By Cindy Atoji

March 18, 2008 | With the Office of the National Coordinator for Health Information Technology (ONC) inviting HIEs (health information exchanges) to apply for 10 $10,000 grants to be awarded at the end of this month, ONC’s John Loonsk, director of the Office of Interoperability and Standards, says these new participants may include health record banks and integrated delivery systems. They’ll join 10 current HIEs in demonstrating interoperability, says Loonsk, who also directs the Healthcare Information Technology Standards Panel (HITSP) and the Certification Commission for Healthcare Information Technology (CCHIT) as part of his duties.

Loonsk spoke with Digital HealthCare & Productivity about laying the pieces of these puzzles together to move the National Health Information Network forward.

 DHP: Give us an update on the National Health Information Network’s (NHIN) progress. Where are we?

Loonsk: Basically at a high level, we have three steps to the NHIN. We started with prototype architectures and now we have nine contracts that will do trial implementations. As a tenth participant, we have many of the federal agencies that provide care participating in this year’s activities, and we have a request for proposal that’s out on the street now, and closes later next week, to bring others into that activity as well.

The trial implementations are about trying to eliminate all the issues that allow us to get to a production NHIN. We’re going to be demonstrating the accomplishments in the fall; they include providing some core services for secure HIE as well as demonstrating certain capabilities that enable the consumer to play a more prominent role in those exchange activities as well.

DHP: What are those activities for the consumer?

Loonsk: This is a very exciting time for the consumer in terms of HIT. A number of major technology corporations have entered into this space with products or platforms for consumer-controlled health records, and I think there’s a real opportunity for these to achieve some capabilities for the consumer. We still have a ways to go in terms of having provider EHRs [electronic health records] online in an electronic form, but the promise is starting to show itself.

DHP: What barriers remain for health information technology, and how can they be overcome?

Loonsk: The simple connection of one system to another is a technical challenge in a domain such as healthcare where the information space is very complicated. The kinds of information we have to express in healthcare are much more complicated than in banking, for example, where you’re largely talking about numeric data, and a specific type of data: money. In the context of healthcare, there are so many different data types and so much complicated information with subtleties and permutations as to what needs to be expressed, and that makes it more of a technical challenge.

Another barrier is clinician adoption of electronic systems. Clinicians are stressed by many different pressures, and putting an EHR into an office environment involves change. We think EHRs add value and have a very concrete and tangible outcome for the clinician, but no question about it, it is a change. We have been trying to address some of these issues by advancing, for example, the certification of EHRs so that providers can understand what they’re investing in.

Clearly there are also concerns that consumers have about the security and confidentiality of information, and we need to make sure that patients are confident in the security of their electronic information, and this is a technical challenge as well.

Another area we’ve been working on is making sure that we all agree on standards so that data exchange can be used in more than one context. So that’s an obstacle.

And there are obstacles in just the exchange of information between different business entities. We’re driving toward a consumer-centric approach to healthcare, but that creates a need for information to flow from one organization to another, and sometimes those organizations are competitors.

DHP: What efforts are underway to put standards and policies in place to facilitate data movement across the country?

Loonsk: The work of HITSP is to identify the standards needed to carry out these activities. HITSP is working on this, and they have made recommendations to Secretary [of Health & Human Services] Leavitt; he recognized the first set of harmonized standards and has queued up others to recognize [them] in January of next year.

There are a number of activities in the policy domain as well; they include programs around security and privacy, and the reconciliation of varying state policies on health information exchange and the converging of state representatives to work on common approaches to advancing these capabilities.

DHP: Recently Secretary Leavitt announced the creation of “value exchanges” that would use nationally recognized standards of care to assess the performance of local healthcare providers. What role will HIEs play in these value exchanges?

Loonsk: HIE is different from the concept of having a value exchange, but these are very complementary concepts. One of the things that is clear from getting to quality outcomes is that at times you need to have longitudinal data -- in other words, data about a patient that may exist outside a particular episode of care. And sometimes that involves the movement of data between two different organizations. So one of the opportunities for HIEs is to help allow for the connection of that information so that a quality measure that might relate to being hospitalized, for example, could be processed in conjunction with ambulatory care information. HIEs could play an important role in allowing for those types of quality metrics to be applied.

