Agrowing federally sanctioned healthcare communityis starting to take hold, sharing information acrossagencies, healthcare providers and other external

partners using CONNECT software to link to theNationwide Health Information Network (NHIN).

Federal, state agencies as well as healthcare solutionsproviders and Health Information Exchange (HIE) participantsall agree. They joined the NHIN participant community primarily as a way to securely and safely share patient medical information that will help them further improve thequality of patient care. What they contribute to the communityvaries by the nature of their involvement, and each sees arange of benefits from the use of CONNECT to access the NHIN.

Why Connect?

Jim Garvie, senior analyst for the Indian Health Service,within the Department of Health and Human Services (HHS) –We have collaborated with the Department of Defense (DoD)and the Department of Veterans Affairs (VA) on patient recordsprograms for many years. We joined this community becausewe value both the ongoing collaboration and commitment toopen standards in the public domain that this participationbrings. As the largest rural healthcare organization in the U.S.,we fully understand the value of bringing health informationtechnology not only to urban populations, but to patients inremote areas as well.

Sandy McCleaf, PMO Director, MedVirginia, CentralVirginia Health Network, Richmond, Va. – MedVirginia hasbeen fortunate to be able to work with a variety of federalagencies, including the Social Security Administration (SSA)for Disability Determination, the Centers for Medicare &Medicaid Services (CMS) as an HIO participant in theirCARE Health Information Exchange Pilot, and the VA andDoD as a private sector supplier of health information for theVLER program. All of these initiatives have been instrumentalin advancing our participation in the NHIN as well as growingthe NHIN participant community. With each new implementation,the standards become more enhanced and better positionedto be implemented by a larger community of participants.

Brian Dixon, Health Information Project Manager,Regenstrief Institute, Inc. Indianapolis, Ind. – As a regional

HIE, our organization has a culture of embracing open sourcetools and using those platforms to advance the open sourcecause. We realize in order to gain true interoperability in thehealthcare sector, transparent standards must be widelyadopted. CONNECT fits well into our philosophy. We nowexchange information with the Indiana State Department ofHealth, and other providers in the state, as well as the Centersfor Disease Control (CDC), primarily to share informationused to monitor influenza rates. We’re also working withSSA to improve the disability approval process, and withCMS to improve data quality reporting. We hope to furtherexpand our use of the NHIN to connect to the VA and otherHIEs in our region to improve the quality of patient care.

Chris Smith, Director of Business Development forMEDNET, a Minneapolis-based integrator working to helphealthcare organizations link to the NHIN using CONNECT. –It’s no longer a question of if, but when HIEs and otherhealthcare providers will connect to the NHIN. This nationwidenetwork infrastructure is really winning as a way to link allkinds of healthcare organizations to the federal agenciesinvolved in healthcare provision.

Jon Teichrow, president of Mirth Corp., a healthcaresoftware developer in Irvine, Ca. – This community’s commitment to open source health IT is invaluable to us, as we couldn’t afford to write our own gateway software tolink to the NHIN. HIEs must move past doing the hard workof building links themselves, and use CONNECT so theycan instead focus on critical clinical applications like thosethat will aid healthcare providers in achieving meaningfuluse requirements. We’ve gained so much from what we’velearned about early case uses from federal agencies alreadyparticipating on the NHIN.

Will Ross, Project Manager, Redwood MedNet, an HIEsolutions provider in Ukiah, Ca., – Until smaller practicesmake the leap to electronic healthcare records, this ongoingeffort to build a nationwide online community for exchanginginformation simply won’t achieve success. Undoubtedly,CONNECT simplifies, or buries, the complexities involvedin linking to the NHIN. What has been difficult for manydoctors isn’t just the cost or the complexity, but ultimately

A Sense of Community Takes Hold

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CONNECT Users Discuss Why Sharing Information Makes a Difference

