. At least one doctor in the RIQI pilot gets it. The following quote is from the previously referenced Government Health IT article:
"It's not just e-mail. The message itself can be consumed by the other EHR and it basically marries the two EHRs," he said.
But … Direct Project as email is still cool
Now, this isn’t all to say that the simple email application isn’t useful. Being able to leverage a familiar inbox solution was a deciding factor in choosing SMTP to underlay the Direct Project. They provide a low entry point into secure messaging. All that's required to Direct Project-enable your practice is a HISP and an Inbox solution. Point-to-point conversational email will absolutely help drive wide-spread adoption of the Direct Project. Just think of it as one of many use cases for the Direct Project.