Another issue with quality is getting the data that is necessary to allow physicians to make the best informed decisions, and making sure that quality measures can be appropriately evaluated. Frequently that is data that is currently not electronic. Or sometimes now quality measures are done on the basis of claims data, and claims data is really not adequate to get to some of the more complex medical quality determinations. These detailed and specific clinical concepts would not reside in a claim but are important to have to apply a measure in. HIEs have demonstrated that they can assist in getting those kinds of data to be useable to apply in this kind of circumstance.

DHP: This fall, nine state or regional health information exchanges and one federal agency, HIE, will demonstrate the exchange of health information using the Nationwide Health Information Network. Can you elaborate on this NHIN demo and what we can hope to see and learn from it?

Loonsk: What they will be doing in the fall is demonstrating core services that enable this non-proprietary exchange of health information in a secure way that supports the kind of consumer services I talked about earlier.

DHP: Can you give us a sense of the types of HIEs that may participate?

Loonsk: We already have geographic HIEs participating as well federal agencies participating. We also have a grant to bring others to participate, and we expect this could include some integrated delivery systems, non-geographic HIEs, and some health data banks and the like, but that remains to be seen. We’ll be able to talk about that after this grant request takes place, which will be at the end of next week.

DHP: What kind of response are you anticipating to this grant request? 

Loonsk: We wish we had more money or resources to put into that — there’s not a lot of money we apply to this at this time, but we think it’s going to give an opportunity for those who are interested in participating. So the grant is going to be somewhat limiting but we’re hopeful. Up to 10 is the limit, and we’re hopeful to get several who are interested.

DHP: How can HIEs derive value and develop a business case?

Loonsk: It has been a challenge for geographic HIEs to all have sustainable business models. There are some who have been successful in this area but there are still challenges and they’re frequently eking out their existence because many of the incentives in healthcare frequently don’t support their charge or task. So there are ways that HIEs have pursued sustainable business models but there’s still more work to do.

DHP: And in your opinion, which of these business models have shown the most promise?

Loonsk: I think I’ll punt on that one. I think the jury’s still out to some extent. I think one of the things that has come forward is that health information exchanges need to act somewhat as a business. Although many of their goals may be noble, if they don’t pay attention to the bottom line, they will not be sustainable.

DHP: Can you make a case that the value of connecting exceeds the cost of doing so?

Loonsk: I think we’re starting to see the value exceed the cost of doing so. I think there’s a threshold effect here, or more negatively, a little bit of a chicken-and-egg effect. With HIEs, the broader the group [of organizations] that are connected, the more will want to connect. We’re still in the early stages, so in some degree, we’re still establishing the value of connection. As more physicians have EHRs, the value of connecting increases because there’s a greater likelihood that information that you actually need will be accessible to you. So there’s a variety of activities here — adoption of EHRs, the ability to have shared standards in a secure way — and the number of organizations that are actually doing that means that we are starting to get to the tipping point. But we’re on the edge of this and there’s a fair amount of work and effort that needs to go into doing this well.

DHP: What will drive physicians and other stakeholders to adopt and rely on NHIN capabilities?

Loonsk: There’s the misconception out there that the NHIN is about something national. But the NHIN is not about a central database or storing anything on a network on a national level. What it’s really about is shared standards for health information exchange that can support care that is most frequently local.

DHP: And so what’s next for NHIN on your agenda?

Loonsk: The next step for NHIN is to begin some production-level capabilities. So after the demonstrations in the fall, as quickly as we can we want to have some production capabilities, and we want to do this carefully and incrementally. It’s not a big bang approach — but it’s not that far off. I think we’ll some production capabilities by the start of next year.

We will continue to work with the Healthcare Information Standards panel to develop the standards necessary and the Certification Commission to ensure that when someone is investing either their funds or their confidence in an electronic health record or personal health record or a health network, that it will do what it needs to do in a secure and reliable way.