Just when I thought the NHIN architecture and NHIN CONNECT were taking shape as the latticework underlying what is to be our Nationwide Health Information Network, a new initiative hit the proverbial street – NHIN Direct.  On its face, the NHIN Direct concept appears perfectly useful and potentially the answer to clinical data sharing – providers securely email continuity of care documents between one another in order to facilitate the transfer and continuation of care.  Upon further rumination, however, I have to ask myself, does the NHIN Direct concept represent a manifestation of Occam’s Razor, or is it just lazy thinking?                                                                     

Allow me to share a few observations: first, NHIN Direct, in its conceptual stage, appears to be separate and distinct from the overarching NHIN architecture originally conceived of and devised to establish a universal platform for health information exchange.  The NHIN architecture’s promise to standardize transactions, content, security, information sharing agreements, and clinical surveillance offers a future of comprehensive clinical and administrative data integration, sharing, access, reporting and analytics. 

Second, I don’t claim to be a NHIN Direct expert, I’m not sure anyone is at this point, since it is only in a conceptual state; but, as I understand the NHIN Direct concept, it essentially suggests the ad hoc distribution of limited clinical and administrative data, as published in a CCD, using a point-to-point secure email metaphor.  Armed with my admittedly limited awareness of the NHIN Direct concept, I find myself concerned that NHIN Direct foretells a future filled with version control confusion, stale data, compromised patient – physician relationships, no integration, incomplete information, no surveillance capabilities, and no true analytical features.  It’s a relatively simple sharing paradigm propped up by the chaotic, unstructured nature of email. Check that: secure email.

In short, the NHIN Direct concept may be a part of the answer, but it isn’t the answer.  Health Information Exchanges in their current and evolving form, HIEs focused on supporting the maturing definition of Meaningful Use, offer the structure, security, discipline, and feature sets required to support a healthcare community in a comprehensive and meaningful way.  Check that: some HIEs offer such capabilities. 

So, if we agree that the NHIN Direct concept is part of the answer and not the answer, why wouldn’t it be an additional service definition on the NHIN, a reasonable extension of the CONNECT platform? Perhaps it will be.  That is certainly my hope.  But appearances lead me to a different conclusion.  Why have new work groups and what appears to be a separate organization and set of committees, spun off to develop NHIN Direct?  To my knowledge, the FHA was already working on adding reliable/directed messaging to the NHIN specifications; so, NHIN CONNECT will support the NHIN Direct concept shortly.  Why the diverging paths?

Bottom line: here’s my concern.  Placing separate, exclusive emphasis on NHIN Direct outside the context of the NHIN architecture creates a very dangerous risk.  The healthcare community will begin to view the secure emailing of health information as the answer, the foundation upon which real change will be built – change intended to truly advance healthcare and support reform.  If this happens the following is lost until the next healthcare IT revolution: clinical and administrative data aggregation, surveillance, analytics, research, quality assessment, outcome measurement, standard exchange of electronic referrals, automated significant event notifications, patient identification (i.e., EMPI), patient access, real system interoperability, patient privacy governed by care relationships, and several other important features facilitated by a more structured approach.  The ability to check a central repository for SSA records and save 42 days per disability determination – gone;  an increase of approximately $2M per participating hospital in additional revenues – gone; the ability to deliver critical health information to organizations caring for patients with the highest need and the lowest ability to otherwise receive care – gone. 

I encourage the ONC to consider NHIN Direct in the context of the larger NHIN architecture and ensure its development coincides with the current path and does not diverge.  Let’s offer truly innovative solutions that add step function increase in value through consensus. Let’s not create confusion by presenting a simplistic solution as the obvious solution.  Let’s use rigorous thinking not lazy thinking.