May 29, 2007

The Quest to Connect
By Kathryn Foxhall
For The Record
Vol. 19 No. 11 P. 12

A progress report on the ambitious National Health Information Network project shows that measured steps have been achieved, but the long-range goal remains off in the distance.

Currently packing more hype than hope, the National Health Information Network (NHIN) is expected to form the foundation of the federal government’s strategy to transform the healthcare industry through HIT.

The long-term vision is that the system will eventually spread into a “network of networks,” allowing geographic networks (ie, states) and nongeographic networks (ie, pharmacy information exchanges) to talk to each other.

The NHIN currently consists of four consortia, including some of the foremost names in U.S. business, each of which built a prototype architecture in 2006 to allow information exchange. Health and Human Services (HHS) sponsored the groups with contracts totaling $18.6 million to develop model services for secure information sharing among hospitals, laboratories, pharmacies, and physicians in three geographic markets and also to ensure that information could move seamlessly between the four networks themselves.

The networks were required to “test patient identification and information locator services, user authentication, access control, and other security protections and specialized network functions, as well as test the feasibility of large-scale deployment.”

In January, the projects reached a landmark when they demonstrated their prototypes to the American Health Information Community (AHIC), the advisory body to HHS, and a special NHIN forum.

Consortia representatives provided a taste of their work, putting their programs through use examples, such as allowing patients to capture discharge summaries, medication histories, or other information into a personal health record. The demonstrations showed how patients could control which providers could view their records and how users could write notes in their records.

The programs were also put through the paces of how clinicians with permission could view a patient’s record prior to seeing that person, get current or historical lab results, or use their own systems to search for information on a patient through the network.

John Loonsk, MD, director of the Office of Interoperability and Standards within the Office of the National Coordinator (ONC) for HIT, cautioned, however, that the demonstrations showed only the software, not the networks behind it, which were the major focus of the consortia’s work last year.

This year, the prototypes are supposed to begin a trial implementation, connecting with state-based HIT efforts. Jodi Daniel, JD, MPH, ONC’s director of policy and research, recently said, “I think that is going to be a really great opportunity for blending the federal government efforts and the state efforts in looking at how a nationwide health information network could really work within a state and across the country.”

The Four Consortia
The contracted consortia are the following:

• the Accenture-led consortium, which worked over the last year with the Eastern Kentucky Regional Health Community, CareSpark in Tennessee, and the West Virginia eHealth Initiative;

• the Computer Sciences Corporation-led consortium, which worked with the Indiana Health Information Exchange (IHIE), MA-SHARE in Massachusetts, and Mendocino Health Record Exchange in California;

• the IBM-led consortium, which worked with the Taconic Health Information Network and Community in New York, the North Carolina Healthcare Information and Communications Alliance in Research Triangle, and the North Carolina Healthcare Information and Communications Alliance in Rockingham County; and

• the Northrop Grumman-led coalition, which worked with Santa Cruz, Calif.’s regional health information organization (RHIO), HealthBridge of Cincinnati, and the University Hospitals Health System in Cleveland.

Working With the ONC Structure
As the ONC pushes to build a completely interoperable system, the NHIN consortia are required to work closely with other ONC-sponsored panels, which means they must abide by the fast-developing standards set by those other efforts. For example:

• The Health Information Technology Standards Panel, established by the American National Standards Institute, leads a consensus-based process to identify the most appropriate standards, including existing technical languages, and identify gaps in standards where they are inadequate or unavailable.

• The Certification Commission for Health Information Technology sets criteria for and certifies health information systems. It began by certifying a number of electronic programs for ambulatory electronic health record (EHR) systems last year, and it plans to certify inpatient records and networks in the future.

• The Health Information Security and Privacy Collaboration, established by the research outfit RTI International and the National Governors Association, addresses the variations in business policies and state laws related to privacy and security that are problems for health information exchange.

Reaching for Self-sustainability
Basic to the ONC’s concept for the NHIN is that it will eventually be self-sustaining through the services it offers. Economists asked by the ONC to analyze a variety of models, by which the structure might develop, recently said that it could break even financially in approximately seven years.

In recently presenting those models to the AHIC, John Glaser of Partners HealthCare System noted that among the possible services an NHIN could provide are: identification, authentication, and authorization; participant registry and directory of services; record location and search; data mapping and deidentification; data persistence (storage); data mining and analysis; electronic or personal health records; audit and consent management; and secure data transport.

However, Glaser stressed that NHIN sustainability as a private undertaking has numerous hurdles ahead of it. Its viability is likely to be dependent on EHR adoption rates over the next few years. And he noted that RHIOs have to become sustainable to be participants in the network, but it’s still early in those groups’ history to determine whether they’ll make the grade.

Glaser warned that the local networks will also have to conform to the necessary NHIN standards and policies. Plus, they may not understand why they should change their agenda to connect with the rest of the country on the chance that patients from other areas show up in their facilities.

Spreading a network across the United States is also dependent on an element of trust, said Glaser. “While we in Boston have our own skirmishes and battles, we do know each other, and we don’t know those guys in L.A.,” he said.

