For years, the Washington, D.C.-based Office of the National Coordinator (ONC) for Health Information Technology (an office in the U.S. Department of Health and Human Services) has been on the receiving end of a lot of criticism, especially from the Washington, D.C.-based U.S. Government Accountability Office (GAO), for not producing a long-range strategic plan.
Although it applauded ONC's progress on several fronts, a February 2008 GAO report noted that despite promising in late 2006 to publish a plan with milestones and performance measures, ONC still had not done so.
However, in June, ONC finally answered those criticisms with a 115-page document that both catalogs ongoing federal efforts related to healthcare IT, and sets goals related to patient-focused healthcare through 2012. The report also places a strong emphasis on public health reporting as it relates to information exchange. The plan details what needs to be accomplished to address privacy and security concerns, achieve interoperability, accelerate IT adoption, and foster collaborative governance. It also sets specific targets; for instance, it projects that 40 percent of physician offices and 12 percent of small practices will use EHRs by 2012.
But what does the plan signal to healthcare CIOs, and how can they use it in developing their own strategic plans?
First of all, it might provide a sense of continuity that the multiple federal agencies working on healthcare IT are all rowing in the same direction, and that efforts undertaken during the Bush administration will likely continue no matter who wins the election this fall.
In a recent interview, National Coordinator for Health IT Robert Kolodner, M.D., and Deputy National Coordinator Charles Friedman, said that the document serves as a statement of what needs to be done, and could serve as a guidepost for the next administration.
“All the evidence suggests that there's a strong embrace of health IT moving forward,” Kolodner says. “There are bills in both the House and Senate that, among other things, include provisions that establish ONC in statute. That reflects bipartisan support. Although there may be variations in emphasis, it is clear that any administration coming in has to focus on making health IT pervasive.”
Mark Frisse, M.D., Accenture Professor of Biomedical Informatics at Vanderbilt University (Nashville, Tenn.), says the plan is helpful because it echoes the national consensus on privacy, security, and interoperability. “I give Kolodner and Friedman credit for really becoming coordinators,” Frisse says. Describing the synergy between different agencies can help clarify issues for CIOs who work with multiple federal agencies.
“One of the messages I hope CIOs get from this plan is the emphasis on population health,” Friedman says. “It implies that you have a role to play beyond supporting individual care and personal health records. You should be thinking about your role in population health and becoming active in emergency preparedness.”
Noting that it's imperative to have secure information exchange for public health reporting, he adds that the population health goals may foster health information exchange. “It's important to remember that it is a two-way street,” Friedman says. As page 39 of Section 2.3 of the report notes: Information can flow in both directions: “upstream” from providers and consumers to authorized population health agencies, and “downstream” from population health agencies to providers, consumers, and their communities.
For example, Kolodner adds, if another anthrax incident occurred, there could be immediate alerts to emergency rooms and primary care physicians to look for a certain cluster of symptoms or type of skin lesion.
Business models in need of improvement
Many CIOs have expressed concern about the sustainability of health information exchange organizations, and the strategic plan concedes that a great deal of work still needs to be done to identify workable business models.
“Organizations look at these opportunities to participate and ask how it translates into a return on investment, and that is understandable,” Kolodner says. “We recognize that's one of the reasons these multi-stakeholder governance groups are important — to sit down together and work through these issues. That's going to be one of the early focuses of AHIC (American Health Information Community) 2.0.”
Despite praising ONC for outlining a coherent federal strategy, Frisse believes ONC's efforts aren't focused enough, as frustration builds with the pace of building the National Health Information Network. He argues it should zero in on achieving small victories like working toward the availability of a medication history for every American. “If HHS would focus on this one thing, in the process of making it happen we would work out issues around privacy and confidentiality, identity management and workflow.”
Frisse argues ONC should focus on one or two key areas and “drop 80 percent of the things on their list.”
David Kibbe, M.D., director of the Center for Health Information Technology (part of the Leawood, Kan.-based American Academy of Family Physicians), agrees with Frisse that the work being done by ONC and AHIC is important, but that the effort is burdened by too many goals.
Kibbe recalls former ONC director David Brailler, M.D., saying in 2004 that he was going to work on interoperability of health-related applications and services within the federal government.
“I thought that was a great idea. Functionalizing interoperability among Department of Defense (DoD), Veterans Affairs (VA), and Indian health service systems, and how they interact with the private sector, would be a big benefit,” he says. “But soon they were moving on to RHIOs, EHRs, PHRs, and use cases. I work with a lot of physicians who interact with the VA, and they still can't get data in or out. So I would call that ‘mission unaccomplished.’”
Kibbe also criticized the plan for not paying enough attention to developments in consumer Internet technology, and how it is impacting healthcare.
“There are parallel worlds,” he says. “There's the Washington, D.C.-based Healthcare IT Standard Panel (HITSP), Certification Commission for Healthcare IT (CCHIT, Chicago) and ONC world, which is out of step with the broad consumer electronics-meets-healthcare world represented by companies like Google (Mountain View, Calif.) and Microsoft (Redmond, Wash.). ONC's focus is too much on large enterprises and heavy iron. The incumbents, the large health IT vendors, are not going to be the ones to get us to the Health 2.0 universe. The policy environment needs to encourage the merging of these worlds,” suggests Kibbe.