2016 iHT2 Miami Health IT Summit

David C. Kibbe, MD MBA President and CEO, DirectTrust

Senior Advisor, AAFP

February 02, 2016 Miami iHT2 Conference

•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

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.

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

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

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

http://www.directtrust.org/

DirectTrust Members 150 and Counting…..

7 7

Lucy Johns, MPH

DirectTrust Members 150 and Counting….

8

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.


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_2015-12-16%20v3.pdf

10

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

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

New Definition of Interoperability

With additional caveat: exchanges should be…

– Standards based

– Content neutral

– Secure

– Identity validated (authenticated)

13

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

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.

Tr

Demand for Interoperable Health Information Exchange now met by Four Main Facilitators

16

Affordability

Scale

HIEs

Traditional point-to-point

Direct Exchange

• Additional examples of more focused, limited interoperable exchange platforms:

– ePrescribing

– Lab results reporting

– Billing and claims submission

– Others

• 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.

• 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?

Stage 2 MU focus is on exchange

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

From the CMS rule…

22 22

http://www.healthit.gov/sites/default/files/meaningfulusetablesseries2_110112.pdf

Transitions of care Patient engagement


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



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


https://www.healthit.gov/sites/default/files/briefs/onc_databrief25_interoperabilityv16final_081115.pdf


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.



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.



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.



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



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


//localhost/Users/dkibbe/Downloads/151007-interopmatters.pdf

The Four (Five) Main U.S. Interoperable Health Info Exchange Facilitators

30

Tr

Affordability

Scale

HIEs

Traditional point-to-point

Direct Exchange

• 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

• 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


Brief Case Studies of the Use Cases for Direct Exchange: Baylor Scott and White, the VA, Tenet Health System








37



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.

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.

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.







Contact Information

David C. Kibbe MD, President and CEO DirectTrust.org

[email protected]

[email protected]

[email protected]

913.205.7968

mailto:[email protected]




Additional Slides


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 48

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.

[email protected] (has been identity vetted, has X.509 Digital certificate bound to address.)

[email protected] (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



Interoperability Matrix

50

DirectTrust Accredited Bundle Interoperability Benchmarking Results as of 10/2/2015

Health

Companion

iShare

Medical

MedAllie

sCerner

Data

Motion

EMR

DirectICA

Max

MD

McKesso

n/RelayMRO

Sure-

scriptsUpdox

NY eHlth

CollabCozeva MHIN Axesson Inpriva Nitor

Glenwoo

d SystemsSES Medicity

Athena-

health

CareAcco

rd

CernerM

obileMD

eClinical

DirectIOD

Rocheste

r RHIO

Orion

Health

NextGen

(Mirth)

Truven

Health

Anltcs

Covisint OptumHealthU

nityHIXNY Shifox

Disp

Support

(respond)

Interop

ScoreInterop %

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

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

http://blog.himss.org/2015/06/22/current-market-view-of-the-usage-value-and-future-of-direct-messaging/





http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemNumber=42810

http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemNumber=42810

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.

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.