DirectTrust Passes 2 Billion Messages – Healthcare Interoperability in Action

The response to my article asking the question “Are we at the end of the healthcare interoperability tunnel?” was quite interesting.  I think some people thought that I was hammering on all the work that’s being done on healthcare interoperability.  Others understood that I was saying we can recognize the progress we’ve made on healthcare interoperability and also recognize that there will always be more work to be done.

A great example of this progress was the announcement from DirectTrust that the community has exchanged over 2 Billion messages (2.12 Billion at the end of 2020 to be exact).  Yes, that’s Billion with a B with the 4th quarter of 2020 seeing $265+ million direct transactions between trusted endpoints.  Here’s a look at a chart showing their growth by quarter since 2014:

What might be even more interesting is that they’re now up to 2,498,542 trusted endpoint addresses across 259,173 organizations that are served by DirectTrust HISPs.  One of the big issues with Direct Messaging when it started was getting everyone a Direct address.  It’s great to see this progressing so that direct addresses will be as common as fax machines.

In fact, one of the really interesting pieces of DirectTrust’s end of year metrics report is the growth in the number of patient/consumers with direct addresses.  The growth of patients using direct could mean direct addresses will become more common than fax machines.  Take a look at the huge growth in patient addresses they saw in 2020:

One other really interesting thing to note is that DirectTrust saw a pretty big dip in transactions at the start of 2020.  You can see the dip in this chart that shows DirectTrust enabled transactions by quarter from 2014-2020:

Obviously, COVID shut down a lot of healthcare organizations and so they weren’t sharing messages at the same rate.  However, it’s still pretty amazing that amidst COVID healthcare organizations were still sending what looks like about 140 million messages per quarter.  Plus, the 4th quarter of 2020 illustrated how messaging came back as healthcare organizations came back.  In fact, transactions continued to grow.  Scott Stuewe, DirectTrust president and CEO, noted that it took 5.5 years to reach the first billion and they passed the 2nd billion in just 18 months.

Looking at interoperability beyond DirectTrust, a report from HEALTHeLINK, an HIE in Western New York, highlighted that they’d sent over 5.4 million COVID-19 related alert notifications since March, are sending 869,013 clinical results (lab test results, radiology reports, etc) monthly, and they delivered over 10 million alerts in 2020.  Plus, they had almost 1 million patient record lookups and now have over 10.4+ million patient encounter records uploaded through HEALTHeLINK in 2020 and that’s just one HIE in New York.

KLAS recently partnered with CHIME on an EMR interoperability report that shows similar progress.  Here’s a look at one chart from their report:

What all this data really shows is that healthcare interoperability is happening.  Although, as the KLAS report shows, there’s still more work to be done.  Of course, if you’re a patient in the 33% of healthcare organizations that doesn’t have electronic access to your data, the billions of transactions might feel like a cognitive dissonance.  In fact, as a patient that doesn’t experience interoperable health data or access to health data, seeing these numbers is likely painful.

This is why the work of healthcare interoperability is so important and hopefully we’re are the start of hockey stick growth when it comes to data sharing.  It’s taken time to get where we are and in some ways that’s not a bad thing.  We don’t want to start sharing health data willy nilly.  Doing so can often hurt patients and has all sorts of privacy challenges.  However, done in a thoughtful way, patients privacy can be protected and patient care can be improved by having the right information at the right place and the right time.

About the author

John Lynn

John Lynn

John Lynn is the Founder of, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference,, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • DirectTrust Messaging is a marvelous tool but concluding that we’re well on our way to interoperability is confusing motion for progress. Can your doctor access all your records when they need them? The answer is no! Until they can — which is years and years away if ever with HIEs — we’re missing the boat. It’s time to take a different approach to interoperability, one that can use DirectMessaging so any doctor anytime, anywhere can access your complete health record.

  • Merle,
    If you don’t think 2 billion messages is progress on interoperability, I’m not sure what to say. As far as your goal of the doctor having access to all your records, I personally am not sure that will ever be possible. There are too many places where patient data is stored. So, I’ve taken a separate view that interoperability of health data that makes a meaningful impact on the care experience is still worth being applauded. I think that’s what we see happening here. Are we there yet? Absolutely not as I noted in the article, but is it a far cry from where we were even a few years back, yes!

    I do find it ironic that you slam this as “confusing motion for progress” and then say that the solution is built on the back of this technology and progress.

  • Hi John,

    2 Billion messages are a lot messages is not interoperability by any stretch of imagination — and I’m glad you agree.

    To a doc caring for a patient, the number of records exchanged each month is irrelevant. What he and his patients want is for him to be able to instantly access his patient’s complete record from all his or her providers at the point of care. Nothing less.

    Moreover, we know from experience that trying to link siloed providers via HIEs will probably never get us there. So why even suggest we’re on the right path because providers can request, send and receive a lot of records?

    The fact is we can have total interoperability today if we give the patient digitized copies of all his records which he can share with any provider he sees. As you know, our MedKaz® system does just that. For example, I have all my records for the past 35 years from all my providers on my MedKaz and anytime I need care, I simply give it to my provider! As the saying goes: Mission accomplished!

    WRT DirectMessaging, I strongly support it because it is a tool that can work on any system, not merely linking silos. For example, we are adopting it to securely move records from providers to our Server for processing and downloading to a patients’ MedKaz, their providers and others.

  • Merle,
    Actually, there are a lot of cases where doctors are fine with less. There are a lot of point solutions where they only want and need a certain set of info and the 2 billion messages is solving that problem for them.

    Of course, there are still hundreds of use cases it doesn’t solve, but we definitely don’t need full interoperability of records to solve many of them.

    As far as you offering the solution that works today, I’d argue that it doesn’t work. I’ve had access to MedKaz since the beginning and never done it because I don’t care. That’s the problem with putting the patient at the center of interoperability. Far too many of them (us) don’t care to do the interoperability ourselves. I think we should empower those patients that do care and do want to do it, but to say that we can have total interoperability today using it is just not true.

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