Earlier this year, DirectTrust embarked on a critical mission: to refine and enhance our Directory Policy in response to valuable feedback from our community. Updating the Directory Policy is one of the ‘three prongs’ of our Directory Improvement Initiative, alongside technical updates to and education about the Directory. 

This policy update process was not just about making incremental improvements; it was about recognizing the power of policy to fundamentally transform the way we manage and share health information as a community. 

Our new Directory Policy will not only elevate the Directory’s quality, making it simpler for users to locate Direct addresses, but also enable new use cases that encourage interoperability. 

Our Consensus-Based Process

A hallmark of DirectTrust continues to be workgroups and collaboration focused on consensus, and updating the Directory Policy was no different. We had a great turnout and amazing support throughout the process. Our Directory Policy Workgroup and Subgroup (open to all Members to participate) met over a dozen times to outline goals, iterate, and achieve consensus on the updates. 

Ultimately, three main objectives were identified: updates to the Directory Policy should spur participation in the Directory, expand Directory use and access, and enable new use cases. 

The new Policy was unanimously approved by the Workgroup, Policy Committee, and our Board of Directors approving the final version on October 18, 2023. While the compliance date of the updated policy is officially October 18, 2024, we encourage all HISPs and participating parties to implement changes to be compliant as soon as possible.

Enhancing Participation: Addressing the Gap in Directory Records

One of the key objectives of the new Policy is to improve Directory quality and make it easier for users to find Direct addresses. The previous policy is very heavy on recommendations rather than requirements, which can be detrimental to a directory’s quality over time. 

For example, HISP participation wasn’t required which meant any Direct addresses issued from a HISP that wasn’t participating in the Directory would be absent. Similarly, many healthcare organizations opted out of having a presence in the Directory since the beginning (but could still consume the aggregated Directory through their HISP). These two issues together account for a gap of roughly 1 million records missing from the Directory. Our new Policy aims to remedy this by making HISP participation required (with possible exemptions), and requires the healthcare organization to publish at least one valid record (which could be an organization/workflow address) if they want to have access to the Aggregated Directory. 

Interestingly, the latter requirement might have a larger impact on missing records; our research shows that a larger percentage of missing records come from organizations simply choosing to opt out of sharing their records in the Directory compared to missing records from HISPs that aren’t participating. Our hope is that an organization that previously preferred to opt out will choose to go beyond the new bare minimum requirement and instead publish all records that make sense to be shared with users of the Directory. Ideally, we will at least gain the presence of all organizations utilizing Direct. 

Our community was clear requiring participation in the Directory is a necessary move to enhance use and usability of the Directory.

Shifting to required participation in the Directory was discussed at great lengths over our many Workgroup meetings. Our community was clear this is a necessary move to enhance use and usability of the Directory.  Additionally, they recognize that some entities may need exemptions from these requirements, and they included appropriate concessions in the updated Policy. 

Increasing Directory Accuracy and Usability

Increased participation alone won’t accomplish a better Directory without adding guidelines on data currency. We are now asking HISPs to upload and download their Directory data at a minimum of 72 hour intervals while making the current version of the Aggregated Directory immediately available to their users. We believe this change will tackle one of the biggest challenges we are hearing related to the Directory’s usability. To explain why, it might be helpful to demonstrate how the Directory works in more detail. 

The Directory is formed by aggregating individual submission files from each participating HISP. Consider, for example, that we have 27 HISPs. The Aggregated Directory is essentially a compilation of individual data from all these HISPs, and a new full version is published nightly. Prior to the policy updates, the frequency of data submission varied: HISP A might update their data daily, ensuring their portion of the Directory is current. On the other hand, HISP B might refresh their data weekly — acceptable, but not ideal. The longer the interval between updates, the higher the chance users may encounter outdated Directory entries, disrupting data flow.

Compounding this issue is the frequency with which HISPs refresh their own users’ view of the Directory. For instance, if HISP C only synchronizes with the Aggregated Directory monthly, users relying on HISP C would have a less reliable experience, potentially working with outdated information that severely hinders information exchange. This has been a source of confusion and frustration for many customers, a concern we’ve frequently addressed. 

