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The Feds’ strange love-hate relationship with health IT policy

With less than loud fanfare — barely a peep, really — the Office of the National Coordinator for Health IT (ONC) finally last week released its ONC-Coordinated Federal Health Information Technology Strategic Plan.

The plan is more than two years overdue and came only after scolding from a Government Accountability Office report in 2006 and an internal, semi-secret review of ONC’s doings by the Institute of Medicine late in 2007. The IOM criticized ONC for the lack of a viable strategic road map almost four years after President Bush’s call for interoperable health information technology and personal health records. A lot has happened since 2004 in this area, though you’d hardly know it reading the ONC Plan.

ONC is a top-down, heavily bureaucratic,
large-medical-enterprise-centric, and large-IT-vendor-led juggernaut
that has always been out of touch with what goes on down on the ground
where consumers, patients, nurses, and primary care doctors live and
work.

By out-of-touch, I mean completely oblivious to the impact that the
Internet and the Web have made in virtually every other
information intensive industry, profession, and realm of social
interaction outside of the stilted world of health care. Out-of-touch
as in asking military defense contractors to bid on a separate and
wildly expensive National Health Information Network in order to make
it possible for "interoperable" exchange of health information between
Harvard and Stanford, and similar large institutions; a plan that
caused former Intel chairman Craig Barrett to comment drily, "We
already have a NHIN; it’s called the Internet."

But there is something eerily obsolete
and downright weird about a strategic plan offered up by ONC in the
dying days of the current administration that proposes sometime in the
next four years to "achieve an interoperable health IT architecture for
the nation in support of patient-focused health care and population
health." While at the same time, the report ignores — and I mean completely
ignores — the progress being made in the private sector to enable
personal health information to travel safely and securely on the Internet using the same IT and communications
networks that most information for commerce, and an increasing
amount of health data, already employs.

What time zone have these folks been lost in?

It’s as though the last four years never occurred. It’s as though
these people and institutions never heard about medical search, health
social networking, wikipedia, Google Health, Microsoft HealthVault, or
the Continuity of Care Record standard. To read the ONC Strategic
Plan
you would never know of the existence of HealthGrades and the
other quality and transparency reporting sites on the Internet; the
SureScripts network that was used for 100 million ePrescriptions
last year,; the hundreds of  thousands of lab results delivered to
medical practices over the Internet using Web applications every day;
or the thousands of medical practices that have deployed Web-based
technology for billing and claims administration, Web portals for
communications with their patients, and clinical systems for helping
with care management. 

The biggest misstep (other than the RHIO fiasco) that occurred at
ONC’s inception was the emphasis on developing new standards, based on
the erroneous assumption that a lack of health data and IT standards is
the root cause of the unwillingness of doctors, medical practices, and
hospitals to adopt health information technology, or the failure to
adopt at a rate fast enough to satisfy Drs. Brailer, Kolodner, and the
most expensive IT vendors (see Extormity and Seedie for
a refreshingly satirical commentary on why EMRs aren’t jumping off the
shelves in the US of A.)  As Adam Bosworth has said on several
occasions, the standards for data exchange always work themselves out
when the incentives within an industry or economic sector reward
efficiency through market forces. Absent those incentives and market
forces, standards are all anticipatory and largely useless — or worse.

The second biggest misstep taken by ONC has been to entirely remove
the consumer from the equation, and to ignore the force of the analogy
that is powering consumer/patient impatience, even anger, at the
calcified hairball our health care industry has become. That is the
analogy with consumer experiences of convenience, affordability, and
service excellence from companies across a wide spectrum of industries
that have effectively integrated the Internet and the Web into their
DNA, from FedEx to NetFlix, from Southwest Airlines to L.L. Bean, and from CNN to iTunes. Education, commerce,
banking, the financial services, and personal communications are all
online.

Too much of health care is still offline, and
nothing in ONC’s obsolete strategic plans reflects this reality or
recognizes the progress that is being made despite ONC’s befuddled time
warp.

Will somebody, please, push the "reset" button on health IT policy inside the Beltway?

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hockeyrefDavid C. Kibbe, MD MBAJeff O'Connorjdtcoyote Recent comment authors
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hockeyref
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hockeyref

Guys, First off, most excellent comments there. It is nice to see other folks outside the small area of strapped PCP’s actually getting most of it. Yes the enterprise based software vendors that want to secure their place at the trough thru cutting out their competition is all too real. What amazes so many of us on my side of the fence is how so many of the medical organizations that are supposed to be objective and analytical thinkers are just getting in line behind all the CCHIT (it’s out joking way of gettingn around censors for $h!t and we… Read more »

David C. Kibbe, MD MBA
Guest

Dear Jeff and others: Thank you for your feedback. I think the best way to “address ONC’s problems” is to let it sunset with the Bush administration, and start over with the Obama or McCain administration, creating an Office of Networked Personal Health Information. But I think you’re right on the money in your comment that avoidance of broad Web consciousness is a problem larger than health care, and it really does cut across many agencies and bureaus that have an interest in consumer empowerment.

Jeff O'Connor
Guest

David, Although not healthcare-specific, the government’s blind spot viz-a-viz the Internet and the Web has made it into the mainstream technical consciousness and is resulting not only in totally valid criticism, but an action plan to deal with the problem. Ars Technica ran a post about a Princeton study that drew similar conclusions to your own about government Web sites in general, and recommended that they should prioritize adoption of Web-standards compliant content before they worry about changing their architecture or trying to implement Web2.0-ish functionality. The upshot was that individual Web developers would then “mash-up” these data sources faster… Read more »

jd
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jd

Really, really good criticisms. Thanks, David.

tcoyote
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tcoyote

It’s all about “enterprise” software, isn’t it?