Commentary: U.S. Health Information Technology Extension Program

Department of Health and Human Services

Office of the National Coordinator for Health Information TechnologyHealth Information Technology Extension Program

The following commentary on the proposed Health Information Technology Extension Program addresses the general context of U.S. health care reform under the American Recovery and Reinvestment Act of 2009 (ARRA). It was submitted to DHHS on June 11.

Comparative 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. [1] Even though there is agreement among physicians that the U.S. health care system is broken, there is no consensus on political action for system reform integrating health information technologies (HIT) in support of evidence-based medical practice, research and education. The U.S. lags significantly behind other developed countries in public investments for HIT; [2] as of 2005 the U.K. had spent $192.79 per capita compared to a U.S. investment of $.43. [3] One reason for this lack of public investment is U.S. policy emphasis on development of sustainable business models for private investment in health information infrastructures.

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 HIT. Their incentives for new technology adoption do not take into account system level efficiencies often external to private HIT 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 in some form of partnership with a variety of stakeholders for effective health information exchange (HIE) at the state and system level. [4]

The nationwide health information network (NHIN) refers to a proposed system linking data intermediaries for health information exchange. Related policies rely primarily on the emergence of locally sustainable infrastructures. An assumption fundamental to this model is incremental development by linkage of regional health information organizations (RHIOs) to form the NHIN. However, early 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. [5-7] Although public policy on HIT seems optimistic about future development of infrastructures based on health information exchange (HIE) and RHIOs, there is no foundation of evidence or experience to justify such apparent assumptions. The insignificant rate of comprehensive EHR adoption (1.5% in U.S. hospitals) further suggests that HIT infrastructures and other technical and training support services are either inadequate or nonexistent. [8]

Few studies in any scholarly discipline or field of professional practice have investigated the reasons for this lack of progress at the level of national U.S. health care systems or markets. While successful efforts for health information exchange seem to align with business models integrating payers and large collaborative systems such as hospital corporations, RHIO organizations are designed to promote flows of health information across competing business entities as well as public health agencies in the health care sector. Such entities will not share the health information that describes their proprietary services and clienteles (albeit de-identified), especially when there is no competitive advantage or service offered as a return on substantial investments required.

The design of the Health Information Technology Extension Program seems to assume the emergence of infrastructures for health information exchange through linkage of regional organizations. Major problems with the design include:

• Lack of definition of regions under the governance of the National Health Information Technology Research Center (HITRC). Applicants for Regional Extension Centers are designated broadly as “affiliated with any United States-based nonprofit organization or group thereof…”. One of the criteria for successful application is definition of the geographic region and the provider population within that region to be served. This provision would mean that applicants might compete on the basis of their definition of a region as well as other criteria. The result would be a fragmented and/or overlapping national extension infrastructure.
  
• The logic of regional extension center design may not be consistent with the structure of many providers offering regional health care services across the U.S.. Some providers may have access to more than one extension center by virtue of such inconsistencies, thus fostering redundant and inefficient services. Differences in regulations among states included in regions defined by extension centers may also create significant problems in developing extension programs.
  
• The short term strategic vision with two-year awards in FY 2010 from ARRA funding does not justify the substantial investment probably necessary for preparation of applications. This difficulty is further exacerbated by uncertainties associated with the priority accorded to applicants identifying “viable sources of matching funds”.

In my opinion, the weaknesses of existing policies for development of the NHIN information infrastructure must be resolved before related programs can be implemented. In particular, this infrastructure should be fully funded at the federal level with a long term strategic vision. Design of the NHIN as a public good is required to support both public and private enterprise in an integrated health care sector. [9]

REFERENCES

[1] Nolte E, McKee CM. Measuring the Health of Nations: Updating an Earlier Analysis. Health Aff 2008;27(1):58-71.
[2] Anderson GF, Frogner BK, Johns RA, Reinhardt UE. Health Care Spending And Use Of Information Technology In OECD Countries. Health Aff. 2006 May 1;25(3):819-831.
[3] Shea K, Holmgren A, Osborn R, Schoen C. Health System Performance in Selected Nations: A Chartpack. The Commonwealth Fund. 2007.
[4] Public Governance Models for a Sustainable Health Information Exchange Industry: Report to the State Alliance for E-Health. State Alliance for E-Health. 2009.
[5] Adler-Milstein J, McAfee A, Bates D, Jha A. The State of Regional Health Information Organizations: Current Activities and Financing. Health Aff 2008;27(1):w60-w69.
[6] Fifth Annual Survey of Health Information Exchange at the State and Local Levels. eHealth Initiative. 2008.
[7] 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.
[8] Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, et al. Use of Electronic Health Records in U.S. Hospitals. N.Engl.J.Med.; 2009 March 25.
[9] Clancy CM, Anderson KM, White PJ. Investing In Health Information Infrastructure: Can It Help Achieve Health Reform? Health Aff 2009 March 1;28(2):478-482

