The HIE Blog

Ever since ONC unveiled its vision for NHIN Direct, I’ve gotten many questions that indicate there’s a lot of confusion out there about what the NHIN initiative is and what it isn’t.

In several presentations given by members of the ONC, I’ve heard very clearly that the Federal government is not in the long-term business of developing HIE software. Rather, their goal with NHIN (and NHIN Direct) is to develop concepts, specifications, standards and frameworks that the private sector must pick up, bring to market, maintain and evolve for years to come. NHIN (or NHIN Direct) is not defined as a long-term, sustainable software package that states or other organizations can pick up and use to replace a commercially-available or home-grown HIE package.  Their intent is for the industry to adopt the specifications and adhere to the governance model to drive a level of consistency across implementations.

So, what is NHIN Direct? I’ve reviewed a lot of the documentation and use cases that frame NHIN Direct. It’s meant to fill a gap left by the traditional NHIN model. Original NHIN was focused on ‘pull’ use cases, or, said another way, trusted patient discovery and document exchange. Alternatively, NHIN Direct focuses on simplifying a series of ‘push’ use cases that were unaddressed by the original NHIN model. These push use cases, taken from the NHIN Direct website, include:

1. Primary care provider refers patient to specialist (including summary care record)
2. Primary care provider refers patient to hospital (including summary care record)
3. Specialist sends summary care information back to referring provider
4. Hospital sends discharge information to referring provider
5. Laboratory sends lab results to ordering provider
6. Providers without a fully certified EHR send and receive data
7. Primary care provider sends patient immunization data to Public Health
8. Pharmacist sends medication therapy management consult to primary care provider
9. Provider sends patient health information to the patient
10. Provider sends a clinical summary of an office visit to the patient
11. Hospital sends a clinical summary at discharge to the patient
12. Provider or hospital reports quality measures to CMS
13. Provider or hospital reports quality measures to the State
14. Laboratory reports test results for some specific conditions to Public Health
15. State public health agency reports public health data to Centers for Disease Control
16. Provider reports to the State
17. Hospital reports to the State

With these simple NHIN Direct use cases, the ONC de-emphasizes content standards and focuses more on using the Internet and understood approaches like email messaging to facilitate exchange based on an implied trust model already covered by HIPAA.

To date, NHIN Direct has no technology or specifications, but they want to iterate very quickly – specifically, they’re aiming for prototypes by the end of the summer. The leaders of the initiative are preaching simplicity and focusing on trying to deliver a shared, Internet-like service similar to domain registrars – i.e., health domain registrars – inspired by a collaboration between Wes Rishel and David McCallie called Simple Interop. Although a simple concept, NHIN Direct probably doesn’t go far enough yet because it still will ask the providers to get registered (trivial), but also in some cases to park their domain on their own server (a bit harder) or find a place they trust (which can be daunting if they’ve never done it; perhaps a nice hook to the REC can solve that problem).

This emphasis on ‘push’ use cases begs the question: what is the role of state-level HIEs in the NHIN Direct paradigm? Dr. Doug Fridsma, the director of standards and interoperability in the Office of the National Coordinator addressed this question well earlier this month. He suggested that states and HIOs serve as “enabling organizations” that offer services like identity management and authentication that participants in the community may not be able to provide for themselves.

Medicity supports a strategy that falls in line with this analysis from the ONC – encouraging state and regional HIEs to provide a thin set of shared HIE services like identity management, record location, provider directory, and medication inquiry while offering choices to providers as to how they want to connect to those HIE services based on their current adoption of Health IT – auto-printing, modular EHR bundles for meeting meaningful use, and native EHR integration itself.

Rather than getting into the business of deploying and managing a complex, monolithic solution of both HIE and EHR technologies that do everything under the sun, states should indeed stay focused on being enabling organizations that guide and drive meaningful HIE in a sustainable manner.