Keynote - David C. Kibbe, MD MBA - Meeting the Demand for Inteoperable HIE 2016: Options and Opportunities

1. David C. Kibbe, MD MBA
President and CEO, DirectTrust
Senior Advisor, AAFP
February 02, 2016
Miami iHT2 Conference

2. •President and CEO, DirectTrust: 2012 – present.
•Senior Advisor, American Academy of Family Physicians: 2006 – present
•Member, HIMSS Identity Management Task Force: 2015 -- present
•Member, North Carolina Institute of Medicine: 2003 – present
•Chairman, ASTM E31 Healthcare Informatics Technical Committee: 2008 - 2012
•Health 2.0 Advisory Board Member - 2007 - 2011
•Former Director, Center for Health Information Technology, AAFP: 2002-2006
•Co-chair, Physicians’ EHR Coalition (PEHRC): 2003 - 2005
•Project Director, Lumetra Doctors Office Quality (DOQ-IT) Project - 2003-2005
•Co-chair, Workgroup on HIT in Small Practices, eHealthInitiative: 2004 -2005
•Co-chair, Workgroup on Data Sharing and Aggregation, AQA: 2004 - 2006
•Chair, Subcommittee on Information Technology, AQA: 2005 - 2006
•Member, JCAHO HIT Advisory Board: 2005 - 2006
•Member, Interoperability Workgroup, CCHIT: 2003 - 2004
•Member, Steering Committee, AHRQ NRC-HIT: 2004 - 2005
Your Speaker
David C. Kibbe, MD MBA recent positions
corporate leader, coach
family physician
software developer
writer / speaker
IT consultant
sailing enthusiast

3. Disclaimer
• The opinions and analyses expressed in this
presentation are entirely those of the author,
and not necessarily those of DirectTrust, the
American Academy of Family Physicians, nor
any of Dr. Kibbe’s consulting clients.

4. Agenda for today’s talk
• Brief introduction to DirectTrust
• Defining interoperability in health care
• The options for health care
organizations and patients/consumers
demanding interoperable exchange
• The determinants affecting demand for
interoperable health information
exchange in 2016-2017
• The opportunities with Direct exchange:
a deeper dive with case studies
4

5. Mission and Goals:
DirectTrust
5
DirectTrust.org, Inc. (DirectTrust) is
a voluntary, self-governing, non-
profit trade alliance of 150
organizations dedicated to the
growth of Direct exchange at
national scale, through the
establishment of policies,
interoperability requirements, and
business practice requirements.
DirectTrust operated under a two-
year Cooperative Agreement with
ONC, 2013-15, to support its work
of creating a national network of
interoperable Direct exchange
services providers.
Security & Trust
Framework
EHNAC-
DirectTrust
Accreditation
Programs
Trust Anchor
Bundle
And Network
Services

6. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036
DirectTrust governs a
Network of Networks For Secure,
Interoperable Exchange
• 40 accredited HISPs
• 400+ Direct-enabled,
ONC certified EHRs & PHRs
• 52,000 health care organizations
• 50+ HIEs in 20 states
• 5 Federal Agencies
• 1.1 million Direct addresses
• 45 million transactions in 2015
• Estimated 200 million in 2016
The DirectTrust Network

7. DirectTrust Members
150 and Counting…..
7
7
Lucy Johns, MPH

8. DirectTrust Members
150 and Counting….
8

9. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036 9
Board
Members
DirectTrust’s
Board of Directors
represent a
diverse and vital
set of stakeholders
from health information
exchange, security, and
identity management
communities.

10. The Definition of
Interoperability in Healthcare
Goes something like this….
• “Interoperability is defined as the ability of two or
more systems to exchange information and the
ability of those systems to use the information that
has been exchanged without special effort.”
• Source: ONC Report to Congress December 2015
https://www.healthit.gov/facas/sites/faca/files/HITPC_Final_ITF_Report_2
015-12-16%20v3.pdf
10

11. This definition requires teasing out the meaning of the
following…
• Systems
– Meaning health systems, e.g. hospitals, medical practices,
imaging centers, home health providers, etc.
AND
-- Information systems, e.g. EHRs, billings and claims/admin,
lab and results reporting, etc.
• Use of the exchanged information “without special
effort.” What about the exchange/transport itself?
• “Two or more” ? Is two a sufficient number?
11

