*Source: Surescripts e-prescribers used as a proxy to estimate physicians in the county. County used as a proxy to define region. **Source: Walgreens and CVS online store locator, represents Phoenix, Glendale, Mesa, Scottsdale and Tempe ***Source: http://www.ehealthinitiative.org/map-of-hie-activity-in-the-us.html
1. The Pulse of Liquid Health Data
Global Directions 2013
September 24, 2013
Brian Ahier, DirectTrust
2. Liquid health data could help reduce costs by $300
- $450 Billion
“The 'big data' revolution in healthcare: Accelerating value and innovation” - McKinsey &
Company, January 2013
Machine-readable data that can be accessible
via application-programming interfaces
Easily downloadable and available via third-part
3. Health Data Initiative core activities: liberate
data and catalyze innovation
• Todd Park, US Chief Technology Officer, coined the term
“data liberación” to describe the Federal government’s
efforts at making health data liquid with goals to:
1. Publish brand new data for public access – while
rigorously protecting privacy and confidentiality
2. Make existing data much more accessible -- “machine-
readable,” downloadable, accessible via application
programming interfaces (APIs), free, much easier to find
3. Energetically publicize our data to innovators -- who
can use it as raw material to develop applications and
services that help improve health and health care
4. “There is no problem
America has that is so
large we can not invent
our way out of it.”
~ Todd Park
“You can always count on
Americans to do the right
thing - after they've tried
5. • Federal Advisory Committees
• Nationwide Health Information Network (NwHIN)
– Services, standards, policies, trust fabric
• eHealth Exchange
– Growing network of federal partners, HIEs,
health systems, technology solution providers
– Transitioned from ONC project to independent,
public-private model - Healtheway
• Direct Project
– Secure messaging for care coordination, e-
referrals and more
– Trust fabric for health internet - DirectTrust
• Standards & Interoperability (S&I) Framework
Graphic: The Value Proposition for
Exchange; Doug Fridsma, July 2011
US Federal Government’s
Health Information Exchange (HIE) Efforts
1101 Connecticut Ave NW, Washington, DC 20036
• The Office of the National Coordinator for Health IT (ONC) is
establishing governance mechanisms for the nationwide
health information network, in part through a cooperative
agreement with DirectTrust.
• The Stage 2 Meaningful Use regulations require eligible
providers to engage in health information exchange via
standards and in a manner consistent with these governance
• DirectTrust is a non-profit industry alliance that is supporting
Direct exchange adoption and use through policy setting,
accreditation via the Electronic Healthcare Network
Accreditation Commission (EHNAC), trust anchor distribution,
and outreach activities.
7. Founded in 1993, EHNAC is a federally-recognized standards
development organization and tax-exempt 501(c)(6) non-profit
accrediting body designed to improve transactional quality,
operational efficiency, and data security in healthcare.
DirectTrust and EHNAC have formed a partnership to accredit
trusted agents in Direct, HISPs, Certificate Authorities, and
Registration Authorities, in order to facilitate security and trust at
scale, helping to avoid the need for costly and complicated one-
off contractual arrangements between relaying parties in Direct
8. near Phoenix, Az.
Direct exchange is designed to help solve fragmentation
9. • Direct exchange is well suited to replace fax, e-
fax, mail, and proprietary connections:
• Between providers during transitions of care;
• Between providers and patients;
• Between federal and state agencies and providers
for document exchange, requests for information;
• Between payers and provider organizations;
• Between patients and patient applications for
organization, display, reconciliation, analysis.
Direct exchange is not just about meeting
meaningful use requirements
10. If HISPs choose to negotiate the “rules of the road” with each
other one at a time, forging one-off contracts, the cost of
Directed exchange goes up with each new HISP contract. This is
complex, rate limiting, and will not scale.
Building a Network via Bi-directional
Contracts is UnworkableHow can we scale Direct?
11. Scalable Trust and the N2 problem
• Scalable Trust is a strategy for enabling Directed exchange between a
large number of endpoints, in this case HISPs and their
• If “scalable,”
– Trust should happen “quickly” and uniformly.
– A “complete” network will be formed voluntarily.
– Complexity and cost of establishing a network will decrease, while
the value of the network itself will increase, as more nodes are
– This “network effect” will be a by-product of making trust
– Eliminates the need for one-off manual business agreements and
• If not “scalable,”
– Parties will be forced to create one-off manual business agreements
and technical connections increasing cost and complexity.
– Manual exchange and maintenance of trust anchors doesn’t scale
beyond the smallest of numbers – N-squared problem.
12. DirectTrust Approach
The goal is to make it easy and
inexpensive for trusted agents, e.g.
HISPs, to voluntarily know of and
follow the “rules of the Road,”
while also easily and inexpensively
knowing who else is following them.
Security & Trust
13. Trust anchor bundle distribution
HISP Accreditation via EHNAC-DirectTrust
• HISPs apply for accreditation, become candidates for DTAAP HISP
• HISPs complete self-attestation and audit, successful complete
HISP obtains trust anchor from accredited CA in accordance with
DirectTrust Standard Operating Policies document.
HISP submits its trust anchor to DirectTrust Review Committee.
Upon successful review, HISP’s trust anchor is included in
trust anchor bundle, available on EV cert-protected website,
HISPs may upload bundle of trust anchors, and place trust anchors
in their HISP trust stores, readying themselves to trust incoming
request from subscribers of these accredited HISPs using end-
entity certificates that march anchors.
14. DirectTrust Community’s “Scalable” Trust
Trust relationship based on accreditation
HISP BHISP A
Centralized Trust Anchor Bundle Site