U.S. Health Care Reform: Continued...

As the debate over U.S. health care reform continues, much of the controversy seems to center on the creation of a "public option" for health care coverage, and the widely-held fear that private plans cannot survive in competition with such an option. Why should private plans survive if they cannot perform in a competitive environment? This question seeks to justify the public plan in the ideological context of its opponents. It is not yet clear whether this logic will be effective in the political process.

In reality, I think that private plans should not survive in their present form as they appropriate either undeserved financial benefits of not-for-profit status - or excessive profits and CEO salaries - while they fail to provide services to American citizens. Other industrialized nations have designed single payer national systems that provide superior care to their citizens at a cost generally half of the per capita cost in the U.S.. (It is interesting to note that neither the Kennedy bill, nor HR 3200, contains reference to a "national system" or "national infrastructure," but the prevailing ideology as well as an essentially "bottom-up" system change process are assumed throughout the text of the legislation.)

Those who doubt the necessity of rapid reform should review the unfolding story of Remote Area Medical Volunteer Corps. While this organization was founded in 1985 by Stan Brock to deploy health care relief services in the developing world - it now has a growing mission in the United States. RAM recently offered free dental and medical services in Wise, Virginia, where as many as 1600 people showed up each day to receive free care, and on August 11-18, a clinic will be open in Los Angeles where as many as 10000 people are expected. (CBS 60 Minutes produced a segment on RAM in March 2008.) The success of RAM in the U.S. is a testament to the suffering of ordinary citizens across the country and a document of third-world America.

On June 15, President Obama made a speech to the American Medical Association in which he pointed out some of the disastrous economic effects of the dysfunctional U.S. health care system:
Our largest companies are suffering as well. A big part of what led General Motors and Chrysler into trouble in recent decades were the huge costs they racked up providing health care for their workers; costs that made them less profitable, and less competitive with automakers around the world. If we do not fix our health care system, America may go the way of GM; paying more, getting less, and going broke.

According to Obama, not only the health care industry but all of "America may go the way of GM." He is right. He is attempting to convince health-care policy holders that the reform legislation under committee review will improve their coverage in the following ways:

1. No Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
2. No Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
3. No Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
4. No Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
5. No Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
6. No Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
7. Extended Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
8. Guaranteed Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.
   (Source: The Washington Post)
   
   Background:
   National Conference of State Legislatures: Federal Health Care Reform:
   Congressional Budget Office - Special Collection on Health
   Commonwealth Fund
   National Academies Press: Health and Medicine
   
   On July 15, Congressman Kevin Brady (R-TX), the lead House Republican on the Joint Economic Committee, unveiled a detailed flow chart of the complex health care reform proposal by Democratic congressional leaders.
   
   Kennedy "Affordable Health Choices Act"
   CBO evaluation - Letter to Senator Edward Kennedy (June 15, 2009)
   
   HR 3200 : ‘‘America’s Affordable Health Choices Act of 2009’’(July 14, 2009)
   CBO Analysis - Letter to Representative Charles Rangel, Chairman: Committee on Ways and Means (July 17, 2009)

Qualitative Case Analysis for Study of National Health Care Systems

Research in science policy, institutional economics, telecommunications, and organization theory has contributed to the growing literature on health care system performance, management and control. The current focus on health care system reform in the U.S. has made apparent the lack of relevant research evidence from country level studies. While many policy makers point to a fragmented health care delivery infrastructure, few reform efforts are framed at the national system level. Systems thinking seems anathema in an ideologically restricted political process.

The premise of my program of research is that study of configurations of virtual institutional health care infrastructures is critical to understanding global and regional health care ideologies and market dynamics. Little research has considered the effects of telecommunications and internet infrastructures on these dynamics, largely because theory, methods and tools have not been adapted adequately to analysis of these structures and processes profoundly transformed by new technologies at every system level.

