The savvy tech strategy behind Obamacare

The ONC's Doug Fridsma explains why the health IT for EHRs and Obamacare should be like the Internet, and not like ERP or traditional IT systems

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Project Direct: A supplement to HIEs for when pass-along makes sense

InfoWorld: I want to ask you a little bit about -- you mentioned this briefly earlier -- Project Direct. What's going on there? What should people know that's coming down the line, or how this might affect them? Because people I've talked to have heard of it but are not quite sure really what Project Direct might do for them.

Fridsma: Sure. Direct is an important part of our portfolio. It's a piece of the puzzle. It's not the only way to exchange information. We've got other ways to do that with the HIEs and things like that. But it's an important piece of the puzzle that we saw early on. We brought the industry together. They looked at a whole variety of options. They chose one to move forward and that became the Direct specifications.

Direct is just, in simple terms, a secure way that's based on email protocols of sending information from one system to the other. It's based around secure email, and so it's pretty well tested. I think there are issues with regard to integration within the health care system or into personal health records and things like that. But it has served an important function in just getting some of the information moving.

Part of the issue was that when we started Project Direct, which I think was in early 2010, we were working very, very diligently to get people to adopt electronic health records. We had all these people that were working toward putting all their information in electronic formats and creating ways to capture the notes electronically. But at that time, the state of the art for getting information from one EHR system to another electronic health record system was using two devices, one called a printer and the other called a fax. The only way to really get information out of one system and into another was to print it all out and to scan it back in for the other system. Direct was really intended to help bridge that gap.

There was a need for an electronic connection between the two systems to be able to keep the entire conduit -- from the collection of the data, through the exchange, to the use -- in an electronic format. My hope is that success in Project Direct occurs when people recognize the value that it provides without necessarily having to understand the fundamentals of what the Direct protocol is, so making sure that certificates that are encrypted are managed in the background, and that when you send it you can trust that it's been both signed and encrypted in a way that will secure it from one system to the other system.

I would hope that the interfaces that doctors and patients and others have to work on aren't necessarily going to specifically call out Direct. But it's like you'll write a consult to a particular provider, you'll drop down their name [in the EHR], and it will then make sure there is the appropriate encryption that occurs to the consult that's sent. When you click OK, it goes from your system to the next system. It will connect those two systems and allow that information to flow from one to the other in a secure fashion.

InfoWorld: With the notion of daisy-chaining the connections as an approach, in addition to the notion of having an exchange hub, it sounds like you're trying to provide approaches for both ways of interacting because they're both valid and both exist.

Fridsma: Absolutely. I use an analogy often when I give talks or presentations. I ask the audience, "How many people keep in touch with their families?" Most people raise their hands. Then I say, "Well, how many of you use email? And how many of you use Facebook? And how many of you use your cellphone? And how many of you text your family?" What you find is that people use all sorts of ways to keep in touch with their families. If they're going to post a bunch of pictures, they do it on Facebook. If they need a quick text message, like "What's for dinner?" they send that off with a text message. If they have something a bit longer and want to send it to a variety of people, they might use email.

The thing is, I think our health care system is as complicated -- perhaps more so -- as many people's family connections. We don't have a single way of doing that with our families. Likewise, I think we can expect in health care that there will be different ways that serve different purposes, depending on the urgency of the request, the amount of data that needs to be exchanged, whether it's a push of information or whether it's a pull of information in response to a question. All of those approaches are valid. It's not an either/or, but it's an and, because what you want is you want to use the right technology for the right purpose.

We anticipate that there will be a variety of ways in which that communication will occur. Our job is to maintain a consistent portfolio of standards, so there is going to be probably a couple of ways that you might exchange information. There may be a couple of content standards, whether it's a summary record or a laboratory test or a radiology image. There are also going to be vocabularies and terminologies and other things like that that we need to use so that computers can understand the words that are being exchanged.

We really see this notion of a portfolio. It's not a one-size-fits-all. Project Direct is an important piece of the puzzle, but there are opportunities I think for other things.

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