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Changing Your Perspective of the National eHealth Exchange

Get Records Across the Street!

If you are like most healthcare professionals, when you hear the concept of the “national” exchange you think of sharing records between Florida and New York and see limited value.  And I do agree that the National eHealth Exchange (eHx) is used in this way as it IS the nation’s largest health information network.  Now let me introduce a new perspective – using the eHx to share with your community referral partners.  The eHx is best thought of as a backbone that includes technical, policy, data use and service level agreements and other requirements that enable data exchange, whether between two different organizations across the country or, what from what we’ve discovered, even across the street.

For the remainder of this article, I’ll reminisce on the origins of the eHx and what it is today then bring to light to what defines a community exchange and end with why it’s now so easy for you to join the eHx.

Origin of the eHealth Exchange

I’ve been in the Health Information Exchange (“HIE” now labeled Interoperability) business for nearly two decades.  I recall my excitement in the early 2000s listening to the nation’s first ‘Health Information Technology Czar” David Brailer as he eloquently spoke about a “network of networks” and “our national effort to modernize healthcare delivery”; real industry and life changing stuff!

The Nationwide Health Information Network Started in 2004

The Nationwide Health Information Network (NHIN), a program under the Office of the National Coordinator for Health Information Technology (ONC), was officially established in 2004 to improve the quality and efficiency of healthcare by establishing a mechanism for nationwide health information exchange.  The NHIN is a set of conventions that provide the foundation for the secure exchange of health information that supports meaningful use.  The foundation includes technical, policy, data use and service level agreements and other requirements that enable data exchange, whether between two different organizations across the street or across the country.  Participants in the NHIN agree to support a common set of web services and data content (NHIN Core Services) that enables private, secure, and interoperable communication of health information among NHIN participants across the public Internet.  A critical component of the NHIN is the trust model that bridges a diverse group of public and private entities.  This trust model provides a common foundation for privacy and security obligations, accountability, and governance in the midst of varying diverse federal, state, and local policies and laws.  One of the significant results of this work is the Data Use and Reciprocal Support Agreement (DURSA) that is now in use.  This combination of a trust model, technical services, and validation process for members enables health information to be securely exchanged with any connected node on the network in a matter of days.

Connection to Five Federal Agencies

As part of the original purpose of the federally funded health information network, the eHx is the only way to connect and electronically share records with the following five federal agencies:

  • Food and Drug Administration
  • Social Security Administration
  • Indian Health Services
  • Department of Defense
  • Department of Veteran Affairs

The eHealth Exchange Today

As you can see the eHx has deep roots and began as a federal program initiative, which helped to incubate it as part of the NHIN efforts.  eHx is now an independent, non-profit health information network and has blossomed into a rapidly growing community of exchange partners.  With its rich history and experience, it should be no surprise that the eHealth Exchange is the largest healthcare information network in the country.

Legal and Technical Backbone

The architecture to connect to the eHx from a technical perspective consists of two major components: 1) a gateway and, 2) adapters.  The gateway can be thought of as the hub or switch which is registered in the national network through the legal DURSA process and manages the connectivity, security, throughput, auditing, and other network level services.  The adapters are then used at each health system, or data source site, to actually collect patient records and documents from transport through the registered gateway.  This model allows for multiple gateways to emerge to support local HIEs, state databases, major health systems, and other entities as nodes on the network of networks.

In other words, the eHx has become the universal backbone to transport clinical patient records.

Over a Billion Transactions a Month

As of May 2022, the eHx announced they achieved the significant milestone of processing over 1 billion requests during the month.  This achievement was largely made possible through the eHealth Exchange’s Hub which provides network members with a single application programming interface (API) for connectivity. This enables members to interoperate with five federal agencies and the nation’s leading health systems, pharmacies, regional and state health information exchanges, medical groups, dialysis centers, and others to reduce information sharing expenses and complexities by leveraging one standards-based connection.

Community Networks within the National eHealth Exchange

Once I understood that the eHx is the legal and technical backbone that enables health information exchange I began to think of it as a cloud hosted service bus for clinical data that is ready for business.  Our job now is to leverage this infrastructure to replace old workflows.  It’s time to dig in and get our hands dirty working with hospital and provider staff within their real-world daily job functions and move clinical data in ways that make their lives easier.  Over the years I have identified a few very important concepts to consider while we tackle this this task.

Healthcare Services Deliver Pyramid

The vast majority of healthcare services are delivered within a localized community and region.  As we roll out data sharing solutions across the nation, it is vitally important to keep this straightforward reality in the front of our minds to ensure proper resource distribution required to truly bring about “meaningful use” for healthcare providers.  The graphic below provides a simple albeit powerful visual for this concept.

Service Areas and Data Sharing

Realizing HIE that is cost-effective yet still valuable to healthcare providers in daily operations is a complex and challenging process.  The first step is to define a service area and the stakeholders – the necessary participants in a patient’s healthcare continuum.  For the network to bring value to participants it must meet an existing need to share information which, in the healthcare environment, equates to the flow of patients through referral pathways.  There are a number of factors that can be used to help characterize these “medical trading areas”.  They include hospital referral regions as defined by Dartmouth, trauma service areas, and feedback from the local community.

Political and geographic boundaries do NOT define how or where patients get treated making it necessary to have access to a national level infrastructure and unified backbone such as the eHx.

How to Join and the eHealth Exchange?

In the early days of the Nationwide Health Information Network, it was a heavy lift to join – containing both a technical interface component as well as a massive legal administrative element.  This made the cost to on-board and use the network prohibitive not to mention the time required to complete the project measured in years.  Today there are private sector HIE service providers like Centralis Health (HIE Networks LLC, dba Centralis Health) that have already completed the heavy lift making it easy for any and all healthcare providers to join.

Centralis Health is the first vendor participant for the eHealth Exchange.  As a vendor participant, Centralis Health has signed the same health information sharing agreement, known as the Data Use and Reciprocal Support Agreement (DURSA), as all eHealth Exchange network participants.  Centralis Health may flow-down these terms to their customers who choose to opt-in to the eHealth Exchange network, dramatically lowering the legal review and administrative costs for their customers.  In addition to being an active participant in the network, Centralis Health is also an eHealth Exchange Validated Product, joining more than a dozen other leading healthcare technology vendors in completing rigorous testing to ensure interoperability for customers using their technology to connect to the eHealth Exchange.

In short, you connect to Centralis Health and we connect you to data across the country, or to your referral partner across the street.