How The Direct Project Will End Faxing In Healthcare

What is the Direct Project?

It’s an open source initiative being convened by the Office of the National Coordinator (ONC) to establish a means for secure communication of medical records between providers, laboratories, hospitals, pharmacies, and patients. Rather than devise some elaborate scheme and then cram it down the public sectors throat, the ONC decided to ask for help in developing a standard that used existing technologies to establish a nationwide exchange. The private sector stepped up to the plate with big name participants including Microsoft, Google, IBM, GE, Intel, and many of the major EHR/HIT providers.

How does it work?

To oversimplify, it’s basically secure email and it can be configured so that you use your existing email client (i.e. Outlook) to send and receive secured transmissions.

Sure, the underlying technologies can sound complicated. The Direct Project Overview describes the technical implementation as follows:

  • Content is packaged using MIME and, optionally, XDM
  • Confidentiality and integrity of the content is handled through S/MIME encryption and signatures
  • Authenticity of the Sender and Receiver is established with X.509 digital certificates
  • Routing of messages is handled through SMTP

To the untrained eye that’s a lot of acronyms and probably sounds like a monumental task to implement. The truth is, as far as technology goes, we’ve all been doing this stuff for a long time. That’s the beauty of the solution that the Direct Project and its community have established.

Are people actually using it?

Absolutely. The original pilot programs can be seen here and new ones are popping up everyday. For example, Clinician-to-clinician Direct Messaging just went live in New York State). Many Electronic Health Record (EHR) providers are adding these capabilities to their platforms. Personal Health Record (PHR) platforms like Microsoft Health Vault already utilize Direct messaging to allow patients to send and receive secure emails with their providers.

There is a problem though…

In order to send secure messages, you must establish a trust that ensures the sender and recipients are who they say they are. Users establish this trust with their Health Information Service Provider (HISP) – a role often fulfilled by their Regional Health Information Organization (RHIO). With this, the individual can easily exchange secure communications with other users who subscribe to the same HISP. The problem is that you typically cannot send a Direct Message to users who subscribe to another HISP. The ONC calls this “Pockets of Automation”. The technology is there to do it, but the HISPs effectively don’t yet trust each other (at least not enough to hand off patient data).

The ONC and the Direct Project community are on it. They held the Direct Scalable Trust Forum in November of 2012 and Deloitte Consulting released a report on their findings on February 6, 2013. As usual, the project community has set some aggressive goals and agreed on the following targets:

  • Feb 2013 – ONC to provide a “Ready to Go” set of policies, pilots, and education for vendors
  • Apr 2013 – Accreditation bodies formed, operating, and ready for business
  • Sep 2013 – Half of HISPs participating in accreditation

Ok… so what does all that have to do with faxing?

The federal government does not want you sending personal health information (PHI) via fax and as soon as they are able, they will make it illegal to do so (and unless you’re taking some pretty specific steps today, one could argue that it’s already not HIPAA compliant…. but that’s a whole other post). The problem is that faxing is ubiquitous in healthcare today and the industry simply cannot survive without it. As soon as the Direct community resolves the “HISP trust issues”, all of the pilot programs will quickly become connected and natural pressures of competition (not to mention Meaningful Use) will cause Direct Messaging capabilities to spread like wild-fire. Once there is a reliable, national network for securely exchanging PHI, non-secure methods like faxing will fade away for good.

For more information on the Direct project, check out the wiki.

For information on how to get started, check out the Reference Implementation Workgroup

Database Organization

Great organization is the key to success in many aspects of our lives. Usability is a key feature in the applications we build, yet these factors don’t always carry over into database organization, especially in growing systems. Just because your database isn’t the face of the application, doesn’t mean it shouldn’t have the same sense of flow and organization that the application does. Maintain and organize your database as you would other areas of your life (i.e. your home). Organization should be purposeful, have a basic sense of flow, and be ready to show off when necessary.

