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General Resources
The Collaborative Response
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The major design principles/elements of a potential technical architecture for a NHIN. This description should be suitable for public discussion.
About the Health Information Environment
© 2004 The Markle Foundation Graphic by Tom Benthin
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The Health Information Environment develops through the creation and connection of sub-networks that conform to the Common Framework of standards and policies.
- The quickest way to expand the Health Information Environment is by encouraging the parallel creation and connection of multiple sub-networks which all conform to the Common Framework.
- The Common Framework consists of the essential technical and policy requirements to enable the interoperation of standard interfaces and transactions at the local, regional and national level.
- Utilizing the Common Framework ensures economy of scale and speed of deployment and is essential because it enables the appropriate and necessary participation of national and super-regional entities (e.g., CMS, Kaiser, VA, etc.).
The Health Information Environment develops incremental
- The Health Information Environment and the Common Framework that supports it should evolve over time and be responsive to new developments and ongoing innovation in technology and policy.
Healthcare applications are end-point systems connected to a "thin" Health Information Environment
- End-point systems include but are not limited to electronic health records, public health reporting systems, and other reporting systems.
- The Health Information Environment should facilitate the exchange of patient health information between end-point systems, or proxies for them, to improve the delivery of patient care and to further other health-related goals.
- The vendors or the operators of end-point systems support clinicians at varying levels of technology adoption (including those who do not yet have their own end-point systems) through "light" tools that offer clinicians Web-based information retrieval asymmetrically.
- A "thin" Health Information Environment builds upon the existing decentralized model and uses available Internet technologies.
- By utilizing existing Internet technologies, a "thin" Health Information Environment fosters increased competition and innovation by allowing industry efforts to focus on providing evolving healthcare-specific solutions.
Key to the Diagram
The Health Information Environment is a circular system; there is no "start" or "end" point because numerous transactions occur throughout it simultaneously. The following descriptions are of the elements portrayed in the diagram and the transactions associated with each of them. It is important to note that the diagram depicts one sub-network -many sub-networks of this type would be linked in an analogous fashion to comprise the full Health Information Environment. It is also important to highlight that all of the activities described by the diagram (excluding those of the end-point systems or applications) take place according to the guidelines set by the Common Framework, which consists of the essential technical and policy requirements to enable the interoperation of standard interfaces and transactions at the local, regional and national level.
Common Framework
- The Common Framework specifies secure Internet based communication methods.
- Participants in the Health Information Environment are authenticated in a common fashion so that secure communications can occur.
- The Common Framework specifies information standards to allow unambiguous communication of clinical data.
Individual Care Providers
- Individual Care Providers, depicted by a circle on the left of the diagram, are the systems used by individuals or organizations to deliver or track care or health care operations.
- An Individual Care Provider system initiates an interaction with the Health Information Environment. For example, an authorized care professional might ask the Patient Index (also referred to as the Record Locator Service) whether there are any authorized records available that are necessary for the care of a patient (see the left side of the arc at the top of the diagram).
- An Individual Care Provider would use an end-point system or application - such as an electronic health record or providers' portal via a thin web based client - as an interface to the Health Information Environment.
Patient Index (Record Locator Service)
- The Patient Index, also referred to as the Record Locator Service, needs to enable a care professional looking for a specific piece of information (PCP visit or ER record) to find it rapidly. An open design question is how and where in the model this capability can best be accomplished.
- The Patient Index (Record Locator Service), is at the top of the diagram. It contains a directory through which information about how to find the sources of authorized records can be found, not any of the actual content of the health records. The registry system knows where authorized records are, not what is in them.
- When an authorized Individual Care Provider submits a request to the Patient Index (Record Locator Service), it responds with information about the location (Data Sources or Information Sources) of any authorized and pertinent records (e.g. records for Jane Doe can be found at Hospital A and Lab B).
Message Transfer (Information Transfer)
- Message Transfer, (also described as Information Transfer), at the center of the diagram, is not an object, person, or institution, but an action-it represents what happens when one authorized part of the Health Information Environment shares authorized information with another.
- The standards and policies associated with the Common Framework include support for Message Transfer (Information Transfer).
- Message Transfer (Information Transfer) is initiated by a request from an Individual Care Provider directly to a Data Source (Information Source). The request could be made through a phone call, by paper, or electronically. The authorized information could be shared by fax, via a secure and standardized network connection using information standards defined by the Common Framework, or via paper.
- Requesting a Message Transfer (Information Transfer) of an actual record from a Data Source (Information Source) is an action distinct from requesting information from the Patient Index (Record Locator Service) about where records are located.
- When a provider retrieves data from another source to support a clinical decision the retrieved copy will usually become a part of the record maintained by the receiver.
- Message Transfer (Information Transfer) can also support anticipatory transfer of authorized patient information, including but not limited to distribution of lab results, referral reports, etc.
Data Sources (Information Sources)
- Data Sources, (also referred to as Information Sources), are the people or institutions that store health records. They are end-point systems supporting patients, providers, hospitals, diagnostic services, payers, or public health providers.
- When Data Sources (Information Sources) receive authorized requests for information from authorized Individual Care Providers, they send the appropriate records (a process described as Message Transfer or Information Transfer) - much as is done today.
- Data Sources (Information Sources) use end point systems or applications - such as electronic health records - as an interface to the Health Information Environment.
- Data Sources (Information Sources) communicate regularly with the Patient Index (Record Locator Service) to make sure it is up to date about the availability of patient data, ideally registering this availability in "real time."
- Data Sources (Information Sources) may also communicate with the Reporting Router as appropriate.
Reporting Router
- Reporting Router, at the bottom of the diagram, is an optional piece of infrastructure - a particular sub-network may choose whether or not to have one.
- The function of the Reporting Router is to find authorized identified or de-identified data appropriate for uses such as public health, quality improvement or research, and send or "push" it to the appropriate recipient (e.g. a public health agency, policy making body, research organization, etc).
Public Health
- Public Health, at the bottom left of the diagram, is an example of an entity, other than an Individual Care Provider, that may need access to health information.
- Public Health, like other users of the system, would access authorized information from the Health Information Environment via an end point system or application.
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