12. New Definition of Interoperability
Let’s try it again…
• Interoperability is defined as the ability to exchange
health information electronically across the
boundaries of multiple organizational and health
information systems, and to use the exchanged
information, without special effort.
• Source: Kibbe, DC, February 2016
12

13. New Definition of Interoperability
With additional caveat: exchanges should be…
– Standards based
– Content neutral
– Secure
– Identity validated (authenticated)
13

14. Demand for Interoperability:
Where did it start?
“We can't wait for interoperability.
You all know this. It's past time. We
have a series of really, really
important standards baked into the
2014 Edition criteria. I think folks
should assume the timelines will
stick.”
Farzad Mostashari, MD
National Coordinator,
ONC, 10/10/2013

15. Demand for Interoperability
has increasing number of sources
• Comes from several distinct but
related sources
– Meaningful Use $$, and specifically
MU Stage 2-3 objectives/metrics for
Transitions of Care and Patient
Engagement
– Expectations both business and
clinical about the need to leverage
huge national investment in EHRs
– Consumer demand to exercise
HIPAA rights of access to PHI
– Value-based payment systems and
Merit-based Incentive Programs,
MIPS. Population risk management.

16. Tr
Demand for Interoperable Health Information
Exchange now met by Four Main Facilitators
16
Affordability
Scale
HIEs
Traditional point-to-point
Direct Exchange

17. • Additional examples of more focused, limited
interoperable exchange platforms:
– ePrescribing
– Lab results reporting
– Billing and claims submission
– Others

18. • And there is considerable “cross over” among
these efforts:
– The Epic Community has created and shared over 190,000 unique Direct
addresses and exchange ~1.3M patient records via Direct each month,
working with 10+ DirectTrust accredited HISPs.
– Epic Community members represent about 50% of the national eHealth
Exchange participants, and as a group, are the most connected to the VA and
SSA.
– Over 2/3s of HIEs report using Direct exchange both internally and to send
alerts and reminders to provider organization members via their EHRs.
– eClinicalWorks providers are offered both non-accredited (internal to other
eCW clients) Direct exchange and accredited Direct exchange options.

19. • Hypothesis: The growth in demand of facilitated, secure
interoperable exchange during 2016-17 will depend upon:
– Positive network effects (create scale)
• Size of the network for provider organizations facing MU and care
coordination, patient engagement, reporting mandates
• Usability of EHRs and PHRs with respect to exchange and use of data
• Readiness and maturity of new drivers and use cases of interoperable
exchanges of health information
• Increasing requirements for security and trust in identity
– Negative network effects (cause congestion)
• Content and payload frictions
• Health IT application interface (edge client) variability
• Provider and patient directory issues
• Costs of ID proofing and certificate management
19
Will demand for interoperable
exchange grow in 2016-2017?

20. Stage 2 MU focus is on exchange

21. The HIE requirements for Stage 2
1. CPOE
2. E-Prescribing
3. Record demographics
4. Record vitals
5. Record smoking status
6. Use clinical decision support
7. Patients view, download, transmit
8. Clinical summaries to patients
9. Protect electronic health
information
10. Incorporate lab results
11. Generate patient lists
12. Reminders for follow-up care
13. Patient educational resources
14. Medication reconciliation
15. Transmit care summaries for
transitions of care
16. Report immunizations
17. Secure messaging with patients
plus menu items……
18. Report syndromic data
19. Record electronic notes
20. Imaging results
21. Record family history
22. Report cancer cases
23. Report other registry cases

22. From the CMS rule…
22 22
http://www.healthit.gov/sites/default/files/meaning
ries2_110112.pdf
Transitions of care Patient engagement

23. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036 23
EHR adoption has increased
steadily since 2010 with
almost all
hospitals possessing a
certified
EHR (96.6%)
75% of hospitals have
adopted at
least a basic EHR, up from
59% in
2013.
Small and rural hospitals
continue
to lag behind.
Adoption of Direct-enabled
ONC-certified EHRs is now
very high

24. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036 24
Hospitals report they are increasing
Electronic exchange of summary of
care records
Almost 10% of hospitals
now report exchanging
summary records with
outside sources
exclusively
electronically.
Two-thirds of hospitals
report sending and
receiving via both
electronic and non-
electronic format, e.g.
mail, fax, e-fax, courier.
Source: ONC

25. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036 25
Adoption of Direct-enabled
ONC-certified by Physicians 74%
Larger practices and
primary care practice
physicians adopt EHRs
at a higher rate than
smaller and solo
practice physicians.

26. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036 26
March, 2015, ONC reports EHR
vendors reported by health care
professionals as participating in
Meaningful Use programs
As of March 2015, 779 health
IT vendors supplied certified
EHR products to 490,575
health care professionals
participating in the CMS EHR
Incentive Programs and/or
ONC REC Program.

27. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036 27
As of Nov. 2015
only 1 out 5 EPs
who attested for
Stage 1 MU had
attested for Stage
2 MU.
For hospitals, the
rate is 1 out of 3.
Opportunity: a
majority of EHs/EPs
have yet to attest
to Stage 2 MU and
the objectives
for Transitions of
Care.

28. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036 28
KLAS reported
provider ratings
of EHRs based
on their ease of
connection and
interoperability.
KLAS reports
that information
blocking is not
widespread, but
business models
and lack of
technical help
remain
problems.
Vendors are starting to be
rated on
their interoperability

29. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036 29
American Hospital Association
issues white paper on
“why interoperability matters.”
In a landmark 2015 study, the AHA
succinctly lists why EHR interoperability
is essential for hospitals:
• Care Coordination
• Patient Engagement
• Public health and quality measures
reporting.
Value-based payment is key driver.
The report is highly critical of the
current non-standardization of the
CCDA, and calls for further federal
government support of interoperability
content standards and their use.
Source: AHA

30. The Four (Five) Main U.S.
Interoperable Health Info
Exchange Facilitators
30
Tr
Affordability
Scale
HIEs
Traditional point-to-point
Direct Exchange

31. • Conclusions: The numbers of Direct-enabled EHRs
serving hospitals and medical practices, who are in turn
serviced by accredited Direct exchange service
providers (HISPs, CA/RAs) is very, very large and is likely
to expand further in 2016 as more provider
organizations attest for Stage 2 MU in 2016 and 2017.
• HIEs, EHR-specific interoperability networks will also
grow, especially EPIC CareEverywhere, but more slowly.
• eHealthExchange is unlikely to see significant growth.
• FHIR + open APIs 4-5 years away.
31

32. • Conclusion: Interoperability networks of all
types face challenges from payload and
content confusion, and from significant
variability in EHR interface usability, e.g. for
Direct exchange. These negative network
effects have the potential to cause congestion
and delay in network growth, and must be
addressed if interoperable exchange is to
become truly reliable and meet demand.
32

33. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036
Brief Case Studies of the
Use Cases for Direct Exchange:
Baylor Scott and White, the VA, Tenet Health System

34. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036

35. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036

36. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036

37. 37

38. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036

39. Key Use Cases for VA Direct Messaging
Use Case
1 Care in the Community
Referral and other health information shared
with community health care providers
2 Transitions of Care (ToC) Documents
VA receives (or sends) CCDA(s) from
community health care provider for a
Veteran. Supports partners Meaningful Use
2 (MU2) attestation
3
My HealtheVet (Patient Portal) Blue Button
Direct
My HealtheVet users can send their CCDA to
a Direct address of their choosing through
Direct
4 Admission/Discharge/Transfer (ADT)
Non-VA partner (often an HIE) sends ADT
information to a VA Medical Center for a
Veteran who receives care in the community
5 Long-Term Care (LTC)
Sharing administrative and clinical
information for a Veteran in a LTC facility
(including State Veterans Homes)
6 Others?
VA is open to using Direct for other use cases
that support Veteran health care
Source: Glen Crandall, VHA presentation 1/20/2016, used with permission.

40. VA Use Case: Care in the Community
• VA pays for millions of “fee consults” for Veterans each year
• Each one requires administrative and clinical documentation
including:
1) authorization for Veteran to receive care paid for by VA
2) results of the consult
• Use of Direct Messaging is more secure and efficient than
faxing, mailing, or hand carrying
40
Source: Glen Crandall, VHA presentation 1/20/2016, used with permission.

