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Shifts in the architecture of the Nationwide Health Information Network

The linked article below Shifts in the architecture of the Nationwide Health Information Network is from the January issue of JAMIA. The abstract states that recent ONC activities (particularly from the Federal Health Information Technology Strategic Plan 2011-2015) undercut the limited business model for RHIOs, decreasing the likelihood of their success, while making the NwHIN dependent on nascent technologies for community level functions such as record locator services. The piece claims these changes may impact the health of patients and communities. They call for independent, scientifically focused debate on the wisdom of ONC’s proposed changes in its strategy for the NwHIN.

The article gives a good overview of the history of RHIO's and makes some good points on community level exchange efforts and does raise some concerns around running headlong into the PCAST recommendations. I agree with the promotion of a non-partisan commitment to achievement of a common vision for the NwHIN. However, there are some flaws in the conclusions of the piece that I think deserve discussion.

First, the article undercuts its own argument against ONC policies by pointing out that many of the ONC funded Beacon Communities are doing exactly what the authors call for. They then cite research that show a dramatic increase in local HIOs under these same policies which they decry. Arguing that the number of RHIOs has more than doubled, funding is coming from a new innovative approach, and the sustainability issues are still not solved, is specious at best.

I also agree with much of the following statement:

The approach is internet-like in its promotion of point-to-point information exchange through standards and interoperability initiatives such as DIRECT. It will also rely upon web services such as directories for identification of providers and facilities that are analogous to the Domain Name Services (DNS) model underlying the internet, along with internet-based security models. These yet to be constructed services will allow users to look up how to send data to providers and will specify security operations. The advantage of this approach is that it may radically lower the cost of connections for data exchange between parties for ‘push’ transmission through elimination of expensive custom interfaces. It may also speed up the process of health information exchange, making it potentially possible to require health information exchange to earn incentives under the administration’s Meaningful Use policy.

The implication of "yet to be constructed services" is that somehow this approach is flawed. I am very impressed with the development of these services and feel extremely confident that this approach will work. This is exactly the type of disruptive innovation that Clayton Christensen refers to as "new approaches or technologies that, while initially offering lower performance than established methods, have far lower entry barriers, opening up new markets of greater scale, in which the disruptive technologies eventually grow to equal and often surpass the capabilities of incumbents." This is the free market at work! How the author's could object on these grounds baffles me...

Finally, they claim that ONC strategy depends on the success of the PCAST model. This is a stretch. While the Strategic Plan does refer to PCAST, it is certainly not wholly dependent on the approach. Concluding that creation of the Health Internet is politically motivated does not wash. I understand that change can provoke fear in some quarters, but using an Internet based approach is the future of health information exchange. You can resist and become irrelevant or work together to create the system of the future...
David C. Kibbe's profile photoMargalit Gur-Arie's profile photoBrian Ahier's profile photoPeter Bachman's profile photo
Obviously, there is much more to say. But I thought this would be a good discussion starter...
The current "architecture" of the NwHIN was presented to the HITSC last week, by Doug Fridsma of ONC, in the form of a set of layered "building blocks" that currently include both push (Direct) and pull approaches (Exchange, aka Connect, aka XDS/XCPD.)

Nothing like PCAST is currently on the ONC list, though Dr Fridsma has queued up additional 2012 HITSC discussions to consider the need for additional "building blocks," presumably to include more "internet-like" services such as PCAST-inspired approaches. But I don't know of anything close to PCAST underway at present, at least not via ONC-sponsored channels. (There was that "metadata wrapper" ANPRM, but we haven't heard much about that for a while.)

I personally think the current set of NwHIN protocols leave something to be desired. I hope the set of choices will evolve to include simpler yet more flexible and more scalable models. Time will tell.
Brilliant read Brian. Thank you for posting this. Much appreciated.
I haven't had a chance to read the entire JAMIA article, but the whole premise is a little messed up for me. ONC is undercutting RHIOs. Since RHIOs have done so well before ONC did anything. (that's in the sarcasm font in case you missed it) I'm sure we could argue all day long about whether ONC is taking the right approach to HIE, but I think we'd all agree that there's more discussion and projects working on HIE than there have ever been before. At least their driving efforts to try and make it a reality and some of them show some promise.

With that said, I do think it's worth looking at how ONC's efforts might be hurting other efforts that are doing well and how they can work synergistally together.
Good comments, Brian. It's clear to me that health data exchange is now seen generally as inevitable, and that this is in part due to the potential for many small provider organizations and low-volume exchangers to avail themselves of low cost, low complexity, point-to-point, and yet very secure solutions via Direct exchange. (ONC should be thanked for stickting to their guns on this one.) As one large vendor put it to me last week, "Direct exchange is simply a cost of doing business for us now." In other words, Direct exchange will increasingly become a foundational building block, upon which additional Internet-based exchange services can be built in succession based on need in the marketplace. I think this is very much as example of "not letting the perfect stand in the way of the merely good enough," and also convergent with Clay Christensen's breakthrough theories about disruptive innovation.
Hard to believe that anyone in 2012 is arguing that there shouldn't be directed messaging, or that such messaging is responsible for the challenges of RHIOs. It's clear that RHIOs that engage with directed messaging, including provision of HISP services are doing very well (Rhode Island Quality Institute among others). Despite the article's appeals, there's no way to put directed messaging back into the bottle.

ONC is supporting development of an NwHIN that has appropriate tools to meet different needs.
A few thoughts:

1) Congress required HIE funding to go to states; nothing in the funding or in ONC's oversight of funding or of related Beacon oversight necessarily undercut RHIOs, and in many cases, Beacon funding went directly to RHIOs and some states decided to directly fund RHIOs out of the state grant.

2) This statement is frankly bizarre: "the plans of
other states abandoned existing RHIOs and set up new entities controlled by political allies of the current state governments (eg, California)." Anyone familiar with CAeHC and CalRHIO knows how fundamentally messed up that situation was; characterizing what happened as the paper describes indicates to me that there are some axes being ground here.

3) The notion that the sustainability model requires monopoly power that artificially raises the cost of basic exchange to subsidize advanced exchange and that efforts that lower the cost of exchange therefore undercut monopoly frankly drive me up the wall. I'm frankly surprised that the premise of the RHIO sustainability model was stated so boldly.

As I kept saying in my role at ONC, the cost of exchange will go down. Any organization, private or public-private, that has a business model predicated on the cost of exchange staying high is doomed. Driving the cost of exchange down is always a good thing, for providers, and ultimately for HIOs. There are many successful RHIOs; the basic models and structures are different, but what's common in all of them is a laser-like focused effort on adding value.

If you are starting a RHIO and your sustainability model is not based on adding value to your customers, but on extracting monopoly rents on the services your customers are asking for and using those monopoly rents to provide services that your customers aren't asking for but you think they should want, you will fail.
I'm not sure what point the article is trying to make, but I did see a report last year from the National eHealth Collaborative were several established exchange organizations expressed lukewarm feelings regarding government grants for State HIE.

But I have a more pragmatic question, if I may, concerning the disruptive innovation argument. When you stand in front of a practicing physician and make the argument that Direct exchange provides a disruptive advantage to him/her, the conversation goes something like this:
Me: Hey doc, there is this brand new Direct exchange that allows you to send referrals to a specialist electronically. All you have to do is scan your paper notes, go to a web portal, search for the specialist (or call him and get his Direct address), attach the scanned files to a short message, click the button and voila, the specialist gets your referral. All for just $15 a month.
Doctor (with a vacant look in his eyes): Isn't just faxing the papers easier? I just put them on the machine, punch in the number and voila, the specialist gets my referral. All for nothing really a month.

Not to mention electronic faxing and p2p features available in most EMRs.
So where is the Southwest style disruption? If NwHIN was an existing mode of communications, I can see the disruption factor, but NwHIN does nor really exist for the vast majority, and disrupting a fax machine (or eFax) with Direct is a bit strange.

What am I missing?
The biggest thing you are missing is in your basic assumption.

1) Direct is not always unstructured or semi-structured
2) Direct is not always accessed through an unintegrated portal

Direct is just a way to send information securely from one address to another; we expect that information will, over time, become more structured and more integrated into EHR features.

I agree with your premise: Doctor A with a fully integrated EHR would prefer to use the integrated faxing feature to the unintegrated Direct feature for a referral. But Doctor A would also prefer to receive the consult note back electronically, and would prefer it to be structured so that it can be matched to the patient and help update the medication, problem and allergy/ADE list, and Doctor A would prefer to do so regardless of what EHR Doctor B uses. Doctor A would therefore prefer an EHR that allows a Direct message with structured content to be sent electronically to Doctor B.
Arien, I apologize for the lack of clarity in my question.
I do appreciate the value of secure exchange of standardized text files that can be parsed by software. This however assumes that software is employed at both ends.
If my memory is correct Direct was supposed to provide an entry ramp for those who don't have EMRs. It's that ramp that I find elusive.
Does Directing have advantages over faxing for physicians still on paper, or who have so called "basic" EMRs, which is the vast majority?
Direct was not supposed to provide an entry ramp only for those who don't have EHRs. By design, Direct was supposed to be easy enough to deploy so that it could be used both to those without EHRs and, integrated in workflow, to those with EHRs.

Direct was designed to create universal access to directed exchange (such would be used in referrals, discharge, or pushing information to patients).
I think one of the most valuable deployments of Direct is when used with an EHR and integrated into the workflow. There has been some great progress already on this by the EHR/HIE Interoperability Workgroup. Dave Whitlinger, Executive Director, New York eHealth Collaborative, and a leader in this effort will be speaking at HIMSS at the eCollaboration Forum:

If you can make it, this should be a very interesting event...
I agree, Brian, and I know some EMR vendors are doing a great job at this, but I was looking for a way to bring the not so advanced practices into the electronic world and I thought maybe some implementations of Direct could do that.
Unfortunately, it seems that either you are all in (and your vendor is all in too), or you are all out.
It's a both/and, ideally, not either/or.
Well, I wouldn't say that it's all in or all out. I would say that while Direct is not only an on ramp for those without an EHR, or those with a vendor that does not provide integration, but that it does allow an on ramp to exchange for both.
I've tried to reach out to the author's so they could discuss the conclusions, but nothing so far...
I share Brian's perspective and also support arguments for some sort of regional resources for specific purposes. It is not an "either - or" in my view.

I think there is confusion over the value of repositories and the need for point-to-point communication. They are not the same thing. (Dr. Lenert knows much about the former; he was instrumental in advancing many CDC initiatives.) I helped create a viable RHIO (Memphis - see JAMIA) and worked on NwHIN. I advocate both. RHIOs can no more maintain hegemony than can an email model based on hub-and-spoke. The two can be disconnected - and must be in many instances.

