DirectTrust was founded on April 5, 2012, and on the ten year anniversary of our establishment, we shared a video highlighting some of the individuals who have contributed to our community, and their stories, memories and milestones. This year, to celebrate our 11th anniversary, we are sharing the transcript of the video, which includes many statements that still ring true today! Read on for some of the most impactful statements from peers, partners, and members who have contributed to who DirectTrust is today.
Dr. David McCallie
Way back in 2009, the Meaningful Use Program was launched and it started with the convening of two federal advisory committees. One of the very early meetings, Wes Rishel and I were at the hotel the night before the meeting and we went to dinner and we’re kind of sketching out in broad brushstrokes: what does the country need at a national scale for interoperability? But one of the things that I sketched for Wes was there is no national standard for secure messaging that could go from one doctor at one hospital using one vendor’s tools to another doctor at another hospital with another vendor’s tools. So, I told Wes I thought we needed a national standard for secure messaging that everybody could participate in, regardless of which system you had locally. And that led to Wes sort of writing it up in a blog post.
We kind of went through the fundamental ideas that David and I had – the advantages – and created a vision of this thin set of standards (mostly Internet standards) that would allow any kind of information to be exchanged among healthcare players.
Dr. David McCallie
His post got noticed. Several people chimed in with their own ideas or saying, “Hey, I’d like to work on that.” Eventually, ONC agreed to convene a meeting where the people who had been sort of weighing in and expressing their interest, we’re all invited to come spend a couple of days in Washington.
Dr. Farzad Mostashari
We really wanted ONC to be the convener, but we didn’t want us or NIST or anybody else to tell the world, like, these are the standards. We wanted them to come out of a consensus process.
Part 1: https://youtube.com/clip/UgkxP_uZ8rWUxNI-aCXOOaisP3dm2t_XAEn4
Todd and Doug Fridsma kind of cornered me and said, “Okay, we’re going to go do this interoperability for small practices thing. We want you to come and join the U.S. federal government, do a tour of duty. We’ll make it like a six-month or a nine-month thing. You go in, do some work, get out advanced work for the nation.” So, after some soul searching, I said, yes. We launched at HIMSS in 2010. I just went around to every EHR vendor, technology vendor, anybody sort of remotely in the space and met with the senior most person that I could meet with and said, “Hey, we’re going to go do this with ONC – you in? And to a person, everyone said yes. I was hoping to get ten organizations really committed to go do this.
Part 2: https://youtube.com/clip/UgkxPd2hMuRaisrQE07lqYQDHin5FMs8V97S
I think by the time we launched our first meeting, we had 50 organizations and we put together kind of an organizational endorsement list. I’m pretty sure we got up to almost 100 organizations on that list. So, we pretty quickly came up with, okay, we’re going to do everything in the open on a Wiki with an open content license, put together a mission statement for what we were trying to go do, outlined an overall approach of we’re going to go define the problem, come up with standards, get to prototypes and get to production testing within a year.
This, I felt, was going to be a critical piece in the interoperability story, something pragmatic and accessible that everyone could rally around that didn’t require significant infrastructure investments and other multi-stakeholder engineering processes.
We had some disagreements about what we thought the technology should be.
Myself and a couple others, and folks felt like maybe an interesting starting part was email. Let’s try to really lower our standards here. Let’s stop sending faxes and just start sending emails and get those into the record. And then we can build and build and build.
So, we decided to do a “Bake Off” in the middle of 2010 where we’re going to have teams that were going to be working together, transmitting messages together using their protocol of choice. So, we did the Bake Off of the four different technologies, just kind of showing the pros and cons of it, the philosophies by it. And then we did some show and tell.
And when we did some of those first demos, especially the Bake Off demos, I was quite proud of what we did because we tried to really draw out the sort of the potential of this thing.
Dr. David McCallie
And we kind of finally reached an agreement with lots of conversation about how to use the basics of standard SMTP with some added security, also based on standards, but customized for healthcare. But also, to make it backward compatible with the way IHE used XDR messaging in those sites, I think notably Epic sites, that used XDR messaging. So, there was a plan to have this sort of set of compromises, like all standards are, put together to create Direct.
You think about the talent involved in the creation of that standard. You wouldn’t dream about a team of folks to come together and reach consensus.
We left that meeting and a guy named Umesh Madan, who is still at Microsoft, just sat down and he built it. It was him, basically, [and] Greg Meyer over at Cerner built the Java version — where we built a .net version of that.
