Friday, April 6, 2012

Commentary: 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.,  Shifts in the Architecture of the Nationwide Health Information Network, Journal of the American Medical Informatics Association, Online First, January 21, 2012.

Abstract: 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.

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. 

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 Adler-Milstein et al. (2008),  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 Adler-Milstein et al. (2011).  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.

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 (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.)   as well as JAMIA (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. 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.

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.

Adler-Milstein, J., McAfee, A.P., Bates, D.W., et al., The State of regional health information organizations: current activities and financing. Health Aff (Millwood) 2008;27:w60–9.(REF. 22)
Adler-Milstein, J., Bates, D.W., Jha, A.K.,  A survey of health information exchange organizations in the United States: implications for meaningful use. Ann Intern Med 2011;154:66–71.(REF. 23)

(Reviewers of this manuscript for JAMIA should have corrected errors in the reading of studies cited.)