Posts Tagged ‘NHIN’

Now that NwHIN has been spun-out into the public-private entity Healtheway one has to wonder exactly what value they can deliver to market that will sustain them as they attempt to ween themselves from the federal spigot. Healtheway has no lack of challenges ahead but they intend to target one area that presents an interesting opportunity. Question is: Are they too early to market?

During a recent webinar, Healtheway’s interim executive director, Mariann Yeager, outlined the origin of Healtheway, the apparent traction Healtheway is gaining in the market and what their plan is going forward.

Healtheway got its start via funding from a variety of federal sources, all of whom who were looking for a solution to address their unique problems. For the Social Security Administration it was the need for a nationwide network to facilitate processing of disability claims. For the VA and lesser extent DoD it was the need to enable military personnel to receive care in the public sector and insure that their records were complete. Health & Human Services led most of the development effort leading to NHIN CONNECT, a less than stellar technology platform built by beltway bandits (who else), that hit the market with a thud.

One of the things the feds did get right though is a clear and comprehensive policy for data use sharing across disparate entities. The DURSA (data use and reciprocal support agreement) remains one of the key differentiators in Healtheway’s portfolio. Healtheway’s intent is to leverage the DURSA as the “unifying trust framework” and build upon that with a common set of technical exchange requirements (standards) to facilitate exchange with eHealth Exchange (this replaces the former NwHIN Exchange). Healtheway has also enlisted CCHIT to perform testing of technology vendors solutions to insure they comply with the technical exchange requirements that will allow for HIE-to-HIE connectivity.

That last sentence is the kicker. Healtheway and its eHealth Exchange is not intended to be an uber-national HIE but a set of policies and technical specs that will allow HIEs, be they public or private, to share information across institutional boundaries. Therefore, Healtheway will not get into the current rat’s nest of looking to on-board the multitude of ambulatory EHRs into an HIE but sit one level above that facilitating exchange across HIEs. This is something that many regional and state HIE programs are looking to facilitate, thus it is not surprising to see that a significant proportion of Healtheway members come from such organizations.

There will be a need for this functionality at some future point in time, but not today and likely not tomorrow either. Three key challenges stand in their way:

1) Getting buy-in from healthcare organizations and technology vendors. While membership has indeed grown, Healtheway is offering membership at a discount (likely a loss) to gain traction and unfortunately they still do not have significant traction as many brand names in healthcare are missing.

2) A tainted history with more than its share of missteps. Slowly coming out from under the wing of federal politics as a pseudo independent organization (Board still has plenty of government influence), Healtheway may begin to act more as an independent organization, more like a business. Unfortunately, due to a likely continual need for government funding that independence will likely be limited.

3) The HIE market, both from a technology, policy and implementation/deployment perspective is still primitive. The broad market is simply nowhere near the point of needing what Healtheway intends to offer for a few years to come, at least as it pertains to the exchange of clinical data. Good idea, too early to market. That being said, tehre will be value on the transaction side, e.g., SSA and disability claims processing.

Hopefully the future will prove us wrong on this one and Healtheway will indeed prosper and contribute to the maturity of the HIE market. But our advice, don’t bet on this horse just yet, give them six months than take a second look.

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Making Sense of the NHIN

The National Health Information Network (NHIN), which was the previous ONC head’s (Kolodner) top priority, or at least seemed that way is a concept that has its advocates and detractors.  To date, we have been more of a detractor as the original NHIN was a very heavy, top down approach by the federal government to establish a national Health Information Exchange (HIE).  Certain federal agencies loved the idea (e.g., Social Security Administration which has an embarrassing 18 month backlog of disability claims), but those in the field (local hospitals, RHIOs, HIEs, etc.) were not such a big fan of the concept.  Heck, we can’t even get RHIOs established, let alone an NHIN.  Adding to NHIN woes was its platform, built by beltway bandits with technology ill-suited to create a flexible, lightweight transport mechanism for the exchange of health information.

Thankfully, a new administration has come on board, new people have joined ONC and the bloated NHIN of recent history is getting a major rework – actually being split with NHIN referring more to the policy constructs that will define information exchange (the DURSA – Data Use and Reciprocal Support Agreement) and NHIN Direct, a much lighter weight technology stack to enable point to point communication.

