tag:blogger.com,1999:blog-60026512444680544482024-02-02T01:10:31.239-08:00eResearch CollaboratoryPhrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.comBlogger43125tag:blogger.com,1999:blog-6002651244468054448.post-8555881012354281582014-10-03T09:21:00.001-07:002014-10-03T09:21:12.384-07:00Commentary: The Federal Health Information Technology Strategic Plan (2011-2015)<div class="Standard">
<span lang="EN-US">This commentary first
published on 5-6-11 remains relevant, particularly in light of slow
progress in development of infrastructures for health information
exchange: </span><br />
<br />
<span lang="EN-US">The <a href="http://healthit.hhs.gov/portal/server.pt/community/federal_health_it_strategic_plan_-_overview/1211"><i><span style="color: windowtext; text-decoration: none;">Federal Health Information Technology Strategic Plan</span></i></a><a href="http://healthit.hhs.gov/portal/server.pt/community/federal_health_it_strategic_plan_-_overview/1211"><span style="color: windowtext; text-decoration: none;"> (2011-2015)</span></a>
lays out the HIT vision, mission and principles as well as goals,
objectives and strategies to be implemented in the next five years. My
commentary will address first the guiding principles for health IT at
the foundation of the overall strategy and how these principles affect
the five goals formulated in the plan: I – Adoption and information
exchange through meaningful use, II – Improvement of care and population
health as well as cost reduction, III - Promotion of confidence and
trust in health IT, IV – Individual empowerment with health IT to
improve care processes and the health care system, and V - Achievement
of learning and technological advancement. In conclusion, some
recommendations will be outlined.</span></div>
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<span lang="EN-US">The
principles on page 8 emphasize the needs and rights of individuals and
the reliance “to the extent possible” on private markets to achieve
societal objectives - with intervention only “when necessary” to correct
market failures. This reliance on private markets is contrary to
international development experience as well as theory and research in
health economics demonstrating inadequacies of capital markets in
provision of social services.[1,2] It is important to distinguish
between competitive innovation in health services and the health
information infrastructure (the NHIN) required to support such
activities. While HIT infrastructure may be defined as a public good,
both public and private services markets may share the resulting
institutional ecology.</span></div>
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<span lang="EN-US">The
focus on outcomes is critical to the success of health care reform, but
this emphasis will not be adequate to motivate performance if national
system design remains fragmented. Private markets will not foster the
emergence of a system infrastructure as seems to be an implicit
principle. Furthermore, costs associated with extensive
micro-measurement of individual health care outcomes should not be
underestimated. (I have reviewed the concept of “value” in health care
outcomes as formulated by M. Porter <a href="http://eresearchcollaboratory.blogspot.com/2011/04/porter-on-value-in-health-care-ii.html"><span style="color: windowtext; text-decoration: none;">on my blog</span></a>
because it seems to me that his model is consistent with the
ideological viewpoint of the majority of the U.S. policy-making
community.[3,4])</span></div>
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<span lang="EN-US">Building
on “what works” is also an essential principle of any learning system,
but as I have suggested in earlier commentaries, the focus in the U.S.
health care system seems restricted to experiences within its
boundaries. There are virtual natural experiments in progress in
developing countries as well as industrialized nations around the world,
and the U.S. could learn valuable lessons and avoid expensive mistakes
through systematic analysis of selected national health care systems.
This approach would encourage evidence-based learning and innovation to
more rapidly close the significant lag in health care system
performance that threatens the competitive stance of the U.S. in the
global economy.</span></div>
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<b><i><span lang="EN-US">Goal I: Achieve Adoption and Information Exchange through Meaningful Use of Health IT </span></i></b><span lang="EN-US">(page 9) should be reformulated: <i>Achieve Adoption and Meaningful Use of Health IT through Information Exchange.</i>
The creation of infrastructure for health information exchange is
prerequisite to adoption of health information technology and its
meaningful use. For example the Veterans Administration (VA)
(mentioned on page 10) operates a single payer system through a
federally supported infrastructure that makes possible HIE. The
functionalities to exchange information integrated in EHRs and to report
data relevant to public health are some of the most important intrinsic
motivators for HIT adoption – affecting all stakeholders: providers,
payers, patients and consumers. The VA offers a demonstration of the
effectiveness of an integrated single payer system, as well as the
benefits of HIE. However, the VA is a subsystem distinct from other
segments of the health care sector, and thus will probably not
contribute to the critical mass (or tipping point) necessary for health
care system transformation as discussed on page 10. Principles guiding
the VA, Medicare and Medicaid are very different from those at the
foundation of private insurance markets for the majority of U.S.
citizens.</span></div>
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<span lang="EN-US">On page 11 Strategy I.A.2 proposes implementation support to help health care providers through the <a href="http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3519"><span style="color: windowtext; text-decoration: none;">Regional Extension Center (REC) Program</span></a>.
While funding for this program has been extended beyond the initial
two-year time horizon, these organizations will be required to develop
business models to become self sustainable. As is the case for Regional
Health Information Organizations (RHIOs) and State Designated Entities
(SDEs), such business models have not been identified.[5] <a href="http://eresearchcollaboratory.blogspot.com/2010/09/regional-extension-centers-and-hie.html"><span style="color: windowtext; text-decoration: none;">Some
observers have further noted that funded RECs may favor selected
vendors for interoperability, thus introducing a significant conflict of
interest in the support they offer.</span></a> <a href="http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/"><span style="color: windowtext; text-decoration: none;">(See SoftwareAdvice, 9-23-2010)</span></a>
It may not be realistic to assume that RECs working with competing
vendor consultants will “collaborate with one another and with relevant
stakeholders to identify and share best practices in EHR adoption,
meaningful use, and provider support.” (page 11). </span></div>
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<span lang="EN-US">Consistent
with M. Porter, the strategic intention is to move away from the
process requirements formulated in stage one of meaningful use towards
improvements in outcomes and quality of care.[3,4] However, it should
not be assumed that such improvements will be correlated with meaningful
use of health information technology as in the Federal HIT Strategy.
In Canada, penetration of EHR is low, comparable to rates reported in
the U.S.[6], but health care system performance measured by public
health indicators and overall per capita cost is ranked higher .[7]
This would suggest that the superior performance of the Canadian system
is explained by other factors – possibly higher rates of sustained <a href="http://www.commonwealthfund.org/Content/Charts/Chartbook/Multinational-Comparisons-of-Health-Systems-Data--2006/P/Public-Investment-per-Capita-in-Health-Information-Technology-as-of-2005.aspx"><span style="color: windowtext; text-decoration: none;">public investment in health IT infrastructures</span></a>
[8]and the single payer model[9]. Furthermore, there may be a variety
of paths to improvements in outcomes and quality of care as a result,
for example, of major technological, institutional or medical paradigm
shifts – in progress but as yet unforeseen. </span></div>
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<span lang="EN-US">Strategy
I.A.5 emphasizes the process to certify EHR technology for meaningful
use. The strategy as formulated does not address the <a href="http://www.cchit.org/sites/all/files/Pricing-ONC-ATCB-2011-2012_0.pdf"><span style="color: windowtext; text-decoration: none;">financial burden on software vendors to achieve certification of their products.</span></a>
There is furthermore little clarification concerning validity of
certification over time and the business model to be associated with
continued certification: <a href="http://www.cchit.org/about/towncalls/CCHIT-Town-Call-Authorized-HHS-certification-program"><span style="color: windowtext; text-decoration: none;">See CCHIT Town Call: ONC-ATCB 2011/2012 Certification Program (September 20,2010)</span></a></span></div>
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<i><span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Do ONC-ATCB certified products have to undergo re-certification for each new release?</span></i></div>
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<span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Following ONC/HHS Final Rules</span><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="color: #215968; font-size: 10pt;">, <a href="http://edocket.access.gpo.gov/2010/2010-14999.htm"><span style="color: #215968; text-decoration: none;">Establishment of the Temporary Certification Program for Health Information Technology</span></a></span></i><span lang="EN-US" style="color: #006b6b; font-size: 10pt;">,
certification is completed with a specific version of the technology
that was tested by CCHIT and found compliant with the relevant
certification criteria. For the purpose of maintaining certification,
“minor product changes” are those modifications and updates to a
certified product that are unlikely to affect the product’s compliance
with the certification criteria. Retesting may not be required but the
vendor is required to notify the ONC-ATCB and provide self-attestation
that the changes are minor.</span></div>
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<span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Modifications
with a significant risk of affecting the product’s compliance are
considered to be a “significant product change.” Retesting is required.
Applicants are required to self-classify their product modifications
and updates into one of these two categories.</span></div>
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<i><span lang="EN-US">Will software re-certification be required for each "meaningful use" stage?</span></i></div>
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<span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Yes;
the criteria, standards and test procedures will change for each stage.
ONC has retained the right to change certification criteria at any
time, but it is most likely that this will not occur until the next
stage. The Final Rule states that the Temporary Certification Program is
scheduled to sunset on December 31, 2011, unless HHS/ONC decides to
extend it or hasn’t defined the permanent program. </span></div>
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<i><span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Is
there an effective period for certification? For example, if an EHR is
certified in January 2011, when would the certification end and when
would the technology need to be retested?</span></i></div>
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<span lang="EN-US" style="color: #006b6b; font-size: 10pt;">The
effective period certification is determined by when ONCs publishes new
rules for standards and certification criteria. If you are selling your
software to providers who wish to meet the requirements of all three
stages of meaningful use, you will need to recertify your EHR technology
for 2013/2014 and 2015/2016.</span></div>
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<span lang="EN-US" style="color: black;">The
process of re-certification will be costly to vendors and entities
implementing self-developed software products. The significant
uncertainties associated with certification also increase risk inherent
in such investments. Little data is available for evaluation of such
risks and published information, such as the CCHIT Toolkit is often
expensive as well. (The Toolkit – developed under federal funding -
costs $1000 unless the entity seeking access to the information is
committed to apply for certification. This policy discourages detailed
review by prospective CCHIT applicants as well as researchers and the
general public.)</span></div>
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<span lang="EN-US" style="color: black;">I have already commented on policies regarding <a href="http://eresearchcollaboratory.blogspot.com/search?q=RECs"><span style="color: black; text-decoration: none;">health information exchange (HIE)</span></a> and <a href="http://eresearchcollaboratory.blogspot.com/2011/02/stage-2-meaningful-use-objectives.html"><span style="color: black; text-decoration: none;">meaningful use</span></a>.
Objective I.B cites the lack of sustainable business model to support
HIE as well as fragmented policy-making at the federal, state and local
levels. The federal strategy mistakenly states that there are “many
sustainable exchange options … for certain providers and certain types
of information.” (page 15) The federal government will: 1-Foster
business models that create health information exchange, 2-Monitor
health information exchange options and fill the gaps for providers that
do not have viable options, and 3-Ensure that health information
exchange takes place across individual exchange models. (page 15) These
roles cannot be assumed by the federal government unless the necessary
infrastructure is redefined as a public good sustained by significant
public investment. In particular, it is not useful to propose “filling
the gaps” where no system exists. It would be more constructive to
leverage <a href="http://eresearchcollaboratory.blogspot.com/2011/03/us-health-care-system-infrastructure.html"><span style="color: black; text-decoration: none;">an existing program such as the National Information Exchange Model (NIEM)</span></a>, thus assuring integration with other systems for national security and disaster management- as suggested on page 18.</span></div>
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<span lang="EN-US" style="color: black;">Another very important policy issue related to federal health IT strategy is <a href="http://www.broadband.gov/"><span style="color: black; text-decoration: none;">broadband </span></a>Internet access as mentioned on page 16. <a href="http://cyber.law.harvard.edu/pubrelease/broadband/"><span style="color: black; text-decoration: none;">Comparative country analysis </span></a>suggests
that the U.S. lags behind other OECD countries in pricing, speed,
penetration and access.[10] Some observers believe that the U.S. does
not now have adequate broadband infrastructure to support full
deployment of HIT meaningful use and health information exchange. The
infrastructures required for HIT implementation are prerequisite to most
of the policies formulated in the Federal Health IT Strategic Plan.
Moving forward without these infrastructures in place will result in
significant waste in funded efforts as well as loss of credibility and
trust at a critical time in health care system reform.</span></div>
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<span lang="EN-US" style="color: black;">On
page 18 it is stated that the ONC is “tracking the activities of other
countries and learning from their experiences with health IT and health
information exchange.” There is very little evidence that this is the
case, particularly with regard to our closest neighbors, Canada and the
Latin American region. <a href="http://www.eresearchcollaboratory.com/POSTER%20AMIA%20SYMP2009%20US%20case.pdf"><span style="color: black; text-decoration: none;">Regional collaboration needs to be extended across the hemisphere</span></a>
to facilitate system integration for health information exchange,
research and education. (Large grid and cloud systems for basic and
translational research are discussed on pages 27-28, while there is no
mention of extension of such systems across regional boundaries.)</span></div>
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<b><i><span lang="EN-US" style="color: black;">Goal
II of the Federal Strategic Plan (page 22) is to improve care, improve
population health, and reduce health care costs through the use of
health IT. </span></i></b><span lang="EN-US" style="color: black;"> Strategy
II.A.2 (page 24) calls for administrative efficiencies to reduce cost
and burden for providers, payers, and government health programs. This
is a very important but also very elusive objective as programs for
payment reform such as the formation of Accountable Care Organizations
call for additional administrative mechanisms to assure outcome
measurement and reporting as well as distribution of savings and
incentives to participants. The strategy also calls for “<i>more
granular understanding of health care treatments and outcomes, and more
complete analyses of treatment costs, ultimately allowing for better
disease management and more efficient health care delivery.</i>”(page
25) Such detailed analysis of treatment costs is aligned with multiple
private health insurers' requirements, and is often accomplished at the
expense of a system-level focus on population health. The public
funding of new health insurance exchanges -particularly in the absence
of a public health insurance option - also subsidizes the interests of
private health insurers by assuming the costs of infrastructure
benefiting for-profit enterprise in health care services. These costs
should be assigned to the private sector.</span></div>
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<span lang="EN-US" style="color: black;">Strategy
II.D.3 (page 27) calls for a mechanism to support information exchange
for research and the translation of research findings back into clinical
practice. This strategy also emphasizes the importance of
infrastructure for HIE as well as large grid and cloud-based systems for
the exploration of the wealth of existing data on the human genome. As
mentioned above, extensive and sustainable public investments are
essential to assure the creation and maintenance of such national
infrastructures (including broadband) and to promote their
interconnection with larger regional systems.</span></div>
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<b><i><span lang="EN-US" style="color: black;">Goal
III (page 29) calls for strategies to inspire confidence and trust in
health information technology by protecting confidentiality, integrity
and availability of health information, informing individuals of their
rights, and improving safety and effectiveness of IT. </span></i></b><span lang="EN-US" style="color: black;"> Central
to these issues is the assurance of an individual digital identity in
the health care services ecosystem. While the individual patient is the
central focus of health care system reform efforts, there is no
credible plan to provide a unique digital identity to every citizen.
(This is one of the most intriguing internal contradictions in the logic
of the U.S. model of reform.) Privacy protections as they are
currently designed are more consistent with the interests of private
health care insurers than those of the individuals they serve. These
protections pose obstacles to data aggregation as well as disclosure
relative to insurance plan performance.</span></div>
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<span lang="EN-US" style="color: black;">The <a href="http://www.nist.gov/nstic/"><span style="color: black; text-decoration: none;">National Strategy for Trusted Identities in Cyberspace </span></a>(April, 2011)[11] “recognizes</span><span lang="EN-US" style="color: black;">
that trusted digital identity, authentication and authorization
processes are one part of layered security. Improvements in
identification and authentication are critical to attaining a trusted
online environment; however, they must be combined with other crucial
aspects of cybersecurity.” (page 8). While recognition of the critical
importance of individual digital identities represents an important
step, the proposed system calls for complex roles to be implemented by
multiple actors in both public and private sectors. While the federal
government plays a significant role in the early stages of the
initiative, it is expected that new and sustainable business models
will be developed for each of the service provider roles of the system
(page 37) so that the identity ecosystem will become a self- sustaining
market place.</span></div>
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<span lang="EN-US" style="color: black;">This
strategy for trusted identities in cyberspace embodies the same errors
as federal policies for promotion of the Nation-wide Health Information
Network (NHIN) for health information exchange. A reliable and valid
digital identity cannot be the output of complex private sector market
dynamics. This policy principle assures that there will not be
universal access to reliable digital identity, and that the U.S. model
will probably not be interoperable with those of other countries. The
consequences of this stance for U.S competitive advantage in the global
economy should not be underestimated. Moreover, a market supporting
for-profit digital ID roles would be a fertile context for fraud and ID
theft as well as other illegal transactions based on digital ID
information.</span></div>
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<div class="Standard" style="tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black;">Examples of strategies for unique citizen identification in other countries include the British</span><span lang="EN-US"><a href="http://www.connectingforhealth.nhs.uk/systemsandservices/nhsnumber/"><span style="color: windowtext; text-decoration: none;"> NHS unique patient identifier</span></a></span><span lang="EN-US" style="color: black;">,[12]and the </span><span lang="EN-US"><a href="http://uidai.gov.in/"><span style="color: windowtext; text-decoration: none;">Indian “Aadhaar”</span></a></span><span lang="EN-US" style="color: black;">, </span><span lang="EN-US" style="font-size: 11pt;"> <i>a
12-digit unique number which the Unique Identification Authority of
India (UIDAI) will issue for all residents. The number will be stored in
a centralized database and linked to the basic demographics and
biometric information – photograph, ten fingerprints and iris – of each
individual.</i> </span><span lang="EN-US" style="color: black;"> (</span><span lang="EN-US"><a href="http://www.hindu.com/2011/04/23/stories/2011042359351300.htm"><span style="color: windowtext; text-decoration: none;">The U.S. State Department has shown some interest</span></a></span><span lang="EN-US" style="color: black;">
in the Indian system - for reasons related to National
Security-according to cable communications made public by
Wikileaks.[13])</span></div>
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<b><i><span lang="EN-US" style="color: black;">Goal IV (page 36) calls for individual empowerment for improvement of health and the health care system.</span></i></b><span lang="EN-US" style="color: black;">
The successful pursuit of this goal depends upon the public
infrastructures for digital identity and health information exchange as
discussed above – as well as</span><span lang="EN-US"><a href="http://www.ahrq.gov/clinic/epcsums/litupsum.htm"><span style="color: windowtext; text-decoration: none;"> health literacy</span></a></span><span lang="EN-US" style="color: black;">
interventions to improve individual skills. [14][15] These studies
suggest that only one in ten adults in the U.S. may possess the
knowledge and skills required to perform at a high level of health
literacy. Population health literacy is prerequisite to individual
empowerment as well as to creation of a learning health system (Goal V).</span></div>
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<b><i><span lang="EN-US">Goal
V (page 42) calls for achievement of rapid learning and technological
advancement through creation of a learning health system to support
quality, research and population health, as well as increased capacity
for innovation and research. </span></i></b><span lang="EN-US">The
national capacity for innovation and research requires infrastructures
developed as a public good. Sustained public investments contribute to
the foundation for a learning health care system. Another important
aspect of learning systems and capacity for innovation and research is
open access to information. Some important steps have been taken in the
U.S. system to improve such access to federally funded research, such
as the </span><span lang="EN-US"><a href="http://publicaccess.nih.gov/"><span style="color: windowtext; text-decoration: none;">National Institutes of Health Public Access Policy</span></a></span><span lang="EN-US">
applicable to any manuscript reporting research funded by the NIH -
accepted for peer-reviewed publication on or after April 7, 2008. <i>“<span style="color: black;">To
help advance science and improve human health, the policy requires that
these papers are accessible to the public on PubMed Central no later
than 12 months after publication.”</span></i><span style="color: black;">
While this policy represents progress toward the goal of open access to
scientific information, the delay of 12 months allowed for compliance
significantly reduces its effectiveness.</span></span></div>
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<div class="Standard" style="margin-left: 4.5pt; tab-stops: 472.5pt; text-indent: -1.5pt;">
<span lang="EN-US" style="color: black;">The </span><span lang="EN-US"><a href="http://regional.bvsalud.org/php/index.php"><span style="color: windowtext; text-decoration: none;">Latin-American and Caribbean Center on Health Sciences Information</span></a></span><span lang="EN-US" style="color: black;">
(Bireme) illustrates a regional model for open access to health
information available through the Virtual Health Library. The model for
this library is published in the </span><span lang="EN-US"><a href="http://regional.bvsalud.org/php/index.php"><span style="color: windowtext; text-decoration: none;">VHL Guide 2011</span></a></span><span lang="EN-US" style="color: black;">
now available for comment and consultation. Background information is
available in the publications of A. Packer, former director of
Bireme.[16]. </span><span lang="EN-US"><a href="http://new.paho.org/blogs/kmc/?p=579"><span style="color: windowtext; text-decoration: none;">Dr. Pedro Urra,</span></a></span><span lang="EN-US" style="color: black;"> the new director of Bireme, has been responsible for the creation and development of </span><span lang="EN-US"><a href="http://www.jmir.org/2006/1/e1/"><span style="color: windowtext; text-decoration: none;">INFOMED</span></a></span><span lang="EN-US" style="color: black;">,[17-20]
the Cuban National Health Care Telecommunications Network and Portal.
[21] The U.S. should develop policies to join this important regional
initiative and to further promote open access to health sciences
research.</span></div>
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<b><i><span lang="EN-US" style="color: black;">Summary </span><span lang="EN-US">recommendations</span></i></b></div>
<br />
<span lang="EN-US" style="color: black;">1.
Public investment in a national health information infrastructure to
promote interoperability for both public and private services - a single
infrastructure does not necessarily imply a single payer design.</span><span lang="EN-US" style="color: black; font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<br />
<span lang="EN-US" style="color: black;">2. Federal government provision of goal oriented services and tools - rather than financial incentives.</span><span lang="EN-US" style="color: black; font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<span lang="EN-US" style="color: black; font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<span lang="EN-US" style="color: black;">3. Restriction of public reimbursement for basic health care products and services to not-for-profit enterprises.</span><span lang="EN-US" style="color: black;"> </span><br />
<br />
<span lang="EN-US" style="color: black;">4.
Extension of open access policies governing availability of public
health information and published research in medicine and the health
sciences.</span><span lang="EN-US" style="font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<span lang="EN-US" style="font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<span lang="EN-US" style="font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="color: black;">5.
Collaboration across the Americas as a foundation for large scale grid
and cloud infrastructures to support regional research and innovation
through the </span><span lang="EN-US" style="color: black;"> </span><span lang="EN-US"><a href="http://regional.bvsalud.org/php/index.php"><span style="color: windowtext; text-decoration: none;">Latin-American and Caribbean Center on Health Sciences Information</span></a></span><span lang="EN-US" style="color: black;"> – BIREME.</span><br />
<span lang="EN-US" style="color: black;">
<br />
</span><br />
<span lang="EN-US" style="color: black;"> </span> <br />
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="color: black;">References</span></i></b></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[1]
Arrow K, Auerbach A, Bertko J, Brownlee S, Casalino LP, Cooper J, et
al. Toward a 21st-Century Health Care System: Recommendations for Health
Care Reform. Ann.Intern.Med. 2009 April 7;150(7):493-495.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[2] Arrow K. Uncertainty and the Welfare Economics of Medical Care. The American Ecocomic Review 1963;53(5):941-973.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[3] Porter ME. What Is Value in Health Care? N.Engl.J.Med. 2010;363(26):2477-2481.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[4] Porter ME. A Strategy for Health Care Reform -- Toward a Value-Based System. N.Engl.J.Med. 2009 July 9;361(2):109-112.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[5]
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.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[6]
Rozenblum R, Jang Y, Zimlichman E, Salzberg C, Tamblyn M, Buckeridge D,
et al. A qualitative study of Canada's experience with the
implementation of electronic health information technology. CMAJ 2011
March 22;183(5):E281-288.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[7]
Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care
System Compares Internationally 2010 Update.Davis K, Schoen C,
Stremikis K. 2010.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[8]
Anderson G, Frogner B, Johns R, Reinhardt U. Health Care Spending and
Use of Information Technology in OECD Countries. Health Affairs
2006;25(3):819-831.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[9]
Tuohy CH. Single Payers, Multiple Systems: The Scope and Limits of
Subnational Variation under a Federal Health Policy Framework. Journal
of Health Politics Policy and Law 2009 August 1;34(4):453-496.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[10]
Next Generation Connectivity: A review of broadband Internet
transitions and policy from around the world.Benkler Y, Faris R, Gasser
U. 2010.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[11]
National Strategy for Trusted Identities in Cyberspace: Enhancing
Online Choice, Efficiency, Security, and Privacy.The White House. 2011.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[12] Smyth RL. Regulation and governance of clinical research in the UK. BMJ 2011 January 13;342.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[13] U.S. interest in unique identification project.Srivathsan. A. The Hindu 2011;Opinion.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[14]
The Health Literacy of America's Adults: Results From the 2003 National
Assessment of Adult Literacy.National Center for Education Statistics.
2006;NCES 2006–483.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[15]
Health Literacy Interventions and Outcomes: An Updated Systematic
Review.Berkman N, Sheridan S, Donahue K, et al. 2011;11-E006.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[16] Packer AL. The SciELO Open Access: A Gold Way from the South. Canadian Journal of Higher Education 2009;39(3):111-126.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[17] Urra González P. Internet a la Cubana: El Ser Humano en el Centro de la Red. ACIMED 2003;11(1).</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[18] Urra González P. Letter: Global Alliance for Health Information. BMJ 2001;321(7264).</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[19]
Urra González P, Rodrígues Perojo K, Concepcíon Báez C, Canedo Andalia
R. Intranet of the National Medical Sciences Information Centre-
Infomed: A Working Space in the Network for the Health Information
System in Cuba. ACIMED 2006;14(1).</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[20]
Urra González P. Program for Strengthening the Scientific and Technical
Health Information System of Cuba. ACIMED 2005;13(3).</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;">[21]
Séror A. A Case Analysis of INFOMED: The Cuban National Health Care
Telecommunications Network and Portal. Journal of Medical Internet
Research 2006;8(1):e1.</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
<span lang="EN-US" style="color: black; font-size: 10pt;"><br />
</span></div>
<div class="Standard" style="margin-top: 12.05pt; tab-stops: 468.0pt;">
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<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">Since publication of my<a href="http://eresearchcollaboratory.blogspot.ca/2012/04/commentary-lenert-l-sundwall-d-lenert.html"> commentary</a> on<b><i> Lenert, L., Sundwall, D., Lenert, M.E., </i></b></span><b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;"><a href="http://jamia.bmj.com/content/early/2012/01/21/amiajnl-2011-000442.full" target="_blank"><span lang="EN-US" style="color: blue; mso-ansi-language: EN-US;">Shifts
in the Architecture of the Nationwide Health Information Network</span></a></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;">, Journal of the American Medical Informatics Association, Online First,
January 21, 2012 - </span></i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;"></span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;">I have pursued correspondence with the authors of the "Perspectives" article cited above as well as with the editorial team of JAMIA. Unfortunately, there has been no satisfactory response to my concerns. In light of this lack of editorial response, it appears that the misinterpretation of research studies in the article literature review is considered trivial - although in fact it is critical to support the authors' proposition that RHIOs offer a sustainable infrastructure for health information exchange in the United States. </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;"> This case in publication ethics raises some interesting issues.</span></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">In particular, the JAMIA editorial team seems to discourage any post
-publication debate regarding papers appearing in the journal, even when
legitimate concerns are raised by readers. Most scholarly journals
have policies governing the correction of errors identified in accepted
publications. (For example, see the Royal Society policies -
available at: <a href="http://royalsocietypublishing.org/site/authors/policy.xhtml" target="_blank"><span style="color: blue;">http://royalsocietypublishing.org/site/authors/policy.xhtml</span></a>
) Organizations specialized in publication ethics such as the Committee on Publication Ethics (COPE : http://publicationethics.org - of which JAMIA is a member) and the World Association of Medical Editors (WAME: http://www.wame.org/ ) require that their members develop such policies. </span></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">The BMJ and other journals published in the BMJ system seem to encourage
online post publication debate using the electronic function designed for that
purpose. I would suggest that the editorial team of JAMIA follow their example.
(See Richard Smith's interesting commentary on BMJ Group Blogs at <a href="http://blogs.bmj.com/bmj/2011/04/06/richard-smith-what-is-post-publication-peer-review/" target="_blank"><span style="color: blue;">http://blogs.bmj.com/bmj/2011/04/06/richard-smith-what-is-post-publication-peer-review/</span></a>
.)</span></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">I first wrote an electronic response to this article – and received an
automated acknowledgement from JAMIA on April 7. The text of my letter
appears on my blog at <a href="http://eresearchcollaboratory.blogspot.ca/2012/04/commentary-lenert-l-sundwall-d-lenert.html" target="_blank"><span style="color: blue;">http://eresearchcollaboratory.blogspot.ca/2012/04/commentary-lenert-l-sundwall-d-lenert.html</span></a>
- as well as the SCIVEE site where a recorded webinar of the JAMIA Journal
Club is available: <a href="http://www.scivee.tv/node/46861" target="_blank"><span style="color: blue;">http://www.scivee.tv/node/46861</span></a> </span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;">This article was subsequently republished in the July issue of JAMIA - without any
corrections - in volume 19(4) pp. 498-502. A letter to the Editor
has remained unpublished and without editorial response. One author's
response to my comments was rather defensive in tone, while </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">
members of the editorial team did not consider it their duty to address my
concerns. They seem to agree that articles accepted for publication
in JAMIA should be considered beyond any further question or debate. This
attitude is unworthy of a scholarly journal, particularly in an interdisciplinary
knowledge domain such as biomedical informatics. (See my response to the editor of CACM:<a href="http://cacm.acm.org/magazines/2012/7/151235-predatory-scholarly-publishing/fulltext"> http://cacm.acm.org/magazines/2012/7/151235-predatory-scholarly-publishing/fulltext</a> ) </span></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">My unanswered email communication with the editor is copied below:</span></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">This is just to let you know that I have submitted a response to the JAMIA article: </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;"><a href="http://jamia.bmj.com/content/early/2012/01/21/amiajnl-2011-000442.full" target="_blank"><span lang="EN-US" style="color: blue; mso-ansi-language: EN-US;">Shifts
in the Architecture of the Nationwide Health Information Network</span></a></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">, Journal of the American Medical Informatics Association, Online First,
January 21, 2012.</span></i></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
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<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">One author has answered my review, as copied below. He seems
particularly offended by my comments regarding his reporting of research
by Adler-Milstein et al. in 2008 and 2011 to support the census of RHIOs in
those years (100 and 200 active organizations-respectively). My intention
is certainly not to be rude, but to point out that it is essential to have
carefully read research cited in published studies - particularly in
interdisciplinary study. I am surprised and disappointed that neither the article authors nor the JAMIA reviewers of this manuscript appear to have read
Adler-Milstein's research. I have noted that JAMIA rarely encourages any
electronic dialogue on published articles, but in my opinion, thoughtful
comments should always have a place in public policy debate.</span></i></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
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<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">Many thanks for your kind consideration...</span></i></div>
<div class="MsoNormal" style="line-height: normal;">
<i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;"><br /></span></i></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;">_________________________________ </span></div>
<div class="MsoNormal" style="line-height: normal;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;">One author's response:</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;"> </span><i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;"> </span></i></div>
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<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">Ann</span></i></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">This article has triggered a great deal of discussion. Our article went
through 3 rounds of peer review at jamia with more than150 specific comments by
reviewers, some quite hostile. Before you accuse them of error and me of mis
representation, you better have a good argument. The fact the RHIOs, conceived
before meaningful use, and not well funded through HITECH don't meet the
requirements is not surprising. I think you should perhaps consider whether the
strength of evidence for MU in your arguments. I think the evidence for RHIOs
impact, flawed as it is, is far better than for MU regulations. These comments
are simply rude and have not place in academic discussion.</span></i></div>
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<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">I agree with your thoughts about organization theory and governance
needing more attention.</span></i></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: FR-CA;">Rather than critique the absence of work from your field, why not tell
us what it has to say? The business model for RHIOs and for national exchange
should be that of a public utility. I would be interested to learn about
organizational theory relevant to that model. I agree that the governance of
voluntary participation RHIOs is difficult. </span></i></div>
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<br /></div>
Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-14443540850934203732012-04-06T14:34:00.003-07:002012-04-07T14:17:25.452-07:00Commentary: Lenert, L., Sundwall, D., Lenert, M.E., Shifts in the Architecture of the Nationwide Health Information Network, Journal of the American Medical Informatics Association, Online First, January 21, 2012.Lenert, L., Sundwall, D., Lenert, M.E., <a href="http://jamia.bmj.com/content/early/2012/01/21/amiajnl-2011-000442.full" target="_blank">Shifts in the Architecture of the Nationwide Health Information Network</a>, Journal of the American Medical Informatics Association, Online First, January 21, 2012.<br />
<br />
<i><span style="font-size: small;"><b>Abstract:</b> In the midst of a US $30 billion USD investment in the Nationwide Health Information Network (NwHIN) and electronic health records systems, a significant change in the architecture of the NwHIN is taking place. Prior to 2010, the focus of information exchange in the NwHIN was the Regional Health Information Organization (RHIO). Since 2010, the Office of the National Coordinator (ONC) has been sponsoring policies that promote an internet-like architecture that encourages point to-point information exchange and private health information exchange networks. The net effect of these activities is to undercut the limited business model for RHIOs, decreasing the likelihood of their success, while making the NwHIN dependent on nascent technologies for community level functions such as record locator services. These changes may impact the health of patients and communities. Independent, scientifically focused debate is needed on the wisdom of ONC's proposed changes in its strategy for the NwHIN.</span></i><br />
<br />
This article contributes to the growing policy literature on ONC strategies to promote health information exchange through infrastructures of the Nationwide Health Information Network. While the authors call for an “independent, scientifically focused debate … on the wisdom of ONC’s proposed changes in its strategy…” there is little pertinent reference to research in organizational science or institutional economics to support such a debate. The authors focus on Regional Health Information Organizations (RHIOs) defined most often as not-for-profit organizations providing universal services for health information exchange in the interest of the communities they serve and more generally, the public good. The market-driven strategy for the NHIN assumes that RHIOs will develop in local communities and will interconnect to scale up to a nationwide infrastructure. Unfortunately this politically expedient assumption is inconsistent with the nature of competitive markets. Furthermore, since the benefits of health information exchange accrue to the broader health care system rather than entities investing in RHIO membership, no business model has been identified to support RHIOs with sustainable revenue streams independent of federal and state funding. <br />
<br />
Organizational research to date has documented the substantial federal and state investments in health information exchange – including variously defined RHIOs, health information exchange organizations (HIEs), and State Designated Entities (SDEs). The authors of the present article cite publications by Adler-Milstein et al. to suggest the progress of policies for RHIOs and health information exchange. Attentive reading of these articles reveals that the numbers of “active organizations” identified is subject to interpretation. Based on <a href="http://content.healthaffairs.org/content/27/1/w60.full" target="_blank">Adler-Milstein et al. (2008)</a>, Lenert et al. report « more than 100 active organizations » while 45 of these were in the planning stages and only 20 qualified to be included in the study sample. In 2011 Lenert et al. contend that the number of RHIOs had grown to more than 200 based on research by <a href="http://www.annals.org/content/154/10/666.full.pdf+html" target="_blank">Adler-Milstein et al. (2011)</a>. In fact this number included SDEs as well as RHIOs, and analysis revealed that none of these organizations met criteria for a « comprehensive RHIO » in light of meaningful use requirements.<br />
<br />
These misleading citations reflect an apparent bias in favor of RHIOs – entities threatened (according to Lenert et al.) by a shift to promote private networks and an Internet-like model for building the NHIN. A similar lack of careful reference to scientific research in organization science appears in other recent articles in health care policy published in Health Affairs (<a href="http://eresearchcollaboratory.blogspot.ca/2012/03/from-office-of-national-coordinator.html" target="_blank">See Williams et al., 2012, From the Office of the National Coordinator: The Strategy for Advancing the Exchange of Health Information, Health Affairs, 23 ( 3) (2012) pp. 527-536.</a>) as well as JAMIA (<a href="http://eresearchcollaboratory.blogspot.ca/2011/11/health-information-exchange.html" target="_blank">See Kuperman, G.J. 2011, Health-information exchange: why are we doing it, and what are we doing?, Journal of the American Medical Informatics Association, 18(5), 678-682.</a> From the perspective of this reviewer, there is no evidence base to conclude that policies for RHIOs (or other entities dedicated to health information exchange) are undermined by new initiatives, particularly where public investment to sustain RHIOs is unavailable. RHIOs also pose very significant challenges with the addition of new organizational layers for governance and accountability to numerous stakeholders.<br />
<br />
Lenert et al. correctly suggest that the successful development of the NHIN requires both nonpartisan consensus in public policy and independent scientific research to evaluate the effectiveness of alternative models. Unfortunately the highly charged political environment of an election year in the U.S. will favor neither.<br />
<br />
REFERENCES<br />
<span style="font-size: small;">Adler-Milstein, J., McAfee, A.P., Bates, D.W., et al.,<a href="http://content.healthaffairs.org/content/27/1/w60.full" target="_blank"> The State of regional health information organizations: current activities and financing. Health Aff </a>(Millwood) 2008;27:w60–9.(REF. 22)<br />
Adler-Milstein, J., Bates, D.W., Jha, A.K., <a href="http://www.annals.org/content/154/10/666.full.pdf+html" target="_blank"> A survey of health information exchange organizations in the United States: implications for meaningful use. </a>Ann Intern Med 2011;154:66–71.(REF. 23)<br />
</span><br />
<span style="font-size: small;">(Reviewers of this manuscript for JAMIA should have corrected errors in the reading of studies cited.)</span>Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-59241309087144054462012-03-24T07:09:00.001-07:002012-03-24T08:47:39.135-07:00From the Office of the National Coordinator: The Strategy for Advancing the Exchange of Health Information, HEALTH AFFAIRS, Vol. 23, No. 3 (2012) pp. 527-536.<a href="http://content.healthaffairs.org/content/31/3/527.short" target="_blank">From the Office of the National Coordinator: The Strategy for Advancing the Exchange of Health Information</a>, HEALTH AFFAIRS, Vol. 23, No. 3 (2012) pp. 527-536. <br />
<br />
This important article from the Office of the National Coordinator for Health Information Technology (ONC) identifies the critical role of health information exchange in the achievement and measurement of meaningful use of electronic health records. Infrastructures for health information exchange are prerequisite to measurement of the criteria for meaningful use, but the development of such a system on a national scale in the U.S. remains a work in progress, threatened by the vicissitudes of a fragmented political process. The authors of the article describe three types of exchange: 1- “sending and receiving health information to support coordinated care,” 2- “finding patient health information for unplanned care,” and 3-“enabling patients to aggregate their own health information.” Each of these modes of exchange poses unique technical challenges, but all are necessary for meaningful communication of health information across the Nationwide Health Information Network (NHIN).<br />
<br />
At issue is the design and implementation of the required supporting infrastructure. As recognized by the authors, strategies for development of Regional Health Information Organizations (RHIOs) have provided initial public funding under the assumption that such organizations could develop sustainable business models and eventually interconnect for health information exchange on a national scale. Unfortunately sustainable business models for RHIOs have not emerged, while many other apparently more viable initiatives are being developed by large hospital systems, electronic health records vendors, and newly formed ACOs. Amidst this organizational diversity, problems remain in promoting interoperability and information exchange among competing systems.<br />
<br />
Some recent research suggests that RHIOs and other publicly funded health information exchange organizations may be inadequate to satisfy the criteria set forth for meaningful use. (See Adler-Milstein et al. 2011, A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use, Annals of Internal Medicine, 154(10) 666-671 available at http://www.annals.org/content/154/10/666.abstract )<br />
<br />
Adler-Milstein et al. elaborated the definition of a “comprehensive RHIO” in light of the HIE requirements for meaningful use of electronic health records (EHRs). This definition was developed by a panel of 9 national health policy experts using a Delphi methodology to arrive at consensus. Analysis revealed that none of the RHIOs included in the sample satisfied the meaningful use criteria. This finding portends the possible failure of the market driven “network of networks” approach to development of the NHIN. (See further comment on my blog at http://eresearchcollaboratory.blogspot.ca/2011/11/health-information-exchange.html )<br />
<br />
In the present article, only one reference supports the statement that “the number of active private health information exchange entities tripled from 52 in 2009 to 161 in 2010.” (page 528) No definition of the “active private health information exchange entity” is offered, nor is there any description of the research methodology used to identify such entities. (The proprietary consulting report is available at https://www.klasresearch.com/store/ReportDetail.aspx?ProductID=642 )<br />
<br />
The paucity of scientific organizational research to orient the design and governance of health information exchange and the NHIN is surprising in a community so engaged in promoting evidence-based medical practice and policy-making. Perhaps the interdisciplinary nature of the research enterprise (well beyond the comfort zone of most medical researchers dedicated to standards of the randomized controlled trial) obscures thinking in terms of large social systems. Systems thinking, however, defines the broader context of the individual EHR and health information exchange. Without attention to the “big picture”, faulty assumptions within diverse disciplinary silos will guide ONC policies described in this article to costly and certain failure. Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-54927323201156252032011-11-12T12:45:00.000-08:002012-09-05T06:06:03.308-07:00Health Information Exchange: Infrastructures and Market Dynamics<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:HyphenationZone>21</w:HyphenationZone> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>FR-CA</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:EnableOpenTypeKerning/> <w:DontFlipMirrorIndents/> <w:OverrideTableStyleHps/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
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<span lang="EN-US" style="mso-ansi-language: EN-US;">Kuperman, G.J. 2011, “Health-information exchange: why are we doing it, and what are we doing?”<span style="mso-spacerun: yes;"> </span>Journal of the American Medical Informatics Association, 18(5), 678-682.<span style="mso-spacerun: yes;"> </span></span><a href="http://jamia.bmj.com/content/18/5/678.full"><span lang="EN-US" style="mso-ansi-language: EN-US;">http://jamia.bmj.com/content/18/5/678.full</span></a><span lang="EN-US" style="mso-ansi-language: EN-US;"> <br />
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<span lang="EN-US" style="mso-ansi-language: EN-US;">This important article offers a very useful conceptual view of health information exchange – set in the context of US health care sector market dynamics.<span style="mso-spacerun: yes;"> </span>The author summarizes the early history of the Nationwide Health Information Network (NHIN) and the HITECH Act of 2009 promoting the introduction of health information technology<span style="mso-spacerun: yes;"> </span>(HIT) on a national scale.<span style="mso-spacerun: yes;"> </span>The article begins with the vision of health information exchange (HIE) as a key enabler of high quality and efficient health care.<span style="mso-spacerun: yes;"> </span>According to the author, early demonstration projects conducted from 2005-2007 have shown that the interconnection of RHIOs for health information exchange in the “network of networks” requires neither a centralized national infrastructure nor a national patient identifier.<span style="mso-spacerun: yes;"> </span>Unfortunately, these conclusions are more ideological than scientific, as there is little corroborating evidence in policy or organizational research.<span style="mso-spacerun: yes;"> </span></span></div>
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<span lang="EN-US">Since 2005, the eHealth Initiative has reported on the development and sustainability of RHIOs and State Designated Entities (SDEs) across the United States. <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Kuperman cites the 2010 eHealth Initiative HIE Survey<span style="mso-spacerun: yes;"> </span>findings (available at <a href="http://www.ehealthinitiative.org/resources/viewcategories.html">http://www.ehealthinitiative.org/resources/viewcategories.html</a> <a href="http://www.ehealthinitiative.org/members-download/finish/4-open/35-hie-survey-report-2010-key-findings.html"></a> ) <span style="mso-spacerun: yes;"> </span>to substantiate the existence of 73 “operational” initiatives, but he does not mention that among those, the report finds that only 18 can be described as “sustainable” – sustained on operational revenue alone and not dependent on federal funding. (See page 2 of the Key Findings.<span style="mso-spacerun: yes;"> </span>One of the findings listed on page 1, states that “<b style="mso-bidi-font-weight: normal;">Sustainability is an attainable goal for health information exchange organizations. There is a small but critical mass of sustainable organizations.</b> ”<span style="mso-spacerun: yes;"> </span>This finding is without adequate foundation in the eHealth Initiative data analysis or other studies of health care organization.<span style="mso-spacerun: yes;"> </span>Such data interpretation threatens the formulation of credible policy on health information technology in US system reform.) <span style="mso-spacerun: yes;"> </span>The terms RHIO, SDE and HIE refer to organizations that address the” business issues of interoperability”, but critical review of<span style="mso-spacerun: yes;"> </span>eHealth Initiative research as well as other published scholarly articles suggests that sustainable business models have not been identified.<span style="mso-spacerun: yes;"> </span></span></div>
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<span lang="EN-US">My reviews of these reports reveal some methodological deficiencies that tend to weaken published study conclusions. (See <a href="http://eresearchcollaboratory.blogspot.com/2009/10/health-information-exchange-update.html">http://eresearchcollaboratory.blogspot.com/2009/10/health-information-exchange-update.html</a> <span style="mso-spacerun: yes;"> </span>.<span style="mso-spacerun: yes;"> </span>My blog review was completed before the eHealth Initiative redefined their HIE reports as proprietary – despite Federal funding supporting the research.<span style="mso-spacerun: yes;"> </span>Only the “key findings” are available for public review.<span style="mso-spacerun: yes;"> </span>The validity of such findings cannot be evaluated without access to the research methodology.)<span style="mso-spacerun: yes;"> </span>From year to year, the eHealth<span style="mso-spacerun: yes;"> </span>Initiative reports that the number of HIE entities has increased - without accounting for sample mortality or changes in their definition of HIEs.<span style="mso-spacerun: yes;"> </span></span></div>
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<span lang="EN-US">Another publication (See<span style="mso-spacerun: yes;"> </span>Julia Adler-Milstein, David W. Bates and Ashish K. Jha, 2009, U.S. Regional Health Information Organizations: Progress And Challenges, Health Aff , 28( 2) 483-492 available at <a href="http://content.healthaffairs.org/content/28/2/483.abstract">http://content.healthaffairs.org/content/28/2/483.abstract</a> <span style="mso-spacerun: yes;"> </span>.) based in part on data from the <span style="mso-spacerun: yes;"> </span>eHealth Initiative (See <a href="http://www.ehealthinitiative.org/resources/viewcategories.html">http://www.ehealthinitiative.org/resources/viewcategories.html</a> <span style="mso-spacerun: yes;"></span>) <span style="mso-spacerun: yes;"> </span>includes a measure of time spent in HIE planning.<span style="mso-spacerun: yes;"> </span>This indicator seems to be negatively associated with operational status of the entities in the sample. While Adler-Milstein et al. conclude that a lengthy planning process may challenge HIE viability, it is also possible that this result reflects the short life expectancy of HIE entities – as time spent in planning may serve as a partial surrogate for longevity.<span style="mso-spacerun: yes;"> </span></span></div>
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<span class="slug-pages"><span lang="EN-US">These authors have also published another study (apparently based on some of the same data). (See Adler-Milstein et al. 2011, <span style="mso-spacerun: yes;"> </span>A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use, Annals of Internal Medicine, 154(10) 666-671 available at <a href="http://www.annals.org/content/154/10/666.abstract">http://www.annals.org/content/154/10/666.abstract</a> )</span></span></div>
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<span class="slug-pages"><span lang="EN-US" style="mso-ansi-language: EN-US; mso-bidi-font-style: italic;">They elaborated the definition of a “comprehensive RHIO” in light of the HIE requirements for meaningful use of electronic health records (EHRs).<span style="mso-spacerun: yes;"> </span>This definition was developed by a panel of 9 national health policy experts using a Delphi methodology to arrive at consensus. <span style="mso-spacerun: yes;"> </span>Analysis revealed that none of the RHIOs included in the sample satisfied the criteria of this definition.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>This finding suggests the possible failure of the market driven “network of networks” approach to development of the NHIN. <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span> </span></span></div>
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<span class="slug-pages"><span lang="EN-US">Such failure may also be attributed to the short time frame (2-4 years) for public funding in support of RHIOs as well as the requirement that they develop business models based on revenue streams from private stakeholders and system users. <span style="mso-spacerun: yes;"> </span>Such business models are all the more difficult to identifiy given that the significant benefits of health information exchange often accrue at the system level rather than the individual provider or payer level of analysis.<span style="mso-spacerun: yes;"> </span>Adler-Milstein et al. (2011) conclude that their findings “…<b style="mso-bidi-font-weight: normal;">call into question whether RHIOs in their current form can be self-sustaining and effective in helping U.S. physicians and hospitals engage in robust HIE to improve the quality and efficiency of care.”</b> (See abstract.) <span style="mso-spacerun: yes;"> </span>Questions raised in this study suggest that the “network of networks” strategy based on the sustainability of RHIOs cannot be assumed as in Kuperman’s analyses of other projects, such as Direct and Connect <span style="mso-spacerun: yes;"> </span>for health information exchange in the context of health sector market dynamics.</span></span></div>
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<span class="slug-pages"><span lang="EN-US">The second issue related to health information infrastructures required for national system reform is the creation of a unique patient identifier.<span style="mso-spacerun: yes;"> </span>As mentioned above, Kuperman suggests that such an identifier was shown to be unnecessary in early demonstration projects for the NHIN and the “network of networks” approach.<span style="mso-spacerun: yes;"> </span>This is another ideologically convenient finding, without an evidence base in policy experience or organizational research.<span style="mso-spacerun: yes;"> </span>Kuperman argues that the advantage of a PUSH model such as Direct is to avoid the necessity of linking patient identifiers across systems before data transfer between health care organizations.<span style="mso-spacerun: yes;"> </span>While directories of authorized organizations (and their identifiers) would have to be established – individual patients would be identified by the authorized senders and receivers using internal matching algorithms– or even manual procedures.<span style="mso-spacerun: yes;"> </span>This approach would probably be effective in small-scale systems,<span style="mso-spacerun: yes;"> </span>but may be impracticable at the regional and national levels (not to mention the global level) as the volume of data increases with mobility and diversity of patient populations served.</span></span></div>
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<span class="slug-pages"><span lang="EN-US">According to Kuperman, clinicians will expect both PUSH and PULL service dynamics for health information exchange, including transmission among providers as well as retrieval of individual patient data across the entire health care system.<span style="mso-spacerun: yes;"> </span>The responsibility for designing and managing these services apparently resides with RHIOs under the assumption of their sustainability<b style="mso-bidi-font-weight: normal;">: “As RHIOs (grapple) struggle to support interoperability-based services that improve the quality and efficiency of care, they will have the opportunity to understand how best to combine pull- and push-oriented capabilities.” </b>(page 681) Given the ongoing failure of federal investments in RHIOs and the “network of networks” strategy to develop infrastructure, this policy direction lacks credibility and remains unfounded in research evidence or policy experience. </span></span></div>
Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-60916854866248940922011-10-27T09:15:00.000-07:002014-10-02T08:21:56.548-07:00Kaplan and Porter: How to Solve the Cost Crisis in Health Care<div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">This commentary is particularly relevant now in light of the ONC revision of the federal Health Information Technology Strategy:</span></div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;"><br></span></div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Commentary : R. Kaplan and M. Porter, “How to Solve the Cost Crisis in Health Care”, Harvard Business Review, September, 2011, 47-64. (See the article at <a href="http://hbr.org/2011/09/how-to-solve-the-cost-crisis-in-health-care/ar/1">http://hbr.org/2011/09/how-to-solve-the-cost-crisis-in-health-care/ar/1</a>) </span></div><div class="MsoNormal" style="text-align: justify;"><br>
</div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">In this important publication Kaplan and Porter develop a methodology for measuring the “right” things in the “right” way to ascertain an account of costs and outcomes in health care service delivery to individual patients in the care delivery value chain (CDVC). The authors argue that most health care costs are not fixed, and therefore accessible to managerial control. (In my opinion, this argument is symptomatic of the absence of a health care “system”, as is the “rule of one” applied to costing expensive equipment in the context of a single health care enterprise competing with others.) In other commentaries on my blog at <a href="http://eresearchcollaboratory.blogspot.com/2011_04_01_archive.html">http://eresearchcollaboratory.blogspot.com/2011_04_01_archive.html</a> - I have discussed Porter’s work on conceptualizing and measuring “value” in health care “per dollar expended”, and some of the pitfalls of reliance on this common denominator. </span></div><div class="MsoNormal" style="text-align: justify;"><br>
</div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">The methodology proposed here addresses the critical need to manage cost associated with health care services. However, some implicit ideological assumptions should be examined. First, the method of process mapping is framed in a for-profit health care services market, assuming that competition to control costs at the enterprise level will result in financial return on investments as well as system-level savings. This approach may result in unnecessary and costly process duplication at the system level as illustrated in the case of McAllen, Texas: <a href="http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande">http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande</a> . Such costly duplication is all the more critical in the increasingly resource poor U.S. health care context.</span></div><div class="MsoNormal" style="text-align: justify;"><br>
</div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">The second apparent assumption is that health care services can effectively be conceptualized and mapped in the same way as manufacturing systems. Kaplan’s “Time-Driven Activity-Based Costing” (TDABC) as described in earlier HBR publications also aims specifically to augment enterprise profits in competitive markets. Many health economists reject these perspectives on service production, profitability and the efficacy of market dynamics in the health care sector.</span></div><div class="MsoNormal" style="text-align: justify;"><br>
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Health care process mapping is not a new idea; it has been practiced in other national systems, including the NHS (UK- See the Institute for Innovation and Improvement at <a href="http://www.institute.nhs.uk/">http://www.institute.nhs.uk/</a>), Canada and Australia. Lack of reference to other national experiences leaves the HBR article reader with the impression that such methods have not been used in the health care sector. </span></div><div class="MsoNormal" style="text-align: justify;"><br>
</div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Review of some of the recent literature suggests that the results of the process mapping methodology vary, for example, according to the choice of hierarchical vs. sequential mapping, as well as selection of participating stakeholders and the overall process perspective. (See Colligan, Anderson et al., <i style="mso-bidi-font-style: normal;">Does the process map influence the outcome of quality improvement work? A comparison of a sequential flow diagram and a hierarchical task analysis diagram, </i> </span><span lang="EN-US" style="font-family: "Times New Roman","serif";">BMC Health Services Research,</span><span lang="EN-US"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">2010, <b>10:</b>7doi:10.1186/1472-6963-10-7:</span><span lang="EN-US"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;"><a href="http://www.biomedcentral.com/1472-6963/10/7">http://www.biomedcentral.com/1472-6963/10/7</a>) </span></div><div class="MsoNormal" style="text-align: justify;"><br>
</div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Evidence based clinical pathways also offer an approach to link evidence to multi-disciplinary care plans for specific clinical conditions. (See Rotter, Kinsman et al., <i style="mso-bidi-font-style: normal;">Clinical pathways: Effects on Professional practice, patient outcomes, length of stay and hospital costs (Review), </i>The Cochran Library, Issue 7, 2010,<i style="mso-bidi-font-style: normal;"> </i> <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006632.pub2/pdf/abstract">http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006632.pub2/pdf/abstract</a> ). The Map of Medicine at <a href="http://eng.mapofmedicine.com/evidence/map-open/index.html">http://eng.mapofmedicine.com/evidence/map-open/index.html</a> (associated with the NHS) illustrates the development and use of clinical pathways in patient diagnosis and treatment. The clinical pathway methodology is designed to integrate high quality evidence from research in medicine with practice-based knowledge. </span></div><div class="MsoNormal" style="text-align: justify;"><br>
</div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">The NHS emphasizes the importance of a culture supporting performance improvement, and a focus on the patient experience. While Kaplan and Porter apply their method at the individual level of analysis, their objective is to map those activities related to a specific medical condition that can be “costed”, thus introducing an activity selection bias in the process map. The resulting focus is the cost of individual disease treatment cycles rather than a holistic view of the patient’s health care experience aggregated in the larger population perspective. </span></div><div class="MsoNormal" style="text-align: justify;"><br>
</div><div class="MsoNormal" style="text-align: justify;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Kaplan and Porter seem to address more effectively the interests of private insurers, to “reinvent reimbursement” by measuring costs at the individual level of analysis – with increasing granularity (including…“consumable supplies such as medications, syringes, catheters, and bandages used directly in the process.” p. 54). The authors do not address the costs of such granular data collection and analysis. Furthermore, they do not demonstrate HOW the TDABC process should be informed by health care “value” or research evidence on health care outcomes – with the result that the managerial values driving the process are not adequately subordinate to the science of medicine or the care of patients and populations. </span></div><div class="MsoNormal" style="text-align: justify;"><br>
</div>Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-68376368763257042802011-09-17T06:48:00.000-07:002011-09-22T08:32:47.888-07:00Comment on the Federal Strategic Plan to Reduce Health IT Disparities - An Update<div class="MsoNormal" style="font-family: inherit; line-height: normal;">
<span lang="EN-US" style="font-size: small;">As in the initial Federal HIT Strategic Plan, the need for health information infrastructures to resolve the fragmentation of the U.S. health care system has not been adequately addressed in the Plan to Reduce Health IT Disparities available at </span><span lang="EN-US" style="font-size: small;"><a href="http://www.healthit.gov/buzz-blog/from-the-onc-desk/federal-strategic-plan-disparities/">http://www.healthit.gov/buzz-blog/from-the-onc-desk/federal-strategic-plan-disparities/</a></span><span lang="EN-US" style="font-size: small;"> . My comments published on May 6 are still relevant on the strategy to reduce health disparities: (See </span><span style="font-size: small;"><a href="http://eresearchcollaboratory.blogspot.com/2011/05/commentary-on-federal-health.html"><span lang="EN-US">http://eresearchcollaboratory.blogspot.com/2011/05/commentary-on-federal-health.html</span></a></span><span lang="EN-US" style="font-size: small;"> ) Individual patient empowerment and engagement in the system especially requires attention to the creation of a unique individual digital identity for health care, education for multilingual health literacy, and open access to health information and scientific research<span style="color: black;">. Moving forward without infrastructures required for a patient-centered system and outreach to under-served populations will result in significant waste in funded efforts as well as loss of credibility and trust at a critical time in health care system reform.</span></span></div>
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<span lang="EN-US" style="color: black; font-size: small;">Central to individual empowerment is the assurance of an individual digital identity in the health care services ecosystem. (See the Analysis of Unique Patient Identifier Options prepared for the Department of Health and Human Services in 1997</span><span lang="EN-US" style="color: black; font-size: small;">: </span><span style="font-size: small;"><a href="http://www.ncvhs.hhs.gov/app0.htm"><span lang="EN-US">http://www.ncvhs.hhs.gov/app0.htm</span></a></span><span lang="EN-US" style="color: black; font-size: small;">) While the individual patient is the focus of U.S. health care system reform efforts, there is no credible plan to provide a unique digital identity to every patient. </span><span lang="EN-US" style="font-size: small;"> <span style="color: black;">The </span></span><span style="font-size: small;"><a href="http://www.nist.gov/nstic/"><span lang="EN-US" style="color: black; text-decoration: none;">National Strategy for Trusted Identities in Cyberspace </span></a></span><span lang="EN-US" style="color: black; font-size: small;">published in April, 2011, (See </span><span style="font-size: small;"><a href="http://www.whitehouse.gov/sites/default/files/rss_viewer/NSTICstrategy_041511.pdf"><span lang="EN-US">http://www.whitehouse.gov/sites/default/files/rss_viewer/NSTICstrategy_041511.pdf</span></a></span><span lang="EN-US" style="color: black; font-size: small;"> ) “recognizes that trusted digital identity, authentication and authorization processes are one part of layered security. Improvements in identification and authentication are critical to attaining a trusted online environment...” (page 8). While recognition of the critical importance of individual digital identities represents an important step, the proposed system calls for complex roles to be implemented by multiple actors in both public and private sectors. The federal government plays a significant role in the early stages of the initiative, but it is expected that new and sustainable business models will be developed for each of the service provider roles of the system (page 37) so that the identity ecosystem will become a self- sustaining market place. </span></div>
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<span lang="EN-US" style="color: black; font-size: small;">The U.S. strategy for digital identities embodies the same errors as federal policies to promote the Nation-wide Health Information Network (NHIN) for health information exchange. A reliable and valid digital identity cannot be the output of complex private sector market dynamics. This policy principle virtually assures that there will not be universal access to reliable digital identity, and that the U.S. model will not be interoperable with ID models of other countries. The consequences of this stance for exclusion of underserved populations should not be underestimated. Moreover, a market supporting for-profit digital ID roles would be a fertile context for medical and administrative error, fraud and ID theft.</span></div>
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<span lang="EN-US" style="color: black; font-size: small;">The lack of a unique patient identifier also has serious consequences for patient safety as the population grows and becomes more linguistically diverse and physically mobile - both nationally and internationally. U.S. patients are generally identified using an internally derived identifier created by a care provider, while between systems, “fuzzy matching” is frequently used to generate lists of patients with similar names and demographic profiles for evaluation as to the “best fit” match. (See </span><span style="font-size: small;"><a href="http://www.corp.att.com/healthcare/docs/mpi.pdf"><span lang="EN-US">http://www.corp.att.com/healthcare/docs/mpi.pdf</span></a></span><span lang="EN-US" style="color: black; font-size: small;"> </span><span lang="EN-US" style="color: black; font-size: small;">for an example.) This approach certainly will incur rising costs and compromise patient safety as more diverse and multilingual health care systems become globally interconnected. (See </span><span style="font-size: small;"><a href="http://gpii.info./news.php"><span lang="EN-US">http://gpii.info./news.php</span></a></span><span lang="EN-US" style="color: black; font-size: small;"> for some relevant research and publications. See also the American College of Pathologists:</span><span lang="EN-US" style="font-size: small;"> </span><span style="font-size: small;"><a href="http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7bactionForm.contentReference%7d=cap_today%2F1109%2F1109j_national_id.html&_state=maximized&_pageLabel=cntvwr"><span lang="EN-US">http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=cap_today%2F1109%2F1109j_national_id.html&_state=maximized&_pageLabel=cntvwr</span></a></span><span lang="EN-US" style="color: black; font-size: small;"> , and an HIMSS White Paper (2009) on Patient Identity Integrity at <a href="http://www.himss.org/content/files/PrivacySecurity/PIIWhitePaper.pdf">http://www.himss.org/content/files/PrivacySecurity/PIIWhitePaper.pdf</a> ) </span><br />
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<span lang="EN-US" style="font-size: x-small;">In the United States, approximately 98,000 people die because of medical malpractice during hospitalization. 13% of the overall number of malpractices in surgery and 67% of errors in conjunction with blood transfusions can be traced back to erroneous patient identification. Source: </span></div>
<span style="font-size: x-small;"><span style="color: #8e7cc3;">Joint Commission International Center for Patient Safety (Eds.): Technology in</span><br style="color: #8e7cc3;" /><span style="color: #8e7cc3;">Patient Safety - Using Identification Bands to Reduce Patient Identification Errors, in:</span><br style="color: #8e7cc3;" /><span style="color: #8e7cc3;">Joint Commission Perspectives on Patient Safety, 5, 2005, pp. 1-10. (See page 2 at http://ehealth.iwi.unisg.ch/fileadmin/hne/downloads/Mettler__Fitterer__Rohner__Strategies_for_a_Systematical_Patient_Identification.pdf ) </span></span></div>
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<span lang="EN-US" style="color: black; font-size: small;">Examples of strategies for unique identification in other countries include the British</span><span style="font-size: small;"><a href="http://www.connectingforhealth.nhs.uk/systemsandservices/nhsnumber/"><span lang="EN-US" style="color: windowtext; text-decoration: none;"> NHS unique patient identifier</span></a></span><span lang="EN-US" style="font-size: small;">, (See </span><span style="font-size: small;"><a href="http://www.connectingforhealth.nhs.uk/systemsandservices/nhsnumber/"><span lang="EN-US">http://www.connectingforhealth.nhs.uk/systemsandservices/nhsnumber/</span></a></span><span lang="EN-US" style="font-size: small;">)</span><span lang="EN-US" style="font-size: small;"> <span style="color: black;">and the </span></span><span style="font-size: small;"><a href="http://uidai.gov.in/"><span lang="EN-US" style="color: windowtext; text-decoration: none;">Indian “Aadhaar”</span></a></span><span lang="EN-US" style="color: black; font-size: small;">, </span><span lang="EN-US" style="font-size: small;"> <i>a 12-digit unique number which the Unique Identification Authority of India (UIDAI) will issue for all residents. The number will be stored in a centralized database and linked to the basic demographics and biometric information – photograph, ten fingerprints and iris – of each individual.</i> <span style="color: black;">The Indian “Aadhaar” is also considered a tool to combat corruption – in particular by improving the ability to extend services to the most vulnerable citizens. (See an article in Le Nouvel Observateur (Sept. 9, 2011) at</span></span><span lang="EN-US" style="font-size: small;"> </span><span lang="EN-US" style="color: black; font-size: small;"><a href="http://tempsreel.nouvelobs.com/actualite/economie/20110909.OBS0074/l-identite-biometrique-arme-anticorruption-des-indiens.html">http://tempsreel.nouvelobs.com/actualite/economie/20110909.OBS0074/l-identite-biometrique-arme-anticorruption-des-indiens.html</a></span><span lang="EN-US" style="color: black; font-size: small;"> ; </span></div>
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<span style="font-size: small;"><span lang="EN-US" style="color: black;">see also an interesting initiative implemented in the U.S. by the </span></span>NYU Langone Medical Center at <a href="http://www.computerworld.com/s/article/9217678/Hospital_turns_to_palm_reading_to_ID_patients">http://www.computerworld.com/s/article/9217678/Hospital_turns_to_palm_reading_to_ID_patients</a> )<span style="font-size: small;"><br /></span></div>
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<span style="font-size: small;"><b><span lang="EN-US" style="color: black;">The U.S. strategy for patient empowerment and engagement should include the creation of a unique biometric patient identifier to be offered on a voluntary basis to all citizens. Similar to the Indian </span></b></span><b><span lang="EN-US" style="font-size: small;"><span style="color: black;">Aadhaar</span></span></b><span style="font-size: small;"><b><span lang="EN-US" style="color: black;">, this identifier would not be mandated for citizens, but health care service providers could require it of those seeking their services. </span></b></span><span style="font-size: small;"><b><span lang="EN-US" style="color: black;"> </span></b></span></div>
