Where is health information exchange going in U.S. healthcare? David Kibbe, M.D., CEO of DirectTrust and longtime policy adviser to the American Academy of Family Physicians, talks with SearchHealthIT about just that -- and how Direct versus more robust EHR-to-EHR health data exchange will evolve in tandem.

This is the second part of a two-part Q&A. Read the first part.

When will more robust health information exchange be a reality for a majority of patients? Or will Direct be the farthest it will go?

David Kibbe: Well, Direct is not the only form of interoperable electronic exchange. Currently there's another protocol, which is called eHealth Exchange [from Healtheway Inc.], which is much more complicated than Direct. We often think of Direct as being push-based. You have information and you know where you need to send it, and you know where it needs to go and you push it there via Direct. EHealth exchange is often referred to as query-based … where you have someone outside your enterprise requesting information on patients or a significant amount of information on a particular patient, and a query is answerable via that protocol.

I think that when you bring patients into the equation, Direct is obviously quite well-suited for exchange between patients and providers. So, there are already these two protocols for health information exchanges [HIEs] across the barriers of organization and health IT systems. Direct is the one that will be used by patients. But the infrastructure of patients' use of Direct is not built out to the extent that the infrastructure for providers' use of [it]. If you're a patient, you need to have some kind of an application that allows us to receive and send messages using Direct. Those applications are being built by innovative companies, but it will be 2015 probably before they're widely available to the public.

Thinking about the slow pace of meaningful use -- or perhaps the withering away of meaningful use, or even the most dire scenario, the end of meaningful use -- how would that affect the future of Direct and of sharing EHRs and moving toward more transparency for patients?

Kibbe: In the near future, meaning in the next two years anyway, Direct exchange will be driven primarily by meaningful use and the requirements therein. But it's very interesting to see how exchange is now framing use cases outside the sphere of MU [meaningful use]. For example, the federal agencies are considering using Direct exchange both for provider-to-provider communications and provider-to-user communications, in particular to replace fax and mail communication.

The use case for payers is also developing. We've got two very large insurance companies within DirectTrust that are using Direct and expanding the scope of the application outside of meaningful use. Claims attachment is possibly a bigger driver [for Direct] over the next three or four years than is meaningful use, because that's where a lot of fax and mail communications occur now that can become more efficient using Direct exchange -- more secure, more efficient and at a much lower cost per transaction.

We're just starting to see the potential for provider-to-patient and provider-to-provider communication. As I say, that's a year or so away. That is going to be driven not just by MU, but by the desire of people to have their medical records in electronic format and in format that can be consumed by applications. We're also seeing device manufacturers and parties that are interested in monitoring patient data at various times get interested in Direct as a means of communication, communicating between those interfaces.

That's really exciting, because there's a ton of connectivity that Direct can provide in those sort of behind-the-scenes interfaces. The connection might not be between a person and another person but between a person and a server or a server and another server or a device and a server. I think ultimately, Direct exchange is going to be successful because of its usability, its low cost, its familiarity, its security -- not just because it's required.

What's the goal of DirectTrust? How do you quantify the success of your enterprise?

Kibbe: If you ask the question, 'Did anyone expect DirectTrust would have an operational accreditation program, in the process of accrediting 50 HISPs [health Internet service providers] by this time?' no one would have said that was achievable. If you said, 'Would you expect to have those parties provisioning 250,000 addresses by this time?' I don't think anyone could have conceived of that. I'm actually quite hesitant to make any kind of goal because I think the members of DirectTrust are just working extremely hard in accomplishing an enormous amount in a very short period of time. Because they desire to see this work.

I think there's also an interesting phenomenon that's occurring. This is creating a market and a capitalization in a new sector of the health IT community that maybe was not there two years ago. We think that the amount of economic activity associated with Direct exchange in 2015 will exceed $250 million, $300 million. That's a significant phenomenon by itself. So my goals are, and the stated goals of the organization are, to support the growth of Direct exchange at a national scale, and we'll see where that goes.

Let us know what you think about the story; email Shaun Sutner, news and features writer, or contact @SSutner on Twitter.

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