Continued on page s6

A Sense of Community Takes Hold, s1 • A Closer Look at Fed Sector Healthcare IT Provision, s2 Spotlight on Governance, s4 • Q&A with the ONC’s Connect Initiative Lead, David Riley, s5

Best Practices Advice from Healthcare Technology Veterans, s6

Advancements in Health IT (part 2)

The provision of healthcare services to members offederally recognized tribes has grown from the ongoingrelationship between the federal government and

Indian tribes that dates back to 1787.Today, members of 564 federally recognized American

Indian and Alaska Native Tribes and their descendants areeligible for healthcare services provided by the Indian HealthService (IHS), an agency within the Department of Healthand Human Services (HHS).

The IHS provides a comprehensive health service deliverysystem for approximately 1.9 million American Indians andAlaskan Natives who live in 35 states. “IHS uses technologicalsolutions to improve health care quality, enhance access to specialty care, reduce medical errors and modernizeadministrative functions consistent with HHS enterprise initiatives,” said Jim Garvie, senior analyst for IHS.

Health services are provided directly by the IHS, throughtribally contracted and operated health programs and throughservices purchased from private providers. The federal systemconsists of 29 hospitals, 63 health centers and 28 health stations. Through self-determination compacts and contracts,American Indian tribes and Alaska Native corporationsadminister 16 hospitals, 250 health centers, 93 health stationsand 166 Alaska village clinics. In addition, 34 urban Indianhealth projects provide a variety of health and referral services.

The Resource and Patient Management System (RPMS) is the IHS enterprise health information system. The RPMSconsists of more than 60 software applications and is used atapproximately 400 IHS, tribal and urban locations. The RPMShas been provisionally certified by the Commission forHealthcare Information Technology, a recognized certificationbody for electronic health records (EHR). Local RPMS data is used to evaluate clinical quality as well as populationand public health status. Aggregate data is used to report onclinical performance measures to Congress. The IHS alsomaintains a centralized database of patient encounter andadministrative data for statistical purposes, performancemeasurement for accreditation, and public health and epidemiological studies. The IHS telecommunications infrastructure connects IHS, tribal and urban facilities andlinks to the HHS telecommunications network. The IHS also works with the Department of Veterans Affairs andother federal partners to develop software and share technology resources.

One example is IHS’s ongoing testing of CONNECT foruse on the Nationwide Health Information Network (NHIN).IHS is testing CONNECT to accommodate health information

exchanges at facilities in New Mexico and Arizona to providemore complete healthcare summaries for each patient. “Oncewe are complete with internal testing, IHS intends to gothrough the ‘onboarding process’ to exchange informationon the national network. Limited production exchange isexpected to commence this fall,” said Mike Danielson, Chief Tech Officer, IHS.

IHS is also working on the implementation of a masterpatient index (MPI) that will link patient records in a centralregistry. The MPI will help bridge an information gap, IHSofficials said. Currently, there is incomplete informationabout patients at the point of care. The MPI is considered“vitally important to enabling healthcare providers to gatheras much information as possible about each patient, to helptreat certain conditions,” Danielson explained.

The Indian health model along with the participation ofIndian people in decisions affecting their health has producedsignificant health improvements. Indian life expectancy hasincreased by more than nine years since 1973. Mortalityrates have decreased for maternal deaths, tuberculosis, gastrointestinal disease, infant deaths, unintentional injuriesand accidents, pneumonia and influenza, homicide, alcoholismand suicide. Disparities continue, however. Indian lifeexpectancy (72.3 years) is still about 4.6 years less than the U.S. general population (76.9 years). Death rates are significantly higher among Indians for diseases such astuberculosis (500% higher), alcoholism (519% higher), diabetes (195% higher), unintentional injuries (149% higher),

A Closer Look at Fed SectorHealthcare IT Provision

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Understanding IHSThe Indian Health Service (IHS) health care services are

administered through a system of 12 area offices and 161 IHS

and tribally managed service units.