Table and Column Naming Conventions

I often see table and column naming conventions that appear cryptic, coded or simply incorrect. Table and column names should reflect the data that they store. Find a standard in your application and stick to it; it will make maintaining and troubleshooting the application in the future a whole lot easier. You wouldn’t organize your office files and label them “x” or “col1,” so why do it with your database?

Related and Duplicate Data

Keeping redundant data can cause multiple issues with your application, including rapid growth in your database and confusion about which data is accurate.

In the same sense, storing related data in unrelated tables can cause the same issues. It falls in line with the same point regarding table and column naming conventions. Data should be grouped together as it makes sense for the application. Doing this will most likely improve the performance of your application; databases with normalized, properly indexed data translate to higher performing applications

Routine Maintenance

Vehicle engines and home utilities require routine maintenance–your application database is no different. Applications grow and evolve over time and you need to ensure that your databases grow and evolve with them. Maintaining database indexes is the key to keeping your application performing at a high level. Scheduling weekly, monthly, or quarterly reviews of your database indexes will help maintain these efforts.

Review the growth of your database tables; it’s easy to assume transactional table data needs to be stored indefinitely. Know how long your application needs to review and access historical data. Data can be easily archived out to a reporting database to minimize the size of your transactional tables

The simple, every day organization and guidelines that make you successful should reflect in your application database. Remember, bad habits and sloppiness in setting up your application database are the quickest way to cause problems for your application.

The Brand Called You – Growing Professionally

Back in 1997, Tom Peters authored an article titled The Brand Called You for Fast Company magazine. I first read the article in 2005, and while I didn’t (and still don’t) agree with everything in it, it contains plenty of valuable career advice to consider. I recently re-read it and humbly suggest a few more strategies:

Grow Your Web Identity

The place most people will go to find more information about you will be the web, especially if you’re in the IT field. Set-up a LinkedIn profile and get connected to people who you befriended during school and your career. Don’t go overboard filling in every professional detail (that’s what your resume is for), or spamming requests to everyone you’ve ever met. I like to think of my LinkedIn contacts as people who would know who I am if my name came up in conversation.

Use Twitter as a way to keep a pulse check on the professionals that you may or may not know, projects or groups of interest, and local events related to your field. Feel free to use it as a way to broadcast things you’re currently up to — blog posts you’ve written, things you’re working on, events you’re attending, etc. I recommend adding a touch of personality to your tweets. Don’t be unprofessional, but don’t be boring either. Be sure to voice your opinion on current topics and trends that you care about.

Be a “Something” Expert

What’s your competitive advantage? Find something that interests you, and become a knowledge expert on it. Maybe it’s integrated marketing, database performance tuning, quality assurance, or Salesforce. Immerse yourself in it. Know the options, and be able to list the pros and cons for each of them. Get involved in conversations and share your knowledge. Ideally you’ll be able to apply your expertise in your current organization, but if not, that’s okay. Don’t be afraid to make suggestions on ways to improve current processes or procedures related to your knowledge area, and don’t be discouraged if you encounter resistance either. If you present your ideas in a clear manner and validate your claims with good evidence, you’ve done your part.

Be a “People Person”

I feel like people skills are becoming a lost art these days. Our society has become accustomed to communication through text message, email, or instant chat conversations. When trying to validate a claim, keep a project on track, or get the nitty-gritty details ironed out on something, I still believe the best way to do it is in person. If that’s not an option, you should at least pick up the phone and hash out the details with a conference call. And even though everyone’s busy these days, carve out some time to drop a “Hi, how is everything going?” now and then. Don’t limit this to clients — your co-workers and contacts matter too. Human interaction will always be more meaningful than digital communication.

Stay Current

Things change–quickly. You should do your best to stay current in your field. It’s not reasonable to expect to be an expert on every new topic or trend, but you should at least be aware of them. In addition to the updates I find on Twitter, I devote time daily to scanning through information technology articles and blog posts just to keep abreast of new tools and trends. My goal isn’t to know everything about everything, it’s to know where I can find more information about something should I need to. Of course, this doesn’t mean you shouldn’t dive into something new every once-in-a-while, too.


