Health net gets a checkup

SAN DIEGO – Amid privacy, security and technology concerns, healthcare IT professionals got a progress report on the status of the Nationwide Health Information Network, a project that seeks to improve patient care and reduce medical errors in implementing electronic health record systems.

At the Health Information Management and Systems Society (HIMSS) show in San Diego last week, 25,100 IT managers and CIOs listened as a number of speakers, including Dr. David Brailer, national coordinator for Health Information Technology for the Department of Health and Human Services, described their visions of such a network, the current barriers to adoption and the progress being made.

In April 2004, President Bush charged the IT industry to build a system that would provide every U.S. citizen by 2014 with an electronic health record (EHR) that could be accessed from any location. He appointed Brailer to coordinate this effort and establish the NHIN.

Last December, Brailer’s office awarded $18.6 million in contracts to four consortia led by Accenture, Computer Science Corporation (CSC), IBM and Northrop Grumman to develop prototype architectures for the NHIN. Each consortium consists of technology developers, hospitals, laboratories, pharmacies and physicians who must prove that EHRs can be exchanged seamlessly among entities. The consortia are using existing collectives of hospitals and other healthcare providers called regional health information organizations (RHIO) to build these data-interchange networks.

“These prototypes are the key to information portability for American consumers and are a major step in our national effort to modernize healthcare delivery,” Brailer said in a statement.

Brailer envisions the architecture of the NHIN to be such that existing RHIOs can connect to it, and organizations and physician offices that are not part of an RHIO also will be able to connect.

“I did not start out by believing the national solution will be a network of regional networks,” Brailer said in his keynote speech at HIMSS. “Our goal with the National Health Information Network is to allow those who do not want to participate in RHIOs to not have to do it.”

Two networks – those proposed by Northrop Grumman and CSC – consist of distributed, peer-to-peer networks, which use a federated identity model that lets organizations share identity data with trusted network access and authentication. Patient information would be identified by unique metadata tags and be exchanged among organizations using standard protocols.

Foremost in IT professionals’ minds in building these networks is how physicians will be reimbursed for adopting information technology. There also are technological issues about adopting EHRs and a nationwide health network that need addressing, such as a lack of recognized standards, the security and privacy of patient health information and the trusted access and authentication of clinicians to EHR information.

Dr. John Halamka, CIO for Harvard Medical School and chair of the Health Information Technology Standards Panel (HITSP), is charged with dealing with one of these concerns by coordinating the standards for medical vocabulary and electronic data exchange.

“You say we have standards for credit cards, but what are the standards for electronic patient health information?” Halamka asked. “We talk about content standards for vocabularies, structural standards like [Health Level 7] and security standards such as [Security Assertion Markup Language]. Many people would agree that, because the network will use the Internet, HITSP would be a reasonable way to exchange information.”

Part of HITSP’s work will be deciding what standards to use – Digital Imaging and Communications in Medicine, HL7, .Net, SAML, Simple Object Access Protocol or XML. The committee is expected to deliver its recommendations as early as June.

Another concern is building out EHR systems to support this network. In an HIMSS survey released at the show, as many as half of the 205 respondents cited the lack of financial support as a barrier to deploying IT projects and systems. The top priorities are reducing medical errors and promoting patient safety, and implementing an EHR system. Over the next two years, 46% of the respondents indicated their top priority is implementing an EHR system.

Only one-fifth of the respondents indicated they have implemented a single sign-on system to give one-step access to the multiple applications they use. Single sign-on is an essential component of an EHR system, users say.

“Single sign-on is one of the first things you need to address,” says Linda Hill, manager for technical assistance at Sharp HealthCare, an 1,867-bed hospital collective in San Diego. “Then you need to look at the ownership of the information – who has it, who doesn’t, what we control access to.”

At Sharp, Hill says she has “made a tremendous amount of progress in getting all the hospital information on a patient in one place at one time. Now we are rolling out a system for our clinics and will have to deal with how we get that information to go back and forth.” Hill uses Courion’s Enterprise Provisioning Suite to do password synchronization among applications.

As for who will operate the NHIN, Brailer says the government will not. He envisions it being managed by a series of companies or service providers that offer access, authentication and connectivity.

“Companies will start offering competitive NHIN service offerings not unlike Verizon and

T-Mobile offer cellular connectivity,” Brailer says. “Electronic health records and connectivity could get packaged together.”

Brailer also doesn’t view NHIN as a client/server network like the network the Department of Defense has implemented for its military personnel.

NHIN is “a lightly brokered network that has an index that says data on this person is at this location,” Brailer says. “That gets layered on with some very specific needs of brokered security. If we don’t have any existing trust relationships [or federation], how do I know who to trust getting the data?” Brailer asks.