I believe most inter-organizational networks supporting accountable care or bundled payments will, in fact, serve more or less as "RHIOs" for the members. I further suspect they will communicate among one another via Direct and, hopefully, also contribute specific data items to a form or HIO that is accountable for measuring the health of populations.

The flaw in the original models, I believe, was to confuse the essential need for repositories with the need to use this same technical, legal, and administrative model as the only way to connect among data sources. I can read my friend Les' article in a different manner that says simply: "don't throw out some of the good things for a promise that many cannot yet realize." Under this interpretation, the notion of RHIO must simply change. I do believe that few - if any - of the original RHIO models will be sustained under their current - and now often obsolete - models.
I am honored to have my paper discussed by you two. The arguments in the paper combine economics, politics, and technology. I suspect we agree that regional organizations that play public utility like functions can be useful in health information exchange. Among public utility like functions are universal access and support of critical services community services that are not economically feasible to sustain. If community level services are valued, it may make much more sense to think about health information exchange from a public utility perspective than the free market. Free market and public utility are "either -- or" alternatives for sustainability and the choice has consequences. I didn't have an opinion about how community level functionality was implemented technically--just that it was needed and that certain technical choices (the Internet like model), make this more difficult.

What's the right architecture for health information exchange? Internet or "hub and spoke"? Community level health functions work far better in hub and spoke. Security is far easier in a hub and spoke.The public utility business model is far easier to implement with hub and spoke. Operations may scale better in an Internet model. Or not--we don't know actually--health is more complicated than communication via this blog. My point in the paper was to make explicit the fact that ONC is leading a shift toward an Internet like architecture and call for debate on that...and hopeful to show how the public utility model is threatened along with community level functionality we have today or that is within easy reach.

Was the shift in architecture political? I define things that the President or Congress does that don't reflect a national consensus as political. Not to be rude, but what does P in PCAST stand for? Look at the list of authors of the report and are there, among its distinguished and visionary contributors, those whose companies stand to benefit by its implementation? Is the report's assessment of current technologies fair and evidence based? Is there a national consensus on the strategies recommended in the report? So is it time to talk about the report and its proposals as if we have a choice about the future in a non political forum?... before it's too late for community based public utility style models...and then move on to that future, bright and glorious as it can be together?
+Leslie Lenert: The preference for a "Health Internet" was expressed by +Aneesh Chopra and Todd Park late in 2009 at a conference convened by Harvard, long before PCAST*. At the time, and currently, the progress towards RHIOs was glacial (with notable bright spots) and most providers couldn't to the basics, such as send and receive referrals electronically, at a time when we all could conduct secure electronic commerce, online banking and financial transactions, and the API and SaaS/PaaS space was exploding, based on the open architecture of the Internet. The counter example of electronic prescribing was based on a set of EDI transactions sent and received via HTTPS. It doesn't take dark motives to explain a policy preference for the Health Internet.

I don't agree with your premise that the architecture of the Internet is essentially in conflict with RHIO models. I do agree that the architecture of the Internet is in conflict with rent-seeking business models, but I would observe that successful RHIO models have not been rent seeking. Direct Project-based services are not going to disrupt IHIE, HealthBridge or +Mark Frisse's work in Memphis, because those organizations add substantially more value than they extract. The proposed model described of RHIOs that "subsidize other information exchange activities conducted for the public good" on the basis of monopoly rents on basic exchange services seems to be purely theoretical. I can't think of a successful RHIO that has been built on this model.

As I noted above, ONC or not, Direct or not, the costs of basic exchange services will drop, and market forces will ruin a monopoly rent-seeking model for information exchange. It was already happening before Direct and the most recent KLAS report on HIE demonstrated a substantially higher growth rate for so-called "private"** HIOs (that is, those that are directly sponsored by a health system, hospital, or provider organization) than for "public" HIOs, even though the private HIEs started at a higher base.

Even if one didn't believe the rent-seeking RHIO business model was doomed due to basic economic trends, one would still need to defend the thesis that the economic value of rapid and sustained reductions of the cost of exchange was lower that the presumed economic value of a rent-seeking business model. I'd contend that, both in the short term and in the long run, policy preference for lower costs of exchange are always going to beat policy preferences for the setting up of local monopoly utilities; I'd further suggest that the opportunities for political abuse and cronyism are always far higher in the latter models than the former.

So both on empirical grounds (real successful RHIOs have not been rent-seeking; market forces were already reducing the costs of exchange) and on theoretical grounds, there are strong reasons to prefer an Internet model and strong reasons to pursue a policy approach to convene stakeholders in focused ways that relentlessly reduce the costs of exchange.

* On PCAST, I'd suggest that this is a distraction to your basic point. The "PCAST conspiracy" is that Microsoft (and, in some versions of the story, Google) politically manipulated the PCAST report to suggest an architecture that would benefit the large Interent players. Since then, Google exited the healthcare business, and Microsoft has sold off all but HealthVault.

** I hate the term "private" HIOs. A true "private" HIO would refuse to exchange except in ways that lock-in the sponsoring organization; many "private" HIOs, by contrast, are based on standards and open architectures, and, over time, form larger communities. In my own private sector work, I've been involved in a number of such organizations, including one that has become the RHIO for the bulk of New Jersey and another that unites many of the health systems in the East SF Bay Area.
I have to say that I am not 100% clear on the definition of a "Health Internet", but I am assuming that it does have the PCAST meaning of neatly tagged and indexed data sitting there ripe for search queries, in which case it does present a conflict to the RHIO business model and also to the yet to be defined business models of the ONC funded State HIOs.
I would go further than that and say that the Direct exchange is not very compatible with searchable data at rest where it was created, because exchanging portions of it between some settings is bound to corrupt the aggregate obtainable from a PCAST envisioned universal search.

It is possible that RHIOs, and perhaps even HIOs, could provide value by aggregating and analyzing a searchable "Health Internet", but it seems to me that most newer organizations are concentrating on enabling exchange and presenting exchange as the value proposition, including Direct exchange.

If the ultimate goal is a "Health Internet", why are we even bothering with exchange? Why would anybody send a referral if all you need to do is run a Google search on the Health Internet for "John Doe referral cardiology 2012", open the hopefully first link and here is everything you need to know?
"Health Internet" and the PCAST DEAS search engine aren't the same thing at all. "Health Internet" is the basic idea of health information exchange using the architecture of the Internet. The PCAST DEAS is the specific architecture of metadata indexed search.

Agree that most real-world organizations are concentrating on exchange because that's where the value is. On a platform of exchange, most migrate upstream to aggregation, coordination, and integration.
+Leslie Lenert I deeply appreciate your comments and willingness to join the discussion. It is a much richer conversation when the author is included. +Mitch Kapor introduced the term "Health Internet" at the ITdotHealth forum in 2009 and highlighted the catalytic role that government played in defining common protocols that enabled the Internet to be created from open source and proprietary software. I HIGHLY RECOMMEND READING the Executive Summaries from that meeting (see

+Mark Frisse, +David McCallie, +David C. Kibbe, +John Halamka, +Kenneth Mandl, +Aneesh Chopra, +Clayton Christensen, +Sean Nolan, +Isaac Kohane and many other brilliant thinkers were on hand. I believe that this conference was a hinge point in history launching us into a new chapter in the development of health information exchange.

What's the right architecture, Internet or "hub and spoke," for health information exchange? I would propose that both can peacefully coexist. Just as I see EHRs moving to cloud based solutions, while still not completely displacing the client server model. As Dr. Christensen said: "In looking at EMRs and other health care IT, the data will become commoditized, systems will become modular, and money will be made in applications... EMRs are needed to coordinate care. But to get them adopted, substitutable applications must be developed that clinicians want to use because they help them do a job. Information technology in health care must be open and modular, and there must be a common language."
Yes, but we already have an Internet and I am not convinced that we need a Health specific one, just like we don't need a financial specific one to achieve the access Arien mentioned above.

In a rare occurrence, I do agree with Prof. Christensen that the data should become commoditized, effectively making the data itself a "public good", and yes, substitutable platforms and applications and modules and whatever pleases the user will indeed flourish in that scenario, but the data need not be, should not be, exchanged. It should just be available.

We are all here "discussing" things on G+. No data is exchanged. We are accessing the same repository in real time, from different, substitutable applications. This is the Internet paradigm now, and I want to see that in health care. I don't want a listserv. I want secure social media for medicine. How can both information integrity and team work be better served?
Thanks for the great perspective. I concur. I had the great opportunity of jumping into the ONC/NHIN debate at about the time Doug Fridsma arrived (and Arien was a member of the working group). I did so because I felt that "State HIEs" as a generalized model were fatally flawed both in concept and in execution. Having worked with a few states, I do believe states have an interest and some sense of a barrier to market entry (along the lines of a Michael Porter concept, I guess.). These barriers are Medicaid and public health. States have a unique interest there and some leverage, but they must work with the remainder of the evolving world or end up very isolated.

I have to find and read the KLAS report. I certainly see that phenomenon where I work - and I am in the thick of it. Certainly not in conflict with regional issues.

I have also had the opportunity to spend time with some of the New Jersey HIE people over the years. Real leaders! My favorite quote? One of them said "you have to understand that where we come from, 'The Sopranos' is a documentary."
This is a wonderful thread, full of sound observations and wise speculations, with enough history thrown in to make it genuinely interesting. In my simplified world view, there are only a limited number of reasons for data exchange of any kind using the Internet as the major route of transport. Most of these are economic. Advertising, for example. Increases in efficiency (lower cost per transaction), for another. High levels of availability and access to customers, partners, or supply chain, for another. I would add 'freedom from control' as another, given that under the proper security precautions, the Internet is a means of sending data point-to-point without network intelligence somewhere in the middle extracting value from the data stream. Socializing of one kind or another is, in my mind, another very large driver of Internet-based exchange (as a verb). However, my guess is that socialization as a driver of connectivity exists only when there are first in place economic drivers sufficient to establish infrastructure, standards, and so on. We didn't start out this journey with Facebook and Google+.

What we have been missing in health care until very recently is an economic driver(s) for health data exchange. Under fee-for-service payment there are such strong economic disincentives for exchange! Providers and their supply chain partners generally don't see value in the sharing or exchange of data, as this might lead to decreases in utilization, increases in efficiency, and, perhaps ultimately most important, price and outcome transparency on a large scale. All those results would reduce health care spending, and therefore they have been strongly resisted by those for whom health care spending by someone else is their own health care income.

Some of us, I think mistakenly, felt that the impetus of socialization could make up for and to some extent correct this basic lack of economic motive for health data exchange. But it couldn't. Hence, Health 2.0, largely a failed exercise. (Ok, I'm going to get nailed for that. Let's say a less-than-successful exercise that didn't meet our unreasonable expectations.)