On the EHR adoption component, Glaser said physicians’ lack of financial incentives still needs to be addressed. In terms of rewarding high-quality care, including EHRs, he said, “We are not there as a country, and it is uneven across the board, let alone on the exchange of data.”

Glaser also mentioned concerns with the economic models studied for the NHIN. “At maturity, secondary uses of the data are often 50% of the revenue stream—for public health purposes, research purposes, looking at care patterns, analysis, etc,” he said. But the nation, he continued, still needs to develop the legal and policy approaches governing that kind of data use.

Beyond those questions, Glaser said, the data are often “crummy.” Researchers sometimes think they can do particular analysis with aggregated healthcare records, he said, “but there is not a chance because of the uneven quality of reporting, gaps in the data, biases on the part of the reporting physician, etc. So it can be startling to learn what the reality is on this type of data.”

Given those factors, Glaser recommended a “sober and thoughtful assessment” if this kind of secondary use is to be a significant part of NHIN financing.

Another speaker at the AHIC meeting, Stephen Parente, an economist and health services researcher at HSI Network LLC, agreed that the NHIN can eventually make money. “The opportunities on the private sector are rather substantial,” he noted.

HIT, he said, presents an “opportunity not just to control costs but to profit as well.”

For example, Parente said, “If you know that you can find out what medical technology—by review of your medical records, not by guessing—is going to give you the best bang for your buck for future innovations, you might be willing to pay a lot of money for that.”

Although over the last two years he has seen a small feeding frenzy in terms of public and private money moving to explore HIT opportunities, Parente said, “I don’t think that is going to make a sustainable business model.” What may be sustainable, he said, are models such as per-transaction user fees or subscription services with sustainable fixed-base pricing and variable add-on pricing.

On the other hand, several AHIC panel members suggested that at some point, consumers’ desire to have their own records, better understand their conditions, communicate with physicians, and make appointments online will drive HIT adoption and financing.

RHIO Financing Models
Some models for bringing money into the HIT network may come from current RHIO activity.

Victoria Prescott, principal investigator on an AHIMA report about RHIO services that seem financially sustainable, recently agreed with Glaser that HIT needs to leverage any infrastructure already built, as well as the data collected. “The key is not to build another silo of data but to reuse it for purposes that are acceptable to the community,” she said.

But Prescott, who recently spoke to the State Alliance for e-Health, noted that some RHIOs are having success with clinical messaging, such as sending lab test results, radiology reports, or transcribed reports to physicians. She said hospitals like the economies of scale and appreciate not having to deliver results themselves. Also, the doctors favor it because they get results faster and only have to log on to one system, not several hospital systems. Hospitals in some RHIOs pay for the services, she said.

The AHIMA report found that the Regenstrief Institute/IHIE has several financially feasible services, including electronically sharing a patient’s medication history obtained from multiple sources. Prescott said the service is attractive to hospitals because, among other things, it helps them fulfill The Joint Commission requirement for medication reconciliation. And the eligibility and formulary functions usually included in the medication history can reduce drug costs and increase efficiencies. Hospitals pay for the service based on the number of patients matched.

In addition, the e-prescribing delivery network pays the IHIE a portion of the fees it receives from the pharmacies. Also, the IHIE’s provision of patient clinical data at the point of care, gathered from various sources, is funded by research grants for the effect of electronic health information on care and by a local foundation that sees it as a public good. The challenges of creating such a data-sharing system, said Prescott, are that you have to be able to match the patient to the record, the data have to be standardized to be of real value, and it has different value across stakeholders so there has been a hesitancy to invest.

The Indiana group is also starting a project in which health payers will pay the IHIE a per-member, per-month fee for quality measurement reports. Prescott said the payers recognize the potential for improvements in efficiency and quality of care, and providers have to comply with only one set of quality measures. Providers also receive performance information and incentives for improvements.

The Privacy Hurdle
Dealing with privacy concerns is still a looming issue, one that has led to plenty of HHS criticism.

Earlier this year, the Government Accountability Office (GAO), a watchdog agency for Congress, reported that HHS had started several projects on HIT privacy, but it “is in the early stages of its efforts and has therefore not yet defined an overall approach for integrating its various privacy-related initiatives and addressing key privacy principles, nor has it defined milestones for integrating the results of these activities.”

The GAO also said the agency had not “determined which entity participating in HHS’s privacy-related activities is responsible for integrating these various initiatives and the extent to which their results will address key privacy principles.”

Without a clearly defined approach with milestones for integrating efforts and addressing key privacy challenges, “it is likely that HHS’s goal to safeguard personal health information as part of its national strategy for health IT will not be met,” said the report.

Testifying on those concerns, Robert Kolodner, MD, the national coordinator of HIT, told a congressional committee, “A critical portion of the required NHIN deliverables is the development of security models that directly address systems architecture needs for securing and maintaining the confidentially of health data.”

Each of the ONC contractors, he said, “is delivering important architecture capabilities that will be used in the next steps of the NHIN to address the complex issues of authentication, authorization, data access restrictions, auditing and logging, consumer controls of information access, and other critical contributions.”

— Kathryn Foxhall is a freelance writer in the Washington, D.C., area. She covers health informatics, public health, health policy, reimbursement, mental health, and other issues.