Recently we have been having many conversations with organizations who are looking for help with getting connected to national networks like eHealth Exchange, Commonwell, and Carequality. We thought it would be helpful to share some insights that might help you if you are also interested. 

What are National Trusted Exchange Networks? 

National Trusted Exchange Networks are nationwide data sharing initiatives that include the following

• A Business and legal framework for sharing data – which serve as the “rules of the road” that help establish a trust framework.
• A technical framework for sharing that data – to ensure data sharing becomes possible between systems.
• An onboarding or certification process to ensure adherence to these rules. 
• Today, this is primarily focused on CCD / C-CDA based data exchange. 

Today, the largest active national trusted exchange networks are eHealth exchange, Carequality and Commonwell.  Which network you should consider participating with depends on the type of organization you are with. Understanding the details of each of the major organizations can be quite challenging, so let’s look at the differentiators between the 3 biggest NTEN’s.

Comparing Ehealth Exchange, Carequality, and Commonwell:

For eHealth Exchange, only provider organizations, HIE’s, and the federal partners are eligible to be direct participants. What I mean by that is that those organizations are eligible to sign the legal documents and are subject to their published fees. They do have a technology certification program primarily focused on those vendors who support health information exchange via their software platforms. Vendors supporting the eHealth exchange use case are not required to be certified technology, however.  

Carequality and Commonwell in contrast are very focused on vendors who represent the bulk of the members.  Those vendors then provide their provider, patient, or payer clients access to the data shared within those networks.   

Cost Comparisons 

From a cost perspective – eHealth Exchange and Commonwell both have a one-time onboarding fee. All three have an annual membership fee tiered based on annual healthcare revenues. For provider organizations – there is no fee you pay directly to Commonwell or Carequality.  You’d pay your vendor who is connecting you to those networks whatever fees apply from the vendor. I recognize this aspect can be confusing and we’ll be a bit more detailed in our deep dive videos on each of these networks.  

Technical Comparisons 

On the technical side; All three of the networks share a very similar technical framework in that they rely on the XCA / IHE standards to share documents. The most common data flow creates a patient query (do you know my patient), and if yes, (what documents do you have), and then a return of the selected documents. Documents are primarily CCD/CCDA’s, but could be PDFs. Be aware that only CCD/CCDA’s are universally accepted. The Treatment Purpose of Use under HIPAA is the most widely supported. Other purposes of use are available but have lagged behind in terms of adoption.

In Commonwell and Carequality – PHR vendors can be members and there is a special use case for Patient queries from PHR software. Be aware that there is not widespread “opting in” to the patient-based exchange use case.  There is more patient-based exchange in Commonwell versus Carequality. However, Carequality is working on expanding the adoption of the PHR use case within their own network.

In the future, you can expect to see the evolution of new technical standards (such as FHIR based exchange), and the expansion of use cases and types of data being exchanged.  Examples include Image Exchange and event notifications.

Implementation Guides 

Carequality Implementation Guides:

• Carequality Query-Based Exchange Implementation Guide 
• Carequality Imaging Data Exchange Implementation Guide
• Carequality Electronic Case Reporting Implementation Guide
• Carequality FHIR-Based Exchange Implementation Guide

eHealth Exchange Implementation Guides:

Since the eHealth Exchange FHIR R4 Implementation Guide references the foundational Sequoia Project FHIR R4 Implementation Guide, you might find it helpful to access the two artifacts simultaneously.

• eHealth Exchange FHIR R4 Directory Implementation Guide
• The Sequoia Project FHIR R4 Directory Implementation Guide
• eHealth Exchange STU3 Implementation Guide

Commonwell Services Specification Guide:

• CommonWell Health Alliance Specification Services (1 of 2)
• CommonWell Health Alliance Specification Use Cases (2 of 2)

IHE based exchange

‘IHE is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. IHE promotes the coordinated use of established standards such as DICOM and HL7 to address specific clinical needs in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively.’2

How does IHE work?

IHE involves an intensive, ongoing process of collaboration and communication among key parties, which can be divided into four phases:

• Problem Identification: Clinicians and IT experts identify common integration problems in access to information, clinical workflow, administration and underlying infrastructure.
• Integration Profile Specification: Stakeholders select standards that address each identified integration need. The technical specifications for implementing these standards are documented in the IHE Technical Framework.
• Implementation and Testing: Vendors implement these profiles and test their systems with software tools and at a face-to-face Connectathon, where they test interoperability with other vendors’ systems.
• Integration Statements and RFPs: Vendors publish IHE Integration Statements to document the integration profiles supported by their products. Users can reference integration profiles in requests for proposals, simplifying the systems acquisition process.

IHE Technical Framework

The IHE Technical Framework is a detailed, rigorously organized document that provides a comprehensive guide to implementing the defined integration capabilities. The Technical Framework delineates standards-based transactions among systems (generically defined as IHE Actors) required to support specific workflow and integration capabilities. Click here to see a graphical representation of the organization of information in the Technical Framework.

IHE Actors

Information systems or applications that produce, manage or act on information are represented as functional units called IHE Actors. Each actor supports a specific set of IHE transactions. A given information system may support one or more IHE actors.

Transactions 

Transactions are exchanges of information between actors using messages based on established standards (such as HL7, DICOM and W3C). Each transaction is defined with reference to a specific standard and additional detailed information, including use cases. This is done to add greater specificity and ensure a higher level of interoperability between systems.

Challenges of IHE Based Exchange

https://www.ihe.net/about_ihe/ 2