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VA, Kaiser plan to link electronic medical records
SAN DIEGO | November 25, 2009
The Department of Veterans Affairs and Kaiser Permanente are launching a pilot program to exchange electronic health record information using the Nationwide Health Information Network (NHIN) created by the Department of Health and Human Services.
The pilot program slated to begin mid-December 2009, will connect Kaiser Permanente HealthConnect and the VA's electronic health record system, VistA, two of the largest EHR systems in the country.
Officials said starting this week, VA and Kaiser Permanente will send a joint letter to Veterans in the San Diego area who receive care from both institutions, to invite Veterans to participate in the pilot program. Veterans, who respond and ask to participate, will enable their public and private sector healthcare providers and doctors to share specific health information electronically.
"The ability to share critical health information is essential to interoperability," said Secretary of Veterans Affairs, Eric K. Shinseki. "Utilizing the NHIN's standards and network will allow organizations like VA and the Department of Defense to partner with private sector health care providers to promote better, faster and safer care for Veterans."
Officials said VA, DoD, and HHS have been working closely to create a system that will modernize the way healthcare is delivered and benefits are administered. DoD will be included in the next phase of the pilot program in early 2010.
"This partnership demonstrates the power of a large-scale EHR that safely connects several care systems. Securely digitizing American's healthcare information is only the first step in realizing the cost saving and improved quality benefits possible with healthcare technology," said Andrew M. Wiesenthal, MD, associate executive director of The Permanente Federation. "The reality is that most people receive care from multiple providers. Without the ability for caregivers and patients to have access to their data, all of the time, there is the possibility for wasted time and resources duplicating tests and procedures. Exchange of current health record data at the point of treatment also improves quality, allowing medical decisions to be made quickly, with the relevant background."
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munnecke say: This is a brittle, unsustainable, overly complex approach
November 25, 2009 | 12:01 PM GMT
This is an issue I have been working on for 30 years. As a VA employee, I was one of the initial designers of the VA's VistA system, then as a VP and chief scientist at SAIC, one of the designers of the DoD's CHCS system. In the 1990's, I worked on a (rejected) proposal to install a variation of the VistA system at Kaiser.
The basic problem with this approach is that it attempts to integrate around the enterprise, not the patient. Each organization places themselves at the center of the information system, and places other organizations at the periphery. N organizations require N-squared integration efforts and agreements.
Imagine that Kaiser had an intercom system connecting all of their vital offices. Each critical office had fixed button position, so that you could instantly talk to the desired office. Now, imagine that VA had the same, and the two announced an effort to "integrate" their two systems. Even if they succeeded in figuring out how to do this, it would be a complex, brittle, non-scalable solution. And if they wanted to integrate with Scripps Health, for example, the complexity would start over again, only more complex as there would be a three-way negotiation involved.
Trying to "integrate" VA and Kaiser information in this way is like trying to integrate their intercoms. What about DoD information from Balboa Naval Hospital? Do we initiate a DOD-VA-Kaiser sharing agreement? (DoD and VA have been at this for 30 years now, and are still bickering about it. I've demonstrated three different VA-DoD interfaces; all of which have been shot down for political, not technical reasons). So now we are layering the political complexity of "integrating" two federal agencies and a large private organization. What about "integrating" Scripps Health? Do we start the whole process again?
And why are we doing this on a regional basis? Even if the two-way integration effort in San Diego works, what happens if the patient moves to Long Beach? What happens to folks in smaller organizations, or who are uninsured and unemployed? Do they simply not have a medical record?
To complicate this already complicated situation, we are asking all of Kaiser to trust all of VA with the information exchanged. As each new tendril in the tangled web of enterprises is added, all have to trust everyone else. And the security of the overall system is only as good as the weakest participant. One bad apple in the system can spoil the entire system; creating an ever-larger barrel through enterprise integration creates an ever-greater incentive for the bad apples to appear.
Then we have to look the evolution of the system over time. This effort is essentially a "stop the world, I want to integrate it" approach. If one enterprise moves in an innovative direction, the others will not be able to participate until they all move in lockstep in the new direction. If advances in genomics or proteomics take place, for example, how will this be communicated. And what if this innovation happens outside of the enterprises who have lock-stepped integrated their complexity?
This represents a brittle, complex, unsustainable model of integration that is a good way to channel billions of dollars of federal funding to vendors and the management teams dedicated to dealing with this.
As a taxpayer and someone who has played a lead role in this process for 30 years, I have to say that it appears to me that we are trying to get out of a hole by digging it deeper.
The way out of this complexity trap is to reframe health information around the individual patient. The patient is at the center, and providers are at the periphery. If someone wants to access that information, it happens according to the policies defined by the access "shell" around the information - and this is appropriately visible.
Health care enterprises (whose half-life is probably one third that of the patients they serve) would integrate with these personal health records. If they want to add their own enterprise approach on top of this, fine. But we shouldn't be paying federal monies to support the internal IT of health care providers any more that tax payers should be paying to support IT within airline companies.
Another way out of the situation is to frame health care IT as a "space" rather than an "integrated system." The web, for example, was designed as a "space for information to exist" rather than an integrated system for Google to search. This invites a different model of patient-centric activities and peer-to-peer linkages, rather than enterprise-centric, hierarchical and regional activities.
The situation we are in is a little like asking Ma Bell to invent the Internet. They had a perfectly good system (in their perspective) of circuit-switched phones and a great billing system to track long-distance calls by the minute. Why invent all of this dynamic routing, packet switching, and make users support their own routers when Ma Bell could do it centrally? Just give everyone a modem, and let them dial in and pay the monthly charges.
The health care industry is acting like the Ma Bell. "We are the smart center, and you are the dumb edges of the network" Inverting this model to a "smart edges" approach to health information technology is a very necessary approach. But I'm afraid we're not going to get there as long as we pour money and efforts into systems such as this.
Tom Munnecke
Encinitas, Ca
http://munnecke.com
(papers on patient centered records: http://munnecke.com/blog/?page_id=248 )
spdavis say: Inclusion of a health infomediary
Any advanced healthcare delivery system must take advantage of IT--a secure EHR health record and integrated providers, to deliver quality information-based care. This assumption invites another approach to the delivery of care and the inclusion of a health infomediary.
According to Munnecke (2009), "Another way out of the situation is to frame health care IT as a "space" rather than an "integrated system." The web, for example, was designed as a "space for information to exist" rather than an integrated system for Google to search. This invites a different model of patient-centric activities and peer-to-peer linkages, rather than enterprise-centric, hierarchical and regional activities".
Patients and caregivers must have access to their healthcare information (patient-centric activity) in this delivery model. However, having access to such information does not ensure effective decision-making by patients and their caregivers. An advanced delivery system that includes health infomediaries (persons/care coordinators) who can "help patients identify the information required to make sound choices, interpret medical information, choose between care alternatives and channels, and interact with providers they choose" (Healthcare 2015, 2006) is vital to the healthcare delivery system. Such a link (health infomediary) promotes coordination of quality care, provides seamless access to care and services in a cost-effective manner and greatly reduces healthcare cost and spending.