March 21, 2011
Cerner and the Direct Project
With today’s Office of the National Coordinator announcement celebrating a major milestone of the Direct Project and the excitement Direct Project generated at HIMSS11, we will be sharing a series of posts about this exciting new approach to solving a variety of issues facing healthcare. This first post focuses on the key essentials you need to know about Direct Project, along with a historical account of the collaboration between Cerner and other industry partners that helped bring Direct Project from concept to reality.
What is the Direct Project and how did it come about?
In the summer of 2009, as the HIT Policy Committee (HITPC) and HIT Standards Committee (HITSC) were advising the Office of the National Coordinator (ONC) about the criteria for “meaningful use," it became clear that there was no widely adopted standard that could be used for easy but secure transfer of patient information from one provider to another. In response to this gap, I worked with fellow HITSC committee member, Wes Rishel (Gartner) to coin the term "Simple Interop." I helped Wes publish a number of blog posts proposing a simple model for secure use of standard email-like services to directly transfer patient information from one provider to another. ONC recognized the value of the proposed approach and agreed to facilitate an industry-wide consortium of volunteers to draft a new standard. Cerner, along with many other industry participants large and small, quickly started to define a specification. In January 2010, the hard work was recognized and endorsed by the Nationwide Health Information Network Workgroup of the HITPC and HITSC. These discussions continued to gain broad traction, and the ONC within Health and Human Services (HHS) collaborated with private sector organizations to officially launch NHIN Direct on March 1, 2010.
The birth of the NHIN Direct project (subsequently renamed the Direct Project) led to more than 50 different organizations and more than 200 participants coming together from across the industry to solve the basic problem of enabling secure electronic health information exchange for common use cases, regardless of the underlying technology providers of the organizations participating in the exchange.
The two basic goals of the original Direct Project charter were to:
1. replace the use of fax/phone/paper, with a simple and secure point-to-point communication over the Internet, and
2. do so in such a way that did not require creation of a new legal framework; rather relying on existing organizational legal policies and procedures covered under HIPAA.
The resulting Direct Project proposal does just that. It defines a secure email transportation infrastructure available in an open source format that ensures the secure delivery of messages between two trusted endpoints for purposes of treatment, payment or healthcare operations. It accomplishes “universal addressing” by standardizing the way email services can use encryption to communicate between trusted endpoints.
The term “HISP” (Health Information Service Provider) describes an outsourced email service provider that follows Direct Project standards and represents the mechanism used to provision users with a universal, Direct email address. The HISP provides its users with an infrastructure that can manage message encryption, the “circles of trust” as to who can be communicated with, and the incorporation of appropriate policies and procedures necessary to ensure a level of confidence in provisioning members on the network appropriate to healthcare.
Direct Project standards can be used to support a variety of “meaningful" use cases such as referrals, lab results and provider-patient communication. The Direct Project is not meant as a replacement for all the other methods for which data is electronically exchanged today, rather it was designed to supplement existing protocols and to create an eventual path to more sophisticated levels of interoperability.
Why did Cerner get involved?
As part of our strategy to better enable the flow of information within and among communities, Cerner became a "founding member" of the Direct Project, recognizing the impact this could have on facilitating universal information exchange across the country. Cerner has made a significant investment of time and resources in a number of areas; from providing initial thought leadership and participating in various workgroup meetings, to developing and donating open source code in an effort to speed adoption by the industry.
As the public/private Direct Project progressed through the early stages, a “bake-off” of several possible technical standards commenced. Cerner joined with Microsoft to propose the use of existing SMTP (email) standards for secure health information exchange. After collaboration with the other “teams,” the Cerner/Microsoft proposal was adopted as the official selection for the Direct Project backbone. This rapid coalescence of major competitors around agreement on a new standard was no small feat.
Following the selection of the backbone protocol, Cerner became the primary source code contributor to the Direct Project’s Java Reference Implementation. The project is now in the implementation phase. Cerner is also leading one of only a handful of pilots across the country being used to validate the Direct Project standards in a production environment (more to come on this in a subsequent blog).
What’s next for Direct Project?
It has been rewarding to be a part of an idea now taking flight and possessing the potential to significantly change the industry. Many other companies are now stepping up to offer Direct-enabled solutions, which further grows and expands the value of the collective “network” of endpoints that can securely communicate. It will be important to continue to maintain a diverse set of these Direct-enabled solutions, as it will better enable the industry to meet providers where they are today within their own native technologies and workflows.
As the additional pilots become operational across the country, we’ll learn more about the Direct Project standards and adapt as an industry, and most importantly, drive new innovations never possible before by taking advantage of this simple and safe way to communicate.
David McCallie, Jr., MD, Vice President, Medical Informatics, is director of the Cerner Medical Informatics Institute. He is responsible for a research and development team focused on developing innovations at the intersection of computer science and clinical medicine. Prior to joining Cerner in 1991, McCallie was director of research computing at Children’s Hospital in Boston, Mass., and an instructor in neurology at Children’s Hospital and Harvard Medical School. McCallie earned a bachelor’s degree in electrical engineering and computer science at Duke University. He earned his medical degree at Harvard Medical School. McCallie has published numerous articles and presented frequently on the subject of healthcare informatics. He is a member of the American Medical Informatics Association.