As a tl:dr followup, as a participant in the process that had already a working version based on the specifications (as voted on for consensus for Direct on the Wiki), as well as a alternative to Direct Trust in which I was a participant, but where there was no approach in which they could manage membership because of the HISP methodologies, I was very interested to see the process outline on the JAMIA paper documented below. It fails to acknowledge how the logical process described in terms of standards maturity could be and was manipulated, (not exactly actually controversial but I was listening to your meetings in recordings where consensus was not reached). There's actually fundamental disagreement on some major points which were identified in 2004 when ONC was enabled and were subsequently not resolved. The usual suspects, Dixie, John Halamka, etc. wrote this.
On the face of it the paper as an intellectual exercise of software maturity to fulfill the legal requirements of the standards committee per the enabling legislation, it makes sense, but nothing like this ever really took place either for NWHIN or Direct from my experience since 2008.
That includes a great deal of complex technical requirements which I am sure the participants understand, but didn't see a solution to make it happen vis a vis Provider Directory enough to form a consensus.
David Kibbe testified that he didn't think a provider directory was necessary for Direct, and during the Direct Boot Camp that David and I both attended, as well as some of the people on this list, the number one most wanted feature for Direct was voted to be provider directory! Subsequently Direct Trust is investigating this and will likely come up with their own version that will pick out another obscure technology like LDIF using XML to exchange data. Those who are in the know regarding this, and have followed the entire process, know this goes back to the beginning of standards discussions regarding provider directory (which everybody agrees is a good thing) in which a fixed idea emerged out of MA that databases should be the logical connecting methodology as opposed to directories that already exist that could be joined together using LDAP. So the insistence to use DNS for certificates that match providers and all the arguments provided simply had to be sorted out. That's why we agreed to use both.
To have Mod Spec rewrite the provider directory architecture (and feel free to argue your approach as I am mine) was entirely out of scope for S&I, but supported by ONC. ONC rapidly began to bleed political capital when legislators found out the game they were playing. But HHS was clearly in a BIND (lol) to claim they were protecting patient security and data integrity, while at the same time exposing that same data with a solution at the business layer as opposed to a technical solution. Since some of those requirements are classified (not all of them) its only recently that we have the "return of the backdoor" policy position into the argument, but without a real risk analysis of what would happen if medical data was actually securely encrypted in transit over the network, not available to be decoded. This is where the IETF has taken a leadership position along with the other forms of Internet governance. In an odd turn of events, the Internet will be more secure than the Direct HISP model. Might take a while.
We don't have the equivalent of an ICANN for Directory because that was the agreement we did for E-Gov way back when, not to put it through the legal controversy over what authority in the root nameservers constitutes, That is causing DNS to collapse under it's own greed. That and a few million dollars can buy your own TLD from an ever expanding list. In short the DNS means nothing, but it's still a useful service and you can keep renewing. OTOH, the ANSI organization registration for reference is here:
It costs about 2.5 K $, and the renewal fees for your registration. None. In perpetuity. Plus you get your own OID like HL7 has that lets you do all sorts of useful things. So far, most people choose the DNS. Then they try to apply security through certificates, which don't required the Directory, but if you have the Directory, you get a great deal of added value since they mesh so well together. And then you don't need to be a member of Direct Trust because as Farzad liked to put it, "It all just works" using the existing system. Even SSL certificates for web sites are going to be offered at zero cost soon through the EFF and partners. In short, while the Medical HIT community insists that they don't understand encryption in any depth and has to have a separate trust network that uses medical bits instead of internet packets, the Internet is moving towards ubiquitious encryption for everyone at low to no cost without having it managed by a service provider who have already demonstrated their vulnerabilities to crypto political pressure.
Nor as they were throwing around ideas in these standards meetings like "lets put all the structured data in Google" (yes that actually happened). Certainly interesting and worthwhile discussions, but for developers who need to write working software, the constraints are much more pragmatic to narrow down the solutions that can work.
This is what happens when you don't listen to your customers. HHS is not the customer, nor are the medical providers who are paying the bills for the software. The true customer is the patient/citizen and the cost comes out of the 18% of GDP that is currently being skimmed. Since CMS is burnt for a big chunk of this, they are driving for certain requirements in regards to improving the integrity of the information.
In 2004 when the ONC was created in the mold of a Health Tsar, to coordinate these things, the RFI had already been returned with one very specific takeaway to HHS. That was "put this stuff on the Internet, and network it to make it accessible and lower costs"
Fine.
As a result, the medical IT community did everything in its power to make that not happen because they felt that would result in a loss of power, and in some cases profits, but the value of transparency in the overall system, has been a very difficult path as they have attempted, and sometimes succeeded in not having to deal with the same pressures that faced the music industry for example.
Think about MP3 for a minute, and who brought it out for the public.
