Democracy in the U.S. Health Care Reform Debate

Yesterday (October 13) I sent the following feedback to AHIP regarding K. Ignagni's performance in an interview on CNN:

This is just to express my deep concern regarding the interview of K. Ignagni by W. Blitzer on CNN this afternoon. Ms. Ignagni has demonstrated a disturbing lack of understanding of the research issues raised in the PWC report. I do hope that there is some other research expertise at AHIP. The instructions given to PWC are not clear, nor is the contractual arrangement between PWC and AHIP. It is also a very significant concern that the names of the researchers involved in the report are not mentioned on the document made available to the public. There seems to be no avenue for questions concerning data analysis or interpretation. I hope that in the future AHIP will be able to fund more competent research.

In other feedback to CNN I deplored the absence of a specific reference to the AHIP report in some of their reporting. There are two issues affecting the democratic process here:

1. A report without reference or authors is interpreted without an evidence base.
2. The confidential contract research executed and interpreted by an organization (PwC) with no accountability to show research competence creates misinformation to inform public opinion. Ms. Ignagni, herself paid to initiate misinformation, represented PwC as a "world-class research organization," while refusing to identify the conditions of this paid contract. No world-class research organization would consent to execute such a contract. Ms. Ignagni probably does not possess any competence in research methodology, nor do the authors of the report.

The health insurance industry has acted irresponsibly in this democratic process, mobilizing what the public in general would recognize as "authoritative research" in order to manipulate public opinion in their favor.

AHIP-PWC Report: Potential Impact of Health Reform on the Cost of Private Health Insurance Coverage

A new headline on CNN, Pushback grows against insurance industry report, points out some significant criticisms of the AHIP-PWC report as self-serving and flawed.

This morning I identified a link where the much publicized report may be accessed:
Potential Impact of Health Reform on the Cost of Private Health Insurance Coverage (October, 2009). (Unfortunately the authors of the report are not listed.)

Review of the analyses in this report reveals methodological features that require comment. CNN has reported (Accessed October 13, 2009):
The report from the group America's Health Insurance Plans concludes that, under the Baucus plan, the costs of private health insurance would rise by 111 percent over the next decade. Under the current system, costs would rise by 79 percent, the report said.

This scenario is partially founded on the following proposition regarding the excise tax to be imposed on Cadillac plans. (See page 6 of the report.) This proposition appears spurious. (Certainly in the next ten years it would be reasonable to assume that the threshold values for assessment of the excise tax would be adjusted):

PwC also examined the impact of the excise tax on the mandated plans expected to be offered under the state health insurance exchanges detailed in the Senate Finance Committee Bill. We estimate that in many metropolitan areas, which tend to have higher than average medical costs, the lowest option plan (Bronze Plan) would be considered a "Cadillac plan" as early as 2016. By 2016 at least one of the mandated plans will be considered a "Cadillac plan" and be subject to the 40 percent excise tax in 17 of 50 states. By 2019 at least one of the mandated plans will be considered a "Cadillac plan" and be subject
to the 40 percent excise tax in 24 of 50 states.

The "baseline" assumptions for this scenario from the Senate Finance Committee Bill include a 6 percent annual trend (premium increase); 15 percent supplemental load for additional benefits, age, morbidity and other factors. Certainly the CBO should examine this industry financed report to evaluate data and assumptions at the foundation of its conclusions.

WellPoint Litigation II

In my last post, I highlighted litigation launched by Anthem, a subsidiary of WellPoint, against the state of Maine. This case raises a number of questions for further investigation of private health insurers' conduct in the U.S. health care services market:

What legal and other strategies are undertaken against state regulatory agencies to promote acceptance of annual rate revisions? How do state agencies respond to these initiatives. What public expenditures are required for these defensive regulatory actions? What proportion of premium revenues is spent on such litigation by private insurance companies against public authorities?

Why are individual policy holders more vulnerable to discriminatory rate increases than other classes of insurance purchasers? What issues and practices restrict the choices and mobility of individual policy holders among insurance alternatives? Consider the discovery of pre-existing conditions making it impossible for individuals to seek other coverage. In general - how do confidentiality and privacy laws prevent publication of systematic information on health insurance performance to guide individual choices?

Why should any rate of profit be guaranteed in a "free market economy"? How is this demand at the state level correlated with the insurer's dominant position in the state economy?

Further examination of WellPoint's record reveals other cases of public interest - for example:

Last year the California Department of Managed Health Care reached agreement with Anthem Blue Cross on contentious cases of rescission. (Accessed October 12, 2009)

Lawsuits filed over health insurers’ payments
for out-of-network care:
A group of health insurers have been named defendants in
multiple lawsuits stemming from payments made to
out-of-network providers.

One lawsuit was filed by the American Medical Association.
It claims thatWellpoint Inc. and others conspired to pay
reduced rates to out-of-network providers. Another lawsuit
was filed by Michael Roberts. Roberts’ lawsuit claims that as
a result of the scheme, consumers were forced to pay increased
costs associated with their care. The lawsuit filed by
Roberts names Wellpoint along with UnitedHealth Group
Inc., Ingenix Inc. and Blue Cross of California.
Roberts v. UnitedHealth Group Inc., No. 09-1886 (C.D.
Cal. complaint filed Mar. 19, 2009)
Counsel for Roberts: Christopher M. Burke, Kristen M. Anderson, Scott
& Scott L.L.P., 213-985-1274, Los Angeles.
Am. Med. Ass’n v. Wellpoint Inc., No. 09-2039 (C.D.
Cal. complaint filed Mar. 25, 2009)
Counsel for AMA: Edith M. Kallas, Joe R. Whatley Jr.,W. Tucker Brown,
Laurence J. Hasson, Whatley Drake & Kallas L.L.C., 212-447-7070,
New York; Stanley G. Grossman, D. Brian Hufford, Robert J. Axelrod,
Pomerantz Haudek Block Grossman & Gross L.L.P., 212-661-1100,
New York; Raymond P. Boucher, Helen Zukin, Michael Eyerly, Kiesel
Boucher Larson L.L.P., 310-854-4444, Beverly Hills, Cal.

Source: http://media.straffordpub.com/products/insurance-law-and-litigation-week/free-sample.pdf (Accessed October 12, 2009)

See also AMA Implicates WellPoint in Price-Fixing Plot at http://www.law360.com/articles/93856 (Accessed October 12, 2009)

An American Psychological Association Practice Update describes a class-action suit brought by state governments and solicits information from psychologists affected:

The complaint seeks damages under the Employee Retirement Income Security Act (ERISA), the federal antiracketeering law known as RICO and antitrust law for past underpayments. Further, plaintiffs will seek changes to make WellPoint’s out-of-network rate setting fairer and more transparent. (Accessed October 12, 2009 )

An investigative report- Underpayments to Consumers by the Health Insurance Industry - was published on June 24, 2009, by the SENATE COMMERCE COMMITTEE in its federal roles of oversight on interstate commerce and regulation of consumer products and services. This report found widespread reliance on Ingenix medical charge databases for calculation of out-of-network reimbursement rates as well as contract arrangements between Ingenix and insurers providing rate data specifically prohibiting disclosure of such information to consumers or doctors. Ingenix does not have any systematic procedures in place for validation of information included in the databases. More than 2 million federal employees and military families are enrolled in health plans affected.

(Accessible publications including what should be the public record are very difficult to find.)

