Is the nation's health network healthy?

The Nationwide Health Information Network might need more work

Getting doctors and hospitals to electronically collect, store and share your patient health records has been one of the great hurdles of the decade. It seemed the men and women clad in white coats and stethoscopes are some of the last adopters of information technology.

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Now the health care community is getting on board, thanks in no small part to financial incentives that will be provided by taxpayers. However, building a nationwide system that helps health care providers access patients' records when the patients arrive for care is proving to be a more difficult challenge.

“Simply having all the medical records become electronic doesn’t magically result in delivery of the records at the point of care,” said Dr. William Yasnoff, a health informatics consultant and senior adviser to federal agencies on health information exchange from 2002 to 2005.

Congress gave a big push to adopting electronic health records (EHRs) this year by including $45 billion in incentive payments to doctors and hospitals in the economic stimulus law. Lawmakers topped that off with $2 billion to advance health information exchanges. Factoring in projected savings in health care delivery, the net cost to the Treasury is supposed to be $19 billion.

However, a critical piece might be missing: So far, there is no fully functioning national information exchange system that can securely collect and share patient medical data and then deliver the data when it's needed.

Most likely, the Nationwide Health Information Network will be assigned that role. Although the NHIN, which the Health and Human Services Department developed, has shown that health data exchanges can work, health officials say it is not ready for a broad and central role for health data sharing.

Also, NHIN's existing design might not be the answer. Some experts say there is an urgent need to retool the entire NHIN architecture. If that opportunity is missed, stimulus funding could be wasted on medical records systems that, in the end, will not fulfill the vision of providing on-demand patient data. The records systems also might not meet public policy goals for quality of care, public health, and reduction of errors and unnecessary procedures.

“I have not seen in the stimulus where the NHIN is being advanced,” said Dr. John Loonsk, chief medical officer at CGI Federal and formerly director of interoperability and standards at HHS. “To get the patient data moving is not going to happen organically. It has to be designed.” Loonsk, an original architect of the system, said the stimulus bill should have offered more specifically to support the architecture.

Some experts say that the NHIN can function effectively with mostly incremental changes. “We will begin to use what is ready and evolve it to meet the needs,” said Dr. Bart Harmon, chief medical officer at Harris, which designed the Connect software that links users to the NHIN.

And redesign vs. incremental growth is not the only debate. Concerns about competition, innovation and overall health care reform are unresolved issues that also affect the viability of health information exchange as currently conceived.

“Why would rural hospitals want to share data that will put them at a competitive disadvantage?” asked Neal Neuberger, executive director of the Institute for E-Health Policy, run by the Healthcare Information and Management Systems Society. “We have a long way to go before health organizations — even with incentives — will get to meaningful use of electronic health records.”

Meanwhile, the timing for NHIN change is complicated. With health care reform and possibly payer reform unfolding at roughly the same time as the introduction of national health data exchange, harmonizing all the changes is extremely difficult, said Brian Wagner, senior director of policy and public affairs at the E-Health Initiative think tank.

“All of these issues are intertwined,” Wagner said. “At the moment, it is more than you can put on the NHIN to solve.”

Those concerns are longstanding dilemmas. Federal officials have been developing the NHIN since 2004, when the George W. Bush administration established the HHS Office of the National Coordinator for Health Information Technology, which runs the NHIN as a pilot project. The NHIN is a network of networks, with technical standards for interfaces, data exchange, and security and access controls.

The NHIN has achieved several milestones in recent months. HHS awarded the Connect contract to Harris in March 2008. Connect is now available free to all health providers and agencies. In September 2008, the Defense and Veterans Affairs departments and the Social Security Administration began demonstrating exchanges on the NHIN with 16 private-sector entities, and the Centers for Disease Control and Prevention, Indian Health Services and National Cancer Institute also joined that effort.

In February, SSA and MedVirginia began a project to share patient records to help SSA adjudicate applications for disability payments. In most cases, NHIN users could get the needed patient data through the system in a matter of minutes, compared with six to eight weeks with paperwork.

The NHIN might not be perfect, but it is a success, said John Fraser, chief executive of MedNet USA, an NHIN contractor. “The NIHN is moving in the right direction, and the federal agencies have a great collaboration,” Fraser said. “We are hearing of discussions among large clearinghouses and billing companies who are ready to make a strategic bet on the NHIN.”

Dr. David Blumenthal, national coordinator of health information technology at HHS, said the department is looking to the NHIN to fulfill the stimulus law goals for health information exchange. However, he also called it a work in progress.

“To say it is finished is premature,” Blumenthal said. The NHIN “has shown that it is capable of exchanging information. I think personally it is a very important piece, and we are working actively on it.”

Meanwhile. the clock is ticking. The $45 billion appropriated by Congress is earmarked for health care providers who buy and "meaningfully use" certified electronic health records. However, meaningful use is a term with a range of interpretations. Precisely what uses fall under its definition is an ongoing debate.

Blumenthal, along with a health IT policy committee advising him, is rushing to prepare recommendations to HHS for defining the standards for certification that go into effect in 2011. Achieving health information exchange goals is supposed to start in 2013 or 2015. HHS will issue several rulemakings later this year.

The policy committee’s workgroup on information exchange said July 16 that nearly half — about 42 of the 94 proposed standards for meaningful use — involve some type of health information exchange. The question is whether — and how — to require participation in the NHIN or some other national exchange under the meaningful use certification framework.

The problem is multidimensional. Deven McGraw, chairwoman of the workgroup and director of the health privacy project at the Center for Democracy and Technology, said the meaningful use/data exchange standard could span communications, content, privacy, security, monitoring and enforcement and legal and business aspects.

“How far should the health IT policy committee go with regard to requirements-setting in each of these categories?” McGraw asked July 16. “How can this approach be pursued without overly hampering market innovation?”

But some experts continue to argue that the NHIN architecture must be re-engineered before pressing forward to implement the current system.

HHS “has not produced a clear statement of the requirements for a national health information exchange infrastructure, nor a clear vision of how a system would work once built,” consultant Yasnoff said in an interview. “Until you do that, it is extremely risky to proceed with implementation efforts. We are going to have a lot of exchange in health information, but we’re not going to achieve the goal.”

Yasnoff also asserted that the current network-of-networks design of the NHIN is experimental and inherently insecure. “It is an unsolved problem in computer science,” he said, adding that NHIN should be reconfigured so that patients collect their own data in a repository or in central repositories and then give consent each time the data is provided to a payer or provider.

The risk is that without an NHIN redesign, the economic stimulus dollars will be spent on the wrong technologies, Loonsk said. If not done correctly, it might increase the number and reach of systems that do not exchange data effectively.

"Failure to recognize the need for engineering risks great inefficiencies in the use of [economic stimulus] funds and a 'paving the cow paths' approach to the isolated health technologies that exist today, which won't produce the system outcomes to accomplish the vision of electronic medical records or justify the investment,” Loonsk said.

Acknowledging those concerns, Blumenthal said NHIN is working to address them.

“We are working on creating a private, creative, secure and interoperable capability for health information exchange,” Blumenthal said. “We won’t finish and spin it off unless it is secure and private. We will get advice on the federal role in NHIN and when we can say it is ready for prime time.”

Overall, there is hope that the NHIN technology will evolve quickly to fulfill the needs for health information exchange, but there also is caution about chugging forward without a deliberate and conscious effort at redesign. But the pressure to complete the system is intensifying, and observers agree that some part of the vision might be sacrificed.

“We’re looking at reforming the entire system, and everything has to move together," said the E-Health Initiative's Wagner. "We have to make decisions, and we cannot wait to create the perfect system.”


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