41. Success Clearing Backlog of Consult Results
• The Ochsner Health System in New Orleans had over 1,000 consultation
reports to provide to VA
• Using Direct Messaging, the documents Ochsner sent the reports securely
to the New Orleans VA Medical Center as a pdf attached to a Direct
message
41
• This saved VA end users many hours
of dealing with faxes and scanning
them so the information could be
included in the Veterans’ electronic
health record
Source: Glen Crandall, VHA presentation 1/20/2016, used with permission.

42. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036

43. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036

44. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036

45. Contact Information
David C. Kibbe MD, President and CEO
DirectTrust.org
David.Kibbe@DirectTrust.org
kibbedavid@mac.com
admin@directtrust.org
913.205.7968

46. Additional Slides

47. www.DirectTrust.org
1101 Connecticut Ave NW, Washington, DC 20036
Things have been moving
very, very fast
April 2010
 Direct Project
launched
 Goal: simple,
secure, scalable,
standards-based
way to send
health data
over the
Internet
April 2011
 Applicability
Statement
published
 “Rules of the
Road” Workgroup
started
 HIEs charged
w/ Direct
Feb 2013
 EHNAC-DirectTrust
accreditation
program starts
 Stage 2 MU
program to
require Direct
in all EHRs
by 2014
Sept 2015
 DirectTrust HISPs
provide service
to >48,000 HCOs
and provision
over 1 million
 Direct email
addresses
Direct = secure, identity validated, vendor/app neutral messaging + content
May 2012
 DirectTrust
incorporated as
non-profit trade
alliance, 501(6)(c)

48. 4848
Health Information Service
Provider (HISP)
Healthcare
Organization (HCO)
Identity vetting at
a specific level of
Assurance, LoA.
Certificate Authority (CA)
Certificate
Validation Service
X.509 Certificate
Issuance Service
Revocation
Services
Certificate Signing
Services
Registration Authority (RA)
Compile/Validate Identity and Trust
Documentation
The CA and RA
enforce the
policies specified
in the DirectTrust
and FBCA
Certificate Policy
(CP).
Crediential issued
on the basis of RA’s
Identity vetting at
specific LoA..
HCO Direct
Addressees
Basic services for user: DNS
discovery; encryption;
certificate signing and
validation; send/receive
MDNs; provide HISP-side of
edge protocol connection
compliance with Direct
standard,
The HISP enforces the
policies specified in the
DirectTrust HISP Policy (HP),
and MUST use accredited RA
and CA.
The HCO relies on HISP, CA,
and RA as accredited trusted
agents, and bears ultimate
responsibility for HIPAA
privacy and security.
NOTE: Three separate roles and
responsibilities from “trusted agents”
combine to enable Direct exchange
1.
2.
3.

49. DrBob@direct.familypractice.com
(has been identity vetted, has X.509
Digital certificate bound to address.)
DrSusan@direct.cardiology.com
(has been identity vetted, has X.509
Digital certificate bound to address.)
Exchange between HISPs requires
active use of the Direct protocols for
secure Internet email exchange
49
EHR EHR
encryption
identity validation

