NHIN: The New Health Internet?

By John Moore
09:34 AM

Chilmark has not been a big fan of the National Health Information Network (NHIN) concept. It was, and in large part still is, a top heavy federal government effort to create a nationwide infrastructure to facilitate the exchange of clinical information. A high, lofty and admirable goal, but one that is far too in front of where the market is today.  The NHIN is like putting in an interstate highway system (something that did not happen until Eisenhower came to office) when we are still traveling by horse and buggy. Chilmark has argued for a more measured approach beginning locally via HIEs established by IDNs (our favorite as there is a clear and compelling business case) and RHIOs in regions where competitors willingly chose not to compete on data, rather seeing value in sharing data.

But what might happen if the folks in DC stopped talking about the NHIN as some uber-Health Exchange, but instead positioned it as a consumer-focused platform?

That is basically what happened yesterday at the ITdotHealth event where the new federal CTO, Aneesh Chopra and new HHS CTO Todd Park presented their conceptual idea to a pretty select group who had gathered together to discuss the idea of platforms in HIT to support discrete, substitutable, modular apps. (John Halamka gave a nice write-up of the event in which he participated on the first day).  Chopra and Park were seeking to float this idea among the movers and shakers of new models for HIT, gauge the interest and ultimately solicit support for the concept.

In somewhat of a re-branding exercise. Chopra and Park are proposing that the NHIN now be viewed not so much as solely a clinician to clinician care coordination exchange platform but rather one that also will focus on the consumer, creating a secure Health Internet to facilitate consumer access to and ultimately control of their personal health information (PHI). The basic NHIN, let’s now refer to it the Health Internet, is still composed of the same technology stack: platform independent, open source, freely available with published standards, etc. that support an independent software vendor’s (ISV) ability to build apps upon the Health Internet stack for consumer consumption (e.g., health & wellness services, PHRs, etc.). In June, we attended the NHIN CONNECT conference and our write-up provides a few more specifics on the Health Internet.

At the ITdotHealth event many of the participants (Google Health, HealthVault, MinuteClinic, etc.) stated that they “are in” and are willing to work with the feds to insure that their respective platforms/services will be able to readily connect to and exchange PHI upon a consumer’s request over the Health Internet.  Even EMR giant Cerner voted tentative support for the idea if the Health Internet would assist them in helping their customers (clinicians, clinics, hospitals) meet some of the forthcoming meaningful use criteria that is now being formulated by CMS – Chopra at the June CONNECT event and Park at this one basically inferred that providing the capability for an EHR to connect to the Health Internet would address some aspects of meaningful use.


Chopra also stated that he has the support of numerous federal agencies (DoD, CMS, and other agencies) who are now working together with HHS to define how the Health Internet might serve their respective constituents.  These agencies have not yet formally committed to allowing PHI to migrate to the Health Internet, but today are addressing the critical process issues of consumer access, control, and consent as it pertains to on-ramping PHI to the Health Internet. Chilmark believes that these issues will be resolved within the year.  When that happens, we can expect some pretty significant movement of PHI across the Health Internet.  For example, the DoD alone has nearly 4M active duty members (multiply that by 2.2 for dependents and the number skyrockets to over 8M) whose PHI may begin to flow on the Health Internet.

And it is not just Google Health, HealthVault or others that may be beneficiaries of the Health Internet.  In speaking with a representative of the VA (yes, VA is a supporter as well) he related that this will allow veterans an opportunity to choose the best services out there in the market to assist them in managing their health.  No longer will the VA have to try and create such apps themselves, or find partners to create the apps to sit on top of the VA PHR HealtheVet. Instead, the VA can simply direct a veteran to the Health Internet where such services will reside and instruct a vet as to how to access those services.

This is exactly what Chopra and Park envision with Chopra adamantly stating at the beginning of his talk that they seek, through the Health Internet, the creation of a fertile environment where innovation can flourish and ultimately consumers will benefit.

Finally, HHS & the Feds are Talking About the Consumer

Chilmark has been quite disheartened as of late with the lack of attention paid to the consumer, the citizen who is footing the bill to get doctors and hospitals wired.  We chided the HIT Policy workgroup for HIEs for their complete lack of acknowledging the consumer’s role and ownership of PHI.  We came back from DC recently disillusioned at the nearly myopic focus of ONC on clinicians.  Chilmark is concerned that the $44k allotted to a physician to adopt an EHR is not enough, another forcing function is required and what better forcing function than the citizen, the customer of the physician to drive adoption of EHRs.

Low and behold others at HHS and elsewhere had similar feelings and are now moving aggressively forward with a concept that directly addresses the consumer. Hallelujah!

The Plan:

At the ITdotHealth meeting, Park and Chopra stated that if interest is high (sure seemed to be at this meeting), they wanted to take that feedback back to DC and work with the federal team to start laying the groundwork to get started ASAP.  Hypothesized goals and objectives include:

The federal team will begin by working with industry stakeholders (PHR providers, EMR providers, services, hospitals, fed agencies, etc.) to identify the gaps, determine if the existing protocols are adequate and lay-out a roadmap to rectify. They also stress that they will seek involvement of consumer representatives and privacy advocates to insure their input is included early on in the process.

By February 2010, begin filling the gaps and modify protocols and standards where necessary.

Launch beta in early Q2′10 moving mock PHI over the Health Internet to test the system, make modifications and hardened the network.

Though they did not go so far as to say when the Health Internet will move live PHI, our estimate, assuming all goes relatively smoothly, is that the Health Internet will be open for business by late Q2-early Q3′10.  This is a very fast track for the Health Internet, but certainly doable as the core infrastructure is already in place and this exercise is more of a fine tuning effort, than building from scratch.

Putting on the Pragmatist Hat:

Chilmark is very encouraged by the idea of the Health Internet and the new direction it is taking, creating a consumer directed and controlled interstate for the secure transfer of PHI. Not only does it finally acknowledge that at the end of the day, all the HIT spending in the world will make little difference if we do not get the one who has the most to gain, the consumer, involved, but this initiative may also create a fertile environment for innovation to occur.

But there are some challenges ahead for the Health Internet, which include:

The DURSA (Data Use & Reciprocal Support Agreement), which all NHIN (Health Internet) users (data providers, services, ISVs, etc) must sign to participate, stipulates that participants must abide by HIPAA requirements. Now HealthVault is on record stating that they have no problem with HIPAA, but Google is another story where they have been fairly adamant that HIPAA does not apply to them.  Will Google now agree to HIPAA?  And what about other ISVs and service providers, will they adhere to the requirements in the DURSA?

Beyond the feds and HIPAA requirements, there is a morass of state-specific laws as it pertains to the release of PHI, many of which go far beyond HIPAA in  their requirements.  As the Health Internet looks to create one common “health interstate” for the movement of PHI, how will these state laws be reconciled to allow this to occur?

Lastly, there is the issue of bringing awareness to the public.  While the vast majority of consumers use Google for a second opinion, very few use the Internet to store, access and share their records.  Very few even know what a PHR is.  Whenever the topic is raised in conversations with lay people, maybe one person might have heard of Google Health or HealthVault, but it is a rare person indeed that has any understanding what these services are for and why they might be interested in using such a service. This may ultimately be one of the biggest challenges for Chopra and Park, but to their credit, they are making the right moves now, garnering industry backing who can assist them in “getting the message out.”

Chilmark Research will assist as best it can from its vantage point.

Aneesh and Todd, we are in!