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.
_________________________________________________

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.