WellPoint Litigation against the State of Maine

The lawsuit recently brought by WellPoint against the state of Maine has not been adequately covered in the conventional media. This case deserves to be more seriously researched to illustrate the market information culture created by private insurance companies in the United States. Documents related to regulatory decisions against Anthem Blue Cross and Blue Shield, a subsidiary of WellPoint, are publicly available on the website of the Bureau of Insurance - Department of Professional and Financial Regulation -of the State of Maine. The mission of the Bureau is to regulate the insurance industry to protect and to serve the public. Specifically the Bureau licenses insurance producers and companies, performs examinations and audits, reviews rates and coverage forms, investigates complaints, educates consumers about their legal rights and responsibilities, and sponsors programs to promote compliance with state laws. The Anthem rate filing for 2009 and the Bureau decision are publicly available even though WellPoint has consistently attempted to have this and related documents and proceedings treated as confidential.

In 1999 Anthem, a subsidiary of WellPoint, bought the Blue Cross and Blue Shield not-for-profit health plans operating in Maine and transformed them into a for-profit business. Since that time premium rates paid into the plans by average individual subscribers have increased 4 fold. (There are approximately 12,000 individual subscribers to Anthem health insurance products in Maine.) The rate increase submitted to the Maine Bureau of Insurance in 2009 was 18.2% to guarantee Anthem a minimum profit margin of 3%. This increase has been rejected as unfair and excessive in favor of an increase of just 10.9%. Anthem is suing the State of Maine for this regulatory action judged discriminatory.

Brave New Films has posted a very informative video account of this suit. See also Sick for Profit:





The Main Public Broadcasting Network aired the story: "Anthem Sues State of Maine over Rate Hike Request Denial" on October 5. The Columbia Journalism Review published an article entitled WellPoint versus the State of Maine on October 9 giving some additional details about the litigation.

Health Information Exchange Update

As already discussed in earlier posts, the eHealth Initiative has published a series of annual reports on the progress of RHIOs across the United States. The most recent report, "Migrating toward Meaningful Use: The State of Health Information Exchange" presents the results of the 2009 Sixth Annual Survey of Health Information Exchange. A review of this report reveals some serious methodological considerations affecting interpretation of study results. Current U.S. policy for health care system reform is founded on the proposition that emerging RHIO networks will coalesce into a national health information infrastructure for HIE. There still is no evidence base to substantiate this proposition, and as pointed out earlier, there is no business model for development of sustainable RHIOs.

The summary results of the 2009 survey claim a 40% increase in the number of "advanced or “operational” initiatives exchanging information," as well as positive impact on efficiency of care and return on HIE investment. Evaluation of the sample described in the full report shows however that the increase in number of initiatives (n=150 organizations - up from 130 in 2008) is based on a shift in the earlier sample. In the report section on study methodology, it is stated that 344 individuals responded to the survey announced through a variety of media and incentivized with $10 Starbucks Cards. It is not clear how these individuals were qualified to respond to survey questions, and there was no control for variance in responses due to different positions held by respondents. After review of responses received, 150 HIE initiatives were judged valid to be included in the analysis although there was no systematic verification of information provided by individuals completing the survey, and no uniform definition of an HIE initiative.

Although authors of the study attempted to obtain responses from all organizations responding to the survey in 2008, only 66 of the earlier sample responded in 2009, while 84 (more than half) of the 2009 sample were new respondents. This shift indicates a highly significant "mortality" rate among HIE initiatives which is not even addressed by the study authors - except as they state that 43 of these initiatives appear to continue their pursuit of HIE. Such "mortality" may suggest the lack of sustainability in business model design. Some of the data presented seem to corroborate this interpretation. While public funds seem very significant in initial HIE start-up (See figure 12.) - including federal, state and local government grants and contracts (n=99) - private payers contribute to start-up much less frequently (n=26). Ongoing sources of revenue shown in figure 13 indicate the withdrawal of public sector funding. This pattern is particularly interesting in light of the exchange of data for insurance enrolment, claims, and eligibility determination (See figure 9.). HIE seems heavily focussed on the management of the financial dimension of health care (n=52). While public funding is mobilized for HIE start-up, the private sector appears to benefit disproportionately from services offered. For example, the Utah Health Information Network is well developed for coordination of information for payers, but offers virtually no clinical services at this time. This network is also characterized as "uniquely Utah", with no provision for future linkage outside the state.

The Directory of Health Information Exchange Initiatives offers a useful database for further examination of emerging RHIOs.

CCHIT has made available a presentation of its New 2011 Certification Programs, including HIE, but there is increasing recognition of the need for a national health information infrastructure. There will be much waste in certification fees paid for an uncertain and ill defined process. Without necessary and sustained public investment in infrastructure, the promise of health information exchange across the U.S. will remain unfulfilled. While some experts and lobbyists claim that this promise will be realized within a time frame of two years, many understand that the ideologically charged debate concerning infrastructure design and implementation will probably extend well beyond 2014. Unfortunately for American patients and taxpayers, many business opportunities reside in the prevailing confusion of future scenarios for U.S. health care reform.

NEJM Online Health Care Reform Center

The New England Journal of Medicine has created an online Health Care Reform Center designed to inform the ongoing U.S. national policy debate in both political and academic arenas. The Center features themed collections of more than 100 NEJM articles as well as links to relevant resources. Visitors to the site are invited to participate in discussions on a series of important health care policy questions. One such question is: "Which countries’ health care systems offer lessons for the United States? What are they?" To date, this discussion seems to have generated little interest.

Other industrialized countries as well as developing countries have designed a wide variety of systems to integrate the diverse functions of their health care institutions. In some cases, they offer natural experiments demonstrating the effects of ideological foundations as well as the strengths and weaknesses of diverse strategies. In the U.S. debate, there has been little reference to the valuable evidence available in international experience. The U.S. academic community has conducted no research programs on the complex social systems associated with health care in other countries, and influential professional associations such as the U.S. Academy of Management have generally rejected such research production as invalid on the methodological pretext that qualitative analysis lacks rigor. The American Medical Informatics Association (AMIA) tends to define research problems at the individual level of analysis (patient or care provider) and to advocate randomized controlled trials (RCT) or experimental methods applied to the study of social implications related to biomedical informatics; there is little place for system-level thinking. Where there should be an extensive body of interdisciplinary research on comparative national health care systems relevant to U.S. policy reform, there is none. Some of the reasons for this appear to be related to American "exceptionalism" and a fundamental ideological rejection of values related to collective social responsibility. (This is evidenced in the Academy of Management's widely held view that public health is unrelated to the problem definition of health care management as business process.)

Political opponents of health care reform have aimed substantial attacks on Obama's "public option" as an attempt to replicate a "socialist" system after the Canadian or British models. Politicians in both countries have been called upon to defend their health care systems in the face of often fanciful calumny. In an editorial published on August 24, the Canadian Medical Association Journal took a position arguing for a better informed and more logical debate considering lessons that could be learned from the Canadian experience. The Economist also published an article on August 20 entitled Keep it honest: Rationing is not a four letter word, pointing out the superior performance of the NHS in cost effectiveness when compared to the U.S. system, and deploring the impoverished and dishonest character of some "delirious" rants of the past few weeks heard from American politicians. Citizens of both Canada and the U.K. seem perplexed at the debate in the U.S.. Certainly a more thoughtful democratic process will be required for any meaningful reform. While policy makers around the world seek to create a forum on global health, the U.S. has lost its leadership role.

