Good Enough? The Debate Over Investments in Healthcare Technology

Are today's healthcare IT systems "good enough"?

David Blumenthal (Harvard Medical School and Institute for Health Policy) said "the debate over whether existing technology is good enough has only emerged recently, with the prospect of a huge national investment in electronic health records. What seems to be happening ... is that passionate health technology advocates fear the country could get locked into an imperfect system."

Healthcare technology interoperability is considered a key component to reduction of administrative costs and improved coordination and continuity of care. Mike Leavitt, Secretary of HHS, contends that "we're already on the road to a system that is universally accessible and secure. Health information experts ... have been working on foundational health IT standards and have made substantial progress."

In Next Steps for Interoperability, John Halamka (Chair of HITSP and CIO for Harvard Medical School and Beth Israel Deaconess) believes that "we can achieve a substantial improvement in care quality and coordination by implementing the systems available now." He posits that the definition of healthcare technology interoperability that is "good enough" includes:

• "Support for medication interoperability such as e-prescribing linking providers, payers, and pharmacies
• Support for laboratory and radiology interoperability such as orders and results integration among providers, hospitals and commercial labs
• Support for seamless electronic interchange between providers and payers for administrative data flows.

In 2009, several EHR vendors will support clinical summary exchange."

Transition into product, and incentive systems for EHR adoption, has been accelerated through certifications including interoperability standards. Mark Leavitt, Chair of the Certification Commission for Healthcare Technology (CCHIT), recently reported on the existing certification programs, which started with an ambulatory EHR certification program launched in 2006.

According to Mark Leavitt, CCHIT certified product are now required for a number of EHR incentive systems which have developed over the last two years, with total investments exceeding $700 million, including 44 distinct public and private EHR programs and "54 new EHR rollouts, representing 147 hospitals under Stark safe harbor rule." Around 46,000 physicians are eligible for, or have received assistance under these programs.

Take time to parse the following from Mark Leavitt: "That there are no good products is absolutely not the problem".

Secretary Mike Leavitt argues that that Obama's Recovery and Reinvestment Plan should require that investments in health IT systems be certified interoperable. This "could spur a critical mass of the nation's doctors to finally enter the information age... If we're going to build a 21st-century health infrastructure, we need to do it strategically, continuing the careful work on harmonized standards that will create one nationwide, interoperable system. That's the only way to make an investment in health IT produce value for providers and patients and improve the quality of health care overall."

Not everyone is convinced that these investments will pay off. David Kibbe (Senior Advisor to the American Academy of Family Physicians) and Brian Klepper argue that "the easy solution would be to spend most of the health IT funds on EHRs. The EHR industry has made it easy by establishing a mechanism to 'certify' EHR products if they incorporate certain features and functions." Kibbe and Klepper contend that EHRs are expensive, disruptive to implement, with no clear patient safety benefits and are not yet interoperable. "These barriers to adoption are well documented; they form the wall that has kept physician EHR adoption overall to less than 25 percent in this country. Even if a hefty federal subsidy reduced the exorbitant cost of the EHRs, many practices would suffer severe negative business impacts, and primary care access could temporarily be reduced on a national scale."

In the meantime, some healthcare organizations are waiting on the sidelines for the federal Recovery and Reinvestment Plan to be enacted before making new health IT investments.

Link here for more on the "Good Enough" debate in Healthcare Technology.

Making Sense of National Healthcare IT

Avance Health Analysis

Recent news of HITSP's submissions to The Community (AHIC) June meeting, prompted a reader to ask: How do the various national healthcare initiatives (AHIC, HITSP, HHS, CCHIT and NHIN) fit together?

Is the relationship between these organizations Rube Goldberg-esque? Or is there some more coherent design?



The mission of American Health Information Community ("The Community" or AHIC) is to provide "input and recommendations to the Department of Health and Human Services (HHS) on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected in a smooth, market-led way." AHIC is presently reorganizing itself to ensure its viability beyond the term of the current administration, by establishing "AHIC 2.0" as a sustainable public-private organization. AHIC is the focal point for guidance to HHS on priorities for interoperability and develops the use cases for these priorities.

The Healthcare Information Technology Standards Panel (HITSP) mission is to "harmonize and integrate standards that will meet clinical and business needs for sharing information among organizations and systems." HITSP takes its guidance on priorities and use case definition from AHIC and proposes standards (like those to be presented today at the AHIC June 2008 meeting) to the HHS Secretary.

