Why Direct is a Lousy and Unproductive Black Hole for Referral Management

Posted by Jeremy Guttman on 6/30/16 1:47 PM


DSM is antiquated, backwards, and “meaningless work for meaningful use” - Physician testimony | ONC HIT Policy Committee

“ONC’s new ‘interoperability roadmap’ downplays the potential of Direct messaging” as a solution for interoperability - Medical Economics

Contrary to what some electronic health record (EHR) proponents believe, DSM (Direct secure messaging) by itself is an unpopular and ineffective solution when it comes to true interoperability, care coordination and referral management. It has almost no practical benefit for referral management beyond what primary care practices use it for right now: getting credit for Meaningful Use stage 2.

Currently, healthcare interoperability is a smoking-hot topic because EHRs are notoriously terrible at sharing information with competing EHR products. Nonetheless, many EHR systems do have one basic communications standard in common called Direct secure messaging — sometimes referred to as “Direct”, with a capital D.

DSM is a technology used to exchange certain types of medical information. It is essentially a secure web-based email protocol that encrypts information to ensure that communication is private.

One of the many downsides of DSM is that configuring it is cumbersome. Every practice or healthcare organization using DSM needs to be signed up for and verified by a Health Internet Service Provider (HISP). Upon verification, each user within the practice is issued new Direct email addresses. DSM email addresses usually include the word direct in them. For example, j.snow@direct.winterfellclinic.org.

Each HISP has a directory of its customers’ Direct addresses, but HISPs don’t have access to other HISPs’ directories. Two DSM trade associations, DirectTrust and National Association for Trusted Exchange (NATE), have separate workgroups tasked with developing standards for a DSM directory. Many states are also working on setting up their own directories, but the current DSM directories are voluntary and not fully comprehensive. John Halamka, the former co-chair of the federal HIT Standards Committee, has even argued that the unpopularity of DSM can be blamed on the lack of a comprehensive DSM directory.

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DSM is a “a quantum step backwards” - Physician Testimony | ONC HIT Policy Committee

There were high hopes for DSM when it was originally launched under a government initiative in 2010 called the Direct Project. The secure protocol was expected to be used to send transition of care documents between EHR systems to help practices successfully coordinate patient care. The government has even incentivized using DSM for that purpose: primary care practices get Meaningful Use stage 2 credit for sending 10% of their transitions of care referral documentation electronically and securely using DSM.

Unfortunately, DSM has turned out to be a failure for referral management because it can’t exchange health information in a way that achieves truly useful interoperability. “Direct messaging can only ‘push’ data from point to point”.

Because of DSM’s limitations, some practices basically hack their EHR systems and referral processes to send meaningless DSM messages for at least 10% of their referrals, just to get Meaningful Use stage 2 credit and nothing more.

“[P]hysicians who use Direct at this point seem to be doing so mainly to obtain Meaningful Use incentives....’We’re just using Direct to appease CMS’” - Medical Economics

Many practices send transition of care messages over DSM to meet MU2 credit requirements without expecting any specialists to actually look at the messages. These messages are sent into a black hole and don't help anyone.

Reasons why DSM is a failure for referral management:



  • Example: Patient calls cardiologist office for scheduling, patient is given responsibility to tell PCP to send more info before appointment can be made, patient does not follow up and no appointment is made unless PCP office happens to manually follow up
    • PCP offices are not notified when patients fail to complete an appointment
    • PCP offices need to manually follow-up with patients or specialists unless consult report is received
    • Following-up for every patient is unsustainable


  • In one study, 15% of patients with incomplete colonoscopy referrals were unaware that they were responsible for scheduling their appointment1
    • When patients need to reach out to specialists, half of referrals don’t result in an appointment2


  • One doctor who used DSM was quoted in an article saying that he had no idea if the specialists he referred to actually logged into their EHR systems to pick up their DSM messages
    • Current system deters specialist offices from reviewing referral orders sent via DSM
    • Consult reports often don’t get into the hands of PCPs in time for follow-up visit with patient
    • Even if practices receive consult reports via DSM, EHRs can’t measure provider performance such as consult report compliance trends

DSM alone is not enough for referral management.

DSM was supposed to facilitate referral management, but its original promise of improving transitions of care has fallen short of that goal. The government has now begun to downplay the potential of Direct secure messaging and EHR vendors are seeing less of a push for it.

The goal of closed-loop referrals is essential, but DSM alone doesn’t achieve it. However, when a SaaS-based high-performance referral management application is integrated with an EHR system, DSM is used as a conduit to facilitate data exchange and rapid connectivity. DSM allows systems to unite, but does not provide accountability, metrics or notifications that are available in a more comprehensive application.


Together, DSM and high-performance referral management applications do what EHRs cannot do on their own: track all referrals and analyze referral performance metrics. With high-performance referral management, there is little to no effort for practices to build out their preferred specialist network and connect to specialists. PCPs seamlessly coordinate patient care with their specialist partners. Referrals are even tracked and analyzed for connected specialist partners who have no EHR system at all. Patient outcomes and satisfaction is improved and valuable referrals are no longer lost in transition or sent into a black hole.

Where does DSM fall short in your practice's patient referral process? Share with us in the comments below.

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1 Journal of General Internal Medicine | http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490266/

2 Archives of Internal Medicine | http://www.ncbi.nlm.nih.gov/pubmed/22271124


Topics: Referral Network, Referral Management, Direct secure messaging, DSM