The Health Information Technology Standards Committee (HITSC) is a federal advisory committee that advises the U.S. Department of Health and Human Services (HHS) and the Office of the National Coordinator for Health Information Technology (ONC) on federal health information technology standards issues to enable secure health information exchange using Nationwide Health Information Network (NwHIN). The ONC has defined the NwHIN as “the set of standards, services and policies that enable secure health information exchange over the Internet”.
To this end, ONC convened a Nationwide Health Information Network (NwHIN) Power Team (NwHIN Team) tasked to assist the ONC in defining this set of standards, services, and policies by:
1. Evaluating the specifications developed for the Exchange and Direct pilots with respect to their usability and scalability to support nationwide health information exchange
2. Recommending those specifications that could be integrated and deployed to support the secure transport and exchange of electronic health information at a national scale, and identifying where further work may be needed
Over the past few months, the NwHIN Team held a series of public meetings to first develop an assessment methodology, and then to assess the Exchange and Direct specifications as potential NwHIN standards, services, and policies.
On September 28, 2011, the HITSC provided recommendations regarding standards and specifications for the nationwide health information network, via this transmittal letter [PDF – 805 KB].
As noted in the transmittal letter, the committee has recognized need for further investigation of the Exchange specifications and has recommended that ONC perform further assessment of industry adoption, and deployment, operational, and administrative complexity of the Exchange specifications – specifically to include inputs from people who have implemented these specifications in organizations other than Federal agencies, and from organizations that have implemented a technology stack different from that represented in the Exchange specifications.
II. Request for Comments Purpose
The NwHIN Power team is seeking input from Exchange implementers regarding their experiences in implementing the Exchange specifications; setting up the required operational and administrative infrastructure; and using Exchange to meet their operational needs. We are specifically interested in hearing the first-hand experiences and observations of individuals involved in the implementation of the Exchange specifications, and in the maintenance and use of Exchange in an operational environment.
Following analysis of the comments received through December 15, 2011, the HITSC intends to present its recommendations to the ONC to help inform decisions regarding future investments in additional NwHIN pilots and specification development.
III. Solicitation of Comments
Introduction
The NwHIN Power team is seeking comments from Exchange implementers regarding their experiences in implementing the Exchange specifications; setting up the required operational and administrative infrastructure; and using Exchange to meet their operational needs. We are specifically interested in hearing the first-hand experiences and observations of individuals involved in the implementation of the Exchange specifications, and in the maintenance and use of Exchange in an operational environment. We request that the implementer providing the comments address the following questions.
Instructions
You may submit your comments in the following way:
- Email the completed survey to ONC.request@hhs.gov. Please be sure to include “NwHIN Power Team” in the subject line.
Please submit your comments by no later than 5 p.m./Eastern Time on Dec 15, 2011.
Questions:
1. Please identify yourself, your organization, and your position within the organization.
2. When did your organization implement the Exchange specifications?
3. Why did your organization implement the Exchange specifications? Are the functional capabilities that Exchange provides adequate for your current and expected information-exchange purposes?
4. What business functions does Exchange currently support in your organization?
5. What is the current monthly volume of documents that are transferred among different organizational entities as part of your implementation?
6. What methods and protocols do you use today for clinical exchange? When considering the exchange activities anticipated for the next few years, what proportion do you expect will use Exchange? What other methods and protocols do you plan to use over the next few years?
7. Have the organizations with whom you want to exchange data implemented Exchange? If not, do they plan to do so? If they are not implementing Exchange, what alternatives are you considering using for these exchanges?
8. What was your personal role in the implementation of the Exchange specifications?
9. Which of the following Exchange specifications did you implement?
– NHIN Messaging Platform Specification
– NHIN Web Services Registry Specification
– NHIN Authorization Framework Specification
– NHIN Patient Discovery Specification
– NHIN Query for Documents Specification
– NHIN Retrieve Documents Specification
– NHIN Access Consent Policies Specification
– NHIN Health Information Event Messaging (HIEM) Specification
– NHIN Document Submission Specification
– NHIN Administrative Distribution Specification
10. Did you implement these specifications as prescribed, or did you make some adjustments for your environment? If the latter, what adjustments did you make at the time of initial implementation or have you made since? Were these adjustments made through bilateral agreements or did they apply to all participants in your exchange?
11. How easy or difficult were the Exchange specifications to understand, interpret, and implement? Compared to other service-oriented implementations you’ve been involved with, was Exchange easier, harder, or about the same level of complexity?
12. What operational and administrative coordination and technical infrastructure have you needed to put in place in order to deploy and operate Exchange?