The HHS Secretary can accept the recommendations which starts the clock on a one year cycle of testing and implementation. At the end of this cycle, the HHS Secretary can choose to "recognize" these standards. Once standards are recognized, by Executive Order, they are incorporated into new Federal Systems and Healthcare Contracts.

Recognition of these standards also serves as input to the Certification Commission for Healthcare Information Technology (CCHIT). CCHIT is a recognized certification body (RCB) for Electronic Health Records (EHR) with the goal of accelerating EHR adoption. CCHIT establishes its roadmap and criteria for Electronic Health Records based in part on the recognized standards from the HHS Secretary.

These recognized interoperability standards are also incorporated by the Nationwide Health Information Network (NHIN), a network of networks promoting Health Information Exchange.

HITSP keeps on rolling

Chair of HITSP, Dr. John Halamka, announced that he will be presenting 4 new harmonized interoperability specifications to Health Human Services Secretary Leavitt and the American Health Information Community (AHIC) at the June 3 AHIC meeting. These specifications focus on Medication Management.





These specifications and definitions include:

Medication Dispensing Status provides a medication prescriber the dispensing status of an ordered prescription (dispensed, partially dispensed, not dispensed).

Medication Orders defines the transactions between prescribers (who write prescriptions) and dispensers (who fill prescriptions)

Medication Formulary and Benefits Information performs two tasks: 1) performs eligibility check for a specific patient's pharmacy benefits and 2) obtains the medication formulary and benefit information.

Patient Generic Health Plan Eligibility Verification provides the status of a health plan covering the individual, along with details regarding patient liability for deductible, co-pay and co-insurance amounts for a defined base set of generic benefits or services. The base set of benefits includes coverage status and patient liability for medical, chiropractic, dental, hospital inpatient, hospital outpatient, emergency, professional physician office visit, pharmacy and vision services that are included in the patient's generic health plan benefit.

Dr. Halamka announced he will also be presenting a technical note on Document Reliable Interchange to support a secure communication of a clinical document over a network.

Whither the Nationwide Health Information Network?

The Office of the National Coordinator for Health Information Technology has announced the expansion of the participants for the Nationwide Health Information Network (NHIN) trial. The six new awardees join the 9 federal agencies that manage health information that already have NHIN contracts.

So where are NHIN trials headed over the next year?

HHS announced that the trials will address four areas of health information exchange:

1. Patient lookup and information retrieval
2. Secure information routing and delivery (including, but not limited to a defined summary patient record)
3. Provision of data for population uses
4. Consumer managed access to appropriate information

The trials will test use of the NHIN standards to address these critical areas of health information exchange. The trials will use sample data to avoid any inadvertent issues with privacy and security. The trials are scheduled to complete mid 2009.

The awards are called cooperative agreements and bring together IDN's, state, regional and other health information exchange participants into the NHIN. Some very capable, high profile organizations are the awardees announced by HHS:

• HealthLINC/Bloomington Hospital
  An e-health collaborative with a multi-stakeholder board of directors consisting of representatives of multiple competing organizations, physicians, and hospitals that serves a ten county area in South Central Indiana with a population of 367,000.

• Cleveland Clinic
  A multi-specialty multi-facility academic medical system based in Cleveland, Ohio that integrates clinical and hospital care with research and education for 5.3 million patients. Cleveland Clinic facilities include the main, downtown Cleveland campus, nine regional hospitals, a Florida hospital, and 13 northeast Ohio community Family Health Center outpatient clinic locations.

• Community Health Information Collaborative
  A partnership among hospitals, clinics, long-term care facilities, tribal health facilities, higher education, and public health departments that serve 650,000 patients in a rural, 18-county region in Minnesota.

• HealthBridge
  The largest and oldest health information exchange located in Cincinnati, Ohio, serving a tri-state region connecting 24 different hospitals and health systems, 17 local health departments, two national and multiple local laboratories, radiology and diagnostic centers, physicians offices, community health center and nursing homes, and currently covering 1.8 million patients.

• Kaiser Permanente
  The nation's largest private integrated health care delivery organization, serving over 8.7 million members in 10 states and DC.

• Wright State University
  HealthLink RHIO, West Central Ohio's regional health information exchange, represents hospitals, providers, Medicaid managed care, labs, state and local public health, public schools, social services and safety net providers, and Clark and Champaign County Health Information Exchange, and covers a population of over 500,000.