Why Direct is a Hit and PCAST is an Outcast

Regular readers know that I find Professor Clay Christen’s theory of disruptive innovation to be a useful lens to explain industry evolution. Let’s look at two recent health IT initiatives and see why one is working and the other is stalled.

Characterizing the Direct Project — why it’s working:

  1. A low-end industry disruption. The Direct Project takes transactions that are routine but inefficient — fax, telephone, mail exchanges between health care providers — and specifies standardized, Internet based technologies to conduct them electronically.
  2. Incremental change — a few specified transactions.
  3. Bottom up — ONC hired a capable project manager (Arien Malec) who choreographed a small team of volunteers working under short deadlines.
  4. Implementing “better, faster, cheaper” technology on the fly (i.e., Internet transactions replace fax, phone).
  5. Under the radar — invoking little response from incumbents. Direct was seen as focusing on transactions that were peripheral to the core EHR.

Characterizing the recommendations of the PCAST report — why it’s stalled under bureaucratic inertia:

  1. A direct frontal assault on the mainstream architecture and technology of today’s health IT vendors and customers — calling for the rapid replacement of billions of dollars of investment in current HIT.
  2. Systemic change — rethinking HIT architecture from the ground up.
  3. Requiring top-down governmental actions to reform an industry. Invoking polarized political responses — “PCAST is socialist.”
  4. Requiring an ONC workgroup to spend 3 months simply to conduct hearings and evaluate possible next steps.
  5. Invoking organized, persistent and uniform denouncements by many industry incumbents and their trade associations. The PCAST report became a political piñata. Many of the objections to the PCAST report were couched in terms of reducing quality and patient safety.

There are some great lessons here.

Vince Kuraitis JD, MBA, is a health care consultant and primary author of the e-CareManagement blog, where this post first appeared.

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2 replies »

  1. David, I can also agree with most of what your wrote…mostly differences in nuance.

    My perception (admittedly anecdotal, but persistent) is that there have been two points of view among some groups of stakeholders (especially EHR vendors and HIEs — the noun):

    * Direct is complementary to their interests
    * Direct is competitive to their interests.

    So yes, your citing the efforts of supportive EMR vendors is very appropriate, but some have seen Direct as competitive (or at least distracting to their development schedules) and to my understanding have not been supporting connectivity of their EMRs to Direct.

    Similarly, the HIE community is divided — again, not close enough to know relative proportions:

    * Some HIEs (the noun — IMHO the wiser ones) see Direct as adding rapid capabilities for HIE (the verb). They are appreciative of Direct’s ability to help fulfill tangible meaningful use criteria and are willing to accept help from wherever it comes.

    * Some HIEs (the noun) see Direct as usurping capabilties that they had planned to provide and charge for, thus undermining the HIE business model. While this emotional response is understandable, markets incentivize players to compete, and while HIEs might want to become one-stop-shops for regional health information exchange, the reality is that niche vendors in a capitalist world will pick off low hanging fruit.

  2. Thanks Vince. I agree with most of what you wrote here. Direct Project is an incremental step forward using existing standards and is widely accepted as a “HIT hit.” But I wouldn’t conclude that it was “under the radar” and invoked “little response from incumbents” (unless you meant little opposition) A look at the Direct Project Wiki pages reveals a high degree of participation (response) from “incumbent” EHR vendors such as AllScripts, Cerner, Epic, GE, Greenway, NextGen, Siemens, and others. Their people did lots of hard work — specifying, coding, testing, documenting, adding to products, and implementing — on behalf of the health community. And I wouldn’t consider Direct transactions as “peripheral to the core EHR” but rather as very connected to the clinical workflows and functionality that EHR users expect. I AGREE with you that Direct opened the door for clinicians who don’t have EHRs, and it’s great that they can exchange info too. But the Direct user stories — e.g., exchange of clinical summaries for transitions of care, results delivery, immunization reporting, and sharing of EHR information to patients’ PHRs — all are (or soon will be) core to any EHR that is “meaningfully used.”

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