Patient-Centeredness: will "Direct-only" get us there?

I read that the HIT Standards Committee recommended that Direct (SMTP, S/MIME secure email) be the only transport protocol for certification. While on the one hand this sounds like a good step toward parsimony (similar to having only one vocabulary for problems or one Consolidated CDA standard for summary of care records), I think it’s different and has some unintended consequences against the patient-centered view that can be advanced with HIEs.

Those of us who worked on Direct recognized its strength for particular “push” use cases. Many also felt strongly that Direct needed a bridge to the HIE world in terms of protocols (hence the XDR and XDM for Direct Messaging specification). The Direct Project Overview made it very clear that Direct “push” is not intended to solve every use case but to coexist with other forms of exchange including “pull” as well explained in this EHRA whitepaper.

This is easy to understand if we look at how businesses are run, and how people manage their personal data. Email push is highly beneficial and essential in my business and personal life. But it’s not all there is. At work, when people collaborate on projects (as providers ought to  collaborate in patient care), they store information in shared resources. They don’t rely upon the project documents existing in every individual’s email or personal folders! That would lead to waste and confusion. Instead, there are repositories that handle version-controlled documents, source code, etc. Wiki pages rather than emails can be used to record the shared project experience. Emails are great for initial notification, but not for the ongoing management of the information. And even individuals don’t email their photos to everyone in their address book: they share them in a single place (like Facebook) from which trusted friends can pull (view and download) them. Information exchange  via Direct should not “push out of the picture” information sharing that benefits the patient and provider community.

HIT SC’s recommendation of a single protocol for certification is fine as a “minimum requirement.” But I’m very concerned that certifying only Direct, if accepted by ONC, could bias providers toward Direct to the detriment of other types of exchange. CMS’ Incentive Program proposes that meaningful use measures only count transmissions to providers using the standards included in certification (page 13708 of the NPRM). This would have the unintended consequence of discouraging sharing through HIEs (at any level), that use IHE profiles such as XDS, XDR, XCA, etc., as most use these instead of Direct. Those profiles require sufficient metadata to support queries against a patient-centered document registry, so that providers can find what they’re looking for. Direct by itself does not provide or require those metadata, so even if Direct were used to push documents to an HIE, the HIE would be hard pressed to correctly index and file the documents.

I’m not criticizing Direct for what it is. I am saying that it was not designed to handle all exchanges, and that overemphasizing it as the only “meaningful use” method that “counts” will have negative impacts on HIEs that provide a patient-centered aggregate view. Point-to-point transmissions don’t provide such a view since each provider’s view from “push alone” is only a “silo” unless everyone copies everyone else on every document (the dreaded “reply to all” email) – not a good idea! While HIEs aren’t required for MU, they should not be discriminated against either. CMS regulations incenting Direct only (implicitly disincenting HIE) could harm progress toward patient-centricity. That would be like a business rewarding people for sending their documents via email but not rewarding them for sharing controlled versions of those documents in a repository. Between ONC and CMS, I hope this problem can be avoided by focusing on the real objective – providers and patients sharing data electronically, without CMS measures counting only Direct SMTP exchanges as qualifying for meaningful use. “Pull” exchanges from an HIE or “push” exchanges using other protocols (e.g., XDR SOAP) should also count toward MU measures. And I hope that HHS goes beyond “permitting” HIEs for MU, but that they will continue to invest in and work with others (e.g., states) on a national healthcare infrastructure (NwHIN Exchange as it evolves) to enable a patient-centered, cross-provider view of data as a public good.