Education for Implementation of Health Information Technology

A thought provoking debate was opened at the Washington Post (April 26, 2009) with publication of an article entitled "End the University as We Know It" by op-ed contributor Mark C. Taylor, chairman of the Religion Department, Columbia University. Dr. Taylor deplores the "division-of-labor model of separate departments" and calls for a new curriculum model structured as a complex adaptive network. In my opinion, as suggested by Dr. Taylor, such a structure would foster interdisciplinary and cross-cultural teaching and research required to face the challenges of the new millennium, including scholarship in the growing field of biomedical informatics. However, it seems unlikely that formal educational programs in biomedical informatics will meet practical workforce needs for development of health information systems in the U.S., particularly in light of the American Recovery and Reinvestment Act (ARRA) of 2009. In 2005, the American Medical Informatics Association created a university-based training curriculum - AMIA 10x10 - designed to present a set of competencies for technology champions acting in their professional settings. The goal of these distance-learning courses is to train ten thousand health care workers by 2010. An evaluation of partner institution OHSU course offerings before the end of 2006 seemed to suggest that support for interaction among participants should be increased, although overall satisfaction with content and process was high. To date, I think only about 2000 participants have completed courses in this program. More generally, the technology champions now active in health care organizations are probably innovators - autonomous learners - working alone or in cross-disciplinary communities of practice, advancing ahead of expensive and rapidly outdated academic curricula. Unfortunately, in the U.S. context there is no national infrastructure to guide these fragmented efforts towards formation of an integrated health information network with standards for interoperability.

Published Evidence: RHIOs and HIE

I have been searching for evidence about the performance of existing RHIOs, and have had some difficulty identifying published research - whether in journals or grey literature. An excerpt from the minutes of a meeting of CCHIT's working group on networks (October 28) refers to a study conducted by Gartner in late 2007. This report should be in the public domain as it was funded by the ONC. Gartner also refers to its research methodology as "proprietary"- contradicting the basic principles of scientific enterprise. (Hype Cycles and Magic Quadrants constitute questionable conceptual frameworks for this type of business intelligence.) While privately funded research results might logically be defined as proprietary, research methodology should always be considered open to review by the scientific and professional communities concerned.

The Healthcare IT Transition Group published reports in 2006 and 2007. While summaries of these reports (2006, 2007) are freely accessible, the full reports are still considered proprietary even though they contain "old news". Some discussion of the study results is available on the organization's blog. One other report on RHIO financing published in 2005 is available in PDF .

The eHealth Initiative has published annual surveys of HIE initiatives since 2005. The 2008 Fifth Annual Survey of Health Information Exchange at the State and Local Levels finds that although the number of organizations surveyed has increased, the extent of health information exchange remains limited and a sustainable business model has yet to be defined.

Chilmark Research, specialized in IT trends in the health care sector, projects a decline in formation of interorganizational RHIOs while HIE, designed for particular organizational entities, may constitute a growing market. The reasons for this are related to difficulties in identifying a viable business model for health information exchange. HIE is focussed on business partnerships much like a supply chain configuration in manufacturing, including suppliers and payers. While RHIOs enable health information "liquidity", HIE incorporates business processes associated with health information flows. According to Chilmark, public investment in RHIOs should be suspended, while the NHIN is an unrealistic goal based on HIE growth; the growth of HIE will not bring development of interoperable networks across the U.S..

An important issue in the distinction between RHIOs and HIE involves the risks of integrating billing and clinical information. For a variety of reasons, billing codes may distort medical conditions and treatments they represent, posing a danger to patient health as in the case of Dave deBronkart as reported in the Boston Globe (April 13 2009).

Another strategy for creation of the NHIN involves development and diffusion of open-source software solutions to allow public and private organizations to link into the NHIN for health information exchange. The U.S. Social Security Administration was the first federal agency to use this solution requiring the user entity to assume costs related to software development, implementation and maintenance.

