Health Information Infrastructures: RHIOs

Recently much has been written about regional health information exchange and RHIOs. Adler-Milstein et al. (The State of Regional Health Information Organizations: Current Activities and Financing, Health Affairs, published online: 11 December 2007 at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.1.w60v1) examine whether "the current US. market-oriented approach - offering small grants and waiting to see which RHIOs flourish - will work." Evidence suggests that this approach will not work. These authors surveyed 145 RHIOs in early 2007, and found that of these only 32 were functioning to facilitate data exchange across independent entities on January 1, 2007, and only 20 were medium to large size organizations. Analyses report per centages (n=20) of this sample processing data from hospitals. ambulatory services, labs, imaging centers, payers, public health services, pharmacies and pharmacy benefit management organizations. Categories of data include test results, inpatient data, medication history, outpatient data, and public health. Support for RHIOs studied (n=20) included time or in-kind resources, one-time financial contributions, grants, and recurring fees. Results reported are very misleading due to use of percentages and the inadequate sample size. This study objective is a very important one but methodological weaknesses of the research design obscure results that might have been drawn from qualitative case analysis of the RHIOs. The reader learns nothing about HOW these organizations work, but it seems clear from the large number of failed or stalled efforts that the policy model for development of RHIOs yields only small scale, unsustainable and fragmented initiatives.

The reasons for this evident failure are many, including reliance on market dynamics with a "bottom-up" approach, for-profit definition of sustainability, and lack of attention to public sector information infrastructures required as a foundation for the success of information exchange. Issues related to privacy impede concept development while lack of regional or national consensus on standards and interoperability prevent the process of "scaling up." (See also Walker et al., The Value of Health Care Information Exchange and Interoperability, Health Affairs, 19 January 2005, at http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.10/DC1 )

Financial services networks offer another model useful as a reference for development of a national and international health information systems satisfying criteria of individual privacy and confidentiality. Viewpoint papers published by Electronic Data Systems (EDS at http://www.eds.com/) show IT infrastructure developments in other industry sectors - especially finance and communications - that might be very instructive for the health care industry. See for example:
Converged Communications Network for Financial Services (2007) available at http://www.eds.com/services/whitepapers/convergednetworks_financialservices.aspx
Governance – The Key to Unlocking the Challenges of SOA (Service-Oriented Architecture) (2007) available at http://www.eds.com/services/whitepapers/soa_governance.aspx
Virtualization: The EDS Perspective (2007)
http://www.eds.com/services/whitepapers/virtualization.aspx

Gartner has developed a conceptual framework for research on application infrastructure: the "Magic Quadrant" (2007) available at http://www.computerworld.com/pdfs/intersystems_gartner_wp.pdf

Evaluating and Reforming the U.S. Health Care System

Many new studies and policy reports focus on the comparative performance of the U.S. health care system and recommendations for its redesign and improvement.

Websites and key publications:

The Commonwealth Fund: http://www.commonwealthfund.org/
Mirror, Mirror on the Wall- An International Update on the Comparative Performance of American Health Care (2007): http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678
A Roadmap to Health Insurance for All - Principles for Reform (2007): http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=553840

The United Health Foundation: http://www.unitedhealthfoundation.org/
America's Health Rankings (2007): http://www.unitedhealthfoundation.org/ahr.html

The Institute of Medicine: http://www.iom.edu/
Knowing What Works in Health Care - A Roadmap for the Nation (2008): http://www.nap.edu/catalog.php?record_id=12038

The U.S. Census Bureau: http://census.gov/
Income, Poverty and Health Insurance Coverage in the United States (2006): http://www.census.gov/hhes/www/hlthins/hlthin06.html

The American Medical Association: http://www.ama-assn.org/
Voice for the Uninsured - The AMA Proposal: http://www.ama-assn.org/ama/pub/category/17712.html

Physicians for a National Health Program: http://www.pnhp.org/
Proposal of the Physicians' Working Group for Single-Payer National Health Insurance (JAMA, vol.290, no. 6 (2003): http://www.pnhp.org/physiciansproposal/proposal/Physicians%20ProposalJAMA.pdf