Unfortunately, Chilmark has not had the time as of late (see previous post) to do a deep dive but while at the recent Governor’s Conference here in Boston, we bumped into Keith who works for GE and has represented GE in many of the discussions/meetings that ONC has held recently on NHIN and NHIN Direct.  Therefore, I asked him if he would be willing to write something on this topic, which follows below.  (Note, in conversations with some State Reps at the Governor’s conference, there is some significant consternation among many regarding the NHIN and NHIN Direct so this is far from a slam dunk for the feds – time will tell as to how this will actually be adopted and used.)

And if this topic of standards evolution, healthcare, information exchange interests you, encourage you to follow Keith’s Blog as he has some good stuff there.

What is the NHIN

John Moore of Chillmark Research asked for this one:

What is the NHIN, NHIN Connect and NHIN Direct, and the differences between them?

NHIN stands for the National Health Information Network.  But NHIN is not really a network, rather, it is a concept describing the infrastructure needed to connect healthcare providers from Maine to California to Alaska to Hawaii to Alabama to …

A better name for NHIN would be the National Health Information Infrastructure, or NHII.  At least that’s what we called it in 2004.  Some of this is covered in a post I did on the history behind ARRA.

The NHIN has been described as the backbone for exchange, much like the Interstate Highway infrastructure.  We really already have the necessary infrastructure needed: that is the Internet.  What NHIN really did was specify the rules of the road for traveling on the healthcare interstate.

In 2006, the newly create Office of the National Coordinator issued an RFP to test (pilot) technologies that would be used to connect heatlhcare providers across the states of this country.  I’m not sure why, but they used the name NHIN for this program, rather that show continuity with the NHII work that had gone on before.  Four organizations were awarded contracts for this NHIN Pilot project.

Subsequently in 2007-2008, a new RFP was issued and awarded by ONC across 11 different healthcare organizations to support NHIN Implementations.  The Federal Health architects across the federal agencies realized that they needed a platform to help agencies and organizations to connect to these NHIN implementations.  This project was an Open Source software project that became NHIN Connect.  NHIN Connect provides the software you need to get on the highway and follow the rules of the road.  It’s been called the onramp to the NHIN.

Finally, we have NHIN Direct.  To get from my home to my doctor’s office, I never go near the highway.  To get from my doctor’s office to one of my specialists,  I still need to travel from the office parking lot, to the interstate.  I drive differently on these back streets and local highways than I do on the Interstate.  The rules are different there.  The same is true for the small practice.  In order to connect to their collegues and to their paitients, they need a different infrastructure.  That infrastructure needs to be sommething that they can purchase from Best Buy, or sign up for over the web, using the stuff they already have, to allow them to connect up to the NHIN.  NHIN Direct is the way that providers can connect to others without having to be aware of the gravel, concrete and steel that they are driving over.  They just want to get into their car and go.

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One of the thornier issues regarding the establishment of public Health Information Exchanges (HIEs) is how to manage consumer consent of personal health information (PHI) sharing.  Today, there is no single standard approach across the US.  Some states have an opt-in process, others an opt-out.  Granularity of data shared, use cases for data sharing, etc. also vary widely from state to state.  These are just some of the findings of an extensive report (92 pgs) that was published this week by HHS’s Office of the National Coordinator (ONC), the ones responsible for funding the multitude of state-led HIEs under ARRA as well as the National Health Information Network (NHIN).

The report looks at the consumer consent policies (and challenges to implement) in eight states as well as three countries based on interviews and an extensive amount of secondary research.  While a tad long, there is some good information tucked inside the report if one spends the time to dig it out.  A good place to start is the Appendix that provides an overview of the consumer consent policies in the various states (HIEs) profiled.

Do not be too surprised if findings and conclusions of this report end up directing future policy, particularly as it pertains to the NHIN as it struggles to define an overarching common data use agreement and self governance model for the sharing of PHI.

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blumenthalYesterday, David Blumenthal published a very thoughtful post on the HITECH Act as a foundation for information exchange in which he reflected on his own personal experience as a doctor.  That experience included the often frustrating realization that he could not obtain a complete longitudinal record of his patients (customers) due to either (or both) technical or business barriers.  In his post, Blumenthal goes on to elucidate on how the HITECH Act’s language is purposely worded to remove such barriers as the healthcare sector transitions from a provider-centric model to one that is patient (consumer) centric.

