Outgoing DirectTrust CEO David Kibbe, M.D., Talks About FHIR, Blockchain, TEFCA and Direct Standards Development

Even though he is planning to step down this year as president and CEO of DirectTrust, the nonprofit organization that support health information exchange via the Direct message protocols, David Kibbe, M.D., has plenty of opinions to share about DirectTrust’s future, ONC and TEFCA, and interoperability’s role in value-based care. In a wide-ranging interview with Healthcare Informatics, Kibbe looked back over his time leading DirectTrust and described its current work to become an accredited standards development organization.  

The use of Direct, largely to replace the fax machine in referral management and transitions of care, continues to grow. DirectTrust said that there were 47.8 million health data exchange transactions in the first quarter of 2018 – a 90 percent increase from the same time period in 2017. Kibbe said that growth in the DirectTrust network    over the past four years is faster than the growth in Facebook accounts in its first four years. “Most people find that an amazing statistic,” he said.

The standard works well and is slowly but surely replacing the fax and other paper courier and telephonic communications in healthcare, but there is still a lot more room for growth, he said. “There were 9 billion faxes in healthcare industry alone in 2017, he said. “The 200 million transactions we think we will achieve in 2018 is a huge growth rate for an early standard. It eclipses what happened with e-prescribing, but we still have a long way to go.”

The use of Direct seems to vary quite a bit by region. “Where there is competition in healthcare and multiple EHR vendors operating in the same community, Direct exchange has been more easily adopted,” Kibbe said. There are places where a particular EHR vendor is so dominant that they don’t need to use Direct very much. But even in markets where Epic has 50 percent of the market, the other 50 percent are on some other EHR. “The expectation that Epic customers have for CareEverywhere to work has also meant they want interoperability with others using athenaheatlh or Cerner or other EHRs,” he said.

ONC and TEFCA

I asked Kibbe whether he thought the Office of the National Coordinator for Health IT (ONC) had done a good job of fostering and promoting Direct, given that it wasn’t really mentioned in the draft TEFCA document. “We have a strong relationship with ONC. We have been partners and we have meetings with them every month, but ONC has not been particularly adept at juggling three or four balls at the same time,” he said. Initially, they pushed Direct exchange hard, and then got onto FHIR, and it became their focus. “We have had a little bit of benign neglect. But now we are working with them on an extension of our trust framework to FHIR. We are coming back into favor, if you will, because of developing that piece that can extend to other technologies.”

Regarding TEFCA, Kibbe called it “a bit of a Rorschach test.”

“It is hard to understand what the Trusted Exchange Framework (TEF) is,” he said. “I think we are going to have to wait until we see an RFI or funding opportunity for the recognized coordinating entity (RCE). I know they were a bit taken aback by the scale and consistency of the criticism for the whole TEF. People were worried that existing trusted exchange frameworks and agreements they have with different parties could be disrupted by something that was top down. That was not the intention at all of ONC. I think it took them aback that they were perceived as being heavy-handed. I think it is going to go much slower than most people thought. For one thing, ONC’s budget has been drastically reduced.”

He said it might not be a bad thing that Direct exchange and the DirectTrust network were left out of TEFCA. “They said, ‘Your community is working fine; we don’t need to include your trust framework because you are getting the job done. We don’t see a purpose in meddling in that. The challenge is FHIR-based query.’”

Potential RCEs Look to DirectTrust

He said one unintended consequence of the TEF that has been beneficial to DirectTrust and its community is that the issue of identity and the role of certificate-based public key infrastructure (PKI), and scaling of trust relationships has been put front and center. “We are talking with three parties that want to be in the running to be the RCE,” he said, “and they all want the same thing from DirectTrust: the PKI-based identity credentialing and access management component put in place to support Direct exchange. We are now pivoting to support trusted exchange with other technologies. There is no reason to re-invent that healthcare-tuned set of policies around identity that DirectTrust had to establish.”

FHIR and Blockchain?

Last month I wrote about a webinar in which members of DirectTrust workgroups discussed their efforts to allow for the exchange of FHIR resources using its certificate-based trust framework. I asked Kibbe if that trust framework could be applied to blockchain as well. “Absolutely,” he replied. “I get calls almost every day from someone in the blockchain community who wants to know more about how DirectTrust certificates might be useful to them.” He cautioned that we are in the very early in the blockchain experiment, and not all types of blockchain are the same. The kind that seems to be fitting in healthcare is not public like bitcoin. They are called private, permission-based blockchains. “In those instances, the access to writing to the ledger needs to be highly constrained to only those parties strongly identified with credentials.” That is where the use of DirectTrust certificates and policy infrastructure for identity might play a role, he added.

DirectTrust as a Standards Development Organization

DirectTrust is in the process of becoming accredited as a standards development organization (SDO) by ANSI, the American National Standards Institute. DirectTrust has a lot of the DNA to become accredited, he said. It requires being very transparent, following strict processes and having procedures for dispute resolution. “Although we have not functioned as a formal SDO, we are confident we can make this transition,” he said. The standard itself has been managed by the Direct project, which is pretty loose and consensus-based, he added. “There is nothing wrong with that, but it is not as process-driven and transparent as it needs to be in the future.”

ONC had expressed interest in handing it off, he said, and stakeholders such as the EHR Association wanted to know there is an accredited SDO shepherding the standard and allowing for more people to participate.

New Components to Make a Smart Network

Kibbe expressed excitement about a new component of the Direct standard starting to be put into production. Called the implementation guide expressing context in Direct messaging, it allows for Direct messages to be accompanied by metadata that could be useful for patient matching, for example. It could allow sender and receiver to agree on workflows such that the receiver knows what the information is for, and to whom it goes and what is expected in return.

“This is a way a dumb network gets smart,” he said. “Because it is electronic, the parties can innovate and create these new components of the standard and get smarter and smarter. We will eventually get to where the transactions will be much easier for both parties to handle.”

Looking to the Future

A DirectTrust search committee is interviewing candidates to take Kibbe’s position. I asked him if he was going to retire to his sailboat or keep working on interoperability issues. “I am going to keep my hand in,” he said. “I am talking to people about potential roles in this area. I have a very strong interest in the application of interoperable standards-based health information exchange in value-based care situations. David Brailer famously said there is no business case for interoperability in fee for service. That is still somewhat true. If we had more incentives for holding provider organizations accountable in terms of quality and cost reduction, I think health information exchange would just explode.”