Shifts in the architecture of the Nationwide Health Information Network

The linked article below Shifts in the architecture of the Nationwide Health Information Network is from the January issue of JAMIA. The abstract states that recent ONC activities (particularly from the Federal Health Information Technology Strategic Plan 2011-2015) undercut the limited business model for RHIOs, decreasing the likelihood of their success, while making the NwHIN dependent on nascent technologies for community level functions such as record locator services. The piece claims these changes may impact the health of patients and communities. They call for independent, scientifically focused debate on the wisdom of ONC’s proposed changes in its strategy for the NwHIN.

The article gives a good overview of the history of RHIO's and makes some good points on community level exchange efforts and does raise some concerns around running headlong into the PCAST recommendations. I agree with the promotion of a non-partisan commitment to achievement of a common vision for the NwHIN. However, there are some flaws in the conclusions of the piece that I think deserve discussion.

First, the article undercuts its own argument against ONC policies by pointing out that many of the ONC funded Beacon Communities are doing exactly what the authors call for. They then cite research that show a dramatic increase in local HIOs under these same policies which they decry. Arguing that the number of RHIOs has more than doubled, funding is coming from a new innovative approach, and the sustainability issues are still not solved, is specious at best.

I also agree with much of the following statement:

The approach is internet-like in its promotion of point-to-point information exchange through standards and interoperability initiatives such as DIRECT. It will also rely upon web services such as directories for identification of providers and facilities that are analogous to the Domain Name Services (DNS) model underlying the internet, along with internet-based security models. These yet to be constructed services will allow users to look up how to send data to providers and will specify security operations. The advantage of this approach is that it may radically lower the cost of connections for data exchange between parties for ‘push’ transmission through elimination of expensive custom interfaces. It may also speed up the process of health information exchange, making it potentially possible to require health information exchange to earn incentives under the administration’s Meaningful Use policy.

The implication of "yet to be constructed services" is that somehow this approach is flawed. I am very impressed with the development of these services and feel extremely confident that this approach will work. This is exactly the type of disruptive innovation that Clayton Christensen refers to as "new approaches or technologies that, while initially offering lower performance than established methods, have far lower entry barriers, opening up new markets of greater scale, in which the disruptive technologies eventually grow to equal and often surpass the capabilities of incumbents." This is the free market at work! How the author's could object on these grounds baffles me...

Finally, they claim that ONC strategy depends on the success of the PCAST model. This is a stretch. While the Strategic Plan does refer to PCAST, it is certainly not wholly dependent on the approach. Concluding that creation of the Health Internet is politically motivated does not wash. I understand that change can provoke fear in some quarters, but using an Internet based approach is the future of health information exchange. You can resist and become irrelevant or work together to create the system of the future...
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