The HITECH stimulus funds have created great buzz in health and health IT. Providers are contemplating electronic medical record (EMR) implementations, vendors are scurrying to be "meaningful use" compliant, and states and others are planning for Medicaid, health information exchange, training and other related services.
This environment should be ripe for movement, yet there are numerous signs that the movement that comes will be begrudging and fragmented - not the kind explosive, coordinating movement that has characterized other major information technology advancements like the Internet.
Projections for physician adoption rates, the timeframe expressed by the "meaningful use" phases, and the push-back received on the first "meaningful use" criteria all point to such a trajectory.
The architecture work of the Nationwide Health Information Network (NHIN) anticipated this situation. The work recognized that to be successful it must leverage the ongoing work of many organizations to develop trust and security in health information exchange. It also recognized that these state, local and federal level organizations each need to build information exchange capabilities that suit their own immediate needs, but also to come together into a "ring" of connected networks that is compelling to join.
And unlike the existing "limited production" implementation of the NHIN, the "ring" would establish the trust and technical relationships to allow each of the participants to work with each of the others and leverage the other's work.
With national name recognition, such a "ring" of connectivity could be the closest thing that that the fractured health system would have to a "killer app" that can truly pull-in electronic participation.
Although connectivity is not an application per se, the right kind of connectivity can create a group of participants that, on reaching a threshold, presents an irresistible case for others to join. In a "ring," the more participants that join, the more compelling is the case to join, as each participant has access to all of the other participants.
The NHIN "ring" of connectivity is a secure and confidential version of the "many to many" connectivity that was the basis for the Internet explosion. It contrasts with the "point to point" connectivity that is generally found in healthcare today and is being operated in the current federal NHIN implementations.
The "ring" or "many-to-many" implementation of the NHIN that was targeted by its architecture efforts looks something like this: organizational participants (state designated entities, integrated delivery networks, state and federal agencies and other organizations that can bring in individual practices and even PHRs) are supported in pursuing their individual health information exchange work, but also connected to each other under a common data use agreement and self-governance.
For the agreed upon uses, each organization supports authorized information requests from all of the others. This "many-to-many" connectivity is the powerful attractant. Those who are outside will want to be inside; and the power of that attraction grows as the number of participants grows. There will also be attractions for federal agencies to have access to participants for their programs built on the work of the local and state health information exchanges. There will be attractions for states and regions to establish connectivity with others to support their HITECH responsibilities.
Moreover, there will be attractions for providers beyond stand alone EMR's when they get appropriate access to information they need from hospitals and from other providers who have information they need to treat their patients. And finally, there will be attractions for consumers who can ensure that they or their designee can get their electronic records when they need them.
With a change in administrations, there is a natural tendency to revisit what has been done previously. With "NHIN Direct", the NHIN now seems to be the subject of such attentions.
With the responsibilities given to the states in HITECH, though, now is not the time to revisit the work that that has been done nationwide to develop organizational trust and momentum for health information exchange. Now is the time to unleash the power that the "many-to-many" connection of these organizations can offer to help make HITECH work.
Now is the time to offer states and state designated agencies not just responsibility for health information exchange but also to enable them with a clear and consistent target. It is time to unleash the NHIN from the limited model that requires each participant to be a contractor to the federal government and to work in only a point-to-point fashion.
Now is the time to let the state designated entities have the governance role that they need to carry out the health information exchange task that has been required of them.
There will be those who say that unleashing the NHIN for "many-to-many" connectivity cannot be done; some will say that confidentially is an issue. But confidentiality can be addressed by starting with the hard-to-refute use case of providers retrieving data on their patients when they have appropriate patient consent in hand.
Some will say that the technology or standards are not ready But the technology and standards have been specified and tested in the NHIN process and are readily available in the free NHIN Connect software. There are some who will say that there are better standards (Rest vs. SOAP) or better approaches, such as a secure email approach that would bypass health information exchanges (and which seems to be the concept of "NHIN Direct"). But there will always be new and different approaches.
What the states and organizations participating in HITECH need now is a stable and tested way forward that can grow and evolve to accommodate new approaches, not a future alternative that is as yet undeveloped, unspecified and untested. There are those that say that the participants cannot agree to the type of participation that requires them to work with all others. But in fact that is exactly what the attorneys and policy folks did for the participants in the NHIN Trial Implementations. A model for a common Data Use and Reciprocal Support Agreement (DURSA) was hammered out for multiple jurisdictions that bound the participants together in this way.
Finally, there are those who will say that governance from this activity will be hard to construct. But self-governance of the participants and by the participants starting with the state designated entities has many potential models and can be established now.
It is time to unleash the NHIN and let it develop into the "killer app" that can actually help draw in participants and make meaningful outcomes attainable.
-- John W. Loonsk, MD FACMI, is chief medical officer of CGI Federal Corp.
