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Chapter 9
Fitting HIE Into a National Context
There are ambitious plans for health information exchange in the U.S. As envisioned by those building a national network for HIE, the eventual goal for the country is to move health information anywhere, whenever it’s needed.
The ultimate product is the Nationwide Health Information Network (NwHIN), which is being called “a critical part of the national health IT agenda” by federal agencies tasked with achieving the digital transformation of healthcare.
The Nationwide Health Information Network
Over the past several years, the NwHIN “is being developed to provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers and others involved in supporting health and healthcare.” See here. Through the NwHIN, a patient’s clinical information can be accessed anywhere in the country.
The NwHIN will make use of a set of standards, services and policies that enable secure health information exchange over the Internet, one of the goals of the HITECH Act.
In 2010, two workgroups under the federal Health IT Policy Committee began essential work intended to result in the formation of the NwHIN. A Governance Work Group prepared recommendations for governance of the NwHIN; and the Nationwide Health Information Network Work Group offered recommendations on how best to use standards, services and policies to enable the sharing of health data.
Work began on the NwHIN by developing prototype architectures to perform a number of key functions, which include:
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Developing capabilities to find and retrieve healthcare information inside of health information exchanges and between health information exchanges.
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Delivering new data to appropriate recipients.
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Offering key consumer services, such as control over who can access a personal health record, data searching, and the ability to choose not to use a network service.
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Proofing, authenticating and authorizing user identities.
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Identifying methods for matching patients to their data without the use of a national patient identifier.
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Accessing control and other security protections.
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Offering specialized network functions.
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Investigating the feasibility of large-scale deployment.
The second phase of the project involved using prototype architectures to securely exchange data between nine HIOs, providers and several federal agencies. Exchanging patient information through a “network of networks” approach is a key strategy to support the NwHIN because the NwHIN isn’t a physical network running on servers supplied by the federal government nor does it enable a central depository for storing records. Thus, as it is envisioned, the NwHIN will be highly dependent on the development of HIE initiatives nationwide to enable the exchange of health information. As such, the NwHIN exists as a long-term goal with which all current and future HIOs are expected to interact.
In assessing HIOs, providers should expect potential candidates to employ NwHIN standards and to have a plan to connect with other HIOs through the NwHIN.
The Direct Project
While the ultimate goal is to use a network of HIOs to achieve information exchange on a national scale, HIE efforts are only just beginning in several areas of the country, and it will take time to build up information exchange on a national scale.
As a result, based on recommendations from the Nationwide Health Information Network Work Group, the Direct Project was launched in early 2010 to develop a simple, secure, scalable, standards-based approach for participants to send authenticated, encrypted health information directly to known and trusted recipients over the Internet. Secure messaging enables simple transfer of information through email client software.
A number of electronic health record and personal health record vendors, integrated delivery systems, HIOs and states have committed to implementing Direct Project approaches to exchanging information. The Direct Project web site includes commitments to participate by 20 ONC-approved state plans, as of mid-August 2011. To view the web site, see online.
Nine pilot projects are currently under way or planned. For example, in Minneapolis, Hennepin County Medical Center has been successfully sending immunization records to the Minnesota Department of Health. In New York state, MedAllies, a Health Information Service Provider or HISP, will launch a pilot project to demonstrate the delivery of critical clinical information across transition of care settings in a "push" fashion that supports existing clinical workflows in the Hudson Valley of New York. MedAllies will implement the full Direct Project infrastructure, including both the required SMTP backbone, as well as support for the Cross-Enterprise Document Reliable Interchange (XDR) elective protocol. Albany Medical Center participated in this Direct pilot project and demonstrated Allscripts Enterprise and Siemens Clinicals CCD-based patient data exchanges between it and other participating pilot organizations. According to George Hickman, executive vice president and CIO at Albany Medical, efforts are continuing to build a production-state exchange with its key vendor partners and MedAllies in an effort to demonstrate the viability of this approach while supporting the needs of its community physician constituents.
CONNECT – A Standardized Way to Exchange Patient Data
CONNECT is billed as an open-source software solution that supports health information exchange, both locally and at the national level. It is intended to promote interoperability in the U.S. healthcare system.
The CONNECT solution was developed by federal agencies that needed to share their health data, not only amongst themselves but also with other levels of the government and the private sector using the NwHIN. Rather than developing individual gateway solutions, the federal agencies banded together through the Federal Health Architecture to build CONNECT.
The government then released the CONNECT gateway to the private sector at no cost, and envisions that it will be further developed and supported by a community of users, which is expected to grow over the next several years.
“Though federal agencies delivered the initial versions of CONNECT, the long-term vision is for a broad community of organizations building upon the CONNECT software to collaboratively define and implement its future direction,” according to the CONNECT website. “The CONNECT team has started this move by opening the development process beyond the initial development team, enabling other stakeholders to contribute to features important to them. The program will go further, implementing a true community governance structure as the stakeholder community matures and the options can be explored collaboratively.”
More information about CONNECT can be found online.
The CONNECT community has conducted a variety of events to spread information about the application, and the latest iteration of CONNECT, version 3.2, was released in mid-June 2011.
In addition to the federal agencies, several vendors, HIOs and provider groups are in the process of pilot-testing the application.
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