Websites:
NHINWatch - maintained by the editors of Healthcare IT News
HIMSS Government Health IT
HHS: NHIN
Health Record Banking Alliance
Connect Community Portal - Open Source Gateway
HHS: Federal Health Architecture
Information and Technology Innovation Foundation
Practice Fusion a web-based EMR service and community of practice

Articles on topics related to RHIOs include:
Adler-Milstein, J., McAfee, A., Bates, D., & Jha, A. 2008. The state of regional health information organizations: Current activities and financing. Health Affairs, 27(1): w60-w69. (Comments on this article)
Adler-Milstein, J., Bates, D., & Jha, A. 2009. U.S. regional health information organizations: Progress and challenges. Health Affairs, 28(2): 483-492.
eHealth Initiative. 2008. Fifth annual survey of health information exchange at the state and local levels. Washington, D.C.: .
Marchibroda, J. M. 2007. Health information exchange policy and evaluation. Journal of Biomedical Informatics, 40(6, Supplement 1): S11-S16.
McDonald, C. 2009. Protecting patients in health information exchange: A defense of the HIPAA privacy rule. Health Affairs, 28(2): 447-449.
McMurry, J., Gilbert, C. A., Reis, B. Y., Chueh, H. C., Kohane, I. S., & Mandl, K. D. 2007. A self-scaling, distributed information architecture for public health, research, and clinical care. Journal of the American Medical Informatics Association, 14(4): 527-533.
Solomon, M. 2007. Regional health information organizations: A vehicle for transforming health care delivery? Journal of Medical Systems, 31(1): 35-47.
Thielst, C. B. 2007। Regional health information networks and the emerging organizational structures. Journal of Health Care Management, 52(3): 146-150.
Tripathi, M., Delano, D., Lund, B., & Rudolph, L. 2009. Engaging patients for health information exchange. Health Affairs, 28(2): 435-443.

Stimulus Bill & HIE, RHIO Market

HIMSS has published a very useful Health Information Exchange Industry Listing of resources. There is still no evidence of a sustainable business model for development of RHIOs or a methodology for scaling up to a national network-NHIN.

Review this SlideShare presentation for a perspective on economic stimulus measures and their effects on industry markets:

Stimulus Bill & HIE, RHIO Market

View more presentations from John Moore.

Health Information Exchange and CCHIT

The U.S. Commission for Certification of Health Information Technology (CCHIT) is developing criteria for certification of health information exchange (HIE) - including a process of public comment accessible through their website. This agency (a government contractor) shows a bias in favor of proprietary software solutions in certification for ambulatory, inpatient, emergency department and enterprise EHR. Health information exchange, however, poses a particular challenge to CCHIT as it really cannot be defined as a software product - as evident in the minutes of meetings of the HIE (formerly Network) Working Group. On October 28, 2008, the WG considered the results of a Gartner report on vendors providing services to HIEs - commissioned in 2007 by the ONC. (This report has not been made available for public review, probably because it contains evidence that existing HIEs are unsustainable; no viable business model has been identified, and these organizations generally fail after initial public or private funding is exhausted. In my opinion, such a report belongs in the public domain and should be required to inform public consultations.)

The WG mentioned that discussions would be continued to decide whether vendor certification should be different than HIE certification. (See page 3.) On November 25, 2008, questions were raised concerning the location of patient and document registries as well as the content of current HIE data exchange. Confusion over the parallel roles of CCHIT and the Healthcare Information Technology Standards Panel (HITSP) was resolved by asserting that HITSP should adapt its standards to CCHIT certification requirements.

The WP seemed to recognize that the interoperability construct is difficult to address in the absence of "an overarching plan for how HIEs will interact as mediators of information exchange." (See page 2.) On January 27, 2009, a substantial commentary and discussion explored the distinctions between HIE certification and accreditation under the Electronic Healthcare Network Accreditation Commission (EHNAC) . According to this discussion and ISO definitions, certification is more appropriate to software products and vendors, while accreditation applies to organizational entities. (ISO definitions: Accreditation is a "third‐party attestation related to a conformity assessment body conveying formal demonstration of its competence to carry out specific conformity assessment tasks" in other words an organization or entity can be accredited. "Certification is a third‐party attestation related to products, processes systems or persons" in other words not an organization. See comment 7 on page 5, minutes of the January 27 WH meeting.)

While the minutes of WG meetings raised the critical need for HIE definition, this question was never directly addressed. What are HIEs? How will they be connected to form the Nationwide Health Information Network (NHIN)? What organizations and institutions may join in these networks? Where does health information reside in the HIE context? The document for public comment offered by CCHIT suffers from this lack of clarity, with the probable result that comments will focus on trivial technical details rather than the more important "big picture".

