Direct secure messaging has been used to enhance care coordination. Its potential to reduce readmissions and costs could make it a powerful tool in an era of reform. 


At a Glance

  • Direct secure messaging (DSM) is a way to send patient information in an encrypted form among physicians, among provider organizations, and to state agencies.
  • Improving efficiency of communication between physicians through DSM also improves productivity—not only for physician users, but also for the practices and organizations they serve.
  • However, use of DSM must expand for users and their organizations to achieve full benefits.

Direct secure messaging (DSM) has emerged as an efficient and secure way for a physician to communicate private patient information with other physicians. Now, hospitals and healthcare organizations are beginning to use DSM to connect with other providers to reduce readmissions and costs.

DSM works in much the same way as regular email, except that the message is encrypted, which prevents unintended users from being able to read the contents, thereby protecting patient privacy and helping to prevent data security breaches. Similar to the way in which email has enabled office workers to communicate easily among colleagues, DSM enables providers to collaborate more effectively and efficiently with other providers. Technology experts and adopters of DSM predict that in the not-too-distant future, the use of DSM will result in better care, reduced readmissions, and a decrease in redundant testing and procedures.

The challenge lies in getting providers connected. DSM is still in its infancy, and it lacks the prevalence of usage necessary for users and their organizations to realize its full benefits.

How DSM Works

DSM is a transmission standard promoted by the Office of the National Coordinator for Health Information Technology that meets stage 2 requirements for meaningful use of electronic health records (EHRs). The technology can be used to securely exchange patient referral information, discharge summaries, and lab reports among providers and to transfer public data to state agencies.

EHRs often include a direct messaging function that enables physicians working within the same EHR to send private patient healthcare information to one another in a secure form. Depending on the EHR, two physicians who work at different organizations but use the same kind of EHR may be able to send data through DSM as well.

However, because smaller hospitals and physician practices often do not have robust EHRs, they have to use other means to electronically connect with larger practices and health systems and to send encrypted messages to other physicians and providers. DSM may be accessed (for example, through a web link) via health information exchanges (HIEs) and other organizations that offer the technology.

How Physicians Benefit

For physicians, the fundamental reason to use DSM is to communicate more rapidly and efficiently with other physicians to be able to provide treatment more quickly. Pioneers of DSM scoff at the old-fashioned methods of communications among physicians: phone and fax. 

“Communicating by phone and fax is a fragmented, inefficient process,” says cardiologist Fred Venditti, MD, vice dean of clinical affairs for Albany Medical Center, Albany, N.Y., an early adopter of DSM.

For the past year or so, Venditti has been using DSM through his practice’s EHR to communicate with other physicians in the practice who refer patients to him. To diagnose and treat these patients, Venditti relies on existing data, such as lab reports and results of electrocardiograms. “In the old world, that information was mailed or faxed to me. Because these communication methods often fail, patients would frequently come in carrying a copy of what their physicians wanted me to see, to be sure I received the information,” he says.

Likewise, after every patient consultation, Venditti will have additional data, such as consult notes or new test results, to share with the referring physician. Here again, using “old-world” methods to transfer this information to the referring physician increases the chances that data will be delayed or lost or will arrive in an incomplete form.

“Direct messaging sends that packet of information electronically,” he says. “This is a better, more efficient method for transferring that information back and forth.”

Electronic transmission inherently reduces the amount of time and resources used to print and scan documents that were sent via fax or regular mail—and that can translate into cost savings, Venditti says. But figuring out how to measure those savings will take time. “While we are convinced that this will make a positive difference, we haven’t quite come up with a way to measure the savings,” he says.

Thomas Nighswander, MD, a primary care physician practicing in Anchorage, Alaska, has benefitted from the efficiencies gained through DSM. Nighswander uses DSM for reporting on infectious diseases to state agencies and to communicate with other physicians in his health system.

In one instance, Nighswander sent a DSM to a cardiologist to confirm his assessment of an ultrasound while the patient was still in his office. “The cardiologist wrote back to me in about 10 minutes,” says Nighswander, whose practice is part of the Alaska Native Tribal Health Consortium, a not-for-profit healthcare organization that includes a primary care practice and 150-bed medical center. Nighswander says that, in the old world of referrals, the patient would have had to have made an appointment with the cardiologist and bring the ultrasound results to that physician visit. “It would have been an elaborate ordeal,” he says.

But physicians and patients aren’t the only ones who benefit from use of DSM. Improving efficiency of communication between physicians through DSM also improves productivity for the practice.

“Clearly, when you husband your resources, you are able to manage many more patients in your office that you couldn’t manage before because you didn’t have this kind of easy communication,” says Nighswander, who uses DSM through both his practice’s EHR and the Alaska eHealth Network (AeHN), a not-for-profit organization that promotes adoption of EHRs and secure HIE. 

Unnecessary referrals at Alaska Native Tribal Health Consortium have dropped dramatically, due in part to the use of DSM, Nighswander says. This decline in referrals has resulted in reduced costs for the health system and benefits physicians and patients as well. “DSM helps to ensure that specialists can focus on the kinds of complicated cases they really need to see. DSM supports their ability to work at the top of their license,” he says.

