ONC to stand up NwHIN Exchange in OctoberApril 13, 2012
If you’re still trying to understand exactly what the Nationwide Health Information Network (NwHIN) is, take comfort. You’re not alone. But the canvas – often impressionistic if not downright abstract – is on the verge of manifesting a certain focus on enabling public-private healthcare interoperability and partnerships.
Indeed, what started as a conceptual network of networks, was then refined by ONC into the array of “standards, services, and policies that enable information to be securely exchanged over the Internet,” and later launched into pilot testing is, today, ready for prime time. The title of this portrait: NwHIN-Exchange.
“What we realized is that 6 months ago, 500 hospitals were already connected, 30,000 clinical users, 3,000 providers, and a patient population coverage area of 65 million people, and 1 million shared records. It became pretty clear this wasn’t a pilot anymore – and it’s time for it to stand on its own,” says Mariann Yeager interim executive director, NwHIN-Exchange. “So there’s been this very collaborative process with ONC and my role is to help this transition from a federal program that has been tremendously successful, although folks aren’t always aware of it, to an actual standable public-private partnership model. And so we will have that pretty much launched and transitioned to stand on its own beginning in October of this year.”
When that day comes the NwHIN Exchange will encompass at least 4 federal agencies – CMS, DoD, SSA, and VA – as well as 21 non-federal entities that can all share patient records for episodes of care.
What standing-up an exchange means
“The NwHIN-Exchange continues to progress, and is now released from some of the previous shackles,” John Moehrke, principal engineer specializing in standards architecture and interoperability at GE, wrote on his Healthcare Security/Privacy blog. “I think that more people need to recognize just how BIG this is.”
In addition to the federal agencies, the roster of participants includes such healthcare heavyweights as Kaiser Permanente, Marshfield Clinic, MedVirginia, North Carolina Healthcare Information and Communication Alliance, Regenstrief Institute and the University of San Diego Beacon Community, to name just half-a-dozen.
And it’s growing. At least two more agencies are currently “coming through the process and will be testing,” Yeager says, as are private healthcare organizations.
“We’re really at a game-changing point in time as the exchange moves into a public-private model with potentially significant expansion, opening up more broadly to the community, engaging the community in development of some solutions going forward,” adds Lauren Thompson, director of the Federal Health Architecture (FHA) within ONC. “Because of the very deliberate approach that’s been taken up to this point we feel very strongly that the exchange is now well-poised to move to this new public-private model and stand from there.”
Specifically, under that new model the Exchange Coordinating Committee, the group driving this effort, voted on March 1, 2012 to approve a plan that maps out the strategy, sustainability model, and operational transition of NwHIN-Exchange to a non-profit organization.
“This is not a federal exchange,” says Tim Cromwell, director of standards and interoperability at the VA.
Rather, NwHIN-Exchange “will enable the sharing of health information among private organizations as well as between private organizations and governmental agencies,” Yeager says. “Once the legal entity is established, we will begin to transition operational functions from ONC to the new organization, which will then support the Exchange ongoing.”
ONC’s Exchange Coordinating Committee is still working to determine where the physical headquarters for NwHIN-Exchange will reside, but Yeager expects it to be in the Washington, D.C. area.
Technological building blocks
Today, those 25 organizations share information using a common set of specifications, some specific to NwHIN, while others are industry standards, and they do so under the Data Use and Reciprocal Support Agreement, affectionately known as the DURSA.
“Everybody agrees to do the exact same thing – you can imagine that took some time to achieve, but the awesome thing is that it worked,” Yeager says. “I mean, it really does work.”
Rather than debating how to protect information, what to do with it, each entity’s obligations and liabilities, everybody abides by the same set of rules, the same testing process. All participating healthcare providers adhere to the same bundles of specs depending on the use case.
“Now that the group has been in production for three years, there’s really rapid growth and interest in expanding participation,” Yeager adds.
NwHIN at the SSA and VA
A pair of use cases exhibit exactly how NwHIN Exchange has progressed thus far. At the VA it’s sharing patient records among not only multiple VA hospitals but also non-military and private providers, while the Social Security Administration has focused on reducing the time it takes to determine disability claims.
One of the NwHIN-Exchange goals is to enable smoother transitions of care between federal health departments such as the DoD or VA and the private counterparts that provide well more than 50 percent of a military veteran’s care, particularly when it comes to seeing specialists.
A veteran might spend the winter in Florida and the summer in Rhode Island, for instance, seeking care at VA hospitals in both states, as well as episodic care at an emergency room or other private provider.
“In those instances it makes perfect sense for us to be able to query the private provider and get a packet of foundational clinical information so that enhances our clinicians knowledge about what the veteran had happen to them in the private sector,” Cromwell explains. “And when our veteran goes to an episodic visit in the private sector it makes sense that those clinicians would be able to pull what we know about them, so it’s enhancing the quality of care for veterans. That’s the big win for all of us here.”
At the Social Security Administration, meanwhile, sharing data via NwHIN-Exchange has cut disability determination in some instances from 84 days to 45 days, Yeager says, with 10 percent of claims filled in one to two days.
“One story the chairman of my board told me is about how they heard from a fellow that he was going to be going on disability and 10 days later he received the first payment,” recounts Cheryl Stephens, president and CEO of the Community Health Information Collaborative (CHIC), in Duluth, Minn. “It’s an extraordinary thing to hear those actual real-life events occurring in your own world, not just in another situation.”
That was just one instance. Echoing Yeager, Stephens said that NwHIN-Exchange reduced disability determinations “easily in half,” across the four sites it has been submitting data to SSA via their EHRs.
