Measuring Progress of Community Health Information Infrastructures

March 8th, 2006

As dozens of communities move forward with their efforts to implement health information infrastructure (HII), there is a widespread and urgent need to be able to determine how these initiatives are progressing. This is necessary so that community stakeholders, outside observers, and policymakers can monitor and understand both what has been accomplished and those tasks that remain. Simply stating that a community is exchanging health information does not differentiate between a few pilot transactions and the availability of complete electronic information for all citizens.

What are the proposed HII measures?

To address this issue, my colleague Steven Labkoff, MD (of Pfizer Global Pharmaceuticals) worked with me to develop and test a proposed set of measures that can help to objectively assess how far a community has progressed on the path to a complete HII. This article summarizes the basic concepts we developed. A complete report of this effort has been accepted for publication and will appear in an upcoming issue of the Journal of Biomedical Informatics (proofs are now available with subscription on Science Direct).

The central idea is to examine the attributes of a fully operational, “complete” HII, and then define simple measures that would give an indication of how far along the path to completion a given community has progressed for each. We defined four such attributes:

1. INFORMATION: All the medical information about every person should be available when and where needed
2. USERS: All the physicians and all the consumers should be using the system
3. USES: The information should be used for the full spectrum of appropriate purposes: 1) providing health care; 2) public health; 3) medical research; 4) quality improvement; and 5) health care operations
4. FINANCING: The operation of the system should be financially sustainable, funded exclusively with ongoing operational income

We subdivided the first attribute (what information is available) into eight categories:

  • 1) inpatient (hospital)
  • 2) outpatient (ambulatory)
  • 3) long-term care
  • 4) home health/personal health record (PHR)
  • 5) laboratory results
  • 6) outpatient medications
  • 7) imaging
  • 8) insurance claims
  • Each attribute or sub-attribute was then scored on a 0-5 scale, where 0 represented no activity, 1 was 1-20% complete, 2 was 21-40%, etc. For the first attribute, separate scores were generated for all eight types of information. For the second attribute (who is using the system), separate scores were generated for physician and consumer use. The third attribute (uses of the information) was scored on a binary basis: if any of the information was being used for a specific purpose, a 1 was given — 0 indicated no activity. The last attribute (financial sustainability) was again scored on a 0-5 scale based on the percentage of funding derived from ongoing operational sources.

    The scores for each attribute were then normalized so each counted for 25% of the total, and the overall score was expressed as a percentage of a perfect score, which would be 100%.

    What are the results of using the measures?

    When we applied these measures to four of the most advanced HII communities in the nation, the scores were in the 60-80% range indicating that additional work was needed to achieve a “complete” HII. The two specific items typically remaining incomplete are not surprising:

    1) outpatient information was usually absent since most physicians do not have electronic health record systems (EHRs). Therefore, this information is not electronic and cannot easily be exchanged
    2) few consumers are using these systems — most communities do not yet provide consumers with access to their own information.

    Of course, this rating system for assessing progress is very crude, and undoubtedly represents only the first step in the evolution of metrics for community HIIs. Implicit in this measurement scheme is agreement about the four key attributes: information, users, uses, and financial sustainability. If other attributes are deemed important, they must also be included.

    In addition, a number of critically important factors are ignored. Privacy and confidentiality protection was not included because it was assumed that all HIIs would be required to deal with these issues before beginning operations. User satisfaction with the system, admittedly a critical characteristic to evaluate, was also omitted — primarily because it is somewhat time-consuming to measure.

    Another item that is not represented in the measures is the degree to which the data being exchanged has been encoded. While it is clear that fully encoded, standardized data is much better (and essential for decision support), it was not clear how to appropriately assess this. Also, it was felt that at this early stage in the development of HII systems, it may not be necessary to do so. However, as HIIs mature, it seems likely that it will be helpful to differentiate communities that score 100% on this proposed assessment scheme by the extent to which the information is encoded.

    As more and more communities begin to exchange health information, these measures should be very helpful in assessing their progress. We certainly hope this simple assessment scheme can contribute to a better understanding about how far we’ve progressed on the road to an HII both in individual communities and the nation as a whole.

    As always, your comments and suggestions are welcome. What do you think?