Umesh got his little desktop set up. I got my little laptop set up. We did the exchange of trust anchors, and over the course of probably a day or two, we exchanged the first kind of “hello world” Direct Messages to each other.
Dr. Farzad Mostashari
Doug Fridsma, who’s our head of interoperability and standards, said, “We’re really proud that we have different implementations.” And each team was doing a point-to-point within the team. And it just came to me, and I was like, “I actually want one of these teams to send a message to a different team…Go.”
Dr. John Blair
Part 1: https://youtube.com/clip/UgkxJHpA-RGrkj9Kf5AE8oW3gk6Iz_hB5A8k
Farzad stood there in the middle of the room and said, “I have a challenge. I’m going up to do my keynote, in one hour, I’ll be back, and I want to see if anybody can pair with a completely different vendor that they didn’t come here with, and show true interoperability on the spot.” And he just walked out of the room.
Part 2: https://youtube.com/clip/UgkxoGEe1O2EQCE4yRiSSso53LPHi9mJA4Qi
Everybody looked at each other, and [we’re thinking] how the heck are we going to interoperate with somebody that we’ve not even worked with at all? And I walked over and I said, “George, do you think we can figure this out so that I can have NextGen send over to this Allscripts system?” About 15 minutes later, George came back and said, “Let’s give it a try. I think things are set up. Things ought to be able to work.”
Part 3: https://youtube.com/clip/UgkxUF9H-3Cll3mr62_yuSxsoa2s5IJxulyv
So, we had the person from NextGen send a referral over to Allscripts, and we’re sitting there with our fingers crossed, and the NextGen guy sent it, and we’re waiting, and the Allscripts person walked in. They go, “We just received something, and he opened it up and he received a CCDA referral. And so, I raised [my] hand [and] I said, “We did it! We got it!”
Dr. Farzad Mostashari
And they did it. People did not think that could happen. I want to see what — and show that this can be real.
And in 11 months, got from vague concept launched HIMSS to first production transactions in January of 2011. It became pretty clear that we were going to take the specification and turn it into something that was going to be certified in stage two of Meaningful Use. But it also became pretty clear that ONC had some limited ability to keep the program up and running, and continue some of the coordination. But it needed more of a nationwide governance model.
The Direct Project started it and got it to a certain point, but DirectTrust made it practical across the entire country. [They] made it nationwide.
The name was not chosen idly, right? It was built around Direct Messaging, for sure, but really, it’s direct trust. That between two parties, they can directly trust each other, as long as the infrastructure is in place. And so really, the role of DirectTrust is to create that environment where trust between two parties can be established and maintained.
Dr. David Kibbe
The Direct Project itself was, I think, in retrospect, an amazing burst of creativity and innovation involving physicians and nurses and engineers around this idea of creating a simple, secure, scalable standard for participants in healthcare to send and receive health information and data over the Internet without any centralized hub or organization in control of those exchanges.
The biggest accomplishment that DirectTrust came out with of our trust models was the scalability piece of it. So, when DirectTrust tried to flush out their model of doing this trust framework, it was trying to do it in a scalable way, but we could really scale out the number of agreements and the way that we started getting trust together. So, if I said there was an important aspect of what DirectTrust brought to the trust equation and literally as an equation, it was the scalable trust aspect
We produced, number one, a framework that would work to allow trusted interoperability into the future. But of course, having a policy is only one thing. We also needed a certification program as well.
Dr. Louis Maas
People didn’t want any more pairwise agreements. They wanted a reusable, contractual framework that could eliminate this — a true network — and backed by something that would make people comfortable in participating in the network, which was the origins of the accreditation program.
So, accreditation is a simple way to know that a third party has both reviewed the security practices of a HISP, and reviewed their technical practices and their implementation of the Direct Standard® to make sure that the standard follows the protocols it’s supposed to in every way, where trust is concerned and formation of messages is concerned.
Dr. John Blair
So, t’s really three pieces: the federated service agreement, the trust anchor bundle piece that plays with certificates, and then the accreditation, which I think makes this run. And the accreditation needed to be strong, and there was a lot of frustration with that. But the accreditation needed to be strong for this to have credibility. So, they created a floor that was pretty strenuous. And between those three things, we, I think, have the success of DirectTrust, and because of DirectTrust, we have the success of Direct.
Being able to send Direct Messages became a component of the Meaningful Use requirements for electronic health records. At that point, it took off and the major vendors developed Direct interfaces. But once the facility was out there and people saw how easy it was to use, I think over time, we saw uses that were much more meaningful than Meaningful Use.
