Improving Direct Secure Messaging through Directory Management

Abstract

Background

Direct Secure Messaging (DSM) is a communication standard for exchanging information between health care entities and practitioners. It relies on access to an address directory. When directory entry is incomplete, health information exchange breaks down. There is an urgent need for standardized DSM address directory management and synchronization workflows that support universal access in a timely manner.

Objectives

Our objective was to develop best practices for maintenance of DSM address directories and create recommendations to encourage adoption of DSM technology in the State of Texas.

Methods

Texas Health Services Authority (THSA) formed a workgroup focused on increasing DSM adoption. Between August 2021 and March 2022, workgroup members used a modified Delphi process to create a directory management best practice policy and published it in May 2022. To measure the effect of the policy, THSA monitored volume of messages sent in a group of 38 hospitals before and after the workgroup was established.

Results

Organizations should standardize DSM address data and routinely sync with external databases to ensure seamless, vendor-independent message flow. Additionally, health systems are expected to update directory entries immediately upon any change in practitioner's status. Between September 2021 and December 2022, there was a decrease in Direct messages not sent due to no known address, from 50 to 42%, respectively. Additionally, between July 2021 and March 2024, organizations participating in the policy development reported a steady monthly increase of new Direct addresses issued.

Conclusion

Health care organizations should adopt a consistent workflow for maintaining their DSM address directories and regularly synchronize with external databases to facilitate unobstructed flow of messages and data. The Maintenance of Provider Database Dictionary Policy developed by the THSA can serve as a model for nationwide implementation and optimization of DSM as an important interoperability standard.

Keywords

communication - data management - health information exchange

Protection of Human and Animal Subjects

This paper does not involve findings or data obtained from human or animal subjects.

