The stars seem to be aligned for rapid progress in health information exchange. We are fast approaching a point in the development of the Health Internet where ubiquitous exchange of health data to improve care coordination and health care quality and ultimately lower costs might be possible. We still face some problems, and standards and policies must be aligned, but there is some great synergy in play that will help drive this vision forward. There are a variety of different initiatives which are coalescing, but there is also a great deal of work still left to do.
HIE Efforts Under Way
The Nationwide Health Information Network Exchange (now called the eHealth Exchange) has successfully transitioned to an independently sustainable public-private partnership. This new organization, called HealtheWay, includes four federal agencies -- CMS, the Department of Defense, the Social Security Administration and the Department of Veterans Affairs -- as well as at least 21 non-federal entities that all share patient records for episodes of care. The ability to provide a platform for national exchange is critical to the success of efforts to reach the triple aim of improving the experience of care, boosting the health of populations and reducing per capita costs of health care. By ensuring that clinicians have the right information at the right place at the right time, we can finally begin to make progress in achieving these goals.
Working in tandem with the transition to HealtheWay have been collaborative efforts fostered by the EHR/HIE Interoperability Workgroup (IWG). One objective of IWG has been to define a single set of standardized, easy-to-implement interoperability specifications that will increase the adoption of electronic health records and HIE services. Formed by the New York eHealth Collaborative, IWG is comprised of several vendors and organizations, as well as seven states:
- New Jersey;
- New York; and
This represents approximately 30% of the U.S. patient population. IWG has joined forces with HealtheWay to enlist the Certification Commission for Health Information Technology (CCHIT) to work on an HIE testing program to ensure they are capable of exchanging standardized content using a specified transport mechanism. CCHIT will employ Aegis, which has a long history with the NwHIN Exchange, to provide a cloud-based testing environment in which vendors can prepare to have their systems tested on a variety of use cases. If the initiative is successful, it will provide a type of plug-and-play connectivity between EHRs and HIEs and between HIEs themselves, which will lessen the need for interfaces between systems.
So with CCHIT accomplishing the important work of product testing there will also need to be a trust fabric in place which will allow accreditation of validated entities. Since the Office of the National Coordinator for Health IT announced it is not currently seeking regulation of HIE and discarded its plan for enforcing Conditions of Trusted Exchange and Network Validated Entities, there has been a need for the private market to provide a voluntary mechanism for this trust fabric to flourish.
DirectTrust has stepped into fill this gap. The organization was formed by members within the Direct Project and was formerly known as the Direct 'Rules of the Road' Workgroup (disclosure: I am currently a board member of DirectTrust). DirectTrust has leadership from organizations like The American Academy of Family Physicians, Surescripts, Walgreens, Cerner, DigiCert, HealthWise, the Rhode Island Quality Institute, MedAllies and Gorge Health Connect.
Now the Electronic Healthcare Network Accreditation Commission (EHNAC) has partnered with DirectTrust to create a national accreditation program for health information service providers (HISPs). HISPs serve as the backbone of the Direct community by providing the framework for secure exchange of clinical messages. With conformance testing by CCHIT and accreditation provided by EHNAC/DirectTust, the trust fabric looks to be developing along strong lines.
Even with product testing and entity accreditation accomplished, there are still issues with identity management when trying to scale health data exchange. The National Strategy for Trusted Identities in Cyberspace (NSTIC) is a White House initiative overseen by the Department of Commerce's National Institute of Standards and Technology (NIST). NSTIC envisions an "identity ecosystem" in which technologies, policies and standards support greater trust and security when individuals, businesses and other organizations conduct sensitive transactions online.
Now five organizations have received more than $9 million in grants to pilot identity solutions that increase confidence in online transactions, prevent identity theft and provide individuals with more control over how they share their personal information. Resilient Networks will be doing two projects, one centered around health care and the other dealing with child safety online. The health care pilot, called Patient-Centric Coordination of Care, will seek to enable convenient multi-factor, on-demand identity proofing and authentication of patients, physicians and staff at a national scale. Resilient is partnering with our own Gorge Health Connect in Oregon and the San Diego Beacon Community, as well as a host of national organizations (American Medical Association, Aetna, American College of Cardiology, LexisNexis, NaviNet, Kantara Initiative and the National eHealth Collaborative, to name a few).
There also is the work of a group of state-level HIEs called the Western States Consortium, one of the projects of the State Health Policy Consortium. The purpose of the consortium is to enable safe and secure exchange of health information between and among health care providers in the western states. The Western State Consortium partners include:
- New Mexico;
- Oregon; and
They will focus on how state-level provider directories and trust services can be federated at a regional level to promote privacy and security and facilitate interstate exchange. After creating a common set of trust anchor services, Oregon and California will implement a proof of concept pilot and then will attempt to leverage provider directory services to allow the ability to look up the email addresses of intended recipients.
Another very exciting development is the Automate Blue Button Initiative (ABBI). Out of a collaboration convened by the Markle Foundation, several federal government agencies have taken leadership roles in developing Blue Button. VA, Medicare and TRICARE developed their Blue Button offering as part of a robust public and private sector collaboration, joined by payers such as Aetna and UnitedHealth, which now offers millions of individuals the ability to download their medical records or claims information from secure websites.
I attended a Health Data Summit at the Whitehouse where the idea was proposed that we could automate Blue Button downloads based on trigger events and patient preferences. ABBI was born out of a desire to make use of the most underutilized resource in health care: the patient. This initiative will advance the implementation standards, tools and services associated with the Blue Button to provide consumers with automated updates to their health information in a human-readable and machine-readable format.
Looking to the Future
All of these efforts are also closely aligned with the Stage 2 Meaningful Use requirements for health information exchange. These requirements are pushing health care providers to the actual exchange of information, as well as engaging patients in their care. The Health Internet must include patients and their caregivers as equal partners in exchange, as well as being members of the care team. Information should follow the patient across the care continuum and be under their control.
As patients, we own our health data, and this concept is foundational to much of the work being done. Adoption of EHRs is necessary, but not sufficient to achieve our goals. Only by creating a platform to easily share health data, while ensuring privacy and security, will we be able to enable our health care system to move from paying for volume to paying for value based on quality and efficiency. We are well on our way down this path, and from a technology standpoint, we may finally be dragging health care into the 21st century.