My sense is that under the dual pressures of intense global competition for goods and services and the threat to our sovereign debt posed by our national health care spending, this is all about to change: that slowly but surely economic circumstances will determine that health data exchange is desirable for more providers to engage in willingly, yeah, even with enthusiasm. I doubt that this will entice large numbers of competing health care enterprises in a state or region to aggregate and pool their data for common benefit, and so I am not optimistic long term on the current HIE model becoming sustainable.

But I do see how it becomes economically and competitively critical for ACOs and accountable care-like arrangements -- in which primary care-based provider groups of considerable size come together to offer the market defined quality and defined price -- to engage in health data exchange that is inexpensive, secure, and highly mobile. The economics of accountable care will, in my opinion, whittle away at complex and costly network exchanges based on proprietary 'standards' and protective rent-seeking contracts for use and maintenance. (It may as well decrease the amount of data in health care while increasing the amount of actionable information, a consequence of value-based health care that many do not appreciate). The economics of accountable care - defining this very broadly - may represent that necessary economic driver for health data exchange that has heretofore been lacking. And if this happens, my prediction is that Health 2.0 would finally become real.

My guess is that we're not there yet. There is still powerful political and economic inertia pushing against this trend. However, my guess is also that when it starts to happen, it will happen quickly and with transformative effect on the health care industry, its supply chain, and its managers, e.g. the health plans and Medicare.

Regards, DCK
I've certainly appreciated the thoughtful comments here. It's not possible to respond to each one but I think we've advanced the discussion. There is a certain sense in Arien's comments, that if I only was experienced enough to understand, I'd agree with him.

One of the hazards of power is to imagine that those that come after will honor your work, rather than attempt to destroy it to make their own reputation or reward their own followers. Sometimes it occurs because they assume, arrogantly, that they are far smarter than those that preceded them. I'd like to put the question at the end of my paper to Arien and others with strong links to the Obama administration. Assuming the Republicans win in 2012 (God forbid, I know--especially now that Mr. Obama is on his knees in front of Him periodically), what keeps the next ONC Director from sweeping away the architecture you have created so far in the name of some "bigger and better" thing with a Republican label on it? What makes your efforts a consensus that can be sustained across administrations?

Keep in mind that I had an intimate knowledge of how the FACA's for the ONC were constructed as part of my role at CDC--so don't waste our time claiming objectivity there...and I think we've dispensed with the PCAST report as being objective--it was a tool to support Chopra's and Park's pre existing views (as expressed at the Harvard Conference). You can't really argue that HITECH is a Congressional consensus. So, what keeps your work from history's ash heap if Obama doesn't win in the fall?
Without engaging in comment on the motives of good people that I know and admire...

This is a funny frame for me, because I see the issue completely differently. I've been at HIE and clinical integration for a while now, and it keeps changing and evolving. Establishing a single specific model, whether utility model RHIO, DEAS, central exchange with NHIOs, or free market HISPs seems like an exercise in arrogance.

I certainly didn't see my role at Direct to undermine, establish or privilege any business model. It was, instead, to concentrate on a well defined problem where the costs of exchange for basic policy-relevant healthcare transactions was high to the point of being unaffordable for most providers, and seek to lower those costs through standards.

As a matter of policy preference, I would advocate that any standards adopted or endorsed by ONC should be model-agnostic and general in nature. One can use Direct in a utility model RHIO, a DEAS, a central exchange or a free market HISP.

To take another example, the Standards and Interoperability Lab Results Interface initiative proceeded from the observation that lab results interfaces are a pain and drive significant cost in industry. The initiative was a focused effort to address that problem and reduce by an order of magnitude the cost and complexity associated with lab results interfacing.

Success here could and will be used by national reference labs, regional reference labs, a local hospital centered results exchange, a central data repository, a DEAS, or what have you. Now it's true that reducing the costs of exchange undermines the business models of organizations that engage in today's world of complex transformation for results distribution.

This initiative could therefore be seen as undermining the rent-seeking utility RHIO model, because results delivery is often a bread and butter exchange transaction and making exchange and interoperability cheaper makes it harder to collect monopoly rents. But again, faced with a policy choice between reducing costs for every model and protecting a specific model or specific set of models, policy makers should chose the former over the latter every time.

So my policy advice to a Romney administration would be the same advice as to an Obama administration: use the policy tools of government, with a preference for the softer tools like convening and spotlighting, to reduce relentlessly the costs of exchange, and let business models fall where they may.
So many interesting points in this thread! A few loosely-coupled reactions:

1) Use of "internet styled" standards (as opposed to hub/spoke?) allows for decoupling of technology from markets. If anyone can connect to everyone, using appropriate Internet standards, then markets can evolve towards the most efficient way to deliver services, where the resulting organizational structure is not constrained by arbitrary technology choices. As per +Arien Malec this seems like a desirable outcome, and is inherently stable across political transitions.

2) It seems unlikely that current incumbents will willingly give up control over information flows that they can affect. Hence, emergence of artificial entities (like some state-sponsored RHIOs?) will face a struggle to assert control of these data flows, since the incumbents won't want to upset the current balance of power (which at times feels like a form of a "mutually assured destruction" standoff.)

3) So, beware of trying to lump services together that don't fit the natural scale of the service. For example, let states deliver state-relevant services (e.g., public health, insurance exchanges), let regional entities deliver regionalized services (e.g., referral management, care coordination services) Let HCOs deliver HCO-specific services (e.g., infrastructure to manage their ACOs), and let individuals control the delivery of their personal health information (e.g., aggregation of a person's medical data in some form of trusted, but personally-controlled health record.)
Even if "driving the cost out" precludes the opportunity to develop infrastructure for the public good?
But are we "driving the cost out"? We may very well be driving the cost down for technology providers, but from what I see on the ground, we are driving the price up for provider organizations. I think the root cause is the arbitrary classification of certain items as "policy-relevant healthcare transactions", which allows suppliers, whether rent-seeking or not, to extract a premium for the designated transaction.

+David McCallie 's comment above is as close to perfect as I could hope for, under current circumstances. However #3 is in direct (no pun intended) contradiction to the policy-driven funding of State HIE organizations, which are currently encouraged to set up HISPs at a state level, as well as provide exchange services beyond their "natural scale". So it's not really a pure technology & standards issue. There is a certain business model that seems to be encouraged by federal funding.
To +Leslie Lenert What I would tell the Romney administration is that a freer market for health care products and services would be a much more efficient market, and that price transparency would be a very critical piece of helping that market to become more efficient. If there is one thing that is pretty constant over the years, it's been the health care industry's ability to obfuscate on pricing, and that regardless of political incumbency of either party. I'm not sure that Romney's people would argue in favor of obfuscatory pricing or barriers to less expensive transport of health data and information, both of which seem entirely consistent with helping businesses get their costs of health care lower.
I tend to lean conservative (much more so than most of my friends on this thread in some areas :-) and yet I do not see this as a partisan issue at all. Certainly there would be changes in leadership undef a new administration, and likely a shifting of strategy. But I would be very disappointed if future leaders destroyed or undermined the good work of their predecessors simply due to ego. Whatever the outcome of the elections in November there is a huge transformation that has begun. A great boulder has started rolling, and we can alter its course somewhat, but there is no stopping it in its tracks or turning it back...
+Leslie Lenert Good point, but I think that even "infrastructure for the public good" has a natural scale to it, and for some infrastructure, federal support makes a lot of sense. Federal support for standards development (Direct, S&I Framework,) federal support for nomenclature standards (RxNorm, NLM,) federally-assisted demonstration projects (NwHIN Exchange, Direct pilots,) and (someday?) federal standards and regulatory support for a distributed but universal trust and identity framework, are all examples of public good that should occur at national (federal) scale.

+Margalit Gur-Arie Thanks for the comment. I think that "policy-driven funding of State HIE organizations" is a consequence of the way ARRA/HITECH was written (which in turn reflects historical approaches of delegating much of health care to the state level.) ONC has little choice in whether or not to follow those state-centric statutes. Interestingly, the administration's PCAST vision did not assume a state-based information-sharing model, as Leslie's article pointed out. My point is that some state-based services make sense, but some others (e.g., personal health records) do not.
That's the economic model that's proposed in the JAMIA paper as being under threat:

"However, few RHIOs have had monopolies on health information exchange in their region, and as a consequence competition for health information exchange services drives the price of those services to their cost, making it difficult to subsidize other information exchange activities conducted for the public good."

My premise is twofold:

1) There have been no successful and sustainable RHIOs that have adopted that model; in fact, RHIOs like IHIE have built efficiency and economies of scale for, in that example, Docs4Docs, that are, in fact, quite competitive
2) Before Direct and other ONC initiatives like S&I, there were already organizations (full disclosure -- the one for which I work is one) that package and sell solutions for health systems that make it very difficult for such a system to chose a higher-than-market-rates RHIO model for higher value connectivity. That's the "Private HIE" market that has been growing much faster than the "Public HIE" market, even on a higher base, as demonstrated in the KLAS market report, Gartner analysis, and Chillmark.

The second part of the argument one hears (and is a key assumption of the JAMIA article) is that advanced HIE services are not valuable in themselves and need to be subsidized by above-market-rate basic connectivity.

My experience is that this isn't true; that advanced HIE services are, in fact, valued and valuable.

I would also note that advanced HIE services are part of a platform for high quality efficient care delivery. If high quality efficient care delivery isn't valued sufficiently for organizations to invest resources to achieve it, it's the wrong-way-round to create a rent-seeking utility model to subsidize the technology to provide it. The value equation for high quality efficient care delivery needs to be driven by the care delivery organizations with support from payers where payment models actively work against high quality efficient care delivery.
So here is what I fail to understand about all this RHIO/HIO construct.
Right now, if I have a fairly decent EHR, I get bi-directional exchange with labs and pharmacies for free. I get bi-directional exchange with patients through my portal for relatively little money and I get bi-directional exchange with payers for a nominal fee. If my EHR is a bit more advanced, I get p2p exchange with other providers, or I get Direct based exchange from Surescripts for very low fees. I also get CQM reporting to CMS through my EHR registry for free. If I am affiliated with a large system, I get hospital exchange usually for free too. Some EHRs have practice networks and will provide me with analytics and benchmarks for free.

