Healthcare communication gets an upgrade

The Direct Project, formerly NHIN Direct, looks to unite health messaging and the Internet.

After nine months of gestation, we are witnessing the birth of a new platform for health information communication. The post below outlines recent developments of the Direct Project (formerly NHIN Direct) and gives a sense of the exciting future for the health Internet.

Arien Malec, Brian Behlendorf and a host of volunteers have guided the project to this point. It’s not complete, but below you’ll see we have achieved some major milestones.

There’s still a need for coders and developers — especially those with open source skills and experience — to help in the healthcare arena. Check out the different workgroups and see where you might fit in. The free NHIN University is also worth attending.

Three volunteers from the project’s Communications Workgroup collaborated on the following post. Read on for a glimpse of what’s been accomplished and where we’re heading. — Brian Ahier

This post was co-authored by Brian Ahier, Rich Elmore and David C. Kibbe.

The Direct Project announced today the completion of its open-source connectivity-enabling software and the start of a series of pilots that will be demonstrating directed secure messaging for healthcare stakeholders over the Internet.

The Direct Project specifies a simple, secure, scalable, standards-based way for participants to send encrypted health information directly to trusted recipients over the Internet.

Also announced:

  • A new name: the Direct Project was previously known as NHIN Direct.
  • An NHIN University course, “The Direct Project – Where We Are Today,” to be presented by Arien Malec, Nov. 29 at 1 PM ET, sponsored by the National eHealth Collaborative.
  • More than 20 health IT (HIT) vendors have announced plans to use the Direct Project for message transport in connection with their solutions and services.
  • Presentations at the HIT Standards Committee on Tuesday, Nov. 30, where three or more vendors will be announcing their support for the Direct Project.
  • A thorough documentation library, including a Direct Project Overview.
  • Best practice guidance for directed messaging based on the policy work of the Privacy and Security Tiger team.
  • A new website at
  • A new hashtag, #directproject, for following the Direct Project on Twitter.

The Direct Project is the collaborative and voluntary work of a group of healthcare stakeholders representing more than 50 provider, state, health information exchange (HIE) and HIT vendor organizations. More than 200 participants have contributed to the project. Its rapid progress, transparency, and community consensus approach have established it as a model of how to drive innovation at a national level.

What is the Direct Project?

Today, communication of health information among providers and patients is most often achieved by sending paper through the mail or via fax. The Direct Project seeks to benefit patients and providers by improving the transport of health information: making it faster, more secure, and less expensive. The Direct Project will facilitate “direct” communication patterns with an eye toward approaching more advanced levels of interoperability than simple paper can provide.

The Direct Project provides for universal boundary-free addressing to other Direct Project participants using a health Internet “email-like” address.

The project focuses on the technical standards and services necessary to securely transport content from point A to point B, and does not specify the actual content exchanged. When the Direct Project is used by providers to transport and share qualifying clinical content, the combination of content and Direct Project-specified transport standards may satisfy some Stage 1 Meaningful Use requirements. For example, a primary care physician who is referring a patient to a specialist can use the Direct Project to send a clinical summary of that patient to the specialist and to receive a summary of the consultation.

Direct Project

How might the Direct Project be used?

The 2009-10 Congress and agencies of the federal government have created regulations that require physicians and hospitals participating in the ARRA/HITECH incentives awarded for meaningful use of electronic health record (EHR) technology to:

  • Send messages and data to each other for referral and care coordination purposes.
  • Send alerts and reminders for preventive care to their patients.
  • Send patients clinical summaries of their visit and of their health information.
  • Receive lab results from labs.
  • Send immunization and syndromic surveillance data to public health agencies.
  • Integrate with HIT vendor systems

Each capability can be enabled with point-to-point secure e-mail or in a more integrated manner as HIT vendors and public health agencies enable communication with the Direct Project.

How will the Direct Project affect states and Health Information Exchanges?

States that are receiving federal funding to enable message exchange are being asked by the ONC to facilitate Stage 1 Meaningful Use information exchange. The Direct Project may serve as a key enabler of directed messaging for all states and Health Information Exchanges. Even states that have some level of health information exchange capability need to address areas that are currently uncovered by a regional or local Health Information Organization (HIO).

