In 2010, our office helped launch the Direct Project amidst the rollout of the ONC Health IT Certification Program and Centers for Medicare & Medicaid Services Electronic Health Record Incentive Programs. The Direct Project created Direct Secure Messaging, a simple, secure, scalable, and standards-based method to send health information between partners and to provide a straightforward pathway to acquire unique provider and organizational addresses to engage in exchange that resembles secure email. Direct was first piloted in two projects: in Minnesota, the Hennepin County Medical Center began sending immunization records to the Minnesota Department of Health; and in Rhode Island, providers sent patient information to support referrals and to populate the State Health Information Exchange. Direct has grown massively in the following decade-plus.

DirectTrust, a non-profit standards development organization, was launched the following year to establish consistent industry practices for the exchange of information using Direct and to lead its continued scaling. In a 2012 final rule, as part of the 2014 Edition certification criteria, we added the ability to send and receive messages according to the Direct Standard®.

Today, DirectTrust supports over 2.7 million Direct addresses and reports over 5.3 billion messages sent and received. 

A Shifting Interoperability Landscape

Needless to say, the interoperability landscape has become more complex since 2010 with the continued work of local, state, and regional health information exchanges and the growth of interoperability networks supported by individual developers of certified health IT and national networks, which have emerged out of collaboration between developers. For a glimpse into these trends, we have tracked how hospitals engage in interoperable exchange for years. Data from the 2023 American Hospital Association Information Technology Supplement provides an updated view of how hospitals engage in interoperability, and in a recent quick stat we demonstrate an overall increase in hospitals using network-based methods of sending and receiving information (with a decrease in the use of mail or fax), particularly using Direct. We also focused on the increasing proportion of hospitals that reported routine rather than intermittent interoperability in a recent data brief.

As of 2023, 58% of non-Federal acute care hospitals reported often using Direct to send information to other organizations. That figure was the highest of the methods surveyed and represented almost twice the number of hospitals that said they often used mail or fax. Importantly, half of hospitals also indicated often using HIEs, EHR vendor-based networks and national networks, indicating that no individual method allowed hospitals to reach all relevant organizations for all use cases. Between 2021 and 2023, the fastest growing method used to routinely send information was through national networks, which increased by 14 points compared to a 7-point increase in routine use of Direct to send information.

Direct was also among the most common method for hospitals to receive information in 2023. At 44%, Direct was the second most common routinely used method to receive information, following national networks, which were routinely used to receive information by 46% of hospitals. It was also the second most common overall, with 66% of hospitals reporting routine or intermittent use of Direct to receive information, compared to 75% of hospitals reporting intermittent or routine use of mail or fax.

Looking Forward

The continued broad use of Direct in 2023 represents an important accomplishment for the industry, as well as a ‘win’ for patients, providers, and information sharing in general. Direct has come “standard” in certified health IT for years and is widely available and frequently used. We expect Direct and DirectTrust will continue to play a role with respect to interoperability into the future.