50. Interoperability Matrix
50
DirectTrust Accredited Bundle Interoperability Benchmarking Results as of 10/2/2015
Health
Companion
iShare
Medical
MedAllie
s
Cerner
Data
Motion
EMR
Direct
ICA
Max
MD
McKesso
n/Relay
MRO
Sure-
scripts
Updox
NY eHlth
Collab
Cozeva MHIN Axesson Inpriva Nitor
Glenwoo
d Systems
SES Medicity
Athena-
health
CareAcco
rd
CernerM
obileMD
eClinical
Direct
IOD
Rocheste
r RHIO
Orion
Health
NextGen
(Mirth)
Truven
Health
Anltcs
Covisint Optum
HealthU
nity
HIXNY Shifox
Disp
Support
(respond)
Interop
Score
Interop %
Sep. Certs
(Send)
Sep. Certs
(Reply)
Health Companion Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Sept Jul Sept Jul Sept Jul Jul Jul Jul Jul Sept Jul Jul Jul Jul Aug Sept Aug Jul, 6
33 97%
iShare Medical Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Sept Sept Sept Jul Sept Jul Jul Jul Jul Sept Jul Jul Jul Jul Sept Jul Sept Jul Sept
33 97% Sept
MedAllies Jun Jul Jul Jun Jul Jun Jul Jul Jun Jul Jun Jul Jun Jun Jun Jun Jul Jul Jul Jul Jul Jun Jun Jul Jul Jun Jul Jul Jul Jul Aug Sept Jun Jul, 9
33 97%
Cerner Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jul Jun Jun Jun Jun Jun Jul Jun Jun Jun Jun Aug Jul Jun Jun Jun Jun Jul Jul Jun Jun Sept
32 94% Aug
Data Motion Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Apr Jun Jun Jul Jun Aug Jul Jun Jun Jun Jun Aug Apr Jul Jun Sept, 16,17
32 94%
EMR Direct Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jul Jun Jun Jun Jun Aug Jun Jun Jun Jun Jun Jul Jun Jun Jun Sept
32 94% Aug Aug
ICA Jun Jun Jul Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jul Jun Jul Jun Jun Jul Jul Jul Jul,19 Aug Sept
32 94%
MaxMD Jul Jul Jul Jul Jul Jul Jul Aug Jul Jul Jul Sept Jul Sept Jul Aug Jul Apr Aug Jul Jun Jul Sept Sept Jul Jul Jul Jul Jul Jul Apr Sept Sept
32 94% Aug Sept
McKesson/Relay Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Aug Jul Jul Jul Jul Jul Aug Jul Jul Jul Jul Jul Jul Jul Aug Jul Aug,9,17,22,20
32 94%
MRO Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Aug Jul Jul Jul Jul Jul Jul Jul Jul Sept
32 94%
Sure-scripts Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Aug Jun Jun Jul Sept Jun Aug Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Aug Jun Sept Aug Sept
32 94%
Updox Jun Jun Jun Jun Jun Jun Jun Jun Aug Jun Jun Jun Jun Jun Jun Aug Jun Aug Aug Jun Jun Jun Aug Aug Jun Jun Jun Jun Aug Aug Jun Sept,13 Aug Sept
32 94%
NY eHlth Collab Jun Jul Jul Aug Jul Jul Jul Jul Jul Jul Aug Jun Aug Aug Aug Jul Jul Jun Aug Jun Jun Aug Jul Jul Sept Jul Aug Aug Sept Aug Aug Sept,12,9
31 91%
Cozeva Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Jun Sept,13 Jul Jun Jun Jun Jun Sept,13 Jul Jun Jun Jun Jun Jul Jul Jun Sept Oct,13 Aug
30 88%
MHIN Aug Aug Aug Aug Sept Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Sept Aug Aug Sept Aug Aug Sept, 2 Aug Aug Sept, 9
30 88%
Axesson Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Sept Jul Jul Jul Jul Jul Jul Jul Aug
28 82%
Inpriva Jul Jun Jun Jun Jun Jul Jun Jun Jun Jul Jun Jun Jun Jun Jun Jul Jun Jul Jun Jul Jun Jun Jun Jun Jun Jun Jun Jun Sept,9,12,23,24
28 82%
Nitor Jul Sept Jul Jun Jun Jun Jun Jul Jul Jul Jun Jun Jul Jun Jul Jul Jun Sept, 2 Jun Aug Jul Jun Aug Jul Jul Jul Jul Aug Sept, 2 Jul Sept, 14
28 82%
Glenwood Systems Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Oct Sept Sept Sept Sept Sept Aug Sept 9,22
27 79%
SES Jun Jul Jun Jun Aug,13 Jun Jun Sept Jun Jun Jul Jun Jun Jun Sept Jul Jun Jun Sept Jun Jun Sept Aug 2,13 Jun Jul Sept Sept Sept Jul,13 Aug,13 Sept,13 Sept,13 Aug Sept,16,17,22
27 79%
Medicity Oct, 2 Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct Oct, 2 Oct Oct Oct Oct, 2 Oct, 2 Oct Oct Oct Oct Sept Oct,1,2 Sept Aug, 16
26 76%
Athena-health Jul Jul Jul Jul Aug Jul Jul Aug Jul Jul Jul Jul Jul Sept Jul Jul Jul Jun Jul Sept Jul Jul Aug Jul Jul,6,9
24 71%
CareAccord Jul Jul Jul,13 Jul Jul Jul Jul Jul Aug,13 Jul Jul Jul Jul Jul Jul Jul Jul Jul Sept Sept Jul Jul,2 Aug,13 Jul, 13 Jul Jul Jul Jul Jul Jul,1,13 Aug2,13, Jul,13 Sept
24 71%
CernerMobileMD Aug Aug Aug Aug Aug Aug Aug Sept Aug Aug Aug Aug Aug Sept Sept Sept,13 Aug Sept Aug Aug Aug Aug Sept Aug Aug Sept, 16,17,24
24 71% Sept
eClinicalDirect Jun Jul Jul Jul Jul Jul, 18 Jul Aug Jul Aug Jun Jul, 2 Jun Jul Jul Jun Aug Jun Jul Jun Jul Jul Jul Jul Jul Sept 17, 20,9,23
24 71%
IOD Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul, 9
24 71%
Rochester RHIO Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Jan Sept,13 Sept Sept,13 Jan Sept Sept Sept Sept,13 Sept Sept Sept Jan Sept Sept,13 Jul, 15
23 68%
Orion Health Aug Sept Aug Aug Sept,13 Aug Aug Aug Sept,13 Aug Aug Aug Aug Aug Aug Aug Sept Aug Sept,13 Aug Aug Sept,13 Sept,13 Aug Aug Aug Sept,13 Sept,13 Sept
21 62%
NextGen (Mirth) Aug,2 Aug,2 Aug Aug Aug Aug Aug Aug Aug,13 Aug Aug Aug Aug Aug Jan Aug Aug Aug Sept Aug,13 Aug Aug Aug Aug Aug,2 Sept Aug,2 Aug,13 Jan Aug,13 Sept
20 59%
Truven Health Anltcs Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Sept 22,17
10 29%
Covisint Sept Sept Sept Sept Sept Sept Sept Sept Sept Sept Aug, 12,16
9 26%
Optum Aug Aug,9,20
1 3%
HealthUnity Sept, 16,12,25
0 0%
HIXNY Sept 17,16,22,23
0 0%
Shifox Sept, 14
0 0%
Interop Testing
Bundle (Test PKI)
Accredited Bundle Results
Summary
S
e
n
d
e
r