Why on earth would I pay anything to an HIE organization? When I asked this question in a local meeting forum, I was told that it's all about the value proposition. Is there a directive from somewhere to use that phrase? What value proposition are we talking about? Value to whom?
I have so far found very little actual capability for p2p exchange between unaffiliated providers on different EHR platforms without the use of HIE services. Also the ability to aggregate data at a community level between disparate sources is one of the value propositions we have seen for services like eMPI and RLS. Having those EHRs that are a "bit more advanced" widely deployed is the trick but. We want the functionality required to better coordinate care across transitions of care, better manage population health, and perform the types of data analytics that are required for showing improvements in outcomes across the care continuum. The value ultimately accrues to the patient in better health and care and to society in lower costs.
What +Brian Ahier said -- if you have all the things you note, you probably have access to an HIE. Perhaps the health system is sponsoring it for you and you don't know it (note that in some cases, the EHR you use has connectivity to other EHRs from the same vendor which isn't the same thing at all, unless everyone in your community uses the same EHR).
Folks, you need to get out more :-)
With the exception of p2p (which is available from eCW, not only for eCW users, and as I said Surescripts Direct services are always there) and the analytics (which are available from McKesson, Arien), everything else I mentioned above is available from any EHR that has any significant presence in the market, including small products for the small practice market. No health system and no HIE required.
And since MU requires CCD exchange testing and will require 3 actual connections in Stage 2 (or an HIE), most big EHRs are building hubs and several are operational. I can see hub-to-hub exchange happening long before some State HIEs get off the ground.

And BTW, if the value accrues to the patient and to society, isn't +Leslie Lenert correct in his assertion that this is a public good and should be treated as such? Otherwise why would we expect providers to pay for this in a free enterprise environment?
Arien, I have to come back to some of your remarks. Your 2:31 PM post suggests that health care organization should bear the costs of advanced technologies for case management through health information exchange. Wouldn't this have the consequence of forcing smaller players out of the market and channeling of patients within existing large organizations? Is that a good thing? Could it be that shared infrastructure at a community level is more efficient and fair (to smaller providers) than repetitive silo'd infrastructure locking patients into large well-infrastructured systems?

I also have to argue with you about IHIE and its funding streams. Doesn't IHIE have a virtual monopoly on exchange in their region as first movers and due to the unusual civic spirit of their community? This allows them to charge more for docs-for-docs than delivery costs. Why wouldn't competition drive from a Surescripts and other vendors eventually drive down their revenues too to levels below where they could sustain unprofitable services they run for the community, like public health alerts via docs for docs and routing of messages to public health for communicable diseases? So what does "rent based" mean? A subscription fee? Isn't that also part of the economic models of most private exchanges?
+Leslie Lenert You raise some good questions. On the role of smaller organizations in transformation of care delivery, I'd note that HIEs often seek to replicate models of care that were proven and demonstrated in large vertically integrated health systems with common technology platforms. In such systems, the choice for providers is, effectively, be employed or be excluded (many such systems, while they do a brilliant job of coordination of care within the system, have difficulties coordination care externally). Against that model, health system sponsored HIE provides more opportunities for individual providers.

I've argued (and Holly Miller has demonstrated) that Direct is a great fit for PCMH (in the model that Holly demonstrated, the enabling organization is a classic RHIO), because PCMH models have strong coordination of care and strong support for anticipated transitions, where push transactions make great clinical sense. In contrast, the prototypical RHIO models want to establish registry/repositories, which are a better fit for uncoordinated transitions. The point is that Direct + PCMH can be an ideal platform for care transformation. (I'd prefer to see Direct + query/retrieve + PCMH + clinical integration + active learning and continuous systemic improvement). I do believe that care transformation should lead HIT business models, rather than the other way 'round.

As for IHIE, based on my memory of conversations with Marc, it started with advanced models for research, funded by research grants, but took off with the introduction of Docs4Docs, which drove connectivity and engagement for providers based on a results and documents delivery value proposition. Participating hospitals subsidize Docs4Docs for individual providers; the value of the HIE accrues to the funding organizations. It's a classic two-sided market. The value provided by Docs4Docs is commensurate with the subscription charged; due to the efficiencies and trust IHIE has in the community, it would be nearly impossible for a competitive organization to steal that business away from IHIE. An organization that drives efficient and cost-effective services is not a rent-seeking monopoly (defined as charging above market rates on the basis of monopoly pricing power).
I think we are all getting tired, but I wanted to circle back to +Margalit Gur-Arie's question. Most of the capabilities she described are powered by HIE (generally with a 2-sided market business model). eRx? HIE provided by Surescripts and RelayHealth Pharmacy. Lab results? HIE, provided by the large national labs and sponsored regionally by heath systems to get laboratory results to EHRs (because the alternative to HIE is MLLP over VPN, which is ugly and unmaintainable). Discharge summaries and transcriptions from the hospital? HIE. Referrals and colleague messaging between different EHR vendors? HIE. Etc. In some cases, the HIE services are provided by the interested parties; in other cases, by a regional entity.
Tired?!??!!! I'm just getting started ;-)
I commend you Brian for your stamina and for starting this thread, but I am beat... :-)
I think Arien, we are bogged down by terminology here a bit. I meant HIE in the sense of an organization, usually State run now, and I think you are referring to HIE as a verb using the latest technologies.... Either way, there are usually business drivers and benefits accruing to those who pay for whatever exchange is taking place, including MLLP over VPN, and that is how it should be.... absent Leslie's model.
+Vince Kuraitis: " I would characterize shift toward a Health Internet as simply REMOVING previous government bias supporting rent-seeking RHIO models, not actively promoting one exchange model over another." -- that's exactly what I was trying to say in a lot fewer words.
+Vince Kuraitis - I think I must be missing something. Where does the current, not previous, Federal funding for State HIE organizations fit into this argument? Those may not be RHIOs (SHIOs?), but rent-seeking seems to be part of their "sustainability" model. Or are those just tentatively monopolistic intermediaries between various service providers and the Health Internet? If so, why do we need such intermediaries in an open Internet model?
Where is that "REMOVING" occurring right now?

If you read the article, I suggest that the IOM/NAS weigh in on the direction through a consensus statement on the future direction for the architecture. That has little to do we D vs M. It's more science vs. politics. An unbiased opinion is within the realm of the possible.
Leadership is sufficient when it reflects consensus. Is there consensus on an Internet architecture? Let's find out at the IOM/NAS

Politics is a strange thing. Might republican thought leaders decide, the way that Chopra and Park apparently decided that we need some other type of architecture for information exchange? Might there be a memory of the democratics did to them when they came to power be enough to motivate extreme change? Who knows. One hopes cooler heads prevail. Failure to link the action to scientific consensus is an unnecessary risk.

States and municipalities act alone for health IT infrastructure? Health IT activity is driven by Federal policy and dollars. State health IT plans are approved by ONC for funding. If MU was off the table, sure you might see this. But states don't have the same borrowing abilities as the Feds to finance this activity.

Vermont and North Carolina are good examples of how certain healthcare activities might work better as public utilities (for example, case management/care coordination). The folks in North Carolina have a far greater success in terms of cost reduction than Geisenger or Group Health--over $1B in savings. However, if ACO regulations made it difficult for public utility model care coordination teams to be sustainable, it might be time to rethink those regulations.

Public utility model enterprises socialist? Are fire departments socialist? Some things work better as government services or regulated monopolies--particularly things that need to work for the public interest in a cooperative way, with a level playing field for all. That said, I think there are models for combining free enterprise with community level functionality. A good example is cellular 911. That's private enterprise and public utility funded by use fees. But, we don't try to have multiple 911 systems for a community. Nor would we encourage a phone system that can't support geolocated 911 and collect use taxes to support that functionality.

sort of except for communities...remove the support and where does infrastructure for the public good come from, like a cellular 911 service.
I am starting to think that I am incapable of expressing myself clearly. So let me try again, and dispense with acronyms this time around.
Prior to HITECH and to the current day, there were two types of electronic information exchange occurring in health care:
1) Private information exchange where various health services providers payed vendors to move data back and forth - lab data, pharmacy data, claim data, imaging data, etc. Technology vendors connected providers either point to point or through hubs to accomplish such exchange. This was not subsidized by government or anybody else. It was payed for by those who derived financial benefits and value from the exchange.
2) Regional, usually non-profit, organizations which facilitate local exchange of some information between local providers with a clear goal to improve quality for local populations. These organizations were supported by their members who recognized the value of those additional services, and to a lesser degree by ad-hoc grant funding from quality oriented local and national organizations.

After HITECH, the Federal government decided to fund State organizations for the purpose of facilitating information exchange. Either the government was unaware that information is already being exchanged, or the government decided that exchange should occur in a different manner than it is already occurring.

It is unclear to me, as evident from all my comments above, how a State entity inserting itself into the flow of information, contributes any value to existing exchange. Therefore, I would qualify the attempts of Federally funded State entities as rent-seeking.
Local/regional organizations supporting the goals of their constituents and adding value above and beyond bits and bytes flowing from A to B, may very well be able to make a case for higher prices than a pure technology vendor. Either way, it is up to those constituents to decide how much they are willing to pay for additional services, and since the better local organizations are governed by local providers, I believe they have made their decisions already.

I don't see any justification for the government to override local efforts, and mandate that all value should be provided at a State level instead. Not to mention that for anything but tiny States, this is practically impossible.

So, Vince, if you are contending that Federally funded State entities, and the promotion of a particular way of exchanging information and a particular locus for value creation, are not the correct course of action, I would agree.
Hey! Don't shoot the messenger...
There's no "u" in social media. Although, there's no "we" either. There is an "i" Ok, that almost works.

One of my bloggers is working on a post off this discussion as well. #LoveIt
I've decided that my new job title is "Chief Antagonist"
Actually, including poll question capability into G+ would be pretty cool. Nice post +Vince Kuraitis
+Vince Kuraitis I agree that politics has somewhat to do with this, but not necessarily. I am happy to publicly define myself as a liberal. I voted for Obama as well, and I will vote for Obama again in 2012.
That said, I don't have to agree with every decision made by his administration, particularly decisions made three or four levels below the White House.
Funding State health information exchanges was a mistake for two reasons:
1) They were not created in a desert of information exchange and their creation is adversely affecting existing efforts by diverting resources and creating political tension unnecessarily.
2) They were created without a well defined mission and without sufficient funding to exist beyond the original subsidy, which, is creating multiple fishing expeditions in search for problems to solve and ways to solve those once found, if found,

The lack of adequate funding and the lack of a clear mission is precisely why Arien's rent-seeking behavior is occurring, and exactly why everybody keeps talking about some "value proposition" where none exists. Granted some of the old RHIOs were suffering from the same lack of direction, but some were/are not, and those should not be killed off just because we are testing new models all of a sudden.
Go back to +David McCallie 's comment on 2/5 regarding "natural scale", and I would submit that we should let that scale evolve naturally.
Great post, Vince. This G+ thing is living up to its promise....
After re-reading many of these comments, I feel compelled to attempt a few generalizations that (I hope) are based on some observations from the real world of patients, doctors, and hospitals.

First, the majority of health care in the majority of communities in this country is highly fragmented. Sometimes that fragmentation takes the shape of two or three large systems competing with one another. More often there are dozens of small, independent practices of different kinds arrayed near one or more hospitals.