EHR Debate

In India a political debate is developing from publication of an IT vision paper,"Transforming Bharat" (India is called Bharat in Hindi), by an opposition party - the Bharatiya Janata Party (BJP). (See a post by Indrajit Basu: Digital Community Innovations from around the World - India's Opposition Party Promises IT Nirvana for All - for discussion of the Indian context.)

An excerpt:

The BJP’s IT Vision will help India (a) overcome the current economic crisis; (b) create productive
employment opportunities on a large scale; (c) accelerate human development through vastly
improved and expanded education and healthcare services; (d) check corruption and (e) make
India’s national security more robust.

Some highlights of this IT Vision are (page 2):

@ Multipurpose National Identity Card with Citizen Identification Number (CIN) in 3 years; to replace all other identification systems.
@ 1 crore students to get laptop computers at Rs 10,000. Interest-free loan for anyone unable to afford it.
@ All schools and colleges to have internet-enabled education.
@ National Mission for Promotion of IT in Indian Languages.
@ Broadband Internet in every town and village, with unlimited upload and download data transfer limits, at cable TV prices.
@ Mobile penetration to be raised in five years from 40 crore to 100 crore subscribers.

@ 100% financial inclusion through Bank accounts, with eBanking facilities, for all Indian citizens. Direct transfer of welfare funds.

@ A basic health insurance scheme for every citizen, using the IT platform. Cash-less hospitalisation.
@ All PHCs to be connected to a National Telemedicine Service Network.
@ National eGovernance Plan to cover every Government office from the Centre to the
Panchayats. The ‘E-Gram Vishwa Gram’ scheme in Gujarat to be implemented nationwide.

Regarding ehealth (page 24) the BJP promises that every hospital and primary health care center (PHC) in rural areas would be connected to a National Telemedicine Service Network, every citizen would have an electronic health record and universal health care would be offered through a basic health insurance program using the IT platform. Service to rural areas would be improved through IT-enabled mobile diagnostic vans and health care work force training programs.

Distinctive features of this Indian vision include the commitment to universal health care with a unique citizen identifier, and integration of government (including health care and education) and financial services through public telecommunications infrastructures.

This Indian example shows how the EHR may be effectively viewed in the broader context of a national IT platform. Patient identification is a fundamental issue which also needs to be addressed in U.S. policy before EHR implementation can be meaningfully promoted through economic stimulus or other measures.

EHR Stimulus

An international debate on solutions for EHR software solutions has recently received more extensive coverage as the US economic stimulus programs focus on promotion of health information technologies in general and electronic health records (EHR) in particular. (See text versions of the American Recovery and Reinvestment Act -HR 1: TITLE XIII--HEALTH INFORMATION TECHNOLOGY )

Many important questions guide this debate, including the role of national information infrastructures and the appropriateness of proprietary vs. open source software solutions. Austin Merritt of SoftwareAdvice.com, an online resource that helps physicians find electronic medical records, offers very salient arguments for caution in evaluating cost savings as a result of EHR adoption in the health care sector: http://www.softwareadvice.com/articles/medical/get-ready-for-ehr-failures-but-dont-blame-the-software-2031209/ An excerpt of the article is copied below.
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With the Economic Stimulus Bill signed and available to subsidize EHR purchases (for more information see “The Stimulus Bill and Meaningful Use of Qualified EHRs/EMRs“), we are seeing a dramatic increase in electronic health records (EHR) buyer interest. Assuming these buyers make use of the stimulus subsidy to buy an EHR, we expect to see a lot of EHR failures over the next couple years.

Don’t get us wrong! We are HUGE advocates of EHR technology. Doctors should be using EHRs. The stimulus subsidy is great. EHR software programs (and software companies) are not the problem.
Our concern is that the subsidies won’t change healthcare providers’ late adopter mindsets about information technology. Providers may jump at “free software” and try to avoid penalties (starting in 2015), but will they:

Truly believe in the value of an EHR over traditional paper charts?

Take a leadership role in advocating adoption of the new EHR in their practice?

Change their old workflows to match the best practices in leading EHRs?

Take part in intensive training to learn the new system?

Ride out the difficult stages of new software adoption and change management?

Traditionally, the substantial costs of EHR systems keep the luddites from buying technology in the face of these challenges. But with “free” EHR software, we expect more than a few providers to throw caution to the wind, buy an EHR and overlook the critical implementation and change management practices that are critical to success.
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The issues raised in this article are of critical importance, especially those related to workflow analysis and training. EHR implementation concerns also need to be evaluated in light of the lack of an effective National Health Information Network (NHIN) with associated national or international standards for interoperability.