The U.S. Office of the National Coordinator for Health IT (ONC) is pushing for interoperable electronic health record (EHR) systems for all providers, coast to coast, enabling patients and doctors to access everyone's data at all offices. To get there, the health care sector needs to build a national network of regional wide area networks -- and that requires addressing some key WAN governance issues.
Technically, pointed out Matt Rozhon, a carrier service specialist for the health care division of CDW LLC, that "network of networks" will itself be a regional WAN.
"WANs in health care specifically can mean physician practices and affiliates spread out more geographically," Rozhon said. "Or, if we are talking about a health care provider, they may be generally all local."
Local, provider-specific WANs, such as those on multi-building hospital campuses, are and will be traditionally cabled. Cost issues come into play when two separate health care providers hook up to share data, raising questions such as who will pay for building the network and how administration costs will be divided.
This means data exchange is done via the public Internet and secure virtual private network (VPN) tunnels, using encrypted data. That is how NYCLIX Inc., a nonprofit New York City regional health information organization (RHIO), shares patient data among hundreds of doctors’ offices and 11 hospitals.
The trick to making these regional WANs work? Stakeholder cooperation and strong WAN governance, said NYCLIX technical manager Thomas Moore. He oversees the exchange of registration data, lab results, past diagnoses, clinical notes, medications, allergies and procedure codes from a number of data sources, including radiology, cardiology, pathology, endoscopy and electrocardiogram (EKG) reports among the hospitals, which cooperate despite their usually competitive nature outside of NYCLIX.
Getting health care providers to exchange data effectively is the short-term problem WAN governance must solve as providers build a nationwide health IT infrastructure.
On top of typical WAN governance issues affecting every type of industry -- agreeing on how to optimize application performance, maintain 24/7 uptime, setting security policies, minimizing costs and assigning who will monitor and benchmark network performance -- health care networks have their own considerations. These include HIPAA compliance and data compatibility among different vendors' EHR systems. In some cases, different EHR installations of the same vendor’s system aren't even compatible.
For effective WAN governance, standards matter
Health Level Seven International (HL7) data exchange standards and encryption are the typical means of addressing these issues -- once stakeholders come to the table and discuss them, Moore said. His organization runs a central record locator service, with providers maintaining their own patients’ data on edge servers. All together, NYCLIX calls the model a "federated health information exchange," which was set by NYCLIX owners and to which members subscribe.
The key to getting health information exchange to work among disparate clinical information systems, Moore said, is standardizing patient databases in the edge servers and feeding them into a common HL7 interface. Then, once the network is up and running, members must be trained and reminded to keep pumping consistent, detailed information into the system.
NYCLIX requires members to provide patient admission/discharge/transfer transactions, lab results and radiology reports at minimum to participate. Beyond that, the RHIO also tries to collect medication, allergy, cardiology, endoscopy, EKGs, vital signs and other indicators to make databases more complete.
"Get the data, get as much of it as you can," Moore said. "You've got to have critical mass, or forget everything else."
Because patient data and patient care are at stake, representatives beyond those from the clinical, IT and hospital administration teams should be on the governance committee. Those groups that look out for patient safety -- such as a quality improvement officer and, in some cases, even the risk manager, who understands how insurers will view the liabilities specific to WAN data exchange -- must be at the table as well.
Getting health care providers to exchange data effectively is the short-term problem WAN governance must solve as providers build a nationwide health IT infrastructure. In the long term, Rozhon said, the focus will shift to achieving carrier diversity and increasing bandwidth to make the WANs go 24/7, with ample throughput to handle ever-increasing needs.
"One of the biggest drivers I see is not just EHRs, but big bandwidth," he said."It's because of PACS [picture archiving and communication systems]. These radiology, cardiology, MRI files are extraordinarily large. If you're doing them a couple hundred times a day throughout your organization, it's going to require a large amount of bandwidth."
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