The following appeared last week.
Thursday, November 04, 2010
The American Recovery and Reinvestment Act represents a significant investment in support of our nation's infrastructure for health care information. In particular, the Health Information Technology for Economic and Clinical Health, or HITECH, Act provisions have been key to advancing health care delivery and outcomes via the use of health IT. Exchanging health care information across settings and among all providers is a central vehicle for health care improvement. Such sharing promotes patient-centered care, improved outcomes and enhanced efficiency.
A major component of the federal infrastructure to support health information exchange is the Nationwide Health Information Network (NHIN). NHIN was initiated to provide linkages that would facilitate information sharing across organizational and geographical boundaries, as well as among health information organizations, delivery systems, federal agencies, health plans, providers, pharmacies, laboratories and other health care stakeholders. To augment NHIN functionality, the Office of the National Coordinator for Health IT initiated the creation of NHIN Direct. Its goal is to support simple point-to-point data exchange between two known entities.
Exchange Versus Direct: A Short Summary
For the purposes of this Perspective, Direct will be used to refer to NHIN Direct, while Exchange will refer to broader NHIN activities.
ONC provides the following definition for Exchange: a set of standards, services and policies that enable secure HIE over the Internet. While Direct also fits these definitional constructs, there is a key difference between the two. Direct supports only "push" use cases, in which a discrete document, template or set of information regarding a specific patient is sent, or pushed, to a known entity or person. These types of transfers would otherwise take place through other means, such as facsimile, mail or email. In contrast, Exchange was designed for "pull" use cases, where a query for information can be sent and, where available, the relevant information is pulled back into a system as a response.
Exchange supports many types of inquiries, whether the entities are known to one another. Exchange could be used by a provider querying to find all incidents of care a patient received, when, for example, a provider had a new patient and needed a more complete medical history. If a patient presented to an emergency department with complications from a chronic disease, such as diabetes, Exchange could also be used by the ED to query the most recent labs or test results ordered by any provider and performed by any entity.
In contrast, Direct's goal is to improve the exchange of health information by beginning with more immediate and easily implemented transactions. Direct would enable point-to-point exchange between two entities. For example, a family physician referring a patient to an endocrinologist could use Direct to send a summary of care record. Similarly, a laboratory could send results to an ordering provider via Direct.
Both Exchange and Direct can be used in concert; use would be governed by the type of information exchange required and the relationship between the exchanging entities. According to ONC, Direct is not intended to address every type of information exchange. Rather, Direct is designed as a way to initially satisfy "meaningful use" requirements. In addition, Direct may be of more immediate benefit for information exchange at the community level, where providers have established professional relationships and referral patterns. In contrast, Exchange has broader applications, pulling information from any relevant source regardless of whether or not providers are known to one another.
All the details and links follow.
What is important to recognise here is that the US is taking the very open approach (as opposed to the usual NEHTA secrecy) of providing basic approaches, software (much open source), standards and then standing back and letting the market get on with it - under the stimulus of some major targeted Government incentives for clinician adoption and ‘meaningful use’ of the technology.
We are also seeing the leadership of their Federal e-Health sponsors ensuring maximum learning is derived from the early implementations of each of the approaches discussed.
Seems to me a pretty smart approach. What is being done provides a quite viable set of options to the approaches being pushed by NEHTA and really should be more widely discussed.