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The benefits of health information exchange yet to leave NHIN behind

The goal of an NHIN has yet to be achieved, but the manageability of HIEs is keeping the possibility alive.

If you follow health IT blogs, you may have noticed the acronym NHIN -- the Nationwide Health Information Network -- seems to be disappearing, and HIE -- health information exchange -- is cropping up in its place. Even Farzad Mostashari, M.D., national coordinator of health IT and the head of the federal agency tasked with implementing NHIN, seems to be focusing on the potential benefits of health information exchange in his public speeches. So does this represent a major policy shift, or just another stirring of the alphabet soup?

Thomas JepsenThomas Jepsen

First, a bit of history: Mostashari's position at the Office of the National Coordinator for Health Information Technology (ONC) was created by executive order in 2004 and tasked with, among other things, creating a national health information network that would enable the secure transmission of health information among a variety of stakeholders, including healthcare providers, insurers, public health agencies and healthcare consumers. Creating a nationwide health information network was a bold and ambitious goal, especially since only a tiny fraction of hospitals and doctors at the time even had the ability to create and transfer medical records electronically. Not only were there technical problems to overcome  -- for example, creation of standards for secure transmission and interoperability -- but also political issues. Many were opposed to creation of unique identifiers for patients, citing privacy issues. There was also opposition to creation of a government-controlled database of patient information.

Nevertheless, there was progress toward the goal. The number of physicians and hospitals implementing electronic health records (EHRs) has continued to climb, and by 2012 nearly two-thirds of primary care physicians and 44% of acute care hospitals had implemented basic EHRs. Several standards groups worked together to create a Continuity of Care Document (CCD) standard that enabled longitudinal health records to be exchanged among healthcare providers, and a number of use cases were developed and tested by the NHIN Cooperative.

But ultimately, progress toward the NHIN became stalled in a bureaucratic paradox. In order to share information, healthcare providers had to implement certified interoperable EHRs; in order to be interoperable, the EHRs had to be certified to meet standards; standards groups had to be formed to establish the necessary standards; certification bodies had to be formed to certify the EHRs, and the certification bodies themselves had to be authorized to perform certification testing; standards and certification requirements became intertwined with the meaningful use guidelines intended to improve quality of care, and sometimes appeared to be in conflict with them. It soon became apparent that a truly national network would take a long time to implement.

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So the new mantra became: "Think globally, but act regionally." A more attainable goal would be a health information exchange in which healthcare providers in a region or state agree to exchange healthcare data using a common platform. To establish governance rules, HIE members would sign a Data Use and Reciprocal Support Agreement, or DURSA, which would specify responsibilities and obligations of each member. Once a sufficient number of HIEs had been established across the nation, they could then begin to exchange data with one another, forming, in effect, a network of networks that would realize the intent of the original NHIN.

Certainly, HIEs face formidable challenges, though there are clear benefits of health information exchange. One challenge is the need for a sustainable business model; HIEs need to provide added value to their members by offering innovative services, such as data backup and format translation. Another is the need for a well-defined regulatory environment; in a response to a requirement for improvement circulated by the ONC, the American Hospital Association recently called on federal regulators to avoid placing any new regulatory requirements on HIE implementation. Health information exchanges also must deal with the politics of data sharing, as many healthcare providers are reluctant to share patient data because they are fearful of losing patients to competitors.

It appears many of the original goals of the NHIN will one day be achieved, but it will take longer and look quite a bit different from the original concept. However, to paraphrase Mark Twain, it appears that reports of the demise of the NHIN have been greatly exaggerated.

About the author
Thomas Jepsen is a health IT consultant and IEEE Computer Society member. Let us know what you think about the story; email or contact @SearchHealthIT on Twitter.

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