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.  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;  as of 2005 the U.K. had spent $192.79 per capita compared to a U.S. investment of $.43.  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. 
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. 
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. 
 Nolte E, McKee CM. Measuring the Health of Nations: Updating an Earlier Analysis. Health Aff 2008;27(1):58-71.
 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.
 Shea K, Holmgren A, Osborn R, Schoen C. Health System Performance in Selected Nations: A Chartpack. The Commonwealth Fund. 2007.
 Public Governance Models for a Sustainable Health Information Exchange Industry: Report to the State Alliance for E-Health. State Alliance for E-Health. 2009.
 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.
 Fifth Annual Survey of Health Information Exchange at the State and Local Levels. eHealth Initiative. 2008.
 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.
 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.
 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