Such analysis requires qualitative research strategies because of increasing system complexity and high rates of social, cultural and technological change. First, case analysis facilitates validation of patterns identified in data collected from diverse sources and construction of comparative frameworks from grounded theory principles. Historical analysis exposes the logic and possible path dependence of system evolution as in the phases of system creation through local unit design, control through centralization, and integration through horizontal coordination.

Another promising qualitative approach is system mapping for sociometric analysis of virtual infrastructures and their contributions to health care services markets and hierarchies. System configurations reflect institutional patterns of information management and control, including free market and centralized social medicine dynamics. For example, density or connectedness may describe the number or proportion of possible linkages appearing in a network, while hierarchy or dominance may describe the distribution of linkages throughout the network. Configurations may be interpreted as complex systems or as cases embedded in a broad context.

Taken together, case analysis, historical analysis and system mapping offer strategies to approach study of the important coherence between underlying ideologies and virtual health care infrastructures.

Some published research programs address country level case analysis of national health care systems - with a view to creation of an evidence base for comparison. Most extensive among these is the program of the European Observatory on Health Systems and Policies of the World Health Organization. The data collected for the 25 member states of the European Union include: (1)Health Systems in Transition (HiT) profiles, (2) other health-related information such as reports from institutions and health reform policy papers, and (3)
links to health-related web sites - ministries of health, national public health institutes, and research centers for health policy, public health and health economics.

The most recent template (2007) for development of Health Systems in Transition (HiT) country profiles includes some data on HIT in sections on planning and health information management (4.2) as well as physical resources (5.1). Information technology must be defined for each country profile in the context of a national IT strategy for the health care system as well as general statistics on Internet access and usage.(page 74)

Another research program on ehealth in national health care systems was initiated by the Rockefeller Foundation in the series of conferences at the Bellagio Center on Making the eHealth Connection organized by the World Health Organization-July-August 2008. The themes covered in the collection of country case studies include:

1. The path to inter-operability


2. Public health informatics and national health information systems


3. Access to health information and knowledge-sharing


4. eHealth capacity building


5. Electronic health records


6. Mobile phones and telemedicine


7. Unlocking eHealth markets


8. National eHealth policies

One background paper addresses The Case for a National Health Information System Architecture: A Missing Link to Guiding National Development and Implementation (by Stansfield, S.; Orobaton, N.; Lubinski, D.; Uggowitzer, S.; Mwanyika, H.) According to the authors, "a national health information system (HIS) plays an important role in ensuring that reliable and timely health information is available for operational and strategic decision making that saves lives and enhances health."(page 1) While this definition is generally acceptable, the strong ideological bias evident in the report is not. The enterprise architecture framework has been applied in the context of the U.S. federal government, but requires a careful adaptation to each country culture under consideration for health care sector applications. For example, in the Latin American social medicine tradition, the definition of health care work flow as a business process would be unacceptable.

The country case studies available in the collection are South Africa, Turkey, Vietnam, Rwanda, and Peru. These studies are generally organized according to the conference themes listed above as adapted by the authors. The greatest weakness of this research program is the lack of a theoretical framework or logic to guide methodological choices as well as data interpretation. Comparative analysis of the cases is especially hampered by lack of theory and the convenience sampling of country cases. According to Yin, selection of a single case for analysis may reflect a typical, critical, or unique set of observations for theory development. I have learned in my study of BIREME (Brazil) and INFOMED (Cuba) that regional leadership dynamics must be taken into account in case selection, and that regional network structures may be critical in the understanding of national health information systems.

Other collections of country studies of interest to researchers on national health information systems include Health Systems Country Briefs produced by USAID (August, 2007) to identify areas for investment in effective health systems strengthening. Published briefs include Mozambique, Rwanda, South Africa, Tanzania, and Zambia.

Earlier case studies (2005-6) examined the systemwide effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria on the national health care systems of Benin, Ethiopia, and Malawi. The interim report on findings from these three cases focused on Global Fund effects on the policy environment, human resources, the public/private sector mix, and the pharmaceuticals and commodities markets.

The larger Global HIV/AIDS Initiatives Network including researchers in 21 countries conducts research on how these programs affect national health care systems. The GHIN promotes cross-country case comparability through common research methods, builds research capacity, informs health care policy through multi-country comparisons, and coordinates dissemination of research conclusions and recommendations. The GHIN has contributed to the WHO Positive Synergies Initiative to strenthen its institutional role in national and global health policy. The WHO also publishes a very useful set of country profiles including data for cross-country comparisons.

The International Telecommunication Union offers country case studies by region and topic-providing context for analysis of national health information systems. (Many of these cases require an update.) Another series of ITU cases (2000-2004) addresses Internet diffusion in various stages of country development. (See also publications of the Mosaic Group on the Global Diffusion of the Internet Project.)

Porter's Value-Based Strategy for Health Care Reform

The New England Journal of Medicine has just published an article entitled "A Strategy for Health Care Reform — Toward a Value-Based System" by M.J. Porter - which has already attracted some international attention. (I learned of the publication as I read a communiqué from the Indian Association for Medical Informatics.) The principles of his approach to health care require critical review-especially as they are aligned with the U.S. health care industry for the promotion of competition as a driver of value, defined as health outcomes achieved per dollar spent. I am particularly concerned about the misuse of Dr. Porter's influence to pedal a U.S. model for health care reform where there exists no evidence in support of such a model.

According to Dr. Porter, while both universal health care insurance coverage and national system redesign are necessary to achieve "true reform", value takes precedence over universal coverage. It seems to me that he is confusing the concepts of universal access to services and universal health care insurance coverage. (In the U.S. system, the private health care insurance industry effectively denies access to millions of U.S. citizens - either by demanding prohibitive deductibles and co-payments or refusing to cover a particular claim for treatment.) Dr. Porter suggests that lower health care costs in other countries are due to universal insurance coverage, but this advantage too is unsustainable without improved value. He fails to recognize the single payer system design with publicly funded health information infrastructures as critical to controlling costs in other national systems. While certainly there has been "no convincing approach to changing the unsustainable trajectory" of the U.S. system, it is inaccurate to suggest that other countries such as Finland, far more advanced than the U.S. in design of an efficient national health care system, should reform their systems according to his recommendations. Rather, the U.S. should be learning from the examples set by other industrialized countries such as the UK, France and Taiwan as well as developing countries such as Cuba and Brazil.

According to Porter, there are six principles to guide health care system reform - all of which address financing:

1. Reform health insurance competition to focus on improvement in subscribers' health.
2. Motivate employers to stay in the system by penalizing "free riders". (The presence of employers in health care insurance markets will foster competition based on value.)
3. Address the unfair burden on those without access to employer-based coverage by equalizing tax deductibility of premiums paid by individuals independently or through their employers.
4. Create regional insurance pools (instead of a national pool) similar to the Massachusetts Health Insurance Connector. Regional pools apparently would be more effective in promoting value-based competition. Reinsurance programs are also critical to "spread risk" related to coverage of very expensive conditions.
5. Create income-based subsidies to assist low-income citizens in purchase of insurance.
6. Require all citizens to purchase health insurance.

