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An Implementation of DIRECT Messaging: HISPs and Provider Directories Connect a Medical Community
Sujansky & Associates led the implementation and operation of a DIRECT Messaging infrastructure in the Palomar Health District in Southern California. The infrastructure enabled several hospitals, large multi-specialty clinics and small independent providers to exchange patient health information per the secure messaging protocols defined by the DIRECT Project. The goals of the pilot project were to assess the utility and practical applicability of the DIRECT messaging model in real-world settings. The project was funded by the California HealthCare Foundation.

Components of the DIRECT messaging infrastructure included:

  • Two Health Internet Service Providers (HISPs) from different vendors.
  • A community-wide provider directory accessible via the HPDPlus web-services standard.
  • End-user messaging via a stand-alone web email client and integrated EHR systems.

The initial use cases included (1) the distribution of hospital discharge summaries to community physicians and (2) the exchange of referral requests and consult notes between primary care physicians and specialists. Following a 10-week period of trial use, a formal evaluation was conducted to assess several end points, including:

  • Do caregivers and their organizations trust secure messaging based on the DIRECT and HPDPlus specifications and recommended policies? If not, what technical or policy mechanisms are missing to achieve trust?

  • Does the direct transmission ("push") of secure messages and structured documents to specific recipients meet the needs for health information exchange in a medical community? What goals do and do not such transmissions achieve?

  • Does the model of HISPs as intermediaries in health information exchange meet the needs of both large and small provider organizations and enable them to interoperate in a mutually acceptable way?

The infrastructure operated in the Palomar Health District under the name SoCalHIE.

Sujansky & Associates' role in this project included:

  • Recruitment of participating hospitals, clinics, and physician office practices

  • Selection and procurement of DIRECT messaging software components (including two HISPs and a Provider Directory) that were compatible with the participants' legacy information systems and health information management processes

  • Integration of the EHRs, HISPs, and Provider Directory to create an effective and user-friendly messaging application at each participating organization

  • Development of a contractual and policy framework that provided for trust and accountability among the participating provider organizations.

Relevant documents:

DIRECT Messaging Pilot: Results and Evaluation (Report) (PDF)
DIRECT Messaging Pilot: A Novel Trust Framework (Presentation) (PDF)
A Provider Directory for DIRECT Secure Messaging (Link)



Sujansky & Associates developed a technical, legal, and operational framework for independent provider organizations using multiple HISPs to securely exchange health information.

Sujansky & Associates integrated commercial software from multiple vendors to evaluate the real-world effectiveness of the DIRECT messaging and provider-directory specifications as industry standards.