Saturday, March 24, 2012

From 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.

From 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.

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).

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.

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 )

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 )

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  )

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.