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learners - working alone or in cross-disciplinary communities of practice, advancing ahead of expensive and rapidly outdated academic curricula.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

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