Following are our own reflections on Blumenthal’s post based on the reality of the market today and where Chilmark sees it heading in the future. Specifically, we’ll tackle each of Blumenthal’s bullet points in order.

HITECH Act squarely tackles the commercial barriers. Yes, HITECH funding is clearly earmarked in support of open and secure exchange of data, in fact it was one of the three core attributes of meaningful use (information exchange for care coordination) defined in the legislative language.  But HITECH Act and its provisions only pertain to those that accept the $$$ and it remains to be seen just how many entities sign-on.

Blumenthal closes his first bullet point with:

Consumers, patients and their caretakers should never feel locked into a single health system or exchange arrangement because it does not permit or encourage the sharing of information.

Ideally, this is the end result but not so sure how we get there from here.  In Boston, a very competitive healthcare market with some of the best healthcare informatists in the business, organizations and subsequently consumers are extremely challenged to get their data, let alone share it.  The video clip below from Microsoft on the deployment of Amalga for the Wisconsin HIE gives some idea as to how this might work, but even in this case, it is limited to ER, there is no consumer control.  We are in for a very, very long journey.

HITECH tackles economic barriers. Not really.  Sure, $36B is a heck of a lot of money for the HIT market and the potential follow-on penalties for not adopting an EHR may be significant for clinics and hospitals that derive a large proportion of revenue from CMS, but that is not necessarily the case for smaller, private practices where it is estimated that 80% of care actually occurs. For smaller practices that do not serve a large CMS population, the reimbursement of $44k/physician does not pay. The incentives, frankly, are not the powerful tool that Blumenthal claims they are for a significant portion of the market.

HITECH tackles the technical barriers. Huh?  Not sure how he came to that conclusion.  Maybe in time if the stars all align perfectly, such will come to pass but today we have a host of legacy systems that do not talk (inter-operate) with one another, strong disincentives for HIT vendors to actually create truly interoperable products (the more open and interoperable you are, the easier it is to be replaced with a competing solution) and then there is that whole issue of adoption mentioned under economic barriers above.

Yes, Blumenthal is correct in that the HITECH Act does instruct HHS to continue its investments in creating a nationwide electronic exchange for health information (the NHIN which will become the Health Internet).  But even here there have been challenges. The technology stack of the NHIN today, created by beltway bandits and not those deeply immersed in HIT, is crippled.  Hopefully, as was presented at the Harvard ITdotHealth Forum, the feds will open up and actively solicit the guidance and input of those that were present, and others to create an NHIN that is truly usable.

HITECH provides the building blocks for information exchange across jurisdictions. Yes and No. Certainly the HITECH Act will fund HIE initiatives in virtually all states with the $560M+ that was announced in early fall (States submitted their proposals earlier this month).  This will certainly accelerate activities at the state level for HIE build-out but the question remains: Will these state activities actually be able to devise a truly sustainable business model?  To date, it is rare indeed to find a public HIE that is self-sustaining.

Beyond the issue of funding these state HIE is the much thornier issue of the myriad of state laws and policies as it pertains to the distribution and sharing of medical records.  The only recourse may be a “super-DURSA” (caution PDF) passed by Congress to supersede state policies, which could prove quite challenging.

Despite outlining what are seen as some fairly significant challenges to Blumenthal’s upbeat and positive post, like him, we share in the desire to move the proverbial ball forward and more importantly (what we really, really liked about his post) focus on the patient, the consumer, the citizen.  In the end, it is they who are footing the bill for this massive initiative to get doctors, clinics and hospitals wired-up. Therefore, is it not they that should ultimately benefit from the HITECH Act through better care, greater flexibility in physician choice and who knows, maybe even receive lower cost of care.  A tall order in deed but certainly one worth working towards.

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Connect09The feds are beating the CONNECT drum. This week, ONC sponsored a two-day event in DC to begin educating the market as to what CONNECT is and how it may be leveraged to support information exchange.  At least that is the impression one had in signing up for this event.  In actuality, the event was somewhat schizophrenic in gyrating back and forth between the National Health Information Network (NHIN) and CONNECT, the software platform upon which the National Health Information Exchange (NHIE) and intra-agency network.