Publikationsverlauf

Eingereicht: 14. Februar 2025

Angenommen: 14. September 2025

Artikel online veröffentlicht:
24. Oktober 2025

• References

• 1 Office of the National Coordinator for Health IT. The Direct Project. March 10, 2010. Accessed September 7, 2025 at: https://www.healthit.gov/sites/default/files/factsheets/the-direct-project.pdf
• 2 Arvisais-Anhalt S, Wickenhauser KA, Lusk K, Lehmann CU, McCormack JL, Feterik K. Direct secure messaging in practice-recommendations for improvements. Appl Clin Inform 2022; 13 (03) 767-773
• 3 Lane SR, Miller H, Ames E. et al; DirectTrust Clinicians' Steering Group. Consensus statement: feature and function recommendations to optimize clinician usability of direct interoperability to enhance patient care. Appl Clin Inform 2018; 9 (01) 205-220
• 4 Office of the National Coordinator for Health Information Technology (ONC), Department of Health and Human Services. Health information technology: standards, implementation specifications, and certification criteria for electronic health record technology, 2014 edition; revisions to the permanent certification program for health information technology. Final rule. Fed Regist 2012; 77 (171) 54163-54292
• 5 DirectTrust. Who is DirectTrust? Accessed September 7, 2025 at: https://directtrust.org/who-we-are
• 6 DirectTrust. Introducing the Directory Improvement Initiative. Accessed September 7, 2025 at: https://directtrust.org/blog/directory-improvement-initiative/
• 7 About THSA. Accessed September 7, 2025 at: https://thsa.org/about-thsa/
• 8 Hospital Data Unit of the Center for Health Statistics. Texas Department of State Health Services. Cooperative DSHS/AHA/THA Annual Survey of Hospitals and Hospitals Tracking Database. May 2023. Accessed September 7, 2025 at: https://www.dshs.texas.gov/sites/default/files/chs/hosp/Hospitallis2022.pdf
• 9 Project US. @ ONC Technical Specifications and AHIMA Companion Guide Project US@. Accessed September 7, 2025 at: https://oncprojectracking.healthit.gov/wiki/pages/viewpage.action?pageId=180486153
• 10 THSA Interoperability Increasing Adoption of Direct Secure Messaging Work Group. Maintenance of Provider Database Dictionary (Provider Directory) Policy. Accessed September 7, 2025 at: https://thsa.org/wp-content/uploads/2024/07/Provider-Database-Dictionary-.-Directory-Policy-Final-3.03.2022.pdf
• 11 THSA Interoperability Increasing Adoption of Direct Secure Messaging Work Group. Maintenance of Clinician/Provider Directory Policy for Direct Secure Messaging (DSM) Addresses. Accessed September 7, 2025 at: https://thsa.org/wp-content/uploads/2025/07/Clinician-Provider-Directory-Policy-7.17.2025.pdf
• 12 American Health Information Management Association Recommended Data Elements for Capture in the Master Patient Index (MPI); 2021. Accessed September 7, 2025 at: https://ahima.org/media/blfdriqj/326_21_namingpolicywhitepaper_final.pdf
• 13 Numbering Resources. North American Numbering Plan Administrator. Accessed September 7, 2025 at: https://nationalnanpa.com/area_codes/index.html
• 14 Health Care Provider Taxonomy; National Uniform Claim Committee. Accessed September 7, 2025 at: https://nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40
• 15 DirectTrust Metrics Q2. 2025. DirectTrust. Accessed September 7, 2025 at: https://directtrust.org/resources
• 16 Centers for Medicare & Medicaid Services. Qualified Health Plan Directory Pilot. Accessed September 7, 2025 at: https://www.cms.gov/qhpdirectorypilot
• 17 Centers for Medicare & Medicaid Services, Department of Health and Human Services. Request for Information; Health Technology Ecosystem. Accessed September 7, 2025 at: https://www.federalregister.gov/d/2025-08701
• 18 Centers for Medicare & Medicaid Services. Interoperability Framework. Accessed September 7, 2025 at: https://www.cms.gov/health-technology-ecosystem/interoperability-framework
• 19 DirectTrust. Resource: DirectTrust Signs CMS Data Networks Pledge and Makes Other Commitments. Accessed September 7, 2025 at: https://directtrust.org/blog/directtrust-signs-cms-data-networks-pledge-and-makes-other-commitments
• 20 Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability and Patient Access for Medicare Advantage Organization and Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, and Health Care Providers. Final Rule. Fed Regist 2020; 85 (85) 25510-25640
• 21 Office of the Assistant Secretary for Planning and Evaluation. U.S. Department of Health & Human Services. How Health Information Exchanges Support Integration for Behavioral Health Settings. Accessed September 7, 2025 at: https://aspe.hhs.gov/sites/default/files/documents/dbf3c475dff9ef1d5bdbcdef7792889a/hie-support-integration-bh-settings.pdf
• 22 National Plan and Provider Enumeration System. NPI Registry. Accessed September 7, 2025 at: https://npiregistry.cms.hhs.gov
• 23 Public Reporting of Missing Digital Contact Information Data Dictionary. Accessed September 7, 2025 at: https://data.cms.gov/resources/public-reporting-of-missing-digital-contact-information-data-dictionary
• 24 THSA. Direct Secure Messaging—Updating NPPES with your Digital End Point. Accessed September 7, 2025 at: https://thsa.org/wp-content/uploads/2022/04/Updating-NPPES-Direct-Secure-Messaging-Blog-Read-Only.pdf
• 25 Assistant Secretary for Technology Policy. TEFCA. Accessed September 7, 2025 at: https://www.healthit.gov/topic/interoperability/policy/trusted-exchange-framework-and-common-agreement-tefca
• 26 The Sequoia Project. Trusted Exchange Framework and Common Agreement (TEFCA) QHIN Technical Framework, Version 2.0 Accessed September 7, 2025 at: https://rce.sequoiaproject.org/qhin-tech-framework
• 27 The Sequoia Project. Standard Operating Procedure (SOP): RCE™ Directory Service (Directory) Requirements Policy. Accessed September 7, 2025 at: https://rce.sequoiaproject.org/wp-content/uploads/2024/07/SOP-Directory-Requirements_508-1.pdf
• 28 CommonWell Health Alliance. CommonWell, the Record Locator Service & TEFCA; 2023. Accessed September 7, 2025 at: https://youtu.be/Fa4l6bHiNSU?si=qmPzYZySo8dpOSLj
• 29 Carequality. Query-Based Document Exchange Implementation Guide; 2021. Accessed September 7, 2025 at: https://carequality.org/wp-content/uploads/2021/07/Query-Based-Document-Exchange-Implementation-Guide-v2.0-Published-07122021-1.pdf
• 30 HL7 International. National Directory of Healthcare Providers & Services (NDH) Implementation Guide 2.0.0—draft. Accessed September 7, 2025 at: http://hl7.org/fhir/us/ndh/ImplementationGuide/hl7.fhir.us.ndh
• 31 Assistant Secretary for Technology Policy. Lighting the Way for FHIR^® API Implementation: Solutions for Endpoint Publication and Discovery; 2023. Accessed September 7, 2025 at: https://www.healthit.gov/sites/default/files/2023-08/20230808_Lantern-lighting-the-way-FHIR-implementation-report-508.pdf
• 32 Integrating the Healthcare Enterprise (IHE). Cross-Enterprise Document Reliable Interchange (XDR). Accessed September 7, 2025 at: https://profiles.ihe.net/ITI/TF/Volume1/ch-15.html#15
• 33 Integrating the Healthcare Enterprise (IHE). Cross-Community Document Reliable Interchange (XCDR); 2023. Accessed September 7, 2025 at: https://www.ihe.net/uploadedFiles/Documents/ITI/IHE_ITI_Suppl_XCDR.pdf