Qual-IT - April 2007 | Archived

As noted above, HIT-related efforts are greatly expanding their concerns from first-level, strictly technical issues to larger questions of how this technology will be applied. A major step forward, addressing one of the most basic barriers to HIT adoption, came with adoption, by the Certification Commission for Healthcare Information Technology (CCHIT), of initial certification requirements, translating consensus standards into objective functional criteria for specific HIT products.  With these criteria as a guide, providers and other stakeholders can select specific HIT products that will be recognized for use in both federal health programs and state and regional HIT initiatives (including projects funded through the HEAL-NY HIT grants).

Such advances have, in turn, promulgated a focus on protecting the privacy and security of electronic health information, addressing important questions about how sensitive data—particularly identifiable personal health information—will be used.  Clinicians need detailed information beyond the records of their own interactions with patients, such as lists of all recently filled prescriptions, or records of visits to other care providers, to build complete patient histories.  Health information technology and health information exchange (HIE) provide the means to record, store, and share these kinds of data, and current federal and state laws do address many of the key questions that arise in the context of such conventional physician-patient interactions. 

But policymakers must also address the implications of broader potential uses of HIT, in part because direct-care uses alone are unlikely to create adequate incentives for physician and patient adoption of this technology, much less generate the financial investment required for building and maintaining IT systems.  These broader applications will, for example, pool data to support population-based analyses, such as drug safety studies and comparisons of the costs and efficacy of various treatment regimens.

With this broader perspective in view, the Department of Health and Human Services (HHS) has moved to support such expanded uses of and demand for HIT and HIE.  The Quality Workgroup of the HHS-sponsored American Health Information Community (AHIC) recently published its report on specific ways for HIT to capture, aggregate, and disseminate data on a core set of quality measures.  Among the workgroup’s recommendations:

• Quality measures need to be translated into data standards, which can then be incorporated into the CCHIT certification process. Similarly, clinical workflows associated with these measures need to be mapped and incorporated into clinical decision support.
• HHS should use its regional value exchange initiative to test approaches to linking clinical and claims data for quality measurement purposes.
• Groups such as the National Quality Forum, which develops consensus on performance standards and measures, should take HIT standards into account as they develop measures in the future.

In a related action, HHS has published for public review and comments a proposed prototype “use case” for HIT in quality measurement, prioritizing a number of essential functions: automating data capture and reporting of hospital and physician core measures; providing feedback to clinicians to improve care for specific patients or populations; and aggregating data from multiple sources for purposes of public reporting.  

The department has also launched the Personalized Health Care Initiative, which will utilize HIT and HIE to advance genomic research to improve patient care and population health.  Key tenets of the initiative include federal leadership in support of research on individual aspects of disease and disease prevention, with the ultimate goal of shaping preventive and diagnostic care to match each person’s unique genetic characteristics; and creation of a “network of networks” aggregating anonymous health care data, to help researchers establish patterns and identify genetic “definitions” of existing diseases.

Clearly there is growing interest in using HIT and HIE for broader clinical and public health purposes than now in common practice.  Efforts such as these, and many similar large-scale applications of HIT, will expand information resources and could fuel investment by a broader range of stakeholders.  But these initiatives also involve the emergence of numerous new entities providing the necessary technology, and introduce a host of new risks that are not addressed by current laws and regulations.

HIE could stimulate health care market forces if the resulting information resources are devoted to improving value and managing risk, states a recent article in the Journal of Healthcare Information Management.  Although current HIE initiatives largely focus on improving individual provider efficiency, they can also serve the broader social need of leveling the playing field by providing greater access to health care information, the authors write.  These HIEs should serve as “infomediaries,” supplying data for comparative performance information, personal health management tools, public health surveillance, and the assessment of new drugs and devices.  The authors call for managing these entities as public utilities, to leverage national, state, and regional health information resources and free up such information for broad use in the community—they should not be proprietary assets owned by any one sector or organization, the writers caution—but stop short of prescribing a specific governance model or means of addressing privacy issues.

A recent report from the American Medical Informatics Association (AMIA) also points to the complex ethical, political, and social issues raised, along with technical questions, as the volume, scope, and accessibility of personal health data continue to increase.  According to the expert panel convened by AMIA:

• Secondary uses of health information are already widespread; these uses, and their benefits and risks, need to be documented and explained to the public.
• Policy and technology should focus on data access and control, not data “ownership.”
• Privacy and consent policies need to be established for otherwise unregulated entities and uses.
• Technology needs to be further developed to adequately monitor and protect data access and uses.
• Federal and state policymakers must focus on developing a comprehensive and coordinated set of policies, standards, and best practices that will address secondary uses in general and deal specifically with data collection, storage, aggregation, linkage, and transmission.

In New York, state and regional initiatives to promote HIT adoption and use are still at an early stage, so few have grappled with these longer-term concerns.  Inevitably, however, these issues will arise, and with them the opportunity to provide leadership, engage stakeholders and the public, and develop a policy agenda that will maximize appropriate uses of HIT to improve health care quality, safety, and efficiency.  Federal standards provide some guideposts, but state policies are needed to take advantage of those standards and provide direction for the diverse regional initiatives emerging across New York State.