Vendors scramble for seats at the table
In the $821.9 billion appropriations bills Congress passed last December, not $1 went to the Office of the National Coordinator for Health Information Technology, which had been established in May.
Lobbyists and activists kicked into high gear. They joined Department of Health and Human Services officials in prodding Congress to fund the office. Legislators approved about $33 million for the office, cobbled together from other parts of the budget.
It wasn't much, but it was enough to keep the coordinator, Dr. David Brailer, from leaving Washington, D.C., and returning to the private sector.
"That was a wakeup point," said Adam Kovacevich, communications director at the IT Industry Council, an association of big-name technology companies.
The battle marked the emergence of the high-tech industry as players in the high-stakes effort to shape a national health IT policy and speed the implementation of clinical information systems.
Last December, Cerner, a leading producer of health IT systems, hired a new director of government relations with substantial Capitol Hill experience. About the same time, the IT Industry Council listed the federal health IT initiative among the council's dozen top-priority issues for 2005.
Since then, Congress has introduced at least 18 health IT bills. Committees held health IT hearings almost once a week before Congress departed for its August recess. Lobbyists and the press packed the hearing rooms, listening for clues about the program's direction.
"There are billions and billions of dollars at stake," said one lobbyist whose high-tech employer forbids him to talk to the press.
Late to the party
By all accounts, the technology industry came late to this party. One reason is that health care tends to be a highly specialized niche of the software and systems integration industry. Companies such as Cerner and Allscripts names unfamiliar even to many in the technology business lead the electronic health records market, not the more mainstream industry leaders.
"The big players haven't been in there," the lobbyist said.
It's a fragmented market. Hundreds of small applications software companies are selling their wares to more than 200,000 medical offices, clinics and hospitals nationwide. Another reason why some tech companies did not see a change coming is that health care has long been the least computerized sector of the economy. Few in the tech industry were paying much attention to it.
But Daniel Garrett, a vice president of Computer Sciences Corp. who heads its Global Health Solutions unit, was paying attention. CSC was working on national health care systems in Denmark, Sweden, Norway, France and Britain, Garrett said, and that experience led him to see the potential in the United States.
At first, Garrett said, he was nervous when he noticed that he was usually the only executive from a large systems integrator involved in health IT projects such as a Massachusetts health network and nonprofit activities that advocate health IT and undertake research and development programs, such as the eHealth Initiative.
Garrett is executive vice chairman of the Steering Committee of Connecting for Health, a public/private initiative whose primary sponsor is the Markle Foundation.
The company's participation in those and other market development activities is a major investment for CSC, Garrett said. But it has been a good investment, he added. "We would not have grown as fast as we did if everyone else had focused on it."
A united front
Now, many other large IT companies have taken notice. One of the clearest indications that they want to share in the building of the National Health Information Network (NHIN) is their participation in a joint venture called the Interoperability Consortium. Besides CSC, it includes Accenture, Cisco Systems, Hewlett-Packard, IBM, Intel, Microsoft and Oracle.
The companies came together to present an industry consensus response to the request for information that Brailer's office issued. The RFI seeks ideas and advice on input from the public on the development of a national health information exchange. More than 500 individuals, organizations and companies also responded to the RFI, issued in January.
"We have a responsibility to talk about what will work and what won't work," Garrett said. But he added that "you don't want to force your opinion into policy" issues.
The consortium recommended using open standards and avoiding proprietary solutions. Garrett said the members have a common vision that "could create a market that doesn't exist right now and everyone's boat would float higher."
The consortium is a rare example of companies that often are rivals coming together to show they can play well with others and move the ball forward. Its leaders, such as Dr. Marshall Ruffin, an associate partner at Accenture, say the group may expand and undertake other joint activities in the interest of interoperable health care systems.
A newcomer to health IT policy issues might be excused for confusing the consortium with the Commission on Systemic Interoperability. The commission was mandated by the Medicare Reform Act of 2003, which directed it to "develop a comprehensive strategy for the adoption and implementation of health care [IT] standards that includes a timeline and prioritization for such adoption and implementation."
Besides their degree of legislative legitimacy, there is one major difference between the two bodies: Only one member of the commission is from the IT industry.
That member is Ivan Seidenberg, chairman and chief executive officer of Verizon Communications. Seidenberg has worked in the telephone industry ever since he started as a cable splicer's assistant.
He offers an occasional insight or word of advice on technology and implementation issues as the commission deliberates. But more often, he mentions the more than $1 billion in health care bills that Verizon pays for its employees each year.
The commission has several medical informatics gurus and health care executives among its 11 members. But at the commission's June meeting, one of the executives, Gary Mecklenburg, president and CEO of Northwestern Memorial HealthCare of Chicago, expressed concern that the commission was not hearing from IT providers about standards and interoperability issues.
"It's this technology piece that concerns me," he said, adding that IT vendors are the ones that will have to deliver regional and national information systems.
Some observers say that the years of work on medical information systems has had relatively little impact on the practice of health care because of the absence of major systems integrators from much of the activity.
Establishing health information exchanges will require systems integrators, the companies that specialize in modernizing existing systems and linking islands of information.
The Commission on Systemic Interoperability has been meeting since January and is required to deliver its report to HHS and Congress by the end of October.
The commission has found it difficult to develop a comprehensive standards strategy in less than 10 months with a small staff, and it appears to have been upstaged by the American Health Information Community.
AHIC is a high-level HHS advisory committee. Sill in the midst of formation, it "will accelerate the development of the standards necessary for the modernization we need," HHS Secretary Mike Leavitt said in announcing AHIC's establishment in July.
Its members will include an equal number of health care executives and representatives from the federal government departments with major health care responsibilities. One seat is specifically reserved for an IT vendor representative.
No one argues that systems integrators should direct the push for interoperability. In the end, the medical community will use the next-generation data networks and benefit from the information they share.
Historically, systems development efforts in many industries have suffered from too little customer and user involvement. The health industry, however, may have gone too far in the other direction until now, some say, in effect asking users to solve too large a portion of their interoperability deficiencies.
"The integrator comes in to create the interoperable architecture," Ruffin said, adding that the health community increasingly recognizes the role of integrators.
Health care leaders have long resisted government and industry efforts to shape the development of medical IT.
For example, at a June meeting of the National Alliance for Health IT, William Plested, a California physician who is president-elect of the American Medical Association, complained about privacy rules in the Health Insurance Portability and Accountability Act of 1996 and called government the biggest culprit in problems of protecting medical privacy.
As for systems integrators, Wes Rishel, research director of the health care provider service at Gartner, said that "among the policy-makers, there's a strong sense that the vendors will define the problem in a way that makes it easy for them to solve it. So, there's a fair amount of resistance to the techies having too much of a place at the table."
Interfaces are crucial to national health information sharing, Rishel said, and multiple regional architectures for information exchange can work if the interfaces are standard.
"The problems of sharing health care information will ultimately be addressed by vendors who have products in the health care IT space," he said.
The integrators' biggest customer is typically the federal government, he said. Now that government has shown serious interest in health care IT, those vendors are getting on board.
The extent to which systems integrators with relatively little experience in health care can help develop the NHIN remains to be seen. Their roles will be decided not only by how fast they learn to work in the new space, but also by how the government decides to proceed, observers say.
One of the best early indicators will be the selection of up to
six HHS contractors this year to build prototype health information exchanges. That's why many believe that hundreds of companies and organizations have responded to HHS' July request for proposals.
"You have to get to a large program," Rishel said. "It's a question of how you get there."