Thoughts on the NHIN

One of the hot button items at HIMSS10 concerned the NHIN. There were a number of educational sessions that had NHIN related content and the Interoperability Showcase seemed abuzz with the Federal Health Architecture and NHIN. Significant Showcase floor space was dedicated to the NHIN. I'm sure it was significant that the ONC had a nearby booth as well. I have tried hard to come up to speed on the NHIN but not all facets are clear to me. My initial impression was that it is a gargantuan government supported HIE. But there is not just one NHIN. First, let's look at some of the meaningful use requirements that may necessitate information exchange.

Health Care Policy 1. Improving quality, safety, efficiency and reducing health disparities.
Care Goals:
1. Provide access to comprehensive patient health data for patient's health care team
2. Generate information for quality improvement and public reporting
Stage 1 objectives:
1. incorporate clinical lab-test results into EHR as structured data
2. generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach
3. report quality measures to CMS or the states
4. send reminders to patients per patient preference for preventive/follow-up care
5. check insurance eligibility electronically from public and private payers
6. submit claims electronically to public and private payers
7. generate and transmit permissible prescriptions electronically (eRx)

Health Care Policy 2.Engage patients and families in their healthcare
Care Goals:
1. Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health
Stage 1 objectives:
1. provide patients with an electronic copy of their health information (including diagnostic test results, problem lists, medication lists, allergies) upon request
2. provide patients with an electronic copy of their hospital discharge instructions and procedures at time of discharge, upon request
3. provide patients with electronic access to their health information (including lab results, problem list, medication list, allergies) within 96 hours of the information being available to the EP
4. provide clinical summaries for patients for each office visit

Health Care Policy 3. Improve care coordination
Care Goals:
1. Exchange meaningful clinical information among professional health care team
Stage 1 objectives:
1. capability to exchange clinical key information (for example, problem list, medication list, allergies, diagnostic test results) among providers of care and patient authorized entities electronically

Health Care Policy 4. Improving population and public health
Care Goals:
1. Communicate with public health agencies
Stage 1 objectives:
1. capability to submit electronic data to immunization registries and actual submission where required and accepted
2. capability to provide electronic submission of reportable lab results (as required by state or local law) to public health agencies and actual submission where it can be received
3. capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice

Health Care Policy 5. Ensure adequate privacy and security protections for personal health information
Care Goals:
1. Ensure privacy and security protections for confidential information through operating policies, procedures, and technologies in compliance with applicable law
2. Provide transparency of data sharing to patient
Stage 1 objectives:
1. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities
So you can see that each of the 5 health care policies for Meaningful Use requires information exchange beyond the boundaries of a single system. Health information exchange is a process that is foundational for Meaningful Use.

Next we will consider two models for information exchange. An excellent discussion of these two approaches may be found in a recent blog by Wes Rishel.

Point-to-point exchange in the medical realm requires secure transport. Also required are agreed standards for data elements/vocabulary, document /messaging, and a basic mechanism to manage patient consents. Users must know the contact information for their counterparts. Queries for information generally are not available or are not automated. So you can see that here ambitions are low and requirements are limited. Functional impact is potentially high for individual patients and organizations but the capability to positively affect the health of populations and our health care system in general is not present.
The NHIN solution for this approach is NHIN Direct-This project is a little over two weeks old. The goal is to bring together major stakeholders to identify the technology (open source preferred) and establish procedures for point-to-point health information sharing. The intent is to use a rapid development approach to arrive at an initial solution by this fall. Emphasis should be placed on the fact that NHIN Direct currently is just an idea- there is not a functioning network; there are no pilot projects to refer to; scalability of this approach to fulfill Meaningful Use requirements has not been tested. Nevertheless those involved in the project, as reported at HIMSS10, and recent webinars, are full of enthusiasm. I highly recommend the excellent webinar series sponsored by the National eHealth Collaborative to learn more about on-going developments.

Comprehensive information exchange offers a menu of possible services including directories for providers, payers, labs, and pharmacies; secure routing of messages/documents; electronic master patient index; aggregation services for public health or quality reporting; document storage via registries/repositories; user identity management and authorizations; audit trails; encryption services; data mapping/cleansing services; and comprehensive data use and reciprocal support agreements among the participants. The extant NHIN for comprehensive information exchange has 3 major components: 1) NHIN Technical Assets-these are the specifications, standards, registries, and testing tools, 2) NHIN Connect Gateway- this is open source software that uses the NHIN specifications, and 3) NHIN Exchange- members use the NHIN Gateway and have signed a common Data Use and Reciprocal Support (DURSA) agreement that establishes a trust framework for participants. Development of the DURSA was a major undertaking that involved multiple legal representatives from the participating organizations.

A number of NHIN Exchange pilot projects have been undertaken over the last few years. Most have involved a small number of partners with relatively limited and carefully defined data exchanges. The participants sound universally thrilled with their successes to date, and rightly so considering the numerous barriers involved. On the other hand, these have truly been pilot projects that are many orders of magnitude beneath the scale envisioned by the Meaningful Use requirements that will affect some organizations as early as this October. I am sobered by the reality.