California HealthCare Foundation: http://www.chcf.org/
Gauging the Progress of the National Health Information Technology Initiative (2008): http://www.chcf.org/documents/chronicdisease/GaugingTheProgressOfTheNationalHITInitiative.pdf

Resources for qualitative health services research

The use of qualitative methods for health services research poses significant challenges in effective study design and data collection particularly when study objectives include information technology. The British National Health Service (NHS) Health Technology Assessment Program offers an extensive review of these methods entitled-
Qualitative Research Methods in Health Technology Assessment: A Review of the Literature (1998) available at http://www.ncchta.org/fullmono/mon216.pdf
Although this report is now ten years old, it provides a very rich historical overview of qualitative methods in technology assessment as well as a discussion of the relation between quantitative and qualitative approaches and criteria for methods selection.



The online journal The Qualitative Report at http://www.nova.edu/ssss/QR/index.html offers a wide range of links in addition to online articles.

Another resource is:


Qualitative Research Methods: A Data Collector's Field Guide (2005)
By Natasha Mack, Cynthia Woodsong, Kathleen M. MacQueen, Greg Guest, and Emily Namey

This ebook from Family Health International is available in PDF format at http://www.fhi.org/en/RH/Pubs/booksReports/QRM_datacoll.htm
The following is a description of the reference from the website:





This how-to guide covers the mechanics of data collection for applied qualitative research. It is appropriate for novice and experienced researchers alike. It can be used as both a training tool and a daily reference manual for field team members. Its question and answer format and modular design make it easy for readers to find information on a particular topic quickly. The Data Collector's Field Guide includes:

-Self-contained modules for each research method (including participant observation, in-depth interviews, and focus group discussions)
-Ethical guidelines for each method
-Case study samples with notes, forms, and transcripts
-Tips for taking field notes for specific methods
-Steps and checklists for what to do and bring for each type of data collection
-Exercises for training data collectors in each method
-Tools for data managers
-Suggested readings


This guide is particularly useful for its focus on research in public health and development.

Research methods for health care system evaluation

Methods for health care system evaluation are gaining prominence in the scientific discourse of a number of related disciplines including medicine, public health, and medical informatics. A new website by Academy Health (http://www.academyhealth.org/) for health services researchers is available at http://www.hsrmethods.org/. The website mission states:

HSRmethods.org provides current information on key research methods and resources in HSR, and aims to spur dialogue about analytic methods among health services researchers.

This important collection of resources effectively frames the debate on appropriate choice of methods and statistics for evaluation research in this interdisciplinary field. The resources offered cover research ethics, privacy issues and data sources as well texts and other readings on quantitative and qualitative research methodologies.

Published evaluation research tends to favor quantitative methods. For example, articles appearing in the journal Health Affairs on comparative country analyses often present tabulations of public health data such as per capita spending and population statistics to construct country rankings. While highly instructive, these analyses shed little light on social or organizational logics explaining country level health care system performance. See for example:

Ellen Nolte and C. Martin McKee
Measuring The Health Of Nations: Updating An Earlier Analysis
Health Affairs, January/February 2008; 27(1): 58-71.

Gerard F. Anderson, Bianca K. Frogner, and Uwe E. Reinhardt
Health Spending In OECD Countries In 2004: An Update
Health Affairs, September/October 2007; 26(5): 1481-1489.

William D. Savedoff
What Should A Country Spend On Health Care?
Health Affairs, July/August 2007; 26(4): 962-970.

Qualitative methods offer more opportunities to assess how health care processes work as well as how medical and public health interventions perform. See for example:

Harald Walach, Torkel Falkenberg, Vinjar Fønnebø, George Lewith, and Wayne B Jonas
Circular instead of Hierarchical: Methodological Principles for the Evaluation of Complex Interventions
BMC Medical Research Methodology. 2006; 6: 29.
Available at http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1540434

Maria Grypdonck,Qualitative Health Research in the Era of Evidence-Based Practice, Qualitative Health Research, 16 (10) 2006, 1371-1385.

See also a report from the Cosmos Corporation by Robert Yin and Darnella Davis: ADDING NEW DIMENSIONS TO CASE STUDY EVALUATIONS: THE CASE OF EVALUATING COMPREHENSIVE REFORMS (2006) available at http://www.cosmoscorp.com/MSPDocs%5CNew%20Directions.pdf