Monday, September 28, 2009

Building the Nationwide Healthcare Information Network

I describe interoperability as a set of business partners with aligned incentives who exchange data to enhance efficiency, reduce costs, and improve coordination of care. Generally healthcare information exchange is local - hospitals, labs, pharmacies, clinician offices, and public health in a region exchange data for a specific purpose. Privacy and data use concerns are resolved locally. I do not believe that an architecture that requires a monolithic central database in the basement of the Whitehouse is going to be acceptable to stakeholders.

So what is the Nationwide Healthcare Information Network (NHIN) likely to be?

It will be a federated network of networks based on a common set of policies and data standards, enabling local, regional and domain specific (VA, DOD, Children's Hospitals) networks to connect with each other. Think of HIE's as similar to local phone exchanges and the NHIN as long distance service. What is required for a successful implementation of a "long distance carrier" for healthcare data?

1. Governance - A national framework for setting policy and technology for the NHIN. The HIT Policy and HIT Standards Committee could serve this purpose.

2. Education/Promotion - We need to ensure all state HIEs think of the NHIN as a connector between regional activities and understand how to use it. ONC could do this or partner with an organization such as the National eHealth Collaborative (NaeHC) or the e-Health Initiative (eHI).

3. Incentives - Meaningful use provides a powerful set of incentives to foster healthcare information exchange. Ideally, communications with Federal stakeholders such as CDC, SSA, FDA, and CMS would be done via the NHIN. This will incentivize all stakeholders to purchase EHRs and build HIEs which are compliant with NHIN policies and data standards.

4. Common transport, content and vocabulary standards - When EHR and HIE data exchanges are built, implementers have a choice of architectures and standards to implement. The work of HITSP and the HIT Standards Committee is architecture neutral, but provides enough constraints in the standards to reduce the number of choices, enhancing interoperability. Ideally, EHRs, HIEs, and the NHIN should should the same data transport (SOAP or REST over TLS), the same content (HL7 2.51, CCD, NCPDP Script 10.x, X12 4010 or 5010), and the same vocabularies (LOINC, SNOMED-CT, RxNorm, UNII) ensuring easy integration of regional and national efforts.

5. An agreed-upon set of security and privacy rules, including data use and reciprocal support agreements to which everyone who links to the NHIN must conform. Entities that link into the NHIN, and consumers who allow their information to be sent over the network, should be able to safely assume that some well defined, basic protection rules are enforced throughout, and that some well defined rules for representing, exchanging, and enforcing authorizations and consents are in place throughout the network.

Over the next year, the HIT Policy and Standards Committees are likely to work on NHIN related issues. I look forward to a secure nationwide network of networks with common policies and data standards that supports healthcare reform, public health, and the needs of patients, providers and payers. This is something we will create - we do not need to wait for our children to build it!


GreenLeaves said...

The following article has some good points and a link to a paper looking at EHR in different nations.

As John succinctly points out, it is about governance, standards and incentives. I think many of these countries are ahead because they are smaller, have government involved in healthcare and standards.

DBBaker said...

Excellent description of the NHIN vision and potential! The only thing I would add to your characterization is that the NHIN should be viewed as an essential, trusted enabler for high quality, well coordinated health care for individuals, as well as for protecting communities at the local, state, and national levels. Ultimately, “incentives” for use should be inherent – to carry your telephone exchange analogy a step further, we certainly don’t need to “incentivize” people to use their cell phones! We use the phone service because it provides value (inherent incentive) to individuals and organizations, and a defined level of privacy protection. That should be the goal of the NHIN as well – not to dictate how enterprises, states, or regional exchanges do their jobs, but to provide a common framework for enabling basic connectivity and base-level protection.

gershater said...

Woohoo! A blog post I have been looking for that describes the requirements of trust and agreed technologies to support NHIN and HIEs.
I have past experience with Identity and Trust (SAML and similar technologies.
I plan to investigate how these Identity technologies relate to HealthIT