This value-based delivery system requires "mutually reinforcing" steps to implementation. The most important features of such implementation appear to be outcome measurement, organization of care according to medical conditions with bundled payments for reimbursement of care, value-based competition for patients across geographical boundaries, adoption of HIT architectures and standards for electronic medical records, and patients' responsibility for their own health.
While many of these features seem painfully obvious, Porter offers no evidence in support of his claims that his framework will bring about the needed reforms in the U.S. system. The use of electronic medical records, for example, is assumed to bring about improved health care efficiency and quality by many researchers and policy-makers. Porter also asserts that "electronic medical records will facilitate both delivery restructuring and outcome measurement" without providing any qualitative or quantitative empirical support for this "bottom-up" change process. Porter's statement has not been demonstrated in any health care system. It would be just as reasonable to suggest that HIT infrastructures for health information exchange form a prerequisite for implementation of electronic health records. The existence of such national HIT infrastructures is certainly required to deliver the comprehensive program of outcome measurement at the foundation of Porter's strategy.
The framework does not mention the role of the public sector in health care system reform, except to affirm the superiority of the private sector to create accountability and value-based care through competition. (Again, there is no research evidence to support this claim. On the other hand, Amartya Sen has pointed out that national health care system performance is related to rate of public health investment. See Sudhir Anand and Martin Ravallion, Human development in poor countries: on the role of private incomes and public services, Journal of Economic Perspectives, 1993, 7: 133-150.)
Porter suggests that his reform strategy requires new independent institutional roles to oversee outcome measurement, set HIT standards, and regulate bundled reimbursement; and that Medicare might be able to "take the lead in some areas." (These new roles should probably be assumed by state or federal entities to assure their independence. Controversies surrounding the Certification Commission for Healthcare Information Technology (CCHIT) illustrate this dilemma.) The Commonwealth Fund has published a comparison of public investment per capita in HIT (2005) (slide #72) showing that the U.S. lags far behind the U.K., Canada, Germany and Australia. This lag probably reflects the lack of public infrastructure to support EHRs and health information exchange at the regional or national levels.
Aside from a significant pro-business ideological bias, Porter's strategy lacks clarity in the definition of "value" as "the health outcomes achieved per dollar spent." Although in the past he has emphasized the role of physicians in health care reform, his perspective has shifted to the system level of analysis. However, value is consistently defined at the individual rather than the population level. In my opinion this conceptual definition is impossible to operationalize for measurement as prescribed - primarily because "value" is to be measured at the individual treatment level of analysis, while the relevant outcome may occur in the aggregate - at the family, community, or population level.
"Value" is a highly subjective dimension at the individual as well as the collective level. How can consensus be developed to prescribe the definition of "value" for such a comprehensive program of outcome measures? Criteria for patient, doctor and provider choices are also very subjective. Objective characteristics of health care delivery would be more useful to inform subjective patient choices. (Porter has not addressed the immense costs associated with production of his outcome measures, including the conduct of extensive comparative effectiveness research programs required to serve as an evidence base.)
The definition of value related to "bundled" services poses substantial methodological problems. Bundled services and reimbursement schemes assume a level of standardization not consistent with the complexity of individual cases - including comorbidity. This design feature would also encumber the dynamics of market competition. (Certain provider organizations would integrate their services in competing industry clusters.) In any event, there is no research to substantiate Porter's far-reaching claims on the benefits of health care services bundled according to medical condition. A CMS (Medicare and Medicaid) initiative to introduce bundled reimbursement in the mid-1990s failed due to provider resistence. The reasons for this failure should be examined to ensure the validity of new proposals in the current environment.
Porter also needs to clarify how the dynamics of consolidation and competition co-evolve in health care services markets. While he deplores "hyperfragmentation and duplication of services", such duplication of services is implicit in the competitive environment he advocates. Certainly the regional structuring of risk pooling would create boundaries to competition and structural redundancy across regions. I do not understand why Porter considers that regional organization "will result in greater accountability to subscribers and closer interaction with regional provider networks, fostering value-based competition." The case of McAllen, Texas and Doctors Hospital illustrates the possible dysfunction of such a model at the local level of analysis-including the exorbitant costs in public CMS reimbursement. (Hear an interview with Dr. A. Gawande on NPR.) Some dimensions of health care in the future will remain anchored in geographic proximity, but others will be more efficiently organized at the national level. Not only will HIT contribute to efficiencies redefined at the national level, but patients will probably be more mobile in pursuit of both work and health care services.
My review has suggested only a few of the many questions to be answered concerning Porter's strategy for health care reform. As many American authors on policy for U.S. health care reform, he needs to consider other national health care systems to identify an evidence base relevant to the American challenge. He refers only to his own publications, and mentions the case of Finland not as an example for study, but as an illustration of the universal crisis in controlling health care costs. One very instructive country case is Taiwan where single payer system reform was implemented in 1995 after thoughtful examination of other national systems to identify desirable features transferable to the Taiwanese context. U.S. policy-makers would have much to learn from this change strategy.
I would like to conclude this review by deploring the excessive emphasis on finance to the exclusion of any reference to medical ethics in the debate on U.S. health care system reform. While financial incentives are certainly important, especially from a business standpoint, physicians and health care professionals should not require micro-management through financial rewards to motivate their service. Implementation of such complex reward systems is very expensive as well as vulnerable to fraud and legal challenge. The most important incentives should be the intrinsic rewards associated with the privilege of offering a public good through health care service.

