Background Secure clinical messaging and document exchange utilizing the Direct
Protocol (Direct interoperability) has been widely implemented in health information
technology (HIT) applications including electronic health records (EHRs) and by health
care providers and organizations in the United States. While Direct interoperability has
allowed clinicians and institutions to satisfy regulatory requirements and has facilitated
communication and electronic data exchange as patients transition across care
environments, feature and function enhancements to HIT implementations of the
Direct Protocol are required to optimize the use of this technology.

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