Friday, July 06, 2012

Expectation Setting For Health Information Exchange - Including the NEHRS. Are We Hoping For Too Much?

The following very interesting perspective appeared a little while ago.
Friday, June 22, 2012

The Dangers of Too Much Ambition in Health Information Exchange

by Micky Tripathi
For those of us who've been toiling in the trenches of health information exchange for a number of years, we're finally living the dream. According to a 2011 KLAS report and a more recent Chilmark report, the HIE market is poised for spectacular growth over the next couple of years. Most of this growth will be driven more by "private" HIE efforts (enterprise efforts usually driven by a hospital system and/or physician organization) than by "public" ones (cross-organization regional or state collaborations usually seeded with government funds), but, regardless of what is driving it, the reality is that HIE is sprouting all around us.
I'm delighted that we're moving rapidly in this direction, but one concern keeps nagging away at the back of my mind, and that is the propensity to pursue over-architected HIE solutions.
This history goes back to the ill-fated community health information networks (CHINs) of the 1990s, continued through the highly-publicized failure of the Santa Barbara Care Data Exchange, the difficulties experienced by the Massachusetts eHealth Collaborative pilot projects and many of the regional health information organizations established by New York's HEAL-NY program. And it continues into the present-day with the demise within the last year of CareSpark (Tennessee) and the Minnesota Health Information Exchange, and the recent challenges experienced by Cal eConnect. Many of the HITECH-funded HIE programs carry this same risk.
What is an over-architected HIE? Put simply, it's one that tries to do too much for too many with not enough money and time. It tries to establish an all-encompassing infrastructure and service to meet multiple, heterogeneous current and future requirements of multiple, heterogeneous current and future customers. It tries to do all of this with a shoestring budget and staff. And worst of all, it focuses more on long-term potential "big-bang" value at the expense of short-term, realizable, incremental value. Or as one HIE organization's promotional material put it, the value proposition is to be a "one-stop shop for Clinical and Administrative Information."
The counter to the over-architected HIE is the incremental or phased HIE, which focuses specifically and radically on concrete, discrete, value-generating and self-standing steps and does not tie its fortunes to a specific future end-state whose horizon is further than the range of our ability to navigate. I was recently describing my concern to a health care system executive, and he said, "Yes, well, but we just want to jump to the end." By that he meant, build the final solution infrastructure and services right away to solve the big problem of creating a "one-stop shop," and assume that by-products of that long-term effort will keep everyone motivated along the way. My concern reached new heights after that conversation.
It's totally understandable how this happens and, interestingly, both "public" and "private" initiatives are led down this same path, albeit for different reasons. For many public HIE efforts, "waste" in health care spending feels like low-hanging fruit. Don Berwick says that 30% of health care spending is "waste", and the CEO of Geisinger recently stated that 40% of health care spending is "crap". 


Lots more here:
It seems to me that Health Information Exchange (which is what the NEHRS is some half-hearted attempt at) is a fundamental and invaluable tool in the provision of safe, properly co-ordinated patient care.
The warning that one can try to do too much too early I find very resonant to our present situation. Had the NEHRS program aimed low and simple while it started I suspect we would have seen a much better and probably even quicker attainment of the desired end point. This stuff is really a classic circumstance where we need to adopt the KISS principle and ‘hasten slowly’!
A very useful discussion in my view.


Anonymous said...

Online rego is back up.... but best not look now or it might go away again :-)

Anonymous said...

The NEHRS all seems to be up and working now -- I created my EHR and though it is empty, everything we were told would be there, seems to be there.

Now begins the wait to see how many GPs etc. will take it up. Anyone know when they will start to get software?

Anonymous said...

Have the regulations governing PCEHR use been passed yet? I will wait until anything I create is covered by regulation, and will only really get engaged when my doctor can look at my records. When is the clinician portal due?

Dr David More MB PhD FACHI said...

Well, I tried, but despite being able to register with, it seems I am not know to Medicare - despite having a card and having a stable address etc for 20+ years.

The number of consents covering pages you have to agree to is amazing and pretty disappointing to get kicked out at the last hurdle!


Keith said...

