Dear NPR: There IS a treatment for that diagnosis: electronic health records and immunizations

NPR’s All Things Considered yesterday described “growing pains” in health information technology (HIT) by saying many doctors in Colorado had to enter immunization records twice: first into their Electronic Health Record (EHR) system, and then into the state’s immunization registry.   According to the story, many doctors fail to do both

In fact, immunization registries, the Centers for Disease Control and Prevention, the HHS Office of the National Coordinator for HIT, and the Centers for Medicare and Medicaid Services (CMS) have worked together to implement solutions for this problem.*  The federal EHR Incentive Program (better known as “Meaningful Use”) includes an objective for EHR systems to upload shot records into immunization registries, eliminating the “double entry” problem.  The Colorado registry has implemented the necessary standards, and instructions for doing so are published on the same website cited in the NPR story.

This process is still not simple.  But the needed standardization is further improved in Stage 2 of Meaningful Use, scheduled to begin in October 2013.  And in October 2015 federally-certified EHRs could be required to download immunization records and alerts for clinicians about which vaccines a patient lacks.   Such automated data and reminders are needed to accelerate the completeness of childhood immunization which remains subpar.

I appreciate NPR’s attention to this challenging issue.  But while various difficulties affect the transition to electronic health records, NPR inadvertently selected a success story to illustrate the problems.

*Full disclosure: I was among those involved in this collaboration.

 

The “X-Factor” for Health Information Exchange: Is competition toxic?

Early in the Wisconsin Health Information Exchange (WHIE) we realized a high likelihood of finding information for a local provider or patient was key to a successful business case.  (Techies call this “network dependency.”)  So I wasn’t surprised November 28 to hear market share penetration labeled the single item that best distinguishes sustainable from struggling HIEs by the HIE Learning Network of the National eHealth Collaborative (NeHC).  What is surprising is that HIE policy often disregards this vital factor.

At Technology Crossroads, Jeffrey Rose (ICG Group) and Delaware Health Information Network (DHIN) CFO Michael Sims presented factors identified by the Learning Network that distinguish profitable from unprofitable HIEs.  (Other factors in addition to high market share penetration are aggressive pricing and investment in product development.)  DHIN is verging on both 95% market penetration and long-term black-ink performance.  (For more on this and other Learning Network lessons, join the December 17 NeHC University webcast.)*  [Update: Dec 18: the Learning Network report has been published.]

Meanwhile, many HIEs around the country are struggling.  The eHealth Initiative’s 2012 HIE survey lists sustainability as the top obstacle, and found that over half are encountering competition from other HIEs.  They are also competing with HIT vendors providing exchange technologies directly to provider networks.

For example, the November 21 IHealthBeat reprinted a story from the Oct. 18 Tampa Tribune detailing how a public HIE serving hospitals is competing with a private HIE serving physicians.  Meanwhile, in several states, new HIE entities created by the Office of the National Coordinator (ONC) State HIE grant program compete with pre-existing regional efforts.  (Most early regional HIEs focused on medical marketplaces defined by referral patterns, not state lines.)  Adding to the confusion are statements from ONC leaders that put exchanges developed inside Accountable Care Organizations (ACOs) on the same footing as regional “all-provider” HIEs.  This fails to acknowledge that such private entities may aggressively compete, including taking information hostage.  A recent New York Times story details how increasing provider consolidation (neither citing ACOs nor excluding them) can block clinical communication with competing providers.

Perhaps, at least initially, competition is toxic for successful health information exchange.  In a 2007 eHealth Initiative report on HIE sustainability, we described social capital (resilient relationships among HIE stakeholders) as a key element for success.

An alternate scenario is that each electronic health record system will contain its own exchange capabilities (like the Direct “push” standard).  But this model still works best with a “central switchboard” managing directories, authentication, record locators, and other services that an HIE can provide.

It seems that HIE resembles mail service, electrification, telephony, highways and fire services, possibly requiring a period as publicly-regulated, public service monopolies.  Once the infrastructure is well established, competition can be introduced to accelerate innovation and price competition.   Today, however, regional HIEs are competing with Federally-funded state HIE designated entities, which are competing with for-profits and ACOs.  Meanwhile, market share is elusive, and network dependency can kill.

*Disclosure: I am currently on the NeHC University Advisory Board and a former NeHC board member.