Federal and state governments, employers, healthcare payers, and many public- and private-sector providers have recognized that electronic health information is instrumental to achieving higher quality and more cost-effective healthcare. In the past, it has been the federal government that has taken the lead in implementing the systems that collect, manage, and exchange electronic information – whether data on individual patients to aid physicians at the point of care, or on populations to monitor the nation’s health.
Most recently, however, the private sector has become increasingly active in the adoption of electronic health records (EHRs) and health information networks (HINs). These efforts are supported, at least in part, by the Bush administration and by the Department of Health and Human Services (HHS) through the creation of the Office of the National Coordinator for Health Information Technology (ONC) and its initiatives.
Customer Service / Market Requirements
In April of 2004, President Bush called for the widespread adoption of interoperable health records for most Americans within ten years and created, within HHS, the ONC to lead the effort. In July, ONC published the Framework for Strategic Action for health information technology (HIT), which established four primary strategies for realizing the President’s vision:
Inform Clinical Practice – through incentivizing EHR adoption, reducing risk of EHR investment, and promoting EHR diffusion into rural and underserved areas;
Interconnect Clinicians – by fostering regional health information exchange initiatives, developing a nationwide health information network, and coordinating federal health information systems;
Personalize Care – by encouraging the use of personal health records (PHRs), enhancing informed consumer choice, and promoting telehealth systems; and
Improve Population Health – through unification of public health surveillance systems, streamlining quality monitoring, and accelerating research and dissemination of research results.
These goals seek to establish an environment in which clinicians have more complete information at the point of care, and therefore deliver better care more efficiently. They create consumers that are more informed about their own care and the healthcare choices they have. They empower health officials, providers, and researchers to better understand how care is – and ought to be -- delivered to continue to improve outcomes, reduce errors, and increase efficiency.
However, there remain significant barriers to realizing ONC’s goals. Little health information is available in electronic form today. It has been estimated that no more than 20% of physicians use EHRs, and many of them for only limited functions such as electronic prescribing. The systems that do exist cannot exchange information electronically. For example, most labs incorporate electronic lab information systems to gain efficiency, but still report results to clinicians in paper form, even if the physician uses an EHR.
At least in part, this lack of interoperability results from a lack of standards for health information exchange (or more correctly, too many standards and a lack of guidance). However, a large component is still due to the lack of willingness to share information – which calls for a different model from what exists today.
To overcome these barriers, Secretary Leavitt and ONC began a collection of initiatives to foster adoption of EHRs and development of HINs. These initiatives include:
Health Information Technology Standards Panel (HITSP) – which is charged with identifying appropriate HIT standards and developing implementation guides for interoperability.
Certification Commission for Health Information Technology (CCHIT) – which develops certification criteria for EHRs (and, in the future, for PHRs and HIN technologies) to help physicians and other stakeholders reduce risk in implementing health information systems.
Health Information Security and Privacy Collaboration (HISPC) – which is engaged with states and territories to identify best practices in HIT security and privacy.
Nationwide Health Information Network Architecture Prototypes – which were awarded, for development of architectures and security and business models, to four vendors, Northrop Grumman Corporation, Accenture, Computer Sciences Corporation, and International Business Machines.
Secretary Leavitt also chartered the American Health Information Community (AHIC), an advisory group from government and industry, to set priorities for realizing interoperable health information records. The AHIC is identifying areas where early progress can be realized – such as: exchange of clinical information to support the clinician at the point of care; consumer empowerment through access to electronic record information and tools to manage their own care; biosurveillance and other initiatives to support monitoring and improving the health of populations; and quality monitoring to support consumer choice and improve the quality of care.
Capabilities Needed
Realization of the government’s vision of interoperable health records is directed at the development of a network of networks that exchanges health information. The purpose of this exchange is often thought of as better informing clinicians so they can deliver better care. However, as outlined in the Framework for Strategic Action, the exchange should also support consumers and public health.
HINs are critically dependent upon the electronic information that is exchanged and the end-user applications that enable clinicians to access that information. The low adoption of EHRs, which are the primary end-user application and one of the largest sources of clinical information, clearly limits the utility of networks in early health information exchange initiatives.
As vendors continue to develop EHR capabilities, they have come to realize that a change in clinical workflow may be required to realize the full vision of HINs. In particular, clinical practices in a paper world revolve around free-text notes about encounters with patients, and structured reports that do not necessarily follow any uniform standard. While early EHRs followed this model, more modern (so-called third generation) EHRs include codified, computable information that follows rigorous content standards. With computable information comes capabilities for mining that information to investigate outcomes and quality, as well as tools to aid the clinician in decision-making. For example, drug interactions can be automatically flagged if, and only if, current medications and allergies are both known and codified in an EHR, and across networks, in a consistent manner.
Beyond the clinical use of health information, state and local health departments and other public health agencies, including the Centers for Disease Control and Prevention (CDC), see the increasing availability of computable information in HINs as an information source for disease detection and monitoring systems.
In the past, these systems have been independent of the clinical sources that might feed them. Now, with the development of HINs and the network-of-networks approach to health information exchange, that information can be made available electronically, and automated to become available in a more timely manner, enabling a better response to health events and better management of health problems.