Ultimately, your growth as a professional in your field is your responsibility. Make the best of your opportunities, and continue to nurture your career by embracing change and improving your skill sets. Make yourself more valuable by strengthening what makes you unique compared to your peers.

Applying the Four H’s in Business and in Life

One of the things I like most about working here at Algonquin Studios is the fact that the company has a set of guiding principles “The Four H’s” – Honor, Honesty, Humility, and Humor, that I can I can apply to both my job performance and my personal life.


As receptionist for Algonquin, I try to incorporate honor into my job every day and, since answering the phone here is a large part of my job, many of my client interactions take place over the phone. I always do my best to really listen to my caller and ask questions to determine what it is they need and who they need to speak to. If the person they’re asking for is unavailable, I often ask if they’d like to speak with someone else, rather than just putting them through to voicemail. When I get a call and the caller seems stressed, I often acknowledge this fact and assure them that I’m committed to finding someone to help them as soon as possible. These might seem like little things, and really, they’re pretty basic ideas for someone trying to be a good receptionist, but it’s often the little things that get taken for granted or pushed to the side during the course of business. I try hard to honor our clients by keeping my level of service high and acting as a means of real assistance for them.

As a receptionist, I know first-hand, that people in service industries often “get lost in the shuffle” of our daily busy lives. I like to acknowledge that I appreciate what the people who serve me do, whether it’s my morning bus driver or my coffee barista. I try to honor these people on a daily basis as well, taking off my ear-buds to say “good morning” to my driver or thanking my coffee shop employee by name when picking up my daily latte.You never know when a genuine “thank you” or “good job” is going to boost that person’s mood or even change their entire day!


As the Algonquin web site states, the truth isn’t always popular, but it is respected. Isn’t that the truth? When dealing with our clients and my co-workers, if I don’t know the answer to a question, I strive to be honest about it… Even if I feel foolish at the time. I might not know why our latest office supply order is short, where our CEO is at the exact moment an important client calls, or how to best format an Excel file for a large printing job but I can do my best to find out and, if I’m honest about the steps I’ll take to do so, I know it will reflect well on me in the long run.

Of course, it’s difficult to be honest all the time, especially in “real life.” Confrontations can occur, feelings can get hurt, and relationships can be damaged when you try to tell people things they may not want to hear. I was recently given some great advice, “If you know you’re correct and are being honest, even if what you’re saying isn’t what the other person wishes to hear, then you shouldn’t lose confidence in yourself.” I’m still working on applying this to my personal life but I think it’s a good idea to apply some of our next “H” to the equation, too.


Humility is an important part of honesty, especially when emotions are at risk. As mentioned on our site, surely, somewhere in the world, someone else has discovered a better, faster, cheaper way. No matter how “right” you know you are, remembering that there are always other valid ideas, opinions, and beliefs at play is key to maintaining healthy, respectful relationships, both at work and at home.

It’s also important to remember that you can’t get very far in this world without the help and guidance of other people. Part of being humble is being thankful for the help others provide along the way acknowledging their assistance whenever you can.Thanking someone sincerely for what they do goes a long way, even when completion of the task is expected or part of their job duties.


I have to admit, humor is my favorite “H”. Laughter is such an essential part of our day here at Algonquin, I see it in the constant joking heard among my co-workers on any given day, and it’s a huge part of why I like coming to work every day. We’re like a family here and our collective sense of humor provides a bond that goes a long way in making us feel that way.

Humor lightens situations, helps us remember not to “sweat the small stuff,” and creates bonds. Often, our most treasured memories are of times of laughter and jokes. Laughter is unifying and finding things to laugh about-with co-workers,  family, and friends-can only serve to bring us closer together whether we’re working together on a client project or trying to agree on a movie on a Friday night.

Learning about the Four H’s when I first joined the Algonquin team last year gave me a new perspective on my interactions with people in both my professional life and my personal one. Applying the H’s every day, during every interaction, isn’t always easy but I believe that making a concerted effort makes me a better employee and a better person. And I’m pretty happy to have an opportunity to apply myself to both!