Ownership of these practices, imaging centers, outpatient centers, etc. is in fairly constant transition, with perhaps a slight trend overall towards consolidation. But, in general, most of these communities will face diversity and multiple ownership, and therefore significant fragmentation that is both physical and reflected in information technology systems.

For the patient, this reality is epitomized by having to fill out similar, redundant insurance and medical history forms for each provider visited in the community. Yes, there are exceptions where a particular health care provider is very dominant, and where the "system knows me" wherever I go as a patient. But that is still not the norm, and even those highly integrated systems have their boundaries outside of which communications devolve to paper, mail, telephone, and fax.

As a generalization, there have been two health IT strategies that have dominated the discussion of how to de-fragment community health care systems. One is some version of the community health information network, CHIN. RHIOs, HIEs, and so on. This model seeks to aggregate data from multiple provider enterprises, organize it, and make it available to members. The other is the mega-EHR, which, it is assumed by proponents, will extend its tentacles out into a critical mass of providers, usually from a hospital or group of hospitals, and therefore connect everyone.

The US is a large enough society that it can accommodate both of these "solutions" to the problems inherent in diversity and fragmentation in health care resources. Both of these models are likely to persist well in to the future.

However, what we are now seeing gain some popularity and mindshare is a third model for information and data de-fragmentation in health care, one that is based upon the standards, protocols, and specifications of the Internet, the web, and a network-of-networks architecture. Unlike the other two models, this new model does not require a controlling and centralized (and probably "rent-seeking") intermediary on the network. This new model, like the Internet, is relatively neutral with respect to operating systems and pre-existing applications. Directed exchange, essentially secure e-mail mediated by a federated trust framework using PKI for point-to-point "push" communications between known participants, is an example of this third model reaching operational status.

To a great many technologists and others involved in health care IT, instances of the new model -- let's call it the Health Internet just to have a name -- seems overly simple, even toylike or retrograde, and hardly robust by engineering or health informatics standards. "Why would you want secure e-mail?" I hear every day from health IT experts. "It seems almost stupidly limited and under-powered given the complexity of health care!"

The answer to that kind of question is "Yes, you're right, Directed exchange, for example, is not very complicated or robust compared to an HIE or an EPIC install. But it might be incredibly low-cost to use and fast-and-easy to deploy; it doesn't require sophisticated expertise by users, and quite the contrary looks and feels like familiar software, e.g. gmail; and for a whole lot of people who are part of fragmented health care systems it may be "good enough" and their only real alternative for secure health data exchange and connectivity."

The Health Internet isn't a substitute for HIEs or for enterprise EHRs. Directed exchange is a "good enough," better-than-fax solution for the enormous volumes of health information moving across geographical boundaries, outside of EHRs or billing systems. It's uses will be at the bottom of the health data food chain, the least sexy but still critical exchanges that move data across practices and between hospitals and doctors via fax because they can't get there any other way cheaply and with minimal technical complexity.

At least that's the idea....If I were Epic, or the health plans, or a leader of an HIE, I'd embrace the Health Internet for the innovation and efficiency it can offer that part of the health care market that can't afford your more sophisticated and expensive products. And, in the process, find very large numbers of new customers. Won't a lot of those new customers be patients and consumers? And aren't there a whole lot of them?

Regards, dCK
As someone following Direct Project at behest of the DoD I am extremely interested in more of the security ramifications of what is proposed by the Direct Project. It's interesting to read through the NISTIR-7497 recommendations to see a diagram like this ( that really doesn't account for something Nationwide yet simple and not complex. It's almost assumed that HIE must be complex in order to scale. The idea of the Health Internet is intriguing yet needs a lot of work to ensure that a simple exchange can be a secure exchange. Kind of a tangent yet I feel important to note.

Edit: Link to NIST 7497
+Brian Hoffman , as you know, as you're a member of the DirectTrust. org wiki, there's a lot of work going on in the two workgroups, Security and Trust Compliance WG and Certificate Policy and Practices WG, on the security and trust framework for Directed exchange. The majority of Directed exchange implementations will live in the green space in the diagram you refer to, which I like a lot and thanks for sharing,where interoperability of health data exchange is high, and complexity of health data exchange is low.

What might be somewhat misleading in such a diagram is that to work at scale, Direct exchange must have a robust trust framework built on a PKI, in which HISPs know and trust one another based upon policies and practices that include identity verification of organization and of individuals who are issued digital certificate credentials. And this is pretty complicated, more complex than many observers of Direct know or care to know about, although I do think it can be done. Trust, security, and privacy are critically important to get right, and to get right on a national scale early on.
Better late then never.

Great discussion here, albeit at times there seems to be a mix of HIE the noun, HIE the verb, which sometimes even leaves me confused as to what someone is trying to say and I follow this market for a living!

Speaking of which, we/Chilmark Research is in the process of updating its HIE Market Trends Rpt which will be published in March. As part of our research, primary & secondary, countless interviews, etc., we've identified a third market, what one vendor referred to as the "micro-HIE".

The First mkt which has been discussed in detail here is the public market (we group both RHIOs and SDE & their HIE initiatives into this pot). By and these have been and will continue to be Exchanges (the noun) that will struggle to find relevance. Over time, we see these exchanges being tightly linked to other critical needs at the State level, chief among them, their Medicaid programs. Problem we see here though is that most states have woefully underinvested in IT for their Medicaid programs so will their HIE efforts suffer the same fate? We at Chilmark have never been big fans of these "public" HIEs for they are most often poorly managed, mired in political infighting and rarely have a clue on how to run a business (deliver value that is greater than risk) for their intended market/customers.

The second market is what we refer to as the enterprise market. Folks, this is where the action is and while last year's report showed a significant number of vendors focusing on the "public" market, this year virtually all HIE vendors have turned their sights upon the enterprise market. It is here where we will see the greatest advances, the greatest innovations as there is a clear and compelling case for organizations to use HIE (the verb) to facilitate care management processes across care settings in a future where reimbursement will be increasingly tied to outcomes.

The third market, the Micro-HIE is one that unlike the previous two markets, does not have a central sponsor of the HIE. It is more ad hoc in nature, self-forming, self-organizing. This is a market where Direct will be prevalent and for those who want a tad more in the way of services, physicians may subscribe to the new Surescripts Clinical Interop solution or a similar offering, albeit coming from the claims side, NaviNet. Medicity is also making a play here with its still nascent Inexx platform. This market is still very much a work in process, but may be the ultimate solution to connect the last mile, if these solutions can deliver value.

And that, at the end of the day is really what it is all about, yes? Delivering value that exceeds risk to the end user whoever that end user happens to be is the fundamental precept of any successful program, initiative or business. That has been the operating principle for the US pretty much since its founding, should it be any different for the HIE market.
Great post as usual, +David C. Kibbe , but I have to go back to the "problem we are trying to solve". I have to admit that I am one of those technologists wondering why we need a much more complex, and health care specific, version of secure email. Everything that can be accomplished with Direct as it stands today, including integration in an EHR and parsing of attachments into structured data, can be accomplished by any secure email product out there. However, those products have been in existence for many years and somehow, no doctor was inspired to dump the fax machine in favor of secure email, and no EHR tried to replace the "MLLP over VPN", or its more advanced siblings, with the same. Why is that? What makes us think that repackaging an existing (and rather old) technology with a Health IT prefix, and with an added layer of complexity will make a difference (excepting of ONC's active encouragement in this direction)?

My observations from the ground, and I apologize for repeating myself, are that used without an EHR Direct has no advantage for the end user over fax, and when integrated into an EHR it will require a huge level of complexity added to the EHR code, since the EHR will have to contain a mini integration engine to identify the type of content received and route it to an appropriate parser. What I am seeing happening though is quite the opposite, where historically client/server EHRs are abstracting the traditional point-to-point interfacing paradigm into centralized vendor hubs. This reduces both complexity and cost to the end user. Perhaps Direct could be used to move information between these hubs, but I am not clear on the advantages of such strategy, if any. Having dedicated exchange "pipes" by type of message makes much more sense in a hub environment.

It takes about a week today, at no cost to the user, for an experienced EHR vendor to bi-directionally connect a practice to a national reference lab, including paper work, testing and customization of preferences, and no respectable lab will forgo appropriate measures to ensure that the requisitions are correctly received and the results are correctly displayed, and I'm sure we wouldn't want them to. It takes even less time and effort and it is equally cost free to the user to set up a connection to almost every pharmacy in the country. How is Direct able to make these examples more efficient? Or is Direct only targeting CCD/CCR/CDA?
+Margalit Gur-Arie Good comments and questions, all. Let me make a few suggestions. First, electronic mail that is secure has a number of advantages over fax, the primary one being data capture for analysis. Practices that use fax communications generally have not a clue to whom they make those referrals, how many referrals they make to which care providers per unit of time, nor whether or not a timely response was received, etc. etc. It all devolves to paper or at best PDF files stored somewhere. So, an Internet mail-like routing of health data per se has advantages over fax and paper.

Secondly, you are absolutely correct that there are all sorts of secure e-mail alternatives to Directed exchange. However, they are not going to be part of a Nationwide Health Information Network, nor are they interoperable. If you want the equivalent of AOL and Prodigy, then that's what you'll get with private e-mail networks. If you want something that is truly point-to-any-point, then the Direct Project has created a set of specifications and protocols to do that.

I don't buy into the persistence of bi-directional EHR to lab interfaces (or EHR to other apps) as the solution. We need to find a way NOT to have to use these bi-directional, one off interfaces, and get to exchanges that are as universal and seamless as the Internet and the Web, if we're going to create a situation of true data liquidity in health care. The big nut to crack is how to create the security and privacy needed for transport of PHI, and although this is challenging, it is do-able.

Thanks, dCK
+David C. Kibbe - Several points jump up at me. First for analysis to be possible, and I think it is very desirable that it is, the practice will have to have an EHR, or something like it, in place to generate and consume health "data", instead of PDFs.
Second, I don't know what Nationwide Health Information truly is, or should be. I do understand the vision, David, but as far as I am concerned, it seems a bit theoretical, and when I look at the document that +Brian Hoffman linked, I am awed by the 5 layers and the frequent reference to human research.
Third, I honestly don't understand why bi-directional exchange of information does not constitute liquidity. The reason these interfaces are "one off" is the lack of an authoritative standard for each. Also, they are not as "one-off" as they seem. One of the stated reasons for the creation of regional organizations for data exchange is to interconnect local providers, including labs and hospitals, since historically those connections were "one off" and tremendously expensive to create in the old point-to-point interface paradigm.

