Electronic Health Records

States’ Will Play a Role in Sharing Your Health Records with Federal Agencies and Others

March 11, 2010

GHIT - "What is the motivation for providers to join a health information exchange if all they need is NHIN Direct to help them achieve meaningful use?"

The question was put to Dr. Doug Fridsma, the director of standards and interoperability in the Office of the National Coordinator by an audience member who had just heard Fridsma describe ONC’s new plan to offer providers the tools to perform a series of basic health information transactions over the Internet.

The project, dubbed "NHIN Direct", had been discussed in bits and pieces before last week’s Healthcare Information and Management System Society’s (HIMSS) annual conference in Atlanta. But the session featuring Fridsma, along with newly named NHIN Direct project manager Arien Malec, was the first time they had discussed the idea in any detail before a general audience.

In a 30-minute presentation, Fridsma explained that ONC had begun working on a project designed to broaden the use of the NHIN to accommodate organizations which had simple, "less technical" requirements for sharing health information with other medical organizations.

NHIN Direct would be a set of policies and services incorporating basic messaging standards as well as directory, identity proofing, authentication and transport services, all bundled intp a "trust fabric" enabling providers to swap health information securely.

Fridsma illustrated a set of "core use cases" in citing a primary care provider who wanted to send a summary care record along with a referral to a specialist; and a lab that wanted to transmit a set of test records to the ordering physician.

Both applications represent the first stage of "meaningful use," which providers must reach to qualify for federal financial incentives to purchase health IT systems.

As a connectivity tool, NHIN Direct follows several years’ work by ONC, federal and state officials, as well as regional health information exchanges to establish a set of gateways through which individual providers, provider networks or hospitals could share data securely over the Internet.

Fridsma emphasized that NHIN Direct would not be designed to compete with these projects.

Nor would it interfere with current federal HIE projects involving the Defense Department, the Social Security Administration, the Veterans Affairs Department, Kaiser Permanente, the Centers for Disease Control and Prevention and a number of other agencies that have joined forces in the last few years to pilot development of a Federal Health Architecture (FHA).

"We recognize there is a broad range of exchange needs, including simple exchanges as well as more robust exchanges with federal agencies," Fridsma said.

Many of these projects have used FHA’s "Connect" software, a robust implementation of the NHIN suited to the sophisticated data sharing policies and services required in large exchanges.

These projects, which Fridsma identified as "Limited Production Exchanges," would continue to have a place in the NHIN "ecosystem," he said.

"It’s critical that the current participants in the NHIN Exchange are at the table and as we broaden this out that we make sure that we maintain those links and that interoperability occurs."

That would include simple exchange partnerships as well as more robust HIE networks envisioned in ONC’s "Beacon" community and state HIE programs designed to foster health information sharing in states and across larger communities.

"It was clear from the very beginning that we have to recognize the states and that enterprise level information exchange needs to be supported," Fridsma said.

But NHIN planners also envision a more heterogeneous playing field, with room for both direct exchanges and more complex HIE at the state and large enterprise level.

"One of the key thing to recognize is that interoperability is not one- size-fits-all," Fridsda said. "And we expect that as exchange occurs across the network different parts of the network will be at different stages in terms of their ability to exchange information."

In this landscape, Fridsma suggested states and larger HIEs may take on new roles as "enabling organizations," providers of "foundation" services such as identity proofing and authentication, addressing and secure routing that those sitting lower in the NHIN hierarchy may not be able to provide for themselves.

"There may be types of exchange that don’t require many intermediaries," Fridsma said. "But as soon as you start talking about making sure things are private and secure; or that directories exist that can route info effectively; as soon as you start talking about ID proofing and authentication, there’s a role for enabling organizations to do that."

"So I think there is a role for states, Fridsma said. "It may be slightly different than a one-size- fits-all but I think there are these foundational elements that the states can provide."

The NHIN Direct project is on a fast-track, Fridsma said. ONC is seeking organizations that "have skin in the game," to implement the project by early summer or early fall.