Health Information Exchange: A Network of Networks

October 12, 2010

Welcome back to the HIEWorks blog.   We took a bit of a hiatus during the summer months.  We’re back and ready to comment on the state and direction of health information exchange.

For some months leading up to the summer, we learned of numerous stalled and failing publicly funded health information exchange (HIE) initiatives.  After speaking with numerous organizations and personnel in the HIE market, including the ONC, it became clear that large, publicly funded HIE initiatives financed with government subsidies and constructed around the delivery of a single technology option for HIE is rapidly falling out of favor.  As we’ve written before, lack of sustainability is the primary issue facing publicly funded HIE initiatives. Moreover, such initiatives often follow geographic boundaries dictated by the public funding sources such as those specific to a particular state, and not the needs of care communities. As a result, public initiatives have been weighed down by considerable challenges and unfortunate entropy.  State patient privacy and regulatory compliance, patient consent laws and regulations, financial and regulatory considerations for inter-state healthcare systems, and Medicaid reporting disparities between states are among the myriad issues that arise from bounding HIEs using arbitrary geographic determinants.

Here’s the good news. A clear change is underway in the HIE marketplace.  Current and planned standards emanating from the ONC and other widely accepted standards committees indicate a strong preference for interoperable exchanges designed to serve individual enterprises, Accountable Care Organizations (ACO), medical referral regions and local care communities – i.e., those communities that serve a logical and well understood population of physicians and patients.  And, through established and evolving standards such as NHIN CONNECT and NHIN DIRECT, the HIE market direction is to support a network of networks (or exchanges) linked together through a common, open source architecture, promulgated by the ONC and other recognized standards bodies.

The sustainability and practicality of monolithic, publicly funded HIEs that do not provide for “on-ramp” connectivity from established and planned exchanges is precarious at best.  The ONC has made it clear that all HIE initiatives should, at a minimum, make provisions to support connectivity between disparate exchanges.   That is the very purpose of the standards, and that is the only way to encourage innovation while leveraging past and planned investments.

It is no secret the healthcare landscape is littered with failed public HIE initiatives designed to deliver a single-source solution to an arbitrarily determined collection of care providers and patient populations.  Simply put, such initiatives are not guided by the free market.  Rather, they are subject to the whims of annual government budget cycles, grants and misguided governance.  So, what do we do? I believe publicly funded initiatives must facilitate and encourage interoperability between HIEs built on sustainable models that support logical healthcare communities – communities built around natural provider-patient relationships, referral patterns, and accountable care organizations.  In doing so, these initiatives (i.e., public initiatives) have an opportunity to add value, properly leverage public funds, and help lay down the necessary infrastructure required to facilitate the network of networks that will someday be known as the Nationwide Health Information Network (NHIN).

Changing the Direction of HIE?

April 13, 2010

I’ve been talking with folks who do HIE on both the community and enterprise levels. Questions come up as to how NHIN Direct might impact HIEs and the secure messaging services they offer: does NHIN Direct erode the business value of a ‘proprietary’ (i.e. non-NHIN-Direct) secure messaging network? Can we wait for the NHIN Direct open source and just use that?

So let’s look at NHIN Direct in the context of both the current and future state of HIE. These Health IT folks are keenly aware of the economic viability and sustainability issues with respect to the HIE. And the promise of an open source solution can certainly have an impact on implementation cost and long term support for such a system.

So, can we wait? My short answer is no. But just ending the blog at “no” is no fun… I’ll expand on my answer in three parts:

  1. The ability to push information in support of an effective, secure clinical dialog between providers in different care settings (or between clinical systems and providers) has an immediate impact on patient outcomes. It therefore presents an opportunity to add immediate value to healthcare providers.
  2. Looking back on my experience with similar initiatives, one can safely assume it will take a while for NHIN Direct to formalize to the point of being production-ready, and even longer to have operational significance. We’re 5+ years down the NHIN road, and that production network is barely off the ground (officially called “limited production exchange” by ONC). I hope Direct moves faster, but the industry, the government, and the process are what they are – the best way to predict the future is to look at the past.
  3. No matter how or when NHIN Direct rolls out, we also know from experience that it will take years for the standard to be supported in the systems and tools of the healthcare community. Until 100% of the provider community uses tools that support Direct out-of-the-box, somebody will need to provide an alternative solution – said differently, an HIE’s “proprietary” solution will continue to deliver value. Compare this to the adoption of IHE’s interoperability profiles for information exchange: currently there are just a few 100% IHE-compliant exchange networks, and they have virtually no IHE-based connectivity to EMRs (through no fault of their own – it is just how the HIT ecosystem evolves).

There are many new pressures on providers to accelerate the need for provider-to-provider messaging: hospitals are concerned about bundled payments, and all providers are watched and measured with respect to readmissions, care transitions, and handoffs.

Secure messaging solutions facilitate the clinical integration and coordination that supports improvement in these areas, as well as supplying what we’ve come to expect in terms of delivery of lab results, consult reports, transcriptions, alerts, and such – all key elements of information exchange that increase efficiency and reduce errors.

So you can see where I’m leaning: NHIN Direct is going to take a while to become relevant, on the order of years, not months. The provider community cannot wait that long.

It still makes sense to invest in an extra-enterprise or community secure messaging solution now, get it operating ASAP, broadly deploy it across the region, and insist that the platform vendor stay 100% compliant with Direct.

The NHIN Direct work groups are striving to have a demonstration later this year. I’m a part of that effort, and I too would like to see something that soon.

In the mean time, let’s not allow the momentum of robust information exchange to slow.

NHIN Bait and Switch

March 12, 2010

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.


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