Health communication and interoperability are evolving rapidly and DirectTrust is at the forefront of this transformation. Since its inception as the Direct Project in 2009, this initiative has facilitated more than 6 billion secure messages across 300,000 organizations.
At the 2025 HIMSS Global Conference, I spoke with Kathryn Ayers Wickenhauser, MBA, FACHDM, CHPC, DirectTrust’s Senior Director of Communication Strategy and a longtime MGMA Stat user (!) about the introduction of FHIR (Fast Healthcare Interoperability Resources) over Direct, the state of secure health communication, the role of metadata in streamlining workflows, and the expanding need for better governance and directories. Below is a condensed Q&A from our discussion.
CH: Direct messaging has been around for over a decade. Now you are introducing FHIR over Direct — how has this evolved, and where is it heading?
KAW: "The infrastructure is there, it's built. It's working… So today, a lot of document exchange [happens through the] CCD (Continuity of Care Document), C-CDA (Consolidated Clinical Document Architecture). There are certain use cases where that makes sense. But as we talk more about FHIR — and FHIR is growing — there's this idea of having the more discrete data elements [and] only exchanging what you need… Can we use the existing infrastructure and the pipes that are built and just change the content? Instead of putting a C-CDA or PDF or image in a Direct message, HL7 v2 message, could we put a FHIR payload? Could we put FHIR resources in Direct instead? … This will allow more people to participate in exchanges, especially looking at under-resourced organizations that don't have the ability to stand up a FHIR server or to do FHIR transport. Could this be a bridge to when maybe that is more ubiquitous?”
CH: You mentioned under-resourced organizations. How does this help them?
KAW: “Many organizations lack the infrastructure to support full-fledged FHIR-based exchange. By integrating FHIR payloads within Direct messaging, we enable them to leverage existing systems while gaining the benefits of more structured data exchange. This approach serves as a bridge to greater interoperability and broader adoption over time.”
CH: Regarding the importance of metadata in message handling, how would that enhance workflow efficiency?
KAW: "There’s the capability within a Direct message to have certain metadata, so it could be labeled… If this is an admission notification, it goes to the clinician, because the clinician may have information they want to share back to the ER or wherever this patient is. But if it's a discharge notification, there's not really an action that a clinician can take at that point. It's more [relevant to] the scheduling team. So, if that message comes through and it's labeled as a discharge notification… you have rules in the background and routing to say, ‘Actually, no, this is going to bypass the clinician and go to the clinician scheduling team, and then they schedule.’ … When you're talking about inbox management, this is huge."
CH: I’ve seen a lot of sessions at HIMSS25 focused on the growing role of health information exchanges (HIEs). How do you see them fitting into this evolving ecosystem?
KAW: "One of our sister peer organizations, Civitas Networks for Health, does an awesome job in the HIE space… But again, there is not one way to do interoperability. To give a personal example: I had to establish care with a new primary care provider… He queried my records from different EHRs, different systems, different states I’ve lived in … It was interesting to see what didn’t return and where there were some information gaps. But overall, it was really heartening to me to see that information come from the HIE and even some of the historical information for me in my care…"
CH: What are the biggest challenges ahead in interoperability, and how can the industry address them?
KAW: "One of the things I am seeing and hearing repeatedly is this collaboration theme. And I'm hearing from people that they want to lean into organizations like MGMA and DirectTrust… and so really, I think this is a call to action to the industry: ‘If you want to see movement here… Look at your associations, find the causes that you believe in, and get involved, send people, actually do the work, and we can do this.’"
CH: With AI and cybersecurity gaining attention, how do they intersect with interoperability efforts?
KAW: "AI is being increasingly discussed in terms of governance and policy rather than just technical capabilities. Cybersecurity is another major focus, especially in protecting data exchanges. Strong governance structures are essential to ensuring trust in digital identity and interoperability."
CH: Many MGMA members know DirectTrust regarding Direct secure messaging. Are there other aspects of your work they should know about?
KAW: "We accredit health technology… [Accreditation] is a big space [we work in] that people are not always aware of."
CH: What is your key message to healthcare leaders looking to improve their interoperability strategies?
KAW: "Collaboration is key. Organizations should engage with industry groups, participate in governance efforts, and actively contribute to shaping interoperability standards. Change doesn’t have to come from government mandates — industry-led initiatives can drive meaningful progress."
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