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Will it take a Federation to create a Federated Patient View?

July 31, 2009
by Joe Marion
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It seems that the news is awash with healthcare legislation these days as the debate over healthcare reform plays out in Washington. With all the publicity, I’ve been thinking about the impact on the advancement of the Electronic Health Record (EHR). One of the promises of an EHR is the opportunity to consolidate a patient’s records (Federation) and provide convenient access. The challenge of such a task will be who pays for it?!

I’ve recently been in discussions with an entity that believes it has some novel technology for a consolidated view of patient imaging information, and a means for quick access to them. Discussions have centered on market demand and timing for such capabilities.

It is not that there haven’t been prior efforts for such a concept. I can recall significant efforts over a decade ago in Illinois (Ameritech) and Wisconsin (WHIN), as well as a flurry of RHIO activity over the past decade. None of these efforts seems to have taken off on a major scale. Early efforts were probably hampered by interface compatibility, as the industry was in the early stages of information standards such as HL7 and DICOM. More recent efforts seem to be encumbered by economics, as entities wrestle with how to fund them.

Now there is the prospect of government-run healthcare. Will that be the impetus to make the Federated EHR viable? If there still is a private sector, can it compete with government initiatives to sustain EHR's? And, will it have the same access to such information? Perhaps healthcare reform will end up as a compromise and address only certain aspects of the whole system. What implications might reform have for the Federated EHR?

One could make the case that the Federated EHR can be economically justified on a national level on the basis of economies of scale. Without a national system, there seems little reason to pursue such initiatives. Regional entities have made the case for them on the basis of patient mobility across a number of cooperating entities and services. But can the same case be made on a national basis? How many patients are nationally mobile? Certainly, one can envision the situation of a patient with a recurring imaging need, such as a patient being treated for a recurring illness, that would benefit from access to prior imaging information should the patient be referred to another facility in a different part of the country. But, how many circumstances are there like this, and is it enough justification for a national repository? More likely, there is the case of a citizen with a medical history in one part of the country who moves to another area, and can benefit from accessibility to their prior medical records. But again, is this mobility significant enough to justify the cost?

Another justification might be the consolidation of a number of patient registries that could be used for research, and greater efficiencies in decease control. The counter argument might be made that individual healthcare entities and organizations would lose control over such data, and there might be greater confidentiality risks and chance for fraud.

In a free market economy, there may still be instances of a federated model that make economic sense. For example, one key opportunity might be to address how individual physician offices address the EHR, as there is little incentive for them individually to make an investment in technology to achieve it. A national entity that develops a web-based EHR would have the incentive to develop a federated model, in that the data could be more economically stored in a cloud than by each physician office investing in its own technology. Could this represent enough business potential for vendors to invest in the technology in a competitive market?

As I have wrestled with how to identify the market potential for technology that enhances the federated EHR, I am struck by the complexity of such a task in an uncertain healthcare environment. Should we go down the path of government run healthcare, it seems clear that the federated EHR will be mandated, and determining the market size will be easy. If we do not end up with a complete government-run system, will there be sufficient economics for a free market economy to invest? And if so, what will be the tipping point? Could the federal government mandate the federated EHR and foster free market competition by allowing universal access? Are there significant enough state-based initiatives to justify on that level?

I welcome any and all viewpoints to this perplexing issue. What do others think? Will federation improve or diminish the opportunity? Are there enough free market opportunities to justify independent investment? I look forward to a spirited debate!



Interesting post. You raise some great issues and took a stand, as well as called for debate. My kind of guy! That's exactly my definition of useful blogging.

I agree with your high level observation that the funding model is (generally) an unsolved problem. The related governance and sharing policy issues are, as large or larger. I'll call your attention to two great summaries of the issues and current state:

1) A Classic Article: Strategies for Creating Successful Local Health Information Infrastructure Initiatives - December, 2003 - Nancy M. Lorenzi, PhD. The two primary case studies are extremely telling.  Despite the word "Local" in the title, the article clarifies the issues and elaborates examples that work and don't work.

2) The Current NHIN model - NHIN CONNECT Lessons Learned - April 6, 2009 - Bart Harmon, MD, MPH, and James Traficant, BSEE, MBA.  The slides, combined with the audio, tell the part of the story behind the closest federal initiative to what you're describing.  Policy agreements, as well as the content of the primary NHIN use cases disclose the promise and the concerns.

Thanks for kicking off this debate.  I'm hopeful that someone will take the health record banking alternative model perspective.