Recently CNN's Lou Dobbs introduced a series of reports on other national health care systems and the lessons that could be learned from these experiences. These brief reports provoked an attack on Dobbs from some political quarters accusing him of being a latent socialist, or even communist. Included in the series are Canada, Denmark, Japan, the Netherlands, Spain, Switzerland, the U.K., as well as vignettes on India, China and Cuba. The series seems to have been dropped from broadcast but some of the short vignettes have been moved to Anderson Cooper's 360 Blog Archive, where a number of the comments posted suggest that readers would be interested in learning more.

Smartphones for Health Care

Software Advice is an online consultancy currently offering an advisory service to connect software buyers and vendors in the health care sector (among others). They recently conducted a survey to determine which smartphone is emerging as the device of choice in U.S. health care markets. Although the survey is not scientific, the results are interesting. There were 700 emails sent out to invite participation, while only just over 10% responded (n=71). (There was no option to indicate that the respondent did not own a smartphone.)

Here is the breakdown of respondents by profession:
22 Physician
9 Student
6 Nurse
16 Healthcare IT professional
2 Administrative support
16 Other

While health care service providers including physicians and nurses preferred the iPhone, personnel in administrative support (n=2) chose the Blackberry - a result consistent with anecdotal observations from my informants in the health care sector. This may be because the Blackberry offers superior infrastructure for large enterprise functions including management and security (the BlackBerry Enterprise Server), while the iPhone delivers attractive software applications and facilities for reference and research. (See the debate on Computerworld Mobile and Wireless.)

Especially interesting is the apparently predominant use of smartphones for email communication and note taking in spite of the strong expectation that such devices should be used for medical imaging, patient records (EHRs) and e-prescribing. These results, although unscientific, suggest that smartphone systems are inadequately integrated in institutional information systems, and that the infrastructures required for EHR functions including health information exchange (HIE) generally remain unavailable.

Related to the question of smartphone choice is scenario analysis of future IT infrastructures for health care service delivery in the U.S. and around the globe. In my opinion, the emergence of cloud computing and web-based services will shift the focus of this debate away from the characteristics of access devices and software - to the design of national and international infrastructures with sustained public investment. This paradigm shift in the next five years would invalidate current definitions of "meaningful use" of HIT at the individual practitioner level of analysis and render irrelevant CCHIT certification policies and procedures. (See a Chilmark research presentation entitled "What's Really Going On? or PHRs, Platforms, & Consumer Trends" .)

U.S. Health Care Reform: Continued...

As the debate over U.S. health care reform continues, much of the controversy seems to center on the creation of a "public option" for health care coverage, and the widely-held fear that private plans cannot survive in competition with such an option. Why should private plans survive if they cannot perform in a competitive environment? This question seeks to justify the public plan in the ideological context of its opponents. It is not yet clear whether this logic will be effective in the political process.

In reality, I think that private plans should not survive in their present form as they appropriate either undeserved financial benefits of not-for-profit status - or excessive profits and CEO salaries - while they fail to provide services to American citizens. Other industrialized nations have designed single payer national systems that provide superior care to their citizens at a cost generally half of the per capita cost in the U.S.. (It is interesting to note that neither the Kennedy bill, nor HR 3200, contains reference to a "national system" or "national infrastructure," but the prevailing ideology as well as an essentially "bottom-up" system change process are assumed throughout the text of the legislation.)

Those who doubt the necessity of rapid reform should review the unfolding story of Remote Area Medical Volunteer Corps. While this organization was founded in 1985 by Stan Brock to deploy health care relief services in the developing world - it now has a growing mission in the United States. RAM recently offered free dental and medical services in Wise, Virginia, where as many as 1600 people showed up each day to receive free care, and on August 11-18, a clinic will be open in Los Angeles where as many as 10000 people are expected. (CBS 60 Minutes produced a segment on RAM in March 2008.) The success of RAM in the U.S. is a testament to the suffering of ordinary citizens across the country and a document of third-world America.

On June 15, President Obama made a speech to the American Medical Association in which he pointed out some of the disastrous economic effects of the dysfunctional U.S. health care system:
Our largest companies are suffering as well. A big part of what led General Motors and Chrysler into trouble in recent decades were the huge costs they racked up providing health care for their workers; costs that made them less profitable, and less competitive with automakers around the world. If we do not fix our health care system, America may go the way of GM; paying more, getting less, and going broke.

According to Obama, not only the health care industry but all of "America may go the way of GM." He is right. He is attempting to convince health-care policy holders that the reform legislation under committee review will improve their coverage in the following ways:

1. No Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
2. No Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
3. No Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
4. No Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
5. No Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
6. No Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
7. Extended Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
8. Guaranteed Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.
   (Source: The Washington Post)
   
   Background:
   National Conference of State Legislatures: Federal Health Care Reform:
   Congressional Budget Office - Special Collection on Health
   Commonwealth Fund
   National Academies Press: Health and Medicine
   
   On July 15, Congressman Kevin Brady (R-TX), the lead House Republican on the Joint Economic Committee, unveiled a detailed flow chart of the complex health care reform proposal by Democratic congressional leaders.
   
   Kennedy "Affordable Health Choices Act"
   CBO evaluation - Letter to Senator Edward Kennedy (June 15, 2009)
   
   HR 3200 : ‘‘America’s Affordable Health Choices Act of 2009’’(July 14, 2009)
   CBO Analysis - Letter to Representative Charles Rangel, Chairman: Committee on Ways and Means (July 17, 2009)

Qualitative Case Analysis for Study of National Health Care Systems

Research in science policy, institutional economics, telecommunications, and organization theory has contributed to the growing literature on health care system performance, management and control. The current focus on health care system reform in the U.S. has made apparent the lack of relevant research evidence from country level studies. While many policy makers point to a fragmented health care delivery infrastructure, few reform efforts are framed at the national system level. Systems thinking seems anathema in an ideologically restricted political process.

The premise of my program of research is that study of configurations of virtual institutional health care infrastructures is critical to understanding global and regional health care ideologies and market dynamics. Little research has considered the effects of telecommunications and internet infrastructures on these dynamics, largely because theory, methods and tools have not been adapted adequately to analysis of these structures and processes profoundly transformed by new technologies at every system level.

Such analysis requires qualitative research strategies because of increasing system complexity and high rates of social, cultural and technological change. First, case analysis facilitates validation of patterns identified in data collected from diverse sources and construction of comparative frameworks from grounded theory principles. Historical analysis exposes the logic and possible path dependence of system evolution as in the phases of system creation through local unit design, control through centralization, and integration through horizontal coordination.

Another promising qualitative approach is system mapping for sociometric analysis of virtual infrastructures and their contributions to health care services markets and hierarchies. System configurations reflect institutional patterns of information management and control, including free market and centralized social medicine dynamics. For example, density or connectedness may describe the number or proportion of possible linkages appearing in a network, while hierarchy or dominance may describe the distribution of linkages throughout the network. Configurations may be interpreted as complex systems or as cases embedded in a broad context.

Taken together, case analysis, historical analysis and system mapping offer strategies to approach study of the important coherence between underlying ideologies and virtual health care infrastructures.

Some published research programs address country level case analysis of national health care systems - with a view to creation of an evidence base for comparison. Most extensive among these is the program of the European Observatory on Health Systems and Policies of the World Health Organization. The data collected for the 25 member states of the European Union include: (1)Health Systems in Transition (HiT) profiles, (2) other health-related information such as reports from institutions and health reform policy papers, and (3)
links to health-related web sites - ministries of health, national public health institutes, and research centers for health policy, public health and health economics.

