Tuesday, March 29, 2011

Virtual Health Care Infrastructures: Mapping Large Systems

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.

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.

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.

1. India

2. Bireme:  The Latin American Region

Wednesday, March 16, 2011

Wednesday, March 2, 2011

The U.S. Health Care System Infrastructure for Health Information Exchange (HIE)

Here is the abstract of a presentation on HIE infrastructure in the US:

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.

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 public investments for HIT; as of 2005 the U.K. had spent $192.79 per capita compared to a U.S. investment of $.43. One reason for this is policy failure in development of sustainable business models based on private investment for health information exchange (HIE).

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.
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 accountable care organizations (ACOs) competing for government incentives. These organizations often lack motivation to exchange health information.

More promising than the NHIN configured among fragmented local and regional RHIOs is the National Information Exchange Model (NIEM). 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.

Conclusions and Recommendations:
1. Public investment in health information infrastructures and the NIEM - a single infrastructure does not necessarily imply a single payer design.
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.
3. Collaboration across the Americas integrating the Canadian Infoway and BIREME – the Latin American Regional Library of Medicine will serve as a foundation for large scale grid and cloud infrastructures to support research and innovation.