Wanted: a business model for information exchange
The HITECH portion of the American Recovery and Reinvestment Act included lots of financial incentives for health care providers to adopt and “meaningfully” use health information technology such as electronic health record systems. It also directed the Office of the National Coordinator for Health IT within HHS to perform a variety of activities “consistent with the development of a nationwide health information technology infrastructure that allows for the electronic use and exchange of information.” (P.L. 111-5, §3001(b)). What is not explicit in the HITECH Act is what funding, if any, should be specifically allocated to establishing or operating such an infrastructure. There seems to be an assumption that at some point one or more private sector organizations will either directly provide infrastructure services used for health information exchange or manage the information flow among health information exchange participants, either under contract on behalf of the federal government or on their own. However, to expect the private sector to step in and provide infrastructure services, even using the Internet, there needs to be a revenue source or other business opportunity to attract service providers. This is hardly an insightful observation, but the lack of attention to incentives for infrastructure, security, monitoring, and other necessary services seems destined to slow health IT adoption.
As noted last week by Dr. John Loonsk — currently chief medical officer for contractor CGI Federal but formerly a member of the management team within the Office of the National Coordinator responsible for developing the Nationwide Health Information Network (NHIN) — in the absence of federal-level coordination of infrastructure development efforts, and, Dr. Loonsk argues, stimulus funding dedicated to those efforts, health information exchange capabilities may be provided separately and incompatibly at regional or state levels, frustrating the widespread interoperability goals the NHIN is intended to achieve. If health IT will really produce anything like the cost savings so often projected, some portion of any savings to be realized could be allocated to paying health information exchange participants, on either a transactional or per-record basis. In theory the amount of money involved could be quite small and still provide the necessary financial incentive to potential service providers. In the early 1990s When the U.S. automated teller networks first made their regional networks interoperable, each ATM transaction generated just 12 cents for the parties involved — 7¢ to the acquirer, 5¢ to the issuer — but that provided enough incentive to achieve widespread interoperability within a couple of years. Not insignificantly, the process of linking regional networks was greatly facilitated by the fact that virtually all of them were using the same technologies, including computing platforms and telecommunications protocols.
Having a financial incentive built into health information exchange could simultaneously foster greater adoption and help participating entities maintain compliance with various privacy and security requirements. If, for instance, the holder of a health record was entitled to a payment each time the record was accessed or information from it was sent to a requester, not only would record holders have an incentive to make the data available for exchange, but by logging each transaction in order to generate billing records, the record holder would also produce an accounting of disclosures as required under HIPAA.
To date, entities exchanging health information purportedly as part of the NHIN are not actually under any sort of monitoring or oversight by any NHIN governing authority, although the provision for such monitoring is included in the Data Use and Reciprocal Support Agreement that has been executed by MedVirgina, the Social Security Administration, and other early adopters of the NHIN technical solution components. Without such monitoring place, the NHIN in “limited production” as it now stands is simply pairs of exchange partners using an agreed-upon messaging format to send information over the Internet between instances of gateway application software that can send and receive those messages. Without a set of services layered on top of that public infrastructure, there will be neither the framework within which new service providers can make their capabilities available nor any means to establish the sort of quality of service and other performance levels commonly associated with purpose-specific network infrastructure today.