Anonymous said...
Anonymous 7/07/2012 07:29:00 AM said:
"Now begins the wait to see how many GPs etc. will take it up. Anyone know when they will start to get software?"

It's not just software: first, GPs have to sign a Participation Agreement. Negotiations have not been easy because DoHA started with an ambit set of draft (daft?) rules that NO GP would agree to. Doctor organizations were reputed to be close to agreement more than a week ago, but I've not seen any announcement. Then of course individual GPs have to accept the term of agreement and sign up.

But wait, there's more: Before they contribute to a PCEHR health providers need NASH-compliant credentials, and NASH isn't even operational yet. When it is, there will be a massive job to distribute tokens to health providers. Oh, and before that happens the health provider has to apply for and obtain an HPI-O and HPI-I. Even that apparently simple process is tied up with so many rules and regulations that many will put it off as long as possible.

Finally there is the clinical software: I think this was one of the casualties of the freeze on development that NEHTA was forced to impose earlier this year when it found incompatible versions of standards were being used. Software vendors will insist on comprehensive testing to avoid the sort of debacle we have seen this week - doctors and their patients actually rely on this software working!

All in all, given the amount of work not completed, I am guessing that it would be unreasonable to expect many GPs to be able to create summaries before next year. The NASH credentials may turn out to be the critical factor.

Anonymous said...

David, I'm surprised you'd register given your well known views. The Medicare proof of record ownership can fail for a number of reasons - it is an identity check so you need exact details or no dice. That is deliberate - better too tight than too loose. There's always phone or in person if you cannot complete the online checks.

Dr David More MB PhD FACHI said...

Anon said

"it is an identity check so you need exact details or no dice."

All it wants is Name, DOB, Address and Medicare Number and serial.

Since I have a current MC Card, and my name, address and DOB have not changed in decades it is very odd. I typed carefully and did it twice so it is a odd problem.

I want to be able to have a record to see how it is working etc. Research you know.


Anonymous said...

David, I also failed the first step in proof of record ownership once, and I worked on the project. I'm pretty sure I either mistyped my Medicare card or my address.

The address is an exact match (again, for good reasons to do with identity checking), and it needs to be an exact match to the address held at Medicare. It is possible for that address to be spelled slightly differently - so if you have correspondence from Medicare and use the address that appears on that you would increase your chances.

We know that some people simply cannot pass online registrations - due to the nature of their situation, due to there being people whose details are too similar and a risk of mis-linking, various other reasons. If you cannot complete registration online, you can get an IVC from Medicare over the phone - so that just verifies your identity - but complete the rest of the process online.

Anonymous said...

Or set up online access to Medicare first via, then go to and link to Medicare. Then link from to the nehrs it worked for me.

Jim Cocks said...

Dear Anonymous 7/07/2012 02:47:00 PM
That sounds pretty easy for your average punter to understand - set up MC access first, then link to MC from, then link from there to nehrs - very intuitive.

Anonymous said...

Jim, the rules for getting Medicare access are identical to PCEHR - uses the same logic. If you already have Medicare online you can upgrade to include PCEHR. If not, you can get access to both at the same time with the same transaction. So no, not confusing.

Anonymous said...

Dear Jim
Agreed it is not very intuitive. But it does give you a chance to check your Medicare details in your Medicare account (your MBS, PBS organ donor etc) against the same data presented in your PCEHR. In my case, they did not match - i.e. Medicare knows correctly that I am an organ donor, but my PCEHR says "no registered organ donor details", which is ambiguous. It should perhaps say 'details not yet available in this record' - as they clearly have not been carried across yet.

Anonymous said...

I'm pretty sure the Minister said that Medicare data wouldn't be there yet. So no surprise there.

Anonymous said...

Yes but even if the minister said that the screen presentation should not be misleading.

Anonymous said...

Well at least someone calls it what it is, the PCEHR certainly falls into the "Crap" category and in fact everything Nehta touches turns to crap. I cetainly can't identify anything they have done that works.

A lot of fuss over login problems, but whats the point when there is nothing there and is unlikely to ever be. This mess could consume a lot of health dollars unless someone faces up to reality and calls it for what it is - A failure - or as identified above "Crap" Its time to pull the plug before it drowns us all.