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.

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