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<span lang="EN-US" style="color: black; font-size: small;">The successful pursuit of goals for individual patient empowerment within a learning health system depends upon the public infrastructures for digital identity and health information exchange – as well as</span><span style="font-size: small;"><a href="http://www.ahrq.gov/clinic/epcsums/litupsum.htm"><span lang="EN-US" style="color: windowtext; text-decoration: none;"> health literacy</span></a></span><span lang="EN-US" style="color: black; font-size: small;"> interventions to improve individual skills. Some research suggests that only one in ten adults in the U.S. may possess the knowledge and skills required to perform at a high level of health literacy. Population health literacy is prerequisite to individual empowerment as well as to creation of a learning health system – particularly in the complex, fragmented, and increasingly multilingual and multicultural U.S. context. (See</span><span lang="EN-US" style="color: black; font-size: small;"> </span><span style="font-size: small;"><a href="http://www.hsph.harvard.edu/healthliteracy/research/"><span lang="EN-US">http://www.hsph.harvard.edu/healthliteracy/research/</span></a></span><span lang="EN-US" style="color: black; font-size: small;"> </span><span lang="EN-US" style="color: black; font-size: small;">for more resources.)</span><span lang="EN-US" style="color: black; font-size: small;"> </span></div>
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<span lang="EN-US" style="font-size: small;">The national capacity for innovation and research requires infrastructures developed as a public good as sustained public investments in health sciences and research contribute to the foundation for a learning health care system. An important aspect of learning systems is open access to information – including data and scientific publications. Some important steps have been taken in the U.S. system to improve such access to federally funded research, such as the </span><span style="font-size: small;"><a href="http://publicaccess.nih.gov/"><span lang="EN-US" style="color: windowtext; text-decoration: none;">National Institutes of Health Public Access Policy</span></a></span><span lang="EN-US" style="font-size: small;"> applicable to any manuscript reporting research funded by the NIH - accepted for peer-reviewed publication on or after April 7, 2008. <i>“<span style="color: black;">To help advance science and improve human health, the policy requires that these papers are accessible to the public on PubMed Central no later than 12 months after publication.”</span></i><span style="color: black;"> (See </span></span><span style="font-size: small;"><a href="http://publicaccess.nih.gov/"><span lang="EN-US">http://publicaccess.nih.gov/</span></a></span><span lang="EN-US" style="color: black; font-size: small;">) While this policy represents progress toward the goal of open access to scientific publications, the delay of 12 months allowed for compliance significantly reduces its effectiveness. Lack of open access to health information and research hinders patient empowerment as well as development of a learning health system.</span></div>
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<span lang="EN-US" style="color: black; font-size: small;">The </span><span lang="EN-US" style="font-size: small;"><a href="http://regional.bvsalud.org/php/index.php"><span style="color: windowtext; text-decoration: none;">Latin-American and Caribbean Center on Health Sciences Information</span></a><span style="color: black;"> (Bireme) illustrates a multilingual (Spanish, Portuguese and English) regional model for open access to health information and publications available through the Virtual Health Library. </span></span><span style="font-size: small;"><b><span lang="EN-US" style="color: black;"> </span></b></span><span lang="EN-US" style="color: black; font-size: small;">(</span><span lang="EN-US" style="color: black; font-size: small;">The model and methodologies for development of this library are published in the </span><span style="font-size: small;"><a href="http://regional.bvsalud.org/php/index.php"><span lang="EN-US" style="color: windowtext; text-decoration: none;">VHL Guide 2011</span></a></span><span lang="EN-US" style="font-size: small;"> available at <span style="color: black;"> </span></span><span style="font-size: small;"><a href="http://guiabvs2011.bvsalud.org/en/presentation/"><span lang="EN-US">http://guiabvs2011.bvsalud.org/en/presentation/</span></a></span><span lang="EN-US" style="color: black; font-size: small;">.)</span><span style="font-size: small;"><b><span lang="EN-US" style="color: black;"> </span></b></span></div>
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<span style="font-size: small;"><b><span lang="EN-US" style="color: black;">The U.S. should develop policies to promote open access to health information and research – taking into account the increasing linguistic and cultural diversity of the nation’s population as well as the globalization of health information systems. </span></b></span></div>
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Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-59517430918584354292011-08-05T14:30:00.000-07:002011-08-05T14:38:01.244-07:00Chinese and U.S. Health Care System ReformSee the Westlake Forum: <span id="ctl00_lblGlobalHeader"><span style="color: #1f497d; font-family: Times New Roman;"><b><span style="font-size: medium;"><i>Healthcare Reform in China and the US: Similarities, Differences and Challenges,</i></span></b></span></span> held at Emory University on April 10-12, 2011. Both <a href="http://www.regonline.com/builder/site/tab1.aspx?EventID=934954">slides</a> and <a href="http://www.regonline.com/builder/site/tab3.aspx?EventID=934954">video presentations</a> are available for review. This program is a valuable reference for researchers working on health care financing reform in any context- at the state or country levels of analysis. William Hsiao of Harvard University points out the critical importance of professionalism and ethics among both physicians and system administrators as a foundation of the reform process. He also emphasizes that China is ahead of the U.S. in designing a system to offer health care services to all Chinese citizens. On the other hand, he suggests that the Chinese strategy of hospital privatization to promote competition is not based on any policy evidence from world experience.Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-1154737261383609742011-06-03T10:03:00.000-07:002011-06-19T12:27:04.380-07:00New Research on EHR and CDS Effectiveness<span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;"><span style="color: black;"><i>The following review illustrates some of the methodological difficulties common in current research on EHR and CDS effectiveness.</i></span> </span><br />
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<div style="color: black;"><b><span style="font-size: x-small;"><u><span style="font-family: verdana,arial,helvetica,sans-serif;">Health Records and Clinical Decision Support Systems: </span></u></span><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;"><u>Impact on National Ambulatory Care Quality</u> </span></b></div><b><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;"><a class="authstring" href="http://archinte.ama-assn.org/cgi/content/full/archinternmed.2010.527#AUTHINFO"> <nobr>Max J. Romano, BA</nobr>; <nobr>Randall S. Stafford, MD, PhD</nobr> </a></span></b><br />
<b><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;"> <i>Arch Intern Med.</i> 2011;171(10):897-903. doi:10.1001/archinternmed.2010.527</span></b><br />
<b><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;">This article is available at : http://archinte.ama-assn.org/cgi/content/abstract/171/10/897</span></b><br />
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<span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;"> <span style="color: #0b5394; font-size: x-small;"><b>Background </b> Electronic health records (EHRs) are increasingly<sup> </sup>used by US outpatient physicians. They could improve clinical<sup> </sup>care via clinical decision support (CDS) and electronic guideline–based<sup> </sup>reminders and alerts. Using nationally representative data,<sup> </sup>we tested the hypothesis that a higher quality of care would<sup> </sup>be associated with EHRs and CDS.<sup> </sup></span></span><br />
<div style="color: #0b5394;"><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;"><sup> </sup></span><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;"><b>Methods </b> We analyzed physician survey data on 255 402<sup> </sup>ambulatory patient visits in nonfederal offices and hospitals<sup> </sup>from the 2005-2007 National Ambulatory Medical Care Survey and<sup> </sup>National Hospital Ambulatory Medical Care Survey. Based on 20<sup> </sup>previously developed quality indicators, we assessed the relationship<sup> </sup>of EHRs and CDS to the provision of guideline-concordant care<sup> </sup>using multivariable logistic regression.<sup> </sup></span></div><div style="color: #0b5394;"><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;"> <b>Results </b> Electronic health records were used in 30% of<sup> </sup>an estimated 1.1 billion annual US patient visits. Clinical<sup> </sup>decision support was present in 57% of these EHR visits (17%<sup> </sup>of all visits). The use of EHRs and CDS was more likely in the<sup> </sup>West and in multiphysician settings than in solo practices.<sup> </sup>In only 1 of 20 indicators was quality greater in EHR visits<sup> </sup>than in non-EHR visits (diet counseling in high-risk adults,<sup> </sup>adjusted odds ratio, 1.65; 95% confidence interval, 1.21-2.26).<sup> </sup>Among the EHR visits, only 1 of 20 quality indicators showed<sup> </sup>significantly better performance in visits with CDS compared<sup> </sup>with EHR visits without CDS (lack of routine electrocardiographic<sup> </sup>ordering in low-risk patients, adjusted odds ratio, 2.88; 95%<sup> </sup>confidence interval, 1.69-4.90). There were no other significant<sup> </sup>quality difference.<sup> </sup></span></div><div style="color: #0b5394;"><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;"> <b>Conclusions </b> Our findings indicate no consistent association<sup> </sup>between EHRs and CDS and better quality. These results raise<sup> </sup>concerns about the ability of health information technology<sup> </sup>to fundamentally alter outpatient care quality.</span></div><span style="font-size: small;"><br />
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<span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;">The conclusions reported in this study are consistent with many other recent studies, suggesting that there is no consistent relationship between the use of these tools and effective patient care. However, it is very important to examine the study design before evaluating the conclusions of this research. Critical points to be reviewed include the delay in publication with respect to data collection, generally limited use of EHRs and CDSs in US physician practice, the choice of patient visits as the unit for statistical analysis, the procedure for defining the sample, and identification of control variables in the regression model.</span><br />
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<span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;">The topic addressed in the study is of critical importance, but the rapidly evolving technologies associated with EHR and CDS use require more current assessment. Data collected in the period 2005-2007 provides an interesting historical perspective, but may not yield analyses relevant to the current context. While EHR adoption in the US remains modest compared to some other industrialized countries (as pointed out by the study authors), state and federal expenditure to promote health information technology adoption is significant, and patterns of adoption have changed on some qualitative dimensions due to emergence of new practice arrangements such as ACOs and implementation of policies such as meaningful use.</span><br />
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<span style="font-size: small;"><span style="font-family: verdana,arial,helvetica,sans-serif;">The unit of analysis for the study is the patient visit rather than the patient, and performance quality was measured as adherence to guidelines by visit rather than by visits associated with a particular patient. It was assumed that a higher proportion of guideline adherence by visit should be interpreted as higher quality care provided to eligible patients. The data analysis does not by itself justify this interpretation. Drawing any conclusion concerning quality of patient care is further complicated by the lack of consideration of patient clinical profiles - apparently because the authors assert that the quality guidelines should apply to any patient except those presenting potentially confounding comorbidities. (Patients presenting such comorbidities have conveniently been eliminated from the sample. The authors provide the following example of comorbidity resulting in exclusion of patients - and their visits- from the sample: </span></span><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;"><sup> </sup>asthma in assessing the use of β-blockers in coronary artery<sup> </sup>disease.) This reductionist methodological strategy does simplify the statistical analysis, but it also seems to defeat the evaluation of CDS in care of patients who should potentially benefit most from its use.</span><br />
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<span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;">The authors also mention that they have included emergency visits in the study sample because </span><br />
<span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;"><b><span style="font-size: x-small;">"they are<sup> </sup>a key source of care and a setting in which EHRs have been more<sup> </sup>widely adopted"</span></b>, while such visits resulting in hospitalization have been excluded. The authors do not adequately examine the consequences of these exclusions for the sample size or for interpretation of study results.</span><br />
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<span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;">The methodology designed for analysis of the data in this study presents several critical weaknesses that may explain the lack of significant results. In analysis of data from </span><span style="font-family: verdana,arial,helvetica,sans-serif; font-size: small;">NAMCS<sup> </sup>and NHAMCS and other similar data sets, future efforts are required to assure patient-centered assessment of care quality - taking into account complex clinical profiles as well as health outcomes over time. Such models would be especially useful for longitudinal analysis as new data become available.</span><br />
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<span style="font-family: verdana,arial,helvetica,sans-serif; font-size: x-small;"> </span>Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-32202572776945659602011-05-06T13:25:00.000-07:002014-10-03T09:09:07.386-07:00Commentary on the Federal Health Information Technology Strategic Plan (2011-2015) - Republished<div class="Standard">
<span lang="EN-US">This commentary first published on 5-6-11 remains relevant, particularly in light of slow progress in development of infrastructures for health information exchange: </span><br />
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<span lang="EN-US">The <a href="http://healthit.hhs.gov/portal/server.pt/community/federal_health_it_strategic_plan_-_overview/1211"><i><span style="color: windowtext; text-decoration: none;">Federal Health Information Technology Strategic Plan</span></i></a><a href="http://healthit.hhs.gov/portal/server.pt/community/federal_health_it_strategic_plan_-_overview/1211"><span style="color: windowtext; text-decoration: none;"> (2011-2015)</span></a> lays out the HIT vision, mission and principles as well as goals, objectives and strategies to be implemented in the next five years. My commentary will address first the guiding principles for health IT at the foundation of the overall strategy and how these principles affect the five goals formulated in the plan: I – Adoption and information exchange through meaningful use, II – Improvement of care and population health as well as cost reduction, III - Promotion of confidence and trust in health IT, IV – Individual empowerment with health IT to improve care processes and the health care system, and V - Achievement of learning and technological advancement. In conclusion, some recommendations will be outlined.</span></div>
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<span lang="EN-US">The principles on page 8 emphasize the needs and rights of individuals and the reliance “to the extent possible” on private markets to achieve societal objectives - with intervention only “when necessary” to correct market failures. This reliance on private markets is contrary to international development experience as well as theory and research in health economics demonstrating inadequacies of capital markets in provision of social services.[1,2] It is important to distinguish between competitive innovation in health services and the health information infrastructure (the NHIN) required to support such activities. While HIT infrastructure may be defined as a public good, both public and private services markets may share the resulting institutional ecology.</span></div>
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<span lang="EN-US">The focus on outcomes is critical to the success of health care reform, but this emphasis will not be adequate to motivate performance if national system design remains fragmented. Private markets will not foster the emergence of a system infrastructure as seems to be an implicit principle. Furthermore, costs associated with extensive micro-measurement of individual health care outcomes should not be underestimated. (I have reviewed the concept of “value” in health care outcomes as formulated by M. Porter <a href="http://eresearchcollaboratory.blogspot.com/2011/04/porter-on-value-in-health-care-ii.html"><span style="color: windowtext; text-decoration: none;">on my blog</span></a> because it seems to me that his model is consistent with the ideological viewpoint of the majority of the U.S. policy-making community.[3,4])</span></div>
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<span lang="EN-US">Building on “what works” is also an essential principle of any learning system, but as I have suggested in earlier commentaries, the focus in the U.S. health care system seems restricted to experiences within its boundaries. There are virtual natural experiments in progress in developing countries as well as industrialized nations around the world, and the U.S. could learn valuable lessons and avoid expensive mistakes through systematic analysis of selected national health care systems. This approach would encourage evidence-based learning and innovation to more rapidly close the significant lag in health care system performance that threatens the competitive stance of the U.S. in the global economy.</span></div>
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<b><i><span lang="EN-US">Goal I: Achieve Adoption and Information Exchange through Meaningful Use of Health IT </span></i></b><span lang="EN-US">(page 9) should be reformulated: <i>Achieve Adoption and Meaningful Use of Health IT through Information Exchange.</i> The creation of infrastructure for health information exchange is prerequisite to adoption of health information technology and its meaningful use. For example the Veterans Administration (VA) (mentioned on page 10) operates a single payer system through a federally supported infrastructure that makes possible HIE. The functionalities to exchange information integrated in EHRs and to report data relevant to public health are some of the most important intrinsic motivators for HIT adoption – affecting all stakeholders: providers, payers, patients and consumers. The VA offers a demonstration of the effectiveness of an integrated single payer system, as well as the benefits of HIE. However, the VA is a subsystem distinct from other segments of the health care sector, and thus will probably not contribute to the critical mass (or tipping point) necessary for health care system transformation as discussed on page 10. Principles guiding the VA, Medicare and Medicaid are very different from those at the foundation of private insurance markets for the majority of U.S. citizens.</span></div>
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<span lang="EN-US">On page 11 Strategy I.A.2 proposes implementation support to help health care providers through the <a href="http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3519"><span style="color: windowtext; text-decoration: none;">Regional Extension Center (REC) Program</span></a>. While funding for this program has been extended beyond the initial two-year time horizon, these organizations will be required to develop business models to become self sustainable. As is the case for Regional Health Information Organizations (RHIOs) and State Designated Entities (SDEs), such business models have not been identified.[5] <a href="http://eresearchcollaboratory.blogspot.com/2010/09/regional-extension-centers-and-hie.html"><span style="color: windowtext; text-decoration: none;">Some observers have further noted that funded RECs may favor selected vendors for interoperability, thus introducing a significant conflict of interest in the support they offer.</span></a> <a href="http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/"><span style="color: windowtext; text-decoration: none;">(See SoftwareAdvice, 9-23-2010)</span></a> It may not be realistic to assume that RECs working with competing vendor consultants will “collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, meaningful use, and provider support.” (page 11). </span></div>
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<span lang="EN-US">Consistent with M. Porter, the strategic intention is to move away from the process requirements formulated in stage one of meaningful use towards improvements in outcomes and quality of care.[3,4] However, it should not be assumed that such improvements will be correlated with meaningful use of health information technology as in the Federal HIT Strategy. In Canada, penetration of EHR is low, comparable to rates reported in the U.S.[6], but health care system performance measured by public health indicators and overall per capita cost is ranked higher .[7] This would suggest that the superior performance of the Canadian system is explained by other factors – possibly higher rates of sustained <a href="http://www.commonwealthfund.org/Content/Charts/Chartbook/Multinational-Comparisons-of-Health-Systems-Data--2006/P/Public-Investment-per-Capita-in-Health-Information-Technology-as-of-2005.aspx"><span style="color: windowtext; text-decoration: none;">public investment in health IT infrastructures</span></a> [8]and the single payer model[9]. Furthermore, there may be a variety of paths to improvements in outcomes and quality of care as a result, for example, of major technological, institutional or medical paradigm shifts – in progress but as yet unforeseen. </span></div>
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<span lang="EN-US">Strategy I.A.5 emphasizes the process to certify EHR technology for meaningful use. The strategy as formulated does not address the <a href="http://www.cchit.org/sites/all/files/Pricing-ONC-ATCB-2011-2012_0.pdf"><span style="color: windowtext; text-decoration: none;">financial burden on software vendors to achieve certification of their products.</span></a> There is furthermore little clarification concerning validity of certification over time and the business model to be associated with continued certification: <a href="http://www.cchit.org/about/towncalls/CCHIT-Town-Call-Authorized-HHS-certification-program"><span style="color: windowtext; text-decoration: none;">See CCHIT Town Call: ONC-ATCB 2011/2012 Certification Program (September 20,2010)</span></a></span></div>
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<i><span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Do ONC-ATCB certified products have to undergo re-certification for each new release?</span></i><span lang="EN-US"></span></div>
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<span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Following ONC/HHS Final Rules</span><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="color: #215968; font-size: 10pt;">, <a href="http://edocket.access.gpo.gov/2010/2010-14999.htm"><span style="color: #215968; text-decoration: none;">Establishment of the Temporary Certification Program for Health Information Technology</span></a></span></i><span lang="EN-US" style="color: #006b6b; font-size: 10pt;">, certification is completed with a specific version of the technology that was tested by CCHIT and found compliant with the relevant certification criteria. For the purpose of maintaining certification, “minor product changes” are those modifications and updates to a certified product that are unlikely to affect the product’s compliance with the certification criteria. Retesting may not be required but the vendor is required to notify the ONC-ATCB and provide self-attestation that the changes are minor.</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Modifications with a significant risk of affecting the product’s compliance are considered to be a “significant product change.” Retesting is required. Applicants are required to self-classify their product modifications and updates into one of these two categories.</span></div>
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<i><span lang="EN-US">Will software re-certification be required for each "meaningful use" stage?</span></i><span lang="EN-US" style="color: #006b6b; font-size: 10pt;"></span></div>
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<span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Yes; the criteria, standards and test procedures will change for each stage. ONC has retained the right to change certification criteria at any time, but it is most likely that this will not occur until the next stage. The Final Rule states that the Temporary Certification Program is scheduled to sunset on December 31, 2011, unless HHS/ONC decides to extend it or hasn’t defined the permanent program. </span></div>
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<i><span lang="EN-US" style="color: #006b6b; font-size: 10pt;">Is there an effective period for certification? For example, if an EHR is certified in January 2011, when would the certification end and when would the technology need to be retested?</span></i><span lang="EN-US"></span></div>
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<span lang="EN-US" style="color: #006b6b; font-size: 10pt;">The effective period certification is determined by when ONCs publishes new rules for standards and certification criteria. If you are selling your software to providers who wish to meet the requirements of all three stages of meaningful use, you will need to recertify your EHR technology for 2013/2014 and 2015/2016.</span></div>
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<span lang="EN-US" style="color: black;">The process of re-certification will be costly to vendors and entities implementing self-developed software products. The significant uncertainties associated with certification also increase risk inherent in such investments. Little data is available for evaluation of such risks and published information, such as the CCHIT Toolkit is often expensive as well. (The Toolkit – developed under federal funding - costs $1000 unless the entity seeking access to the information is committed to apply for certification. This policy discourages detailed review by prospective CCHIT applicants as well as researchers and the general public.)</span></div>
