I recently chaired a couple of conferences and my next HealthIMPACT event is coming up later this month in NYC. At each one of the events and many times a year via twitter and e-mail I am asked whether the Direct Project is successful, worth implementing in health IT projects, and if there are many people sending secure messages using Direct. To help answer these questions, I reached out to Rachel A. Lunsford, Director of Product Management at Amida Technologies. Amida has amassed an impressive team of engineers to focus on health IT for patient-centered care so their answer will be well grounded in facts. Here’s what Rachel said when I asked whether Direct is a myth or if it’s real and in use:

Despite wide adoption in 44 States, there is a perception that Direct is not widely used. In a recent conversation, we discussed a potential Direct secure messaging implementation with a client when they expressed concern about being a rare adopter of Direct messaging.  While the team reassured them that their organization would in fact be joining a rich ecosystem of adopters, they still asked us to survey the market.

In 2012, the Officer of the National Coordinator for Health Information Technology (ONC) awarded grants to State Health Information Exchanges to further the exchange of health information. There are two primary ways to exchange information: directed and query-based. ‘Directed’ exchange is what it sounds like – healthcare providers can send secure messages with health information attached to other healthcare providers that they know and trust. The most common type of ‘Directed’ exchange is Direct which is a secure, scalable, standards-based way to send messages. Query-based is a federated database or central repository approach to information exchange which is much harder to implement and growth in this area is slower.  Thanks in part to the grants and also in part to the simplicity of the Direct protocol, 44 States have adopted Direct and widely implemented it. And yet the myth persists that Direct is not well adopted or used.

As with other new technologies, it may be hard to see the practical applications. When Edison and Tesla were dueling to find out which standard – direct or alternating current – would reign supreme, many were unsure if electricity would even be safe enough, never mind successful enough, to replace kerosene in the street lamps. It was impossible for people to foresee a world where many live in well-lit homes on well-lit streets, and none could have imagined using tools like the computer or the Internet. Thankfully, the standards debate was sorted out and we continue to benefit from it today.

There are two groupings of data we can look towards for more detail on use of Direct. The first are the States themselves; they self-report transaction and usage statistics to the ONC. It was reported in the third quarter of 2013 that the following were actively exchanging some 165 million ‘Directed’ messages:

  • 20,376 Ambulatory entities (Entities/organizations that provide outpatient services, including community health centers, independent and group practice, cancer treatment centers, dialysis centers, etc.)
  • 738 Acute Care Hospitals (Hospitals that provider inpatient medical care and other related services for surgery, acute medical conditions or injuries)
  • 157 Laboratories (Non-hospital clinical)
  • 16,329 other health care organizations (Home health care, long-term care, behavioral health programs/entities, psychiatric hospitals, payers, release of information vendors, health care billing services, etc.)

Another organization collecting data on Direct implementation is DirectTrust.org. Charged by ONC, DirectTrust.org oversees development of the interoperability framework and rules used by Direct implementers, works to reduce implementation costs, and remove barriers to implementation. Additionally, DirectTrust supports those who want to serve as sending and receiving gateways known as health information service providers (HISPs). By DirectTrust.org’s count, the users number well over 45,000 with at least 16 organizations accredited as HISPs. Further, over two million messages have been exchanged with the roughly 1,500 Direct-enabled sites. With Meaningful Use encouraging the use of Direct, we can expect even more physicians and healthcare organizations to join in.

As more doctors are able to exchange records, everyone will benefit. When a provider can receive notes and records from other providers to see a fuller, more complete view of her patient’s health, we have a greater possibility of lowering healthcare costs, improving health outcomes, and saving lives.  Once we open up the exchange to patients through things like the Blue Button personal health record, the sky is the limit.




As I’ve been preparing to chair the HealthIMPACT conference in Houston next Thursday I’ve been having some terrific conversations with big companies like Cisco, some of our publishing partners, and smaller vendors entering the health IT space for the first time. One great question I was asked during a discussing yesterday by a tech publisher was “so what’s it going to take to achieve real interoperability in healthcare and how long will it take?” To that my answer was:

  • We need to move from anecdote-driven systems engineering to evidence-driven systems engineering and
  • We need to move from complaint-based interoperability design to evidence- and workflow-driven interoperability design

Although the discussion was over an audio telecon I could almost see the eyebrows being raised by the editors on the other side of the phone and could tell they were thinking I might be a little weird. I proceeded to explain that systems engineering and interoperability design in healthcare IT suffer from three major flaws:

  • The myth that there is a lack of interoperability
  • The myth that we don’t have enough standards
  • The assumption that health IT leadership has provided staff with the tools they need to do proper systems engineering and interoperbility design

The first myth is perpetuated usually through anecdote after anecdote by anyone who has ever had to fill out their name on two separate paper forms in a waiting room. The fact that you have to fill out forms (the anecdote) doesn’t mean that there isn’t interoperability — it just means that the cost of filling out a form is probably lower than the cost of integrating two systems. Healthcare systems are already interoperable in areas where they have to be — namely, where required by statue, regulation, or law. And, systems are interoperable where there’s a reimbursement (payment) reason to have it or in many cases if there’s a patient safety reason to have it (e.g. for Pharmacy or Lab Orders). Unfortunately, convenience and preference (e.g. for patients to not have to fill out forms twice) doesn’t factor into designs much right now because we have bigger fish to fry. If a non-integrated multi-system workflow isn’t demonstrably unsafe for patients, isn’t costing a lot of money that can be easily counted, or isn’t required by a law that will force leadership’s hands then complaining about lack of interoperability won’t make it so. We need to come up with crisp and clear evidence-driven workflow reasons, patient safety reasons, cost savings reasons, or revenue generating reasons for interoperability if we want improvement.

The second myth of lack of standards is perpetuated by folks who are new to the industry, looking for excuses (vendors do this), or are otherwise clueless (some of our health IT leaders are guilty of this). There are more than enough standards available to solve most of our interoperability woes. If we do workflow-based evidence-driven analysis of systems we come to see that most interoperability can be achieved quickly and without fanfare using existing MU-compliant standards. We have HL7, we have CCDA, ICD, CPT, LOINC, and many other format, transport, and related standards available. I’m not talking about flawless, pain free, error-free, interoperability across systems — I’m talking about “good enough” interoperability across systems where workflow reasons, patient safety reasons, cost savings reasons, or revenue generating reasons are clearly identifiable.

The third problem, lack of proper leadership, is probably the most difficult to tackle but perhaps the most important one. I’ve been as guilty of this as anyone else — we have many environments where we’re demanding interoperability and not giving the time, resources, budget, or tools to our staff that will allow them to prioritize and execute on our interoperability requirements. Leadership means understanding the real problem (workflow-driven, not anecdotal), making decisions, and then providing your staff with everything they need to do their jobs.

If we want to make progress in healthcare interoperability we need to train the next generation of leaders that proper systems engineering approaches are required, better interoperability is possible because some of it already exists now, and that you shouldnt wait for standards to get started on anything that will benefit patients and caregivers. Health IT integration woes can be overcome if we get beyond anecdotes and complaining and start doing something about it.


My friend John Lynn was kind enough to cover the new HealthIMPACT Conference that I’m chairing in Houston on April 3 in his recent piece entitled “Getting Beyond the Health IT Cheerleaders, BS, and Hype Machine“. While the article was great, Beth Friedman’s comment was priceless:

What are the criteria to be considered part of the cheerleader squad? This PR agency wants to be sure we are providing valuable, actionable, [practical], relevant content….NOT HYPE! And we’re open to your guidance.

John gave her a great reply:

It’s interesting how in high school you always wanted to be a cheerleader, but in marketing you don’t want to be seen as the cheerleader;-)

I think your description describes what you need to do to avoid hype. You have to focus on what really matters to the customers. Provide value to the customer as opposed to trying to sale your product. A deep understanding of the domain will create a relationship where people trust your views and then can talk about what you’re doing to solve their problems which you understand deeply.

Since Beth posted a great question I wanted to do it justice by answering more specifically. By the way, we’ll be covering a lot similar material at the inaugural Health IT Marketing Conference taking place in Vegas on the 7th and 8th of April. Join us!

Health IT “Cheerleaders” in my mind are those that push technology without considering deep value, return on investment, return on assets, and productivity loss. The hype machine is built around technology when health IT “cheerleaders” focus more on the gadgetry itself rather than the value proposition. If content is built around workflows, workflow optimization, and those tasks within existing or new workflows that optimize patient care through the use of technology then that’s real value.

This morning a college student sent a great question around health IT related productivity loss:

I am currently working on a capstone project for my MBA and my team is required to address a set of challenges as well as opportunities. One of the challenges they seem to be concerned the most [about] is the reduction in productivity of the physicians during and after the implementation of the EHR platform (they are currently working on a paper-base workflow). Since EMR requires doctors to type in the information which eventually takes significantly larger amount of time compared to their traditional method of handwriting, they are asking about ideas what they should do.

I replied that this sounds like a great project – and promptly advised them to conduct an analysis on whether the concern or productivity loss is warranted. I suggested they do a current workflow analysis to figure out their efficiency of existing steps and how those steps would change after an EHR is installed. If such an analysis is not done, evidence-driven technology choices cannot be made.

For a great example of how to build content around clinical workflows, check out HRSA’s guidanceIt’s still surprising to me how many of us in the tech business suggest usage of technology without a deep understanding of workflow. Progress will come, and cheerleading will be reduced, when tech meets workflow in a measurable way.


This year I’m chairing a healthcare IT event series called HealthIMPACT — it’s what I’m hoping will be some of the best places for healthcare technology enthusiasts and buyers to get actionable advice on what’s real, what’s BS, what to buy, what not to buy, and perhaps most importantly, which guidance is worth following. In order to make sure we cover the right topics, we have created a very short survey so that we have some evidence-driven approaches to proving we’re focusing on the right areas.

The survey should only take a couple of minutes to take and includes the following questions:

  • Your top three IT challenges in 2014
  • The one thing you would want to walk away from the HealthIMPACT Forum with
  • Whether you agree that these are important topics for us to cover:
    • How IT can support the overarching financial, operational, and clinical goals of your organization
    • HIEs in your region and provider participation in them
    • Technologies that support value driven care and population health management
    • Cloud based systems in healthcare
    • Programs that drive patient engagement
    • Leadership strategies that drive innovation
    • Predictive analytics that improve care delivery
    • EHR implementation and meaningful use
    • ICD10 compliance, readiness and physician training
  • Types of technologies and solutions are you most interested in learning more about and hearing other healthcare providers share their experiences with

If you have a few minutes, please take the survey and help us make sure that these events are as filled with actionable advice as possible.



Learn how to cut through the noise at the first ever Health IT Marketing Conference

John Lynn, prolific blogger and health IT media magnate, and I are teaming up to produce and deliver the world’s first marketing conference focused on helping innovators cut through the noise when trying to market their healthcare and medical tech products to physicians, hospitals, and similar customers. Called The Healthcare IT Marketing Conference, it will cover very […]

2 comments Read the full article →

Meet up with me at my HIMSS’14 sessions and events

I’ll be leaving for HIMSS’14 on Saturday and plan to be around for meetings and sessions from Sunday through Wednesday. Here are some of the places I plan to be, catch me if you’re around: Sunday — covering the Venture Forum, CHIME, and special sessions. Heading to Susquehana Equity Capital cocktail party in the evening. […]

0 comments Read the full article →

Join Stericyle Communication, John Lynn, and Shahid at the HIMSS’14 New Media Meetup

John Lynn and I are hosting the 5th Annual New Media Meetup next week at the HIMSS Conference. This year’s HIMSS tradition is sponsored by Stericycle Communication Solutions. Thanks to Stericycle’s generous participation, John and I can host, quench the thirst of, and feed our New Media friends at Tommy Bahama Pointe, just a short […]

0 comments Read the full article →

Keeping medical device designs relevant in a big data world migrating to outcomes-driven payment models

Last week I presented the closing keynote at the Medical Design & Manufacturing (MD&M) West Conference & Exhibition in Los Angeles. MD&M has always been about what’s next in medical device design and this year’s event didn’t disappoint. While still being primarily focused on hardware, many smart device manufacturers came out to MD&M looking for […]

1 comment Read the full article →

Why do Avon sales reps selling makeup deserve better usability than hospital physicians saving lives?

I was watching the Super Bowl tonight and lost interest after Bruno Mars’ very nice halftime concert so I started picking up some “Read it Later” articles I saved late last year; one specifically caught my eye. In December the Wall Street Journal (WSJ) reported that Avon is pulling the plug on a $125 million software […]

4 comments Read the full article →

Moving from paper-native to digital-native requires disciplined Healthcare Information Lifecycle Management (ILM)

We’re all familiar with the idea that medicine is, slowly but surely, going from a paper-native to a digital-native industry. Most of our processes and procedures were designed in an environment where information started on paper and then was either scanned as a PDF document or entered into a structured electronic record in some software. […]

2 comments Read the full article →