Coordinate less, achieve more
By Dr. Mark Frisse
The Government Accountability Office recently assessed the progress that has been made in health information technology based on the work of the Office of the National Coordinator for Health IT (ONC).
GAO outlined ONC's considerable accomplishments. They include advancing outpatient and inpatient electronic health records; creating models for networking and exchanging information, including the Nationwide Health Information Network I and II pilot projects; and encouraging the development of standards in health information privacy and security at the state and national levels.
However, in listing those achievements, GAO failed to acknowledge the broader foundation from which that progress springs.
The innovation that has stemmed from Health and Human Services Secretary Mike Leavitt's vision is important, but health IT progress is equally the product of thousands of professionals and consumers who - on their own and without a strong government mandate - have concluded that a more effective technology infrastructure is essential to improving our ailing health care system.
One could argue that the national coordinator should be responsible for harnessing the momentum of those programs for the greater good. At the same time, the impact of some of ONC's accomplishments should be put in perspective. For example, I believe the NHIN I initiative was conducted too hastily to identify the essential components of such a network and articulate how those components could be used.
"According to HHS, in early 2007 its contractors delivered final prototypes that could form the foundation of a nationwide network for health information exchange," a GAO report states. The NHIN I summary report cited 24 core services, 12 common transaction features and 14 annexes on common themes such as identity arbitration, consumer data-sharing permissions and data routing.
One hopes a smaller set of high-priority items will emerge that can be adopted across the health care sector. I believe about 12 of the core services are must-do high priorities, and many others could be set aside for future consideration.
In the meantime, how should an organization as talented as ONC develop a national strategy? Here are a few suggestions.
1. Look to all successes, not just the NHIN pilots. Many health care providers, insurers, corporations and health information exchanges are doing good work.
Some of the most vibrant and promising efforts are operating outside NHIN.
2. Build on the goal - first raised by the Commission on Systemic Interoperability - of making the availability of a medication history for every American a top priority.
3. If a second quick win is desired, focus the same approach on clinical laboratory information.
4. Create guidelines for managing identities. That is an important topic for consumers, and it is crucial to e-prescribing and other applications. If e-prescribing is expanded to include controlled substances, identity management will become even more important.
5. Focus on simple core guidelines for confidentiality and privacy that transcend applications and can serve as the basis for a new and revised legislative and policy approach.
6. Focus - as HHS does - on incentives to adopt helpful technologies that foster a more effective system of care.
7. Postpone or abandon 50 percent of the discussions taking place on topics that are not foundational. To paraphrase Tennessee Gov. Phil Bredesen: Don't try to build Version 6.0 before you've got Version 1.0 working.
The literature and our experiences are full of examples of successful ways to create a winning strategy that transcends presidential administrations and the ongoing changes in states and communities. That approach requires a realistic set of expectations, a clear focus and incremental steps toward the larger goal.
-- Frisse is a professor of biomedical informatics at Vanderbilt University and project director for a regional health information infrastructure program funded by Tennessee, Vanderbilt and the Agency for Healthcare Research and Quality.