August 14, 2007

Requiem for an HIE Dream

A Health Affairs supplement from earlier this month offers five complementary post-mortems on one of the nation’s most pioneering and visible health information exchange (HIE) efforts: the Santa Barbara County Care Data Exchange or Santa Barbara Project (SBP), which ceased operation this past December after only eight years.

HIEs—advocated in the supplement’s final article by the CEO of the successful Indiana Health Information Exchange (IHIE) as “an essential strategy”—are local information systems designed to share healthcare data among physicians and others providing medical care to community patients. Examples of HIEs include Regional Health Information Organizations (RHIOs) (such as SBP and IHIE), and the CDC’s Public Health Information Network (PHIN). The current vision of the National Health Information Network (NHIN) is as an interconnected string of local or regional HIEs.

The first article, written by Professor Robert H. Miller, PhD (Health Economics), University of California, San Francisco,  tells What Happened to the SBP. The Project began in 1998 as an HIE demonstration experiment proposed by the technology company CareScience (whose CEO at the time was David Brailer, MD, who later became this nation’s first National Coordinator of Health Information Technology) and funded by the independent philanthropy California HealthCare Foundation. The article describes the details of SBP’s early evolution, slow progress, CareScience’s technical difficulties and business upheavels midway through, and SBP’s subsequent revamping and ultimate demise amid legal liability issues and insufficent post-grant funding. 

The rest of the first article, and the other four that follow, propose reasons for SBP’s demise and the lessons learned. ”The main underlying cause [for the Project’s slow progress, according to the first article,] was lack of a compelling value proposition for Santa Barbara [participating healthcare] organizations [and physicians].”  Almost none of the Project’s participants saw medical or financial value in the project, partly because physicians could already obtain electronic patient data using the less extensive and relatively closed Web portals already in place. SBP highlights the lack of efficiency and security inherent in peer-to-peer (Napster-type) design; the importance of active local governance; the need for an incremental series of small successes rather than, as CHCF staff describe in the third article, an “all-at-once” design; and how long-term planning results in a sustainable business model. SBP also demonstrated how HIEs need to be flexible, to change and grow in response to the community and to keep pace with the advances in technology and evolving needs of practitioners and their patients. Even today, and in spite of the advances in technology compared to SBP’s beginnings nearly a decade ago, HIEs are still very much a work in progress, still awaiting practical standards and privacy laws, software advancement and funding options in most communities. 

As Dr. Brailer closes in the second and easily best article of this strong series, From Santa Barbara To Washington: A Person’s and a Nation’s Journal Towards Portable Health Information, ”Thomas Kuhn described in The Structure of Scientific Revolution how the cumulative weight of research and experimentation–whether positive or negative–can hasten the collapse of an existing paradigm. We are in the earliest steps toward major upheaval in the obsolete paradigm of U.S. health care. Health IT is one of the prime forces of innovation and disruption. It will both hasten this change and soften the fall when change does occur. Projects like Santa Barbara—whether they ’succeed’ or ‘fail’—are part of a justified and relentless attack on the status quo of health care amid the unending hope for something better. Without these efforts, the old paradigm will continue, and we will have no chance for meaningful progress.”

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