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<span lang="EN-US" style="color: black;">I have already commented on policies regarding <a href="http://eresearchcollaboratory.blogspot.com/search?q=RECs"><span style="color: black; text-decoration: none;">health information exchange (HIE)</span></a> and <a href="http://eresearchcollaboratory.blogspot.com/2011/02/stage-2-meaningful-use-objectives.html"><span style="color: black; text-decoration: none;">meaningful use</span></a>. Objective I.B cites the lack of sustainable business model to support HIE as well as fragmented policy-making at the federal, state and local levels. The federal strategy mistakenly states that there are “many sustainable exchange options … for certain providers and certain types of information.” (page 15) The federal government will: 1-Foster business models that create health information exchange, 2-Monitor health information exchange options and fill the gaps for providers that do not have viable options, and 3-Ensure that health information exchange takes place across individual exchange models. (page 15) These roles cannot be assumed by the federal government unless the necessary infrastructure is redefined as a public good sustained by significant public investment. In particular, it is not useful to propose “filling the gaps” where no system exists. It would be more constructive to leverage <a href="http://eresearchcollaboratory.blogspot.com/2011/03/us-health-care-system-infrastructure.html"><span style="color: black; text-decoration: none;">an existing program such as the National Information Exchange Model (NIEM)</span></a>, thus assuring integration with other systems for national security and disaster management- as suggested on page 18.</span></div>
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<span lang="EN-US" style="color: black;">Another very important policy issue related to federal health IT strategy is <a href="http://www.broadband.gov/"><span style="color: black; text-decoration: none;">broadband </span></a>Internet access as mentioned on page 16. <a href="http://cyber.law.harvard.edu/pubrelease/broadband/"><span style="color: black; text-decoration: none;">Comparative country analysis </span></a>suggests that the U.S. lags behind other OECD countries in pricing, speed, penetration and access.[10] Some observers believe that the U.S. does not now have adequate broadband infrastructure to support full deployment of HIT meaningful use and health information exchange. The infrastructures required for HIT implementation are prerequisite to most of the policies formulated in the Federal Health IT Strategic Plan. Moving forward without these infrastructures in place will result in significant waste in funded efforts as well as loss of credibility and trust at a critical time in health care system reform.</span></div>
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<span lang="EN-US" style="color: black;">On page 18 it is stated that the ONC is “tracking the activities of other countries and learning from their experiences with health IT and health information exchange.” There is very little evidence that this is the case, particularly with regard to our closest neighbors, Canada and the Latin American region. <a href="http://www.eresearchcollaboratory.com/POSTER%20AMIA%20SYMP2009%20US%20case.pdf"><span style="color: black; text-decoration: none;">Regional collaboration needs to be extended across the hemisphere</span></a> to facilitate system integration for health information exchange, research and education. (Large grid and cloud systems for basic and translational research are discussed on pages 27-28, while there is no mention of extension of such systems across regional boundaries.)</span></div>
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<b><i><span lang="EN-US" style="color: black;">Goal II of the Federal Strategic Plan (page 22) is to improve care, improve population health, and reduce health care costs through the use of health IT. </span></i></b><span lang="EN-US" style="color: black;"> Strategy II.A.2 (page 24) calls for administrative efficiencies to reduce cost and burden for providers, payers, and government health programs. This is a very important but also very elusive objective as programs for payment reform such as the formation of Accountable Care Organizations call for additional administrative mechanisms to assure outcome measurement and reporting as well as distribution of savings and incentives to participants. The strategy also calls for “<i>more granular understanding of health care treatments and outcomes, and more complete analyses of treatment costs, ultimately allowing for better disease management and more efficient health care delivery.</i>”(page 25) Such detailed analysis of treatment costs is aligned with multiple private health insurers' requirements, and is often accomplished at the expense of a system-level focus on population health. The public funding of new health insurance exchanges -particularly in the absence of a public health insurance option - also subsidizes the interests of private health insurers by assuming the costs of infrastructure benefiting for-profit enterprise in health care services. These costs should be assigned to the private sector.</span></div>
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<span lang="EN-US" style="color: black;">Strategy II.D.3 (page 27) calls for a mechanism to support information exchange for research and the translation of research findings back into clinical practice. This strategy also emphasizes the importance of infrastructure for HIE as well as large grid and cloud-based systems for the exploration of the wealth of existing data on the human genome. As mentioned above, extensive and sustainable public investments are essential to assure the creation and maintenance of such national infrastructures (including broadband) and to promote their interconnection with larger regional systems.</span></div>
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<b><i><span lang="EN-US" style="color: black;">Goal III (page 29) calls for strategies to inspire confidence and trust in health information technology by protecting confidentiality, integrity and availability of health information, informing individuals of their rights, and improving safety and effectiveness of IT. </span></i></b><span lang="EN-US" style="color: black;"> Central to these issues is the assurance of an individual digital identity in the health care services ecosystem. While the individual patient is the central focus of health care system reform efforts, there is no credible plan to provide a unique digital identity to every citizen. (This is one of the most intriguing internal contradictions in the logic of the U.S. model of reform.) Privacy protections as they are currently designed are more consistent with the interests of private health care insurers than those of the individuals they serve. These protections pose obstacles to data aggregation as well as disclosure relative to insurance plan performance.</span></div>
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<span lang="EN-US" style="color: black;">The <a href="http://www.nist.gov/nstic/"><span style="color: black; text-decoration: none;">National Strategy for Trusted Identities in Cyberspace </span></a>(April, 2011)[11] “recognizes</span><span lang="EN-US" style="color: black;"> that trusted digital identity, authentication and authorization processes are one part of layered security. Improvements in identification and authentication are critical to attaining a trusted online environment; however, they must be combined with other crucial aspects of cybersecurity.” (page 8). While recognition of the critical importance of individual digital identities represents an important step, the proposed system calls for complex roles to be implemented by multiple actors in both public and private sectors. While the federal government plays a significant role in the early stages of the initiative, it is expected that new and sustainable business models will be developed for each of the service provider roles of the system (page 37) so that the identity ecosystem will become a self- sustaining market place.</span><span lang="EN-US" style="color: black;"></span></div>
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<span lang="EN-US" style="color: black;">This strategy for trusted identities in cyberspace embodies the same errors as federal policies for promotion of the Nation-wide Health Information Network (NHIN) for health information exchange. A reliable and valid digital identity cannot be the output of complex private sector market dynamics. This policy principle assures that there will not be universal access to reliable digital identity, and that the U.S. model will probably not be interoperable with those of other countries. The consequences of this stance for U.S competitive advantage in the global economy should not be underestimated. Moreover, a market supporting for-profit digital ID roles would be a fertile context for fraud and ID theft as well as other illegal transactions based on digital ID information.</span></div>
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<span lang="EN-US" style="color: black;">Examples of strategies for unique citizen identification in other countries include the British</span><span lang="EN-US"><a href="http://www.connectingforhealth.nhs.uk/systemsandservices/nhsnumber/"><span style="color: windowtext; text-decoration: none;"> NHS unique patient identifier</span></a></span><span lang="EN-US" style="color: black;">,[12]and the </span><span lang="EN-US"><a href="http://uidai.gov.in/"><span style="color: windowtext; text-decoration: none;">Indian “Aadhaar”</span></a></span><span lang="EN-US" style="color: black;">, </span><span lang="EN-US" style="font-size: 11pt;"> <i>a 12-digit unique number which the Unique Identification Authority of India (UIDAI) will issue for all residents. The number will be stored in a centralized database and linked to the basic demographics and biometric information – photograph, ten fingerprints and iris – of each individual.</i> </span><span lang="EN-US" style="color: black;"> (</span><span lang="EN-US"><a href="http://www.hindu.com/2011/04/23/stories/2011042359351300.htm"><span style="color: windowtext; text-decoration: none;">The U.S. State Department has shown some interest</span></a></span><span lang="EN-US" style="color: black;"> in the Indian system - for reasons related to National Security-according to cable communications made public by Wikileaks.[13])</span><span lang="EN-US"></span></div>
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<b><i><span lang="EN-US" style="color: black;">Goal IV (page 36) calls for individual empowerment for improvement of health and the health care system.</span></i></b><span lang="EN-US" style="color: black;"> The successful pursuit of this goal depends upon the public infrastructures for digital identity and health information exchange as discussed above – as well as</span><span lang="EN-US"><a href="http://www.ahrq.gov/clinic/epcsums/litupsum.htm"><span style="color: windowtext; text-decoration: none;"> health literacy</span></a></span><span lang="EN-US" style="color: black;"> interventions to improve individual skills. [14][15] These studies suggest that only one in ten adults in the U.S. may possess the knowledge and skills required to perform at a high level of health literacy. Population health literacy is prerequisite to individual empowerment as well as to creation of a learning health system (Goal V).</span><span lang="EN-US"></span></div>
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<b><i><span lang="EN-US">Goal V (page 42) calls for achievement of rapid learning and technological advancement through creation of a learning health system to support quality, research and population health, as well as increased capacity for innovation and research. </span></i></b><span lang="EN-US">The national capacity for innovation and research requires infrastructures developed as a public good. Sustained public investments contribute to the foundation for a learning health care system. Another important aspect of learning systems and capacity for innovation and research is open access to information. Some important steps have been taken in the U.S. system to improve such access to federally funded research, such as the </span><span lang="EN-US"><a href="http://publicaccess.nih.gov/"><span style="color: windowtext; text-decoration: none;">National Institutes of Health Public Access Policy</span></a></span><span lang="EN-US"> applicable to any manuscript reporting research funded by the NIH - accepted for peer-reviewed publication on or after April 7, 2008. <i>“<span style="color: black;">To help advance science and improve human health, the policy requires that these papers are accessible to the public on PubMed Central no later than 12 months after publication.”</span></i><span style="color: black;"> While this policy represents progress toward the goal of open access to scientific information, the delay of 12 months allowed for compliance significantly reduces its effectiveness.</span></span></div>
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<span lang="EN-US" style="color: black;">The </span><span lang="EN-US"><a href="http://regional.bvsalud.org/php/index.php"><span style="color: windowtext; text-decoration: none;">Latin-American and Caribbean Center on Health Sciences Information</span></a></span><span lang="EN-US" style="color: black;"> (Bireme) illustrates a regional model for open access to health information available through the Virtual Health Library. The model for this library is published in the </span><span lang="EN-US"><a href="http://regional.bvsalud.org/php/index.php"><span style="color: windowtext; text-decoration: none;">VHL Guide 2011</span></a></span><span lang="EN-US" style="color: black;"> now available for comment and consultation. Background information is available in the publications of A. Packer, former director of Bireme.[16]. </span><span lang="EN-US"><a href="http://new.paho.org/blogs/kmc/?p=579"><span style="color: windowtext; text-decoration: none;">Dr. Pedro Urra,</span></a></span><span lang="EN-US" style="color: black;"> the new director of Bireme, has been responsible for the creation and development of </span><span lang="EN-US"><a href="http://www.jmir.org/2006/1/e1/"><span style="color: windowtext; text-decoration: none;">INFOMED</span></a></span><span lang="EN-US" style="color: black;">,[17-20] the Cuban National Health Care Telecommunications Network and Portal. [21] The U.S. should develop policies to join this important regional initiative and to further promote open access to health sciences research.</span><span lang="EN-US"></span></div>
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<b><i><span lang="EN-US" style="color: black;">Summary </span><span lang="EN-US">recommendations</span></i></b><b><i><span lang="EN-US" style="color: black;"></span></i></b></div>
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<span lang="EN-US" style="color: black;">1. Public investment in a national health information infrastructure to promote interoperability for both public and private services - a single infrastructure does not necessarily imply a single payer design.</span><span lang="EN-US" style="color: black; font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
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<span lang="EN-US" style="color: black;">2. Federal government provision of goal oriented services and tools - rather than financial incentives.</span><span lang="EN-US" style="color: black; font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<span lang="EN-US" style="color: black; font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<span lang="EN-US" style="color: black;">3. Restriction of public reimbursement for basic health care products and services to not-for-profit enterprises.</span><span lang="EN-US" style="color: black;"> </span><br />
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<span lang="EN-US" style="color: black;">4. Extension of open access policies governing availability of public health information and published research in medicine and the health sciences.</span><span lang="EN-US" style="font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<span lang="EN-US" style="font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><br />
<span lang="EN-US" style="font-family: Symbol;"><span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="color: black;">5. Collaboration across the Americas as a foundation for large scale grid and cloud infrastructures to support regional research and innovation through the </span><span lang="EN-US" style="color: black;"> </span><span lang="EN-US"><a href="http://regional.bvsalud.org/php/index.php"><span style="color: windowtext; text-decoration: none;">Latin-American and Caribbean Center on Health Sciences Information</span></a></span><span lang="EN-US" style="color: black;"> – BIREME.</span><br />
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<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="color: black;">References</span></i></b></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[1] Arrow K, Auerbach A, Bertko J, Brownlee S, Casalino LP, Cooper J, et al. Toward a 21st-Century Health Care System: Recommendations for Health Care Reform. Ann.Intern.Med. 2009 April 7;150(7):493-495.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[2] Arrow K. Uncertainty and the Welfare Economics of Medical Care. The American Ecocomic Review 1963;53(5):941-973.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[3] Porter ME. What Is Value in Health Care? N.Engl.J.Med. 2010;363(26):2477-2481.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[4] Porter ME. A Strategy for Health Care Reform -- Toward a Value-Based System. N.Engl.J.Med. 2009 July 9;361(2):109-112.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[5] 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.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[6] Rozenblum R, Jang Y, Zimlichman E, Salzberg C, Tamblyn M, Buckeridge D, et al. A qualitative study of Canada's experience with the implementation of electronic health information technology. CMAJ 2011 March 22;183(5):E281-288.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[7] Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update.Davis K, Schoen C, Stremikis K. 2010.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[8] Anderson G, Frogner B, Johns R, Reinhardt U. Health Care Spending and Use of Information Technology in OECD Countries. Health Affairs 2006;25(3):819-831.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[9] Tuohy CH. Single Payers, Multiple Systems: The Scope and Limits of Subnational Variation under a Federal Health Policy Framework. Journal of Health Politics Policy and Law 2009 August 1;34(4):453-496.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[10] Next Generation Connectivity: A review of broadband Internet transitions and policy from around the world.Benkler Y, Faris R, Gasser U. 2010.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[11] National Strategy for Trusted Identities in Cyberspace: Enhancing Online Choice, Efficiency, Security, and Privacy.The White House. 2011.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[12] Smyth RL. Regulation and governance of clinical research in the UK. BMJ 2011 January 13;342.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[13] U.S. interest in unique identification project.Srivathsan. A. The Hindu 2011;Opinion.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[14] The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy.National Center for Education Statistics. 2006;NCES 2006–483.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[15] Health Literacy Interventions and Outcomes: An Updated Systematic Review.Berkman N, Sheridan S, Donahue K, et al. 2011;11-E006.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[16] Packer AL. The SciELO Open Access: A Gold Way from the South. Canadian Journal of Higher Education 2009;39(3):111-126.</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[17] Urra González P. Internet a la Cubana: El Ser Humano en el Centro de la Red. ACIMED 2003;11(1).</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[18] Urra González P. Letter: Global Alliance for Health Information. BMJ 2001;321(7264).</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[19] Urra González P, Rodrígues Perojo K, Concepcíon Báez C, Canedo Andalia R. Intranet of the National Medical Sciences Information Centre- Infomed: A Working Space in the Network for the Health Information System in Cuba. ACIMED 2006;14(1).</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[20] Urra González P. Program for Strengthening the Scientific and Technical Health Information System of Cuba. ACIMED 2005;13(3).</span></div>
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<span lang="EN-US" style="color: black; font-size: 10pt;">[21] Séror A. A Case Analysis of INFOMED: The Cuban National Health Care Telecommunications Network and Portal. Journal of Medical Internet Research 2006;8(1):e1.</span></div>
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Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-37300233700311858362011-04-11T08:38:00.000-07:002011-04-11T08:38:01.597-07:00Porter on Value in Health Care II<div align="JUSTIFY">In his most recent NEJM article on value in health care (2010), Michael Porter expands the definition and measurement of this complex and elusive construct. He considers value as health outcomes relative to costs, or efficiency. Although he comments on outcomes as condition-specific and multidimensional, he does not adequately define effectiveness of delivered care. As is the case throughout the U.S. health care system, the model of value is an attempt to associate cycles of health care and the “outcome measures hierarchy” with an estimate of dollar cost for individual patients. Certainly time is a critical dimension in evaluation of health care value, but scaling this dimension to condition-specific cycles of individual care is itself a costly operation in measuring value. Furthermore, this approach ignores individuals of the population in sustainable good health due to effective preventive health care strategies or other social welfare policies. The individual patient should not be considered in isolation from the relevant population. Rather data on patient outcomes related to value should be aggregated to reflect not only cycles of care for particular conditions of disease or ill-health, but also the presence of sustainable good health. </div><div align="JUSTIFY"><br />
</div><div align="JUSTIFY">Porter advocates a market-based vision of health care and deplores the lack of competition among providers based on actual results, but appears very careful to recognize the threat posed by public access to data describing such provider performance. Instead of patient choice of provider based on performance data, he emphasizes evidence based provider innovation and improvement through analysis of their own performance. Health care services markets in the U.S. are substantially weakened by the lack of patient access to provider performance data as well as a professional culture highly protective of provider privacy with respect to such data. Evidence based patient choice in health care services markets would significantly enhance value provided.</div><div align="JUSTIFY"><br />
</div><div align="JUSTIFY">Health information systems for such data in the U.S. are primarily designed to support billing processes in the pervasive fee-for-service business model. This is the underlying motivation for ever more detailed and multidimensional data collection on the care of individual patients. Relentless focus on the individual renders more difficult the measurement of teamwork contributions to patient care. Thus one of the most important value-creating organizational reforms tends to be obscured in the complexity of rigorous attribution of shared clinical services and reponsibilities to individual care. It should also be emphasized that the use of billing codes for compilation of clinical conditions and treatments results in an unresolved bias in the quality of such data. </div><div align="JUSTIFY"><br />
Porter's “value equation” does not consider the administrative component of the care cycle,apparently under the assumption that these costs remain invariant across medical conditions. Institutional arrangements designed to improve delivery of value in health care include Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Accountable Care Organizations (ACOs), and Patient Centered Medical Homes (PCMHs). They require varying administrative arrangements to incentivize and transact payment schemes for improvement of service quality to specific populations. These arrangements may increase the administrative component of health care costs as well as the complexity of the integrated system. Although difficult to estimate, such costs must be taken into account in the “value equation,” especially in the U.S. health care context.</div><div align="JUSTIFY"><br />
</div><div align="JUSTIFY">I mentioned in an <a href="http://eresearchcollaboratory.blogspot.com/2009/07/porters-value-based-strategy-for-health.html">earlier commentary on Porter's value framework</a> that the exclusive focus on financial dimensions of care obscures the more elusive ideological, cultural and ethical assumptions underlying the U.S. health care system. In particular, the value framework assumes that individual patients have a sustainable relationship with their care providers, which is obviously not the case. Even if it were feasible to calculate value in the “equation” suggested by Porter, the model would not be applicable in a context where there is such a high rate of patient mobility among providers as well as in and out of various insurance arrangements over relatively short time horizons. The relationship between the patient and his or her providers is probably the most important dimension of value in health care – encompassing values of access, trust, sustainability and continuity. The U.S. corporate health insurance business has designed this relationship out of the system – and thus destroyed the very foundation of health care value-creation. </div><div align="JUSTIFY"><br />
References</div><div style="margin-bottom: 0cm;"></div><div align="LEFT" style="line-height: 100%; margin-bottom: 0cm; margin-top: 0.43cm;">[1] Bohmer RMJ, Lee TH. The Shifting Mission of Health Care Delivery Organizations. N.Engl.J.Med. 2009 August 6;361(6):551-553.</div><div align="LEFT" style="line-height: 100%; margin-bottom: 0cm; margin-top: 0.43cm;">[2] Lee TH. Putting the Value Framework to Work. N.Engl.J.Med. 2010 12/23;363(26):2481-2483.</div><div align="LEFT" style="line-height: 100%; margin-bottom: 0cm; margin-top: 0.43cm;">[3] Porter M. What is Strategy? Harvard Business Review 1996 November/December;74(6):61-78.</div><div align="LEFT" style="line-height: 100%; margin-bottom: 0cm; margin-top: 0.43cm;">[4] Porter ME. A Strategy for Health Care Reform -- Toward a Value-Based System. N.Engl.J.Med. 2009 July 9;361(2):109-112.</div><div align="LEFT" style="line-height: 100%; margin-bottom: 0cm; margin-top: 0.43cm;">[5] Porter ME. What Is Value in Health Care? N.Engl.J.Med. 2010;363(26):2477-2481.</div><div align="LEFT" style="line-height: 100%; margin-bottom: 0cm; margin-top: 0.43cm;">[6] Porter ME, Teisberg EO. How Physicians Can Change the Future of Health Care. JAMA 2007 March 14;297(10):1103-1111.</div>Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-71977608143684111542011-03-29T13:57:00.001-07:002011-03-30T10:37:53.553-07:00Virtual Health Care Infrastructures: Mapping Large Systems<span style="font-family: inherit;">Qualitative case research methods offer a flexible approach to the understanding of large and complex health service delivery systems embedded within their extended social context. Taken as the relevant unit of analysis, the Indian national health care system is a complex inter-organizational network valuable to the process of scientific study as a critical case, particularly for analysis of the co-evolution and integration of networks under a diverse ideologies. Despite recognition of the importance of systems science in medical informatics, little research has focused on studies of health care at the national system level, in part because of the size and complexity of such systems and the lack of interdisciplinary consensus regarding appropriate methodologies and theoretical foundations for this important field of study. Some authors suggest that there is a pragmatist epistemic argument for use of qualitative and mixed research methodologies in the field of medical informatics as clinical practice is a hybrid sociotechnical field. This view rejects belief in a single “scientific method” and recognizes that research is always situated in a particular context.</span><br />
