JAMIA: A brief history of HIE
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Gilad J. Kuperman, MD, PhD, from the department of information systems at New York-Presbyterian Hospital in New York City, sought to describe how interoperability activities have unfolded over the last decade and how recent initiatives are likely to affect the directions and benefits of HIE.
In the 1980s and 1990s, such leading healthcare organizations as Intermountain HealthCare, Partners HealthCare, and Wishard Memorial Hospital began to demonstrate the quality and efficiency potential of EHRs. “However, even in the midst of those successes, it became clear that there are key healthcare problems that ‘siloed’ EHRs do not solve. Examples of problems that could only be addressed by interoperability included support for the patient across transitions of care, the ability to perform longitudinal analyses of care and public-health needs.”
Taking a tour through the ages, Kuperman focused a great deal of attention on the Direct Project. “The constrained information flows supported by Direct and other push models of HIE leverage existing privacy frameworks,” Kuperman wrote. “The Office of the National Coordinator for Health IT (ONC) Privacy and Security Tiger Team recently recommended that for Stage 1 meaningful use, directed exchange of health information for treatment should not require patient consent beyond what is required to make a disability determination law or has been customary practice.
“Federal privacy guidelines for more complicated models of HIE, for example, retrieving a patient's health data from multiple sources with a single query, have yet to be created,” the author added.
A push model, such as Direct, avoids problems that arise when trying to integrate a patient's data across a community. “Most notably, it is not necessary to link a patient's identifiers across systems before data can be transferred. The cost and complexity of developing a record locator service, as well as developing privacy policies to support the retrieval of data from multiple sources, can be avoided. An inbound message is linked to a particular patient file by the message recipient, and the linking may be done manually,” Kuperman wrote.
Implementation of Direct services may present some pragmatic challenges as well. “From a policy perspective, an interesting question is: What proportion of the problems that HIE was intended to solve would the Direct Project solve?” Kuperman posed. “From an informatics perspective, the Direct Project offers a model of HIE that is more constrained than models that involve record locator services.”
However, Kuperman admitted that the Direct Project is recent and the vision emerged in early 2010. Thus, there is much to be learned about the technical, policy, privacy, security and business aspects of this approach to interoperability as well as the clinical problems that it will solve.
“Direct has a strong chance of being an important step forward. It remains to be seen how much of the interoperability problem it will solve and what other components are needed to meet the interoperability needs of clinicians, the needs of the healthcare reform program, and the vision of interoperability that was laid out over a decade ago,” they concluded.