    Next time: Governance of community health information infrastructure systems

    Louisville to be first eHealthTrust™

    February 1st, 2006

    Today, Louisville, Kentucky, became the first community in the nation to announce plans to build an eHealthTrust to provide lifetime health records for all its citizens. This is an exciting and important event in the development of our National Health Information Infrastructure (NHII) in the U.S. that should be closely tracked by the many other local and regional efforts working on these same issues. It also provides a tremendous opportunity for health information technology (HIT) vendors to participate in this truly groundbreaking project.

    What exactly is Louisville planning to do?

    After more than two years of research and community organizing, the leadership in Louisville concluded that an eHealthTrust would be the best approach to developing a community health information infrastructure (see last month’s posting for a description of the advantages). Having chosen the model, the question Louisville faced was “how to get started?” Working with stakeholders in the community, it was clear that the idea was appealing to purchasers of health care (e.g. employers) because it would make the complete patient information available that would allow higher quality and lower cost care. They expressed substantial enthusiasm about providing the eHealthTrust to their beneficiaries, and even subsidizing the modest cost (about $5/month). However, there was little appetite in the community for underwriting the development costs.

    It became clear that if there were enough customers to guarantee sufficient revenue to cover operational costs (about $6 million/year), then the system could be procured as most enterprise software is — by offering vendors a contract to operate it profitably. Not only does this provide an incentive to offset development costs, but it gives the vendor the opportunity to market the software to other communities. This is better for both Louisville and subsequent communities that implement eHealthTrusts, because the software will be available on the open market rather than being owned by a community non-profit that is not focused on its dissemination.

    So today, the Louisville Health Information Exchange (LOUHIE) issued an RFP inviting bids for operating their eHealthTrust. The successful vendor would receive a four-year cost plus fixed fee plus market incentives contract to provide management, marketing, operations, and security. The maximum allowable bid is $4.5 million/year plus a $500K fee and $10/net new member marketing incentives, making the total contract potentially worth over $20 million. A bidders conference is scheduled for 2/13/06 (in San Diego), required letters of intent are due 2/27/06, and the proposals must be submitted by 5/1/06. Anticipated start date is July 1st.

    In addition, the community wanted to be sure that eHealthTrust members had access to other health information resources, customized by the information in their own lifetime health records. For example, being able to check your own list of medications for interactions without retyping all the information would be exceedingly convenient as well as potentially life-saving. The community’s goal is to provide a wide selection of such health information services from a variety of sources.

    To address this issue, the capability for sending selected non-identified parts of a medical record to an outside information service vendor needed to be included in the system. In addition, all such services must have secure, established mechanisms for receiving the information. The result was the second RFP, which invites health information service providers to bid on licenses to link with the eHealthTrust to provide such customized services.

    The successful bidders will have a link on the Louisville eHealthTrust web site that takes the user to a vendor-specific page with a list of available services. Selecting one of them, e.g. drug interactions, will result in a window being displayed with the non-identified information from the user’s medical record that needs to be sent in order to provide the service — in this case, the list of current medications. The user is then asked to approve the secure transmission of this information. Once approved, the data is encrypted and sent (via web services), and the user is shown a new window at the vendor’s web site with the resultant list of drug interactions.

    A maximum of ten such licenses for these links will be awarded to information service vendors submitting the highest bids. Louisville will guarantee at least 100,000 subscribers to the eHealthTrust (although they cannot guarantee any minimum level of usage of the links). The minimum bid amount is $200K, with the same timeline for proposals as the first RFP.

    Why is this important to other communities?

    Many communities have started to plan and organize the development of a community health information exchange (HIE), recognizing its potential value in improving health care quality and increasing efficiency. While there is a great deal of excitement and optimism, these efforts are exceedingly challenging. In particular, communities typically are stymied by four key issues:

  • Business model: who will pay for the HIE? (startup and operations)
  • Privacy: how can privacy be protected effectively?
  • Complete information: how can complete electronic medical information be available (especially when most physicians still use paper records in their offices)?
  • Intercommunity connection: how can the HIE be built to ensure that it will be compatible with other communities?
  • Business model

    One of the most critical issues communities face in building HIE systems is funding — both for the startup and continuing operations. Louisville has addressed both these issues. The ongoing funding is being provided by securing commitments from subscribers to pay for the system when it is available. The eHealthTrust model lends itself to this approach, because it clearly can provide complete electronic medical information for each subscriber — which can then be used to provide better and more efficient health care. It is relatively easy for prospective sponsors to understand how the eHealthTrust model does this — thereby facilitating their decision to commit to participation.

    By obtaining these initial customer commitments, the need for startup funding to create the initial eHealthTrust product can be eliminated by asking the vendors to build it in exchange for a multi-year operations contract. This is also better for the vendors since it allows them to profit from marketing the system elsewhere. The risk to vendors is minimal since Louisville is guaranteeing the needed customer revenue for operations. Meanwhile, the second RFP is designed to help provide some startup funds for the LOUHIE organization itself. In addition, it can provide a buffer against any unanticipated shortfalls of operational revenue.

    Privacy

    Protecting the privacy of medical information is essential for an HIE system. This requires both establishing appropriate policies about what information is accessible to whom, and then enforcing those policies with good personnel and computer security. It is the area of appropriate policies where the most difficult problems arise. Devising general policies that cover every situation and satisfy all stakeholders is maddeningly complex, and may not even be possible. The Louisville eHealthTrust solves this problem by making each person responsible for controlling access to their own health information. In this way, each subscriber can determine their own policies about who can see what information and when — and the decisions can change as needed. By adopting the principle that each person must authorize all use of their own health information, every person’s privacy can be protected as they wish — and each person can make their own choices in their own way.

    Complete Information

    Missing information is what leads to inefficient, error-prone health care. Therefore, successful HIE systems must make complete (or nearly complete) patient information available when and where needed. The most difficult information to provide is from outpatient records, which remain largely paper since over 85% of physicians do not yet have electronic health records (EHRs). There has been a tremendous amount of discussion and study of the “slow adoption rate” of EHRs by physicians, but the basic issue is that most of the benefits do not accrue to the physicians being asked to foot the bill, but to those who pay for care. To overcome this barrier, the eHealthTrust provides direct payments of about $3/outpatient encounter to physicians for submitting standard reports of encounters, resulting in $10-20,000 of additional annual revenue to offset the costs of an EHR system (which can require over $40,000 of initial investment for each physician). This will be a potent stimulus to physicians to acquire and use EHRs. No other proposed HIE model even attempts to solve this problem. Unless physicians are using EHRs in their offices, it will not be possible to have complete patient information in an HIE system, since the outpatient records will be missing.

    Intercommunity connection

    There has been a great deal of discussion about the need for HIE systems in different communities to interconnect. For example, the current Federal demonstration projects REQUIRE such connections. The theory is that to be able to immediately retrieve information about a patient from any location where care has been received, queries must potentially be able to travel nationwide. The need for such intercommunity connections creates understandable anxiety for HIE planners. Since the standards and procedures for such connections have yet to be defined, how can communities build HIEs without the risk of being incompatible with some as-yet-unknown future requirements?

    But the eHealthTrust model does NOT require connections between communities — each person’s entire record resides in the community eHealthTrust. No queries beyond the eHealthTrust that contains each person’s complete record are needed. If a community member ever receives care from an out-of-town provider connected to another eHealthTrust, any information sent to that provider’s eHealthTrust will automatically be “redirected” to the “home” eHealthTrust. This “redirection” does not have to occur instantaneously, since no one is waiting for the record to be retrieved when the information is sent.

    Why is this an exciting opportunity for HIT vendors?

    HIT vendors should be excited by the opportunity to respond to this RFP for a community eHealthTrust HIE system. With a potential value in excess of $20 million, it is the largest such RFP ever issued. The selected contractor (or consortium) will be the first to implement the eHealthTrust model, resulting in significant competitive advantage in other markets as additional communities turn to this approach to solve the difficult HIE problems discussed earlier. The potential market for eHealthTrusts is very substantial — at $60/person/year, nearly $18 billion in annual revenue across the entire U.S. (1% of overall health care costs). With the expectation that such systems can reduce health care costs 8% or more, the potential benefits for health care stakeholders in communities are compelling.