The most recent template (2007) for development of Health Systems in Transition (HiT) country profiles includes some data on HIT in sections on planning and health information management (4.2) as well as physical resources (5.1). Information technology must be defined for each country profile in the context of a national IT strategy for the health care system as well as general statistics on Internet access and usage.(page 74)

Another research program on ehealth in national health care systems was initiated by the Rockefeller Foundation in the series of conferences at the Bellagio Center on Making the eHealth Connection organized by the World Health Organization-July-August 2008. The themes covered in the collection of country case studies include:

1. The path to inter-operability


2. Public health informatics and national health information systems


3. Access to health information and knowledge-sharing


4. eHealth capacity building


5. Electronic health records


6. Mobile phones and telemedicine


7. Unlocking eHealth markets


8. National eHealth policies

One background paper addresses The Case for a National Health Information System Architecture: A Missing Link to Guiding National Development and Implementation (by Stansfield, S.; Orobaton, N.; Lubinski, D.; Uggowitzer, S.; Mwanyika, H.) According to the authors, "a national health information system (HIS) plays an important role in ensuring that reliable and timely health information is available for operational and strategic decision making that saves lives and enhances health."(page 1) While this definition is generally acceptable, the strong ideological bias evident in the report is not. The enterprise architecture framework has been applied in the context of the U.S. federal government, but requires a careful adaptation to each country culture under consideration for health care sector applications. For example, in the Latin American social medicine tradition, the definition of health care work flow as a business process would be unacceptable.

The country case studies available in the collection are South Africa, Turkey, Vietnam, Rwanda, and Peru. These studies are generally organized according to the conference themes listed above as adapted by the authors. The greatest weakness of this research program is the lack of a theoretical framework or logic to guide methodological choices as well as data interpretation. Comparative analysis of the cases is especially hampered by lack of theory and the convenience sampling of country cases. According to Yin, selection of a single case for analysis may reflect a typical, critical, or unique set of observations for theory development. I have learned in my study of BIREME (Brazil) and INFOMED (Cuba) that regional leadership dynamics must be taken into account in case selection, and that regional network structures may be critical in the understanding of national health information systems.

Other collections of country studies of interest to researchers on national health information systems include Health Systems Country Briefs produced by USAID (August, 2007) to identify areas for investment in effective health systems strengthening. Published briefs include Mozambique, Rwanda, South Africa, Tanzania, and Zambia.

Earlier case studies (2005-6) examined the systemwide effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria on the national health care systems of Benin, Ethiopia, and Malawi. The interim report on findings from these three cases focused on Global Fund effects on the policy environment, human resources, the public/private sector mix, and the pharmaceuticals and commodities markets.

The larger Global HIV/AIDS Initiatives Network including researchers in 21 countries conducts research on how these programs affect national health care systems. The GHIN promotes cross-country case comparability through common research methods, builds research capacity, informs health care policy through multi-country comparisons, and coordinates dissemination of research conclusions and recommendations. The GHIN has contributed to the WHO Positive Synergies Initiative to strenthen its institutional role in national and global health policy. The WHO also publishes a very useful set of country profiles including data for cross-country comparisons.

The International Telecommunication Union offers country case studies by region and topic-providing context for analysis of national health information systems. (Many of these cases require an update.) Another series of ITU cases (2000-2004) addresses Internet diffusion in various stages of country development. (See also publications of the Mosaic Group on the Global Diffusion of the Internet Project.)

Porter's Value-Based Strategy for Health Care Reform

The New England Journal of Medicine has just published an article entitled "A Strategy for Health Care Reform — Toward a Value-Based System" by M.J. Porter - which has already attracted some international attention. (I learned of the publication as I read a communiqué from the Indian Association for Medical Informatics.) The principles of his approach to health care require critical review-especially as they are aligned with the U.S. health care industry for the promotion of competition as a driver of value, defined as health outcomes achieved per dollar spent. I am particularly concerned about the misuse of Dr. Porter's influence to pedal a U.S. model for health care reform where there exists no evidence in support of such a model.

According to Dr. Porter, while both universal health care insurance coverage and national system redesign are necessary to achieve "true reform", value takes precedence over universal coverage. It seems to me that he is confusing the concepts of universal access to services and universal health care insurance coverage. (In the U.S. system, the private health care insurance industry effectively denies access to millions of U.S. citizens - either by demanding prohibitive deductibles and co-payments or refusing to cover a particular claim for treatment.) Dr. Porter suggests that lower health care costs in other countries are due to universal insurance coverage, but this advantage too is unsustainable without improved value. He fails to recognize the single payer system design with publicly funded health information infrastructures as critical to controlling costs in other national systems. While certainly there has been "no convincing approach to changing the unsustainable trajectory" of the U.S. system, it is inaccurate to suggest that other countries such as Finland, far more advanced than the U.S. in design of an efficient national health care system, should reform their systems according to his recommendations. Rather, the U.S. should be learning from the examples set by other industrialized countries such as the UK, France and Taiwan as well as developing countries such as Cuba and Brazil.

According to Porter, there are six principles to guide health care system reform - all of which address financing:

1. Reform health insurance competition to focus on improvement in subscribers' health.
2. Motivate employers to stay in the system by penalizing "free riders". (The presence of employers in health care insurance markets will foster competition based on value.)
3. Address the unfair burden on those without access to employer-based coverage by equalizing tax deductibility of premiums paid by individuals independently or through their employers.
4. Create regional insurance pools (instead of a national pool) similar to the Massachusetts Health Insurance Connector. Regional pools apparently would be more effective in promoting value-based competition. Reinsurance programs are also critical to "spread risk" related to coverage of very expensive conditions.
5. Create income-based subsidies to assist low-income citizens in purchase of insurance.
6. Require all citizens to purchase health insurance.

