If You Build It

Photo: Randall Scott

"We're going to use the purchasing power of the government to make sure this happens," says Dr. David Brailer, the national coordinator for health IT.

Legions have chuckled at Digital Equipment Corp. founder Ken Olsen's notable quip: "The nicest thing about standards is that there are so many of them to choose from."

But for Health and Human Services Secretary Mike Leavitt and Dr. David Brailer, national coordinator for health information technology, it's not a laughing matter.

Why? Because creating well-defined, unified standards for health data is of the utmost importance to both men as they lead a presidential initiative to build a National Health Information Network (NHIN).

Leading Change

The government deems a standard, interoperable health IT system crucial to the nation's welfare, saying it will help reduce medical errors, improve quality, lower costs and eliminate paperwork. To help make the system a reality, the government wants to be a first-mover in getting it up and running.

The dollar incentive to do something is real, HHS notes in a report on responses it received to a request for information on how to build NHIN:

• A reported 20 percent to 30 percent of medical procedures, accounting for $300 billion in annual expenses, do nothing to improve patient health, duplicate other care or are simply inappropriate.

• Meanwhile, a system that would allow health-care providers and others within the medical community to share information via a common format could save almost $78 billion a year, about 5 percent of what is spent annually on health care in the United States.

The strategy calls for agencies to collaborate with private payers in developing and adopting an architecture, a method of governance and—perhaps most crucial—standards.

Leavitt has said—to paraphrase Kevin Costner—if we build it, the public sector will come. He's reminded many audiences that the federal government foots 46 percent of the nation's health-care bill.

Brailer, who's commonly referred to as the government's health IT czar, echoes this: "We're not going to put out a mandate. We're going to use the purchasing power of the government to make sure this happens."

The bud of NHIN blossomed after President Bush signed an executive order in April 2004 calling for such a system to be up and running—and for every American to have an electronic health record—within a decade. In November 2004, Brailer's office issued the RFI seeking public comment on how widespread interoperability of health IT and health information exchange could be achieved through NHIN, which the request document described as an Internet-driven network. This fall, HHS is awarding as many as six contracts to develop prototypes.

Two key components of this massive work-in-progress are the Federal Health Architecture (FHA) and the American Health Information Community (AHIC).

"The FHA is the health line of business initiative that was launched by the original e-government efforts that go back maybe six or eight years," Brailer says. At first, it was intended to create a framework for all health-care concerns to communicate and collaborate, with the aim of expediting access to health information and services. But now, Brailer says, "It's evolved toward being a mechanism by which standards and common architecture are agreed to across the federal sphere involved in health care."

To make sure the initiative doesn't begin and end as an elaborate government exercise, HHS recently established the AHIC, or the Community. This collection of stakeholders is charged with advising HHS on how to make health records digital and interoperable while assuring ironclad security and unsullied privacy.

In September, Leavitt selected 16 commissioners for AHIC. They range from Steven S. Reinemund, chairman and CEO of PepsiCo, and Craig R. Barret, chairman of Intel, to Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, and Dr. William Winkenwerder Jr., assistant secretary of Defense for health affairs.

"My aspiration is for the Community to provide stakeholders with a meaningful voice in a federal process that will ultimately shape health care for generations," Leavitt says. The group met for the first time at a public meeting last month in Washington.

At the heart of the current effort, and a topic that the RFI report returns to repeatedly, is the need for standards for NHIN and medical data. Brailer cites the recent hurricanes along the Gulf Coast to illustrate how and why standards are so necessary.

In the days and weeks after hurricanes Katrina and Rita decimated Gulf Coast communities, doctors could not access patients' medical histories—many of which were at best hundreds of miles away or at worst destroyed—or verify prescriptions, and patients often were unable to provide accurate, up-to-date data.

In such a disaster scenario, "people are injured, and doctors need information acutely," Brailer says. "People become mobile, and we have to be able to have information to follow them, so that's what we're focused on now as a crash effort because this infrastructure's not up and running. Will we learn things from it? Absolutely. It's creating a great test for whether or not the ideas and plans we've laid out really could pass muster."

The recent events are helping Brailer and his team solidify how to approach the standards effort and how to integrate that into building a real-world system that can be tapped by medical and health-care practitioners at every tier of the medical and care professions.

David Powner, director of IT management issues at the Government Accountability Office, agrees that the hurricane response work by HHS is offering a live learning lab. He recounted at a recent hearing on NHIN how the small online prescription information system that HHS established for doctors and health-care providers following Katrina supports the broader objective.

"Although the scope of this effort is much smaller than the national network and the comprehensive electronic health records envisioned, it demonstrates the need called for by the president," Powner told lawmakers.

In GAO's view, the success or failure of the initiative will hinge on the standards work. It's clear, Powner said during the hearing, that "identifying health IT standards is essential to achieving interoperable systems and data in the health-care industry."

Because the parties involved are still finding their sea legs, it's not quite certain how the adoption of standards and interoperability—as well as other practical considerations, particularly individual states' privacy laws and security issues—will affect agencies and their employees.

Agency Impact

GAO's Powner points to IT purchasing as one area to watch. "If you'd look at any investments in technology, whether it's through HHS, Veterans Affairs or Defense, [agencies would have to] align those investments with this future architecture and then also to the standards that would fall out of that architecture," Powner says.

Then there's the staffing side, says Dr. John Loonsk, acting director of the new National Center for Public Health Informatics, an arm of the CDC that provides national leadership in the application of IT in public health. Loonsk thinks the development of NHIN and other health IT systems is beginning to create demand for a new breed of government employee.

"There's a new area—a new discipline, if you will—for federal employees," Loonsk says. They must have "medical knowledge, public health knowledge and also be able to know enough about the technology to be able to bridge those disciplines. It's not just about programming software anymore."