DirectTrust Files Comments on How to Measure Interoperability Under MACRA

Calling the measurement of interoperability a difficult area of study, DirectTrust has filed comments applauding the Office of the National Coordinator of Health Information Technology’s (ONC) initiative to develop metrics for electronic health information exchange and interoperability. At the same time, DirectTrust is urging ONC to begin the development of metrics in a “simple” manner, recognizing that further research will be needed as the interoperable exchange of health information among providers, patients and consumers becomes more widespread. The comment letter is in response to an ONC request for information on assessing interoperability for the Medicare Access CHIP Reauthorization Act (MACRA).

“DirectTrust welcomes ONC’s efforts to seek input from the industry and the public on how to develop metrics for interoperability,” said DirectTrust President and CEO David C. Kibbe, MD, MBA. “Developing meaningful and useful measurements, however, will be a challenging task, given the many complexities surrounding interoperability. The interoperability of electronic exchange of clinical information is a relatively new and highly innovative phenomenon in an industry historically dependent on fax, mail and courier services for transports of most clinical information. Additionally, the infrastructure standards that make it possible for the electronic exchange are also relatively new and are unfamiliar to many providers.”

DirectTrust commends ONC’s plans to use measures it describes as ‘electronically sending, receiving, finding and integrating data from outside sources, and subsequent use of information electronically received from outside sources.’ However, DirectTrust believes ONC should go one step further and develop baseline measures of fax and mail communications that are being replaced by electronic change.

In its letter, DirectTrust stated, “These measures are all useful in determining how widespread interoperable health information exchange is and the extent to which the information is being used ‘meaningfully.’ In addition, it would be very useful to have some baseline of understanding about usage of non-electronic and non-interoperable methods currently in place for health information exchange; e.g., fax, e-fax, mail and courier. These largely paper-based methods of health information exchange remain the predominant means of moving health information within the health care industry, and are relied upon very heavily in most medical practices and hospitals, in effect competing with electronic messaging and other forms of electronic transport on a daily basis. Reliance upon fax and mail is a source of inertia within many health care organizations and one of the primary reasons adoption of electronic exchange methods is occurring at a slower than desired pace.”

DirectTrust is encouraging ONC to expand the focus of interoperability measures beyond certified electronic health record (EHR) technology. In its letter, DirectTrust writes, “It is important to measure activity by any and all exchange partners, notwithstanding that ONC plans to assess interoperability primarily among ‘meaningful EHR users.’ The reason for our preference is that there are significant numbers of exchange partners outside the population of providers using certified EHR technology, for example, home health agencies and social service agencies. These exchange partners are growing in number, especially as Accountable Care Organizations take hold, and in many instances have the opportunity to significantly improve care coordination by participating in interoperable exchanges of health information with EHR users.”

While DirectTrust does not keep track of the number of exchange partners outside the population of providers using certified EHR technology, the organization says in its letter that it knows, based on innumerable conversations with DirectTrust members, that physicians, medical practices, hospitals, and health information exchanges use Direct messaging to communicate both among themselves and with other persons or entities that are not using certified EHR technology at their end.

In its letter, DirectTrust also suggests that ‘message disposition notifications’ (MDNs) may be a useful additional national-level measure. The letter stated that these acknowledgements are a key aspect of Direct exchange.

“DirectTrust may be the only entity that stresses the importance of quantifying exchange via fax and mail, as a baseline of non-electronic exchange, in order to compare and gauge the success of electronic iHIE in replacing the paper-based systems that still predominate. Additionally, we are suggesting that the acknowledgement of receipts and use of exchanged data through message disposition notifications, delivery system notifications, and failure notifications are an important and achievable measure that should be quantified,” said Dr. Kibbe.

DirectTrust’s comments letter may be accessed HERE.

About DirectTrust
DirectTrust is a three-year old, non-profit, competitively neutral, self-regulatory entity created by and for participants in the Direct community, including Health Internet Service Providers (HISPs), Certificate Authorities (CAs), and Registration Authorities (RAs), doctors, patients and vendors, and supports both provider-to-provider as well as patient-to-provider Direct exchange. DirectTrust recently received a Cooperative Agreement Award from ONC as part of the Exemplar HIE Governance Program. DirectTrust serves as a forum and governance body for persons and entities engaged in Directed exchange of electronic health information as part of the Nationwide Health Information Network (NwHIN). DirectTrust’s Security and Trust Framework is the basis for the voluntary accreditation of service providers implementing Directed health information exchange. The goal of is to develop, promote and, as necessary, help enforce the rules and best practices necessary to maintain security and trust within the Direct community, consistent with the HITECH Act and the governance rules for the NwHIN established by is committed to fostering widespread public confidence in the Direct exchange of health information. To learn more, visit

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