This value-based delivery system requires "mutually reinforcing" steps to implementation. The most important features of such implementation appear to be outcome measurement, organization of care according to medical conditions with bundled payments for reimbursement of care, value-based competition for patients across geographical boundaries, adoption of HIT architectures and standards for electronic medical records, and patients' responsibility for their own health.
While many of these features seem painfully obvious, Porter offers no evidence in support of his claims that his framework will bring about the needed reforms in the U.S. system. The use of electronic medical records, for example, is assumed to bring about improved health care efficiency and quality by many researchers and policy-makers. Porter also asserts that "electronic medical records will facilitate both delivery restructuring and outcome measurement" without providing any qualitative or quantitative empirical support for this "bottom-up" change process. Porter's statement has not been demonstrated in any health care system. It would be just as reasonable to suggest that HIT infrastructures for health information exchange form a prerequisite for implementation of electronic health records. The existence of such national HIT infrastructures is certainly required to deliver the comprehensive program of outcome measurement at the foundation of Porter's strategy.
The framework does not mention the role of the public sector in health care system reform, except to affirm the superiority of the private sector to create accountability and value-based care through competition. (Again, there is no research evidence to support this claim. On the other hand, Amartya Sen has pointed out that national health care system performance is related to rate of public health investment. See Sudhir Anand and Martin Ravallion, Human development in poor countries: on the role of private incomes and public services, Journal of Economic Perspectives, 1993, 7: 133-150.)
Porter suggests that his reform strategy requires new independent institutional roles to oversee outcome measurement, set HIT standards, and regulate bundled reimbursement; and that Medicare might be able to "take the lead in some areas." (These new roles should probably be assumed by state or federal entities to assure their independence. Controversies surrounding the Certification Commission for Healthcare Information Technology (CCHIT) illustrate this dilemma.) The Commonwealth Fund has published a comparison of public investment per capita in HIT (2005) (slide #72) showing that the U.S. lags far behind the U.K., Canada, Germany and Australia. This lag probably reflects the lack of public infrastructure to support EHRs and health information exchange at the regional or national levels.
Aside from a significant pro-business ideological bias, Porter's strategy lacks clarity in the definition of "value" as "the health outcomes achieved per dollar spent." Although in the past he has emphasized the role of physicians in health care reform, his perspective has shifted to the system level of analysis. However, value is consistently defined at the individual rather than the population level. In my opinion this conceptual definition is impossible to operationalize for measurement as prescribed - primarily because "value" is to be measured at the individual treatment level of analysis, while the relevant outcome may occur in the aggregate - at the family, community, or population level.
"Value" is a highly subjective dimension at the individual as well as the collective level. How can consensus be developed to prescribe the definition of "value" for such a comprehensive program of outcome measures? Criteria for patient, doctor and provider choices are also very subjective. Objective characteristics of health care delivery would be more useful to inform subjective patient choices. (Porter has not addressed the immense costs associated with production of his outcome measures, including the conduct of extensive comparative effectiveness research programs required to serve as an evidence base.)
The definition of value related to "bundled" services poses substantial methodological problems. Bundled services and reimbursement schemes assume a level of standardization not consistent with the complexity of individual cases - including comorbidity. This design feature would also encumber the dynamics of market competition. (Certain provider organizations would integrate their services in competing industry clusters.) In any event, there is no research to substantiate Porter's far-reaching claims on the benefits of health care services bundled according to medical condition. A CMS (Medicare and Medicaid) initiative to introduce bundled reimbursement in the mid-1990s failed due to provider resistence. The reasons for this failure should be examined to ensure the validity of new proposals in the current environment.
Porter also needs to clarify how the dynamics of consolidation and competition co-evolve in health care services markets. While he deplores "hyperfragmentation and duplication of services", such duplication of services is implicit in the competitive environment he advocates. Certainly the regional structuring of risk pooling would create boundaries to competition and structural redundancy across regions. I do not understand why Porter considers that regional organization "will result in greater accountability to subscribers and closer interaction with regional provider networks, fostering value-based competition." The case of McAllen, Texas and Doctors Hospital illustrates the possible dysfunction of such a model at the local level of analysis-including the exorbitant costs in public CMS reimbursement. (Hear an interview with Dr. A. Gawande on NPR.) Some dimensions of health care in the future will remain anchored in geographic proximity, but others will be more efficiently organized at the national level. Not only will HIT contribute to efficiencies redefined at the national level, but patients will probably be more mobile in pursuit of both work and health care services.
My review has suggested only a few of the many questions to be answered concerning Porter's strategy for health care reform. As many American authors on policy for U.S. health care reform, he needs to consider other national health care systems to identify an evidence base relevant to the American challenge. He refers only to his own publications, and mentions the case of Finland not as an example for study, but as an illustration of the universal crisis in controlling health care costs. One very instructive country case is Taiwan where single payer system reform was implemented in 1995 after thoughtful examination of other national systems to identify desirable features transferable to the Taiwanese context. U.S. policy-makers would have much to learn from this change strategy.
I would like to conclude this review by deploring the excessive emphasis on finance to the exclusion of any reference to medical ethics in the debate on U.S. health care system reform. While financial incentives are certainly important, especially from a business standpoint, physicians and health care professionals should not require micro-management through financial rewards to motivate their service. Implementation of such complex reward systems is very expensive as well as vulnerable to fraud and legal challenge. The most important incentives should be the intrinsic rewards associated with the privilege of offering a public good through health care service.

Commentary: Meaningful Use

“The American Recovery and Reinvestment Act authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “meaningful users” of an electronic health record (EHR). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing an EHR in compliance with the “meaningful use” definition or they will be subject to financial penalties under Medicare.” Source: Meaningful Use: A Definition, Recommendations from the Meaningful Use Workgroup to the Health IT Policy Committee, June 16, 2009.

The Office of the National Coordinator for Health Information Technology (ONC) is seeking comments on the preliminary definition of “Meaningful Use,” as presented to the HIT Policy Committee on June 16, 2009.

The definition and measurement of "meaningful use" in the context of health information technology (HIT) implementation has emerged as a critical policy discussion - particularly in light of the need to establish benchmarks for incentive payments mandated in ARRA. The most important difficulties in this discussion result from confusion in other definitions including electronic health records (EHRs) and health information exchange (HIE). Although CCHIT has apparently made progress in presenting criteria for certification of both EHRs and HIEs, their clear definition remains elusive and subject to ongoing debate. In their call for public comment, the HIT Policy Committee proposes a Preamble: Meaningful Use – A Definition and a Meaningful Use Matrix structured according to health care policy priorities. The ultimate goal of meaningful use - as stated in the Preamble – is to “enable significant and measurable improvements in population health through a transformed health care delivery system.” While this broad goal encompasses the entire system, health information technology seems narrowly defined as an Electronic Health Record (EHR), excluding any discussion of infrastructures required to support health information exchange and other core functions of EHRs. The challenge in this framework is to demonstrate how the adoption of an EHR can be associated with emergence of a transformed health care delivery system for improved population health. What are the dimensions of this goal and how should they be operationalized and measured within a particular health care context? The Matrix is an attempt to identify health care policy priorities on five axes – regardless of context: (1) Improve quality, safety, efficiency, and reduce health disparities; (2) Engage patients and families; and (3) Improve care coordination; and (4) Improve population and public health; and (5) Ensure adequate privacy and security protections for personal health information. Each of these axes yields a set of care goals with more specific objectives and measures to be applied in 2011, 2013, and 2015.

Unfortunately, the logic of the Matrix is highly inconsistent. The five policy axes are certainly not orthogonal, but must be interrelated in different ways among complex care delivery systems. For example, improving population and public health would be closely associated with reduction in health disparities, and improved coordination would certainly be linked with better health care quality. Some of the goals listed for particular policy priorities seem misplaced while corresponding objectives and measures seem unrelated or indistinguishable. For example, the goal to “Report to patient registries” in Priority #1 would seem more appropriate to the public health priority (#4). The goal to “Apply clinical decision support at the point of care” (under priority #1) appears also as an objective in 2013 and 2015. Logically the objectives and measures in the Matrix should represent more specific instances within each stated goal. Clinical decision support is a very complex problem inadequately presented as a required component in the determination of meaningful use.