As state plans seek to address a means to fill the gaps in exchange capability coverage, the Direct Project may provide a bridge to enabling the basic exchange requirements for Stage 1 Meaningful Use. The Direct Project does not obviate the need for state planning for HIE, neither does it undercut the business case for HIOs. More robust services can be layered over simple directed messaging that will provide value to exchange participants.

There are already organizations that have announced the establishment of national clinical exchange networks, including integration with the Direct Project. States and HIOs will need to decide how best to provide Direct Project services to their constituents, whether by partnering with existing exchange networks or incorporating direct messaging into the services they provide.

The Direct Project implementation

The Direct Project is organizing real-world pilots to demonstrate health information exchange using The Direct Project standards and services. Six pilots are ramping up including:

Rhode Island Quality Institute, Redwood MedNet and MedAllies will be sending Continuity of Care Documents to other providers for referrals and transitions of care. Visionshare will be linking to immunization registries. Carespark (Tennessee) will be linking the Department of Veterans Affairs with private clinics providing health services to veterans. And Connecticut’s Medical Professional Services, an independent practice association (IPA), will be linking Middlesex Hospital with primary care providers.

Direct Project output

The reference implementation

To help the Direct Project implementers, an open source reference implementation of the Direct Project standards and services has been developed under the guidance of the Direct Project. To ensure the broadest possible participation, the reference implementation has been implemented in two flavors: Java and .NET.

Health Information Service Providers

Connectivity among providers is facilitated by Health Information Service Providers (HISP). HISP describes both a function (the management of security and transport for directed exchange) and an organizational model (an organization that performs HISP functions on behalf of the sending or receiving organization or individual).

Best practices

The Direct Project is bound by a set of policies that have been recommended to ONC by the HIT Policy Committee (HITPC) or are being examined by the HITPC’s Privacy and Security Tiger Team for directed messaging. Within this context, the Direct Project has developed best practice guidance for secure communication of health data among health care participants who already know and trust each other.

The Direct Project assumes that the Sender is responsible for several minimum requirements before sending data, including the collection of patient consent. These requirements may or may not be handled in an electronic health record, but they are handled nonetheless, even when sharing information today via paper or fax. For example, a sender may call to ask whether a fax was sent to the correct fax number and was received by the intended provider.

The following best practices provide context for the Direct Project standards and services:

  • The Sender has obtained the patient’s consent to send the information to the Receiver.
  • The Sender and Receiver ensure that the patient’s privacy preferences are being honored.
  • The Sender of a Direct Project transmission has determined that it is clinically and legally appropriate to send the information to the Receiver.
  • The Sender has determined that the Receiver’s address is correct.
  • The Sender has communicated to the receiver, perhaps out-of-band, the purpose for exchanging the information.
  • The Sender and Receiver do not require common or pre-negotiated patient identifiers. Similar to the exchange of fax or paper documents, there is no expectation that a received message will be automatically matched to a patient or automatically filed in an EHR.

The communication will be performed in a secure, encrypted, and reliable way, as described in the detailed Direct Project technical specifications. When the HISP is a separate entity from the sending or receiving organization, best practice guidance for the HISP has been developed for privacy, security and transparency.

What the Direct Project isn’t

The Direct Project is not targeted at complex scenarios, such as an unconscious patient who is brought by ambulance to an emergency department (ED). In the unconscious-patient scenario, a provider in the ED must “search and discover” whether this patient has records available from any accessible clinical source. This type of broad query is not simple and direct, and therefore requires a more robust set of health information exchange tools and services that the Direct Project does not provide.

The Direct Project in context of the Nationwide Health Information Network

The Direct Project is an integral component in a broader national strategy to have an interconnected health system through a Nationwide Health Information Network (NHIN). The NHIN is:

“… a set of standards, services and policies that enable secure health information exchange over the Internet. The NHIN will provide a foundation for the exchange of health IT across diverse entities, within communities and across the country, helping to achieve the goals of the HITECH Act.”

The authors

Brian Ahier is chairman of the State of Oregon’s Health Information Technology Oversight Council Technology Workgroup.

Rich Elmore is Vice President, Strategic Initiatives at Allscripts.

