Survey Says: Yes, National HIT Architecture is Shifting, Thank Goodness!


Brian Ahier sparked a feud with his Google+ post commenting on a recent JAMIA article entitled Shift in the Architecture of the Nationwide Health Information Network. We’re at 60+ comments and going strong. The discussion has also been picked up on in Modern Healthcare.

The JAMIA article was written by Leslie Lenert and colleagues, and Lenert joins in heartily in the Google+ discussion. From the abstract, here are 3 key points they make:

1) …a significant change in the architecture of the NwHIN is taking place. Prior to 2010, the focus of information exchange in the NwHIN was the Regional Health Information Organization (RHIO). Since 2010, the Office of the National Coordinator (ONC) has been sponsoring policies that promote an internetlike architecture that encourages point to-point information exchange and private health information exchange networks.

2) The net effect of these activities is to undercut the limited business model for RHIOs, decreasing the likelihood of their success…

3) These changes may impact the health of patients and communities. Independent, scientifically focused debate is needed on the wisdom of ONC’s proposed changes in its strategy for the NwHIN.

What does the Family Feud survey audience think of these points?

While I’ll acknowledge that one could draw many inferences from the discussion, here’s my interpretation, synthesis and commentary of the main points in the Lenert, et. al. article.

1) A Shift in NwHIN Architecture is Occurring

Survey says: “Yes, the observation is correct, but this is a good thing.” 

Arien Malec: The preference for a “Health Internet” was expressed by +Aneesh Chopra and Todd Park late in 2009 at a conference convened by Harvard, long before PCAST*.  At the time, and currently, the progress towards RHIOs was glacial (with notable bright spots)…

David C. Kibbe: It’s clear to me that health data exchange is now seen generally as inevitable, and that this is in part due to the potential for many small provider organizations and low-volume exchangers to avail themselves of low cost, low complexity, point-to-point, and yet very secure solutions via Direct exchange. (ONC should be thanked for stickting to their guns on this one.) As one large vendor put it to me last week, “Direct exchange is simply a cost of doing business for us now.” 

Richard Elmore: Hard to believe that anyone in 2012 is arguing that there shouldn’t be directed messaging, or that such messaging is responsible for the challenges of RHIOs.

Brian Ahier: As Dr. Christensen said: “In looking at EMRs and other health care IT, the data will become commoditized, systems will become modular, and money will be made in applications… EMRs are needed to coordinate care. But to get them adopted, substitutable applications must be developed that clinicians want to use because they help them do a job. Information technology in health care must be open and modular, and there must be a common language.”

2) The Shift in NwHIN Architecture Limits RHIO Likelihood of Success

Article author Leslie Lenert: I suspect we agree that regional organizations that play public utility like functions can be useful in health information exchange. Among public utility like functions are universal access and support of critical services community services that are not economically feasible to sustain. If community level services are valued, it may make much more sense to think about health information exchange from a public utility perspective than the free market. Free market and public utility are “either — or” alternatives for sustainability and the choice has consequences.

Survey says: “Maybe, maybe not. And is that such a bad thing?”

John Lynn:…but the whole premise is a little messed up for me. ONC is undercutting RHIOs. Since RHIOs have done so well before ONC did anything. (that’s in the sarcasm font in case you missed it).

Margalit Gur-Arie: Right now, if I have a fairly decent EHR, I get bi-directional exchange with labs and pharmacies for free. I get bi-directional exchange with patients through my portal for relatively little money and I get bi-directional exchange with payers for a nominal fee. If my EHR is a bit more advanced, I get p2p exchange with other providers, or I get Direct based exchange from Surescripts for very low fees. I also get CQM reporting to CMS through my EHR registry for free. If I am affiliated with a large system, I get hospital exchange usually for free too. Some EHRs have practice networks and will provide me with analytics and benchmarks for free. Why on earth would I pay anything to an HIE organization?

Arien Malec: I don’t agree with your premise that the architecture of the Internet is essentially in conflict with RHIO models. I do agree that the architecture of the Internet is in conflict with rent-seeking business models, but I would observe that successful RHIO models have not been rent seeking. So both on empirical grounds (real successful RHIOs have not been rent-seeking; market forces were already reducing the costs of exchange) and on theoretical grounds, there are strong reasons to prefer an Internet model and strong reasons to pursue a policy approach to convene stakeholders in focused ways that relentlessly reduce the costs of exchange.

As a matter of policy preference, I would advocate that any standards adopted or endorsed by ONC should be model-agnostic and general in nature. One can use Direct in a utility model RHIO, a DEAS, a central exchange or a free market HISP.

As I kept saying in my role at ONC, the cost of exchange will go down. Any organization, private or public-private, that has a business model predicated on the cost of exchange staying high is doomed. Driving the cost of exchange down is always a good thing, for providers, and ultimately for HIOs. There are many successful RHIOs; the basic models and structures are different, but what’s common in all of them is a laser-like focused effort on adding value. If you are starting a RHIO and your sustainability model is not based on adding value to your customers, but on extracting monopoly rents on the services your customers are asking for and using those monopoly rents to provide services that your customers aren’t asking for but you think they should want, you will fail.

…HIE services are part of a platform for high quality efficient care delivery

3) The Shift in NwHIN Architecture Harms Patients and Communities

Survey says: “Not so fast.”

David McCallie: Use of “internet styled” standards (as opposed to hub/spoke?) allows for decoupling of technology from markets. If anyone can connect to everyone, using appropriate Internet standards, then markets can evolve towards the most efficient way to deliver services, where the resulting organizational structure is not constrained by arbitrary technology choices. As per +Arien Malec this seems like a desirable outcome, and is inherently stable across political transitions.

David C. Kibbe: What we have been missing in health care until very recently is an economic driver(s) for health data exchange. Under fee-for-service payment there are such strong economic disincentives for exchange! Providers and their supply chain partners generally don’t see value in the sharing or exchange of data, as this might lead to decreases in utilization, increases in efficiency, and, perhaps ultimately most important, price and outcome transparency on a large scale.     My sense is that under the dual pressures of intense global competition for goods and services and the threat to our sovereign debt posed by our national health care spending, this is all about to change: that slowly but surely economic circumstances will determine that health data exchange is desirable for more providers to engage in willingly, yeah, even with enthusiasm. 

Mark Frisse: I believe most inter-organizational networks supporting accountable care or bundled payments will, in fact, serve more or less as “RHIOs” for the members. I further suspect they will communicate among one another via Direct and, hopefully, also contribute specific data items to a form or HIO that is accountable for measuring the health of populations.


There are a number of great lessons here. The first is in simply educating yourself on the evolution of HIT policy. Hopefully my summary is helpful, and I would encourage you to read the entire Google+ thread

The second is the power of social media to disseminate and advance critical thinking on important topics. The article and the subsequent Google+ comments show how rapidly discussion and understanding can occur. How long would this have taken through a traditional journal peer review process? Years?

Finally, Health IT advancement in the U.S. has remained one of very few issues that is not politicized — it is supported by both Republicans and Democrats. We all need to work hard (together) to keep it that way!


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