Population Served –1.9 million American Indians and Alaskan

Natives residing on or near reservations.

FY 2010 IHS budget appropriation – $4.05 billion

IHS Third-Party Collections, FY 2010 (estimated) – $829 million

Per Capita Personal Health Care Expenditures Comparison:

IHS user population, $2,690

Total U.S. population, $6,826

Total IHS employees:

15,676 (71% are Indian)

Continued on page s4

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The Office of the National Coordinator (ONC) is currently addressing a complete set of rulemakingrequirements for participation in the Nationwide

Health Information Network (NHIN), to establish governanceprocesses to manage, monitor and enforce the rules.

The Nationwide Health Information Network (NHIN) is adeveloping infrastructure that provides a secure, nationwide,interoperable health information infrastructure that will connectproviders, consumers and others involved in supportinghealthcare. New governance for NHIN was deemed necessaryearlier this year, to ensure users have trust in how informationis shared, along with an understanding that the exchange ofinformation on NHIN is working effectively and that consumers’expectations are met.

While current participation in the NHIN is limited to federal agencies and contractors or grant recipients, thelong-term vision includes a wide range of state, regional and federal government entities, commercial health careenterprises and potentially researchers and other relevantorganizations. “ONC is working hard to create a vetted process,the rules of road for allowing us to broaden participation in NHIN,” said Doug Fridsma, Acting Director of the Officeof Interoperability and Standards within the ONC.

The intention is to be open practical process. The SocialSecurity Administration, for example, is currently bringing15 contractors on board the NHIN, along with an unknownnumber of Health Information Exchange (HIE) grantees.Meanwhile, the Centers for Medicare and Medicaid Services(CMS), along with the Centers for Disease Control (CDC)are also bringing partners on board the NHIN. “Even withinthe limitations of the current NHIN framework, we can stilldo a lot of preliminatry testing of information exchange,”said Mary Jo Deering, senior policy advisor in the Office of Policy and Planning within ONC.

ONC officials plan to publish an initial request for publiccomment, and to keep the arduous rulemaking process ‘on abrisk pace.’ “The process can take 18 months or longer,

because due diligence is required at every step, so publicand stakeholder input can be incorporated throughout theprocess. Meanwhile, public hearings and policy committeeinput will also be important,” Deering explained.

The rules to be incorporated in the new NHIN governancewill likely incorporate agreed upon business practices, policyand legal requirements, transparent oversight, enforcementand accountability, identity assurance and technical requirements. Questions to be addressed include, “Where are the urgent priorities? What can we deliver that is flexible enough to evolve over time?” Deering said.

Because of the issue’s complexity, the Office of Policy and Planning will be requesting public comment on NHIN’sgovernance.

Formal governance procedures, not to mention a governingbody, are still to be determined. At this point it’s also unclearwhether there’s a need for a governance czar, Deering said.There will also be an evolution of uses and users on theNHIN and there must be a mechanism flexible enough toaccommodate changes and make the governance at leastfuture friendly.

Ultimately, crucial elements that governance rules mustaddress include security and privacy provisions, includingthe obvious requirements to secure communication, provideentity authentication and authorization, and conduct audits,along with other practices such as consent management.

“We want to support meaningful use and the concept of data liquidity, where data freely flows because all of thenecessary security and privacy pieces are in place. Governancereally only provides one piece of puzzle, albeit an importantone, trust in the information to be exchanged. ONC is working to develop a transparent process to help with interoperability, security and provide the glue that ensures all pieces are working properly,” said Fridsma.