Still to come is secondary use of clinical information outside of public health surveillance. As the largest healthcare payer in the world, the Center for Medicare and Medicaid Services (CMS) is responsible for 47% of the $1.7B healthcare expenditure in the United States. CMS and, in fact, payers in general see HINs as a mechanism for reducing costs, improving care, and better managing chronic disease.
In addition, researchers, including academic institutions, large care providers, health officials, regulatory agencies, and the pharmaceutical and other industries, see the availability of electronic health information as an opportunity to establish better care practices, identify problems, and improve overall healthcare.
As a result, future HINs will likely include interfaces to payers to help process claims and monitor performance, interfaces to support adverse event reporting and other activities, and registries and other repositories of anonymous health information to use for research purposes. Again, computable information and rigorous HIT standards for content will be critical in making these capabilities useful.
Northrop Grumman Solutions
Northrop Grumman, in developing the NHIN prototype, concentrated on bringing standards to a network-of-networks while making it easier for users to participate. The company established a prototype exchange that integrated tightly with end-user EHR applications to reduce the impact to physician workflow, while hiding the complexity of the network from the users.
The exchange demonstrated scalability by linking three healthcare markets in California, Colorado, and Ohio, local and national lab systems, and pharmacy information providers, as well as by tying in consumers through a novel, network-enabled PHR application. A unique “consent registry” provided consumers with a mechanism for controlling access to their information over the network, and thus helped build trust and, ultimately, participation.
The technical approach was based on existing HIT standards and industry best-practices for a loosely-coupled Web-services architecture. It relied on an internal canonical information model coupled to translation and transformation services to make best use of legacy systems that participated in the exchange. It implemented a hybrid, federated information storage model that allowed participants to remain in control of information they provided for the exchange. Nationwide scalability could be realized through its super-peer, services bus approach to the NHIN backbone.
The NHIN project leveraged three other important Northrop Grumman programs.
First, the company develops, deploys, and operates the Department of Defense (DoD) EHR, known as AHLTA. AHLTA is a third-generation EHR that includes records for over 9.4 million military personnel and their beneficiaries, making it the largest EHR implementation in the world. As a third-generation EHR, AHLTA gives more attention to computable information than free-text notes. Working with this system, the company acquired much experience in the major terminology standards in use today, as well as in a technology developed for the DoD that translates among terminologies. This latter capability enables the company to facilitate exchanges between systems without requiring normalization in a central repository.
Second, Northrop Grumman developed the Bi-direction Health Information Exchange (BHIE), a working example of a nationwide health information network that links approximately 170 VA hospitals and clinics to each other and the DoD EHR system. The architectural approach to NHIN mirrors many of the aspects of BHIE, while adding components necessary for private-sector needs and more modern developments in HIT standards and technologies.
Finally, biosurveillance in NHIN was implemented by connecting the network to the CDC’s Public Health Information Network (PHIN) and BioSense, CDC’s nationwide program for biosurveillance. Northrop Grumman has long supported the CDC PHIN initiatives, including BioSense. Use of PHIN standards as the interface between NHIN and public health agencies helps formalize the linkage between these two networks.
Northrop Grumman extended its NHIN prototype during 2007 to include an exchange between private-sector physicians and the DoD and VA EHRs, incorporating federal care providers into the network-of-networks. The company also developed the Global Disease Surveillance Platform (GDSP™), a patent-pending methodology and framework for incorporating disparate structured and unstructured data from many sources to support disease surveillance and response. GDSP provides a mechanism for incorporating NHIN, as a structured data source, into a larger network to support population health.
Northrop Grumman continues to support development of health information networks for more accurate and more complete health records available to more clinicians, as well as more timely and more complete information to public health agencies in support of population health. The company provides provider and health official customers with advanced capabilities that reflect its extensive expertise acquired as an industry leader in health IT and contractor to the government agencies that are driving the next generation in health information interoperability.
However, there remain significant barriers to realizing ONC’s goals. Little health information is available in electronic form today. It has been estimated that no more than 20% of physicians use EHRs, and many of them for only limited functions such as electronic prescribing. The systems that do exist cannot exchange information electronically. For example, most labs incorporate electronic lab information systems to gain efficiency, but still report results to clinicians in paper form, even if the physician uses an EHR. 
As vendors continue to develop EHR capabilities, they have come to realize that a change in clinical workflow may be required to realize the full vision of HINs. In particular, clinical practices in a paper world revolve around free-text notes about encounters with patients, and structured reports that do not necessarily follow any uniform standard. While early EHRs followed this model, more modern (so-called third generation) EHRs include codified, computable information that follows rigorous content standards. With computable information comes capabilities for mining that information to investigate outcomes and quality, as well as tools to aid the clinician in decision-making. For example, drug interactions can be automatically flagged if, and only if, current medications and allergies are both known and codified in an EHR, and across networks, in a consistent manner.
The exchange demonstrated scalability by linking three healthcare markets in California, Colorado, and Ohio, local and national lab systems, and pharmacy information providers, as well as by tying in consumers through a novel, network-enabled PHR application. A unique “consent registry” provided consumers with a mechanism for controlling access to their information over the network, and thus helped build trust and, ultimately, participation. 