In terms of attendance, probably close to 700, with a huge contingent of consultants (beltway bandits) such as Harris, Northrup, MITRE, IBM, SAIC and of course Sun (soon to be Oracle).  Event also attracted high level visibility with ONC head David Blumenthal kicking off the event, followed by Obama’s new CTO, Aneesh Chopra.  (Note, for all of you developers out there, Aneesh talked about government transparency and the new data.gov site. Though in its infancy, released just over a month ago, data.gov may provide some interesting mash-up opportunities but unfortunately lacking healthcare data.)

So what is CONNECT?

In simplest terms, CONNECT is a technology stack built with Open Source software (Sun-derived) to support the development of the NHIE and more broadly a NHIN.  Thus, from the onset CONNECT has had broad participation from the likes of CMS, the VA, DoD, Bureau of Indian Affairs and the first true test case user, the Social Security Administration (SSA) who recently completed a successful beta test of the platform with RHIO MedVirginia.  In March 2009, V1.0 of CONNECT was released to the market.  On July 9th, V2.1 will be released.  While CONNECT was developed to create an NHIE, it longer-term goals are to become the backbone to the NHN.

CONNECT was built on Open Standards, mostly the Sun open source stack.  The underlying database today is Sun Solaris, on top which sits a common 3-tiered architecture built with Java tools.  Directly above the database is the secure, NHIN messaging layer for secure transport.  A Services layer for query, search, patient identification and exchange sits above messaging. The final layer is the “Profile” layer for specific domain functionality and the building of novel apps such as those for biosurveillance, population health, quality reporting, etc.

In building the core CONNECT platform, developers paid special attention to keeping functionality to a minimum to insure flexibility and enable innovation as the NHIN gains traction.  Naturally, Web Services are supported within the context of CONNECT’s core SOA.  For the consumer preference profile, CONNECT developers adopted the OASIS standard, XACML.  The CONNECT services directory uses UDDI V3.0.

And Current Thinking on the NHIN?

John Glaser, who was also on the agenda listed five key activities of the NHIN development:

  1. Create and demonstrate a series of standards and protocols for defining data exchange at State & National level.
  2. Establish DURSA (Data Use & Reciprocal Support Agreement) & legal agreements for data exchange.
  3. Establish governance mechanism to set path for future development direction of the Open platform.
  4. Conduct a series of demos to test functionality, usability and value.
  5. Promote development of “interstitial technology” for NHIN platform to make it actually functional and useful (e.g. patient identifier).

And in grand style, Glaser went on to conclude that the NHIN sets the “framework, the structure and foundation” for broader future exchange in support of “meaningful use.”  In fact, throughout the first day numerous speakers would keep circling back to meaningful use, the HITECH ACT, ARRA etc. and how CONNECT fits in.  Many of these connections between CONNECT and ARRA legislative language were quite a stretch of the imagination making one wonder why the need for such over-reaching justification? Does CONNECT really need to be so heavily pitched to the market to justify its existence and promote its adoption?

Business Model Anyone?

Maybe one of the biggest red flags was a complete lack of discussion over the course of this two-day event on viable business models for Exchanges, a notorious issue that most public-sponsored Exchanges have struggled to address. That’s not to say the money is not there, it just seems as though the policy wonks in DC and the multitude of beltway bandit contractors that the feds (HHS) hires just don’t think about this issue, or just do not know how to address it.

For example, currently, the SSA spends $500M/year (yes a half billion dollars a year folks) on converting medical records to a digital format, and that has nothing to do with the huge back-load of disability claims that SSA is trying to address which has its own hidden costs to both providers and the SSA.  Now there is a business here, we’re sure of it and CONNECT might play an important role if one were to develop a novel “interstitial app” on the platform that would facilitate the SSA in addressing this problem.

Addressing Data Ownership: The Bane of Most Exchanges

In Chilmark’s past research on Exchanges, beyond establishing a viable business model, data ownership within the Exchange is an extremely difficult challenge where it appears only the lawyers come out ahead.  For the CONNECT NHIN, the initial consortium has drafted a DURSA that addresses virtually all aspects of data exchange and use, from consent, to obligations to permitted purposes for using data and ultimately data ownership.  The DURSA is currently undergoing internal agency review and likely to be released by end of year.

