Why NEHEN Succeeded

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The health care industry has been slow to comply with new federal requirements for the electronic exchange of medical data. So how did one cooperative find a way to comply—four years ago?

Why NEHEN Succeeded

Halamka, Glaser and DeBor each credit NEHEN's immediate and ongoing success to learning from past mistakes and sticking to the Bourbon Street Coalition's core criteria:

The Data Stays Home: All proprietary data remains on each member's own system. One lesson taught by early efforts at creating networks of hospitals exchanging information was that health care providers do not like seeing their proprietary data leaving their premises. They like it even less when they have to put their data into some sort of common storage.

Earlier networks' "requirement that members part with their data and send it to a central database outside their control just ran against human nature," Halamka says.

One Size Fits All: A single, standard format was adopted for preparing and exchanging data, creating a common TCP/ IP gateway that works for everyone regardless of their legacy systems or company size. Once the extraction and translation layers were in place, connecting each member to the peer network was entirely handled by the NEHEN middleware.

"Suddenly all of us had a single implementation guide," Halamka says. "It was completely standardized. This meant that since the system worked for Harvard Pilgrim it would work for any health insurance company that joined NEHEN. And since it worked for CareGroup and Partners, it would work for every health care provider. This proved amazingly powerful. We were suddenly able to share our intellectual property without having to do any serious retooling or changing our basic business processes."

Gated Community: By using leased lines and frame relays, this peer-to-peer network was designed to be accessible to members only, eliminating risks of having a break-in similar to the University of Washington's (see p. 32), and thereby also avoiding that dreaded "Boston Globe moment." By keeping the entire NEHEN network off public lines, there were no public points of entry a hacker could exploit—at least for data traveling between NEHEN members. Only a knowledgeable insider could potentially be a risk. And even then, the security of each member's proprietary databases was still its own individual responsibility.

"There is no central repository, no central database," Halamka says. "Every member's proprietary data still sits on their proprietary legacy systems where it always has. So it's impossible to hack the NEHEN system because there is nothing there to hack."

Secret Handshakes: Even though the data may move unencrypted between gateways, because the lines are private, the data generally is encrypted when it moves inside a network. So, even in the unlikely case a hacker figured out a way to get in, all he'd get is nothing but gibberish for his efforts. But, before a "cracker" could even get that far, he would have to find the right relay or fiber and physically tap into it—a very unlikely prospect.

"While we use TCP/IP and other standard Internet technologies, none of NEHEN's data ever crosses the public Internet," Halamka says. "If someone wanted to tap into our data streams they would have to find the hardwire or cable to do it—an unlikely possibility. Even then, the data is securely encrypted."

Low Hanging Fruit First: The first step in NEHEN's implementation targeted the area where the biggest benefits could be proven fast—the eligibility process. It was the easiest to implement and showed immediate positive reinforcement for all involved. This is where CareGroup cut its costs from $4.74 per inquiry to just 15 cents.

"Everyone sitting around the table could see there were potential gains for them—and I am talking nontrivial gains,'' says Partners' Glaser. "Second, for me to realize my gains I needed Tufts, I needed Harvard Pilgrim, I needed CareGroup and so on. I couldn't get those gains working unilaterally. So, we all understood that we had to work together to see our individual gains."

On the Cheap: Implementation costs were low because members did not have to chuck their legacy systems or retrain their workforce in new workflows or procedures. NEHEN simply melded into their existing systems. Large enterprises that had their own technology staffs simply needed to develop extraction and translation layers to bridge between their legacy databases and the NEHEN middleware. Small companies could skip or delay that step by adopting NEHEN Lite, a Web-based interface. They could then move toward a fully integrated solution later if they desired.

"We did not require the participants to throw out their legacy systems," says Glaser, "did not require the participants to divert major capital to fund the thing, and we did not require members to comply with an arbitrary feature-adoption timeline. Instead, they could move as fast or slow as they wanted and we would simply wrap ourselves around the member's own technology choices and directions.''

NEHEN's success has made it a role model for other communities struggling to catch up. One of those communities is Buffalo, N.Y., says Bob Hoover, CIO of a regional health maintenance organization called Independent Health. "We're trying to build just that kind of network here in Buffalo right now," Hoover says. "We were able to look to [NEHEN] and say, hey, here is a group of companies that compete fiercely on a daily basis but were able to get past that to bring value to themselves and their community."

Hoover says that at the time NEHEN began there was no model. "They were starting from zero," he says. "They did not try to go so far or get too complicated. They looked at available technology and made use of it. Sure, maybe using XML would now be more elegant. But back then, they used what was there to satisfy the needs of these different groups. They kept the costs low and the system simple to use and implement. I give them a hell of a lot of credit. They were real trailblazers."

This article was originally published on 2002-02-04
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