Direct Secure Messaging in Practice—Recommendations for Improvements

Background and Significance

Transitions and coordination of care require communication among clinicians that may occur through a variety of channels. Ideally, information received from a referring clinician is integrated automatically into the patient's electronic health record (EHR) to allow the seamless use of the information.[1] As clinicians work in a plethora of locations and for different employers, handoffs and collaborations rarely occur in a face-to-face setting and instead through electronic communication, such as messaging through EHR-based inboxes.[2] Most clinicians are familiar with EHR-based electronic communication within a health system and some may be aware of electronic communication across organizations that use the same EHR vendor.[3] However, fewer are aware of Direct Secure Messaging (DSM), which facilitates EHR-based electronic communication by health care organizations using different EHR systems (either different instances from the same vendor or across different vendors), even if they use it daily. This editorial intends to introduce the reader to DSM and its functionalities. Additionally, we highlight current challenges and shortcomings of this point-to-point communication tool that have prevented DSM from achieving a more important role in health care interoperability. Since 2011, DSM has been available as a push mechanism (sender-initiated) for exchanging encrypted health information among clinicians, patients, and organizations via the Internet.[4] EHR vendors are required to support DSM capabilities to meet the Certified Electronic Health Record Technology (CEHRT) requirements of 2014 and 2015.[5] [6] Although CEHRT helped to promote near-universal implementation of DSM capabilities among EHR vendors, EHR vendors implemented this feature under a variety of names resulting in a confusing nomenclature ([Table 1]).

Table 1 Examples of Direct Secure Messaging aliases in different EHR systems

EHR vendor	Alternate terms
Allscripts	Direct
athenahealth	Direct, Direct Messaging, Secure Messaging, Direct Secure Messaging
Brightree	Direct Secure Messaging, eReferral
Cerner	Cerner Direct, Secure Messaging, Direct Referrals, Direct Email, Direct Secure Messaging, Direct
CPSI	Direct Message, Direct Messaging, Transition of Care, TOC
eClinicalWorks	eClinicalDirect, P2P, Provider to Provider, Direct, Direct Secure Messaging, Direct Plus
Epic	Care Everywhere, Care Everywhere Outside Messaging, CE Outside Messaging, Direct Messaging, Direct Protocol
Evident (Centriq)	Secure Messaging
Glenwood Systems	Direct Messaging
Greenway	Direct messaging
iShare Medical	iShare Medical Messaging
MatrixCare	DIRECT
MEDITECH	Direct Messaging
NextGen	NextGen Share, Direct Messaging
PointClickCare	Integrated Direct Messaging
Wellsky	Wellsky IaaS, Wellsky IO, Wellsky Direct

Abbreviation: EHR, electronic health record.

Source: Adapted from Direct Secure Messaging Aliases. Available at: https://directtrust.org/what-we-do/direct-secure-messaging#directaliases. Accessed April 26, 2022.

DSM is a flexible technical framework that was designed from the start to support a wide range of use cases for secure patient information transmission. Because DSM is agnostic to the message contents and can support multiple file formats as attachments, common uses include transitions of care (sending patient care summaries and coordinating referrals), notifications and messaging (real-time notification of acute care admissions, discharges, and transfers), and administrative functions (patient-specific pharmacy notifications). [Table 2] lists some of the currently used or proposed use cases for DSM in contrast to other modalities of health information exchange (HIE).

Table 2 Use cases for Direct Secure Messaging (DSM)

	DSM	Fax	HIE	HL-7	FHIR	QBIE	Email	Paper or voice
Transitions of care
• Exchange care summaries	x	x	x		x	x		x
• Send and receive referrals	x	x						x
• ADT notifications	x	x	x	x				x
Provider messaging
• Provider-to-provider	x	x					x	x
• Patient-to/from-provider	x	x					x	x
• Pharmacy, payer, other messaging	x	x						x
Additional use cases
• Public health reporting	x	x	x	x	x			x
• Immunization status	x	x	x	x				x
• Test result delivery	x	x	x	x				x

Abbreviations: ADT, admission/discharge/transfer; FHIR, fast health care interoperability resources; HIE, health information exchange; QBIE, query-based information exchange.

If the data are formatted using existing standards such as the Consolidated Clinical Document Architecture, discrete elements may be incorporated directly into the receiving EHR. For example, a DSM message that contains the patient's immunization data in a machine-readable format can be used to incorporate past immunizations into the local EHR's immunization section allowing the EHR's forecasting tool to access the data and avoid duplicate, unnecessary immunizations. The benefits of incorporating data contrast with traditional modes of communication such as fax, scanned paper records, or email ([Fig. 1]). Even if incorporated into the EHR, scanned or faxed records are usually in the form of attachments that are not searchable or accessible to decision support. Given DSM's secure and encrypted nature, the authors are unaware of any cases where it has been misused to send spam.

Fig. 1 Email versus Direct Secure Messaging: what's the difference?

Publication History

Received: 14 March 2022

Accepted: 06 June 2022

Article published online:
04 August 2022

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