Federal agencies are forging what some experts call "industrial-strength health information exchanges," high-level, standards-based, HIEs that eventually will provide public and private sector health care providers the tools necessary for sophisticated clinical information sharing.
Working under the auspices of the Federal Health Architecture (FHA) community, a group of 26 health agencies and offices, they have developed increasingly detailed versions of "Connect," a set of software tools and standards that drive some of the most sophisticated HIEs now operating.
Connect-powered HIEs are up and running between the Defense and Veterans Affairs departments, and with private sector health care providers whose clinicians treat military patients. Other non-clinical health-related agencies, such as the Centers for Disease Control and Prevention and the Social Security and Food & Drug administrations, are also Connect users.
Together these HIEs represent anchors in the emerging nationwide health information network, an architecture that will be made up of both high-level hubs and provider-to-provider spokes. Connect's developers are adding features that will help extend the network at both levels.
Connect for direct HIE
Dave Riley, a independent consultant who is under contract to the Office of the National Coordinator (ONC) and is the Connect program's lead manager, said FHA continues to update the Connect gateway"a Web site for provisioning HIE software"on a quarterly basis, adding features and services for more robust HIE.
The current version of Connect includes specifications for "NHIN Direct," a streamlined version of the standards and services of the Nationwide Health Information Network (NHIN), designed to help physicians and small practices which lack a complex IT infrastructure share basic electronic health records.
With the NHIN Direct tools now a part of Connect, small providers can send information requests and responses using simple secure e-mail protocols. Yet Connect also enables them to send messages to federal agencies and other current "industrial strength" users of the NHIN.
Using Connect, the Centers for Medicare and Medicaid Services (CMS) is working on the Care Health Information Exchange Project (C-HIEP), which focuses on the exchange of continuity of care information across health settings.
Large HIEs MedVirginia, Health- Bridge and Regenstrief Institute are participating in the project, in which CMS wants to gauge the changes in the health of a patient as they move across chronic care settings, such as from a hospital to a skilled nursing facility and back to the nursing home.
"That project has been designed to test whether the care document is a valid tool for assessing that or not," said Riley. "It is also a way for them to dip their toe into the water of health information exchange through NHIN," he said.
Another Connect-supported project is being tested under which electronic documents sent by physicians participating in the Physician Quality Reporting Initiative (PQRI) are reviewed electronically. Once the documents are submitted, a message is sent back telling the physician whether the document was accepted or needed additional information.
The Centers for Disease Control and Prevention is also working on Connectenabled pilots in Indiana, New York and Washington designed to share data about public health symptoms reported in emergency rooms. So far, only Indiana has used Connect to send public health data"H1N1 flu data.
"Sometimes threats cross state boundaries and this data-sharing mechanism can help public health professionals alert multi-state areas of an emerging event, and ultimately contribute to a cohesive picture of the nation's health," said Nedra Garrett, acting director of CDC's Division of Informatics Practice, Policy and Coordination (DIPPC).
Beyond clinical information exchange, agencies are also showing an interest in using Connect for administrative transactions, such as checking on prior authorization in submitting a claim. "We don't have a clear set of priorities yet, but we're beginning to see requirements around these coming out of the federal agencies," Riley said.
Other types of Connect-supported HIE may emerge between federal and state agencies, according to Larry Albert, health care sector president at Agilex Technologies, which works on application integration for Connect.
Among those may be the creation of a registry for health insurance enrollment information among state health and human services programs to support health insurance exchanges called for by the health reform law. The Connect gateway could provide the means to link with such a registry, query it and bring back confirmation or denial, he said.
Federal test bed
Because federal agencies were out of the gate early on these and other examples of HIE development, the Office of the National Coordinator (ONC) will continue to rely on them to test HIE standards and make new use cases easier to adopt, say ONC officials.
"Within FHA and Connect, we're developing new ways of providing exchange and demonstrating success in the real world," said Dr. Doug Fridsma, ONC's director of standards and interoperability.
That includes the VA-DOD's virtual lifetime electronic record (VLER) project, the Obama administration's effort to develop a single electronic system to track the medical, benefits and administrative records of service members from the time they are inducted into the military through the remainder of their lives as veterans.
The VLER project involves testing complex HIE between DOD and VA clinics in four communities so far, including San Diego, Hampton Roads, Va., Indianapolis, Ind., and Spokane, Wash. The FHA has been instrumental in getting the VLER pilots up and running by conducting tests and bringing other HIE partners on board, Fridsma said.
One of the critical lessons taken from these pilots is the need for making HIE standards more precise so they can be used consistently from one implementation to another. "Moving from pilot to production means we have to be able to scale these things," Fridsma said.
For example, VA and DOD use the C-32 document format standard for sharing patient summary data, which has a number of options for how it can be used by different providers. However, the variations were enough to block the actual exchange of information until the two agencies reconciled their differences in implementing the standard.
"We have to make sure that we have very explicit specifications, that we reduce the options and that we make it clear how we expect people to interpret and use that implementation," Fridsma said.
Along with being specific, the standards need to be as simple as plug and play. "We want to get to the point where we have explicit drivers, explicit protocols that say I am an EHR information system and I know how to write orders and do laboratory exchange, and these are the kinds of drivers that you're going to need to interoperate," he said.
Along the way, federal health agencies have become key test beds for [solving] problems that we know the rest of the country is going to have to address as they start to move toward more interoperable solutions," Fridsma said.
