To deliver safe, effective, high quality and affordable care in the 21st Century, strategic adoption of an interoperable Health Information Infrastructure is needed to transform health care from today's largely paper-based system to an electronic, interconnected health care system. As one of its principle health care reform initiatives, New York has engaged in the development and implementation of New York's Health Information Infrastructure comprised of three interrelated components – organizational, clinical, and technical – to harness the power of health information to support patient care improvements.
With respect to the technical infrastructure, it is comprised of three interrelated building blocks depicted below.
"Cross-Sectional" Interoperability - People, Data, Systems
The Statewide Health Information Network for New York (SHIN-NY) is viewed as a bedrock component that is essential to support New York's broader health care goals with respect to improving the quality and efficiency of health care for all New Yorkers. Other aspects of the technical infrastructure include electronic health records and personal health records, and clinical informatics services which refer to the tools required for the aggregation, analysis, decision support and reporting of data for various quality and public health purposes.
The SHIN-NY or "information highway" will allow clinicians and consumers to make timely, fact-based decisions that will reduce medical errors and redundant tests and improve care coordination and the quality of care. The successful implementation of the SHIN-NY will result in improving health care quality, reducing costs and improving outcomes for all New Yorkers.
The challenge in implementing the technical infrastructure is made more difficult in that each of the three elements of functioning health information exchange: demand, supply and the infrastructure, exist only in part or are in the very early stages of development. The cross-sectional interoperability approach addresses this by implementing capabilities in limited amounts that include all three technical building blocks: SHIN-NY, Clinical Informatics Services (CIS), and Clinician, Consumer, and Community (3Cs). A complete cross section can be designed to provide real benefit as soon as possible. One goal of the clinical priorities and use cases is to identify opportunities amenable to this approach. In this way a clinician can begin to derive benefits from these 'cross-sections' without having to wait for an entire health information exchange component to be completed and available via the SHIN-NY. Like any infrastructure project, be it roads, water treatment or information, limited efforts can provide value by integrating demand and supply through the infrastructure. For example, a small number of well chosen roads will enable some transportation and commerce that was not possible prior to their construction.
The Road to Interoperability
New York's health IT framework is built upon common statewide information policies, technical standards, and protocols, as well as regional "bottom-up" implementation approaches and care coordination to allow local communities and regions to structure their own efforts based on clinical and patient priorities. This framework promotes innovation across the full range of New York's diverse health care delivery settings – from solo-physician offices and community health centers to large academic medical centers and nursing homes, and from Manhattan to rural upstate towns – with vastly different market conditions and health care needs.
Interoperability is essential to realizing the expected benefit from health IT and vastly improving the availability and use of health information to improve patient care. Perpetuating siloed information systems that do not interconnect will significantly impede the adoption and effective use of health IT tools, including electronic health records. Interoperability enables patient health information to be exchanged in real time among disparate clinicians, other authorized entities, and patients, while ensuring security, privacy, and other protections. Interoperability is necessary for compiling the complete experience of a patient's care and ensuring it is accessible to clinicians as the patient moves through various health care settings. This will support clinicians in making fact-based decisions that will reduce medical errors, reduce redundant tests and improve care coordination. Interoperability is critical to cost-effective, timely, and standardized data aggregation and reporting for quality measurement, population health improvement, biosurveillance, and clinical research. Interoperability is also needed to facilitate convenient access by patients to their own personal health information, enabling this information to be portable rather than tethered to a particular payer or provider.
Health information exchanges, like the SHIN-NY, use the term "liquidity" to express the level of interoperability or rate of flow of assets through the exchange. Exchanges are characterized as very liquid when almost all uses succeed (e.g., finding clinical information about a patient to inform medical decisions; receiving a drug-drug interaction alert). Conversely, in an illiquid exchange a large number of uses may fail (e. g., not finding current and/or complete medication profiles for patients).
A high level of liquidity for the health information flowing through the SHIN-NY is essential. The key to generating liquidity in any exchange is the belief on the part of stakeholders that uses of the exchange will succeed and be beneficial and that, in rare cases of problems, the stakeholders will be protected and problems will be solved. This is as much a function of trust as technology or clinical participation, and is achieved through an organizational infrastructure responsible for policy and governance. New York is implementing a two-tiered governance structure through which information policies and technical standards and protocols are developed, implemented and adhered to enabling secure and interoperable exchange of health information. The DOH, the New York eHealth Collaborative and Regional Health Information Organizations (RHIOs) are responsible for the governance structure and policy framework.
SHIN-NY Materials and Architecture – The Internet Model
The SHIN-NY is an infrastructure pattern that enables widespread interoperability among disparate healthcare systems. The requirement to support very large-scale environments leads to two critical assumptions that lead directly to principles for the overall technical infrastructure: the environment will be very heterogeneous and continuous changing. Heterogeneity and change will be constant and flexibility to accommodate unanticipated components and retire existing components without significant disruption to the overall system will be essential. The 'system' is never down.
We have a good example of this today. It's the Internet.
The infrastructure pattern includes two major architectural components. The first is architectural materials and processes used in building the SHIN-NY. The second is the architectural structure of the SHIN-NY.
With sound materials like connections, messages, standards and wrappers defined by protocols, there are three main options for structuring health information exchange via the SHIN-NY: (i) between geographies, (ii) between systems and (iii) between affinity groups. The choice and sequencing of the structural options drives the construction and operation of SHIN-NY. Additionally, all distribution models as depicted below are supported by the SHIN-NY architecture in an effort to avoid constraints.
A Peer-to-peer (P2P) protocol can support any form of distribution architecture. Servers and clients are really just "special" peers and a centralized system just has a "special" server.
An implementation of the overall SHIN-NY infrastructure pattern may be accomplished using any applicable technology components. The SHIN-NY specifications are vendor agnostic and technology agnostic, only espousing technical standards, protocols, and architectural patterns. The goal is that the implementation of the prescribed architecture provides a framework that sets boundaries on the dimensions of technical implementation to ensure interoperability and consistent operation.
In other words, the SHIN-NY is using architecture and materials that fit the problem. Again, the Internet is the best model available for this.
The vision for the clinician or other authorized users is to experience one big exchange. In reality there are many health care organizations and systems participating in HIE services and their ability to coordinate creates the illusion of a central exchange, simplifying the clinician experience. For example, a physician desiring the prescription (Rx) history of a patient should only need to 'press a button' to fulfill the request. Underneath, the Rx service may have to traverse many HIEs or subnetworks which comprise the SHIN-NY to obtain the information.
The SHIN-NY is based on a service-oriented architectural (SOA) paradigm, implemented through web services operating through an enterprise service bus (ESB), with a four-tier protocol stack. The protocol stack, called the Common Health Information eXchange Protocol (CHIxP), divides the protocols into categories, with the lower two corresponding to system architecture patterns, and the upper two dealing with healthcare architecture patterns.
SHIN-NY Architectural Specifications – Version 1 Statewide Policy Guidance
The New York eHealth Collaborative, in partnership with NYS DOH, is overseeing the Statewide Collaboration Process (SCP) through which common policies, standards, and technical approaches for New York's health information infrastructure will be developed. As part of the SCP, the Technical Protocols and Services Work group is developing statewide policy guidance regarding the SHIN-NY architectural specifications. All state funded health IT initiatives are required to comply with the statewide policy guidance.
SHIN-NY architectural specifications can be accessed via the following links: