Why and How Secretary Sebelius Should Avoid a Network Monopoly

Adrian GropperObama is smart. His signing of the Health Information Technology for Economic and Clinical Health

(HITECH) Act (as part of the Stimulus package) recognizes the
importance of health IT as the foundation for health care reform and
cost savings. Good data and good consumer experience is a way to drive
a policy consensus when payment reform and health reform come to a vote
on Capitol Hill.

Technology certification and meaningful health
records exchange are the cornerstones of the HITECH Act. Health IT
should be engineered to promote transparency in health care
effectiveness and to reduce regional differences. To achieve this, the
secretary of HHS must ensure that scope of the Certification Commission for Health Information Technology (CCHIT) does not extend beyond hospital health records.

must stimulate reform through systems and services innovation. As with
previous federal actions, such as the the break-up of the AT&T
monopoly, HHS can enable future generations of innovation by excluding
health information exchange and patient-controlled health records from
the domain of CCHIT, big hospital and big vendor interests.

Continuity of Care Record (CCR) formats and Web protocols of Google
Health, Microsoft HealthVault and MedCommons are innovations in
patient-centered, vendor-neutral collaboration. They must be certified
by HHS because they enable low cost software and encourage effective
competition by new and focused healthcare venues that help
Internet-connected consumers to get the best advice and the most
effective care.

The CCHIT commission has tied its fate to a
tormented system that many business experts decry as a total failure of
competition. To the benefit of mega hospital networks and their mega
software vendors, CCHIT raises costs and bars market entry by
innovative services and the software they need. Where would the
Internet be today if AT&T and a few major companies had been
allowed to control both who can connect and what goes on the wire?

has codified the business strategy of the large established software
vendors – the ones who can afford the "volunteer" labor that came up
with our so-called harmonized standards. The vendor strategy is mainly
to lock-in the doctor by hosting both the clinical data store and the clinical application
needed to use the data. The analogy to old Ma Bell is uncanny– and a
harbinger of bad things that could come. As long as the established EHR
vendors are granted a monopoly on all standards, innovation by both
doctors and patient users of "certified" health records will be
effectively blocked.

CCHIT also has a direct impact on
innovation through the high costs for certification. Open source
business models depend on volunteers to write and support software
applications. An open source community cannot raise the $50 – 100,000 /
year to achieve and maintain certification.

Aside from seeking a
monopoly on all standards, CCHIT has also seen as its mission to grant
a monopoly to only one standard even when the public and commercial
adoption would argue for at least two alternatives. Even in the face of
requests from its own board members, CCHIT has refused to endorse the
the physician-led CCR clinical summary document standard as an
alternative to the vendor-promoted CCD document standard.

I urge
HHS Secretary Sebelius and Head of the White House Office of Health
Reform Nancy-Ann DeParle to support a strategy that will build
consensus and public approval through increased transparency and
citizen participation. CCHIT's scope must be confined to the hospitals
and their "integrated" delivery network vision. Alternate,
de-centralized solutions to health information exchange must be given a
fair chance.

The ASTM-CCR standard
must be allowed as a format for meaningful health information exchange.
To date, all commercial initiative on the Web has gone to CCR and its
continued growth should not be discouraged.

To help solve
daunting privacy problems, lightweight patient-controlled health
information exchange must be allowed as a certifiable alternative.
These Web-standard systems use widely accessible REST, OAuth and OpenID
protocols instead of the expensive and byzantine protocols favored by

Physician concern over the the quality and authenticity
of patient controlled clincal information can be addressed through
current technology. As an alternative to the CCHIT choice, the ASTM-CCR
allows each order, immunization, report and prescription in the summary
document to carry the digital signature of its original author. This
key CCR innovation enables competition with the integrated delivery
model by new, independent and focused venues for care.

health records policy has great leverage over health reform because it
is a non-partisan and low cost intervention that will greatly influence
more critical and expensive choices in the coming years.  A policy that
keeps EHR certification separate from health info exchange
certification will avoid a monopoly and yield dividends for generations
to come.

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13 replies »

  1. We have been begging the Obama administration & our new head of HHS
    Secretary Sebelius to invite us to the discussion table to lower health care costs. We are still waiting to be contacted. We know you are busy but come on, what will it take to get someone with real world, everyday experience taking care of thousands of the sickest, oldest, and most costly patients to the table?
    Dr Anderson geriatric specialist is well known for her physician
    home care program over the past 10 years seeing real patients that reduces costs by 75% and increases quality of care.
    See more at:
    and program video at:
    dr anderson & associates

  2. Recent security breaches at MasterCard and Visa make me wonder how secure any system can be. An IT pro I know agreed with my statement that there isn’t a system built that can’t be hacked. The conflicts of interest between providers of record storage who also want to provide physicians with financial management are obvious. I’m not in the field, but the comments I have read here are depressing; once again the small businesses are being left out. I’ve HAD IT with corporatocracy!
    Re: Ma Bell—at the time, we had a really well-functioning national telephone system. I thought that nationalization, not breaking up into Baby Bells, was the answer—and years later New Jersey’s Bell Atlantic combined with the next northern Baby Bell (forget it’s name) to become Verizon, a gorilla in the business if there ever was one, but defined as a private corporation, and not regulated as a utilty. The concept of a health-care-record system being considered an old-fashioned, nonprofit public utility works for me. (Remember the days when all BC/BS cos. were nonprofit? Greed has certainly broken our health-care system.)

