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.”

July 19, 2007

HIT the Road

Filed under: — mlazoff

A provocative editorial published in the current issue of Modern Healthcare, “Scrap the National IT Plan” was written by Assistant Managing Editor Todd Sloane. From the editorial: “Why is it that nobody in government recognizes that the sharing of any data should be for medical and research purposes only? Until government absorbs this lesson, we shouldn’t have a national IT system…What may be needed now is simplicity, something in short supply when IT experts get together. One thing that stands out is that modest IT success tends to happen in larger, integrated health systems. Doctors operating in small practices, without any formal ties to hospitals beyond admitting privileges, may simply be left behind on the IT front.”

February 13, 2007

Tooting their own horn

Filed under: — mlazoff

Missing from among the initiatives on Health and Human Services (HHS)’s Health Information Technology list of Major HIT Accomplishments: 2004-2006 is the creation of their much improved Web site.

The list provides a nice review of past major government initiatives and, more important, what projects the federal government will support in 2007 and beyond. Leading the list is the National Healthcare Information Network, followed by future recommendations from HHS’s advisory board, the American Health Information Community; and the coordination of state with federal laws on privacy and security of patient data. Details on each can be accessed from the site’s left navigation panel.

January 2, 2007

Brailer on Health IT

Before the holidays, the former National Coordinator for Health IT David Brailer, MD, gave an interview for iHealthBeat, the news digest of the California HealthCare Foundation. The full interview, released today, is available as an audio file (excerpts above, downloadable mp3 file below) or a PDF transcript.

From the interview:

  • “I always told people that the battle over health IT adoption was over. It was just a matter of time. The real fight, and this one I don’t have such optimism about, is the fight over patient centricity, or patient control of their health care, and, therefore, control over their health care information…And that’s not so much a health IT battle. That is a battle over the heart and soul of who owns controls and who sets the priorities for the health care system.”
  • “I think we don’t have the right privacy and security regiment. The one that we have under HIPAA and state laws was created largely in a world that didn’t anticipate electronic information that was stored for, or by, or used on behalf of the patient…And I think the American public has been very clear that they want to see privacy protections in place before they’re really willing to jump into [electronic medical records].”
  • “…incentives for adoption [of health IT]. We had the one-year fix to the sustainable growth rate…which gave physicians a bonus for submitting quality data. That has no effect whatsoever on health IT adoption. So it’s time to come back to the question that we’ve put aside during the whole pay-for-performance discussion for three years about the market incentives and the policy incentives to bring us into full adoption of electronic records. I, as a very keen supporter of incentives, withheld my judgment on that during the pay-for-performance period. I think it has now had its chance, and it hasn’t been able to deliver a policy with the impact that I think convinces me that it’s going to help us with adoption, particularly among doctors in rural areas, in a safety net and even small practices.”
  • “Well, I think the change…comes from every place but Washington…in states and in the private sector…I see states moving quickly, and they will do more in 2007 to create a more fertile environment for health IT.”
  • “But I think the promise of personal health information being shared goes beyond a record. I’m particularly excited by remote monitoring, remote patient management; things where it’s not just a static database but where we’re monitoring someone in their home so they don’t have to be in a nursing home or where someone can be monitored in an ICU bed and a doctor doesn’t have to be present all the time but can be tele-present…That is the same concept of a personal set of health information that is centered around the person, but it probably doesn’t meet our definition of what we would call a PHR today. I view more convergence happening between that concept of the database and the streaming set of information, as we really ask the questions about what problems the PHR solves or what opportunities it creates. I think as we start thinking that way, we will come back to this set of functional tools that help us improve the patient role in health care, just like health information has helped us in traditional care delivery beyond the electronic health record — medication administration, reduced errors in inventory management, the way communication occurs, let alone computerized physician order entry. These things that are unheralded heroes of how IT does help are a broad bundle of change, and I think you’ll see that on the personal side as well.”
  • “I think there are two subdebates that will play out, so it creates kind of a two-by-two table with four outcomes. The first one is whether we will go beyond all of the lip service. The patient should be in control of the health care system, in control of their care. They should have information to make treatment choices. They should have information to make a choice about a doctor. They should have the information to be able to make tradeoffs when it comes to various outcomes. And I think this is quite pronounced as we start thinking about the genomic world, where you have so many genomic risks, like, you know, you might have heart disease in the future, or you may have breast cancer, or you may have memory loss. And you have to decide if you’re going to act on that 20 or 30 years in advance. This question about whether we are going to move beyond the promise and actually make the health care industry centered on that, which is profoundly disruptive to the established interests that rely upon a very high volume of hospitalizations, or bouncing patients around, and churning patients a lot because we can’t quite create integrate care processes around them, you know, that’s disruptive. And I think that’s a debate about how far the industry will come towards focusing on patient control and consumer choice. And so you could think about that as either happening or not.
           Secondly, and I think apart from that, there’s a debate about the role of government. We’re sitting in a hybrid system now. Government intrusion in private sector, or participation — neither one is dominant and neither one has the leverage to make it cohesive. The industry can’t do what it’s done in other industries, which is squeeze out the inefficiencies and create, really, a seamlessly integrated experience. Look at the financial sector, elsewhere. Nor can government do this because it doesn’t have control, and I think it has a lot of conflicts of interest with respect to how to make health care work versus the Medicare Trust Fund be solvent. And so you see kind of that being … now sitting at a point of maximum agony. I think that’s going to flip one way or the other. So we could have a very government-controlled system that’s consumer responsive or a government-controlled system that is quite provider-driven, and we could have a private-sector system that’s one or the other.”