    Furthermore, much valuable knowledge and experience will be gained in this first eHealthTrust. The actual availability of complete electronic medical information has never before been achieved in a community, and there are undoubtedly many key lessons that will be learned along the way to this exciting goal.

    Finally, the simplicity of the eHealthTrust model allows for a rapid timeline, which means early results — the Louisville system should be fully operational by January, 2007. So the experience gained will not only be important, but will be available soon for application elsewhere.

    Conclusion

    The Louisville eHealthTrust project, along with a number of other demonstrations underway across the country, will make 2006 a very exciting year in the development of the NHII.

    Next time: A Framework for Measuring HIE Progress in Communities

    Seven Keys to RHIO Success: The eHealthTrust Model

    January 9th, 2006

    In a recent interview with NHIN Watch, I indicated that a complete RHIO must have:

  • All medical information available in electronic form
  • Stakeholder cooperation
  • Financial sustainability
  • Public trust
  • To achieve these goals, I described seven key requirements to RHIO success:

    1) financial incentives to clinicians who use EHR’s (electronic health records)

    2) central repository for data to allow rapid access and offline searching for public health and research

    3) having patients as the source of requests for information

    4) asking consumers (patients) to pay for their records to be electronic (about $5 per month)

    5) releasing medical information ONLY with patient approval

    6) establishing a community non-profit organization with independent privacy oversight to build and operate the system

    7) using a trustworthy technical architecture so consumers/patients can be sure that their information is safe and carefully protected against loss or improper release

    So how do you implement a RHIO that meets these requirements?

    Use the eHealthTrust model.

    The eHealthTrust makes complete patient information available when and where needed by serving as the community custodian of the complete medical records for everyone.

    Each person controls all access to his/her records, and is charged about $60/year ($5/month) for the service (which may be and should be reimbursed as an allowable medical expense).

    The eHealthTrust pays physicians about $3 for the “deposit” of each standardized electronic report of an outpatient encounter, thereby creating potential new revenue of about $15,000/year for physicians with EHR systems (and providing the needed incentives for their acquisition and use).

    Since the patients explicitly provide consent for the eHealthTrust record keeping activities, cooperation of all health care stakeholders in providing information is assured (since medical records must be provided on patient request under the Federal HIPAA statute). The eHealthTrust model assures public trust by putting the patient in control of his/her information.

    How does the eHealthTrust address the seven key requirements?

    1) financial incentives to clinicians for EHR (electronic health record) use

    The eHealthTrust uses the bulk of the fees from consumer/patients to pay clinicians to deposit standardized electronic reports from outpatient encounters. These reports must be generated from EHR systems; therefore, clinicians that have EHRs can receive substantial additional revenue (e.g. $15,000/year), which they need to pay for the systems (which may cost $40,000). The eHealthTrust is the only proposed business model for RHIOs that includes such financial incentives, thereby ensuring that the records of outpatient visits are electronic and thus can be easily available when needed.

    2) central repository for data to allow rapid access and offline searching for public health and research

    A central repository provides fast response time, and a searchable (offline) copy of the medical records for public health and research. By using an architecture that is trustworthy (see 7 below) and putting the patients in control of their information (see 5 below), it is possible to use this easy, low-cost solution. The alternative “scattered model,” which retrieves information from its existing locations only when needed, suffers from high cost, lack of reliability, and slow response time, and also does not readily allow the information to be searched for public health and research purposes.

    3) having patients as the source of requests for information

    In the eHealthTrust, patients submit a standing request for their medical information. This ensures the cooperation of the stakeholders, since the Federal HIPAA statute requires release of medical information when the patient requests it. Lack of such cooperation has been a major issue for many RHIOs.

    4) asking consumers/patients to pay for their records to be electronic (about $5/month)

    In a recent survey, 52% of consumers indicated that they would be willing to pay $5/month or more for their records to be electronic. This provides an immediately available source of funding – which is critical to financial sustainability.

    5) releasing medical information ONLY with the approval of the patient

    Medical information should be controlled by the consumer/patient – this is the central guiding principle of the eHealthTrust. An overwhelming majority (79%) of consumers support this (see my December posting for more details). Trust in the system depends on consumers/patients having control over their information – which they should have!

