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Providers, patients, and other stakeholders in the delivery of healthcare across the country can be connected through the Nationwide Health Information Network (NwHIN). The NwHIN is NOT a physical network running on servers that store patient records, but a set of standards, services, and policies that enable the secure exchange of health information over the internet. Currently, several government agencies and private entities use NwHIN standards architecture to exchange health information.
Three initiatives have been launched that leverage NwHIN standards to expand secure and standards-based health information exchange: NwHIN Exchange, CONNECT software, and the Direct Project. Additional information regarding use of and participation in these initiatives is provided below.
NwHIN Exchange
Participation in the NwHIN Exchange is limited to a group of federal and non-federal entities that are part of federally funded initiatives to develop and test the standards, services, policies, and processes needed to operationalize the exchange of health information. Many of the participants were part of the NHIN 1 and NHIN 2 pilot projects that occurred in the beginning of 2004. Participants in the Exchange have implemented NwHIN standards and specifications, have signed a comprehensive trust/legal agreement entitled the Data Use and Reciprocal Support Agreement (DURSA), and are either a federal agency or have a grant or contract with the federal government to participate in the Exchange.
The HITECH Act requires that ONC establish a governance mechanism for the NwHIN Exchange. In response to this requirement, ONC is initiating a rulemaking process for governance. Until governance rulemaking is final, only federal agencies and non-federal entities that are part of a federally-sponsored contract, grant, or cooperative agreement that pertains to nationwide health information network activities, can engage in this effort.
During the rulemaking activities, those eligible organizations will be able to exchange data and continue to evaluate and mature the processes needed to support nationwide exchange of health information. This group of entities continues to grow, and it is expected that around 35 organizations will be production members of the Exchange by the end of 2011.
Using CONNECT Software
CONNECT is a free, open-source software solution, developed by more than 20 federal agencies, enabling organizations both locally and across the country to share information through use of NwHIN standards, services, and policies. Some of the federal agencies that are currently using or are planning to use CONNECT are DoD, VA, SSA. Those HIEs in regions that regularly interact with these federal agencies could make CONNECT available through the HIE. Some examples include regions that have VA Hospitals or military bases.
Health information exchanges can adopt and customize the CONNECT software and significantly reduce the monetary investment necessary in getting the statewide exchange up and running, and keeping it running. Using the CONNECT software, organizations can share information internally (i.e. an enterprise HIE or within an integrated delivery network) or across organizations, including across state lines. Individual HIEs can also integrate with a network comprised of other HIEs, facilitating inter-state and intra-state exchange of health information.
The Core Services Gateway of the CONNECT solution makes it possible for providers to locate patient information residing across organizational lines. After patient data is located, CONNECT enables providers to gain access to these records. The Enterprise Service Components of the Connect solution put in place the infrastructural pieces to enable exchange through the Core Services Gateway. These components include the Master Patient Index and an audit log, among other building blocks of health information exchange that can be adopted by HIOs, HIE vendors, and systems integrators. Many HIE vendors and system integrators have developed their own CONNECT Gateway and adapters, enabling connectivity and exchange with other HIEs utilizing CONNECT gateways. Click here for additional information on CONNECT.
Point-to-Point Exchange via the Direct Project
Health IT interoperability and standards efforts have continued to mature and evolve, and industry adoption is steadily increasing. However, potentially expensive custom EHR interfaces are still needed to support EHR integration with HIE. In March 2010, an initiative, called the Direct Project, was launched to support use of internet protocols for an easy-to-use secure method to replace mail and fax transmissions between providers and stakeholders, such as other providers, labs, and public health departments, and alleviate the need to build EHR-specific custom interfaces due to the lack of interoperability between EHRs. This effort is part of the Nationwide Health Information Network, developed to specify a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet. Stage 1 of Meaningful Use criteria includes the ability for EHRs to exchange patient health information with providers, patients, laboratories, and public health departments. Those HIEs that serve providers that are paper-based or have EHRs that do not meet Meaningful Use requirements may be able to use the Direct Project through the HIE to meet Meaningful Use Requirements.
The Direct Project provides methods for point-to-point utilization of lightweight NwHIN standards. Infrastructure requirements are minimal, as Direct Project specifications allow providers to send and receive documents over the internet without having the full NwHIN capability. By connecting providers to specialists, results to providers, and health systems to public health agencies, the Direct Project works towards the goal of total open communication directly between all interested parties.
