Recently a person organizing a state’s HIE effort reported a hospital CIO saying, “why do I need your complex HIE when can have NHIN Direct?”
This question gets to the heart of the confusion that some states or stated designated entities are experiencing with the introduction of NHIN Direct into the mix. I wrote this fellow back, outlining the relative value propositions of HIEs and NHIN Direct. It is clear that the two notions are complimentary even if there is still some need to work out the rough edges. Here is what I wrote.
The hospital that is evaluating its need to participate in a state HIE needs to answer the following questions.
How long will the hospital and community physicians be satisfied with the following assumptions that will probably be baked into NHIN Direct:
- We will be sending information but not offering clinicians the opportunity to look up a patient and retrieve their information.
- We will be sending the information to a practice without sending the practice’s patient ID number
- We will send out structured lab information from our lab using standard LOINC codes
- We will independently determine whether it is appropriate to send each transmission to a specific provider.
- We will send all information with only a very general usage agreement in place.
- We will accept inbound information without our patient ID so each such input will have to be matched by the receiver.
- We will accept information without assurance as to whether coded information is standard.
Most of the hospital CIOs that I talk to say, “I’d be happy to live with those restrictions in order to get started reaching out to physicians in my community sooner. I know that practices that I send info to would be willing to live with them as well.”
This is a fair trade-off. However, it provides clear limits in supporting care transitions in that the sender has to know to whom the patient is transitioning – or the receiver has to make a special request for information that must be manually approved by the sender.
Furthermore, it is unlikely that community physicians will remain satisfied with this approach if an HIE is available that supports both the hospital and the practice or if HIEs are linked in a way to provide the connection.
The value that HIEs typically add include
- Maintaining a common patient index
- Providing the trust mechanism, software interfaces. access control and consent mechanism that enables lookup up information
- Developing a common trust agreement that all parties can accept.
- An interface to consumer advocates that will assert their role protecting the interests of the patients.
- A common software channel and active support to enable multiple data sources (e.g., labs and hospitals) to send results to multiple recipients and provide both senders and receivers a single point of contact for troubleshooting.
- Mapping imprecise recipients data (e.g., taking a physician name as the recipient of the lab result and determining whether to deliver the result by fax, on-line lookup or structured transmission to the EMR).
- Aggregating data at a community or state level for measuring quality, epidemiology, and other programs.
The only thing that an HIE has to do to compete with NHIN Direct-based communications is exist.
How, then should an HIE deal with the fact that by the time it comes to an operational state a great deal of communication may be going on under NHIN Direct? Easy: join it instead of fighting it. Be prepared to bring practices that are already using NHIN Direct into the fold without having to immediately change what they do. Add immediate value by forwarding patient results and notes with the practice’s patient ID. Provide shims for labs that cannot get to standard approaches. Allow them to begin to look up patients (using new interfaces) as soon as their EHR is ready. Allow them to use a portal to look up patients and have the results sent to them through NHIN Direct.
To really seize the initiative the HIE should become a provider of NHIN Direct services to physicians that don’t yet have an EHR or have an EHR that is not yet capable of dealing with NHIN direct. Operators of such a portal are in an ideal state to gradually introduce services that add value as soon as they can make the software and business agreement arrangements.