David Kibbe, MD recently penned a detailed post on the basics of the NHIN Direct project titled “Getting to the Health Internet” . It is great reading and I highly recommend it. Below are a few of the points I found the most interesting.

NHIN Direct is a project within the federal Office of the National Coordinator (ONC) to develop protocols for streamlined and secure internet communication among physicians and hospitals. Think of it like email for health records. Physicians should be interested in NHIN Direct because it has the the potential to open up electronic health records to new kinds of innovation.

Dr. Kibbe made the comparison that the rise of NHIN Direct is analogous to the rise of the open internet from its early closed days when individuals who wanted to get on the “internet” had to sign up for an account on one of the proprietary providers, such as Prodigy, Compuserve or AOL. Each of these monoliths acted as a gateway and collected tolls.

Eventually, the collected power of open standards and protocols allowed wide-open communication overcame these information silos. This democratizing effect empowered businesses and even individuals to build web sites with enough functionality to lure millions of users.

NHIN Connect

NHIN Direct did not arise in a vacuum. The Federal government had already envisioned a national network for transmitting data in 2005. This effort was centered around regional health information networks (RHIOs) which would incorporate large health networks and hospitals who would form collectives to share clinical information. These regional networks are now termed health information exchanges (HIEs) and the national network of RHIOs is termed the NHIN Connect.

In Dr. Kibbe’s, analogy this “top-down” approach was analogous to the likes of Podigy and AOL in that large organizations were gateways to information transfer. End users would likely have pay fees to get on the highway and the complexity of the system would likely preclude participation by small practices.

NHIN Direct

NHIN Direct takes a different approach. It does not actually provide for the development of a health network. Rather, it is a collection of standards and protocols that are built on top of internet protocols and standards that promote security and authentication to transmission of health information on the open internet itself.

The core of the NHIN Direct is an entity called the health internet service provider (HISP) which is a sort of middle man that authenticates the sender and recipient of any clinical information payload. HISPs maintain a directory of addresses and are responsible for authenticating that the addresses belong to legitimate health providers.

The actual clinical information itself is attached as an encrypted payload to prevent unauthorized “sniffing”. The HISPs themselves cannot read the data, only the sender and recipient can decrypt the payload.

It should be noted that standards for encapsulating health data already exist. Many physicians have heard of “HL7”. This is a format routinely used to transmit laboratory and diagnostic data. Other formats such as “CCR” are based on XML (extensible markup language) and allow for sophisticated clinical summaries to be machine generated and parsed by EHRs, without a human having to read and translate each header (e.g. “diagnosis” or “name”). NHIN Direct does not specify the format of the payload. Even PDFs can be transmitted, of course such files are not machine-readable.

Meaningful Use

The impetus for NHIN Direct comes out of the the 2009 HITECH act which provides for large dollar incentives for physicians and hospitals if they employ health information technologies that achieve “meaningful use”.

The definition of meaningful use is complex and layered but among its stipulations is facilitation of communication among providers and patients, so that:
– parties can send data to each other for referral and care coordination
– physicians can send patients alerts and reminders
– physicians can offer patients views of their clinical data
– physicians make clinical summaries available to patients and can send quality data to the CMS

The Patient as Platform

Dr. Kibbe’s analogy between the the development of the internet and the evolution of NHIN Direct is an interesting comparison. If he is right, the adoption of NHIN Direct to could potentially be transformative for health IT.

While the impetus for development of NHIN Direct is the need to transfer clinical data securely between trusted parties, as its standards and protocols become widely adopted, new and as yet unimagined applications will undoubtedly arise. What is particularly exciting is the potential for a large ecosystem of small companies to arise within health IT arena, each bringing previously unimagined ideas and solutions.

Currently, health systems and physicians commit to a single vendor to manage their electronic health records. That vendor will naturally jealously guard access to the clinical data.

If open standards flourish, providers can share that same data among a wide variety of applications, allowing infinite customization and much more rapid innovation. Perhaps then, we can hope to see a flourishing of networked applications transforming health IT, like how we saw the internet has transformed retail, travel, publishing and just about every non-health industry thus far.