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In the Public Interest

John Moore  The Health Information Exchange (HIE) market is the Wild West right now.  Vendors are telling us that theyre seeing an unprecedented level of activity both for private and public HIEs.  Private HIEs are being set-up by large and small healthcare organizations to more tightly align affiliated physicians to a hospital or IDN to drive referrals and longer term, better manage transitions in care in anticipation of payment reform.  Public HIEs are those state driven initiatives that have blossomed with the $560M+ of federal funding via the HITECH Act.

But this mad rush is creating some problems.

While the private HIEs seem to have their act together in putting together their Request for Proposals (RFPs), such is not the case for the state-driven initiatives.  Rather then formulating a long-term strategy for the HIE by performing a needs assessment for their state, setting priorities and laying out a phased, multi-year strategy to get there, far too many states are trying to “boil the ocean” with RFPs that list every imaginable capability that will all magically go live within a couple of years of contract reward.  Now it is hard to say who is at fault for these RFPs, is it the state or the consultants they have contracted with that formulated these lofty, unreachable goals, but this is a very real problem and unfortunately, the feds are providing extremely little guidance to the states on best practices.

While the above is more of a short-term concern, longer-term we may have a bigger problem on our hands.  The proliferation of private HIEs, coupled with state-driven initiatives with very little in the way of standards for data governance, sharing and use (this includes consent both within a state and across state lines) has the very real potential to create a ungodly, virtually intractable mess that will be impossible to manage.

So maybe it is time to rethink what we are doing before we get to far down this road.

What if we were to say, as a country, that much like Eisenhower did during his presidency to establish the Interstate Highway system, we made the decision that it is the public interest to lay down the network for an “interstate” system for the secure electronic transport of health information?  And rather than be cheap about it as we have done in the past dedicating only modest funding (e.g., NHIN CONNECT), let’s really make the investment necessary to make this work.

Yes, it won’t be cheap, but think of the alternative – 50 states, countless regions all with their own HIE.  Yes, states are required under HITECH to work collaboratively with neighboring states, but this will not lead to enough consistency to create a truly networked nation for the delivery of quality healthcare for all US citizens.

It is indeed time to take a stand for much like Eisenhower’s Interstate system, which I had the pleasure to enjoy as I traveled cross-country this week from Boston to my beloved mountains of Colorado, such an interstate system for the delivery of health information at the point of care will be something all citizens will benefit from. And taking a cue from the image above, rather than a “Symbol of Freedom” it would become a Symbol of Health.

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ciphertextdavidjames walkerMerle BushkinMD as HELL Recent comment authors
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ciphertext

In other words, even with robust interoperability standards, the real threat to the appropriate and open flow of patient data to those who should have it / need it lies less with the technology than with the politics. — james walker Well said!As I’ve come to understand in my adult life and via my profession, you do not trust the politicians and bureaucrats. The federal government is less trustworthy than the state government. The state government is less trustworthy than the county (or parish if you are in Louisianna). The county/parish is less trustworthy than the city/town/village. The reason being… Read more »

david
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david

John its not about the public interest-its about money. Doctors could provide better care if they spent more time with each person-but then they wouldnt make as much money. So as the health care industry could have created health it in 1994 they now see a profit in health it.
Public good isnt the prime mover in the health care industry as 70% of the public want the health care system overhauled

james walker
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Good brief post expressing a pithy dichotomy of extremes on a spectrum – top-down vs. decentralized HIE architecture. I agree with the gist of the post, that we need quick interoperability somehow; and I agree with Merle above about our ultimate goal so well-said: “Our objective is to make a patient’s complete medical record available to any care provider who treats the patient!” The devil, however, lies in the details. Unlike the internet, which is based on a common protocol for transferring text and images from point A to point B in an agnostic fashion, legitimate privacy / security concerns… Read more »

Merle Bushkin
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John, I must differ with you. I have no problem with each community and/or state having its own HIE. I do have a problem, however, dictating that all HIEs must adopt a standard, mandated system. This folly implicitly assumes that all HIEs must be linked together for care providers to be able to access a patient’s complete record and coordinate the patient’s care. We neither need nor can we afford such a massive top-down system. To continue your analogy, John, what you are proposing is that everyone drive the same, standard vehicle on President Eisenhower’s Interstate Highways. Don’t get me… Read more »

Tom Leith
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Tom Leith

> The “public interest” in individual care is
> to spend as little as possible on the individual.
What definition of “public interest” leads to that? What constraint is there on “possible”?
This entire comment is BS.
t

MD as HELL
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MD as HELL

The “public interest” in individual care is to spend as little as possible on the individual. This entire concept is BS.

Tom Leith
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Tom Leith

Yes, BobbyG, there will be lots of duplicative effort. You correctly point out in your blog post that the difficulty getting to “Meaningful Use” is not technical, but rather political. The duplicative effort bypasses non-local politics, and that has value. “Meaningful Use” even in the 2015 understanding of the term doesn’t really require integration beyond regions so long as professional medical leadership is there. Which is another political problem…
t

BobbyG
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Interesting. Nice post.
I noted the following on one of my blog posts a while back:
“I continue to be concerned with the sometimes contentious, duplicative attributes of much of this HIE thinking and effort (i.e., primarily the potentially heterogeneous “regional” aspect).”
http://bgladd.blogspot.com/2010/03/irrespective-of-national-health-care.html

Tom Leith
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Tom Leith

> within a couple of years of contract reward. Freudian slip? 😉 Tip O’Neill told us “All politics is local”. So is healthcare local. The regional HIE is primarily about healthcare. Not that it isn’t worth doing, but a non-local (i.e. national) HIE is about something else. Which leads me to this: Dijkstra’s Prescription for Programming Inertia: http://en.wikipedia.org/wiki/Edsger_W._Dijkstra If you don’t know what your program is supposed to do, you’d better not start writing it. Stanford Computer Science Colloquium, April 18, 1975, headlined and famously quoted in “The Official Rules: The Definitive, Annotated Collection of Laws, Principles, and Instructions for… Read more »

Bill Jones, MD
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Bill Jones, MD

I could not agree more: “Now it is hard to say who is at fault for these RFPs, is it the state or the consultants they have contracted with that formulated these lofty, unreachable goals, but this is a very real problem and unfortunately, the feds are providing extremely little guidance to the states on best practices.”
In other words, well meaning well paid eggheads are in charge of patients’ lives.
This is a takeover of medical care which will worsen all outcomes and increase costs. Report your complaints when patients are injured to FDA’s MedWatch.