Then consider that since Edison there were countless turf wars who controlled music, and films, and the distribution, radio, movie theaters, and the entire supply chain regarding Intellectual Property leading up to the payola scandals of the 1950's. Then things went digital.
"And by the way, which ones Pink?"
These are all things that have riled policy makers causing them to rethink their core ideas.
All of a sudden supply chain takes on a new meaning. Interactivity, one of the keys to lowering health care costs, takes on a new meaning because it's already part of a highly customer focused commercial side of the Internet that feeds on itself in terms of innovation like a worm ouroboros. It's the fun of using Google, you never know when they will simply decide to dump something that didn't work out like they thought, and try something new.
But you and I know who wrote the code for Direct, and how that subsequently affected the any to any encryption paradigm by taking a detour to Web Services for the patient. That clearly satisfied the View part, but not the download and transmit part that allowed people to use the smart end devices (as opposed to hosted services) to do analytics. No, it all had to happen via API to a cloud service (even that is still somewhat advanced and developmental) or just interacting with a Portal.
So rather than do the logical thing which other countries (did that didn't have the money to waste), we engaged in what Markle's Shirky and Diamond, (and to some extent the RAND corporation), called "Magical Thinking" regarding the cost savings power of the MU1 EHR that was off the charts so to speak on the Gartner hype cycle enough to push the needle on quality measures and outcomes.
What we did that was smart, was we didn't spend billions on consultants to design the system, after the UK NHS scandal that tanked CSC, and we instead used consultants in a more intelligent way with a lot of community feedback.
But from an architectural perspective the current thinking entirely surfaced in
healthcare.gov, it's failure, and subsequent fixes.
And by 2014 when it was supposed to be wrapped up, it wasn't due to conflicting requirements. So all of a sudden it's "we can't send this over an insecure network", but that's the basic point, you have to. The network has be deemed insecure as a given and one has to apply the technology that assumes it is insecure, and fix it.
The above JAMIA paper makes that clear at the outset that the medical community wants to build it's own national standards, for medical data, but ignores the fact they failed to really make that happen and that represents the crux of the problem. There is no point in Dixie talking about SHA-1 versus SHA-2 being required for vendors because the reality on the ground is far more advanced. I spoke with NSF security experts who had been testing SHA-3 implementations on line, and they were getting SHA-3 signed content from attackers using a version of the standard that had not even been standardized. So while I am confident that the CAs and NIST can develop good infrastructure there are huge gaps like what we experienced with OpenSSL that are developmental because of these highly sophisticated attacks. Literally it was only one day that Heartbleed was made public before a VPN was penetrated by a Chinese AP team, and accessed the internal sever using SQL injection out of XKCD using admin credentials resulting in the breach of millions of records at CHS. The patch was installed that same day.
There is no encryption standard that is "healthcare specific", (certainly you have written about those that are acceptable) there is just a series of mathematical techniques in which encryption can be proven to be work. There is no medical version of TCP-IP version 4 or version 6, there is no medical version of the Internet.
But there are existing standards widely used which do fit the paper's model. And that's what should have and could have happened back in 2004 and did in other countries that don't have different U.S. specific requirements that involve a heavy political calculus.
I would challenge anyone to find a widespread example of UDDI for web services except used by the original Connect model. I think the Direct Project learned from that example, to specify a protocol that the Internet did not actually for that purpose, (DNS) but could use within a closed user group of HISPs that wanted to develop a business layer monopoly. I don't think there was an emergency to punt to Direct Trust, because I attended that meeting and presented my case, but there definitely was a policy level failure around the concepts floated by the HHS Policy group of nationally verified entities. Be that as it may, the requirement still exists, and can be done.
Without addressing the potential of FHIR to update this all to the current API economy (which really would not have been possible back in 2004), there was a great deal of potential to improve the security of encryption on the Internet and we really didn't understand at the IETF level how broken it really was. Now we do, and it's being fixed. I would say there are other paradigms dearly held by the standards committees, that don't really correspond to the "on the ground truth" which developers must face. But with MU3 requirements the developers will have to satisfy those requirements.
And this is an area that is undergoing vast improvement. Fraunhofer just announced an all encompassing encryption initiative aimed at overcoming the barriers of individual use by making it easier to use. That means not sending your messages to a third party (in this case a HISP), who encrypts the message for you using Direct Applicability Statement to another HISP. While they don't come out and say they are using a national focused X.500/LDAP Directory, the integration with EID (which is a component of the PKI model) makes me pretty much guess that's what they will use since they plan on using existing technology. What they are not saying is we need a way to Federate existing LDAP Directories, which of course is a more attractive option to the vendors on this list that sell that product. Of course, you could also sell a product that references the X.500 model, since that was the intent of TC-215 in 1988 when they came up with the idea, the subsequent descriptions in: