In the next year, thousands of doctors, hospitals and other healthcare providers will begin to create electronic medical records and exchange the data with other providers. That almost-certain groundswell of adoption" prompted by big federal incentives as well as by desires for better patient care"is both the good news and the bad news for the teams that have worked for nearly a decade now to develop a Nationwide Health Information Network (NHIN).

The NHIN teams, formed by the Office of the National Coordinator of Health IT during the Bush administration and continuing in modified forms under the Obama administration, have worked ceaselessly to figure out how to get healthcare providers to use EHRs and share information about their patients. So the team members are pleased at the prospect of faster adoption of health IT.

"I think this is the piece that was needed," agreed one observer, Mary Lamb, chief operating officer of Jenkintown, Pa.-based Suss Consulting Inc.

At the same time, ONC officials acknowledge that the NHIN scheme as conceived under the last administration is not yet ready to accommodate a horde of new users. And some of the new users may never use the "network of networks" envisioned by the planners, until now.

The network-of-networks concept has been the underpinning of NHIN planning and implementation at least since 2006. The idea is for accredited organizations to establish secure gateways to the network, which always has been expected to run over the Internet, but have its own access and communication rules.

The accredited organizations"often health information exchanges (HIE), regional health information organizations (RHIO) or large healthcare delivery systems, such as Kaiser Permanente or the U.S. Department of Veterans Affairs" would provide their members or operating units with NHIN software and communications services.

That structure would limit administrative burdens because the NHIN gateways would number in the hundreds"at least for a while"rather than thousands. The organizations accessing the network either would have their own technical experts or would be large enough to contract for the expertise.

As David Lansky, chairman of the NHIN work group for ONC's official HIT Policy Committee, put it in an interview, "the individual NHIN components were relatively well-established exchanges, and the challenge was in interoperating among them."

Meaningful start
Activating this strategy has been under way for several years, and is proceeding gradually. But NHIN development was thrown off course with congressional passage of ARRA in February 2009. The bill, sometimes called the stimulus bill, provides $19 billion-plus for health IT. One large chunk of the money is set aside for incentives that will encourage healthcare providers to begin exchanging health records in 2011.

The incentive structure is designed so that the sooner providers begin using health IT in a "meaningful" way, the more they will collect. Incentive payments, which are available to Medicaid and Medicare providers, can add up to $44,000 and $65,000 and respectively "no small piece of change.

To obtain the incentive payments, provider must use electronic health records that can "exchange electronic health information with, and integrate such information from other sources," according to a proposed regulation. It lays out other requirements as well.

Proposed meaningful use criteria include such items as sending information from medical offices and hospitals to immunization registries; sending laboratory test results to state authorities to comply with mandates for reporting certain communicable diseases; and checking the patient's insurance eligibility electronically"tasks that require secure communications.

Robust NHIN?
The federal government has an obligation to support healthcare providers in achieving meaningful use and earning the incentive payments, said Dr. Farzad Mostashari, a senior adviser to ONC. But giving them all access to the evolving NHIN in the next year or two may not be practical or desirable.

"Those stage 1 criteria are simpler than the use case the current NHIN was built to support," Mostashari said in an interview. "The current NHIN was built to support sophisticated, robust information exchange where patients' information is queried with their permission from multiple locations, pulled together from multiple health information organizations and returned."

"What we're dealing with for stage 1 meaningful use is much simpler, directed communication, usually for treatment and payment purposes, where you know who it's coming from and you know where you want to send it," he added. "It's a much simpler problem of, basically, secure routing."

Many of the standards and policies that are needed for the limited exchanges envisioned in the next few years are in place. But to draw in more users and give them technical options, HHS has proposed to expand the number of standards the NHIN will accommodate. For example, either the Health Level 7 (HL7) Continuity of Care Document (CCD) or the American Society for Testing and Materials Continuity of Care Record (CCR) standard may be used for summaries of patient records.

This concerns some observers, who say that allowing for more choices will slow down, not speed up, the process of getting users connected. What will happen, they say, is that technical staffers will evaluate all the options, instead of just proceeding to comply with a single official standard. The techies also may feel they need to support all the allowable standards to achieve full interoperability with other NHIN participants.

"I'm concerned that we've made everybody's life more difficult," said Robert M. Cothren, executive vice president, technology solutions, at health IT consultancy Cognosante LLC.

To-do list
And other NHIN issues still remain to be ironed out. As Lansky said at a January meeting of the Health IT Policy Committee, "there are tens and hundreds and thousands of people that need to be part of this whole process. We don't know where they are today, where to find them, how to talk to their EHRs, and to feel confident that the potential users are who they say they are, and that we can successfully manage the communications across the network."

The medium for the exchanges could be secure e-mail, officials said, or some other technique, such as directing someone to a secure Web site to view lab test results. "You can't just use the Internet or e-mail," Mostashari said. "It's got to be secure enough to provide the trust needed and the privacy and security protection."

That means that users will have to be vetted by a trusted organization before they can use the network. With health information exchanges and other existing NHIN participants unavailable to many healthcare providers, additional organizations will have to be authorized to permit and enable medical practitioners to use the NHIN.

But "it's hard to centrally authenticate and identity-proof individuals one by one, hence part of the need for a chain of trust involving organizations in the NHIN," said Dr. John Loonsk, vice president and chief medical officer at IT company CGI Federal.

With all the focus on the new NHIN Lite, what about progress of the original, more structured NHIN? That's a concern for some, including Loonsk, who headed up the NHIN development effort at ONC for four years before joining CGI Federal.

"It is laudable to have a focus on the individual and try to make any barriers to entry as low as possible, but because of the practical issues of implementation, including the time it takes to move from aspiration to implementation, it is very important to build on the existing foundation of the work that h