13. How many hours of technical time did the project entail before reaching full interoperability?
14. What other questions do you wish we had asked about your experience deploying, operating, and maintaining your Exchange implementation?
I should condition my comments with the understanding that I am not the technical person who implemented UHIN’s connection to the VA via the Exchange protocol so I am relaying their comments.
We are very excited about the Nw-HIN Exchange functionality. It will solve many of UHIN’s cross-country exchange challenges. We are hoping to us it to connect to Quality Health Network in Western Colorado to the Idaho Health Data Exchange, among others.
However, as with most things HIT, particularly any new process, there were significant challenges in the implementation. Our HIE vendor, Axolotl chose to build a connection using the Exchange documentation. Apparently, the documentation was never tested (unfortunately, a common problem in IT) and hence contained some serious discrepancies. I believe we are still working on the last of the bugs but are nearly there.
I believe there were some significant problems with the testing as well. Apparently the testers were not as familiar with the ‘built from the documentation’ form of the Exchange and hence, were not particularly helpful in trouble-shooting problems. From what I heard, it was quite frustrating.
Our experience illustrates a common problem in HIT: poor documentation, particularly for new processes. It also illustrates another problem. IT people are very bright and hate to say “I don’t know how to do that”. So, they say “I can do that” even when they can’t. Until that protocol becomes widespread in its use, HIT professionals will struggle with implementing it.
We are also having the same problem with Direct. It is also not ‘easy’.
I hope this is helpful.
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Thanks for the opportunity to comment. We always appreciate the FACAs being open to listening to the experiences of those who are involved in implementing information exchange. We emailed our specific responses to all 14 questions (to ONC.request@hhs.gov). I’ve copied below our reply to question #14, “What other questions do you wish we had asked…?”
14. We wish the questions were not narrowly focused only on experiences with NwHIN Exchange specs. Maturity and usability of the Exchange specs should not be considered only in the context of cross-community exchanges. Many more vendors, including us, have much more development experience and live production experience in community-based HIEs using XDS, XDR, PIX, PDQ, etc. Those successful experiences mean that expanding to cross-community access using NwHIN Exchange is much easier because it’s just the next logical step. While many providers are not yet connected to community-based exchanges, we believe that this is the logical sequence: walk before you run, start locally and then expand to NwHIN Exchange.
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[...] The recommendations call for further investigation of the exchange specifications along with ONC performing more assessment of industry adoption and deployment. And specifically to solicit input from exchange implementers on their implementation experiences. From this the Committee is seeking comments on the subject through December 15th. For more information on and how to comment, see the Federal Advisory Committee blog. [...]
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@R C Johnson
RE: “I am working to foster the idea of a single patient record in my community where all physician choose to use the same record for cost, quality and convenience reason”
What is the size of your “community”, how long has the work that you’re doing been ongoing, do you have any early results, and have you published or are you planning to publish your experiences and findings?
TJL
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General business moved to enterprise systems during the Y2K era for cost and error reasons. Hospitals are in this transition phase now. I makes no sense to push physicians to adapt a technology platform that is out of date for cost and date reliability and other quality reasons.
As a patient it is impossible for me to determine who has a digital file on me, if it is secured properly and with whom the files were shared with. Now I see that data exchanged are setting up standards to exchange data. Having introduced pay-at-the-pump to the market place and having worked in the electronic payments industry in both Europe and the United States I can say without reservation that the health industries approach to automation is one of the largest disservices to the American public ever and should not only be stopped but recinded. On the current path costs will grow and quality will decline. The government may pass all legislation and rules to protect consumers – but it will never have the resources to enforce these rules.
Automation was an opportunity to fix all the problems that impact care (fraud, waste, abuse, inappropriate treatments, quality, risk and convenience) and has failed. The data exchange strategy allows vendors to sell more hardware, software and consulting services and does nothing to protect patients from system failure and in-fact puts them at risk by allowing a system to be built that can be so easily breached.
Automation should not be about automating a physician’s office it should be about automating the delivery process. It should not be driven by hospitals where less than 5% of care occurs. Automation demands are causing physicians to sell their practices to hospitals – putting them under the control of a system that has the highest costs and error rates in the industry and expecting anything less than a new round of cost growth and a further decline in quality is wishful thinking.
I am working to foster the idea of a single patient record in my community where all physician choose to use the same record for cost, quality and convenience reason – this is what all patient should demand. HHS has failed to come to terms with the realities of automation which is going to result in a worse health care system than we have today.
I encourage the agency to stop all data exchange efforts immediately so that it may reevaluate the path it has chosen. A single patient record is the only model that makes economic and quality sense.
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