Large EMR vendors came to the table and wanted to be involved because a lot was at stake, and it was important to make sure that the right guardrails and bars for minimum security assurance were in place. So, I think something really important and interesting about DirectTrust is that if a conversation about health information is occurring there — or when it is occurring there, actually — all of the folks are at the table who need to be. And I think that’s been powerful to making things happen within DirectTrust historically, and will allow DirectTrust to be impactful in the future.
And I really look at DirectTrust as, again, this concept of nationwide governance with a not-for-profit is now a thing. We’ve got Carequality, we’ve got CommonWell; we’ve got a bunch of other organizations that are stood up.
Linda Van Horn
I think we understood from the very beginning that interoperability is a team sport. And it takes all of us working together.
To provide a forum where we could work out solutions, and we could collaborate on one level and compete on another — that’s remarkable.
Dr. David Kibbe
DirectTrust proved that widespread trust in security and privacy of electronic communications among competitors in our very fragmented healthcare system, including competitors who are provider organizations and competitors who are electronic health record companies, is indeed possible to attain. And that it doesn’t have to be expensive or complicated.
Dr. Luis Maas
It takes two to interoperate. It’s a dance, you know? If I can do it and you can’t, we can’t interoperate, and that makes both of our customers unhappy. So, from the beginning, there has been a really unusual collaborative spirit, like unusual in a good way — a unique collaborative spirit amongst the entities working on this, who often are competitors.
Dr. John Blair
Because the piping is so ubiquitous now across hospitals and providers, there will continue to be more use cases. We’re here today, and you’ve got millions and millions and millions of transactions going over those networks. And you’ve got, in addition to the initial Transition of Care kind of use case, you’ve got newer use cases. Condition of Participation last year leverages Direct very strongly. So, I think we’ve got a success story here.
I’m unbelievably impressed with not just the people who were there then, but the steady hand. If I’ve learned anything about this healthcare space, it’s [that] it matters way more to stay in the fight and just keep at it and keep at it, than to have the latest, most shiny thing. We were building a new shiny thing, and a lot of us were new at it, and we thought it was going to take right away. But it needs time and it needs those people who are going to say, “I’m going to keep at it, I’m going to keep at it.” And that impresses me [to] no end. And I’m so glad that you all are continuing to do that work, and I think we’ll benefit from it.
Dr. David McCallie
The fact that literally a table napkin drawing could result in something that, ten years later, is a national valuable asset for the country is pretty amazing. And that lightning doesn’t strike too many times.
I remember John Halamka, when I took over the co-chair position of the HIT Standards Committee, he handed me a baton, really symbolizing the notion that this is not a 100 meter dash. This isn’t even a marathon. It’s a long running relay race where we all take on some piece of it, run with it for a while, and pass the baton on to somebody else. And so, I’m very, very thankful that David Kibbe kind of launched DirectTrust; very thankful that DirectTrust has been in running and operation for the last ten years, establishing the trust fabric. And I can’t wait for continuing to pass the baton along and advancing interoperability over the next ten years.
Dr. Luis Maas
We’re past the “Will this take off? Will this stay in the certification program? Will enough people do it that it’ll make it worth everyone doing? Now we’re in the “What can we do next?” How can we take this fabulous, working, trusted network that we have and just build on it to do more and more things?”
How can we simplify provider usability? How do we facilitate in the digital health arena? Digital health messages on a mobile app can transmit through Direct into a physician’s EHR and back. How do we do more with transparency?
Linda Van Horn
We’re not stagnant at DirectTrust. We are constantly looking at the horizon and saying, “How do we make it better? This is really good what we built. Okay, let’s do more. Let’s push that envelope. Let’s go the next mile because we want to live in a world where patients, providers, payers, and devices, like servers, cardiac pacemakers or insulin pumps, can communicate data.” And it’s really about getting the right information on the right patient to the right provider at the right time, every time.
With DirectTrust, that trust is part of the name for a reason. It’s all about trust and that trust has been created because we were very specific and transparent about what we wanted to accomplish, and we have accreditation programs that validate that folks are actually doing what they said they’re going to do. But then more than that, the principals who are active in this community — they’re active because they have the best interests of the community at heart. And I’ve seen that in action time and time again, and it’s one of the things that brings me back and makes sure that my heart is in DirectTrust. Love it. Love it.