More information on the NHIN Work Group and the HITPolicy Committee can be found at http://healthit.hhs.gov/policycommittee. ❑

Spotlight on Governance

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Continuing Evolution of NHIN Governance Strives to Balance Info-sharing Goals with Privacy and Security Requirements

Continued from page s2, A Closer Look at a Fed Sector Healthcare IT Provision

homicide (92% higher) and suicide (72% higher).Federal initiatives, such as the NHIN are expected to

dramatically improve the exchange of health care information.The HHS priority to accelerate the adoption of IT in healthcare will reduce medical errors and improve health carequality. The IHS EHR initiative, meanwhile, provides

computer-based physician order entry, encounter documentation, access to medical literature and other capabilities. These initiatives, as well as more affordable and available telehealth alternatives, are part of the ongoingcontinuous improvement programs at IHS, officials said. ❑

David Riley functions as the CONNECT InitiativeLead for the Office of the National Coordinator’s(ONC) Federal Health Architecture (FHA) program.

In this role, he promotes the advancement of federal healthIT and especially, CONNECT, the software gateway used for access to the Nationwide Health Information Network(NHIN). In an interview, he discussed features of the latest CONNECT release, along with future upgrades andsecurity/privacy improvements.

Question: What’s the status of CONNECT Release 3.0?

Riley: The new release, launched in June, gives CONNECT platform independence in terms of operatingsystem (Windows, Linux, Solaris); application server(Glassfish, JBoss, WebSphere) or integrated developmentenvironment (Netbeans, Eclipse) giving adopters of the solution more flexibility in running it in their operationalenvironment of choice. There also continues to be a refactoring of the core to improve performance, scalabilityand support both new protocols and interfaces. CurrentlyCONNECT uses SOAP over HTTP, and the refactoring over the next two releases will enable support for REST,XMPP and SMTP, which provide support for multiple protocols in the CONNECT backbone.

Question: How will the new release support meaningful use?

Riley: CONNECT fulfills the meaningful use requirementsfor health information exchange. Now with the finalizationof meaningful use requirements, we believe the CONNECTfederal agency partners will begin to articulate their requirements for supporting additional meaningful use capabilities in the CONNECT solution. In general thesecapabilities will be implemented in the CONNECT adapter and Universal Client Frameworks. Some of thesecapabilities include identity management, semantic interoperability, the NHIN Direct scenarios, etc. Becausehealth information exchange is part of the meaningful use requirements, ONC will also be working to exchangeinformation between doctors in differing settings, such as a primary care hospital and a rehabilitation center or othercare facility.

Question: Can you address the need for greater communication

among electronic health records (EHRs)?

Riley: The more platform neutral CONNECT becomes,the more these systems will be able to talk to each other. By building integration services into the adapter layer edge

systems such as EHRs, Lab systems and pharmacy systemsthey can now communicate using NHIN services throughthe CONNECT gateway, for example. The addition of open source interface engines such as Mirth only adds toCONNECT’s interoperability. If an EHR system sends outHL7 messages, the integration engine in CONNECT cancapture and convert the messages to a standard format foruse on the NHIN.

Question: What about privacy and security improvements?

Riley: Among the strongest features of CONNECT features that express policies for the release of information.If for example, as a consumer I don’t want to share information about my mental health in transferring medical documents, I can restrict which documents are sent, so labs and other healthcare providers querying mymedical information only receive the information I agree to release. In the future, information will be able to berestricted by type, or by section within documents. Users of CONNECT can expect to see more granularity of controlin terms of the release of information.

Question: So what’s coming next for CONNECT?

Riley: There will be refactoring in Release 3.1 to furtherimprove performance, scalability, efficiency and the additionof more interfaces. There will also be an ability to send larger file sizes so multi-gigabyte files can be transferredamong healthcare facilities. New logging capabilities willalso be incorporated to trace messages. And there’s also aplanned addition of an Administrative Distribution Servicebased on the HITSP/T63, which uses the OASIS EDXL-DEstandard for data sharing among emergency information systems. Finally, there will also be added support for secured and unsecured communication between the adapter and the gateway which will be configurable by theorganization using it. ❑

Q&A with the ONC’s Connect Initiative Lead, David Riley

s5

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Healthcare providers who participated in the creationof this report offered advice aimed primarily at howto continue the migration to electronic health records

and the sharing of information via the Nationwide HealthInformation Network (NHIN).