The Matrix time frame in general poses a challenge as the measures for achievement of objectives appear to lose definition (or disappear entirely) from 2011 to 2015, when they are mostly “to be determined” (tbd). (What happened to measurement of health disparities in 2015? Are they supposed to have been resolved by then?) In my opinion there are several reasons for the inadequacy of the Matrix framework.
(1) The logic of the Matrix assumes the existence of infrastructures required for HIT implementation – including the adoption of EHRs. As I have already commented on the proposal for regional extension centers, it is unrealistic to assume that existing policies to foster formation of RHIOs and HIEs will effectively promote a Nationwide Health Information Network (NHIN) without sustained public investment at the federal level. Essential institutions excluded from the ONC discussion of meaningful use include educational and research providers. The eventual NHIN infrastructure - including education and research institutions - will have a very substantial impact on the evolving parameters of HIT and EHR meaningful use in health care delivery, especially for health information exchange and interoperability.
(2) Another invalid assumption is that HIT or EHRs – implemented at the physician, group practice or hospital level - will reduce costs or improve the quality of health care without very significant national system redesign. HIT implemented in the existing fragmented system may only result in greater redundancies and inefficiencies – as well as higher costs. (See the report by the CBO: Evidence on the Costs and Benefits of Health Information Technology, 2008. See also the very provocative article by A. Gawande in the New Yorker: The Cost Conundrum: What a Texas town can teach us about health care, 2009)
(3) Information technologies evolve very quickly and new innovations as yet unforeseen may radically affect the field of biomedical informatics and the redesign of the U.S. health care system, especially in this time of crisis. Since the logical structure of the Matrix appears fatally flawed, it is unlikely that this framework would survive even relatively small technology-driven adjustments - to be useful as a robust theory would. This framework would therefore not be effective in motivating the individual or institutional decision-maker to make the sustained financial and human resource investments required for effective EHR implementation and meaningful use.

Like the ONC, professional associations such as AMIA and HIMSS appear to have avoided issues related to operational definition of meaningful use by considering EHR adoption as an essentially binary variable and emphasizing the association between presence of EHR technology and health care outcomes. There should be more careful attention to the complex health care processes linking HIT with such outcomes. According to AMIA, criteria for meaningful use of EHRs should focus on "clinical endpoints achieved," and the "relationship between, and effectiveness of, key EHR functions and performance on quality measures over time." (See AMIA letter to James Scanlon dated April 30, 2009) HIMSS states unequivocally that "quality measures are a by-product of the successful implementation of CCHIT-certified EHR technology, not separate initiatives." (See lines 74-86: Definition of Meaningful Use of Certified EHR Technology for Hospitals - Approved by the HIMSS Board of Directors on April 24, 2009) They formulate an untested assumption of a unique causal link between certified EHR usage and quality - for which there is no logical or empirical justification - except apparently to promote the value and necessity of CCHIT certification.

Unfortunately, there is no evidence base to associate HIT or EHR usage (certified, meaningful or otherwise) with many of the measures of general health care quality outcomes appearing in the Matrix. The low rate of EHR adoption in the U.S. renders quantitative research on the relationship between EHR technology and health care quality impossible at this time. One recent study by Li Zhou et al. to appear in JAMIA attempts to examine EHR functions and performance based on data from the Healthcare Effectiveness Data and Information Set (HEDIS) - only to report that there is no statistical association between usage of EHRs and such performance data. Although this result is probably due to numerous methodological weaknesses - including sample sizes and construct definitions - the study suggests to me that reductionist research designs cannot capture the complexity of EHR meaningful use or the possible causal effects on quality of health care. Furthermore, had this study demonstrated such a statistically significant association, there would have been no validity to any claim of causality. Many unmeasured and uncontrolled contextual variables may co-vary to explain quality of health care.

The lack of a research program and evidence base demonstrating the positive health care outcomes promised with implementation of HIT or EHRs has serious consequences for the motivation to adopt these technologies as well as the determination of financial incentives as mandated through Medicare and Medicaid. Where research evidence for meaningful use of HIT and EHRs does not exist and cannot be generated in the proposed framework, the program of incentives will be wasteful of public funds not only through ineffective incentive payments but also through vulnerability to legal challenge.

Rather than attempting to prescribe and incentivize implementation of HIT and EHRs, the government should directly offer public services funded through sustained federal investment - such as the NHIN - that will shape meaningful use of these technologies. An incentive for example, might be access to technical support services freely available through linkage to the NHIN.

Commentary: U.S. Health Information Technology Extension Program

Department of Health and Human Services

Office of the National Coordinator for Health Information TechnologyHealth Information Technology Extension Program

The following commentary on the proposed Health Information Technology Extension Program addresses the general context of U.S. health care reform under the American Recovery and Reinvestment Act of 2009 (ARRA). It was submitted to DHHS on June 11.

Comparative studies of national health care systems in the industrialized world demonstrate that health care service delivery in the U.S. performs poorly in light of the level of per capita expenditure in the sector. [1] Even though there is agreement among physicians that the U.S. health care system is broken, there is no consensus on political action for system reform integrating health information technologies (HIT) in support of evidence-based medical practice, research and education. The U.S. lags significantly behind other developed countries in public investments for HIT; [2] as of 2005 the U.K. had spent $192.79 per capita compared to a U.S. investment of $.43. [3] One reason for this lack of public investment is U.S. policy emphasis on development of sustainable business models for private investment in health information infrastructures.

In the U.S. multiple payer system, competing health care providers and insurance companies focus on automation of financial transactions and implementation of redundant proprietary HIT. Their incentives for new technology adoption do not take into account system level efficiencies often external to private HIT purchasers in the health care sector. While policy emphasis on electronic health records (EHR) focuses on internal efficiencies and improved health care quality, these investments require public infrastructures in some form of partnership with a variety of stakeholders for effective health information exchange (HIE) at the state and system level. [4]

The nationwide health information network (NHIN) refers to a proposed system linking data intermediaries for health information exchange. Related policies rely primarily on the emergence of locally sustainable infrastructures. An assumption fundamental to this model is incremental development by linkage of regional health information organizations (RHIOs) to form the NHIN. However, early research on the performance of RHIOs shows a high failure rate among these organizations and offers no significant evidence to substantiate interoperability among their systems. No sustainable RHIO business model has been identified to integrate public and private stakeholders. [5-7] Although public policy on HIT seems optimistic about future development of infrastructures based on health information exchange (HIE) and RHIOs, there is no foundation of evidence or experience to justify such apparent assumptions. The insignificant rate of comprehensive EHR adoption (1.5% in U.S. hospitals) further suggests that HIT infrastructures and other technical and training support services are either inadequate or nonexistent. [8]

Few studies in any scholarly discipline or field of professional practice have investigated the reasons for this lack of progress at the level of national U.S. health care systems or markets. While successful efforts for health information exchange seem to align with business models integrating payers and large collaborative systems such as hospital corporations, RHIO organizations are designed to promote flows of health information across competing business entities as well as public health agencies in the health care sector. Such entities will not share the health information that describes their proprietary services and clienteles (albeit de-identified), especially when there is no competitive advantage or service offered as a return on substantial investments required.

The design of the Health Information Technology Extension Program seems to assume the emergence of infrastructures for health information exchange through linkage of regional organizations. Major problems with the design include:

• Lack of definition of regions under the governance of the National Health Information Technology Research Center (HITRC). Applicants for Regional Extension Centers are designated broadly as “affiliated with any United States-based nonprofit organization or group thereof…”. One of the criteria for successful application is definition of the geographic region and the provider population within that region to be served. This provision would mean that applicants might compete on the basis of their definition of a region as well as other criteria. The result would be a fragmented and/or overlapping national extension infrastructure.
  
• The logic of regional extension center design may not be consistent with the structure of many providers offering regional health care services across the U.S.. Some providers may have access to more than one extension center by virtue of such inconsistencies, thus fostering redundant and inefficient services. Differences in regulations among states included in regions defined by extension centers may also create significant problems in developing extension programs.
  
• The short term strategic vision with two-year awards in FY 2010 from ARRA funding does not justify the substantial investment probably necessary for preparation of applications. This difficulty is further exacerbated by uncertainties associated with the priority accorded to applicants identifying “viable sources of matching funds”.