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This research contributes to development of a methodology and conceptual framework for comparative analysis of the virtual infrastructures of national health care systems. Health care is defined as the preservation of mental and physical health by prevention or treatment of illness through services offered by the health professions. A health care system is a dynamic set of interconnected individuals, institutions, organizations, and projects offering products and services in health care markets. The functions of the health system include all categories of service delivery, resource generation and allocation, and governance. Governance includes both policy making and regulation of the system. Service delivery encompasses information, research, and education services as well as public health and delivery of patient care, both preventative and curative. These functions, as well as their interrelations, are critically important to the performance of an integrated health care system and the quality of health care services. <br />
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Data are drawn from published accounts of system development and the websites of the constituent organizations, networks and services to describe the configuration of virtual infrastructures. The context of the case analysis is developed using historical data to show how the current system has unfolded over time. E-mapping software is used to visualize the linkages among institutions and resources identified in the case analysis. Electronic linkages among institutions and services are considered in the analysis as well as linkages integrating national health care systems with international institutions. Using this specialized software, an online database includes a dynamic electronic representation of virtual infrastructures identified in the research program. Visualization of data reveals how information resources are linked and integrated in development of the virtual infrastructure. These data describe configurations of web-based services revealing patterns associated with electronic markets and hierarchies. <br />
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<span style="font-family: inherit;">1. India</span> <br />
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<iframe src="http://webbrain.com/brain/brain/986150AC-9E54-66DB-5710-692F2DBFF067/thought/92/options/showToolbar%3Dfalse%2CshowPins%3Dfalse%2CshowPTL%3Dfalse%2CshowSearch%3Dfalse%2CshowContent%3Dfalse%2Cwander%3Dtrue%2CtextHeight%3D11%2C" style="height: 400px; width: 400px;"></iframe><br />
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2. Bireme: The Latin American Region<br />
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<iframe src="http://webbrain.com/brain/brain/0673AB99-E205-2FB2-2976-47144CC20F25/thought/81/options/showToolbar%3Dfalse%2CshowPins%3Dfalse%2CshowPTL%3Dfalse%2CshowSearch%3Dfalse%2CshowContent%3Dfalse%2Cwander%3Dtrue%2CtextHeight%3D11%2C" style="height: 400px; width: 400px;"></iframe>Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-66380297856051074902011-03-16T08:29:00.000-07:002011-03-29T06:43:09.171-07:00Meaningful Use Rap<iframe allowfullscreen="" frameborder="0" height="300" src="http://www.youtube.com/embed/dUiARwgKzi0" title="YouTube video player" width="360"></iframe><br />
Have a look at this!Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-4331925762224318272011-03-02T09:58:00.001-08:002012-04-10T17:59:00.512-07:00The U.S. Health Care System Infrastructure for Health Information Exchange (HIE)Here is the abstract of a presentation on HIE infrastructure in the US:<br />
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<i>Abstract<br />
Health information technology and infrastructures for increasingly web-based services will drive the future development of national health care systems. However, implementation of HIT without attention to institutional infrastructure will only amplify the uncontrollable surge in health care expenditures. The objective of this talk is to consider published evidence and develop a conceptual framework for design of a national health information infrastructure integrating public and private enterprise in the health sector. A comparative analysis of the National Information Exchange Model (NIEM) and the Nationwide Health Information Network (NHIN) concludes that the NIEM would be more effective in reducing barriers to health information exchange.<br />
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Recent 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. The U.S. lags significantly behind other developed countries in<a href="http://www.commonwealthfund.org/Content/Charts/Chartbook/Multinational-Comparisons-of-Health-Systems-Data--2006/P/Public-Investment-per-Capita-in-Health-Information-Technology-as-of-2005.aspx"> public investments for HIT</a>; as of 2005 the U.K. had spent $192.79 per capita compared to a U.S. investment of $.43. One reason for this is policy failure in development of sustainable business models based on private investment for health information exchange (HIE).<br />
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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 HIS. Their incentives for new technology adoption do not take into account system level efficiencies often external to private HIS 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 for effective health information exchange at the system level.<br />
The nationwide health information network (NHIN) refers to a proposed system linking data intermediaries for health information exchange. Related policies rely primarily on the principle of regional health information organizations (RHIOs) that can collaborate and exchange data. An assumption fundamental to this model is incremental development by linkage of state designated entities (SDEs) and regional health information organizations (RHIOs). However, 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. Further complicating the design of health information exchange are policies promoting medical homes and <a href="http://healthpolicyandreform.nejm.org/?p=13699">accountable care organizations (ACOs) </a>competing for government incentives. These organizations often lack motivation to exchange health information.<br />
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More promising than the NHIN configured among fragmented local and regional RHIOs is the <a href="http://en.wikipedia.org/wiki/National_Information_Exchange_Model">National Information Exchange Model (NIEM)</a>. Even though this development of the NIEM has suffered some of the same difficulties as HIE in defining an effective and sustainable business model, it has benefited from more consistent and longer term public funding.While the NHIN is designed as a many to many mapping of communication among participating entities, the NIEM proposes a canonical mapping through the common infrastructures of the model shared among communities of interest. Such a national – and eventually global - infrastructure offers services as well as a system of governance to assure economies of scale and scope in information exchange across enterprise domains served. Extension of the NIEM to the U.S. health care system would offer much needed cost reduction advantages and help reduce barriers to health information exchange among competing organizations.<br />
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Conclusions and Recommendations:<br />
1. Public investment in health information infrastructures and the NIEM - a single infrastructure does not necessarily imply a single payer design.<br />
2. Design of public health information infrastructure as a public good required to promote interoperability for both public and private services offered in the U.S. health care sector.<br />
3. Collaboration across the Americas integrating the <a href="https://knowledge.infoway-inforoute.ca/EHRSRA/flash/index_big.html">Canadian Infoway </a>and <a href="http://regional.bvsalud.org/local/Site/bireme/I/homepage.htm">BIREME</a> – the Latin American Regional Library of Medicine will serve as a foundation for large scale grid and cloud infrastructures to support research and innovation.Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-2714023037181480932011-02-21T09:27:00.000-08:002011-03-09T13:23:05.483-08:00Stage 2 Meaningful Use ObjectivesThe following text is a commentary on s<em>tage 2 meaningful use</em> objectives, criteria and measures - mainly from the perspectives of social and organizational sciences - in response to <a href="http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__home/1204">the call for public comment</a> issued by the <a href="http://healthit.hhs.gov/media/faca/MU_RFC%20_2011-01-12_final.pdf">HIT Policy Committee</a>. My previous commentaries on <a href="http://eresearchcollaboratory.blogspot.com/2010_03_01_archive.html">MU</a>, <a href="http://eresearchcollaboratory.blogspot.com/2009/04/published-evidence-rhios-and-hie.html">Regional Health Information Organizations</a> (<a href="http://eresearchcollaboratory.blogspot.com/2009/10/health-information-exchange-update.html">and update</a>) and <a href="http://eresearchcollaboratory.blogspot.com/2010/09/regional-extension-centers-and-hie.html">Extension Centers </a>also remain pertinent to the discussion context.<br />
<br />
<em><span style="font-size: 130%;">Commentary on the MU stage 2 matrix (with page references to the call for public comment):</span></em><br />
On page 6, MU objectives refer to "unique patients" for recording vital signs and smoking status. This criterion raises a question concerning the definition of "unique patient". (It is somewhat ironic that in the US system that purports to focus on empowering the individual patient and his or her needs/choices, a unique patient identifier seems to be out of the question.) On December 9, 2010, a Patient Linking Hearing hosted by the ONC Health Information Technology Policy Committee heard testimony on idividual patient identification. Paul Oates of Cigna pointed out that in the US patient ID (and that of his/her family) is generally tied to an employer. When patients lose their jobs or move from one employment to another, their identification may be compromised. Oates further clarifies:<br />
<br />
<span style="font-size: 85%;">"The historical purpose of keeping person data was to derive eligibility for benefits and pay claims, not primarily to improve care or service an individual. So, the primary data attributes linked to a person largely revolved around tying a person to their dates of eligibility, their plan type and features."(Page 1-See <a href="http://healthit.hhs.gov/portal/server.pt/document/949216/oates-patient-linking-hearing-tigerteam_pdf" onclick="javascript:return processLink('http://portal.ahrq.gov/portal/server.pt/gateway/PTARGS_0_949216_0_0_18/oates-patient-linking-hearing-tigerteam.pdf');" target="_blank" title="oates-patient-linking-hearing-tigerteam.pdf">oates-patient-linking-hearing-tigerteam.pdf</a>) </span><br />
<br />
This testimony suggests the tenuous relationship between clinical and claims information resulting in a dual view of patient/consumer identity. Problems in linking patient ID to relevant data further hamper the integrity of research efforts in medicine and public health. Some of these difficulties and possible solutions were suggested at the hearing by Assistant <a href="https://www.amia.org/files/Malin_AMIA_Tiger_Team_Testimony_Final.pdf">Professor Bradley Malin </a>of the Department of Biomedical Informatics, School of Medicine, Vanderbilt University.<br />
<br />
(The logical conclusion to this discussion would be a call for a <a href="http://uidai.gov.in/">unique biometric patient identifier</a>, similar to that being implemented in India.)<br />
On page 7 formulary checks are prescribed for MU, but accomplishment of this objective depends on the collaboration of multiple health plans which may or may not offer the necessary electronic support. Care must be taken to assure that this provision does not result in an excessive administrative burden to meaningful users of EHRs and health information technology.<br />
Also on page 7, where it is stipulated that lab results should be entered into EHRs as structured data, it may be important to distinguish between test results and their interpretation. For example, where digital images are not included in the EHR, lab results constitute interpretation rather than original data. The lack of available raw data may contribute to requirements for unnecessary repetition of clinical tests in some clinical decision processes.<br />
On page 10, the new requirement that secure online patient messaging be in use depends on the existence of supporting infrastructures and health information exchange. Individual EHR users cannot be responsible for the availability of such infrastructures. Also on page 10, the requirement that patient preferences for communication medium be recorded is not really useful under real operational contingencies. Availability of media depends on the context and may change as a patient moves from one facility or geographical area to another. Communication also frequently requires a dynamic suite of synchronous as well as asynchronous media.<br />
Electronic self management tools (page 10) require content beyond the functions of the EHR. Patients choose such tools depending on their health care culture and provider affiliations as well as their ability to invest time and other resources in self management. The patient has access to his or her health information, but content other than that within the patient-specific EHR should not be included in criteria for MU.<br />
For care coordination it is suggested in stage 2 (page 11) that the meaningful user <em>connect to at least three external providers in "primary referral network" (but outside delivery system that uses the same EHR) or establish an ongoing bidirectional connection to at least one health information exchange. </em>As I have frequently mentioned in other commentaries, requirements for health information exchange imposed on meaningful users assume the existance of effective telecommunications infrastructures and institutions such as RHIOs. Such assumptions are invalid. While policies to promote RHIOs, state health information exchanges and the Nationwide Health Information Network (NHIN) are in place, they are so far not sustainable, and public investments remain inadequate.<em> </em><br />
Submission of data including <a href="http://en.wikipedia.org/wiki/Clinical_surveillance">clinical</a> and patient generated information to public health agencies (pages12-13) also depends on the availability of telecommunications infrastructures for such health information exchange. There are not necessarily any preparatory steps to be taken by health care practitioners for these stage 3 objectives. Public initiatives and investment are required rather than individual EHR user steps in stage 2 of MU. Privacy and security protections also depend significantly on design of infrastructures for health information exchange. <br />
<em><span style="font-size: 130%;">Section D-questions 3, 5, 6, 9, and 10 (pages 14-15):</span></em>Question 3: <em>What strategies should be used to ensure that barriers to patient access – whether secondary to limited internet access, low health literacy and/or disability – are appropriately addressed?</em> Strategies to promote patient access to their EHRs and other electronic health information are outside the criteria for MU. However, I would like to suggest the possible usefulness of mentoring among patients and patient support groups focused on competencies necessary for access to and meaningful use of electronic health information. These programs could be offered by public or private entities, including health plans, health care providers, and patient advocacy groups. Physical access to the Internet might further be facilitated through the use of self-service <a href="http://www.gokis.net/self-service/archives/002223.html">kiosks</a> designed to guide patients lacking experience in the use of electronic information and the Internet. Such kiosks could be set up in medical centers, hospitals, clinics and offices of physicians as well as other health care service providers.<br />
<br />
Question 5: <em>For future stages of meaningful use assessment, should CMS provide an alternative way to achieve meaningful use based on demonstration of high performance on clinical quality measures? </em>This would be an important strategy to recognize that there may be many paths to high performance in clinical quality - with or without meaningful use of EHRs. Measurement of clinical quality is also more accessible than assessment of complex and dynamic processes of meaningful use. This strategy would focus users' motivation on the quality objective rather than the means to its achievement - and open the door to incentivize innovative methods other than meaningful use. <em><br />
</em><em></em>Question 6 : <em>Should Stage 2 allow for a group reporting option to allow group practices to demonstrate meaningful use at the group level for all EPs in that group?</em> The answer to this question depends on the organizational and infrastructural health care context. Groups might be defined as <em>medical homes</em> or <em>accountable care organizations</em>. Some EPs may perform part of their practice within such organizational structures. How might such participation be taken into account? Physicians and other health care professionals have multi-affiliated practices and they may also be highly mobile, moving from one US region to another - or even outside the country. It is difficult to imagine how the MU objectives, criteria and measures can take this dynamic context into account.<br />
<br />
Question 9: <em>What additional meaningful-use criteria could be applied to stimulate robust information exchange?</em> As mentioned above with reference to page 11 of the MU matrix, requirements for health information exchange imposed on meaningful users assume the existence of effective telecommunications infrastructures and institutions such as RHIOs. Such assumptions are invalid. While policies to promote RHIOs, state health information exchanges and the Nationwide Health Information Network (NHIN) are in place, they are so far not sustainable, and public investments remain inadequate. EHR users cannot participate in electronic HIE without these infrastructures.<br />
<br />
Question 10: <em>There are some new objectives being considered for stage 3 where there is no precursor objective being proposed for stage 2 in the current matrix. We invite suggestions on appropriate stage 2 objectives that would be meaningful stepping-stone criteria for the new stage 3 objectives.</em> The achievement of MU is not a linear process due to its complexity as well as the high rates of technological change and innovation. It may not be necessary to define stage 2 "stepping stones" towards achievement of stage 3 objectives.<br />
<br />
<em><span style="font-size: 130%;">The evidence base (Section E, page 15):</span></em><br />
The list of studies presented to justify formulation of new MU objectives illustrates the difficulty in the linear (and static) definition of meaningful use. These studies represent single data points in the literature review and meta-analysis required for the propositions guiding meaningful use - under the assumption that these research results will continue to be relevant irregardless of fast moving processes of health care system reform and technological innovation. Meaningful use will also be affected by institutional evolution in the formation of regional (RHIOs) and state organizations for health information exchange as well as <a href="http://healthsystemcio.com/2011/02/18/premier-releases-aco-roadmap/">accountable care organizations (ACOs) </a>and <a href="http://www.medicalhomeinfo.org/">medical homes</a>. There is little or no research evidence (or other policy information) to substantiate any scenario describing the development of these institutions - while they lie at the foundation of meaningful use.<br />
<br />
<em><span style="font-size: 130%;">Concluding thoughts and references:</span></em>Much progress has been made in development of national policies for implementation of health information technology in the US. [1] However, as I have mentioned in earlier commentaries, rapid change and innovation[2,3,4] may result in new policy models - invalidating or competing with the current policy model of MU. The significant risk of a technological paradigm shift may compromise the credibility of MU policies as well as user motivation to accomplish early stage 1 and 2 steps to satisfy MU criteria at stage 3 - after 2015. Unfortunately, even though Blumenthal[5] describes the adoption of EHRs in the US as “inevitable,” recent research on effectiveness of EHRs (as well as ehealth more generally) has shown inconclusive results regarding both improved quality of care and cost effectiveness. [6-8] These studies suffer from a paucity of theoretical frameworks[9] as well as many methodological weaknesses. The absence of an evidence base substantiating the benefits of EHR implementation tends to discredit current policy discourse and undermine efforts to incentivize EHR adoption and meaningful use in the US. It would be useful in this regard to broaden focus on EHR context to include social networks and global telecommunications, and to consider the benefits of enhanced international collaboration for health care service delivery as well as for research in medicine and the health sciences. [10]<br />
<br />
[1] Buntin MB, Jain SH, Blumenthal D. Health Information Technology: Laying The Infrastructure For National Health Reform. Health Affairs 2010 June 01;29(6):1214-1219.<br />
[2] Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care 2010 October 01;19(Suppl 3):i68-i74.<br />
[3] Golembiewski RT, Billingsley K, Yeager S. Measuring Change and Persistence in Human Affairs: Types of Change Generated by OD Designs. The Journal of Applied Behavioral Science 1976 April 01;12(2):133-157.<br />
[4] Millsap R, Hartog S. Alpha, Beta, and Gamma Change in Evaluation Research: A Structural Equation Approach. Journal of Applied Psychology 1988;73(3):574-585.<br />
[5] Blumenthal D, Tavenner M. The “Meaningful Use” Regulation for Electronic Health Records. N.Engl.J.Med. 2010 08/05;363(6):501-504.<br />
[6] Romano MJ, Stafford RS. Electronic Health Records and Clinical Decision Support Systems: Impact on National Ambulatory Care Quality. Arch.Intern.Med. 2011 January 24.<br />
[7] Black A, Car J, Pagliari C, et al. The Impact of EHealth on the Quality and Safety of Health Care: A Systematic Overview. PLoS Medicine 2011;8(1):e1000387.<br />
[8] Jones S, Adams J, Schneider E, et al. Electronic Health Record Adoption and Quality Improvement in US Hospitals. American Journal of Managed Care 2010;16(12).<br />
[9] Pingree S, Hawkins R, Baker T, DuBenske L, Roberts LJ, Gustafson DH. The Value of Theory for Enhancing and Understanding e-Health Interventions. Am.J.Prev.Med. 2010 1;38(1):103-109.<br />
[10] Shachak A, Jadad AR. Electronic Health Records in the Age of Social Networks and Global Telecommunications. JAMA: The Journal of the American Medical Association 2010 February 03;303(5):452-453.<br />
<br />
<em><span style="font-size: 130%;">Addendum: Other significant issues raised in response to the call for public comment:</span></em>Issues raised concerning MU objectives, critera and measures include (1) the integration of digital imaging in EHRs and (2) consistency of public policies to promote eprescribing. These are mentioned below:<br />
<br />
In a <a href="http://www.healthimaging.com/documents/MITA_040510.pdf">recent policy document</a>, the <a href="http://www.medicalimaging.org/">Medical Imaging and Technology Alliance (MITA)</a> deplores the absence of MU criteria regarding formats and electronic transmission of medical imaging. The criteria so far only address data that may be entered into the record by descriptive text or numerical data - while software certification and meaningful use of EHRs will not take medical imaging into consideration until after 2015. MITA points out the need for EHR standards to support sharing digital images generated by equipment made by different manufacturers. <a href="http://medical.nema.org/dicom/geninfo/Strategy.pdf">The Digital Imaging and Communications in Medicine (DICOM) Standard</a> was developed by the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA). The current standard, DICOM 3.0 is nearly universally accepted to enable data exchange among DICOM compliant systems, either on CDs or through available transfer functions. An industry and professional initiative, <a href="http://www.ihe.net/About/">Integrating the Healthcare Enterprise (IHE)</a>, further promotes adoption of EHRs by facilitating service coordination and data exchange among health care information systems. IHE tests more than 100 systems for compliance every year. These efforts supporting DICOM and health information exchange should be an integral part of the EHR MU scenario.<br />
<br />
Another important issue is the lack of coherency between two CMS incentive programs promoting use of electronic prescriptions and EHRs. The GAO has published an analysis of program inconsistencies and their consequences.(See <a href="http://www.gao.gov/new.items/d11159.pdf">Electronic Prescribing: CMS Should Address Inconsistencies in Its Two Incentive Programs that Encourage Use of Health Information Technology - February 2011</a> - GAO-11-159)Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-61445701899834753242010-09-27T11:20:00.002-07:002012-04-07T15:02:57.004-07:00Regional Extension Centers and HIEThe <a href="http://www.softwareadvice.com/medical/">Software Advice team </a>has written an interesting critique on recently created Regional Extension Centers (RECs) designed to advance adoption of EHRs. You are invited to complete their online <a href="http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/">survey </a>with special emphasis on reporting anecdotal experience with these organizations. Although it is probably too early to draw substantial conclusions, I agree with Houston Neal that RECs will remain ineffective. My arguments suggest inadequate public funding and institutional arrangements, while his deplore the slow pace of government programs and their interference with free market dynamics.<br />
<br />
As Neal points out, the <a href="http://www.ehealthinitiative.org/">eHealth Initiative </a>has published a disappointing report on RECs to assess progress in their implementation across the US. They have also issued their 2010 report on Health Information Exchange (HIE).<br />
<br />