51. HIMSS Survey shows Direct
exchange now mainstream
Current market view of the usage, value and future of Direct Messaging
Themes from the survey results:
• substantial use of Direct in support of care coordination use cases,
• broad availability to a provider directory but great variability in the method of
access,
• continued challenges incorporating structured data into the EHR,
• extensive membership [of provider organizations] in a HISP,
• some knowledge of the availability of Direct messaging among the clinician
community, and
• that most participating organizations support Direct as the method choice for
exchanging data. 51

52. Short lexicon of terms
Health Information Service Provider, HISP
An entity or service providing its subscribers Direct accounts, addresses and
secure, encrypted exchange of messages between users within the same domain,
and also with users in different domains, that is, who are subscribers of different
HISPs. It is typically also the responsibility for a HISP to arrange for its
subscribers’ identity proofing and verification (the Registration Authority
function) and for its subscribers’ digital certificate issuance and management (the
Certificate Authority function). HISPs may be organized along several different
business models. For example, an EHR technology vendor may operate a HISP
internally for its customers. A so-called “full service” HISP may operate a stand
alone business, and partner with several EHRs as well as offer its Direct services
through a web portal or other set of tools and devices.

53. Short lexicon of terms
Direct Project
A public-private sector initiative sponsored and run by ONC whose aim was to create a
simple, secure, and open standard for transport of messages and attachments between
health care participants over the Internet, regardless of end-user technology.
Direct Standard
The outcome of the Direct Project. A set of protocols and specifications, along with a
security and trust architecture, for simple, secure, inter-vendor communications over the
Internet for use by health care professionals and patients.
Direct Message Exchange
Use or deployment by individuals or entities of health information exchange utilizing the
Direct standard. Also sometimes referred to as Directed “push” exchange, Direct exchange.
Direct User or Subscriber
An organization or an individual that participates in sending and receiving messages and
attachments using technology equipped to do so, e.g an EHR or a web portal, via the Direct
standard, and who has the authority to do so.