The NHIN Direct Project thanks the HIT Standards Committee review team for providing review and feedback. As part of the NHIN Direct Project, four teams have created what we are calling Concrete Implementations, which are both specifications and example working code that are intended to solve the major goals of directed health information exchange involving known participants in support of the goals for Stage 1 Meaningful Use.
As we evaluate the concrete implementations, it would be helpful to get strong, independent review of the options. As part of that review, we are looking for the following:
- Feedback on strong and weak aspects of each concrete implementation proposal with respect to the suggested evaluation criteria
- Feedback on the decisional criteria themselves (including suggestions of additional evaluation criteria)
- Evaluation of suitability of each concrete implementation to meet the overall project goals
- Recommendation to the full NHIN Direct Implementation Group (including recommendations on implementation as well as overall process recommendations)
The review team's evaluations will be provided to the NHIN Direct Implementation Group as part of a set of decisions we are making on June 10th and 11th; the full Implementation Group will take the review comments into strong consideration when making the final decision on a final specification or set of interoperable specifications.
In order to meet the wider timeline for Stage 1 Meaningful Use, the NHIN Direct Project is on an accelerated timeline, driving towards real-world early implementations to test the specifications by October, 2010. Accordingly, we are asking Implementation Group participants to implement the agreed on specifications between June and October.
This accelerated schedule requires a rapid review schedule. We apologize for this schedule, and thank the reviewers for their work.
- June 2nd – Provide HITSC with NHIN Direct Concrete Implementation Capability Review Worksheets
- June 2nd – 7th – Hold individual HITSC reviewer meetings as needed
- June 7th - First-round HITSC NHIN Direct options review meeting
- June 8th – NHIN Direct Concrete Implementation Workgroup discussion
- June 9th - Second-round HITSC NHIN Direct options review meeting
- June 9th – By end of day: HITSC to submit NHIN Direct report & recommendation
- June 10th/11th – NHIN Direct Implementation Group face-to-face consensus vote on concrete implementations
Overview of the NHIN Direct Project
The immediate genesis of the NHIN Direct Project was an HIT Standards Committee Implementation Workgroup meeting in October, 2009. That workgroup invited a number of participants to provide feedback into the real-world implementation of standards. One of the more engaging sessions in that workgroup meeting was a provider panel that clearly articulated the challenges in real-world healthcare interoperability, particularly in the smaller practices that make up the vast majority of physician private practice. The clear lesson was that the fax machine is, by far, the norm for real-world healthcare information transfer. A compelling anecdote underscoring this problem was presented during the meeting: A physician in Pennsylvania had a patient who was moving to Arizona. He referred her for care to a physician he knew in Arizona, and he and the referred to provider both had the same EHR technology, which was capable of exporting and importing a standard patient summary document. Unfortunately, he had no standard way of securely transmitting the summary document to the physician in Arizona. What was missing was a simple, secure, easy-to-use Internet-based method for transport to get the clinical summary where it was needed.
Many of the clinical transactions that enable coordination of care have a common set of characteristics:
- They are directed transactions, which is to say, they are sent from one known sender and directed to a known recipient
- The data holder is the transaction initiator, and has made appropriate data disclosure decisions prior to initiating the transaction
Many examples of such transactions are required as part of Stage 1 Meaningful Use. Examples include:
- Referral to a provider or hospital
- Care summary to the referring provider
- Discharge summary to the referring provider or medical home
- Lab reports to the ordering provider
In addition, many patient engagement needs can be addressed through the same sorts of directed transactions. Examples that are part of Stage 1 Meaningful Use include:
- Clinical summary from provider or hospital upon request and after an encounter
- Reminders for preventive or follow-up care
The NHIN Direct Project is a project to design and test a set of specifications for satisfying this health information exchange need. The core project deliverable is the set of specifications; secondary deliverable include additional reference and conformance tools and documentation.
Motivating User Stories and Design Principles
The motivating user stories, and their tie to the core Meaningful Use criteria are documented at User Stories. While the Priority 1 user stories are defined in terms of the core Meaningful Use criteria, they describe a general capability that will have broader extensibility and applicability.
Core design principles are documented at Design Principles. A few of these design principles call for special consideration:
- Principles 10-12 call for a simple technology set that designs "for the little guy", where "little guy" implies:
- Supporting the typical practice of 5 or fewer physicians where approximately 2/3rds of the physicians in private practice work, as well as suporting those in larger practice setttings
- Supporting the smaller health IT organization, vendor, or consultancy, who may be designing the next HIT innovation with a small technology team, as well as supporting the large HIT vendors and larger practice settings and delivery networks employing IT and informatics teams
- Principles 5 and 6 call for a capability that is foundational yet can scale up to a health information organization deploying record locator services, longitudinal registries and other comprehensive capabilities, including HIOs that are part of the NHIN Exchange
These two sets of principles may point the design in different directions; balancing these two sets of principles will be a key design tradeoff.
The following documents document many of the key foundational outputs of the NHIN Direct project:
- User Stories
- Design Principles
- NHIN Direct Abstract Model documents the core abstract model and terminology used in concrete implementations. Note also the Abstract Model Examples
- Addressing Specification documents the core requirements for a Health Internet Address.
In addition, the Content Container Specification is used by some of the concrete implementations (SMTP and REST, in particular).
The Implementation Capability Worksheet provides an agreed upon set of evaluation capabilities. For the purposes of review, please assess each concrete implementation on the following capabilities described in the worksheet:
- Specification: Review with particular attention to completeness and clarity
- Security and Trust model: Review each concrete implementation in terms of the appropriateness and flexibility of the security and trust model
- Comprehensive HIE: Review each concrete implementation in terms of its ability to fit within a larger comprehensive HIE framework
- Cost and Complexity of Development: Review with respect to the technology capabilities of a small ISV concentrating on healthcare. Reviewers may wish to review reference implementations to evaluate cost and complexity
- Workflow Practicality: Review each implementation with regard to the capability of the average small or medium size medical practice, the physicians and other staff members in the practice, to participate and make full use of the specifications, while also considering their levels of available IT support or lack of availability of IT support. Pay particular attention to the situations faced by the smaller and rural providers and their patients.
- Metadata and content capabilities: Review according to the design goals of supporting simple text through to complex structured documents
- Extensibility: Highlight features that enhance or detract from the ability to support additional functionality or use cases over time, both with respect to the base functionality of directed transactions as well as future capabilities that may be needed over time.
In addition to those capabilities, please provide a general review of the overall approach and technology of each concrete implementation. Add any additional categories or criteria as needed for the purposes of evaluation.
Please review each concrete implementation technology choices against the policy considerations from the HIT Policy Committee (in particular, the Privacy and Security Workgroup, NHIN Workgroup, and HIE Workgroup). Please elevate any technology choices that overly constrain or complicate policy.
Please note that many of the linked artifacts are draft and works in progress.
Summary and Case: The Case for IHE
Specification: IHE NHIN Direct Specification
Capability Worksheet: IHE Concrete Implementation Capability Worksheet
Code Repository: 
Team Page: IHE Implementation Development Team
Summary and Case: The case for SMTP
Specification: SMTP Implementation
Capability Worksheet: 
Code Repository: See the links from: SMTP Implementation Development Team
Team Page: SMTP Implementation Development Team
Summary and Case: The Case for XMPP
Specification: XMPP Implementation
Capability Worksheet: XMPP Implementation Capability Worksheet
Code Repository:  (Code will be baselined on 6/6/2010)
Team Page: XMPP Implementation Development Team