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NwHIN: At the 'Speed of Trust'

May 25, 2012
by Jennifer Prestigiacomo
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Will a voluntary validation process be enough to spur nationwide health information exchange?

During last week’s NeHC webinar, “Building the Proposed Rule: An Overview of the Governance RFI,” Steven Posnack, director of the federal policy division, ONC, discussed the RFI it would be issuing to seek comment on governance policies and procedures for the nationwide health information network. As a part of the RFI, the ONC introduced a voluntary validation process for entities’ conformance to conditions for trusted exchange (CTEs), so that those entities could then become nationwide health information network validated entities (NVEs). But will that be enough to spur nationwide health information exchange?   

Before embarking on this trust conversation, I think it’s important to echo the distinction Brian Ahier, health IT evangelist at Mid-Columbia Medical Center in Dalles, Ore., made in a post he wrote earlier this month. Ahier pointed out the important difference between the Nationwide Health Information Network Exchange (upper case), an organization that is reported to be turned into a nonprofit entity this fall as its weaned off federal funding, and the nationwide health information network (lower case), which is defined as the set of standards, services, and policies that enable secure health information exchange over the Internet.

It is reported that the NwHIN Exchange will be an independent, nonprofit, public-private partnership that includes the Department of Defense, the Social Security Administration, the Department of Veterans Affairs, the Centers for Medicare & Medicaid Services (CMS) and many nonfederal hospitals and health care organizations, as well as local health information exchanges. “So really the ONC has released an RFI for comment on the governance mechanism for the nationwide health information network, and I don't know what will happen [to] the commonly used NwHIN acronym (which used to be NHIN) except used as part of the NwHIN Exchange,” Ahier said in his post.

What is necessary for all HIEs, from private health information exchanges that link up inpatient and ambulatory physicians to larger statewide efforts, that participate in the NwHIN—upper and lower-case—is the imperative for trust brokering. If a single hospital has difficulty gaining the trust of its employed physicians to share information, one can only imagine the trust issues on a national scale.

Posnack said during the webinar that the ONC was trying to determine the value proposition for a governance mechanism and how it could add value to the market. “We hope that by establishing a consistent set conditions for trusted exchange, that would help jumpstart trust building relationships, that there would be value in different entities across the spectrum in seeking NVE status,” he added. “We hope that this designation would allow a trust basis for folks that are facilitating electronic health information exchange to be able to represent to parties that they have met certain baseline standards.”

Posnack also emphasized that now was the time to establish a governance mechanism to shift the trust paradigm of today, which is “trust on first name basis” to “where trusted exchange can occur beyond those providers whom you’re on a first name basis to any provider, at any time from which a patient may seek care.”

At the May 24 Health IT Standards Committee meeting, HCI’s David Raths reported that Farzad Mostashari, M.D., national coordinator for health IT, said that it is critical to move from information exchange trust that is established at great expense for point to point connections between organizations to a more scalable approach where once conditions are met, healthcare organizations can be assured of reliable exchange. John Halamka, M.D., CIO of Harvard Medical School and vice chair of the Standards Committee, echoed Mostashari’s sentiments in that meeting when he said the establishment of an ecosystem of NVEs would allow “healthcare organizations to stop working on these one-off agreements before they trust each other to share data. It would be plug and play instead of plug and pray.”

I’m very interested in seeing how this voluntary validation process unfolds and will it work similarly to how the validation model has been established for meaningful use. Will a voluntary process end up being effective for ensuring that entities engaged in exchange comply with CTEs, and will that end up breeding trust? Also, will the NVE process encourage the adoption of exchange standards and be the galvanizer for more widespread exchange? Another question I have is who will be accreditation body for NVE? All these questions will be answered in time, but the first inclination will be in the public comments, which are due June 15.