Interoperability of health care records in the state of Wisconsin

What are we planning in Wisconsin… is a fresh view needed… is the apparent direction a costly error?

Governor Doyle, in issuing Executive Order 129 on November 2, 2005, called for “a statewide eHealth infrastructure that would improve the quality and reduce the cost of healthcare in Wisconsin.” This announcement came on the heels of president Bush's State of the Union Address on January 20, 2004, when he stated that “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”

But what does this really mean? The statements were both politically appropriate at the time, but as of June, 2008, little has been achieved in Wisconsin.

We have been at this for a long time. The CHINs (community health information networks) of the mid-1990s were an idea that had merit but was not adequately supported by the technology of the day. The RHIOs (regional health information organizations) of later times were also a great attempt at interoperability but suffered from lack of community acceptance and viable business plans to sustain them. It is telling that only a handful of RHIOs continue in business from the several hundred that were founded on initial seed money only to fail when those funds became exhausted. The poor support from the healthcare providers and the payer community, and the absence of inspirational insight into the opportunity being presented to us by the technology, contributed to the lack of success of what I will call the second generation of this approach at interoperability.

Now we are at the crossroads again, with the potential to truly deliver interoperability of the electronic medical record. There is no doubt that we in the technology world of 2008 can rise to meet the need. Politicians have made significant announcements of their support of this innovation, and now is the time to transform this political commitment into pragmatic deliverables together for the people of Wisconsin.

On June 10, 2008, a request for proposal was issued by the Wisconsin Department of Health and Family Services to select a consultant who will define/recommend an architecture upon which the interoperability of health records will be based in Wisconsin. It appears clear from minutes of the Governor's eHealth Board of Directors, and also from its most recent annual report, that the state is planning for three to five health information exchanges to be established in Wisconsin. The health information exchanges, in reality a RHIO under a more propitious name, will in effect be a regionally developed and supported, centralized data base containing your health information. This information will be a partial duplicate of the data held at your primary place of care which has been transmitted to this centralized database.

Presumably, the healthcare provider and payer will bear the cost of this process. The finance subcommittee of the eHealth Board, before its demise, had estimated the cost of this project, as planned, at $1.2 billion, a significant burden to place on the state of Wisconsin. Importantly, to be viable, the plan further assumes that all healthcare providers in the State of Wisconsin will maintain patient records electronically. This is not the current or the foreseeable situation, as many small hospitals and physician practices do not have the available funding to achieve this goal with only their own resources.

The RFP states, in part: ”a critical step towards achieving the state's eHealth goals is developing and implementing state-level HIE business and technical services which will support the development and operation of regional HIE's in Wisconsin.” If the finance subcommittee's estimate is correct, and I believe it is, it is incumbent upon us to assess alternatives in light of the opportunity costs inherent in an expenditure of this magnitude and the limited deliverables planned.

As there is no question that access to the key components of an individual's medical record from another provider facility will certainly enhance clinical outcomes and save lives, is there an alternative method by which to facilitate interoperability?

Let us pause for a moment and consider another industry with high security, accuracy and privacy demands: finance and banking. We all use bank cards to obtain cash from an ATM, and we are accustomed to undertaking this process in almost all countries in the world. The banking system network, including regional boundaries and security controls, is a great example of what can be done when private enterprise understands a need. Yes, the banking/credit/cash process of the international network is to some extent more simple relative to the actual complexity of the healthcare environment. However, at the core, the processes involve achieving confidential, accurate and secure data interoperability. We can surely learn and customize standards and processes from this industry to ours and apply this concept to healthcare in the state of Wisconsin and beyond.

Please consider the concept. Application (systems) vendors in healthcare are working together under the auspices of the Certification Commission for Healthcare Information Technology (CCHIT) to develop standards for interoperability. By working together it is planned that their output will become accepted as was the HL7 interface standard. A peer-to-peer network with communications between healthcare providers using software from the same or different software vendors and based on the CCHIT standards could follow a model based on the Banking system model. Of essence, there would be little cost for each provider, as the internet would become the vehicle for data transport. The possible addition of a communications server and minimal staff time would achieve the goal of interoperability of essential healthcare records, thus providing what is needed for clinical care, when and where it is needed.

This peer-to-peer network lends itself to progressive growth and expansion, as warranted as additional providers implement electronic medical records systems. Importantly, a sustainable business plan at the operations level is not needed to finance the exchange of key clinical information in a time of need. The network traffic generated will be low, as transactions will be only on an as-needed basis. Yes, legal and privacy issues must be managed, as they need to be with any access to healthcare records, but this approach will work.

Patient identification verification is no more or less of a problem than that posed by an HIE. Positive patient identification must be absolute, and should be verified by the system or physician at the time of the first interoperable transaction/encounter for that patient. Thereafter, the master patient identifier (MPI) in each system will be noted to facilitate future need. The addition of biometric identification into healthcare in the near future will further aid absolute identification.

I ask all of you who read this newsletter to discuss this approach with your leadership teams, talk to your elected representatives, and let us develop a practical approach to interoperability of healthcare records at a practical cost! Let us take this innovative step allowing Information technology to facilitate a function in the healthcare system, which will significantly enhance care and help to manage costs. Among the benefits of the comprehensive networking solution I ask you to consider are:

• Significantly lower cost than other approaches
• Only light network traffic generated
• Clinical data transferred only when required for treatment
• Little technical overhead
• Implementation simplicity, reasonable straightforward
• Implementation will use technologies in existence today
• Minimized duplication of health records
• Enhanced security
• Easily scalable

By working together we can help to ensure a high standard of health care in the state of Wisconsin, without placing a high cost onto the already high costs of healthcare in our state.