The concept of interoperable care centers on the ability of providers to share patient information. Still, providers continue to find navigating the exchange of patient data difficult.
A 2019 data brief from the Office of the National Coordinator for Health Information Technology underscores the interoperability challenges that clinicians face:
- 85% find it challenging to exchange data with EHRs that aren’t theirs
- 73% use multiple systems or portals to exchange data
- 71% of referral partners lack the capability to exchange data electronically
- 56% report difficulties finding the electronic address of providers
Lack of adequate data communication poses a significant threat to quality of care and safety of patients. Among hospitalized patients, communication failures contribute to more than half of “never events.” Failures are also linked to adverse outcomes, including “delays in care, surgical errors, falls, extended and inappropriate hospitalizations, serious injury, and death.”
Although reporting digital contact information is required by the National Plan and Provider Enumeration System (NPPES), that information remains incomplete for more than 3.3 million providers and organizations in the United States. The Centers for Medicare & Medicaid Services (CMS) broached the idea for a National Directory of Health Care Providers and Services (NDH) in 2018, putting out a request for information on the topic in 2022 which underscores the importance of this issue.
To better support the 90% of U.S. hospitals that participate in Direct Secure Messaging, DirectTrust is currently executing a multi-year project (the Directory Improvement Initiative) to expand and update its own directory, which could serve as a template for ongoing federal efforts.
Common Standard Needed to Link Providers, Payers, and Exchanges
CMS developed NPPES to assign unique identifiers to healthcare providers on an individual and organizational basis, establishing the National Provider Identifier (NPI) that has been in effect since 2007.
However, more than 15 years later, “The health care directory landscape is fragmented, resulting in patients sometimes struggling to find up-to-date information about providers in their network and providers facing redundant and burdensome reporting requirements to multiple databases,” according to CMS. “Because of that burden, directories often contain inaccurate information, rarely support interoperable data exchange or public health reporting, and are costly to the health care industry.”
DirectTrust is positioned to serve an important role in support of the NDH by helping to align to a common standard. The organization could also be a proprietor of data, curating and pushing verified Direct addresses to a national directory. The possibilities of a national directory extend well past discovering and listing endpoints such as provider capacity, participating networks, languages spoken, demographic information, and much more.
While there are multiple methods for interoperable exchange, nine out of 10 hospitals in the U.S. participate in Direct Secure Messaging. In Q1 2024, nearly 2.8 million providers, departments, and organizations had Direct addresses, and more than 294 million Direct Secure Messages were exchanged, pointing to the ubiquity of Direct Secure Messaging.
Still, the DirectTrust Directory contains provider NPI on less than 79% of practitioners. Unfortunately, disparate directories and multiple efforts at standardization won’t bring the industry closer to the goal of interoperability and better outcomes for patients. A common standard is necessary.
The DirectTrust Directory Can Inform Federal Efforts
DirectTrust has undertaken an ambitious, three-pronged directory improvement effort to enhance the quality and utility of the DirectTrust Aggregated Directory while modernizing the architecture. The prongs are as follows:
- Improve Directory confidence and accuracy by launching a community-wide communication and education campaign designed to reveal content accuracy problems and provide clear guidance on how to correct them.
- Increase Directory accessibility and use by offering a new FHIR®-based API that can be adopted by health information service providers (HISPs) to improve search functionality of directory information.
- Enhance Directory updatability and sustainability by updating the policies for participants in the Directory to require specific items like populating specific fields and publishing at least one Direct address per participating organization.
By the conclusion of this initiative, Directory contributors can expect significantly enhanced record validation and reporting capabilities using FHIR®-based API access supporting queries and updates.
As part of the Directory Improvement Initiative, DirectTrust is implementing validation checks against NPPES. For each Aggregated Directory entry that contains an individual or organization NPI, a validation engine will compare provider names, specialty codes, organization names, addresses, and fax numbers to what NPPES has associated with that NPI. When an Aggregated Directory entry doesn’t contain an NPI, attempts are made to find one in NPPES using other demographic data. The results of these comparison queries are reported in detail to the submitter of the entry. Ideally, these validation reports will drive improved data quality in both the DirectTrust and NPPES databases.
The initiative also aims to improve the quality of Directory data through field validation and verification against primary sources, as well as a pivot toward the National Directory of Healthcare Providers & Services (NDH) guidelines under development by HL7®. The member-driven, nonprofit organization is dedicated to promoting interoperability among healthcare technologies. HL7 advocates for using FHIR® APIs to allow organizations to contribute to and access the directory. As data is updated, that information would flow to the Directory and participating providers and organizations without additional effort to keep it continually updated.
Provider organizations continue to see substantial reconfiguration caused by acquisitions and other organizational changes. Requiring attestation periodically to a centralized source would allow for a single source of truth and eliminate duplicate efforts for both providers and payers. The idea of an “attestation service provider organization,” could help health systems and others deal with substantial curation challenges for their Directory data.
Faster, Better Patient Care is a Worthy Goal
Enhancing the Aggregated DirectTrust Directory with appropriate NDH interactivity will be advantageous for the healthcare ecosystem. The connections that HISPs provide to EHRs — particularly as FHIR®-based integration alternatives to the EHR community become available — represent a significant leverage point for CMS. The DirectTrust Directory may be the only directory available today that can provide a crosswalk between individuals and organizations and their chosen communication mechanism for a given use case.
Locating a provider’s FHIR® endpoint or their Direct address is a prerequisite to successful interoperability, and aligning with the standards of the National Directory of Health Care Providers and Services will allow DirectTrust to exchange data reciprocally with the NDH.
Compiling information from numerous sources in a standard manner can be difficult. However, the benefits of a national directory far outweigh the challenges. An accurate and accessible directory helps identify and locate healthcare providers on time, improving the lines of communication that can bring better, faster, and more efficient care.
About Alex Young
As Director of Technical Operations, Alex Young is responsible for executing DirectTrust’s objectives on schedule, managing cloud infrastructure, and other technical development such as our Directory and Trust Anchor bundles. Previously, Alex worked in the healthcare release of information and interoperability strategy space. During that time, Alex led efforts to integrate aggregated data sources (HIEs, EHR data repositories) and third-party medical record requestors to release of information workflows. He also successfully led over 100 new client implementations in an EHR agnostic environment. Alex holds a Bachelor of Science in Finance from the University of Kansas.