Health network is ready — and waiting for your records

The Social Security Administration expects to receive more than 3.3 million applications for disability benefits in fiscal 2010, a 27 percent increase compared to 2008, and each case requires medical records to make a determination.

“We make about 15 million to 20 million requests for medical records to about 500,000 providers as part of out disability program each year,” said Jim Borland, SSA special adviser for health IT.

Gathering that data takes time, contributing to the weeks or months it can take to make a decision. “Today, information exchange in the health care environment is done by fax,” Borland said.

That slowly is changing. In February 2009, SSA became the first agency to take part in the Nationwide Health Information Network, digitally requesting and receiving health records from the MedVirginia health information exchange. During the past year, it has used NHIN to gather records on about 4,500 cases from MedVirginia and a Massachusetts-based health care provider. Those cases represent a small percentage of the SSA caseload, but they have demonstrated the network’s value.

“Absolutely, it has made a difference,” Borland said. “We have cases we are deciding in 48 hours.”

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Those are the fast-tracked cases, in which initial data clearly indicates a disability exists. Without the use of NHIN, those cases typically take about two weeks to decide. Decisions in cases being handled on a normal schedule have been sped up from about 90 days without NHIN to about 60 days when the network is used.

The program is expanding, and in February, SSA announced that 15 more health care providers and networks have received $17.4 million in contracts through the Recovery Act to take part in NHIN. SAA hopes that during the next decade, the program will gain enough traction to move health information exchanges away from the fax machine and make digital exchanges the norm.

The Health and Human Services Department views NHIN as a critical element in enabling the use of electronic health records, which promise to ease the exchange of critical information among providers of care and payments that make up the health care system. EHRs also could give patients greater control over their records.

Ensuring the security of that sensitive information is a challenge. “We are not going to build 500,000 point-to-point connections,” Borland said. The Internet offers a practical alternative to private links, but it has problems. “The common perception is that there are risks associated with transmitting any kind of information over the Internet.”

That is where NHIN comes in. “NHIN is a collection of standards and specifications for data transport, as well as for the data itself, for securely exchanging information over the Internet,” Borland said.

“It’s not a physical network,” said Jim Traficant, vice president of Harris Healthcare Solutions, a division of Harris that has led development of a NHIN gateway for HHS. “You don’t go into the enterprise that is providing the information. They publish it to the network.”

The program to develop an architecture to enable collaboration and information sharing began about four years ago through HHS' Office of the National Coordinator for Health Information Technology. The NHIN technology was not the biggest challenge to making a network work.

“The difficulty was that there was grant money to get this started, but they couldn’t come up with a business model to keep it going,” Traficant said. That changed with a new round of funding. “It’s just starting to catch. What you’re seeing today is the front edge of a wave, and that wave is being fueled" by the American Recovery and Reinvestment Act.

The first wave of implementation came in 2007, when HHS awarded contracts worth $22.5 million to nine health information exchanges to begin development and trials of NHIN. Another $600,000 in grants was awarded to six more organizations in 2008. The participating organizations, which eventually included the Indian Health Service, National Cancer Institute, SSA and the Veterans Affairs Department, formed the NHIN Cooperative to securely exchange summary patient records. It also helped to establish the core requirements for standards and specifications.

By August 2008, the group completed testing of core capabilities to support NHIN, and in December 2008, SSA announced that it would become the first agency to use the network for some disability benefit applications.

SSA is using the Connect gateway developed by Harris Healthcare Solutions to link existing IT systems to NHIN. It is an open-source software package that features:

• A core services gateway that locates records and handles authentication and authorization.
• An enterprise server component that enforces regulatory and policy requirements.
• A universal client framework to create an edge system.

“Connect allows the enterprise to quickly connect to the NHIN,” Traficant said. It is available for free through the Three-Clause BSD open-source license and now is in its sixth release. It allows authorized organizations to request records through NHIN. The request is authenticated with the use of digital certificates, and the records are encrypted and published to the network. “Only the requester can unlock it.”

NHIN users apply through the Office of the National Coordinator for Health IT and sign a Data Use and Reciprocal Support Agreement, which is a trust agreement that specifies how they will work within the network. The office issues digital certificates, and each organization installs a gateway, such as Connect, to link its health IT systems to the network.

Although its use is limited, NHIN is out of the test and pilot stages and is now in full production, Borland said. VA, the Defense Department and Kaiser Permanente are also using the network separately from SSA and MedVirginia.

“Our next step is to achieve interoperability with DOD, VA and Kaiser because we are all using the same standards,” Borland said. Because some standards and specifications are mandatory and others are optional, interoperability among various organizations using NHIN is not automatic. Users must make sure that operational elements are in sync and that data being requested is properly mapped. “It’s an iterative process that the trading partners move to.”

SSA also will be expanding its use of NHIN to the 15 health care providers and networks that received contracts in February. Those include regional health information exchanges and health care providers from California to Florida and from the Great Lakes to the Gulf Coast. “We are getting a lot of geographic and organizational diversity in this expansion,” Borland said.

As the trust relationships among trading partners develop and become standardized, along with the systems that are storing, managing and exchanging medical information, the expansion of NHIN should become simpler. “We are hopeful that the lessons learned from the implementation will be used by vendors in their products,” Borland said.

But it is not the availability of compliant products for NHIN that will control the pace of the network’s expansion.

“The limiting factor in expanding this faster is adoption of electronic health records,” Borland said.

Most records are still maintained on paper, which requires the use of fax for transmission. But if the adoption of electronic records proceeds at the pace predicted by the Congressional Budget Office, 90 percent of health records will be created digitally by 2020. “The key for this is to reach a critical mass,” Borland said.