    6) establishing a community non-profit organization with independent privacy oversight to build and operate the system

    It is important to create an organization with representation from all the stakeholders and open, transparent processes. A community non-profit is the easiest way to accomplish this. An independent privacy oversight committee is needed to ensure that the information is properly protected and never misused.

    7) using a trustworthy technical architecture so consumers/patients can be sure that their information is safe and carefully protected against loss or improper release

    In an eHealthTrust, there are two separate repositories of information. One would provide access to the clinical records. Using a special, ultra-secure operating system, an authorized user would only be able to access a single person’s record before being logged off. This “cubbyhole” system would have no capability for searching or retrieving more than one record. By having the information in a central repository, it is easier to apply state-of-the-art computer security techniques since you know where the information is at all times.

    There would be a second offline repository of the medical records that would be used for public health and research. It would have no phone lines or network connections, and therefore would not be subject to improper electronic access. Only authorized personnel in the same room would be able to perform searches. Personnel would be carefully screened, and their activities closely monitored.

    In summary, the eHealthTrust provides a solution to building a RHIO that meets all the key requirements.

    Next time: The first eHealthTrust system in a community

    Consumer Attitudes about Health Information Infrastructure

    December 13th, 2005

    Introduction

    What do consumers think about health information infrastructure (HII)? Are they aware of the growing activity in the HII field? Are they supportive? What services do they want? What are their concerns?

    Fortunately, there is a growing body of consumer polling data that addresses these issues. In this article, I will review what I consider the key highlights and refer you to the sources of this information so that you can explore further on your own. I’ll conclude by describing an excellent set of consumer HII principles that already has substantial organizational endorsement.

    Of course, consumers are the ultimate beneficiaries as well as a critical user group for HII. The idea of consumer access to health care information has been widely discussed over the past few years. Also, the concept of the electronic personal health record (EPHR) – which allows consumers to enter their own relevant health-related data — has become very popular in health information infrastructure discussions (e.g. see the report from the Personal Health Working Group of the Connecting for Health project)

    Providing consumers with access to their own electronic medical records, the ability to enter additional information about their health, electronic communication with their providers, customized reminders about prevention and treatment, and access to the latest authoritative medical news and information are all very important components of HII that will help to improve the health of individuals and populations.

    I find it useful to divide the consumer attitudes about HII into three categories: 1) the overall system; 2) value & uses; and 3) privacy & trust.

    What do consumers think about a national system of electronic medical records?

    Consumers are very supportive of the idea of a nationwide health information exchange. Seventy-two percent of consumers like this idea (composed of 38% who strongly favor it, and 34% somewhat in favor), while only 23% are against it (12% who strongly oppose & 11% somewhat opposed). This is a large and, in my view, remarkable majority who are supportive of the idea of electronic health records on a nationwide basis. I believe it is remarkable because this has not really been a prominent issue for the general public.

    Even more interesting are the percentages of consumers who feel that key issues should be “absolute top priorities” in the development of a nationwide health information exchange. They show a high level of public understanding and support of the key elements necessary to protect health information: authentication (91%), auditing of access (81%), and permission-based access to the information (79% for general access & 50% for access control of specific items so sensitive material such as mental health visits can be suppressed if desired).

    Consumers also express a high level of concern about discrimination on the basis of health information (72% want prevention of this to be “absolute top priority”), as well as a strong desire to keep employers away from their records (68%). A majority of consumers (53%) want access to their own records as an “absolute top priority.” Finally, 38% of respondents expressed a desire for independent governance with public accountability and full consumer participation.

    It is clear from this information that consumers are both well-informed and savvy about these issues.

    What is the value of HII to consumers? What would they use it for?

    Overwhelming majorities of consumers agree that EHRs improve care by reducing medical errors and improving quality (80%) and are very helpful for medical research (81% indicated that using de-identified data from EHRs provides up-to-date medical information and knowledge). Consumers would use HII to check for mistakes in their medical record (69%), check and fill prescriptions (68%), get results over the Internet (58%), and exchange secure, private email with their provider(s) (57%).