David C. Kibbe is a family physician, senior adviser to American Academy of Family Physicians and co-founder of the Clinical Groupware Collaborative.

tags: , ,

    The Government and the private Sector have spent over 8 years on trying to implement a Nationwide EHRs/EMRs.

    NHIN success will depend on the Deployment of a pure Packet-based, All Opticl/IP, Multi-Service National TRANSPORT NETWORK IINFRFASTRUCTURE, using optical Ethernet through this (NHIN) “NETWORK OF NETWORKS.”

    Please See:

    Gaadema Korboi Quoquoi
    President & CEO

  • Brian, Rich and David, great read, thanks. I still have many questions but I am glad to see that the NHIN_D has stepped it up a notch.

    What is the plan to take this from pilot to production?

    What is the plan to ensure security and testing of a crowd source open source project?

    Who will take the responsibility for acceptance testing?

    Who will take responsibility of support of this open source project?

    I have a few more but I will dig in a bit more before posting.

    thanks again for the coverage, I look forward to hearing more!


  • Jeff: Thanks for your comments and questions. There is no formal plan to go from pilot to production, but there are several companies — some involved in the pilots, some not — who are already planning to use Direct and Connect protocols in their networks, including as one example Surescripts. See

    My guess is that production is already underway at a number of health information exchanges, both local and regional.

    Kind regards, DCK

  • Hi Jeff,

    Thanks for your questions. For more on the security issues see:

    Information on documentation and testing is here:

    The wiki has lot’s of great information and also the opportunity for those interested to join in and help with the project.

  • Love the write up.. I will be promoting on my blog and twitter.

    Probably the clearest exposition of the Direct protocol and its implications that I have seen.


  • Thankyou for such an informative and succinct overview – much appreciated from this non-technical clinician.

    I note your statement: “The project focuses on the technical standards and services necessary to securely transport content from point A to point B, and does not specify the actual content exchanged.”

    I am wondering what the plan is to determine the content of these messages, and specifically safe exchange of content such as alerts from one system to another, beyond the obvious starting point, and short-term achievability, of structured clinical documents.

    Certainly in Europe and Australia, increasing focus is on standardising clinical content for EHRs, exchange between systems and secondary use. In particular the Swedish national eHealth program recently held a public meeting to share it’s position and plan. Their Chief Health Information Officer at CeHIS, Inger Wegerfeldt stated that their national decision was: “Standards with focus on the information & not the communication only” – p5, PDF

    I’m interested in your thoughts on this in the US context.



  • @Heather — Thanks for the note. We agree that content standardization is critical as well. The ONC Standards and Interoperability project will be going through a similar process in the US, and you can be assured that we will share notes with our European colleagues.

  • I love this idea, a bottom up approach to meet the top down NHIN and moving Health Information Technology (HIT) to the mainstream. Soliciting minds and skills from outside to develop a solution to help all.

    The standardization is a must, or at least it is a basis for a common goal. Commercial vendors will be able to provide the custom translation if the data follows or at least comes close to a standard.


  • Jeff Brandt

  • @Arien,
    Thanks for the reassurance but I’m still unclear if there is a cohesive plan for approaching content standardization.
    Rather than clutter up this thread, I’ve posted my thoughts here –

  • Heather, I have some thoughts on this topic. One of them is to continue some of the excellent work of Dave Carleson on MDHT, HL7, IHE, Health Story and HITSP on harmonizing content.

    Some Thoughts on Meaningful Use Phase 2
    A Perfect Implementation Guide

  • A directed exchange is an important solution to some use-cases. But there are other use-cases that a directed exchange does not work for. We need to have an open discussion about the use-cases, and transport possibilities.

  • My company is performing 2 Pilot projects for the Centers for Medicare and Medicaid Services (CMS) that involve 1) electronic submission of Medical Documentation (esMD) that uses the NHIN to allow providers to receive Recovery Audit Contractor (RAC) requests for supporting documents and allows them to respond over NHIN, and 2) we serve as an HIH in a eRAC pilot. I’m interested in more of the developments with Project Direct and hope you will keep posting updates. I found the article very informative.

  • Thanks JR. Your projects look pretty interesting. I suggest you also look at the the President’s Council of Advisors on Science and Technology (PCAST) recent report entitled “Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward.” (webcast)

    This will have ramifications on your projects as well the NW-HIN efforts.