The purpose of the NwHIN RFI is to seek information from the public on how the NwHIN should be governed. However, the idea of the NwHIN is abstract and evolving, and so we are trying to govern smoke in the wind. It's a complex network supporting a variety of exchanges, but nowhere has ONC described it concretely. In order to evaluate the govenerance RFI, I imagined a future NwHIN that includes nodes supporting:
- Query/Response Exchange to get at problems/meds/allergies for patients in life-threatening situations.
- Direct-based exchanges supporting referrals and responses to them.
- Support of payer audits through something like esMD
- Support of ad-hoc research through something like Query Health
- Consumer enabled provider search and encounter scheduling
- Alerting and surveillance for communicable diseases
I also looked at kinds of exchanges I see performed today through intermediaries to support quality measurement and operations (PQRI/S), treatment (med history, lab delivery, summary data exchange, other HIE), payment (clearinghouses), and even to some degree research (based on what my friends in IHE QRPH are looking at).
ONC does seem to have concrete idea about what the NwHIN will be is based on its recent history. And they've already decided what the priorities are to "improve" adoption of the NwHIN by proposing a framework of requirements around security, interoperability, and operations. This set of requirements will be applied to NwHIN nodes of significance in order to be considered a good NwHIN citizen. A structure based on accreditation and validation (which I interpret mostly to mean "certification") would provide credibility to these good citizens.
Except that as a whole, the concept doesn't work.
The requirements individually seem to make sense. The underlying principles behind these requirements are obvious and laudable. Implementation of the simplified expression of these requirements requires a great deal more detailed expression. Some requirements only apply to certain kinds of exchange.
The requirements applied to nodes in these exchanges haven't been organized in any way so that we can see whether they make sense based upon the exchange. It is only when I start holding up each of the requirements and comparing it against my concrete examples where they start unraveling. There are requirements that don't apply to certain kinds of exchange, others that just don't hold up given the particular missions and existing legal frameworks. There are requirements that could decimate existing exchange networks in use today.
To move forward, we first need to step back and look at what the fundamental principals we are trying to achieve through NwHIN Governance, identify how we will establish reasonable requirements in a trusted way, and then establish the governance mechanism TO SET the requirements for trusted exchange. The set of requirements that ONC has proposed is one of the end-products of a governance process, not the starting point.