How Hospitals Can Benefit

DSM has been available through Alaska’s HIE since about February of 2012, according to the organization’s executive director, Rebecca Madison, and its use has grown substantially in the past year. Ten hospitals with about 4,500 total users—including 900 practice-based physicians, other clinicians, health information management staff, and business office employees—are using the network, Madison says. Alaska’s HIE recorded usage of about 25,000 messages per month over a four-month period. Madison expects all of the state’s 27 hospitals to join the network and begin using DSM at some point.

Some hospitals that use DSM through Alaska’s HIE are seeing efficiencies in medical record departments, which can send patient records more easily, Madison says. Although Madison does not know of any hospital in Alaska’s HIE that has conducted a formal measure of savings, she notes, “Every medical record department is adamant that direct secure messaging is saving them time and money.”

Other HIE organizations also are using DSM to connect providers. The Missouri Health Connection (MHC), a not-for-profit health information network based in Columbia, Mo., is working with the University of Missouri, Sinclair School of Nursing on a federally funded pilot program to set up area nursing homes with DSM technology. The overall goal of one health information network’s efforts to provide nursing homes with DSM technology is to better connect area hospitals with nursing homes to reduce the state’s high readmission rate, says Kim Day, chairman of the board of the MHC.

“A lot of readmissions are occurring from the nursing home back to the hospital,” Day says. According to the Centers for Medicare & Medicaid Services, research shows that nearly 45 percent of hospitalizations among Medicare-Medicaid members living in nursing facilities are avoidable.

MHC has installed a DSM email system on desktop computers and tablets at area nursing homes, says Marc Andiel, interim president and CEO of MHC. Previously, one method of conveying patient data from a long-term care facility to a hospital was to send an envelope containing the patient’s name and condition with the patient in the ambulance and hope that it would be delivered to the correct person. “There is a fundamental need to provide methodologies and lightweight tools for these nursing homes to communicate more effectively with hospitals,” he says. 

Currently, MHC is working to connect three large area health systems to 16 nursing homes via MHC CareMail. The DSM technology will support more secure transfer and routing of patients’ information to and from the nursing homes and health systems. 

“MHC’s goal is eventually to connect all Missouri hospitals to our DSM so that this service will be available to nursing homes across the state,” Day says. “We’ve established targets for reductions in avoidable admissions, medication errors, and unnecessary tests and procedures.”

Beyond DSM, providers can connect to MHC CareNet, MHC’s more robust query-based network. This network has the capacity to query all participating hospitals and clinics for a patient’s treatment history and conditions. One crucial application is the ability to find medical information on emergency department (ED) patients. An ED physician, for instance, could input a patient’s name into the hospital’s EHR that is connected to MHC CareNet. The system would then query all participating providers and retrieve the patients’ information and medical history into a summary document that allows for additional drill-down capabilities. The ED physician would be able to simply view the information or actually have the patient’s complete medical history integrated into the patient’s electronic medical record, depending on the capacity of the system, Andiel says.

The technology is more sophisticated than DSM, but that does not mean that direct, point-to-point communication will not continue to be valuable, he says, especially for smaller practices and hospitals that do not have the means to employ sophisticated EHRs.

“There’s an evolution taking place with this type of technology; the next step forward will be a query-based network that works with all kinds of EHRs and connects to the national eHealth Exchange. But DSM will continue to be a viable network for those who need it,” Andiel says.

Critical Mass Challenges

One of the current downsides of DSM is that more health systems and physicians need to be connected for users to reap the benefits. Consequently, current users are trying to gain greater buy-in.

Albany Medical Center is in the process of establishing a DSM connection with a physician multispecialty group that is part of Glen Falls Hospital, Glen Falls, N.Y. The group includes about 40 physicians, most of whom practice primary care, Venditti says. “They refer a lot of patients to us already, so this will definitely test this use case of referral, request, and consult information,” he says.

The MHC has initiated two pilot programs to connect hospital- and practice-based physicians. At St. Louis Children’s Hospital, which has a significant referral business that draws from outside the St. Louis market, 20 hospitalists and five practice-based primary care physicians are involved in the pilot, which started in June, says Pele Yu, MD, chief medical information officer for St. Louis Children’s Hospital. Yu says he will recruit additional hospitalists and practice-based physicians beyond the pilot phase. In a third pilot, the health network is installing DSM technology at a rural hospital in Missouri so it can connect to about 15 primary care physicians who send referrals to the hospital.

The primary care physicians in the pilot programs like DSM because it supports communication that is much more in tune with their workflow. “The community doctors like the real-time feel of the updates they receive through DSM on their patients,” Yu says.

An Evolving Tool in an Era of Reform

DSM has the potential to enhance care delivery for hospitals and healthcare systems and help these organizations meet accountable care and other value-based performance requirements in an era of reform. Early adopters are reporting positive results, such as better communication and improved productivity, as they use DSM to send patient data more quickly to other connected providers.

“You’re increasing communication in the transition of care for the patient. That, I think, leads to better care because you have this continuity of communication,” Yu says. “This type of communication really gets you ready for an era of enhanced care coordination.”


Karen Wagner is a healthcare freelance writer, Forest Lake, Ill., and a member of HFMA’s First Illinois Chapter.

Publication Date: Monday, February 03, 2014

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