    A large majority (71%) of consumers believe that getting medical records quickly in an emergency could mean the difference between life & death. Interestingly, in this same group of consumers, 53% said they had never thought about this before! Closely related to this, 93% of consumers want emergency room doctors to have access to their electronic medical records to reduce treatment errors.

    Finally, 52% of consumers said that they would be willing to pay $5/month or more to have their medical records stored electronically. Clearly, consumers recognize that having their medical records in electronic form has real value.

    What privacy concerns do consumers have about HII and electronic health records?

    Two-thirds of consumers said they are concerned about the privacy of their medical records (36% very concerned & 31% somewhat concerned). Of note is that 34% are NOT concerned (which is surprising to me).

    In the most revealing finding in these recent surveys, 13% of consumers admitted to using one of the following four “information hiding” behaviors: 1) Asking a doctor not to record a health problem or record a less serious or embarrassing diagnosis; 2) going to another doctor to avoid telling their regular MD about a health condition; 3) personally paying for a test, procedure, or counseling rather than submitting a claim out of concern someone else would access the information; or 4) deciding not to be tested out of concern that others might find out about the results. While nearly all health care practitioners are aware of these behaviors (and other similar ones), this is the first time I’ve seen them documented in a survey. Also, it seems likely that even more consumers actually do this than the 13% who admit it.

    Finally, who would consumers trust to be the online host of their electronic medical information? The most popular option is a physician-sponsored web site (57%). Other options are favored by small minorities: health insurer 14%, government 12%, commercial 8%, non-profit 7%, and employer 2%. This may mean problems ahead for those companies that are sponsoring “personal health record” initiatives for their own employees.

    Consumer Principles for HII Development

    Recently, the Markle Foundation’s Connecting for Health project worked with representatives of 14 other organizations to develop a thoughtful and comprehensive set of seven consumer principles for HII:

  • 1. Consumers must have access to their information
  • 2. Consumers must control access to their information
  • 3. Consumers may delegate access control
  • 4. Consumers are informed about how their data may be used/shared
  • 5. Consumers may review names of entities that have had access to their information
  • 6. Information integrity, security, privacy, and confidentiality is protected
  • 7. The system has independent oversight, accountable to the public, with full voting participation of consumers
  • These important principles should be incorporated into every effort to develop HII, as they are both consistent with the views expressed in the polling data, and also address the key concerns of the public. Developers of community HII systems will find it much easier to engage consumer support by following them.

    REFERENCES

    Connecting for Health Surveys
    (2005)
    (2003)

    California Health Care Foundation Survey (2005)

    Accenture Survey (2005)

    Consumer Principles (2005)

    Next time — Measuring HII progress in communities

    Criteria for choosing a community Health Information system

    November 9th, 2005

    Welcome to my eHealth blog. I will be using this space to talk about issues related to converting the U.S. health care system from paper to electronic records. Since you’re reading this, you undoubtedly know that making complete electronic health information and decision support available whenever/wherever needed would save lives, improve care, and save money.

    My objective is to help expedite the transition to electronic records, while protecting (maybe even enhancing) privacy.

    I am a physician (MD) and also have a PhD in computer science. My entire professional career (now over 3 decades) has been spent working on the effective utilization of computers in health care. I currently am an independent consultant helping organizations and communities to develop & implement health information systems.

    Most recently, I was the Senior Advisor, National Health Information Infrastructure, at the U.S. Department of Health and Human Services (2002-5). While there, I succeeded in focusing the attention of the nation and the President on this issue, leading to the creation and funding of the Office of the National Coordinator for Health Information Technology.

    In the mid-1990s, I built the successful (and still operational) statewide immunization registry in Oregon. I’ve posted a separate message (below) with more on my background for anyone who’s interested.

    Today I’d like to discuss a key issue facing communities wishing to move ahead with health information systems. The idea of such systems is to make all the medical records of a patient in that community available for care anytime. These records are now mostly paper, and every location where a patient gets care only has a piece of the “total” record. Many communities are trying to decide how to move forward with developing these systems, so I’m going to suggest a set of evaluation criteria to help guide the decision-making process.

