Direct Trust: Spurring use, creating best practices

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A new direct exchange accreditation nonprofit wants to guide the growing communications technology through its next adoption phases, trying to spur adoption and ensure cyber security without much federal regulation.

The nonprofit Direct Trust is creating best practices, guidelines and an accreditation program for vendors and providers, with the ultimate goal of bringing direct exchange into broader use, Direct Trust president and CEO David Kibbe, MD, said.

It’s a trade group that’s also a sort of self-regulator, Kibbe said, issuing guidelines for Health Internet Service Providers (HISPs) and Certificate Authorities (CAs).

Direct messaging is relatively simple, using email, “the world's most familiar paradigm,” Kibbe said. But the Internet creates a number of hazards with identity and cyber security, which the federal government, by its nature, may not be nimble enough to regulate without quashing, at least for the time being, Kibbe added.

“It's probably best if the government doesn't come in and just try to dictate,” Kibbe said. “A lot of people have said, ‘This is just emerging; we're just figuring out how to use this.’ I think ONC heard that pretty loud and clear.”

Direct Trust is helping standardize the use of direct messaging, while also helping providers and health information exchange networks adopt it. Though Direct messaging is relatively simple and user-friendly, it never really evolved in tandem with other EHR and HIE systems — partly, Kibbe said, because of the various proprietary systems used by different providers, which didn’t naturally allow for interoperability.

“The hallmark of direct messaging is care coordination,” Kibbe said. “Most big providers organizing around accountable care have a multiple of EHRs from different vendors.”

It’s been especially frustrating for primary care doctors, said Kibbe, who’s also a senior advisor at the American Academy of Family Physicians. Kibbe said in talks with several hundred physicians, many expressed frustration with their provider systems’ lack of direct messaging, having to instead use portals to communicate with clinics and physicians in other networks that use different HIE software.

“Docs who use EHRs don't want to go to a separate portal,” Kibbe said. “They're very willing to use direct messaging.”

Asking vendors to create or adapt direct messaging systems that don’t require conversion systems like portals could be huge boon for providers “who are trying to crack this nut of trying to coordinate care without ripping apart their IT infrastructure,” Kibbe said.

It is possible that Direct messaging, simple as it is, could threaten the business of EHR vendors. But it’s more a complimentary technology, Kibbe added, and some vendors, like Cerner, seem to be aiming to provide EHR software, HISPs and CAs.

Considering the EHR landscape, Kibbe said, accreditation through the Direct Trust is a way to bring direct messaging to more providers, regardless of their EHR systems. (The Direct Trust board includes employees from a number of vendors, including Cerner and SureScripts.)

Currently, Direct Trust has about 180 participants, HISP and CA vendors, state and regional HIEs, EHR vendors, doctors groups and others. Direct Trust, Kibbe said, wants to build use of Direct exchange while regulating it, sort of as a model for the federal government.