In my opinion, the weaknesses of existing policies for development of the NHIN information infrastructure must be resolved before related programs can be implemented. In particular, this infrastructure should be fully funded at the federal level with a long term strategic vision. Design of the NHIN as a public good is required to support both public and private enterprise in an integrated health care sector. [9]

REFERENCES

[1] Nolte E, McKee CM. Measuring the Health of Nations: Updating an Earlier Analysis. Health Aff 2008;27(1):58-71.
[2] Anderson GF, Frogner BK, Johns RA, Reinhardt UE. Health Care Spending And Use Of Information Technology In OECD Countries. Health Aff. 2006 May 1;25(3):819-831.
[3] Shea K, Holmgren A, Osborn R, Schoen C. Health System Performance in Selected Nations: A Chartpack. The Commonwealth Fund. 2007.
[4] Public Governance Models for a Sustainable Health Information Exchange Industry: Report to the State Alliance for E-Health. State Alliance for E-Health. 2009.
[5] Adler-Milstein J, McAfee A, Bates D, Jha A. The State of Regional Health Information Organizations: Current Activities and Financing. Health Aff 2008;27(1):w60-w69.
[6] Fifth Annual Survey of Health Information Exchange at the State and Local Levels. eHealth Initiative. 2008.
[7] Adler-Milstein J, Bates DW, Jha AK. U.S. Regional Health Information Organizations: Progress And Challenges. Health Aff. 2009 March 1;28(2):483-492.
[8] Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, et al. Use of Electronic Health Records in U.S. Hospitals. N.Engl.J.Med.; 2009 March 25.
[9] Clancy CM, Anderson KM, White PJ. Investing In Health Information Infrastructure: Can It Help Achieve Health Reform? Health Aff 2009 March 1;28(2):478-482

Education for Implementation of Health Information Technology

A thought provoking debate was opened at the Washington Post (April 26, 2009) with publication of an article entitled "End the University as We Know It" by op-ed contributor Mark C. Taylor, chairman of the Religion Department, Columbia University. Dr. Taylor deplores the "division-of-labor model of separate departments" and calls for a new curriculum model structured as a complex adaptive network. In my opinion, as suggested by Dr. Taylor, such a structure would foster interdisciplinary and cross-cultural teaching and research required to face the challenges of the new millennium, including scholarship in the growing field of biomedical informatics. However, it seems unlikely that formal educational programs in biomedical informatics will meet practical workforce needs for development of health information systems in the U.S., particularly in light of the American Recovery and Reinvestment Act (ARRA) of 2009. In 2005, the American Medical Informatics Association created a university-based training curriculum - AMIA 10x10 - designed to present a set of competencies for technology champions acting in their professional settings. The goal of these distance-learning courses is to train ten thousand health care workers by 2010. An evaluation of partner institution OHSU course offerings before the end of 2006 seemed to suggest that support for interaction among participants should be increased, although overall satisfaction with content and process was high. To date, I think only about 2000 participants have completed courses in this program. More generally, the technology champions now active in health care organizations are probably innovators - autonomous learners - working alone or in cross-disciplinary communities of practice, advancing ahead of expensive and rapidly outdated academic curricula. Unfortunately, in the U.S. context there is no national infrastructure to guide these fragmented efforts towards formation of an integrated health information network with standards for interoperability.

Published Evidence: RHIOs and HIE

I have been searching for evidence about the performance of existing RHIOs, and have had some difficulty identifying published research - whether in journals or grey literature. An excerpt from the minutes of a meeting of CCHIT's working group on networks (October 28) refers to a study conducted by Gartner in late 2007. This report should be in the public domain as it was funded by the ONC. Gartner also refers to its research methodology as "proprietary"- contradicting the basic principles of scientific enterprise. (Hype Cycles and Magic Quadrants constitute questionable conceptual frameworks for this type of business intelligence.) While privately funded research results might logically be defined as proprietary, research methodology should always be considered open to review by the scientific and professional communities concerned.

The Healthcare IT Transition Group published reports in 2006 and 2007. While summaries of these reports (2006, 2007) are freely accessible, the full reports are still considered proprietary even though they contain "old news". Some discussion of the study results is available on the organization's blog. One other report on RHIO financing published in 2005 is available in PDF .

The eHealth Initiative has published annual surveys of HIE initiatives since 2005. The 2008 Fifth Annual Survey of Health Information Exchange at the State and Local Levels finds that although the number of organizations surveyed has increased, the extent of health information exchange remains limited and a sustainable business model has yet to be defined.

Chilmark Research, specialized in IT trends in the health care sector, projects a decline in formation of interorganizational RHIOs while HIE, designed for particular organizational entities, may constitute a growing market. The reasons for this are related to difficulties in identifying a viable business model for health information exchange. HIE is focussed on business partnerships much like a supply chain configuration in manufacturing, including suppliers and payers. While RHIOs enable health information "liquidity", HIE incorporates business processes associated with health information flows. According to Chilmark, public investment in RHIOs should be suspended, while the NHIN is an unrealistic goal based on HIE growth; the growth of HIE will not bring development of interoperable networks across the U.S..

An important issue in the distinction between RHIOs and HIE involves the risks of integrating billing and clinical information. For a variety of reasons, billing codes may distort medical conditions and treatments they represent, posing a danger to patient health as in the case of Dave deBronkart as reported in the Boston Globe (April 13 2009).

Another strategy for creation of the NHIN involves development and diffusion of open-source software solutions to allow public and private organizations to link into the NHIN for health information exchange. The U.S. Social Security Administration was the first federal agency to use this solution requiring the user entity to assume costs related to software development, implementation and maintenance.

Websites:
NHINWatch - maintained by the editors of Healthcare IT News
HIMSS Government Health IT
HHS: NHIN
Health Record Banking Alliance
Connect Community Portal - Open Source Gateway
HHS: Federal Health Architecture
Information and Technology Innovation Foundation
Practice Fusion a web-based EMR service and community of practice

Articles on topics related to RHIOs include:
Adler-Milstein, J., McAfee, A., Bates, D., & Jha, A. 2008. The state of regional health information organizations: Current activities and financing. Health Affairs, 27(1): w60-w69. (Comments on this article)
Adler-Milstein, J., Bates, D., & Jha, A. 2009. U.S. regional health information organizations: Progress and challenges. Health Affairs, 28(2): 483-492.
eHealth Initiative. 2008. Fifth annual survey of health information exchange at the state and local levels. Washington, D.C.: .
Marchibroda, J. M. 2007. Health information exchange policy and evaluation. Journal of Biomedical Informatics, 40(6, Supplement 1): S11-S16.
McDonald, C. 2009. Protecting patients in health information exchange: A defense of the HIPAA privacy rule. Health Affairs, 28(2): 447-449.
McMurry, J., Gilbert, C. A., Reis, B. Y., Chueh, H. C., Kohane, I. S., & Mandl, K. D. 2007. A self-scaling, distributed information architecture for public health, research, and clinical care. Journal of the American Medical Informatics Association, 14(4): 527-533.
Solomon, M. 2007. Regional health information organizations: A vehicle for transforming health care delivery? Journal of Medical Systems, 31(1): 35-47.
Thielst, C. B. 2007। Regional health information networks and the emerging organizational structures. Journal of Health Care Management, 52(3): 146-150.
Tripathi, M., Delano, D., Lund, B., & Rudolph, L. 2009. Engaging patients for health information exchange. Health Affairs, 28(2): 435-443.