Under the Health Information Technology Research Center (HITRC), RECs were created to provide technical assistance, guidance and information on best practices to support meaningful use of Electronic Health Records (EHRs). The competitively selected RECs - announced in February and April 2010 - serve health care providers within their geographical areas. The Survey of Regional Extension Centers, <i>Planning for Adoption: The Early Direction of Regional Extension Centers</i> (September 2010), presents the following findings (page 3):<br />
<ul><li>Many Regional Extension Centers remain in the planning stages.</li>
<li>Progress has been slow in transitioning pre-award letters of commitment<br />
by providers to signed contracts by PCPs with a Regional Extension<br />
Center.</li>
<li>Opinion is evenly divided on progress toward REC objectives being reliant<br />
upon assistance from the Health Information Technology Research Center.</li>
<li>Among Regional Extension Centers planning to offer a preferred EHR<br />
vendor list to PCPs, the most important criteria for selecting a preferred<br />
EHR vendor are:<br />
o Price/ total cost of ownership over 3 years<br />
o Guarantee of meaningful use functionality<br />
o The number of installations locally<br />
o Use of an ASP hosted model</li>
<li>After stimulus funds are removed, a majority of Regional Extension<br />
Centers will change their fees as a means to sustainability.</li>
</ul>The sample for this survey included only 46 of the 60 RECs in operation. The above findings suggest difficulties in defining the relationships among RECs and other health care institutions, as well as the lack of a sustainable business model. It is also not clear how these centers will provide support services across the US. The competitive selection process for RECs considered neither the issue of comprehensive geographical coverage, nor design of the requisite institutional arrangements with RHIOs, the HITRC or SDEs. I pointed out some of these weaknesses in <a href="http://eresearchcollaboratory.blogspot.com/2009/06/commentary-us-health-information.html">my commentary on the proposed REC design and selection process </a>last year.<br />
<br />
The eHealth Initiative has also published a report based on their Seventh Annual Survey of Health Information Exchange - <a href="http://www.ehealthinitiative.org/uploads/file/Final%20Report.pdf"><i></i></a><i>The State of Health Information Exchange in 2010: Connecting the Nation to Achieve Meaningful Use.</i> The survey identified 234 active health information exchange initiatives (HIEs) in the US, among which 199 responded to and qualified for inclusion in the 2010 Annual Survey on Health Information Exchange. It should be noted that 48 of 56 state designated entities (SDEs) have been included in this sample. This shift in the definition of health information organizations needs to be taken into account in the survey findings reported. On page five, a description of the geographical coverage of organizations included in the survey shows that they cannot be considered comparable in size or clientele:<br />
<br />
<span style="font-size: 85%;">"Most non-SDE initiatives are operating at a multi-county coverage area. Fifty-five<br />
initiatives report covering a multi-county area, while 21 initiatives report covering an<br />
entire state. Other coverage areas include: 17 at a multi-state level, 11 at a county level,<br />
7 at a metro level, 5 that do not cover a geographic area, and 6 initiatives that cover<br />
another area such as part of a city or county, or are working with a specific population<br />
group."</span><br />
<br />
While the 2010 survey claims an increase in the number of operational exchanges, the rate of "mortality" among the sample from 2009-2010 is not considered, nor is the redefinition of "exchange initiatives" (defined as RHIOs in earlier reports) to include state designated entities (SDEs). The interpretation of survey results makes no distinction between state and federal programs for health information exchange.<br />
<br />
<span style="font-size: 85%;">In 2009, 57 health information exchange initiatives reported being operational. In 2010,<br />
the number of operational health information exchanges increased to 73, 5 of which<br />
report being SDEs. (page 8)</span><br />
<br />
At least 28 of the 2009 respondents who did not respond to the 2010 survey were thought to continue their pursuit of HIE - although there is no data presented to support this assertion. The research methodology does not clearly state the total number of organizations included in the 2009 survey who did not respond in 2010. This number is essential to evaluate the 2010 survey response rate as well as sample mortality. (In my <a href="http://eresearchcollaboratory.blogspot.com/2009/10/health-information-exchange-update.html">commentary on the 2009 survey</a>, I identified similar problems in the research methodology.)<br />
<br />
The significant methodological deficiencies of the surveys conducted by the eHealth Initiative seriously undermine the optimistic claims made by their authors.<br />
Some useful websites:<br />
<br />
<a href="http://statehieresources.org/"><span style="font-size: 85%;">The State HIE Toolkit</span></a><br />
<a href="http://slhie.org/"><span style="font-size: 85%;">The State Health Information Exchange Leadership Forum</span></a><br />
<a href="http://www.himss.org/ASP/topics_rhio.asp"><span style="font-size: 85%;">HIMSS Health Information Exchange</span></a><br />
<a href="http://healthit.hhs.gov/portal/server.pt?open=512&objID=1200&mode=2"><span style="font-size: 85%;">The Office of the National Coordinator for Health Information Technology</span></a><span style="font-size: 85%;"> (ONC)</span><br />
<a href="http://en.wikipedia.org/wiki/Regional_Health_Information_Organization"><span style="font-size: 85%;">Wikipedia Regional Health Information Organization</span></a><br />
<a href="http://healthit.hhs.gov/portal/server.pt?open=512&objID=1142&parentname=CommunityPage&parentid=4&mode=2"><span style="font-size: 85%;">Nationwide Health Information Network Overview </span></a><span style="font-size: 85%;">(ONC)</span><br />
<a href="http://www.phii.org/">Public Health Informatics Institute</a> (PHII)Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-80022546175254218202010-09-27T07:24:00.000-07:002010-09-27T07:52:15.585-07:00Reflections on Business ModelsIn commentaries on US policies to promote meaningful use of health information technologies and electronic health records, I have pointed out the importance of a system level view of infrastructures for health information exchange. Key to the development of such infrastructures is the underlying business model to assure nationwide integration and system sustainability. A number of papers on health care system business models are available from a variety of agencies:<br /><br /><br /><br /><br /><br /><a href="http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047556.hcsp?dDocName=bok1_047556">A Strong State Role in HIE: Lessons from the South Carolina Health Information Exchange</a><br /><br />(2010) AHIMA<br /><br /><br /><br />Abstract:<br /><br /><span style="font-size:85%;">HIEs provide the infrastructure for information exchange, including the business model, governance structure, operating principles, legal model, and technology model for the exchange of healthcare information among various organizations. HIEs and regional health information organizations (RHIOs) have struggled with development and sustainability. The causes of failures are varied, but a lack of a compelling value proposition for all stakeholders is often cited as the prevailing reason.1<br />The primary beneficiary from an HIE is often the patient, who contributes the least directly toward the HIE’s development and operational costs. Other vested stakeholders, such as payers and providers, all receive varying benefits and bear varying responsibilities for the costs. A major barrier in the development of HIEs then is the identification of a model that fairly and equitably distributes the costs and benefits among the various stakeholders. At the crux of this issue is whether HIEs should follow a private, market-driven model that requires the generation of profit and value for the participants, or if HIEs are a public good that requires public financing. RHIOs and HIEs typically rely on a mix of government and private grants in the start-up phase, with the expectation of self-sustainability in the future: Four categories of business models are: <strong>not-for-profit, public utility, physician-payer collaborative, </strong>and<strong> for-profit</strong>.<br /></span><br /><br /><br /><br />ICT for the Health Unit, Directorate General Information Society and Media, European Commission: <a href="http://ec.europa.eu/information_society/activities/health/docs/studies/business_model/business_models_eHealth_report.pdf">Business Models for eHealth</a> (2010)<br /><br /><br />Abstract:<br /><br /><span style="font-size:85%;">The evidence suggests that a solid business model is required for developing and<br />implementing a value-creating and sustainable eHealth service. In particular, this business<br />model needs to map all key supporting activities, value chain relationships and<br />dependencies impacted by the introduction of an eHealth service. This state of affairs can<br />be achieved if a set of activities and steps are implemented.<br />First, the structuring and implementation of such business model requires strong senior<br />management involvement throughout the various phases of the design, development and<br />delivery of an eHealth service. More importantly, senior management should not just act<br />as a project or programme manager; instead, it should make sure that the eHealth system<br />that it is supporting is provided with the required funding throughout its entire<br />development and implementation phases. Essentially, senior management is expected to<br />have a clear vision of what its healthcare delivery organisation wants to achieve with a<br />specific eHealth service and system, and lead the required operational steps.<br />In addition, staff involvement is essential in designing a business model of an eHealth<br />service. They need to be given the opportunity to understand how the specific service is to<br />change their activity or role, and need to provide evidence for mapping their interactions<br />in order to see how the eHealth service is going to improve or modify them. All of these<br />activities are aimed at making sure that business models do not fall short of reflecting the<br />interactions of those actors who are to use them in their day-to-day professional activities.<br />A business model of a value-creating and sustainable eHealth system is a static entity. It<br />might change as a consequence of technological and organisational evolution. However, it<br />can evolve following an evaluation aimed at measuring the potential and current impact of<br />the eHealth system. This may require data collection concerning activity, costs and<br />benefits. It also involves the need to apply sensitivity analysis to assess different scenarios<br />through which it is possible to design or modify a business model. Although the literature<br />provides several eHealth evaluation models, their implementation requires strong senior<br />management and process management, since regular performance data needs to be<br />collected and examined in order to assess current performance and estimate future<br />developments.</span><br /><br /><br /><br /><br /><p><a href="http://www.longwoods.com/content/19625">US Regional Health Information Organizations and the Nationwide Health Information Network: Any Lessons for Canadians?</a> D. Protti <a href="http://www.blogger.com/publications/electronichealthcare/541">ElectronicHealthcare, 6(4) 2008: 96-103 </a></p><br /><p>Abstract:<br /><span style="font-size:85%;">There seems to be general agreement in the United States that a Regional Health Information Organization (RHIO) is a neutral, non-governmental, multi-stakeholder organization that adheres to a defined governance structure to oversee the business and legal issues involved in facilitating the secure exchange of health information to advance the effective and efficient delivery of healthcare for individuals and communities. The geographic footprint of an RHIO can range from a local community to a large multi-state region. As regional networks of stakeholders mature, they often find the need for a formal independent organizational and governance structure (i.e., an RHIO) with systems to ensure accountability and sustainability for the benefit of all stakeholders. Experts maintain that RHIOs will help reduce administrative costs associated with paper-based patient records, provide quick access to automated test results and offer a consolidated view of a patient's history. The terms RHIO and Health Information Exchange (HIE) are often used interchangeably though most would see HIE as a "concept" relating to the mobilization of healthcare information electronically across organizations within a region or community as opposed to an "organization." Typically, an HIE is a project or initiative focused around electronic data exchange between two or more organizations or stakeholders. This exchange may include clinical, administrative and financial data across a medical and or business trading area. HIEs may or may not be represented through a legal business entity or a formal business agreement between the participating parties. Local Health Information Infrastructure (LHII) is a term occasionally used synonymously with RHIO. LHII was originally termed by the Office of the National Coordinator of Health Information Technology (ONCHIT) to describe the regional or local initiatives that are anticipated to be linked together to form an envisioned National Health Information Network (NHIN). The NHIN describes the technologies, standards, laws, policies, programs and practices that enable health information to be electronically shared among multiple stakeholders and decision makers to promote healthcare delivery. When completed, the NHIN will provide the foundation for an interoperable, standards- based network for the secure exchange of healthcare information in the United States.</span></p><br />eHealth Initiative (2007): <a href="http://www.ehealthinitiative.org/sites/default/files/01%20-%20HRSA_CCBH_Report_Summary.pdf">Health Information Exchange: From Start-up to Sustainability</a><br /><br /><br /><br /><br /><br />University of Copenhagen Masters Thesis (2009):<br /><br /><a href="http://studenttheses.cbs.dk/bitstream/handle/10417/358/Ieva_Berzina_og_Paul_van_Bommel.pdf?sequence=1">Behind the Internet Business Models: An E-health Industry Case</a><br /><br /><br /><br /><br /><br />OECD International Futures Project on<br />“The Bioeconomy to 2030: Designing a Policy Agenda”<br /><br />Health Biotechnology:<br /><a href="http://www.oecd.org/dataoecd/12/29/40923107.pdf">Emerging Business Models and Institutional Drivers</a> (2008)<br /><br /><br />Abstract:<br /><span style="font-size:85%;">Up until today, two business models have been dominant within the application of<br />biotechnology for human health, or what is called health biotech in this report. One is the<br />classical biotechnology model. In this model, scientific discoveries and technological<br />inventions have been quickly developed within entrepreneurial firms, usually based upon<br />venture capital. They compete through their specialized scientific knowledge, often sold to<br />large companies, and they also compete through their flexibility, especially quick<br />commercialization of new fields. The other dominant business model is that of the large,<br />vertically integrated company. These large firms have integrated everything inside the<br />boundaries of the firm, from research and development (R&D) to production to marketing<br />and after sales monitoring. Firms in pharmaceuticals have competed through finding the<br />next ‘blockbuster drug’ and those in medical devices have also competed through<br />developing specific technologies and devices for large numbers of customers.<br />The report argues that four institutional drivers will form a very different context to deliver<br />human health care. Those four institutional drivers for change are 1) Scientific and<br />technological advances; 2) Public research and the public-private interface; 3) Public policy,<br />institutions and regulation; and 4) Demand and consumers.</span><br /><br /><br /><div align="justify"></div>Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-27483400629379912162010-03-23T14:45:00.000-07:002010-03-29T15:38:41.512-07:00Meaningful Use and Health Care Reform (Commentary updated)Since my last <a href="http://eresearchcollaboratory.blogspot.com/2009/06/comment-meaningful-use.html">commentary on "meaningful use"</a> of an electronic health record (EHR) on June 22, 2009, progress has been made in elaborating relevant definitions as well as specific metrics for evaluation and measurement. Progress has also been made in developing certification criteria for <a href="http://www.cchit.org/products">EHR software products </a>available on the market. The <a href="http://www.regulations.gov/search/Regs/home.html#docketDetail?R=CMS-2009-0117">Proposed Rule </a>on the CMS Electronic Health Record Incentive Program, published on January 13 in the Federal Register, builds on previous consultations and hearings concerning definition and measurement of "meaningful use" of EHRs. "This proposed rule would implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) that provide incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified electronic health record (EHR) technology." (Page 1844, Federal Register, Vol. 75, No. 8) My comment and recommendations address the context of the U.S. health care system through the lens of organizational behavior and theory.<br />On December 30, 2009, <a href="http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3564">CMS proposed a definition of meaningful use of EHR technology</a>. In summary this definition considers <a href="http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11113_872719_0_0_18/Meaningful%20Use%20Matrix.pdf">three phases of EHR adoption and meaningful use</a>. In stage I (2011): "... criteria for meaningful use focus on electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes, and initiating the reporting of clinical quality measures and public health information." Definitions to be applied for stages 2 and 3 remain to be finalized in time for 2013 and 2015 incentive payment years, as do corresponding dimensions of EHR certification. (In the proposed rule published on January 13, CMS refers to ONC definitions of qualified and certified EHR technology.)<br /><br />This linear design of EHR adoption omits critical dimensions of organizational context and the reticular, multilevel process of change and development in social systems. Furthermore the logical structure of the process has been reversed in two important ways. First, narrow, short-term criteria have been defined for 2011 in stage 1, leaving adopters at a loss to understand how early adoption prepares them for future returns on their investment. Second, infrastructures necessary for meaningful use seem to be viewed as an outcome of the process rather than a prerequisite. The absence of health information exchange (HIE) organizations forming a Nationwide Health Information Network (NHIN) invalidates the most important intrinsic benefit of meaningful use, the communication of health information across institutional and geographical boundaries.<br /><br />Discussion of the EHR reporting period for determination of ARRA incentive payments (page 1849) reveals concern for a tradeoff between "robust verification and time available to achieve compliance." To resolve this tradeoff, the EHR reporting period in the first incentive payment year is defined as any continuous 90 day period, while subsequent reporting periods should be extended over the entire payment year for more robust measurement of compliance rates. This provision recognizes neither the dynamic, nonlinear character of this complex process nor the critical importance of the initial determination of meaningful use in the process of awarding incentive payments. It might be more reasonable to establish continuous monitoring, for example over a period of the previous 3 to 6 months of EHR use. Measurement of health information exchange (HIE) would further require identification of the organizational configuration of associated Regional Health Information Organizations (RHIOs) or the Nationwide Health Information Network.<br /><br />The policy priorities for meaningful use presented in the proposed rule are generally consistent with the recommendations of the HIT Policy Committee: 1- To improve quality, safety, efficiency and to reduce health disparities; 2- To engage patients and families in their health care; 3- To improve care coordination; 4- To improve population and public health; and 5- to ensure adequate privacy and security protections for personal health information. Stage 1 criteria for meaningful use include a set of objectives for each policy priority, along with the requirement that all objectives be satisfied for provider qualification. This requirement may be too rigid to accommodate the increasing diversity of health care providers in the U.S.. For example, physician and emerging mid-level provider organizations may satisfy different objectives.<br /><br />Careful review of the proposed rule reveals that issues related to development of a national health information infrastructure have not been addressed since June, 2009. The criteria for meaningful use exclude functions requiring effective health information exchange - in recognition of the absence of HIT infrastructure and the current low rate of EHR adoption in the U.S.: "Given the anticipated maturity of HIT infrastructure inherent in the strengthening criteria (through 3 stages of meaningful use) and the increased adoption of certified EHR technology predicted in section V. of this proposed rule, these barriers to meaningful use will be removed." (page 1853) Unfortunately, there is no evidence-based argument to support these apparent assumptions at the foundation of EHR meaningful use.<br /><br />In the proposed rule, there are several examples of criteria adjusted to the lack of infrastructure for HIE. For example, the use of computer provider order entry (CPOE) is defined as "the provider's use of computer assistance to directly enter medical orders (from a computer or mobile device) captured in a digital, structured and computable format for use in improving safety and organization. It does not include the transmittal of that order to the pharmacy, laboratory, or diagnostic imaging center in 2011 or 2012."(page 1856) The formulation of this meaningful use criterion illustrates how the intrinsic motivations for CPOE - the ability to communicate such orders to other health care providers - may be compromised where no infrastructure exists for HIE. Another example is the exclusion of the objective to provide access to patient-specific education resources upon request. An important reason for this exclusion is the lack of infrastructure for open access to such resources.<br /><br />On the other hand, on page 1856, the goals associated with improved care coordination require health information exchange, and the proposed rule apparently assumes the presence of necessary infrastructure. For example, qualified providers and eligible hospitals must demonstrate capability to exchange key clinical information (such as problem list, medication list, allergies and diagnostic test results) among providers of care and patient authorized entities electronically. Furthermore, concerning meaningful use objectives related to administrative simplification, it is proposed that the phrase "where possible" be deleted from the requirement that insurance eligibility be checked and that claims be submitted electronically since these are already standard HIPAA transactions. However, there is no indication that these electronic transactions are "standard" in practice. An <a href="http://www.ama-assn.org/ama1/pub/upload/mm/368/hipaa-tcs.pdf">AMA interpretation of HIPAA regulations </a>(AMA Practice Management Center, Understanding the HIPAA Standard Transactions: The HIPAA Transactions and Code Set Rule, published in 2009 -page 7) states that CMS will focus on "...voluntary and complaint-driven enforcement." The responsibility for securing insurer compliance appears to belong to the physician and his or her practice - a substantial additional burden associated with "meaningful use."<br /><br />The above discussion shows that the assumption of available NHIN infrastructure varies from one section of the proposed rule to another. This is especially inappropriate in the formulation of Stage 1 criteria for meaningful use.<br /><br />As stated on page 1858, it is surely important to measure conformity with the objectives of meaningful use. However, the measures presented in the proposed rule focus mainly on percentages based on frequency, for example in use of CPOE. This measure ignores the fact that without appropriate HIE, such orders cannot be effectively communicated. The data generated for these measures (the numerator and denominator for calculation of conformity to the required percentage of use) are further difficult to verify, and would be subject to legal challenge especially for qualified providers practicing in multiple settings and through multiple payers (page 1859). EPs practicing in multiple settings are required to conduct 50% of their patient encounters in locations or practices equipped with certified EHR technology. Is it really feasible that "…in evaluating the 50 percent threshold, our proposal is to review all locations-organizations at which an EP practices."? (page 1859) Among EPs whose pattern of practice is changing over time, this suggested review cannot be valide. The measurement further excludes HIE :<br /><br />"As this objective (CPOE) relies solely on a capability included as part of certified EHR technology and is not, for purposes of Stage 1 criteria, reliant on the electronic exchange of information, we believe it would be appropriate to set a high percentage threshold....For other objectives that are reliant on the electronic exchange of information, we are cognizant that in most areas of the country, the infrastructure necessary to support such exchange is not yet currently available..."(page 1859) The effect of these stipulations will be conflation of "meaningful use" with implementation of certified EHR. The entry of data in a certified EHR is not by itself evidence of meaningful use.<br /><br />The most persistent problem in creation of infrastructure for HIE is the business model for these enterprises to be created across the U.S.. Until this problem is solved, no meaningful use of EHR will be possible. In a study reported by Wright et al. (<a href="http://jamia.bmj.com/content/17/1/66.full.html">Physician Attitudes Toward Health Information Exchange: Results of a Statewide Survey, JAMIA 2010 17: 66-70</a>), 45% of respondents reported no usage of EHR while 28% reported usage of a simple EHR defined as "an integrated clinical information system that tracks patient health data and may include such functions as visit notes, prescriptions, lab orders, etc." (page 67). It is difficult to conclude from this survey that physicians would be willing to pay for HIE, as so few have any meaningful experience with this function. Further, in a study by Adler-Milstein et al. (<a href="http://jamia.bmj.com/content/17/1/61.full.html">Characteristics Associated with Regional Health Information Organization Viability, JAMIA 2010 17: 61-65</a>), it is concluded that "Exchanging a narrow set of data and invoking a broad group of stakeholders were independently associated with a higher likelihood of being operational." (Abstract page 61)<br /><br />This conclusion omits reference to the extremely low rate of viability observed among RHIOs under study. In another very recent study by Ross et al. (<a href="http://www.ijmijournal.com/article/S1386-5056(09)00179-8/abstract">Health Information Exchange in Small-to-Medium Sized Family Medicine Practices: Motivators, Barriers, and Potential Facilitators of Adoption</a>, IJMI 2010 79: 123-129), electronic prescribing was ranked favorably among health information exchange functions, but no surveyed practice identified available government incentives as a significant motivator for adoption of this function in HIE, particularly in practices where eprescribing was already included in EHR functions.