Wednesday, March 10, 2010

Introducing NHIN Direct







Here's a few highlights from the NHIN Direct FAQ page

What is NHIN Direct?

Why NHIN Direct?



How will the specifications and standards for NHIN Direct be developed?

What NHIN Direct doesn’t solve

How can I or my organization participate?
There are three basic ways to participate

The NHIN Direct effort philosophy is expressed in design rules















Mike said...

John - thanks for your ongoing dialog.

Briefly as we jump into NHIN direct or exchanges, we are finding a great deal of immaturity with interoperability vendors and EMR's. One poignant example is our current document exchange turns richly formatted documents into jumbled ascii text. The reason for this is that we must build our interfaces to the lowest common denominator in the information chain. We cannot assure that the downstream user can view an XML tagged document. Therefore, for the next year or more we will transfer summary documents using an ASCII. Without an interim achievable format we may undermine the readability of important handoff information and diminish physician enthusiasm for HIE. NHIN direct sounds like a much needed interim model but the documents need to appear better than a fax machine to the end user!

How can we encourage high quality exchange and usability of these documents while we wait for compatibility with the ultimate CDA/XML standard? Do we say the low bar is RTF, ODF, HTML, PDF, something else? Anyone know if there is a common denominator among the leading EMR vendors? I don’t think PDF is usable by most EMR’s. Alternatively, do we need to package more than one document type in the NHIN direct message until we get to XML/CDA standard across the board?

I am thinking NHIN Direct should specify a lowest common denominator for document formatting that is reachable by all EMR vendors in by phase 1. This will go a long way to improving handoffs and increasing physician acceptance of document exchanges. “better than a fax machine.”

J Mike Kramer - CMIO Trinity Health

adelea said...

I am an HIE novice - non-development resource - for an ambulatory EHR company. While we serve over 40 medical specialties, 68% of our clients are primary care, and 75% of those are in practices of 10 or less. We also serve about 10% of the U.S. community health center market.

I follow your blog religiously for educational purposes and particularly appreciate the NHIN Direct philosophy articulated herein. Yesterday, I attended a "all stakeholders" meeting for statewide HIE in the south. The excitement was tremendous. The scope - all things to all people - was overwhelming. They would benefit from a read of this blog.

As an EHR vendor, our simpliest development tasks will likely be the workflow engine (managing the message - when is the info. available and where does it come up for the provider), construct (we already do C32 messaging and are stepping into XDS)and transport (pretty much a non-issue). Our biggest development challenge will be in the bi-directional translation component, namely because of the multitude of vocabularies.

We are engaged in the NHIN University, with development staff. I agree with Dr. Kramer - and you. Let us start simple and evolve from there.

Thank you for your blogs!

Adele Allison - National Director of Government Affairs, EHS, Inc.

Rajesh said...

John, Here's a perspective from the other side of the ocean! It's 5 years since I have known about NHIN. I agree with you about establishing a simple and common set of standards which can be rolled out at the base of the healthcare pyramid.

Actually NHIN should be divided into 3 levels, Basic, Intermediate and Advanced. With NHIN-Basic the stress should be to cover more than 90% of the base.

If the small healthcare providers find it easier to be part of the Network which is the toughest part of the implementation, it would be half the job done for NHIN to be a success story. Just some thoughts away from the battleground as an observer :-)

Dirk Stanley said...

So glad to see NHIN Direct getting momentum - I'm hoping our SpeakFlower project ( can perhaps lend some more momentum to the effort. I'm still not sure exactly which technical lingua-franca is best to handle this, but if NHIN Direct has a clear answer, then it makes sense to endorse their standard. (If they don't have a clear answer, then I agree with the ASCII approach - Heck, uuencode could handle all other document types, and then we deconstruct at the local level.)
Anyway, thanks for the post!

Larry said...

Hi John,

Not much seems to be defined yet, but NHIN Direct looks very similar (almost identical) to prior work done in AHIC, HL7, IHE, and HITSP.

For example, the use case "A hospital wants to send discharge information back to the referring provider on patient discharge" was defined several years ago.
IHE and HITSP have profiled this use case for both content and transport.

The listed content types can be either HITSP C32(CCD structured document), or IHE XDS-MS (discharge summary as CDA with corresponding level 3 encodings), or HITSP C62 (unstructured documents such as PDF or text)
The exchange mechanism described - secure email - is covered by HITSP T31 (IHE XDR).

Will NHIN Direct reuse and build apon and reuse this prior work, or try to create something new? If something is wrong, incompletely described, or needs simplification/clarification, I would prefer an approach to correct those original profiles (i.e., submit change proposals) rather than creating new ones.

I think the market is getting confusing signals with a new group forming every couple years to define new and slightly different solutions to the same problems (reinventing the wheel) . Rather, we should put our efforts into simplifying existing layered implementation guidance into singular documentation directly on top of the standards referenced, as you have wisely proposed yourself. If further simplification of the underlying standards is necessary, while still meeting the increasingly complex interactions across the continuum of care settings, let's address that separately.

Creating an 'Internet of Things' said...


Thanks for your call for a new, simpler approach that leverages REST, simple SOAP, and SMTP for data exchange. Regarding NHIN Direct, would it not make sense to adopt W3C Linked Data standards, whereby data properties, as well as individual products, are assigned URI's to promote use of common HL7 taxonomies?

Brett Peterson said...

Note that virtually every comment on this blog entry would be great input over on I'd like to encourage folks to post their perspectives and thoughts on the NHIN Direct discussion group or wiki.

Personally, my perspective has been broadened based on interactions on, but more participation and ideas from a wider set of perspectives would be wonderful.


hitstakeholder said...

1.Is Direct project –“Over the internet” or “Over the Internet but Nationwide only”
Does that mean it is not geographically confined within US?
2. Can healthcare providers viz physicians and small hospitals in Asia participate in Direct Project.

3. Any URL for better understanding on this concept.?