The Evolution of HIE as a Technology
INFORMATION EXCHANGE IS anything but new. Health Level
7 (HL7) started to tackle cross-system exchange back in 1989,
aiming to bridge gaps in IT systems within hospital-based
workflows. In those days, teams of interface developers in the
basement of a hospital manhandled systems and an integration engine to get a hospital’s own internal systems talking to
As the benefits of broader information exchange became
apparent and hospitals’ IT capabilities grew, a number of potential solutions came to light for information exchange across
organizations, or what many call cross-enterprise exchange.
Integrating the Healthcare Enterprise, HL7, and others
brought us standard specifications like Clinical Document
Architecture, Continuity of Care Document, Clinical Data Repository, XDS, and others to help providers in one organization
share with providers in another.
The Office of the National Coordinator for Health IT also
shepherds the Nationwide Health Information Network Exchange project, including specifications and policies for exchange between one community of providers to another community (for example, one HIE network to another).
The Evolution of HIE as a Business Enabler
Today’s healthcare world continues to focus on pay for performance and outcomes (both clinical and financial). Accountable care organizations (ACOs) and patient-centered medical
homes (PCMH) are prime examples.
That is essentially why ONC started the Direct Project (
originally NHIN Direct). On its wiki, where much of the work takes
place ( http://wiki.directproject.org), the Direct Project describes itself as a “simple, secure, scalable, standards-based way
for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet.”
This lightweight set of specifications is meant to encourage
participation in electronic exchange of information by leveraging existing protocols and standards that can be implemented
quickly and easily. Direct complements the set of technology
specifications produced for the more comprehensive Nationwide Health Information Network Exchange project and is
meant as an entry point for providers and introduction to more
robust types of exchange.
Direct’s simple starting point was fleshed out by a set of seven
primary user stories that helped define the purpose and boundaries of the project. The stories consist of one or more simple,
unsolicited exchanges of patient health information:
1. A primary care doctor refers her patient to a specialist. She
sends the specialist a copy of the patient’s clinical snapshot.
2. When the specialist completes his consult, he sends in-
In order for these programs to achieve success from a clini-
cal and financial outcome perspective, each requires a high
level of connectivity across a patient’s care community, for all
enrolled patients. Free-flowing data, system-wide guidance in
the form of care plans, protocol- and evidence-based decision
support, real-time updates of patient dashboards, and even
centralized financial management all are components of these
formation about his findings back to the patient’s primary
3. A primary care doctor refers her patient to the hospital for
observation or a scheduled surgery. She sends the hospital a copy of the patient’s pertinent clinical information.
4. The patient is discharged from the hospital, which also
sends her discharge information to the referring provider.
5. A care provider orders a lab on a patient. The laboratory
sends the results back to the care provider.
6. A provider, clinic, or hospital sends a clinical snapshot,
follow-up reminders, or information about a recent visit
to the patient.
7. A patient receives an immunization, and the record of the
immunization is sent to public health.
The Direct Project has been a largely volunteer effort, with
contributions from more than 200 individuals and 50 organizations, including those from the vendor, provider, government,
and consultant communities.
One of the project’s key outputs is a set of open-source codes
that allow a vendor, provider, or HIE to operate a Direct Project
gateway capable of sending and receiving messages in the stan-