Key components of the DURSA include:

  • Extension of HIPAA to all participants on the NHIN.
  • HIPAA is the floor for all activities on NHIN but local and State laws that go beyond HIPAA are not preempted.
  • Limited permitted uses of data (e.g., neither use for research or legal/enforcement is allowed).
  • All participants must respond to a data request from an NHIN member. One is not required to share data, but must, at a minimum, acknowledge request for data.
  • Once data is transferred to recipient, data is now owned by recipient and they can share/exchange data anyway they see fit that is in conformance to their policies.

Clearly, the fed consortium that put together this DURSA is looking to maximize data liquidity.  Despite their good intentions, it is unlikely that this will be readily adopted in the market for despite assurances, risks to the consumer, the patient appear greater than the value derived.  In speaking with one doctor after the DURSA session, he just shook his head saying that very few practicing physicians that he knows would accept these DURSA terms.

Where is the Consumer Voice in All of This?

One the morning of the first day, Sarah Wade, the wife of a retired soldier wounded in Iraq spoke to the challenges of caring for her husband in this convoluted healthcare system that we all, as citizens, must contend with.  Her talk was real, it was heartfelt and something that many of us can relate to within some aspect of our own lives.  Yes, the secure exchange and sharing of personal health information (PHI) has far more benefits than many of the purported risks.  But that does not mean that citizens do not have a voice in these discussions as ultimately, these discussions involve the most personal aspects of their lives, their PHI.

Unfortunately, there seems to be little here within the hallowed walls of those developing the NHIN that pertains to the US citizen.  Yes, they have insured that at a minimum, HIPAA is there to protect PHI, and yes, there are provisions to gain consent for exchange of PHI among certain participant types and maybe most importantly, one of the six permitted data uses is allowing the consumer to request that their data be exported to a PHR – all well and good, but simply not enough.

First, when data is exchanged on the NHIN there is no capability to discretely tag data to share only that data which is pertinent to specific care and treatment.  A spokesperson stated that data tagging was simply too complicated an issue to address, thus taken off the table.  Weak excuse – Microsoft HealthVault has that capability today.

When asked about the role of consumer data ownership and the PHR within the context of the NHIN, ONC stated that they have had internal discussions, yet have reached no conclusions, apparently, no clear policies.  For now, it looks like they have put this on the far back-burner.

As mentioned previously, the DURSA allows for the transmittal of PHI from one participant to another and once the requester receives the data, the requester becomes the data owner as well and may share/distribute the data in anyway they desire in accordance with their own policies and guidelines.  Big question here is how will the NHIN provide a citizen with a clear audit trail of all who have viewed their PHI? No answer to date.

Based on what was presented this week, it appears that these critical issues were by and large side-stepped as the agenda for CONNECT and NHIN is all about the enterprise, be it a government agency or a hospital.  Certainly understandable that someone like the SSA would have such a view but it is unfortunate that HHS/ONC has not been more inclusive of the citizen in its deliberations and development of core policies.

Looking Ahead

At first blush, Chilmark saw CONNECT competing with existing Exchange vendors such as Axolotl, InterSystems, Medicity and Wellogic. Conversations with a couple of these vendors, however, gave a different view – they see little threat today. CONNECT is simply too immature and despite it being open source, adoption of the CONNECT platform will still need a full team to configure and implement the solution and support it, no small task.  As one vendor told me: “…technology is only 20% of the problem in setting up an Exchange.” For the foreseeable future, it is unlikely that CONNECT will impact these vendors.  Of course, a large service provider with a strong healthcare IT practice (e.g., CSC, IBM, Perot, etc.) could make a play here successfully leveraging CONNECT into a full-service offering competing directly with these vendors. Yet even this scenario is still a few years out due to CONNECT’s immaturity as a full-fledge Exchange platform.

Where CONNECT will see the greatest traction is within the federal and possibily state governments that are looking to take waste out of the system, such as the SSA example cited previously.  In that context we will see service providers capitalize on this service opportunity to government agencies.  We will also see vendors create CONNECT gateways allowing others outside of government to participate in the NHIN in support of anything from meaningful use (quality reporting and information exchange) to facilitating care transition (military to private practice – RelayHealth did a nice demo of this), to supporting transactional processes.

