HIE, RHIO, and Direct Project on Google Plus

The past couple days, a deep and thoughtful conversation has been happening on Google Plus around the idea of HIE, RHIO and the Direct Project. As of this posting, the G+ discussion has generated 80 comments from a broad spectrum of people. If you’re interested in HIE, RHIO, Direct Project or any related healthcare data exchange you’ll want to go read the entire thread.

I’ll just bring out a comment made today by David C. Kibbe that I believe does a pretty good job summarizing a good portion of the conversation. Plus, I think he does a good job describing the various methods of healthcare data exchange. I look forward to hearing from readers about Kibbe’s comments and the other comments in the thread which stand out for others.

Without further ado….David C. Kibbe’s comments:

After re-reading many of these comments, I feel compelled to attempt a few generalizations that (I hope) are based on some observations from the real world of patients, doctors, and hospitals.

First, the majority of health care in the majority of communities in this country is highly fragmented. Sometimes that fragmentation takes the shape of two or three large systems competing with one another. More often there are dozens of small, independent practices of different kinds arrayed near one or more hospitals.

Ownership of these practices, imaging centers, outpatient centers, etc. is in fairly constant transition, with perhaps a slight trend overall towards consolidation. But, in general, most of these communities will face diversity and multiple ownership, and therefore significant fragmentation that is both physical and reflected in information technology systems.

For the patient, this reality is epitomized by having to fill out similar, redundant insurance and medical history forms for each provider visited in the community. Yes, there are exceptions where a particular health care provider is very dominant, and where the “system knows me” wherever I go as a patient. But that is still not the norm, and even those highly integrated systems have their boundaries outside of which communications devolve to paper, mail, telephone, and fax.

As a generalization, there have been two health IT strategies that have dominated the discussion of how to de-fragment community health care systems. One is some version of the community health information network, CHIN. RHIOs, HIEs, and so on. This model seeks to aggregate data from multiple provider enterprises, organize it, and make it available to members. The other is the mega-EHR, which, it is assumed by proponents, will extend its tentacles out into a critical mass of providers, usually from a hospital or group of hospitals, and therefore connect everyone.

The US is a large enough society that it can accommodate both of these “solutions” to the problems inherent in diversity and fragmentation in health care resources. Both of these models are likely to persist well in to the future.

However, what we are now seeing gain some popularity and mindshare is a third model for information and data de-fragmentation in health care, one that is based upon the standards, protocols, and specifications of the Internet, the web, and a network-of-networks architecture. Unlike the other two models, this new model does not require a controlling and centralized (and probably “rent-seeking”) intermediary on the network. This new model, like the Internet, is relatively neutral with respect to operating systems and pre-existing applications. Directed exchange, essentially secure e-mail mediated by a federated trust framework using PKI for point-to-point “push” communications between known participants, is an example of this third model reaching operational status.

To a great many technologists and others involved in health care IT, instances of the new model — let’s call it the Health Internet just to have a name — seems overly simple, even toylike or retrograde, and hardly robust by engineering or health informatics standards. “Why would you want secure e-mail?” I hear every day from health IT experts. “It seems almost stupidly limited and under-powered given the complexity of health care!”

The answer to that kind of question is “Yes, you’re right, Directed exchange, for example, is not very complicated or robust compared to an HIE or an EPIC install. But it might be incredibly low-cost to use and fast-and-easy to deploy; it doesn’t require sophisticated expertise by users, and quite the contrary looks and feels like familiar software, e.g. gmail; and for a whole lot of people who are part of fragmented health care systems it may be “good enough” and their only real alternative for secure health data exchange and connectivity.”

The Health Internet isn’t a substitute for HIEs or for enterprise EHRs. Directed exchange is a “good enough,” better-than-fax solution for the enormous volumes of health information moving across geographical boundaries, outside of EHRs or billing systems. It’s uses will be at the bottom of the health data food chain, the least sexy but still critical exchanges that move data across practices and between hospitals and doctors via fax because they can’t get there any other way cheaply and with minimal technical complexity.

At least that’s the idea….If I were Epic, or the health plans, or a leader of an HIE, I’d embrace the Health Internet for the innovation and efficiency it can offer that part of the health care market that can’t afford your more sophisticated and expensive products. And, in the process, find very large numbers of new customers. Won’t a lot of those be patients and consumers?

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • Wow, this summarizes the state of the art of provider integration as well as the role of central spine enabling role of HIT, HIE (extensions), ‘megaEHR’s’, et al in a way that’s easy even from my brain to wrap around.

    Thanks for reposting John. Clearly I need to get into G+, this no doubt is the kind of thoughtful thread I don’t want to miss.

    Kudos to David aka @KibbeeDavid, I tweeted the introduction today between he and Gary Thompson at @CLOUDhealth who seems to building the building internet of health, that 3rd model which seems to have the strategic upside of ubiquitous access, device agnosticism is where i’d place my bets. Legacy interests, their appetite for enabling middleware apps notwithstanding, just seem too stuck in the inertia of their self interests to be a open community player.

    Thanks John!

  • Gregg,
    I felt the same way about the description. Glad you appreciated it the way I did.

    There wasn’t a G+ hangout. It was just a thread/discussion which is linked at the top of this post. I hear there will be a G+ hangout during HIMSS though.

  • Yikes! I need to do a better job of editing, based on the original post above!

    Thanks for the link to ‘Shifts in the architecture of the Nationwide Health Information Network’. Tweeted it today.

    Tomorrow, I chat with @VinceKuraitis on ‘HIT Platforms and Accountable Care’, see: http://bit.ly/xdVxrt | part of our HIMSS 2012 countdown series.

    p.s. David Kibbe’s twitter handle is @KibbeDavid. Corrected on Twitter as well.

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