Connected Health: Blumenthal provides path for nationwide health info network

BOSTON—Creating a nationwide health information network dwarfs just about all other human achievement, said David Blumenthal, MD, MPP, former national coordinator of health IT and incoming president of the Commonwealth Fund. He spoke at the ninth annual Connected Health Symposium on Oct. 25.

A national health information network is needed to support an effective healthcare system, he said, but “providing information is clearly a critical challenge.”

One step in reaching the goal is recognizing the nature of the challenge—a challenge which is huge and it’s a sociotechnical project with enormous political, economic and social aspects, he said. “No one has done this before in the history of human affairs.” Blumenthal said that the creation of a national health information network even dwarfs previous major achievements such as sending man to the moon and mapping the human genome.

We’re making progress, he said, as demonstrated by the adoption rate of EHRs which has doubled in the past three years. The interoperability and exchange components remain the most resistant and challenging, he said.

Technical requirements of a nationwide network include standards that work and are incorporated into electronic records. The Office of the National Coordinator for Health IT (ONC) is making progress, he said, calling the latest standards issued in August “a major step forward.” But more regulations are required. “We need more iterations before we reach the point where we have standards in good enough shape and implementation specifications so that interoperability becomes a real and relatively easy thing to accomplish.”

Continuation of the Meaningful Use framework is important as well, said Blumenthal. “Meaningful Use is the number one force driving the incorporation of standards into electronic health information systems. It creates incentives and a mechanism for enforcing the incentive to put standards into EHRs and get providers to use those systems to exchange information.” The latest Meaningful Use standards took an enormous step forward in making transitions of care work electronically, he said, but that will not continue unless the incentive program stays in place.

Another issue impacting the creation of a nationwide health information network is the need for a more nimble and responsible, user-friendly approach to privacy and security. “We need better understanding of the mechanisms of moving information from one place to another. In an ideal world, that would all happen with the flick of a switch directly from one provider to another. What kinds of organizations need to play that role? How should they be governed?”

A national network also requires a governance process, Blumenthal said. Who owns a functioning system of health information exchange, he posed, along with several other questions, such as who is responsible when it breaks down; once we’re dependent on the system, who answers the phone when the system goes down; what happens if there is abuse of access; what if the process fails; and who owns this vital national resource. “We need to address these questions collectively. When the ONC tried to address these questions, there was enormous pushback about overregulation. We need to deal with this as a collaborative national activity. In the meantime, intermediaries are arising and the process is developing in a decentralized, unregulated way.”

Despite the technical challenges, “there is no such thing as a completely technical aspect to this problem,” Blumenthal said. For example, health information exchange is a team sport. “You can be Tom Brady, but if there are no receivers down the field you’re not going to run up the score. Any single organization or practitioner can be capable of exchange but if no one in community wants to participate the effort is wasted.” Creating teams is an enduring problem in our fragmented, competitive, decentralized healthcare system.  

Providers must start locally, he said. “Start where there’s a need and likely to be demand. Make it easy.” There are enormous disincentives that need to be turned around.

Early accountable care organizations (ACOs) still have their foot in the fee-for-service world, he said. “They see an ACO as a way of capturing patients. They pull up the drawbridge and keep their information and think they can control patients. That’s not a practical way to manage patients because if any patients are getting care outside of the ACO you’re accountable for those costs. You desperately need to know about those costs. ACOS need exchange of information and that will be a source of demand for local exchange.”

Another potential way to make this easier is to empower consumers with their own information, Blumenthal said. If the consumer is the steward of his or her own information, they can provide that information on demand to the providers of their choice. “Whether that will work is an open question.”

We need information for accountability, costs, quality, population health and to manage ACOs from outside to make sure they are forming as expected, he said. “Getting information into fluid, dynamic form is a huge sociotechnical project that dwarfs most such projects. The human element makes it so challenging. The laws of human behavior are less precise and predictable.”