But CONNECT and the NHIN have a long road ahead of them.  For CONNECT it will be about the creation of a community of developers that look to build apps and ultimately businesses that leverage the core technology stack that is CONNECT.  Unfortunately, at this event organizers did not have anyone address the business opportunity of building for CONNECT.  Without that ecosystem of apps, CONNECT may ultimately fade into a small, relatively irrelevant platform.

On the NHIN-side, it is hard to see a massive groundswell of support. Within the context of the NHIE, yes there is value, but when one extends the model beyond those confines it becomes increasingly difficult to define a sustainable model and some of the DURSA language will be met with strong resistance outside the cloistered government view.

In addition to sustainability, there are some serious issues regarding citizens’ PHI rights to control the sharing of their data.  Without clearer, more defensible answers to some of the questions outlined above regarding PHI, NHIN could face some siginifcant hurdles on the public stage.  HHS leadership would be wise to go back and rethink their strategy to engage citizens in promoting NHIN beginning with giving the citizens a greater say in just how there PHI will be shared and used. Ultimately, HHS/ONC is going to need that strong citizen support to induce change in the healthcare sector, including adoption and use of the NHIN.

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The online publication, NextGov has a good article that further outlines the new privacy framework that Sec. Leavitt announced on Monday during the NHIN event being held in DC.  Article is the best one I have seen yet on the subject (all the HIT rags have been pretty abysmal covering this announcement).

Reflecting back on the presentation I gave to Sec. Leavitt in late July, one of the key topics on which there was much discussion pertained to how does the government help insure that consumer’s health records remain private and in their control within a PHR construct.  I’ve come to realize that one of the key points I made to the Secretary regarding this important issue (in fact I practically begged him) was to not be prescriptive in defining such policies, but set-up guideposts.  The analogy I used was: “Put up guardrails, do not put down railroad tracks.” The new Privacy Framework announced this week does just that!

I’m sure I am not the only one who gave such advice, but damn it feels good to think that maybe, just maybe, I had some influence on their internal deliberations that resulted in what was published by HHS this week.

For sure, a very nice ending to the year.

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Back at the beginning of the year, I did a Top Ten Predictions post where one of the predictions was the continued struggles of Regional Health Information Organizations (RHIOs) and the steady rise of Health Information Exchanges (HIEs).  Since much of the ballyhooed National Health Information Network (NHIN) is built upon the premise of RHIOs and their success, the NHIN is basically dead in the water.

Sure, NHIN supported by RHIOs is a great and grand vision, but that is about it – a great and grand vision created by policy folks in government (and their academic counterparts) that has little basis in reality.  That divorce from reality stems from a lack of a true, justifiable business case.  There is simply no compelling business reason for the vast majority of health industry stakeholders to invest in RHIOs. (Note: those that have invested in RHIOs are most often doing it for political reasons, not business ones.)

This is not the case for HIEs. These networks are created by entities, typically large hospitals, that do have a compelling business reason (one reason: encourages referrals to their hospital) to share health information within a network of business partners (their provider network).  This is quite similar to a supply chain network within the manufacturing sector.  In manufacturing its about sharing bills of materials, design drawings and the like to accelerate time to market.  For hospitals its about delivering value to smaller practices, most often giving a physician a window into the HIE host’s EMR to facilitate care and insure referrals.  The August cover story of the publication Health Data Management has an excellent story that goes into greater details on why HIEs are growing in popularity.

It is an expensive and time consuming endeavor to build these HIEs.  RHIOs, well, there are another order of magnitude more difficult to accomplish and likewise costly to support.  And let’s not even begin thinking about NHIN – that is one vision that is at least a decade away, if not longer.

How might we move the proverbial ball forward?

First, discontinue investing federal/state funds into RHIOs.

Second, redirect energies (not necessarily funding) towards supporting HIEs.

Support for HIEs can come in multiple forms, but maybe a tax break or rebate to the sponsoring entity of an HIE is possible with some caveat to the effect that th HIE will support open, interoperable standards.  This will insure that the HIE will be capable of participating in a broader entity e.g. RHIO and further down the road the NHIN.  Taking this approach will provide a logical, stepwise strategy to growing the connections towards a nationwide network that begins at a very local level delivering incremental value every step along the way.

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