<br /><br />In conclusion to this commentary, I would agree with some other observers: physicians and other health care providers should not wait for U.S. government incentives for adoption of certified EHR or "meaningful use". Rather they should assess the intrinsic benefits to their workflow as well as ROI resulting from prospective software adoption, and they should act in accordance with internal scenario analysis. System level efficiencies at the regional or national levels of analysis will only become accessible with sustained public investment in necessary infrastructures. Unfortunately in the U.S. health care sector such investment remains unlikely.<br />More promising than the NHIN configured among local and regional RHIOs is the <a href="http://www.niem.gov/files/NIEM_Introduction.pdf">National Information Exchange Model (NIEM)</a> originated in 2005 by the Department of Justice (DOJ) and the Department of Homeland Security (DHS) to address information exchange among government agencies in the context of national security. Even though this development of the NIEM has suffered some of the same <a href="http://fcw.com/articles/2008/04/21/funding-worries-fusion-center-officials.aspx">difficulties as HIE in defining an effective and sustainable business model</a>, it has benefited from more consistent and longer term public funding.<br />While the NHIN is designed as a many to many mapping of communication among participating entities, the NIEM proposes a canonical mapping through the common infrastructures of the model shared among communities of interest. Such a national – and eventually global - infrastructure offers services as well as a system of governance to assure economies of scale and scope in information exchange across enterprise domains served. [1] [2] [3] [4]<br />Websites: <a href="http://www.it.ojp.gov/default.aspx?area=nationalInitiatives&page=1181">Justice Information Sharing</a> ; <a href="http://www.niem.gov/">National Information Exchange Model</a><br /><br />RECOMMENDATIONS<br />­<br />1-Emphasize intrinsic benefits available through meaningful use rather than unsustainable extrinsic incentives. NIEM implementation model values stakeholder participation in system development and governance. HIE is a fundamental intrinsic motivation for meaningful use of EHRs as well as a central criterion for its assessment. For example, where CPOE does not include the functionality for communication across health care providers and pharmacies, it seems meaningless to require that 80% of such orders be entered electronically. Modest financial incentives for individual providers will not be adequate to motivate behavior perceived to be meaningless.<br />­<br />2-Recognize the benefits of meaningful use of certified EHR software to integrate clinical research and practice. According to Chris Thorman of <a href="http://www.softwareadvice.com/">Software Advice, </a> a <a href="http://www.softwareadvice.com/medical/electronic-medical-record-software-comparison/?wfvar=wfctrl" target="_blank">website that reviews electronic health records</a> this important motivation for EHR adoption surpasses the HITECH incentives in terms of return on investment in health information technology. According to <a href="http://www.synergystresearch.net/clinical.html">Synergyst Research </a>only 10% of more than 720,000 licensed American physicians participate in clinical trials, mostly because of the significant burdens associated with data collection, extra paperwork, compliance with regulations, and staff training. EHRs contribute to solve these problems. Chris Thorman has summarized the usefulness of EHRs in clinical trial participation in the following table appearing in his article, <a href="http://www.softwareadvice.com/articles/medical/medical-news/electronic-health-records-and-clinical-trials-an-incentive-to-integrate-1031910/">Electronic Health Records and Clinical Trials, An Incentive to Integrate</a>:<br /><strong>Identify potential opportunities</strong><br />EHR vendors whose software integrates with clinical trial providers will have access to trials, studies, and registries that your practice is eligible to participate in.<br /><strong>Identify number of potential trial subjects</strong><br />The search function in an EHR database allows a user to quickly identify how many of a practice's patients are potentially eligible for a clinical trial. From there, the clinical trial provider can determine if a practice would be a good partner.<br /><strong>Patient enrollment</strong><br />The EHR has the capability to implement trial-specific screening requirements into new patient records to determine their eligibility for a study. The EHR will also have the ability to identify patients who meet the exact requirements of a study.<br /><strong>Study execution</strong><br />During the trial, the EHR can create trial-specific data fields that can be populated during routine patient encounters. Conflict alerts can also be created to notify providers of actions that violate a study's protocol.<br /><strong>Data submission</strong><br />The EHR will be able to submit information to EDC software without having to convert the data. This eliminates redundant data entry and increases accuracy of the data.<br /><br />­3-Recognize the reticular, nonlinear process of EHR adoption and meaningful use by considering the configuration of communities of interest in the process of use assessment. Greater emphasis, particularly in definition of the time frame, should be placed on evaluation of meaningful use at the initial and most important phase. Failure to adequately assess the initial phase will result in serious problems in subsequent phases of evaluation for incentives. The time frame should be a moving period of 3 to 6 months to better reflect the dynamic character of the process.<br />­<br />4-Examine assumptions related to HIE infrastructures as they shape the formulation of the rules throughout the document. These assumptions appear to vary, affecting whether the exchange of information is required or not. They should be realistic and consistent throughout. Furthermore, qualified providers should not be charged with obtaining compliance on the part of insurers or other partners, as appears to be the case in checking insurance eligibility.<br />­<br />5-The U.S. could develop a more effective long-term strategy through collaboration with the Brazilian BIREME and the Canadian Infoway. This approach would contribute as well to creation of an effective regional and hemispheric health information system.<br />­<br />­<br />[1] Allen, C. Information sharing and the federal state and local levels. Testimony before the Senate Committee on Homeland Security and Governmental Affairs. July 23, 2008. Washington, DC. <a href="http://www.dhs.gov/xnews/testimony/testimony_1216992676837.shtm">http://www.dhs.gov/xnews/testimony/testimony_1216992676837.shtm</a><br />[2] Carter DL, Carter JG. The Intelligence Fusion Process for State, Local, and Tribal Law Enforcement. Criminal Justice and Behavior 2009 December 1;36(12):1323-1339.<br />[3] Garson GD. Securing the Virtual State: Recent Developments in Privacy and Security. Social Science Computer Review 2006 November 1;24(4):489-496.<br />[4] Rollins J. Fusion Centers: Issues and Options for Congress. 2008; RL34070. <a href="http://fas.org/sgp/crs/intel/RL34070.pdf">http://fas.org/sgp/crs/intel/RL34070.pdf</a>Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-81113197276103635512010-01-27T14:11:00.000-08:002010-02-02T14:40:47.675-08:00Meaningful Use and Health Care ReformSince my last <a href="http://eresearchcollaboratory.blogspot.com/2009/06/comment-meaningful-use.html">commentary on "meaningful use"</a> of an electronic health record (EHR) on June 22, 2009, much progress has been made in elaborating relevant definitions as well as specific metrics for evaluation and measurement. Progress has also been made in developing and applying certification criteria for <a href="http://www.cchit.org/products">EHR software products </a>available on the market. Chris Thorman of <a href="http://www.softwareadvice.com/">Software Advice </a>has published a very useful article, <a href="http://www.softwareadvice.com/articles/medical/the-stimulus-bill-and-meaningful-use-of-qualified-emrs-1031209/">"Updates on Meaningful Use, Certified EHR Technology and the Stimulus Bill"</a>, to help physicians and hospitals evaluate their software needs and qualify for EHR incentive payments under the <a href="http://hitechanswers.net/">HITECH Act</a>. An earlier article, "<a href="http://www.softwareadvice.com/articles/medical/dont-wait-for-the-government-to-start-your-ehr-implementation-1122209/">Don't wait for the Government to Start Your EHR Implementation,"</a> provides important background information on EHR return on investment (ROI).<br /><br />The following resources contribute to my updated commentary on "meaningful use":<br /><br /><a href="http://www.regulations.gov/search/Regs/home.html#docketDetail?R=CMS-2009-0117">Proposed Rule: Medicare and Medicaid Programs: Electronic Health Record Incentive Program</a> – CMS-2009-0117-0002- Posted 01-13-10<br /><br />National Committee on Vital and Health Statistics<br /><a href="http://www.ncvhs.hhs.gov/090428rpt.pdf">Observations on “Meaningful Use” of Health Information Technology</a><br />June 1, 2009<br /><br />Adler-Milstein, J., Landefeld, J., Jha, A. Characteristics Associated with Regional Health Information Organization Viability, Journal of the American Medical Informatics Association, 2010, 17(1), 61-65.<br /><br />Sweeney, L. The Medical Billing Framework as the Backbone of the National Health Information Infrastructure. Carnegie Mellon University, <a href="http://advancehit.org/index.html">AdvanceHIT Project</a>. Working Paper 1001. October 2009. <a href="http://advancehit.org/publications/p1001/AdvanceHIT1001.pdf">PDF</a><br /><br />Wright, A. Soran, C., Jenter, A., et al., Physician Attitudes Toward Health Information Exchange: Results of a Statewide Survey, Journal of the American Medical Informatics Association, 2010, 17(1), 66-70.<br /><br />The <a href="http://www.regulations.gov/search/Regs/home.html#docketDetail?R=CMS-2009-0117">Proposed Rule </a>on the CMS Electronic Health Record Incentive Program, published on January 13 in the Federal Register, builds on previous consultations and hearings concerning definition and measurement of "meaningful use" of EHRs. "This proposed rule would implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) that provide incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified electronic health record (EHR) technology." (Page 1844, Federal Register, Vol. 75, No. 8) This comment focuses on the context of the U.S. health care system as well as the definitions of "meaningful use" and software certification.<br /><br />On December 30, 2009, <a href="http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3564">CMS proposed a definition of meaningful use of EHR technology</a>. In summary this definition considers <a href="http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11113_872719_0_0_18/Meaningful%20Use%20Matrix.pdf">three phases of EHR adoption and meaningful use</a>. In Stage I (2011): "<em>... criteria for meaningful use focus on electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes, and initiating the reporting of clinical quality measures and public health information</em>." Definitions to be applied for stages 2 and 3 remain to be finalized in time for 2013 and 2015 incentive payment years, as do corresponding dimensions of EHR certification. (In the proposed rule published on January 13, CMS refers to ONC definitions of qualified and certified EHR technology.) <br /><br />Discussion of the EHR reporting period for determination of ARRA incentive payments (page 1849) reveals concern for a tradeoff between "robust verification and and time available to achieve compliance." To resolve this tradeoff, the EHR reporting period in the first incentive payment year is defined as any continuous 90 day period, while subsequently the reporting period should be extended over the entire payment year for more robust measurement of compliance rates. This provision recognizes neither the dynamic and nonlinear character of this complex process nor the critical importance of the initial determination of meaningful use. It might be more reasonable to establish a process of continuous monitoring, for example over a period of the previous 3 to 6 months of EHR use. Measurement of health information exchange (HIE) would further require identification of the organizational configuration of associated RHIOs or the Nationwide Health Information Network.<br /><br />The policy priorities for meaningful use presented in the proposed rule are generally consistent with the recommendations of the HIT Policy Committee: 1- To improve quality, safety, efficiency and to reduce health dispartities; 2- To engage patients and families in their health care; 3- To improve care coordination; 4- To improve population and public health; and 5- to ensure adequate privacy and security protections for personal health information. Stage 1 criteria for meaningful use include a set of objectives for each policy priority, along with the requirement that all objectives be satisfied for provider qualification. This requirement may be too rigid to accommodate the increasing diversity of health care providers in the U.S.. For example, physician and emerging mid-level provider organizations may satisfy different objectives. <br /><br />(Commentary to be continued...)Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-33623845844484149532009-10-14T07:07:00.000-07:002009-10-15T07:32:24.166-07:00Democracy in the U.S. Health Care Reform DebateYesterday (October 13) I sent the following feedback to AHIP regarding K. Ignagni's <a href="http://docs.google.com/Doc?docid=0ATgyF1Dj5uVKZDhuZ21iaF8xMjNnd3RieGRkZg&hl=en">performance in an interview on CNN</a>:<br /><br /><em><span style="font-size:85%;color:#990000;">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.</span></em><br /><br />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:<br /><ol><li>A report without reference or authors is interpreted without an evidence base.</li><li>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.</li></ol><p><a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/10/13/AR2009101303472_pf.html">The health insurance industry has acted irresponsibly </a>in this democratic process, mobilizing what the public in general would recognize as "authoritative research" in order to manipulate public opinion in their favor.</p>Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-79181615938530108772009-10-13T09:24:00.000-07:002011-12-07T08:48:14.989-08:00AHIP-PWC Report: Potential Impact of Health Reform on the Cost of Private Health Insurance CoverageA new headline on CNN, <i><span style="color: #cc0000;"><a href="http://www.cnn.com/2009/POLITICS/10/13/health.report.fallout/index.html">Pushback grows against insurance industry report</a></span></i>, points out some significant criticisms of the AHIP-PWC report as self-serving and flawed.<br />
<br />
This morning I identified a link where the much publicized report may be accessed:<br />
<span style="color: #cc0000;"><a href="http://72.10.55.160/policy-documents/potential-impact-health-reform-cost-private-health-insurance-coverage?quicktabs_1=1" target="_blank"><i>Potential Impact of Health Reform on the Cost of Private Health Insurance Coverage</i></a><i> </i></span><span style="color: black;"><i>(October, 2009). (Unfortunately the authors of the report are not listed.)</i></span><br />
<i></i><br />
Review of the analyses in this report reveals methodological features that require comment. <a href="http://www.cnn.com/2009/POLITICS/10/12/health.care/index.html">CNN has reported</a> (Accessed October 13, 2009):<br />
<i><span style="color: #990000; font-size: 85%;">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. </span></i><br />
<i><span style="color: #990000; font-size: 85%;"></span></i><br />
<span style="color: black;">This scenario is partially founded on the following proposition regarding the excise tax to be imposed on </span><span style="color: #990000;"><i>Cadillac plans.</i></span><span style="color: black;"> (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):</span><br />
<br />
<span style="color: #cc0000; font-size: 85%;"><i>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<br />
to the 40 percent excise tax in 24 of 50 states.</i></span><br />
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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.Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-33956471127916111782009-10-12T11:27:00.000-07:002009-10-12T13:29:26.438-07:00WellPoint Litigation IIIn 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:<br /><br /><span style="font-size:85%;"><em>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?<br /><br />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?<br /><br /><span style="color:#cc0000;">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?</span></em><span style="color:#cc0000;"><br /></span><br /></span>Further examination of WellPoint's record reveals other cases of public interest - for example:<br /><br />Last year the <a href="http://www.bio-medicine.org/medicine-news-1/Anthem-Blue-Cross-Statement-on-Settlement-Discussions-with-the-California-Department-of-Managed-Health-Care-23409-1/">California Department of Managed Health Care reached agreement with Anthem Blue Cross on</a> contentious cases of rescission. (Accessed October 12, 2009)<br /><br />Lawsuits filed over health insurers’ payments<br />for out-of-network care:<br /><em><span style="font-size:85%;">A group of health insurers have been named defendants in<br />multiple lawsuits stemming from payments made to<br />out-of-network providers.<br /><br />One lawsuit was filed by the American Medical Association.<br />It claims thatWellpoint Inc. and others conspired to pay<br />reduced rates to out-of-network providers. Another lawsuit<br />was filed by Michael Roberts. Roberts’ lawsuit claims that as<br />a result of the scheme, consumers were forced to pay increased<br />costs associated with their care. The lawsuit filed by<br />Roberts names Wellpoint along with UnitedHealth Group<br />Inc., Ingenix Inc. and Blue Cross of California.<br />Roberts v. UnitedHealth Group Inc., No. 09-1886 (C.D.<br />Cal. complaint filed Mar. 19, 2009)<br />Counsel for Roberts: Christopher M. Burke, Kristen M. Anderson, Scott<br />& Scott L.L.P., 213-985-1274, Los Angeles.<br />Am. Med. Ass’n v. Wellpoint Inc., No. 09-2039 (C.D.<br />Cal. complaint filed Mar. 25, 2009)<br />Counsel for AMA: Edith M. Kallas, Joe R. Whatley Jr.,W. Tucker Brown,<br />Laurence J. Hasson, Whatley Drake & Kallas L.L.C., 212-447-7070,<br />New York; Stanley G. Grossman, D. Brian Hufford, Robert J. Axelrod,<br />Pomerantz Haudek Block Grossman & Gross L.L.P., 212-661-1100,<br />New York; Raymond P. Boucher, Helen Zukin, Michael Eyerly, Kiesel<br />Boucher Larson L.L.P., 310-854-4444, Beverly Hills, Cal.<br /><br /></span></em>Source: <a href="http://media.straffordpub.com/products/insurance-law-and-litigation-week/free-sample.pdf">http://media.straffordpub.com/products/insurance-law-and-litigation-week/free-sample.pdf</a> (Accessed October 12, 2009)<br /><br />See also <em>AMA Implicates WellPoint in Price-Fixing Plot</em> at <a href="http://www.law360.com/articles/93856">http://www.law360.com/articles/93856</a> (Accessed October 12, 2009)<br /><br />An American Psychological Association <a href="http://www.apapractice.org/apo/in_the_news/california_is_latest.GenericArticle.Single.articleLink.GenericArticle.Single.file.tmp/California%20Is%20Latest%20State%20to%20Join%20Nationwide%20Class%20Action%20Litigation.pdf">Practice Update</a> describes a class-action suit brought by state governments and solicits information from psychologists affected:<br /><br /><span style="font-size:85%;">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 )<br /></span><br />An investigative report- <a href="http://commerce.senate.gov/public/_files/UNDERPAYMENTSTOCONSUMERSBYTHEHEALTHINSURANCEINDUSTRYREPORT.pdf"><em>Underpayments to Consumers by the Health Insurance Industry</em> </a>- was published on June 24, 2009, by the <a href="http://commerce.senate.gov/public/index.cfm?FuseAction=PressReleases.Detail&PressRelease_id=e9ccfecc-07c9-405d-a945-e431c71f0393&Month=6&Year=2009">SENATE COMMERCE COMMITTEE </a>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.<br /><br />(Accessible publications including what should be the public record are very difficult to find.)Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-58784046920681738802009-10-10T14:38:00.000-07:002009-10-11T13:29:02.211-07:00WellPoint Litigation against the State of MaineThe lawsuit recently brought by <a href="http://www.wellpoint.com/">WellPoint</a> 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 <a href="http://www.anthem.com/">Anthem Blue Cross and Blue Shield</a>, a subsidiary of WellPoint, are publicly available on the website of the <a href="http://www.maine.gov/pfr/insurance/index.shtml">Bureau of Insurance </a>- 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 <a href="http://www.maine.gov/pfr/insurance/bluecross_anthem/2009_rate_filing/">Anthem rate filing for 2009</a> and the <a href="http://www.maine.gov/pfr/insurance/hearing_decisions/09-1000.htm">Bureau decision </a>are publicly available even though WellPoint has consistently attempted to have this and <a href="http://www.maine.gov/search?q=Anthem&button=Go&as_sitesearch=http%3A%2F%2Fwww.maine.gov%2F&site=test_collection&output=xml_no_dtd&client=test_collection&proxystylesheet=test_collection">related documents </a>and proceedings <a href="http://www.maine.gov/search?q=Anthem+confidentiality&button=Go&as_sitesearch=http%3A%2F%2Fwww.maine.gov%2Fpfr%2Finsurance&site=test_collection&output=xml_no_dtd&client=test_collection&proxystylesheet=test_collection">treated as confidential.<br /></a><br />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.<br /><br /><a href="http://bravenewfilms.org/blog/?p=71981">Brave New Films</a> has posted a very informative video account of this suit. See also <a href="http://sickforprofit.com/">Sick for Profit</a>:<br /><br /><object width="560" height="340"><param name="movie" value="http://www.youtube.com/v/AKXWP2HuxGE&hl=en&fs=1&"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/AKXWP2HuxGE&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="560" height="340"></embed></object><br /><br /><object width="425" height="344"><param name="movie" value="http://www.youtube.com/v/R62FZLJVEcw&hl=en&fs=1&"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/R62FZLJVEcw&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="425" height="344"></embed></object><br /><br />The <a href="http://www.mpbn.net/News/MaineNews/tabid/181/ctl/ViewItem/mid/3475/ItemId/9253/Default.aspx">Main Public Broadcasting Network</a> aired the story: "Anthem Sues State of Maine over Rate Hike Request Denial" on October 5. The Columbia Journalism Review published an article entitled <a href="http://www.cjr.org/campaign_desk/wellpoint_versus_the_state_of.php">WellPoint versus the State of Maine</a> on October 9 giving some additional details about the litigation.Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-89878887164555466602009-10-10T09:53:00.001-07:002012-04-07T14:32:40.553-07:00Health Information Exchange UpdateAs 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,<a href="http://www.blogger.com/goog_375912870"> </a><a href="http://www.ehealthinitiative.org/resource-list.html" target="_blank">"Migrating toward Meaningful Use: The State of Health Information Exchange"</a> 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. <br />
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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.<br />
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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 <a href="http://www.uhin.com/" style="color: #002e5e;">Utah Health Information Network</a> 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.<br />
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The <a href="http://www.ehealthinitiative.org/directories/hie-map.html">Directory of Health Information Exchange Initiatives </a>offers a useful database for further examination of emerging RHIOs.<br />
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CCHIT has made available a presentation of its <a href="http://www.cchit.org/sites/all/files/CCHIT%20Town%20Call%20for%20Developers%20and%20Vendors%20-%20Sept%203%202009.pdf">New 2011 Certification Programs</a>, 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.Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0tag:blogger.com,1999:blog-6002651244468054448.post-15730763049386622542009-09-04T08:24:00.000-07:002009-09-04T09:33:00.234-07:00NEJM Online Health Care Reform Center<a href="http://content.nejm.org/">The New England Journal of Medicine </a>has created an online <a href="http://healthcarereform.nejm.org/?p=1268">Health Care Reform Center</a> 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: <a href="http://healthcarereform.nejm.org/?p=1429">"Which countries’ health care systems offer lessons for the United States? What are they?" </a> To date, this discussion seems to have generated little interest.<br /><br />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 <a href="http://en.wikipedia.org/wiki/American_exceptionalism">American "exceptionalism"</a> 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.)<br /><br />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 <a href="http://www.cmaj.ca/preview_earlyreleases/24aug09_editorial.shtml">editorial published on August 24</a>, the <em>Canadian Medical Association Journal</em> took a position arguing for a better informed and more logical debate considering lessons that could be learned from the Canadian experience. <em>The Economist</em> also published an article on August 20 entitled <a href="http://www.economist.com/opinion/displaystory.cfm?story_id=14258877"><em>Keep it honest: Rationing is not a four letter word, </em></a>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. <br /><br />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 <a href="http://www.npr.org/templates/story/story.php?storyId=111833816">latent socialist, or even communist.</a> Included in the series are <a href="http://www.cnn.com/video/#/video/us/2009/08/05/ldt.canada.healthcare.cnn?iref=videosearch">Canada</a>, <a href="http://www.cnn.com/video/#/video/bestoftv/2009/08/03/ldt.pilgrim.usa.vs.denmark.cnn?iref=videosearch">Denmark</a>, <a href="http://www.cnn.com/video/#/video/health/2009/08/14/pilgrim.japan.health.care.cnn">Japan</a>, <a href="http://www.cnn.com/video/#/video/bestoftv/2009/08/10/ldt.netherlands.healthcare.cnn?iref=videosearch">the Netherlands</a>, <a href="http://www.cnn.com/video/#/video/bestoftv/2009/08/12/ldt.pilgrim.spain.health.care.cnn?iref=videosearch">Spain</a>, <a href="http://www.cnn.com/video/#/video/bestoftv/2009/08/11/ldt.healthcare.switzerland.cnn?iref=videosearch">Switzerland</a>, the <a href="http://www.cnn.com/video/#/video/bestoftv/2009/08/06/ldt.pilgrim.uk.healthcare.cnn?iref=videosearch">U.K.</a>, 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 <a href="http://ac360.blogs.cnn.com/2009/08/10/a-look-at-global-health-care-systems/">Anderson Cooper's 360 Blog Archive</a>, where a number of the comments posted suggest that readers would be interested in learning more.Phrygiennehttp://www.blogger.com/profile/07406260130197586111noreply@blogger.com0