A doctor in Rhode Island, per his daily routine, has just updated and closed a patient's chart in the practice's electronic health record. As he punches up the next record or heads to the exam room, a routine of another sort is underway between the EHR and the state's health information exchange database.

The EHR signals the HIE network to send what amounts to a self-addressed envelope, attaches the record and automatically moves the message to a gateway that applies the patient's pre-set consents to share information fully or with limitations. Then it's on to the HIE net, which detaches the record, breaks it into discrete data, checks for and eliminates elements previously entered in the database and uploads the rest.

No interfaces were built between the two points of exchange; it's a direct, uncomplicated, securely conducted event.

"What's exciting about that is that it's all behind the scenes – no doctor has to remember to do it. It doesn't get involved in their workflow," said Laura Adams, president and CEO of the Rhode Island Quality Institute, which operates the HIE network.

And it would not be possible without the technical capabilities built into a simple e-mail protocol called, aptly, Direct.

Direct technology, however, is a mere backdrop for the comprehensive patient information that doctors will be able to access.

Direct is "efficient, it's cost-effective, it's inexpensive and it really enhances care," said Holly Miller, chief medical officer for MedAllies, a healthcare information service provider serving New York's Hudson Valley. "It's getting the right information at the right time at the right place for the right patient, but across systems."

Upside potential: Surpassing expectations

The Rhode Island doctor is by no means alone. Indeed, the Direct project is gaining widespread traction, with more than 20 states and 60 healthcare organizations pledging support as of late March, according to the Office of the National Coordinator for Health Information Technology – encouraging numbers because they comprise some 90 percent of the market share covered by participating health IT vendors.

The ONC gave such technology providers a booster shot of finalized specifications for Direct. These include core requirements and details about how EHRs and other health IT systems can tap into Direct's standards and services to exchange messages and information securely.

The RIQI is one of several organizations piloting the freshly-minted protocol for a range of information-sharing projects, from populating HIE networks and healthcare registries to communicating patient details critical to safe and effective transitions in care between providers.

Developed over a 10-month period of intense collaboration in the health IT industry – convened and supported by ONC – Direct has given IT pros "a simple-to-use, secure, publicly available, nonproprietary protocol which can be adopted across the industry," said John Feikema, president of Ability, a healthcare Internet service provider that is participating in a pilot to automate immunization reporting to and from the Minnesota Health Department.

On the surface, the basis of the Direct protocol is just a garden-variety Internet message – a simple mail transfer protocol, or SMTP. Another component of the Direct specification is the common standard for sending e-mail attachments, called multipurpose Internet mail extensions, or MIME.

The potential is not so much that providers now can send secure e-mail but that the uniform use of the protocol by the healthcare industry opens up countless ways to automate exchanges of information in the background of clinical routines without having to set up dedicated transfer networks using all manner of proprietary linking technology. It's as simple as hooking up one Direct address to another.