April 27, 2009

The NHIN: A Country Connected
By Alice Shepherd
For The Record
Vol. 21 No. 9 P. 10

The Nationwide Health Information Network is making steady progress toward its goal of creating a standards-based, secure system that uses the Internet to transfer patients’ medical records.

In October 2007, the public-private NHIN Cooperative was formed to lay the groundwork for a secure, interoperable nationwide health information network (NHIN). The project’s goal is to connect providers, consumers, and others to facilitate the accurate, appropriate, timely, and secure exchange of health information that follows the consumer, supports clinical decision making, and integrates public health needs. Through a nationwide “network of networks,” health information will be exchanged by diverse entities such as state and regional health information exchanges, integrated delivery systems, health plans that provide care, personally controlled health records, federal agencies, and other networks and the systems they connect.

Federal interfaces to the network will be through NHIN CONNECT, a cross-agency collaboration initiated by Health and Human Services, which articulates a coherent federal strategy to enable the exchange of health information. In this effort, the Department of Defense, the VA, the Social Security Administration (SSA), the Indian Health Service, the Centers for Disease Control and Prevention, and the National Institutes of Health’s National Cancer Institute are pooling their resources to develop a set of standards-based services, along with software to connect those services to their internal electronic medical records (EMRs), or in the case of the SSA, benefits assessment workflow systems. The secure exchange of interoperable health information will facilitate the care of wounded soldiers, applications for disability benefits, and emergency response to pandemic and natural disaster victims.

First Steps
The project’s primary tool for the health information exchange is a “gateway” being developed by Harris Corporation based on an agile development methodology that takes its lead from satellite control systems. Bart Harmon, MD, MPH, the company’s chief medical officer for healthcare solutions, explains, “A ground station that operates a satellite in space monitors the ‘health and wellness’ of the satellite. The people who developed these satellite systems are applying their experience to the development of the NHIN CONNECT Gateway.”

NHIN CONNECT began with a service that made it possible for the entities on the network to identify themselves in order to obtain approval to deliver messages. The next services added were subject discovery, document query, and document retrieve. “Subject discovery means that if a patient visits a facility connected to the network, the facility’s electronic health record [EHR] can call out to the network and ask which other provider may have knowledge of this patient,” Harmon explains. “Once other entities have been identified with relevant information, the next query is a document query, which obtains a list of documents available on the patient. The third step is document retrieve, in which the provider requests specific summary documents on the patient from other health enterprises on the network.”

“The workability of the patient identification and record-locating system has already been demonstrated in Canada by eight provinces,” says Lorraine Fernandes, RHIA, RHIT, vice president and healthcare industry ambassador at Initiate Systems, the software provider for these services. “The provinces have already blazed the trail by creating a blueprint for these services. In fact, in Canada, you have to meet that blueprint in order to receive funding from Canada Health Infoway [a not-for-profit organization that works to accelerate EHR use], although the provinces have some flexibility with regard to meeting their unique goals and objectives. The Canadians have also dealt successfully with the challenges of building an infrastructure that serves both rural and urban areas. In the last couple of years, there has been a fair amount of dialogue between Canadian and U.S. stakeholders so that we don’t have to reinvent the wheel.”

Initially, the scope of information that will be exchanged is a Healthcare Information Technology Standards Panel C.32 document based on the Continuity of Care Document. “It’s a health summary that includes identifying information, a list of an individual’s medical problems, medication list, allergy list, recent lab results, and similar basic items,” says Harmon. “But that’s just the starting point. Eventually, services will expand to include medical notes, discharge summaries, procedure notes—there’s really no limit on the types of information that could be requested, identified, and transported using these mechanisms. Ultimately, the gateway will grow into a delivery mechanism for complete EHR information and potentially even images.”

In March, the project achieved a milestone when the SSA became the first agency to exchange data with an NHIN partner as it began receiving medical records for some disability applicants electronically from MedVirginia, a health information exchange organization and a member of the NHIN Cooperative. The migration from paper to electronic verification is expected to decrease the time from application to determination of benefits from months to minutes, resulting in efficiencies and cost savings while improving the quality of life for those applying for Social Security disability benefits. In addition, the gateway technology was released by the federal government as an open source product.

“This has the potential to create a tipping point in healthcare reform by improving quality of care, accelerating benefits to those in need, and taking out cost—all with security, privacy, and patients in charge of how their data is shared,” says Jim Traficant, Harris Corporation’s vice president for healthcare solutions. “This is exactly in line with what President Obama is trying to accomplish with the stimulus package. It’s a compelling capability and a tribute to the federal government’s ability to create a standards-based, interoperable framework for health information exchange.”
Accelerating access to Social Security benefits is just the beginning. Eventually, the gateway technology could be leveraged by 14 federal agencies and up to 10 institutes at the National Institutes of Health, avoiding the need for each agency to build its own solution.

Patients Control Their Data
While the NHIN will enable the widespread sharing of health information, it will be the patients who control access to what type of information. “At one extreme, a patient could choose not to have his or her information shared with anyone,” Harmon says. “Another individual might choose to have data released to any valid health enterprise he or she is about to visit. Or a patient could permit sharing of data only in a specific time frame with one particular clinic but not with a specific individual (say, an ex-spouse) working at that clinic. That level of patient control was already demonstrated in December 2008 at NHIN forum demonstrations hosted by then Secretary of Health and Human Services Mike Leavitt. Security of information is also assured because nothing will transit the public network without being encrypted.”

