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What is the Nationwide Health Information Network?

The Nationwide Health Information Network is the set of standards, services and policies that enable the secure exchange of health information over the Internet. Accordingly, it is not a particular instance of network connectivity; rather, it is nationwide exchange of health information using nationally recognized standards.

What is the Direct Project?

The Direct Project is the set of standards, policies and services that enable simple, secure transport of health information between authorized care providers. The Direct Project enables standards-based health information exchange in support of core Stage 1 Meaningful Use measures, including communication of summary care records, referrals, discharge summaries and other clinical documents in support of continuity of care and medication reconciliation, and communication of laboratory results to providers.

Why Direct?

There is a need to extend the Nationwide Health Information Network to support a broader set of participants and providers through a simple, standards-based, widely deployed and well-supported method for providers to securely transport health information using the Internet in support of the core Meaningful Use outcomes and measures.

What is the relationship between The Direct Project and the currently described Nationwide Health Information Network architecture?

The currently described Nationwide Health Information Network Architecture (see the Nationwide Health Information Network Inventory of Tools for more detail) describes a method for universal patient lookup and document discovery and exchange between National Health Information Organizations, including Federal providers such as the Veterans Health Administration, Department of Defense Military Health System, RHIOs, and large Integrated Delivery Networks (IDNs). The Direct Project supports cases of pushed communication between providers, hospitals, laboratories, and other health settings of care.

The current members of the Nationwide Health Information Network Collaborative will be able to support the Direct Project model, and providers and enabling organizations for the Direct Project will scale to support to support the discovery and exchange use cases. Both models are required and will be in use at the same time for the same participants, depending on the information exchange needs.

Does the Direct Project replace the current Nationwide Health Information Network model? Or is the Direct Project the current Nationwide Health Information Network model on “training wheels”?

No. The Direct Project and the current National Health Information Network model support different use cases and are coequal in a system of robust nationwide health information exchange.

How will the specifications and standards for the Direct Project be developed?

The specifications and standards will be developed in a rapid, open process intended to draw from a varied set of stakeholders representing both public and private providers and technology enablers.

What use cases does the Direct Project support?


The Direct Project aims to first address cases where one known endpoint pushes health information to another known endpoint in a secure manner. See our user stories, a set of common clinical scenarios based on Meaningful Use requirements, for more details.

How does the Direct Project ensure semantic interoperability?

The core mission for the Direct Project is to enable secure transport of information. Explicit specification of the payloads of health information exchange is out of scope, not because we don't think it is a good idea, but because the Interim Final Rule (IFR) and the existing work of the SDOs already establishes strong recommendations of what information should be exchanged. We expect that the Direct Project specifications and services will be used to transmit unstructured messages, including simple text and PDF, semi- structured text (e.g., CDA), and highly structured messages and documents, including HL7, CCD, and CCR documents with well defined vocabulary. We anticipate work in the Direct Project to create specific profiles for end-to-end semantic interoperability (for instance, transmission of HL7 2.5.1 ORU messages with SNOMED and UCUM codes in support of laboratory results). We also believe that, over time, new content representations will be created to solve innovative use cases, such as gap in care messaging.

We would note that, even when content is constrained for a particular use case, there are reasons to support additions. For example, one may want to standardize the use of an HL7 v2 REF message with an attached C32 CCD document for a referral, but support the addition of optional content. That might include an image of skin for a dermatology referral, a EKG file for a cardiology consult, etc.

We also anticipate that the Direct Project will allow an enabling organization to perform content negotiation to enable health information exchange between systems that support different standards.

So in short, the Direct Project doesn't ensure semantic interoperability, but it helps to support data exchange by supporting one important foundational element of exchange: a common transport layer.

Why doesn’t Direct solve…

In order to create rapid innovation, we are deliberately constraining the scope of the Direct Project to a spare set of specifications and standards that solve a well-defined pain point. Unless a particular capability is essential to support the core use cases, we will leave it out or defer it to a later day. In doing so, we do not intend to devalue any particular health information exchange area or need, but merely to define a scope that both advances the state of nationwide health information exchange and is achievable in the short term.

How can I or my organization participate?

There are three basic ways to participate
  1. A core group of Direct Project stakeholders will come together frequently from March through the end of the year to develop iteratively the core enabling specifications and service descriptions, and test those specifications with working code in both demonstration and real-world implementation contexts. To enable close collaboration, the core group is expected to include 5-8 stakeholders who commit to active participation, code development and contribution, and, most importantly, to implement the resulting specifications and services in a real-world setting that demonstrates the core use cases.
  2. The Direct Project work will be conducted in an open manner, with ample opportunities for participation. We welcome comment and feedback, working code, code contribution to the open source reference implementation, and implementations of the specifications in different technologies.
  3. Technology enablers may passively participate in the standards development work, by monitoring the work and resulting specifications, implementation guides and reference technology implementations, and then actively participate in late 2010 and in 2011 by building the core Direct Project services into EHRs, HIEs, and other healthcare technology implementations.