Commentary: Meaningful Use

“The American Recovery and Reinvestment Act authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “meaningful users” of an electronic health record (EHR). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing an EHR in compliance with the “meaningful use” definition or they will be subject to financial penalties under Medicare.” Source: Meaningful Use: A Definition, Recommendations from the Meaningful Use Workgroup to the Health IT Policy Committee, June 16, 2009.

The Office of the National Coordinator for Health Information Technology (ONC) is seeking comments on the preliminary definition of “Meaningful Use,” as presented to the HIT Policy Committee on June 16, 2009.

The definition and measurement of "meaningful use" in the context of health information technology (HIT) implementation has emerged as a critical policy discussion - particularly in light of the need to establish benchmarks for incentive payments mandated in ARRA. The most important difficulties in this discussion result from confusion in other definitions including electronic health records (EHRs) and health information exchange (HIE). Although CCHIT has apparently made progress in presenting criteria for certification of both EHRs and HIEs, their clear definition remains elusive and subject to ongoing debate. In their call for public comment, the HIT Policy Committee proposes a Preamble: Meaningful Use – A Definition and a Meaningful Use Matrix structured according to health care policy priorities. The ultimate goal of meaningful use - as stated in the Preamble – is to “enable significant and measurable improvements in population health through a transformed health care delivery system.” While this broad goal encompasses the entire system, health information technology seems narrowly defined as an Electronic Health Record (EHR), excluding any discussion of infrastructures required to support health information exchange and other core functions of EHRs. The challenge in this framework is to demonstrate how the adoption of an EHR can be associated with emergence of a transformed health care delivery system for improved population health. What are the dimensions of this goal and how should they be operationalized and measured within a particular health care context? The Matrix is an attempt to identify health care policy priorities on five axes – regardless of context: (1) Improve quality, safety, efficiency, and reduce health disparities; (2) Engage patients and families; and (3) Improve care coordination; and (4) Improve population and public health; and (5) Ensure adequate privacy and security protections for personal health information. Each of these axes yields a set of care goals with more specific objectives and measures to be applied in 2011, 2013, and 2015.

Unfortunately, the logic of the Matrix is highly inconsistent. The five policy axes are certainly not orthogonal, but must be interrelated in different ways among complex care delivery systems. For example, improving population and public health would be closely associated with reduction in health disparities, and improved coordination would certainly be linked with better health care quality. Some of the goals listed for particular policy priorities seem misplaced while corresponding objectives and measures seem unrelated or indistinguishable. For example, the goal to “Report to patient registries” in Priority #1 would seem more appropriate to the public health priority (#4). The goal to “Apply clinical decision support at the point of care” (under priority #1) appears also as an objective in 2013 and 2015. Logically the objectives and measures in the Matrix should represent more specific instances within each stated goal. Clinical decision support is a very complex problem inadequately presented as a required component in the determination of meaningful use.

