A paper in Health Affairs by Drs. Adler and Milstein from the Harvard School of Public Health reports some not-so-comforting findings regarding the Regional Health Information Organizations (RHIOs) and the interoperable electronic health records they are responsible for developing and implementing: The State Of Regional Health Information Organizations: Current Activities And Financing -- Adler-Milstein et al., 10.1377/hlthaff.27.1.w60 -- Health Affairs.
Electronic clinical data exchange promises substantial financial and societal benefits, but it is unclear whether and when it will become widespread. In early 2007 we surveyed 145 regional health information organizations (RHIOs), the U.S. entities working to establish data exchange. Nearly one in four was likely defunct. Only twenty efforts were of at least modest size and exchanging clinical data. Most early successes involved the exchange of test results. To support themselves, thirteen RHIOs received regular fees from participating organizations, and eight were heavily dependent on grants. Our findings raise concerns about the ability of the current approach to achieve widespread electronic clinical data exchange. [Health Affairs 27, no. 1 (2008): w60-w69 (published online 11 December 2007; 10.1377/hlthaff.27.1.w60)]
EHRs have been difficult to implement in nations with universal, single-payer healthcare. It's not surprising they would be even more difficult in a country with a healthcare system as fragmented as ours. But what are the critical factors for successful propagation of interoperable health IT?
In her 1990 MIT working paper entitled "The duality of technology : rethinking the concept of technology in organizations", Wanda Orlikowski described the process of technology adoption in terms of the interplay of social structures and social dynamics:
By moving across levels of analysis and boundaries of time and space, the structurational model of technology affords an examination of technology transfer among organizations. Many of the technologies used by organizations today are not built internally. Rather they are acquired from other organizations--either custom-designed, off-the-shelf, or in some form that is part mass-produced and part customized.
Recognizing the disjuncture in time and space between the design and use mode, allows us to analyze the role of multiple organizations in developing and deploying a particular technology. A technology may be designed by one organization, built by a second, and then transferred into a third for use. In these cases, the institutional conditions and human agents involved in technology development are different to those involved in technology use. That is, external entities--the developing organizations--play an influential role in shaping the social practices of the organizations using the technology.
The RHIOs are external to the organizations that will actually produce and consume interoperable health records, even though their human participants are almost always employees of such organizations. There are actually at least four major classes of actors in this space: the RHIOs, health providers, third-party payers, and health information technology vendors. Health consumers could be considered a fifth class, but they play little or no role in the technology development and adoption processes.
RHIOs play the role of designers (or in some cases merely specifiers) of standards for health records and messages, architects of inter-organizational network topologies, and in the selection of ontologies and other types of controlled vocabularies for populating the value domains of record fields (e.g., the caBIG Common Data Elements). Vendors and in-house development teams implement the designs and incorporating selected standards. Either the software product vendors themselves, vendors of system integration services, in-house integrators, or collaborations involving any or all of these technology providers deploy the developed systems and build out the inter-organizational network. Health providers and third-party payers are the end users of the systems, generating inputs and consuming outputs.
The reward systems and motivators for the different classes of actors are very different. Interoperability is a two-pronged threat to vendors: adapting to the RHIO's standards is often perceived as an unfunded mandate, new work without new revenue (or with insufficient revenue) to pay for it, for one thing. The other threat to the vendor is that interoperability means the data you once kept in proprietary formats is now accessible in well-documented formats, eliminating potential service revenue and making encroachment by other vendors on your customer base much more straightforward and independent of your involvement.
Payers want well-documented data flows to make their work more efficient, and thus the cost of conversion has a significant payoff for them in the medium if not near term. Health care providers, on the other hand, perceive any new system as an impediment to their operational efficiency - a perception that is often very rational and well-founded. There will be payoffs for them in terms of improved service to their patients and added revenue due to systems that can easily help providers take advantage of opportunities for standard-of-care procedures that are both billable and a sign of quality health care. However, these benefits ensue only after the pain of adapting to a new and possibly very green system has been endured.
Successful RHIOs will deal proactively with the people problems, helping all classes of actors harmonize their efforts and ensure that their internal and external rewards are well aligned with the movement to greater interoperability. Accordeing to the study, not many are succeeding in this delicate undertaking, and some have actually been disbanded due to "failure to thrive" for many different reasons. But technology advances according to an evolutionary plot line, and success in this endeavor is inevitable - the real question being when rather than whether.
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