Direct Exchange

Three Things You Should Know About Interoperability and Direct Exchange

What is Direct?

Direct is a national standard for sending authenticated, encrypted health information directly to known, trusted recipients over the Internet. It was developed in 2010 as part of the Direct Project, a public-private collaboration sponsored by the Office of the National Coordinator for Health IT (ONC). Use of the Direct standard to securely push health information from a sender to a receiver is called “Direct exchange.”

Three Things You Should Know About Direct Exchange

1. Direct exchange is a secure, HIPAA-compliant way for personal health information to be sent electronically from one electronic health record (EHR) to another.

Direct provides a foundation for “interoperability,” which is the ability for health information to be shared and used by two or more systems. Interoperability requires EHRs to “talk” to each other across organizations and health information technology (IT) platforms.

  • Health information service providers (HISPs) supply specialized network services to connect EHRs that are engaged in Direct exchange. There is no single hub or central server handling all Direct messages and attachments.
  • HISP functions can be performed by an existing organization (e.g., EHR vendor, hospital, health information exchange [HIE] organization) or by a vendor that specializes in HISP services.
  • An HISP encrypts Direct messages/attachments from the sender and validates the identity of both the sender and the receiver; the receiving HISP decrypts incoming messages/attachments. Encrypted content travels over the Internet from the sender’s EHR to the receiver’s HISP, and then on to the receiver’s EHR.
  • To exchange health information using Direct, both the sender and the receiver need to have a Direct address. It looks similar to a regular email address but has the word “direct” in it (e.g., Direct addresses are assigned by the HISP, or, in some cases, by the EHR. 

2. Almost all EHRs on the market are capable of Direct exchange.

  • As of 2014, the ONC requires that all EHR technology certified for use within Meaningful Use programs must be capable of Direct exchange. This means that Direct is available to virtually all eligible providers and hospitals attesting to Meaningful Use in 2015. 
  • More than 300 certified EHR vendors enable customers to engage in Direct exchange. Companies that are actively supporting Direct exchange by their EHR customers in all 50 states include the following: Allscripts, athenahealth, Cerner, eClinicalWorks, Epic, Greenway Health, McKesson, MEDITECH, and NextGen Healthcare.
  • As of July 2015, approximately half of the U.S. health care system is capable of using Direct exchange to replace fax, eFax, and mail transmission of health information. As of late March 2015, approximately 27 million Direct messages had been sent and received; these have been primarily related to care coordination that meets Meaningful Use objectives for transitions of care.

3. You may need to work with your EHR vendor to begin engaging in Direct exchange.

  • You should have the version of your EHR's software that has been upgraded to include Direct and to meet the ONC certification for 2014 and Stage 2 Meaningful Use. Alternatively, many HISPs offer web browser applications that enable secure Direct exchange capability.
  • You may need additional training to learn how your EHR’s Direct features work. In some EHRs, the Direct user interface has features similar to familiar email applications (e.g., an inbox, buttons for composing/sending messages and attaching files) and is easy to use with little or no training. In other EHRs, the Direct user interface may be more difficult to access and use. For example, it may be buried deep within a workflow for referring patients to a subspecialist.

Direct Functionality May Not Equal Ease of Use

The usability of Direct user interfaces varies among EHRs that the Office of the National Coordinator for Health IT (ONC) has certified as capable of Direct exchange. ONC certification is only based on laboratory testing of the functionality of an EHR’s Direct user interface, not how easy it is to use in the real world. Critics assert that this oversight has allowed some EHR vendors to impede interoperability and discourage the use of Direct exchange by making the user interface difficult to access and use.