October 21, 2006

Journey of a 1K mile begins with a single definition…

Filed under: — mlazoff

The HHS’s National Committee on Vital and Health Statistics released a draft report on the Minimum but Inclusive Functional Requirements for the Initial Definition of a National Health Information Network. According to an entry on the Healthcare IT blog, the draft is “expected to be approved by the end of this month. The report includes a list of high-level functional requirements for a Nationwide Health Information Network [NHIH]. Recommendations include: [1] extending HIPAA privacy rules to cover health information exchanges and other forms of personal health information. [2] developing policies and procedures to accurately match people to their health records (but not recommending a national patient ID). [3] including functionality to enable patient or physician privacy requests that would follow the record regardless of location.”

The usually insightful blog is maintained by the information technology consulting firm BSTI, who advises: “If your organization can’t participate in HIEs [Health Information Exchanges such as Regional Health Information Organizations (RHIOs) or Public Health Information Network (PHIN)] and the NHIN, your patients (read customers) will probably go to an organization that does.” [ Editor’s note: I asked what organizations they are referring to, that an otherwise satisfied patient might leave if the patient can’t be among the first to link up his medical records with the local HIE? The consultants’ reply is posted on their blog.]

October 19, 2006

AHIC’s Mini-Me

Filed under: — mlazoff

From an article posted on GovernmentHealthIT: “Through a [$2 million dollar, 1 year] contract with the National Governors Association (NGA), the Office of the National Coordinator for Health Information Technology will sponsor formation of a State E-Health Alliance in 2007…Under the agreement, NGA’s Center for Best Practices will form a high-level steering committee that includes governors and state legislators to tackle barriers to the formation of health information networks…Interim National Coordinator Robert Kolodner described the states’ project as mirroring at the state level the American Health Information Community, which is the Department of Health and Human Services’ advisory committee consisting of federal, health and corporate leaders.”

September 21, 2006

Interim announcement

Filed under: — mlazoff

According to an article posted last night on the healthcare business news site Modern Healthcare, “HHS Secretary Mike Leavitt announced the appointment of Robert Kolodner [MD] as HHS’ interim national coordinator for health information technology. Kolodner, previously chief informatics officer at the Veterans Health Administration, replaces David Brailer, the first occupant of the HHS post, who resigned in May. A physician, Kolodner was involved in the VA’s VistA information technology system and has been instrumental in the development of the VA’s overall electronic medical records system.”

September 14, 2006

Are all (HIT) politics local?

Filed under: — mlazoff

Today’s iHealthBeat  includes Health IT at the Crossroads, a literate commentary by attorney Bruce Fried. The final sentence summarizes the disharmony Mr. Fried describes between individual regional health information organizations (RHIOs) and even smaller local health organizations, and the National Health Information Network (NHIN), which many envision as a daisy chain of RHIOs forming one centralized backbone technology.  “It looks to me like the national, state and local efforts to build an HIT system are at a crossroads. In one direction, there is a return to a fragmented, every-man-for-himself strategy. In the other direction, there is a shared vision that fosters collaboration and coordination. Which way shall we go?” Mr. Fried shares other insights: the shift from “the administration’s roundly embraced objective…to digitize health care to achieve greater patient safety, better quality of care and administrative efficiencies” to HIT as “a prop to support CDHC [consumer driven health care],” and increasing partisan poliitcs that characterize recent Congressional HIT bill activity. 

According to multiple news sources…

Filed under: — mlazoff

…by the end of next week, the HHS will announce an acting National Coordinator for Health Information Technology. This is the position previously (first) held by David Brailer, MD.

August 21, 2006

The electronic era of per$onalized medicine

Filed under: — mlazoff

The Business/Your Money section in this past Sunday’s The New York Times includes Smart Care via a Mouse, But What Will it Cost? (available to free registrants), a futuristic look into how data collection and analysis associated with a widespread use of electronic medical records might affect healthcare quality and cost. “An information revolution in health promises to be powerfully disruptive for some lucrative businesses in the industry, according to medical experts and economists, and could lead to more spending on health care instead of less. ‘Information is a dual-edged sword, especially in health care,’ said David M. Cutler [PhD], a health economist at Harvard. ‘Better information might blow apart some of the blockbuster markets in the pharmaceutical industry, for example. But it might also increase demand for other drugs in smaller, more focused markets. And if better information really helps us understand what is happening in health care,’ Mr. [sic] Cutler added, ‘it could well lead to more care for more people and higher costs for the system as a whole.’” (For more on Dr. Culter and his beliefs, see The Quality Cure? from the March 13, 2005 edition of The New York Times).

The article goes on to describe the potential benefits of outcome measures using anonymous data collected from electronic records in the proposed Nationwide Health Information Network. Today, smaller integrated health systems such as the Veterans Health Administration and the health maintenance organization Kaiser Permanente are described as “leaders in adopting electronic records,” where each organization’s electronic data collection and analysis makes possible “market-disrupting cost savings.” For example, by educating physicians using outcome measures, VA and Kaiser physicians now prescribe more generic lovastatin than other, more expensive “blockbuster” statins. “Ideally, electronic patient records and a national health information network would someday give doctors everywhere the information to make similar prescribing decisions and to track their patients closely, if they chose…Whether more data threatens blockbuster drugs or not, there are likely to be cases in which more information is likely to generate more prescriptions, more care and more health care spending.” For example, future genetic testing might identify an individual patient’s ideal dose of the currently difficult-to-regulate blood thinner, warfarin—and so likely increase its use among physicians and benefit to patients, though at an increased cost. The article closes: “The electronic medical record, for all its promise, is no silver bullet for the nation’s health system. Placing too much faith in technology, skeptics warn, could be counterproductive. Dr. David Himmelstein, a physician and associate professor at the Harvard Medical School, said: ‘It encourages the belief that we don’t need real reform, all we need is computers.’”

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