Fernandes, who attended the forum demonstrations, was impressed with the NHIN Cooperative’s pragmatic approach. “They showed various use cases and how they would manage patient identification and consent and how the network call-out would obtain information with a standards-based approach,” she says. “If a patient chose not to share medical records, the query went out and was simply not answered. It wasn’t a carte blanche. The technology embraced and executed each region’s policy and each patient’s preference.”

An additional benefit of electronic information sharing is that it heightens the participating organizations’ awareness of data quality and how well the data serve internal business purposes and patients, notes Fernandes. “Every provider wants to have its data in good order before it begins sharing,” she says. “There can be no silo approach. When the Canadian provinces developed the blueprint for their version of NHIN, they also started working to establish best practices for ensuring data quality, data stewardship, and accountability.”

Next Steps
When will NHIN CONNECT advance beyond the SSA? The speed of progress depends not on technology but on consensus among the participating organizations. “All the stakeholders have to agree to the same standards and on next steps,” says Harmon. “The next milestone is for each partner to sign the Data Use and Reciprocal Support Agreement [DURSA]. One aspect of the DURSA is how the partners will work out problems. For instance, let’s say information that originated in one health enterprise is handed off to a second health enterprise, which makes a mistake and releases the information inappropriately. The DURSA specifies the legal agreements between the enterprises to include how and when they indemnify each other. However, the federal government is not allowed to indemnify another organization from breaking a federal law. Those are the kinds of things that need to be worked out when you’ve got a nationwide network that includes federal and nonfederal entities.”

Although the electronic exchange of health information becomes complicated when it involves both federal and nongovernmental organizations, its workability has already been demonstrated at the community level. “A community-based model of care is the foundation for leveraging the value of electronic health records,” says Gary Zegiestowsky, CEO of Informatics Corporation of America, a clinical solution technology provider focused on interoperability and tools to drive quality outcomes. “In our work with metropolitan and rural health information exchanges, we have seen very significant value to be gained from providing an electronic health record across the population within a community. NHIN takes that further with the goal to span across communities toward a broad, national approach. When physicians and clinicians have electronic medical records from other facilities the patient has visited, they can spend their time more efficiently caring for patients rather than searching for data, and they can make better decisions based on complete information.

“As the adoption of electronic medical records continues to expand, accelerated by the stimulus package, sharing of data on a broader scale will gain stronger traction and deliver deeper value,” he continues. “Fortunately, the stimulus package focuses on driving utilization. It provides financial incentives for actually using the technology, and that’s key to deriving value from electronic capabilities.”

Zegiestowsky sees other opportunities to leverage the technologies being pioneered as part of NHIN CONNECT. “Sharing patient information across treatment centers or communities has great value, but another part of the equation is leveraging that information at the point of care to improve health services,” he says. “Electronic patient records are critical to treating patients, but communities and providers also have a strong need for help in managing chronic disease states and key quality initiatives.”

Aggregate Health Information Is Vital
One of the NHIN’s goals is health information that can follow the consumer, with care for military personnel and their families being just one of many applications. “When a wounded soldier returns from Iraq or Afghanistan and transitions from Germany to the United States, delivering optimal care depends on the aggregation of information from the different providers,” says Traficant. “Sixty percent of the care to military families is delivered by the private sector, and 40% of the care delivered to veterans by the VA comes from the private sector. The need is to create situational awareness and a full picture of the continuous care for our wounded warriors. NHIN CONNECT makes that possible.”

Harmon notes that currently, more information is moving via the Department of Defense and the VA from combat zones to peacetime healthcare at Walter Reed Army Medical Center to the VA than is moving from a private practice clinic to a hospital three blocks away to a therapy organization and then to a specialist. “The vision of NHIN is that as patients move around, they will be empowered to make their information available ahead of their moves,” he says “Having shared, accurate information will create a safety net around people that reduces errors, increases quality, and saves money.”

“In our increasingly mobile population, benefits of the NHIN will reach far and wide,” says Fernandes, “from emergency rooms, where comatose or seriously injured patients cannot be expected to provide accurate information, to sharing basics like immunization records across state lines.”

Traficant has personally experienced how decision making improves with aggregate information. In the past 10 years, he has had two liver transplants and other health challenges that presented him with opportunities to view HIT at the intersection of life and data. After his first transplant, his physicians told him they could not predict if or when rejection would occur but assured him they could handle it when it did. When rejection did occur, they injected him with a drug that they said would either cure him or kill him—they would know within 20 minutes which way it would go. He survived but had another episode of rejection later and underwent the same risky treatment.

 Traficant decided to take action. After his release from the hospital, he studied his blood work and medications and found a correlation that could predict when rejection would occur. When he developed symptoms of rejection again, he worked with his doctors to change his medication, and a rejection did not occur. “Together, we determined that it was possible to treat the individual case rather than the general case and to predict when rejection would happen,” he says. “That’s when I knew that healthcare providers had the data but not necessarily the information needed at the point of clinical decision making. An interoperable national health information network can ensure critical information is delivered to the right person at the right time to save lives.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.