Role of the Health Information Service Provider (HISP)
Health information service provider organizations (HISPs) provide the framework for secure exchange of clinical messages over the internet between disparate electronic health record systems. The HISP enables users to easily send information through Direct protocols, while structuring an interface to verify Direct addresses of users and organizations. Additionally, the HISP ensures that clinical messages are sent and received in an accurate and usable manner at both ends of the exchange.
Stage 1 of Meaningful Use does not stipulate that providers be a part of an HIE network. Interoperability objectives and measures in Stage 1 can also be achieved through a more lightweight solution, such as the Direct protocol. With these protocols in place, an organization must build an interface for the secure exchange of clinical information with other organizations. Health information service providers build these secure gateways for providers. The HISP interface grants providers access to a database listing of verified organizational and individual Direct addresses, and authenticates the identity of both sender and recipient of clinical messages. Data contained in a message will also be packaged in a practical format for ease of use by the recipient when sent through the HISP framework. Without such a framework in place, organizations would be sending unstructured and unsecure clinical messages back and forth, inhibiting the most meaningful use of patient data in the delivery of care. HISPs will also contract with other HISPs to ensure the free exchange of data across organizations with different frameworks or interfaces.
The Direct Project maintains a Wiki site for Best Practices for HISPs and Best Practices for HISP-HISP Agreements.
Direct Project Pilots
Leveraging NwHIN standards and testing new approaches to exchange, The Direct Project demonstrates the power and potential of localized exchange through a number of pilot programs currently in progress. In 2011, initiatives in eight states are pilot testing Direct Project protocols for exchange. In February 2011, two pilot projects have launched, using the Direct Project, in Minnesota and Rhode Island:
- Minnesota – This NwHIN Direct pilot explores the possibilities of information exchange with public health organizations. Hennepin County Medical Center in Minneapolis, a large Level 1 and pediatric trauma center, is sending updates of immunization records to the Minnesota Department of Health using Direct protocols. Testing of communication to an immunization registry is a requirement for Stage 1 of Meaningful Use incentives. This pilot uses Vision Share as its Health Information Service Provider (HISP).
- Rhode Island – The Rhode Island Quality Institute has spearheaded a pilot program to demonstrate Direct capabilities in setting up a health information exchange infrastructure. The program will connect Polaris Medical Management, a management services organization, and the Rhode Island Primary Care Physicians Corporation, an independent practice association (IPA), using Direct protocols
Additional pilot projects underway or to be launched in 2011 include:
- New York – This Direct Project pilot exhibits the capabilities of utilizing Direct protocols to “push” health information across the continuum of care, to support transitions of care. This project focuses on information exchange to support three common scenarios: patient seen by their primary care physician post discharge from a hospital, primary care physician request for a specialist consultation, and the completion of the consultation by a specialist. MedAllies is the HISP working with numerous stakeholders in the Hudson River Valley to implement the Direct infrastructure.
- Tennessee – This pilot demonstrates using Direct protocols to connect private health information organizations with a public federal entity. The stakeholders in this case are CareSpark, an operational regional health information exchange and HISP in east Tennessee and southwest Virginia, and the Department of Veterans Affairs. Exchange efforts will center specifically on referrals and care summary exchange between providers.
- California Redwood MedNet, a health information exchange in Northern California, leads this pilot, using the power of secure messaging in achieving Meaningful Use. The pilot will focus specifically on rural settings where coordination between disparate providers may be especially challenging. Secure messaging will be used for communication of structured lab results, immunology reports, and patient care summaries.
- Connecticut – This pilot program will use Direct to exchange laboratory results and referrals across several care settings, including a hospital (Middlesex Hospital), an FQHC (Community Health Center, Inc.), and an IPA (Medical Professional Services). This pilot will use the Direct protocol to deliver lab results back to the ordering provider.
- Texas - Stakeholders in South Texas are participating in this pilot program, using Direct protocols to improve the health status of persons with diabetes. Health Plans, hospitals, public health entities, social service organizations, and academic institutions exchange data utilizing the Direct protocol for: physician to physician referrals, physician to hospital referrals, hospital to physician office lab results reporting, and communication of hospital or physician office information to the state’s newborn registry.
Additional information regarding the Direct Project and pilots is available on the Direct Project Web site. The Direct Project Implementation Group maintains a Wiki page that includes information on Workgroups, documentation, user stories, and participation guidance.
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