Looking at the above, it seems to me that the role of government (back to +Vince Kuraitis remark) should be to make sure that everybody has an EHR capable of creating and consuming health "data", and setting unequivocal standards for data formats. Both these tasks are currently performed by ONC rather successfully. I would think that this is where it should stop. I would think that technology vendors would be able to take it from there based on market needs.
To a certain extent, the government is also influencing market needs through payment reforms, but there is no need, in my opinion, to micromanage how exactly information flows, any more than there is a need to micromanage how physicians interact with patients in the exam room.

It is possible that exchange will evolve to be a point-to-point Internet mail like, and it is possible that it will evolve to utility like clearinghouses, or dedicated exchanges (which are more transactional in nature), or mixtures of the two, or a myriad of other paradigms, best fitting the situation of those exchanging information, and as you wrote above, there is room for all and I don't think ONC or NIST or whoever, should be in the business of promoting one model over the other, particularly since technology is a moving target anyway, not to mention that health care is an even faster moving target.
Thanks, David :-) I didn't mean that literally, but I do appreciate the information.
+Margalit Gur-Arie and +John Moore While it might seem to make sense to consign Directed exchange to "mini-HIEs," I would contend that as a strategy for securely moving PHI point-to-point across practice settings, organizational boundaries, and application hurdles, there could well be adoption of Direct by some large Accountable Care Organizations, ACOs, and many smaller provider groups who enter into accountable care-like arrangements with payers, employers, and Medicare/Medicaid.

Imagine an environment with multiple vendors' EHRs in use, two or three different vendors' enterprise HIS components, pharmacies with their own EHR-lite applications, and nursing home, home health, and care coordination nurses and NPs with web access, smart phones, and iPads. Now imagine that all of these applications are Direct-compliant, that is, capable of sending and receiving secure e-mail + attachments in a standardized fashion according to the Direct Project protocols and specifications and a trust framework capable of managing the digital credentials for both organizations and individuals. In the larger organizational components of this ACO, data would come and go using more than one set of protocols, and switches and hubs would handle the interoperation. EHR vendors would be able to send and receive data via one-off interfaces, if these were well established and working, but they would also be able to use the SMIME over SMTP of Directed exchange to communicate with clinical nodes on the edge where an EHR isn't present, e.g. home health nurses, a solo rheumatology practice, a small pharmacy, or a community case manager.

This would not be a static environment. In just the same way that most of us communicate via smart phones, land phones, Skype voip, depending on location and circumstances, and we count on the telephony to work so that we can talk and be heard, people in this ACO would have multiple opportunities for exchange of PHI, not just one. Directed exchange in this ACO might be the "least common denominator" in the sense that all parties are required to be equipped to engage in Directed exchange as a default when no other more sophisticated exchange method is available. But no one gets left out, and no one isn't connected. And it's cost effective, flexible, and vendor neutral.
David, many lg HCOs I have spoken with are already looking to use DIrect to connect the last mile but virtually all of them have two primary concerns:
1) Direct needs to be directly embedded into workflow/EHR that the clinician is using and right now, most systems do not offer such capability.
2) Direct, by its very nature is not a going to provide much in the way of data analytics, unless of course you can extract/consume information in a Direct message readily (and automatically via M2M) into a data warehouse, which to my knowledge is not possible today.

So the end result is: These HCOs are looking to use Direct, or other micro-HIE like solutions to connect the last mile - basically deliver results to those far flung physician practices that are extremely hard to reach via traditional HIE models of engagement, but that is about it.
John, don't get me wrong. I like the concept of "micro-HIE" a lot. As to your two points above, I would agree that Directed exchange needs to find its way into EHRs. Fortunately, that integration can be done in several ways, and is relatively painless to achieve by the EHRs (except that they have so much else on their plates right now.) The first e-prescribing apps were all web or handheld, before they were integrated into EHRs. And it is true that Direct is a set of protocols and specs for data transport, not in themselves constituting a software app. However, don't you think that data can be derived from the flow of messages and attachments by apps and applets that are either embedded in the desktop, the iPad, or the Android tablet -- or provided as a service by HISPs? Isn't it likely that EHRs that have a Direct-compliant "clinical messaging module" will add on the basic analytic functions, perhaps in the way of a dashboard or other simple reporting interface, to help derive value for the practice, hospital, or ACO with respect to the messaging workflow? I've already seen some of this kind of integration from Fujitsu.
If Direct is integrated into an EHR, it will be integrated the same way eRx is integrated. The attachments will be generated by the EHR, say a CCD, and consumed by the EHR, which will open up the file and parse the content. This is not any different than how every other "interface" ultimately works in an EHR.
Direct messages sent or received in a PDF format will be dealt with exactly the same as electronic faxing, or receipt, is currently dealt with in an EHR. There will be no need for special apps and dashboards, because it is all one integrated view. Actually, the fact that Direct is being used by the EHR to communicate with another EHR or a paper based practice, should be transparent to the user. You should take a look at the p2p functionality in some EHRs, because Direct will be similar as far as the user is concerned, but presumably larger in scope.
+Margalit Gur-Arie I think you have it exactly right! If Direct is succeeding it will be invisible to the end user. The goal would be that in the future few would know that Direct even existed...
Although late to this debate, I have the benefit of a different perspective - the Guardian Angel perspective and I think the public HIEs, with or without Direct, are still missing the boat.

I too attended the 2009 Harvard meeting. It was put on by and paid homage to a 1994 MIT project that introduced the concept of personally controlled health records. Its descendants include Indivo, Dossia and my previous business.

The elephant in the HIE room is privacy and patient consent. I see no mention of it in the 81 comments above. I'm aware of no significant patient portals in any of the HIEs being discussed. I see the current implementations of Direct avoiding the topic of secure emails to patients or delegating it to the assumption that patients will have a PHR to receive Direct messages.

A sustainable NwHIN cannot be built as a zero-sum game between ACO economics and federal IT mandates. I think ONC realizes this better than we give them credit for.

The Guardian Angel perspective is that rent-seeking cannot occur around an asset that belongs to the individual patient. I think it's time to start another thread.
I promise you that the Privacy issue is being discussed and pondered over on the federal side. The DoD does not have the same consent issue as other groups because of their unique relationship with active duty service members but we are aware of consent challenges based on our work with VLER and the NwHIN Exchange.
Just curious - how many people in this thread have ever implemented an EHR or HIE for more then a couple of dozen providers? It would help to know what perspective people have that of researcher, reporter, analyst or boots on the ground? All are vaulable but bring a different perspective. For example we are doing both a thin client here in Washington (although our Beacon project is using a different model and vendor) and no one is even considering direct at this point although I am consulting on a mental health direct project in another couple of states. FYI - I implemented the EHR state-wide for Group Health and sit on the Advisory board for the INHS Beacon.
+Sherry Cascadia The company I work for (+RelayHealth) powers well over 50 HIOs nationally. Most "private" but we also power Jersey Health Connect and many of the healthsystems we power connect to public HIOs as well (e.g Peninsula Regional Medical Center just completed a test to CRISP in Maryland).
+Ross Martin NeHC has started charging for attendance to these webinars. +John Moehrke used the IHE list to send out a call for their mostly corporate members alerting them to the opportunity for "providing balance" in this forum. This does not bode well for patient perspective and comments on Stage 2.

Let's all urge ONC and their outreach partners like NeHC to keep patients and patient advocates in mind if they actually seek our "engagement".

Well, I payed my $25 to support open and transparent government for the 1%.
+Adrian Gropper This is a very important point. I have several consumer advocate friends for whom I know a $25 charge may well deter their participation. If they must recoup some costs on these webinars, I suggest NeHC look at a voluntary donation model rather than a rigid admission ticket model.

(and thanks +Brian Ahier for starting this thread)
Of course, I agree that broader participation and open dialogue is best, while also understanding the financial realities of keeping the lights on. My hope is that NeHC will make the webinar available free of charge when it is archived, and I also would prefer +Steven Daviss MD method ~ solicit donations but don't cut anyone out...
As I read the comments I thought often of Clay Shirky's "In Praise of Evolvable Systems" ( The opening line in particular: "If it were April Fool's Day, the Net's only official holiday, and you wanted to design a 'Novelty Protocol' to slip by the Internet Engineering Task Force as a joke, it might look something like the Web."

Risking an overly simplistic comparison I think Direct may well be our health information exchange (verb) April Fool's Day joke. And at the risk of misinterpreting many well written comments I think that many of the supportive positions in this thread resemble Shirky's opening comment "Why something as poorly designed as the Web became The Next Big Thing". Insert Direct and Health Internet. (BTW, I think using Health Internet as a descriptor is about establishing a trusted brand and not technology).

Among the reasons I think this way is my experiences living through all of the previous "shifting sands" of pre-Stark hospital-to-physician networking, CHINS, RHIOS and HIEs .... Our experience here in GA in particular informs my view. We do not have a RHIO threatened by Direct because we don't have a RHIO. This is not from the lack of trying from as far back as 1996 (ironically the same year Shirky published his paper). Each attempt started with great fanfare and "stakeholder" summits (pep rallies). All of the energy and enthusiasm faded to 0 when confronted with two questions: "Who is going to step up and take on the high start-up and operating financial risk" and "Can this stakeholder be trusted with the "monopoly" powers required to mitigate the financial risk (or, will my stakeholder's "good" be part of the "public good"). At least here in GA with our highly fragmented industry model, but with some fragments more politically powerful than others, we have not been able to satisfactorily answer these questions. Sadly, no stakeholder trust, or even political strength for a fiat, exists to establish a public good monopoly. Information is seen as a strategic weapon in a zero sum game.

What has happened however is that financially and market strong fragments are creating Service Area HIEs, Enterprise HIEs, Community HIEs, micro-HIEs, pick your name. The consequence is that monopoly transaction HIE pricing is the least of the monopoly worries of providers and their patients.

In the meantime we have patients/care givers suffering through transitions of care. I think solving this problem - quickly - should always be our focus. In my opinion Direct is a key to this "speed-to-market" solution requirement. I think it delivers the basics, as warty as they may be, necessary to kick start a highly "evolvable" health information exchange as well as kick start a culture shift to actually exchanging information for the right reasons rather than hoarding information for the wrong reasons. In fact, by eliminating the hub and being boundariless, the "system" may have a chance of evolving quickly enough to redistribute value before it is once again aborted. I also think that once kick-started the current generation of innovators and inventors already poised to exploit web-services are going to feel perfectly at home and value creation will accelerate. In some cases value we cannot even foresee.

The key seems to me then to be staying focused on the word "smart" in the ONC's oft quoted phrase "Start small and smart, and release early and often". Again to draw on Shirky I think that for this to succeed we need to be aware of his first rule of evolvable systems:"Only solutions that produce partial results when partially implemented can succeed. The network is littered with ideas that would have worked had everybody adopted them. Evolvable systems begin partially working right away and then grow, rather than needing to be perfected and frozen." This is why I also support starting with Transitions of Care information packets. The partial results of this partial implementation is saving patients from harm.