What’s more, NwHIN-Exchange enables the state of Minnesota to even have such contracts with SSA and the VA, the latter to pilot VLER. “We have a VA clinic that has always been forlornly sitting on its own because nobody could share data with it,” Stephens says of the Duluth area. “Now we’re piloting with it and that exchange is going to begin.”
The implementation of NwHIN specifications enable that kind of connectivity. “The VA and DoD utilize the Connect gateway as their transport,” Thompson adds. “Private partners use other transport software but federal partners are using the Connect Gateway.”
Stephens considers the three most significant aspects of CHIC’s participation to be those contracts with federal partners that truly affect the exchange of patient data, having an HIE based upon federal standards, “so nobody can say ‘We don’t want to connect with you because you’re weird,’” both of which contribute to CHIC having become the HIE folks can turn to because they know it’s keeping abreast with federal standards and guidelines.
Adding to that list of benefits, MedVirginia CEO Michael Matthews points to “tremendous value for, first and foremost, the patients.” Then on the business side, both Matthews and Yeager mentioned a surprising revenue impact for Bon Secours Richmond Health System that, in it’s work with the SSA was able to eliminate some $2 million annually in uncompensated care by recognizing where patients qualified for Medicare or Medicaid.
Participating in NwHIN-Exchange also enabled Marshfield Clinic to automate its release of information workflow to the SSA, says Melissa Owens, interoperability development manager at Marshfield Clinic.
“We were able to move from theoretical discussions on the applications of new interoperability standards to actually putting them into practice in a production setting,” Owens explains. “The incorporation of SNOMED, RxNorm and LOINC terminologies was the largest component of the project for us.”
Next up: Governance
While everyone interviewed for this article agreed that NwHIN Exchange is ready to stand on its own, much work remains.
“A year from now, we anticipate that the number of NwHIN-Exchange members is going to be over 50,” the VA’s Cromwell said. Some optimists say it could reach 10,000, but Cromwell believes the top is somewhere around 100 partners.
“So we’d like to make sure that the infrastructure required to sustain 100 or so members – and these are potentially state HIEs acting on behalf of all the healthcare providers in the state – that the infrastructure sustains us in a way that addressed our needs for identifying the patient, exchanging the information in a rapid way, can change quickly if needed so if new standards come out then we embrace the standards,” Cromwell continues. “It has to be resilient and robust at the same time and there’s an infrastructure there that needs to be supported. And that’s the value of taking it to the public-private partnership we’re envisioning.”
Those are among reasons why ONC has been working on governance for NwHIN. Speaking this past June at the Government Health IT conference in Washington, D.C., Doug Fridsma, MD, director of ONC’s office of standards and interoperability, said that ONC is working on a draft governance Notice of Proposed Rulemaking (NPRM) document, to be released in late 2011 or early 2012, that would ultimately enable more providers to join the NwHIN effort. Then during an interview at HIMSS12 in February, Fridsma said that ONC is “working on that as quickly as they can,” in terms of writing the document. “They’re trying hard to get things out.”
But as everyone anxiously awaiting the meaningful use Stage 2 NPRM learned, there’s just no hurrying the regulation writers – and the process can be a bit like watching paint dry.
A critical tipping point ahead
While that canvas is still being painted, NwHIN-Exchange participants are looking toward the future and what they hope the organization will provide – beginning with continuing federal support.
We’re very proud of the accomplishments so far but we also recognize that there’s a long way to go,” says Matthews. “Government’s continued support is going to be critical. Now is not the time for any of the stakeholders to back off. We have to stay at this until we really have ubiquitous HIE as the standard, not the exception.”
As Cromwell notes, that will require an architecture both resilient and robust – and one on which more services can be built.
“Everybody is worrying about stage 2 meaningful use, public health reporting, CDC, CMS, I would like to know that all that reporting could be pulled using NwHIN connectivity and standards,” CHIC’s Stephens says. “So let’s pull everybody together in using a singular set or a singular process to determine what those guidelines need to look like.”
In addition to reporting, Stephens and others are hoping for analytical analysis of de-identified data – something of a still-drying portrait, a horizon in its own right.
Matthews adds that, although he advocates improved clinical care as the biggest return on investment, proving a purely-financial ROI on the business side “should take cost concerns off the table, and the rest of the effort can be spend on how to maximize the benefits for stakeholders.”
That kind of ROI manifests not just in instances such as the VA, SSA, and Bon Secours Richmond but, ultimately, across all participants as NwHIN-Exchange enables them to implement and test once, then use that connectivity for multiple permitted purposes.
Thompson said ONC is bringing together federal agencies to discuss the next high priority areas, particular to NwHIN-Exchange as well as other NwHIN facets, such as Connect.
“As far as Exchange, we’re developing a strategic roadmap where we’ll begin to take a look at future uses and business cases that can be supported,” NwHIN-Exchange’s Yeager adds. “We’ll certainly have more on how current and future participants can leverage this connectivity.”
More partners will serve as final brushstrokes that continue bringing the picture into a clearer and clearer focus, which several participants believe will only increase interest in NwHIN-Exchange.
“The tipping point happens when you get state-to-state information exchanges,” says Cromwell. “A person in Idaho comes to Salt Lake City for care and the Salt Lake City private hospital is able to query and retrieve patient information from the Boise, Idaho private hospital. Once that value case is seen, I think you reach the tipping point and we’ll get a lot of buy-in there.”
Article written by Tom Sullivan, Editor with Government Health IT