There Is No ‘One-Size-Fits-All’ in Building
a Nationwide Health Information Network

Dr. David Blumenthal

A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology 
Emailed May 14, 2010 (and copied below)

Private and secure health information exchange enables information to follow the patient when and where it is needed for better care.  The Federal government is working to enable a wide range of innovative and complementary approaches that will allow secure and meaningful exchange within and across states, but all of our efforts must be grounded in a common foundation of standards, technical specifications, and policies.  Our efforts must also encourage trust among participants and provide assurance to consumers about the security and privacy of their information.  This foundation is the essence of the Nationwide Health Information Network (NHIN).

The NHIN is not a network per se, but rather a set of standards, services, and policies that enable the Internet to be used for the secure exchange of health information to improve health and health care.  Different providers and consumers may use the Internet in different ways and at different levels of sophistication.  To make meaningful use possible, including the necessary exchange of information, we need to meet providers where they are, and offer approaches that are both feasible for them and support the meaningful use requirements of the Centers for Medicare & Medicaid Services (CMS) Electronic Health Record Incentives Programs.  As with the Internet, it is likely that what is today considered “highly sophisticated” will become common usage.  Moreover, users may engage in simpler exchange for some purposes and more complex exchange for others.

Current NHIN exchange capabilities are the result of a broad and sustained collaboration among Federal agencies, large provider organizations, and a variety of state and regional health information organizations that all recognized a need for a high level of interoperable health information exchange that avoided “one-off” approaches.  Based on this pioneering work, a subset of these organizations is now actively exchanging information.  This smaller group currently includes the Department of Defense, Social Security Administration, Veterans Health Administration, Kaiser Permanente, and MedVirginia.  They initially came together to show, on a pilot scale, that this type of highly evolved exchange was possible.  Having succeeded, they continue to expand the level of exchange among their group and with their own respective partners in a carefully phased way to demonstrate and learn from these widening patterns of exchange. The robust exchange occurring at this level has several key attributes, including the:

1. Ability to find and access patient information among multiple providers;
2. Support for the exchange of information using common standards; and
3. Documented understanding of participants, enabling trust, such as the Data Use and Reciprocal Support Agreement (DURSA).

Not every organization and provider, however, needs or is ready for this kind of health information exchange today.  Nor do the 2011 meaningful use requirements set forth by CMS in the recent proposed rule require it. Direct, securely routed information exchange may meet the current needs of some providers for their patients and their practices, such as receiving lab results or sending an electronic prescription. 

To enable a wide variety of providers – from small practices to large hospitals – to become meaningful users of electronic health records in 2011, we need to ensure the availability of a reliable and secure “entry level” exchange option that aligns with the long-range information exchange vision we have for our nation.  Such an option should balance the need for a consistent level of interoperability and security across the exchange spectrum with the reality that not all users are at the same point on the path to comprehensive interoperability.  In an effort to provide the best customer service possible, the Office of the National Coordinator for Health IT (ONC) will consider what a complete toolkit would be for all providers who want to accomplish meaningful health information exchange.

Broadening the use of the NHIN to include a wider variety of providers and consumers who may have simpler needs for information exchange, or perhaps less technically sophisticated capabilities, is critical to bolstering health information exchange and meeting our initial meaningful use requirements.  Building on the solid foundation established through the current exchange group mentioned above and the recommendations of the HIT Policy Committee (which originated with the Committee’s NHIN Workgroup), ONC is exploring this expansion of NHIN capabilities to find solutions that will work across different technologies and exchange models. 

The newly launched NHIN Direct Project  is designed to identify the standards and services needed to create a means for direct electronic communication between providers, in support of the 2011 meaningful use requirements.  It is meant to enhance, not replace, the capabilities offered by other means of exchange.  An example of this type of exchange would be a primary care physician sending a referral and patient care summary to a specialist electronically.

We are on an aggressive timeline to define these specifications and standards and to test them within real-world settings by the end of 2010.  Timing is critical so that we may provide this resource to a broader array of participants in health information exchange as a wave of new, meaningful users prepare to qualify for incentives provided for in the HITECH Act and ultimately defined by CMS. This model for exchange will meet current provider needs within the broader health care community, complement existing NHIN exchange capabilities, and strengthen our efforts toward comprehensive interoperability across the nation.

A natural evolution in NHIN capabilities to support a variety of health information exchange needs is being reinforced by trends that are leading us toward widespread multi-point interoperability. The current movement toward consolidation in health care, coupled with health reform’s encouragement of bundled payments for coordinated care, will mean more providers need it.  Quality improvement, public health, research, and a learning health care system all require it.  Ultimately, simple exchange will be part of a package of broader functions that allows any provider, and ultimately consumers, to exchange information over the Internet, enabled by NHIN standards, services, and policies.

Your continued input will help guide us toward and maintain a direction that is in harmony with the rapid innovations in health IT today.  The NHIN Direct Project will conduct an open, transparent, and collaborative process throughout its development by using a community wiki, blogs, and open source implementation already available on the project’s website (http://nhindirect.org/ ).  I encourage you to participate through the website, via public participation at the implementation group meetings, and by deploying and testing the resulting standards and specifications.  For those of you who are participants in the current exchange group, I urge you to take every opportunity to share your experiences.  Lessons learned from the NHIN Direct Project and the exchange group will inform the evolution of the NHIN as new uses and users come forward, and as continued innovation occurs to meet the growing needs of our community.

As we head into the next stage in the development of nationwide health information exchange, we should all take a moment to reflect on how far we have come and evaluate our plans for the future.  ONC is committed to providing resources and guidance to stakeholders at all levels of exchange through HITECH programs, such as the Health IT Regional Extension Centers, the national Health IT Research Center, and the State Health Information Exchange Program.  As you assess your own needs for exchange, please take advantage of the many Federal resources available to you on the ONC website and the online resources of the programs mentioned above, as well as through the “NHIN University” education program hosted by our public-private partner, the National eHealth Collaborative .

We have done a great deal of work in the short period of time since the passage of the HITECH Act.  We at ONC appreciate your willingness to stay engaged and involved in every step of our journey, and we look forward to our continuing collaboration to improve the health and well-being of our nation.

Sincerely,
David Blumenthal, M.D., M.P.P.
National Coordinator for Health Information Technology
U.S. Department of Health & Human Services

The Office of the National Coordinator for Health Information Technology (ONC) encourages you to share this information as we work together to enhance the quality, safety and value of care and the health of all Americans through the use of electronic health records and health information technology.