Plus, after now almost 4 decades of conferences, forums, summits, papers, maybe it is time that we heed Shirky's reminder of Orgel's Rule:"Evolution is cleverer than you are".
+Steve Rushing: you utterly and totally nailed what I was after in Direct and ToC.

And just to be totally, completely clear, none of that is intended as an attack on advanced HIE. It's simply the idea that getting national adoption of something basic and evolvable is a good thing; not a statement that it is the only good thing.
+Arien Malec that's part of the reason why the federal partners haven't been seeing a lot of participation in the Presidents VLER program. Getting organizations to sign the DURSA and set up an Exchange gateway and adapter is pretty burdensome for many potential participants, not to mention those that don't have an EHR yet. That makes a lot of information out there unreachable. Now Direct is one piece of the puzzle: transport. Sending scanned PDF forms to an EHR isn't going to make the data consumable or useful for clinical decision making. Early pilots seem to stop at the web mail interface. We need to start moving into XD* like the MedAllies demo showed at HIMSS. 
I'm glad that you added your clarity comment. I share it whole heartily.I should have made it in my comment as well. If things go as planned here in GA we will arrive at an advanced HIE. We will move through Phases starting with Direct connecting communities that are ready and willing to participate. Each Phase adding robustness and value. What I also think (and hope) will happen is each Phase's advances will be intently patient focused and the cost to benefit ratio of each new advancement will be market confirmed, i.e., the stakeholders will be "free" to make economically rationale decisions of how best to exchange information - there will be no need for a monopoly.
+Brian Hoffman My impression from HIMSS is that XD* is history and the Stage 2 MU rules make this clearer than ever. SOAP, DURSAs and all of the heavy HL7 back-end technologies beloved by IHE are tied to a business model where interfaces cost tens of $thousands and require months to set up. 21st century Internet business builds on free interfaces. Charging for interfaces and connectivity is a poor sustainability strategy for HIEs.
First of all, my understanding is that even the reference implementations for Direct will deliver SMTP messages to XDR endpoints. This is clearly something that is being built into most major EHR vendors products. NextGen and Greenway will roll it out later this year. Perhaps you're referring to XDS? Maybe I'm way off but I don't know when they clearly decided to move away from XD* in its entirety. Direct Project worked for a long time discussing the step up and step down from XD messages. S&I Framework also discussed it ( I haven't heard discussion to deprecate support for that.
+Adrian Gropper As a consultant (both in general and specifically to ONC), discretion dictates that I steer clear of proffering opinions as part of public discourse (informatimusicological ones notwithstanding). As a result, much as it pains me at times, I limit my comments to non-controversial subjects or the referencing of others' comments (distilled to 1+ing in Googlespeak). I didn't anticipate that my mention of an upcoming webinar would end up being controversial! So since I've already unwittingly blown my cover, I may as well chime in and seal my fate...

Perhaps there can be a Kickstarter pool to which the many likeminded and means-laden among us who want to see the consumer's voice well represented in these dialogues can contribute to support their participation. Even better, we could raise the expectation bar for webinar hosters and conference conveners so that they all include slots on agendas and attendee rosters for consumers as a matter of course. +Regina Holliday and +e-Patient Dave deBronkart are two voices certainly worth including.

But at some point, we are all consumers of healthcare -- or lovers of the same -- and should always have this voice first in our minds. It is sad to me that we still find ourselves behaving in a way that is corporately advantageous and personally damning -- and ominously resonating with the quip often attributed to Lenin that a capitalist is someone who will sell you the rope with which to hang him.

So we give a nod to consumers, avowing "Put the patient first!" with the soto voce caveat (right behind me). The recursive calculus of this proposition results in the patient ending up dead last.

A few months back, a new federal employee who had just come from working for a very large HIT vendor told me about the powerful speech given by her former company's CEO at an all-hands staff meeting. His wife had become severely ill and he was moved to tears describing how hard it had been to coordinate her care and get her information to move among the many leading specialists conscripted to save her.

On one hand, I really felt for the guy, knowing the price my 29-year cancer surviving wife has had to pay to make the system (less than more) work for her so that she can stay vigilant and healthy. But the story also made me burn inside because I know how that vendor has chosen to control information as a core component of their business model. And they are not alone in seeing gold in them thar hills a data.

I know there are timing issues and sustainability model challenges and it's all hard to make work in our fragmented system. But can we work for some early, simple wins to make data at least sludgy if not liquid? If advanced exchange models are so threatened by something as imperfect as Direct, then what are we really protecting?

Can we just agree to put the patient first with no ifs, buts or provisos? If not, what are you going to say when the last person in line turns out to be you?
+Ross Martin your sentiments are music to my ears! The patient is why we do this.

Health data as commodity is not the way... Innovation in turning that data into useful information is where it's at.
Not to take this thread completely off topic, but +Ross Martin reminded me of an observation I heard someone make at the Digital Health Summit at CES. They said, "Isn't it interesting how all these old tech guard have started investing in healthcare?" I guess all it took was them getting old and needing better quality healthcare to realize that we should be doing better for the patients then we are doing now.
+John Lynn that's hilarious. I think it's probably more that investors have exhausted all the photo sharing and privacy destroying social network opportunities. Failing fast in health carries a lot more risk than in photo sharing. The great thing is that there is increasing interest in helping people/patients. It's time to innovate hard in health IT. Let's change the paradigm. I think that's why direct scares the old guard. It challenges the de facto thinking of over complicating HIE. The first step of success is starting. Direct is starting. It's accepting that it's not perfect but functional and lets build off it. 
+Brian Hoffman Yes. Direct is scary to the old guard for many good reasons.

(1) By using attachments to human-readable messages, Direct encourages humans to read and, more importantly, re-use the attached document - this makes it very difficult to sell a document per-use through the back door of charging for interfaces. The music industry is still adjusting to MP3s as re-usable.

(2) By working within existing institutional practices, Direct reduces the barrier of Consent. This highlights the major weakness of registry/repository sharing architectures (a la XDS) that require years of bureaucracy, governance and sustainability work before data can flow.

It is indeed time to start building onto Direct. Let's support Stage 2 to ensure that Direct messages flow in and out of EHRs without cost or friction. Let's also insist on simple RESTful interfaces (on free Web portals) that capture patient consent to automated exchange - OAuth.
Of all the insightful and interesting things +Steve Rushing had to say in his note above, the phrase "Information is seen as a strategic weapon in a zero sum game" hit me like a punch to the gut. It is a very accurate summation of much that has both driven and simultaneously impeded the progress of health IT during the past 25 years. Viewed as a capitalistic endeavor, health care has become a game -- all business is a game -- for large swaths of participants of the "health care system." Play the game well and you make a lot of money, maybe you get rich. But the processes of healing and of genuine caring for people with health problems are not a game, zero sum or otherwise. There's a fundamental disconnect between for-profit medicine and a healthy society. And we all know this somewhere in our hearts and minds and bones. Having impeded the free flows of data and creation of information for years, the for-profit business interests in health care are now trying to sell "information" as the next boost, the next big weapon, to winning the game as they've been playing it. But there's a counter-balancing and uncomfortable truth, which is that information is revealing, is on the side of evolution, and its outcomes/consequences cannot be easliy controlled. Thus, the quiet almost imperceptible but very real sense of panic I felt on the exhibition floor at HIMSS. There was a curious air of desperation about the forty-something, almost too-good looking salespeople, wafts of aftershave about them if you got too close, busy delivering their glib over-rehearsed ad messages about the "power of data and information" soon to emerge from their software. As though they knew the game was about to change in some fundamental way, and they might be selling something else this time next year.
I think +Adrian Gropper is really on to something when he says that "Direct reduces the barrier of consent." To some privacy advocates (and I'm a privacy advocate myself) this may sound kind of scary. You mean we don't need consent with Directed exchange? No, that's not what Adrian means at all. What he means is that, within the context of privacy and security of HIPAA that already covers most health care entities and their business associates with strong privacy and security obligations, and within the context of most provider-to-patient or patient-to-provider online communications about situations where a care relationship has been established, the use of Directed exchange does not require any additional central control point on the network to manage consent between known parties. It does not require a central point of failure with respect to the transport and end-to-end exchange of the data and information in a Direct message or one of its attachments. (Remember, many health care organizations have often used the threat of risks to privacy as a rationale for restricting access by providers and patients to health care data, while often at the same time doing a truly awful job of protecting breaches of privacy themselves. So I'm always a bit skeptical when people with vested interests in restraint of information flows raise the privacy flag.)

But there is a caveat, and that is that Directed exchange requires assurance of online identity (of health organizations, health professionals, and patients in relationships with both) to be reasonably high in order to effect transport in a secure manner, a manner capable of guarding against breaches of privacy of PHI in transit. If we can solve the trusted identity in cyberspace aspect of Directed exchange in an efficient and economical manner, the relying parties will be confident in the use of Direct. And that confidence is important to Direct succeeding.

My observation is that each time we reach this conclusion, some elements to the discussion, primarily those from large enterprises, suggest that we need a central control mechanism to go forward, e.g. a national directory, or a DURSA, or at least a set of standards for directories and a bureaucracy to manage them, and that this control mechanism must be imposed upon the Direct community. And it's important that those of us who believe this is not the case to push back, and try to keep it simple and workable, with a minimum of governance but just enough, within the contexts of HIPAA and the provider-patient relationship

Now, I'm with +Arien Malec in supporting the position that both central controlled, HIE, and IHE-like systems along with more open and Direct-like systems need to co-exist in this new environment. We don't need to pick "just one" to go forward. I'm not attacking those high-control systems out of hand. They serve a purpose, and informed participants should be able to build them, use them, and go on about their business. But they in turn would be wise to allow the simpler systems be tried.
Sometimes, +David C. Kibbe you write something that makes me want to cry, like this: "There's a fundamental disconnect between for-profit medicine and a healthy society. And we all know this somewhere in our hearts and minds and bones.".
And there is nothing I can think of that we can do to change this, unless +Adrian Gropper 's model of data belonging to the patient in its entirety is adopted. It doesn't really matter where it is stored and by whom, or what technology is used to exchange it. Unless we place legislation in place to disarm the hordes of "secondary users" who are anything but panicky due to these new developments, data will be amassed and monetized under the "patient-centered" covers, with very little regard to patients' best interests. Whether data is acquired through a traditional HIE platform or through a more nimble HISP platform, is irrelevant. The big players will do both and much more.