    There are three categories of evaluation criteria that communities should consider in evaluating a potential health information infrastructure:

  • Requirements – does the system do what is needed?
  • Feasibility – can the system be built and operated?
  • Financial – is there a way to pay for the system and sustain it?
  • Let’s start with requirements. To answer this question, the functions of the system (at least at a high level) must be defined. Folks experienced with the development of information systems know that there must be a statement of requirements before you start or you’ll never know when you’re done. In plain English, a requirement is something that you will be able to do AFTER you have implemented a system that you cannot do now.

    There are at least five requirements in this context:

  • 1) privacy
  • 2) transition from paper records
  • 3) access to information
  • 4) incremental steps
  • 5) universal availability
  • Privacy is absolutely critical. Medical information is perhaps the most sensitive personal information there is – everyone should be able to keep this information private and only have it used by clinicians when needed to take care of them. In the context of community health information systems, this means that patients/consumers must control ALL access to their complete records. In my view, this is the only sure way to maintain the trust needed to establish and operate such a system.

    Any electronic records system must provide a reasonable transition from paper records, which are still used widely. At present, only 10-15% of physicians are using electronic health records (or EHRs) in their offices (more on this in a later post). Any new information system must recognize and accommodate to the existence of these paper records. The decision may be to ignore them (which I don’t think is best), but they have to be considered.

    The central requirement for any community health information system is to provide a way to make all the information about a patient available for care when and where needed. To do that, there must be a way to collect and deliver all the accumulated records from the various places where the patient has been (including sites outside the community).

    A community health information system is a large undertaking. Like any other large information system, it is best done in small incremental steps. The “finished system” takes time and it’s best if the gradual development of it results in benefits for more and more people as time goes on.

    Finally, such a system should be available to everyone. I believe participation in such systems should be voluntary. However, no one should be precluded from participating because of the way the system is designed. For example, access to the system via the Internet makes sense, recognizing that 99+% of public libraries provide such access at no charge. Therefore, anyone in the community can utilize the system via the Internet even if they do not have access to it at home. However, for those who cannot use the Internet at home, there may need to be emergency access to certain critical functions by phone.

    The next major evaluation category is feasibility. First, there is user acceptance – will the system satisfy them enough to be used? Next is stakeholder acceptance – closely related to user acceptance. All the stakeholders need to be happy about the system (even if they are not users). For example, while employers may not directly use such a system (except in their individual roles as consumers), they should be comfortable that it is meeting their needs – for example, for improved health care and better accountability. Finally, there is technical feasibility. Has such a system been built before? Does it require new technology? How complex is it (simpler is better)?

    Lastly, financial issues should be considered. How much will it cost to build? Where will the funds come from? Perhaps more importantly, who will pay for the system once it’s built? These questions should be answered very specifically. It is very risky to build a community health information system with a financial sustainability plan that says “it will benefit everyone, so everyone will pay according to the benefits they receive.” While this is a nice principle (and hard to argue with), it is hard to apply after-the-fact. So there’s a need to identify beforehand where the benefits are and who will pay what (and when).

    So if your community is thinking about implementing a health information system, consider using these criteria in the evaluation process as you look at various alternatives. I’ll look forward to your questions and comments about these.

    Do you think there are other questions that should be added to our discussion?

    Next time – Consumer attitudes about electronic health records

    My Background

    October 31st, 2005


    William Yasnoff

    William A. Yasnoff, MD, PhD, FACMI, is Founder/Managing Partner of NHII (National Health Information Infrastructure) Advisors, a consulting firm that helps communities and organizations successfully develop health information infrastructure systems and solutions. Previously, as Senior Advisor, NHII, Department of Health and Human Services, he initiated and organized the activities leading to the President’s $50 million FY05 budget request and creation of the Office of the National Coordinator for Health Information Technology, establishing the NHII as a widely recognized goal for the nation. He is an Associate Editor of the Journal of Biomedical Informatics, Adjunct Professor of Health Sciences Informatics at Johns Hopkins, a Board Member of the non-profit Public Health Foundation Enterprises, Inc., and the author of over 250 publications and presentations, including co-editor of the textbook Public Health Informatics and Information Systems. Dr. Yasnoff earned his Ph.D. in computer science and M.D. from Northwestern, and was elected a Fellow of the American College of Medical Informatics in 1989. A more detailed biography is available in this profile.