Commentary: How will national health programs fare in an electronic world
There is a dizzying array of national health programs in the United States. They range from the Affordable Care Act (a.k.a. Obamacare) with its health insurance exchanges and accountable care organizations, to Medicaid and Medicare, disease surveillance, health monitoring, networks of health centers and labs, all the way to drug monitoring, regulation and more. All of these programs have been, or are now, becoming electronic, just as health records are. Indeed, many of these programs will play major roles in either incenting or conflicting with efforts to advance the electronic healthcare infrastructure. And as with other industries, becoming electronic changes the way these programs can and should be carried out themselves. With the advent of cloud and other approaches, these changes can have a large impact on the most effective and efficient use of large amounts of taxpayers’ dollars as well as the achievable outcomes.
[See also: Transaction technology critical to MU Stage 2.]
Funding the stovepipes
Health programs frequently start with a perceived need. Eventually, sometimes with the support of advocacy groups, the need achieves a degree of congressional funding. Congressional funding, tied to the goals of that program, flows through one of several health-related federal agencies and operational divisions. As an example, although there are fewer now, the Centers for Disease Control and Prevention once had more than 120 different congressional funding lines. For the CDC, the funding lines were mostly organized around individual diseases or conditions. Most federal agencies are themselves organized around such funding lines. They develop staffs that are oriented to achieving those specific missions. Not only does the amount of funding limit the number of staff, there is a rough expectation that the program will be sized as a branch, division, center or more, depending on the amount of funding there is.
The federal employees are required to use the funds to achieve congressional intent. Their career advancement and even their passions (many of these programs have truly inspirational individual missions) are tied to those specific objectives as well. Needless to say, the strong alignment in these program “stovepipes” can be both powerful and difficult to overcome when necessary. While others may increasingly reuse infrastructure, code and services, these dynamics have made it very hard for federal health programs to do so. Much of the technology needs seem similar, but program differences tend to be emphasized because of the funding and other dynamics.
[See also: Commentary: What about interoperability?]
Some federal programs carry out direct activities with funds, but many also pass these funds onto state and local jurisdictions to move closer to direct execution.
Many times more
There is more variation at the next level, but frequently “50 states” or “56 states and several large metropolitan city-states” are the next stop on the health programs’ progression. Not surprisingly, each of these jurisdictions is frequently organized to match the federal programs that fund them. Funding cross-cutting infrastructure, like IT frequently can be, is also difficult here because the funding lines don’t encourage, and frequently have precluded, even the perception that funds are being used for something different than the intent of the grant or other funding vehicle that transfers the congressional intent onto the state. Data sharing can also be a particular problem between jurisdictions and with the federal government.