Q&A: The case for NHIN Direct

The Office of the National Coordinator for Health Information Technology recently lanched the Nationwide Health Information Network (NHIN) Direct Project, an initiative that aims to create an easy-to-use process for relatively simple, local health information exchanges. Leading the project is Doug Fridsma, MD, PhD, acting director of the Office of Interoperability and Standards at ONC, who spoke with CMIO about the NHIN Direct initiative.

What is the NHIN Direct Project trying to do that’s different from the mission of the NHIN?
NHIN is [a set of] specifications, standards, services and policies that describe how computer systems can securely exchange health information over the internet. ONC developed the specifications for the gateway, and the Federal Health Architecture (FHA)  took those and created the CONNECT software.

Much of that was built around the use case where an unconscious patient might present in the emergency room, and there would be an [urgent] need to find information that would help in taking care of that patient. You could perform a lookup, patient discovery and ask all the people who were also using the NHIN to see if they had any information that would be helpful in taking care of this particular patient.

As meaningful use emerged in the past year, the policy committee set up a subcommittee or working group in the NHIN, [charged with looking] at the specifications within the NHIN, in light of all of the activities that were ongoing with meaningful use and in light of the direction of the NPRM [Notice of Proposed Rule Making] that defined meaningful use and the IFR [Interim Final Rule] that defined the standards and certification criteria.

One of the early recommendations that came back to us…was that we needed to broaden the kind of participation that could happen with the NHIN. We needed to make sure we enabled the kind of exchange the NPRM and IFR had in mind. They examined the meaningful use requirements for data exchange, and realized that a significant number of those weren’t about the patient discovery use case that the NHIN was initially constructed around, but had a lot more to do with directed kinds of communications.

[For example,] having a doctor be able to send a consultation request to another doctor or having an EHR be able to receive laboratory results that were sent from a laboratory information system. We needed to examine the specifications and the standards and services that NHIN currently provides, and…how that could be expanded to include some of these other use cases that would be applicable to meaningful use.

That was the genesis of the NHN Direct project. We want to convene interested parties to say what are the kinds of standards and services that we would need? What policies and business rules would be important?

Can you talk about enabling organizations?
One of the things in the NHIN also talked about were enabling organizations that would help support that kind of exchange by providing specific kinds of services that would enable that exchange to occur. They talked specifically in the working group about things like authoritative directories—being able to find someone and know where to send information to—[as well as] identity-proofing and authentication, making certain that people are who they say they are, and we have the ability to authenticate and we’ve assured their identity on the internet and in the exchange.

Other kinds of enabling services that might be possible [are] aggregation services or public health services that would support that kind of exchange using the specifications that the NHIN Direct project was going to develop.

We took their advice to heart and moved fairly quickly in large part because we recognize the urgency and the timelines that we have that are legislatively mandated to get providers to meaningful use so they can qualify for the incentive payments that are out there. We’ve been moving very quickly to try to make sure that motivated providers and organizations have the resources that will allow them to build or enable software that will support providers in meaningful use.

We have focused on the exchange between providers. The directories that we talk about in the enabling organization are directories of providers. We have been focused on making sure we can get secure routing of that information taken care of.

Will NHIN Direct specifications be standards-agnostic?
Our expectation is that the specifications will be publicly accessible, that they will define the set of standards and services necessary for the exchange of information, that they won’t lock people into proprietary solutions for that, and I think it enables organizations and decision makers in medical organizations to require, in some sense, if we are going to purchase or build software, that it match the kinds of standards and specifications that are defined by the NHIN. It gets you to that ability to plug different services together to achieve the functions that you want without getting locked into a proprietary, potentially vertically integrated system.

We are trying to do this as part of transparency and open government: We espouse the value of the FHA CONNECT project in having open source initiatives. We believe that kind of approach is what’s going to help us achieve the kind of interchange that we hope this will foster.

How far along is the NHIN Direct Project?
Everything within the ONC moves fairly quickly, particular given our desire to assist provider organizations and providers in meeting meaningful use. We received [the subcommittee’s] recommendations toward the end of January and launched the NHIN Direct Project in the first part of March. We have a Wiki that describes the work that’s ongoing. We’re really trying to do this in a way that is inclusive, transparent, and where we can get good feedback from lots of different people about how to do this, and do this in a way that serves the needs out there in the community.