Stimulus Bill & HIE, RHIO Market

HIMSS has published a very useful Health Information Exchange Industry Listing of resources. There is still no evidence of a sustainable business model for development of RHIOs or a methodology for scaling up to a national network-NHIN.

Review this SlideShare presentation for a perspective on economic stimulus measures and their effects on industry markets:

Stimulus Bill & HIE, RHIO Market

View more presentations from John Moore.

Health Information Exchange and CCHIT

The U.S. Commission for Certification of Health Information Technology (CCHIT) is developing criteria for certification of health information exchange (HIE) - including a process of public comment accessible through their website. This agency (a government contractor) shows a bias in favor of proprietary software solutions in certification for ambulatory, inpatient, emergency department and enterprise EHR. Health information exchange, however, poses a particular challenge to CCHIT as it really cannot be defined as a software product - as evident in the minutes of meetings of the HIE (formerly Network) Working Group. On October 28, 2008, the WG considered the results of a Gartner report on vendors providing services to HIEs - commissioned in 2007 by the ONC. (This report has not been made available for public review, probably because it contains evidence that existing HIEs are unsustainable; no viable business model has been identified, and these organizations generally fail after initial public or private funding is exhausted. In my opinion, such a report belongs in the public domain and should be required to inform public consultations.)

The WG mentioned that discussions would be continued to decide whether vendor certification should be different than HIE certification. (See page 3.) On November 25, 2008, questions were raised concerning the location of patient and document registries as well as the content of current HIE data exchange. Confusion over the parallel roles of CCHIT and the Healthcare Information Technology Standards Panel (HITSP) was resolved by asserting that HITSP should adapt its standards to CCHIT certification requirements.

The WP seemed to recognize that the interoperability construct is difficult to address in the absence of "an overarching plan for how HIEs will interact as mediators of information exchange." (See page 2.) On January 27, 2009, a substantial commentary and discussion explored the distinctions between HIE certification and accreditation under the Electronic Healthcare Network Accreditation Commission (EHNAC) . According to this discussion and ISO definitions, certification is more appropriate to software products and vendors, while accreditation applies to organizational entities. (ISO definitions: Accreditation is a "third‐party attestation related to a conformity assessment body conveying formal demonstration of its competence to carry out specific conformity assessment tasks" in other words an organization or entity can be accredited. "Certification is a third‐party attestation related to products, processes systems or persons" in other words not an organization. See comment 7 on page 5, minutes of the January 27 WH meeting.)

While the minutes of WG meetings raised the critical need for HIE definition, this question was never directly addressed. What are HIEs? How will they be connected to form the Nationwide Health Information Network (NHIN)? What organizations and institutions may join in these networks? Where does health information reside in the HIE context? The document for public comment offered by CCHIT suffers from this lack of clarity, with the probable result that comments will focus on trivial technical details rather than the more important "big picture".

EHR Debate

In India a political debate is developing from publication of an IT vision paper,"Transforming Bharat" (India is called Bharat in Hindi), by an opposition party - the Bharatiya Janata Party (BJP). (See a post by Indrajit Basu: Digital Community Innovations from around the World - India's Opposition Party Promises IT Nirvana for All - for discussion of the Indian context.)

An excerpt:

The BJP’s IT Vision will help India (a) overcome the current economic crisis; (b) create productive
employment opportunities on a large scale; (c) accelerate human development through vastly
improved and expanded education and healthcare services; (d) check corruption and (e) make
India’s national security more robust.

Some highlights of this IT Vision are (page 2):

@ Multipurpose National Identity Card with Citizen Identification Number (CIN) in 3 years; to replace all other identification systems.
@ 1 crore students to get laptop computers at Rs 10,000. Interest-free loan for anyone unable to afford it.
@ All schools and colleges to have internet-enabled education.
@ National Mission for Promotion of IT in Indian Languages.
@ Broadband Internet in every town and village, with unlimited upload and download data transfer limits, at cable TV prices.
@ Mobile penetration to be raised in five years from 40 crore to 100 crore subscribers.

@ 100% financial inclusion through Bank accounts, with eBanking facilities, for all Indian citizens. Direct transfer of welfare funds.

@ A basic health insurance scheme for every citizen, using the IT platform. Cash-less hospitalisation.
@ All PHCs to be connected to a National Telemedicine Service Network.
@ National eGovernance Plan to cover every Government office from the Centre to the
Panchayats. The ‘E-Gram Vishwa Gram’ scheme in Gujarat to be implemented nationwide.

Regarding ehealth (page 24) the BJP promises that every hospital and primary health care center (PHC) in rural areas would be connected to a National Telemedicine Service Network, every citizen would have an electronic health record and universal health care would be offered through a basic health insurance program using the IT platform. Service to rural areas would be improved through IT-enabled mobile diagnostic vans and health care work force training programs.

Distinctive features of this Indian vision include the commitment to universal health care with a unique citizen identifier, and integration of government (including health care and education) and financial services through public telecommunications infrastructures.

This Indian example shows how the EHR may be effectively viewed in the broader context of a national IT platform. Patient identification is a fundamental issue which also needs to be addressed in U.S. policy before EHR implementation can be meaningfully promoted through economic stimulus or other measures.

EHR Stimulus

An international debate on solutions for EHR software solutions has recently received more extensive coverage as the US economic stimulus programs focus on promotion of health information technologies in general and electronic health records (EHR) in particular. (See text versions of the American Recovery and Reinvestment Act -HR 1: TITLE XIII--HEALTH INFORMATION TECHNOLOGY )

Many important questions guide this debate, including the role of national information infrastructures and the appropriateness of proprietary vs. open source software solutions. Austin Merritt of SoftwareAdvice.com, an online resource that helps physicians find electronic medical records, offers very salient arguments for caution in evaluating cost savings as a result of EHR adoption in the health care sector: http://www.softwareadvice.com/articles/medical/get-ready-for-ehr-failures-but-dont-blame-the-software-2031209/ An excerpt of the article is copied below.
_____________________________
With the Economic Stimulus Bill signed and available to subsidize EHR purchases (for more information see “The Stimulus Bill and Meaningful Use of Qualified EHRs/EMRs“), we are seeing a dramatic increase in electronic health records (EHR) buyer interest. Assuming these buyers make use of the stimulus subsidy to buy an EHR, we expect to see a lot of EHR failures over the next couple years.

Don’t get us wrong! We are HUGE advocates of EHR technology. Doctors should be using EHRs. The stimulus subsidy is great. EHR software programs (and software companies) are not the problem.
Our concern is that the subsidies won’t change healthcare providers’ late adopter mindsets about information technology. Providers may jump at “free software” and try to avoid penalties (starting in 2015), but will they:

Truly believe in the value of an EHR over traditional paper charts?

Take a leadership role in advocating adoption of the new EHR in their practice?

Change their old workflows to match the best practices in leading EHRs?

Take part in intensive training to learn the new system?

Ride out the difficult stages of new software adoption and change management?

Traditionally, the substantial costs of EHR systems keep the luddites from buying technology in the face of these challenges. But with “free” EHR software, we expect more than a few providers to throw caution to the wind, buy an EHR and overlook the critical implementation and change management practices that are critical to success.
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The issues raised in this article are of critical importance, especially those related to workflow analysis and training. EHR implementation concerns also need to be evaluated in light of the lack of an effective National Health Information Network (NHIN) with associated national or international standards for interoperability.