The Matrix time frame in general poses a challenge as the measures for achievement of objectives appear to lose definition (or disappear entirely) from 2011 to 2015, when they are mostly “to be determined” (tbd). (What happened to measurement of health disparities in 2015? Are they supposed to have been resolved by then?) In my opinion there are several reasons for the inadequacy of the Matrix framework.
(1) The logic of the Matrix assumes the existence of infrastructures required for HIT implementation – including the adoption of EHRs. As I have already commented on the proposal for regional extension centers, it is unrealistic to assume that existing policies to foster formation of RHIOs and HIEs will effectively promote a Nationwide Health Information Network (NHIN) without sustained public investment at the federal level. Essential institutions excluded from the ONC discussion of meaningful use include educational and research providers. The eventual NHIN infrastructure - including education and research institutions - will have a very substantial impact on the evolving parameters of HIT and EHR meaningful use in health care delivery, especially for health information exchange and interoperability.
(2) Another invalid assumption is that HIT or EHRs – implemented at the physician, group practice or hospital level - will reduce costs or improve the quality of health care without very significant national system redesign. HIT implemented in the existing fragmented system may only result in greater redundancies and inefficiencies – as well as higher costs. (See the report by the CBO: Evidence on the Costs and Benefits of Health Information Technology, 2008. See also the very provocative article by A. Gawande in the New Yorker: The Cost Conundrum: What a Texas town can teach us about health care, 2009)
(3) Information technologies evolve very quickly and new innovations as yet unforeseen may radically affect the field of biomedical informatics and the redesign of the U.S. health care system, especially in this time of crisis. Since the logical structure of the Matrix appears fatally flawed, it is unlikely that this framework would survive even relatively small technology-driven adjustments - to be useful as a robust theory would. This framework would therefore not be effective in motivating the individual or institutional decision-maker to make the sustained financial and human resource investments required for effective EHR implementation and meaningful use.

Like the ONC, professional associations such as AMIA and HIMSS appear to have avoided issues related to operational definition of meaningful use by considering EHR adoption as an essentially binary variable and emphasizing the association between presence of EHR technology and health care outcomes. There should be more careful attention to the complex health care processes linking HIT with such outcomes. According to AMIA, criteria for meaningful use of EHRs should focus on "clinical endpoints achieved," and the "relationship between, and effectiveness of, key EHR functions and performance on quality measures over time." (See AMIA letter to James Scanlon dated April 30, 2009) HIMSS states unequivocally that "quality measures are a by-product of the successful implementation of CCHIT-certified EHR technology, not separate initiatives." (See lines 74-86: Definition of Meaningful Use of Certified EHR Technology for Hospitals - Approved by the HIMSS Board of Directors on April 24, 2009) They formulate an untested assumption of a unique causal link between certified EHR usage and quality - for which there is no logical or empirical justification - except apparently to promote the value and necessity of CCHIT certification.

Unfortunately, there is no evidence base to associate HIT or EHR usage (certified, meaningful or otherwise) with many of the measures of general health care quality outcomes appearing in the Matrix. The low rate of EHR adoption in the U.S. renders quantitative research on the relationship between EHR technology and health care quality impossible at this time. One recent study by Li Zhou et al. to appear in JAMIA attempts to examine EHR functions and performance based on data from the Healthcare Effectiveness Data and Information Set (HEDIS) - only to report that there is no statistical association between usage of EHRs and such performance data. Although this result is probably due to numerous methodological weaknesses - including sample sizes and construct definitions - the study suggests to me that reductionist research designs cannot capture the complexity of EHR meaningful use or the possible causal effects on quality of health care. Furthermore, had this study demonstrated such a statistically significant association, there would have been no validity to any claim of causality. Many unmeasured and uncontrolled contextual variables may co-vary to explain quality of health care.

The lack of a research program and evidence base demonstrating the positive health care outcomes promised with implementation of HIT or EHRs has serious consequences for the motivation to adopt these technologies as well as the determination of financial incentives as mandated through Medicare and Medicaid. Where research evidence for meaningful use of HIT and EHRs does not exist and cannot be generated in the proposed framework, the program of incentives will be wasteful of public funds not only through ineffective incentive payments but also through vulnerability to legal challenge.

Rather than attempting to prescribe and incentivize implementation of HIT and EHRs, the government should directly offer public services funded through sustained federal investment - such as the NHIN - that will shape meaningful use of these technologies. An incentive for example, might be access to technical support services freely available through linkage to the NHIN.

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.