  3. I’m really not certain that anything will help. I see the health care reform as bad timing and more debt to the United States – not to mention my job will probably be eliminated thanks to Obama in 2010.

  4. The innovation in USA has been killed by big corporations….and the quality of EMR/EHR are an example. The product today is expensive, wieldy and in most cares people have lost money.
    But then they have the money to get contract from the govt. On this forum, I have said and I have written upon time that $20 billion is too much for IT. It should be around 1 billion. I am confident that I and many like us can deliver. I also have mentioned that IT is not going to solve the healthcare crisis. The current healhcare problems have alot to do with process, values, competence, etc…IT will help but it is just a tool.
    I am dispappointed that the focus on IT might take away the real focus on important things. Few years down the road we will have rude awakeing on what we messed up again

  5. More reason to hope. To those of us looking for guidance on what “meaningful” health information exchange and outcomes reporting might look like, Health and Human Services (HHS) put out for comment a rather progressive document titled “Common Data Transport Draft AHIC Extension/Gap”. http://www.hhs.gov/healthit/usecases/commondata.html For example, personally controlled health records and support of the medical home are given great importance when it comes to the network.
    From the introduction:
    “To date, the national health agenda, including the activities of AHIC and HITSP, has not formally addressed all of the interoperability considerations for secure data transport between organizations.”

  6. Other than hospital systems and patient-controlled health records, there is a third category of systems that CCHIT is currently controlling – the ambulatory systems used in private practices by individual physicians. The financial end game here is similar to the hospital systems and I don’t believe CCHIT should be allowed to regulate that market either.
    The article refers to communication standards, but CCHIT regulates much more than that. It regulates every little functionality from patient previous name management to useless comment additions to diagnostic orders.
    For example, CCHIT requires that diagnoses are printed on prescriptions. Can you imagine how many calls a clinic gets and what their nature is when this “functionality” gets enabled in an EMR?
    Functionality should be regulated by users. Sure, there are some basic things that need to be there for the software to be able to call itself “EMR”, and the HITECH act does mention those basics, but is there really a need for over 500 required functions in just the plain vanilla EMR “certification”, not including interoperability???
    If the HHS wants to certify something, then by all means, please certify standards of communication and interoperability and make them open, like XML. The vendors will comply or die. Let physicians have the freedom to choose what functionality they want and, more important, what functionality they don’t want.

  7. I applaud your well-articulated position, and agree wholeheartedly that CCHIT has become an organization that protects the interests of those “in the club”, while putting up barriers to innovation. As a Chief Medical Officer of an emerging web-based EHR company, I understand the challenges posed by trying to achieve CCHIT certification: (1) it is very expensive to apply for certification ($30,000+), and (2) building a product to their specifications is something that consumes many a start-up’s resources (“studying to the test”), and distracts away from developing truly innovative functionality, interoperability and security that are not part of the CCHIT standard.
    One of the biggest gripes I have with CCHIT is the failure to consider Usability as a criterion. Usability can be defined as “accuracy, efficiency and satisfaction with performing a set of work-tasks commonly done in a medical practice.” As a result of not considering Usability, a number of large, expensive, cumbersome, hospital-centered systems have been “certified” which have truly awful user experiences, and may even result in causing harm. My belief is that the criteria set should be Usability / Interoperability / Security – with, as you mention, security being something apropos a web-based system, not a pre-internet client/server system. Of course, physicians using an EHR should look at Usability, Interoperability and Affordability as their criteria.
    Again, thank you for adding your voice to a number of others about this issue.
    Robert Rowley, MD
    Chief Medical Officer
    Practice Fusion, Inc.

  8. Can you provide me with robust proof of the statement “importance of health IT as the foundation for health care reform and cost savings” (Not to mention, improved outcomes and safety)? This seems more a statement of faith than a scientific one.
    I don’t mean theoretical predictions or shallow observational studies, either.
    Where is the solid evidence?
    For example, in this week’s JAMA we find this article:
    “IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans’ Medical Centers”, Journal of the American Medical Association 2009;301(9):919-920
    My comments on that article are here:

  9. I agree with Dr.Gropper. But I disagree that HIT is as mature a technology as is currently touted.
    I use a system,for example,- the largest in the world- that is an abyssmal multi-billion dollar failure.
    Dr. Ross Koppel from the University of Pennsylvania writes eloquently (see JAMA and other Koppel publications) about the downsides of overconfidence and/or poor implementation of HIT
    Good Luck to all of us.
    Dr. Rick Lippin

  10. Thanks for writing this article, this new legislation came up pretty quickly and actually has some pretty significant changes for organizations. The most suprising one to me was that companies now have 60 days to notify at most if there is a breach, that is not much time.
    Anyways, there is a complimentary webinar that has industry experts reviewing the details of the new stimulus bill and the new California law as it relates to data breaches and privacy. To register go to https://www2.gotomeeting.com/register/361943582.