A long time ago the beleaguered Dr. Berwick said about doctors that "We are guests in our patients' lives". By the same token, those "secondary users" are uninvited guests and right now we have no ability to kick them out of the living room as they sit there eyeballing all our valuables, making lists of how much every piece would bring them on the open market, and pretty much calling all the shots.
+David C. Kibbe I agree with much of your sentiment. However, for open disclosure, I spent my career until returning to academia as a "private" industry consultant. Over the last 3+ decades I've helped a large number of healthcare enterprises evaluate, select, contract & implement HIT. For me, there have been 0 cases of the vendor holding a gun to the customer's head. IMO, especially for the large delivery players (i.e., where the most money is), including not-for-profit and for-profit, the customers got exactly what they asked for (in 00s of pages of function & feature RFP checklists, something for which I seek redemption).

Some of the most intense battles in the Healthcare Industry Revenue Zero Sum Game that I've observed have been between not-for-profit (not-so-) Integrated Delivery Systems.

I need to be very clear. I am not indicting all IDS leadership. The majority of decisions made were well-intentioned and in support of the enterprise's mission. But,in our bizarre healthcare financing & revenue cycle the fact is that being not-for-profit (a tax-exemption status) is distinctly different than being truly non-profit. No "revenue in excess of expenses" (profit) dooms a not-for-profit just as it does a for-profit IDS. No "revenue in excess of expenses" equals no capital replenishment - at least in the current bizarre public/private financing.

As a result, not-for-profit IDS's are under tremendous pressure to use information as a strategic weapon. Over the years I've come to the conclusion that the best way to hide the intentional (or just well-intentioned) use of information as a strategic weapon in IDS market share battles is to hide it in the "Complexity Bunker". There is absolutely no question that the health industry and it's mirror image of information architecture is immensely complex. But I'm now at the point in my career that I can (should) admit that that complexity has been the perfect hiding place for any number of self-advantageous business models across all stakeholders. If we are to bend the healthcare cost rate curve down then that means reduction in someone's revenue on the other side of the value chain. I've haven't seen any stakeholder jumping up saying take mine.

So here we are in a transformation stalemate cleverly hidden in complexity. And since complexity equates to high costs, both in terms of $ and time, the end result is the big players control the game and as in the TV show Survivor all sorts of interesting alliances can grow for mutual benefit. For example (and not an indictment), as IDS's ask (demand?) that all use cases in their complex glory be perfectly addressed by their vendors and the vendors dutifully absorb handling the complexity a very profane (imo) transfer of capital from care to technology has taken place. And, yes the for-profit vendors have most benefited openly, what is not always so openly observable is how all the other stakeholders have benefited. Just think of the costs of the HIMSS floor (revenue) you describe which must be carried as cost-of-sales to the customer. Yet, we all show up because it brings us all together in one place so we can convene our annual reveille to complexity. Interesting everyone bemoans this information-lock stalemate but almost all players continue to "play the complexity card". There is obviously future revenue in mining the vast stores of data, but the current cash cow is dealing with complexity, including catchment area market share gamesmanship.

Now along comes Direct and as +Adrian Gropper points out "Direct reduces the barriers of consent". Imo, this is exceptionally important because it drives the first wedge into the Complexity Bunker and (hopefully) starts a crack. And imo most importantly, begins to deal with the collateral damage of the Zero Sum Game battles - patients and independent providers.

I think that it is this simple fact that Direct has the potential to bring patients and independent providers into the Healthcare Industry Revenue Cycle Zero Sum Game - as determiners of winners and losers - is what is most frightening to those whom to date have indirectly but at the same time directly (pun intended) benefited from HIT complexity - those funding HIE (noun) and using it as "market differentiation".

I think the power of Direct is quite literally a message's ability to jump over barriers of business model and technology closed networks. The future example I think is possible is a small, independent practice in Hahira Ga (pop 1626) that sends referrals to Augusta GA because that is the correct independent judgement call on behalf of the patient. And in doing so the message literally goes to the Cloud and jumps over two closed HIEs. Two HIEs funded by competing IPA and Healthcare System that have approached the practice and offered to buy the practice, including using the "value proposition" of managing the HIT and HIE complexities of Meaningful Use. There is a growing sense of urgency around here by those that fund the vendors to close these deals quickly before the new Cloud EHRs with near-free subscription costs merge with HISPs and make their multi-year, mult-$M investments in "integrated" delivery systems obsolete, much less being able to control frictionless entry and exit from ACOs.

It is becoming clear that Direct can possibly force future competition not on data hoarding but actually on measurable brand qualities - brand quality and efficiency. Pretty scary for an industry that has almost to a stakeholder "revenued" their way out of most financial problems.
+Steve Rushing - Those "near-free" cloud EHRs that will be merging with HISPs exemplify a possible shift in power from the old HIT barons to the new ones. Nothing is free and nothing is near-free either. Delivering an EHR in the "cloud" costs as much as delivering one to you on a set of CDs, including the operational costs. The business model is different though. In the old paradigm, you made money from servicing your customer directly. In the new paradigm you make money from (legally) stealing your customer's patient data (a.k.a. analytics).
Which one seems more palatable to you, as a patient, or as a country doctor who has no dog in this billion dollars fight?
+Margalit Gur-Arie Good point & good question. My personal answer is I look forward to a market in which my health information is 'monetized'. It can be 'monetized' by the secondary users and paid to me directly to net offset my increasing out-of-pocket costs (High Deductible/HSA). This is the desired outcome in the Walgreens' suit ( Or, aggregated for all his patients (with consent) by my primary care physician and the value used for 'near-free' applications that offset his operating costs. I prefer the latter. The former I think entails yet another high cost revenue cycle to manage a very large number of small $ transactions. I'm sure there are companies willing to be intermediaries and take small amounts per transaction X millions of transactions and find yet another way to enrich themselves on the 'complexity of healthcare'.

The latter, I think, has the bonus of making his practice more financially viable, not forcing sale of the practice (an increasing phenomenon here) or abandonment altogether and therefore continuing to provide me continuity of services.

This to me is an important attribute of Direct and TOC standard information packets of increasingly structured data as MDHT progresses. I would in the near-term benefit from removal of the dangers inherent in the current TOC. My provider would benefit from efficiency of eTOC - assuming his EHR vendor embeds the TOC natively in his workflow (and as +David C. Kibbe points out even starting with simple FAX replacement). Then overtime, with legal consents and enforcement in place and transparency of the value, we should both benefit from the 'monetirzation' of the data.

The Walgreens' suit brings an interesting twist on your statement: "In the new paradigm you make money from (legally) stealing your customer's patient data (a.k.a. analytics)."

There appears to be a strong proponent emerging for opposing "legally stealing" and moving to gain-sharing the value from analytics - the plaintiff's bar. From the linked article: "The plaintiffs aren't concerned about privacy. They're going after the comercial value of their prescription information, which they claim Walgreens has taken from them, according to Reuters."

Of course the (at a minimum) $64K question is what price will the plaintiff's bar extract. We all know they don't come into a market at anywhere near-free :)
+Steve Rushing 's point about monetization of streams of structured patient clinical summaries is well taken. With a few short years consumers will likely have access to meaningful clinical summary information in structured formats that they can direct wherever they like. How do we offer a PatientsLikeMe-like public benefit organization to take advantage of this opportunity, offer it on a completely voluntary basis, and return the benefits of de-identified aggregation and analysis to the community of contributors? Is it an extension of PatientsLikeMe? Does HealthVault get this franchise? What is the role of government in seeing this done with strong privacy protections in place?
....and with David's last comment, we have reached the beginning of this entire thread, and +Leslie Lenert 's original dilemma on the role of "public good" in this exercise and how much profit are we willing to forgo in the private sector to support public good, or benefit, and whether a responsible government should provide such support, or at least not actively prevent it from being created by local communities.
Brilliant. And just like everything else in health care, this is not about specific technologies.
I believe that health information exchange enables health data to follow patients to point of care, and will ultimately allow patients to manage their own health data
"The Office of the National Coordinator is focused on establishing the initial set of policies and standards that are the foundation for the three following key forms of exchange: first, sending and receiving health information to support coordinated care (directed exchange); second, finding patient health information for unplanned care (query-based exchange); and third, enabling patients to aggregate their own health information (consumer- mediated exchange). The goal of the Office of the National Coordinator is to enable all three forms of exchange, which fulfill different purposes. They will all be needed—and will exist side by side—to support coordinated, high-quality, and efficient care."

via Claudia Williams, Farzad Mostashari, Kory Mertz, Emily Hogin and Parmeeth Atwal,
From The Office Of The National Coordinator: The Strategy For Advancing The Exchange Of Health Information
Health Affairs, 31, no.3 (2012):527-536
The current proposal I have before NIST is to create a Internet medical home for the entire U.S. for PCP and their patients. The governance of that would be through NSTIC.

It looks like a X.500/LDAP provider directory with a IHE HPD/ISO-21091 schema and is compatible with DNS via the SRV resource record, complementing the DNS CERT approach but with richer attributes, which enable other types of medical records exchange.

In the Directory is an attribute-value pair, userCertificate, where one can store a number of different certificates, including the specific Direct project/Direct Trust subject-alt certificate.

The Directory links provider identity, to the certificate per the X.509v3 specifications and ANSI.

It is structured as a "imagined community". which falls within the scope of RFC-5280.

It has enough useful information to support the simple interop Direct layer across the entire country and abroad.

Since this is equally a civics experiment, the separation of power occurs at the state level, at their directory level, and "below" in the Directory Information Tree. Organizations exist under state directories, or nationally if appropriate.

There is currently a one time fee for ANSI identity proofing and registration, which requires no additional fees or defensive registrations in multiple IANA GTLD to avoid semantic any possible confusion of domain names. If one registers, that registration is unique and perpetual.

There will be certificate policies and liability models clearly spelled out, but the Directory is not itself a CA, and thus relying party agreements would be handled by the CA.

A simple example of this is Mozilla, (which has a local certificate store) which is now asserting it's own policy that approved CAs will not issue sub-ca roots that MITM, (claimed to be a common practice), antithetical to the whole idea of a CA. There's a great deal of thought taking place right now within the Internet regarding CAs, which I won't attempt to recap.

CAs were able to advertise 100% browser compatibility and also MITM, this is starting to be no longer the case, so the development of health care policy CPS as Direct Trust is highly relevant, since the CAs are currently fragmented between various communities of interest.

I can already pull in S/MIME certificates from the French physician directory for visitors from France, or residents. The barriers to this are immense from vested incumbents, the same ones who have openly criticized the HIT community and its ability to self-organize. I'm afraid this well goes beyond collegiality and really is at the heart of the Health Care Industrial Complex which is holding the economy for ransom.

The proposed NIST pilot is a litmus test to see if NSTIC will broker a solution that reached consensus in S&I Framework.

I first attended to get an idea what I would be up against. I sat next to someone who flew down on their corporate jet, who said, "You really think you can change this?, Good luck."

Well let's see what the Millenium Falcon can do compared to a Lear Jet.
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