Brian Dixon, Health Information Project Manager,Regenstrief Institute, in Indianapolis, Ind., said it’s importantNOT to ‘boil the ocean.’ This means trying to do too muchtoo quickly, which can lead to disaster. Pressure to meet theARRA funding requirements will likely make it tempting togo through the process of achieving meaningful use all atonce, but it’s much better to break the process down, andincorporate data elements incrementally. Making incrementalchanges has brought us the greatest success. It’s best todefine a use case and identify the data elements to improvethe capture of records electronically. Once you makeprogress on those initial data elements, you can move on toincorporate additional elements. Trying to get everything upand running at once is a recipe for disaster. Starting smalland building incrementally is the best route to successfulEHR implementation. Nearly every healthcare practice isdifferent in the way it codes and collects information.Suppose a federal agency was planning to use data onpatient weight. That information may not be readily available,or measured in the same way, from all sources.

Will Ross, Project Manager, Redwood MedNet, recommended that healthcare providers attend softwaredevelopment forums such as the CONNECT Code-A-Thons,which are periodically held in various U.S. locations, attendedby representatives of federal and state agencies, healthcareproviders, insurance companies, health information exchanges,cities, universities and health IT vendors, among others.Code-A-Thons typically last two days and include short plenary sessions where experts provide detail about theirexperiences in the open source community, and program per-sonnel provide insight into the current and future architecture ofthe solutions. This is followed by hand-on programming whereattendees break up into groups and work on projects they are

interested in. Learn more about CONNECT code-a-thons at:http://www.connectopensource.org/about/code-a-thon.

Chris Smith, Director of Business Development, MEDNET,Minneapolis said healthcare providers must understand theydon’t need to do this alone. There are really good supplierswith experience who are ready to help. There are workgroups,resources and professional services organizations who can help any provider get started. One place to start ishttp://www.connectopensource.org/. Leverage the expertiseavailable to reduce your costs in the long run.

According to Sandy McCleaf, PMO Director, MedVirginiaCentral Virginia Health Network, Richmond, Va., for thoseseeking to participate in the NHIN it’s important to understandthat its not just a technical endeavor, but a combination oftechnology, standards, governance, policies and procedures.All of these elements must be brought together to achievesuccess.

CMS Offers Advice

The American Recovery and Reinvestment Act authorizedthe Centers for Medicare & Medicaid Services (CMS) toprovide a reimbursement incentive for physician and hospitalproviders who are successful in becoming ‘meaningful users’of an electronic health record (EHR). These incentive paymentsbegin in 2011 and gradually phase down. Starting in 2015,providers are expected to have adopted and be actively utilizingan EHR in compliance with the ‘meaningful use’ definitionor they will be subject to financial penalties under Medicare.

The focus on meaningful use is a recognition that betterhealthcare does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care. Providers of all kinds can now get up-to-date and accurate information about the Medicare and Medicaid EHR incentive programs from CMS athttp://www.cms.gov/EHRIncentiveprograms/. Visit the website to get specifics about the program and downloadnew tip sheets. ❑

Best Practices Advice fromHealthcare Technology Veterans

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Continued from page s1, A Sense of Community Takes Hold

understanding the benefits they will derive from linking tothis community. Our surveys regularly indicate that abouthalf of all doctors in our region are willing to link to NHIN.But that leaves 50 percent who have either no interest, or onlylong range plans to consider linking to the NHIN someday inthe future. That’s because the typical onboarding process can

take as long as 18 months, and most smaller doctors’ practicesare simply still waiting to see more direct benefits. If, bymid 2011, 40 percent or more of physicians start the processof linking to NHIN, this effort will have finally reached acrucial tipping point, using CONNECT as the fulcrum to liftinformation sharing to ‘critical mass’ in acceptance. ❑