The new policy mandates more regular updates and data synchronization — at least every 72 hours — to ensure that all users have access to the most current information, thereby resolving many of these usability issues. 

Expanding Access

The previous policy contained language that inadvertently barred anyone without a Direct address from viewing the Directory. This restriction has since been recognized by our community as overly limiting in today’s more interconnected environment. Our revised policy now permits limited access and use of the Directory for a broader range of purposes. 

While the primary access point to the Aggregated Directory will still be through a HISP or other technology partner, DirectTrust will now be able to develop a secondary means of looking up addresses. The new Policy allows DirectTrust to present a simplified search of the current Directory on our website to help users obtain real time confirmation on whether a provider or address is currently published to the Directory. This may look like entering an NPI number with a result returned of a name and a Direct address. 

The new Policy allows DirectTrust to present a simplified search of the current Directory on our website

Additionally, we recognize interoperability often uses multiple modalities of exchange.  Our Policy updates also allow us to extend beyond listing Direct Secure Messaging addresses and include FHIR endpoints. In the future, the Directory can be expanded to include other endpoints like the Home Community ID for the IHE Profile of XCDR. Incorporating other endpoints into the Directory expands its use as a crosswalk for multiple methods of communication.

By updating our policy, we’ve carefully widened access, allowing for the integration of services that enhance patient care and support interoperability. This strategic move not only accommodates current needs but also anticipates and prepares for future developments in healthcare interoperability.

Encouraging New Use Cases through Innovation and Collaboration

For those following our Directory Improvement Initiative, our Directory has evolved to include a synchronized FHIR-compatible version. Previously, access was exclusive to users with a Direct address, unintentionally excluding organizations that may primarily utilize FHIR endpoints. As mentioned previously, the old Policy prevented users without a Direct address from viewing the Directory. Consider a scenario where a HISP or their clients could present partial Directory data to their patient customers and select existing patient/provider relationships to enable healthcare workflows; such innovative applications would have required using something other than our Directory under the old policy.

Speaking of new capabilities, one of the most intriguing is the ability for DirectTrust to now collaborate with external parties like Centers for Medicare & Medicaid Services (CMS) to exchange data that may eventually improve the accuracy of our Directory and NPPES. As ways to exchange information continue to grow, being able to collaborate with partners on similar problems holds a ton of promise.

Forging Ahead: A Vision for the Future

The robust consensus process behind our policy updates has been a testament to DirectTrust’s commitment to modernization and future-proofing our Directory. Through the collective effort of numerous workgroup meetings and the invaluable input from our community, we have forged a path toward a Directory that not only meets today’s standards of interoperability, usability, and data quality but also anticipates the needs of tomorrow.

We have forged a path toward a Directory that not only meets today’s standards of interoperability, usability, and data quality but also anticipates the needs of tomorrow.

The journey that began (officially) in May has culminated in a set of strategic enhancements that are more than just policy changes, they are a reimagining of how we facilitate secure and efficient health information exchange. By requiring HISPs to participate and update their data more frequently, we are closing the gap on missing records and ensuring that the Directory reflects the most current information available. This, coupled with the introduction of a ‘give to get’ model, incentivizes the sharing of information, thereby enriching the Directory for all users.

Moreover, the policy revisions have opened doors to innovative use cases and collaborations, which promises to enhance the accuracy and reach of our Directory. As we look to the future, we envision a Directory that is not only comprehensive and current but also serves as a beacon for interoperability across the healthcare spectrum.

We extend our heartfelt thanks to everyone who has contributed to this initiative. Your dedication and insight have been instrumental in shaping these pivotal changes. As we approach the compliance deadline of October 18, 2024, we anticipate seeing the fruits of our labor: a transformed Directory that stands as a paragon of trust, collaboration, and innovation in health information exchange.

This post was contributed by Alex Young, Director of Technical Operations.