Embargoed Until:
August 19, 2008
12:00 a.m. Eastern Time



Christopher Fleming

Is Overreliance On Technical Standards Undermining Efforts To Use IT To Transform The U.S. Health System?

Health Affairs Authors Question Whether Efforts On Technology Standards Absent Alignment Of Policy Objectives And Financial Incentives Is “Magical Thinking”

 The Nation’s Health IT Coordinator And Colleagues Say Current Policy Strikes The Right Balance

Bethesda, MD -- If we are to unlock the potential of information technology (IT) to help transform the U.S. health system, we need to expand beyond narrowly focused standard setting, according to a new article published today on the Health Affairs Web site. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.5.w383

Proponents of health IT must resist “magical thinking,” such as the notion that technology on its own can transform our broken system, absent alignment of policy objectives and financial incentives at the same time. IT is critical to improving health care quality and cost-effectiveness, but a sole focus on technical standards overlooks the “serious structural barriers to the use of IT that have nothing to do with technology,” write researchers Carol Diamond, managing director of the Health Program at the Markle Foundation, and Clay Shirky, an adjunct professor at New York University.

“Current legal and financial incentives provide little motivation to share information across institutions, which is critical to improving patient outcomes as well as efficiency. There is also deep concern on the part of doctors and hospitals about how the technology will be financed, and on the part of consumers about how their data will be used and kept safe from misuse,” say Diamond and Shirky, who have both worked extensively on Markle’s public-private health IT collaborative, “Connecting for Health.”

Three years ago the Office of the National Coordinator for Health Information Technology established the Health Information Technology Standards Panel to establish and harmonize health information standards, and the Certification Commission for Health Information Technology to certify vendor products that meet those standards. Yet to date these efforts are not tied to real-world data exchange, Diamond and Shirky point out.

The two researchers look to the evolution of the Internet and other successful standard-adoption efforts. Highlights of their observations include the following:

-- We should make information policy decisions overtly, not back into them through standards and technology choices. For example, technological choices affect the types of risks to which data will be exposed. Because today’s standards are being created with no clear set of health IT policies in mind, those standards may be incompatible with the health IT policies that are eventually adopted. Post hoc overlay of information policy can modify these kinds of risks but is unlikely to remove them. The benefit of clear policy choices is that they serve to require or forbid certain kinds of implementation.

-- Successful standards -- such as the basic standards for the Internet -- are incremental, never solving every problem at once and often leaving prospective data-sharing protocols to be worked out in the field and later ratified based on user utility. “This approach requires a willingness to accept a high degree of underlying variability at first, as well as the discipline to address only critical requirements for any given increment of improvement. By contrast, the history of failed standards efforts is filled with vendor-approved standards that never passed the crucial test, which is clear utility for the user,” Diamond and Shirky say.

-- Standards can’t make up for the lack of a business case for sharing health information. “The current way we pay for health care undermines the case for investing in the sharing of data -- even though people agree that such sharing is both in the patient’s best interest and a critical tenet of high-quality care,” the researchers say. Diamond and Shirky cite the case of a failed regional arrangement for exchanging health data that would have relied on hospital financing, even as it reduced hospital revenue from duplicative tests.

Diamond and Shirky propose an alternative route to using health IT to help transform the U.S. health system. “This alternative approach would focus on a minimal set of standards at first,” they say, and would make utility for the user and improved health outcomes, rather than vendor agreement, the key criteria.

Diamond and Shirky’s alternative approach “would mean working simultaneously on removing other obstacles while concentrating on those standards necessary for sharing the information, however formatted in the short term, to flow between willing and authorized participants. Finally, it would require clear policy statements that will guide the design of technology.”

Kolodner And Colleagues On The National Health IT Agenda:
“Strategic Thinking,” Not “Magical Thinking”

The national health IT agenda represents “strategic thinking” rather than “magical thinking,” Robert Kolodner, the national coordinator for health information technology, states in a Perspective on the Diamond and Shirky article. Kolodner and coauthors Simon Cohn, associate executive director of the Permanente Federation, and Charles Friedman, deputy national health IT coordinator, describe a broad and multifaceted plan focusing on (1) promoting adoption and use of health IT; (2) establishing collaborative governance; (3) ensuring the privacy and security of patients’ health information; and (4) achieving information interoperability. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.5.w391

“Although we must bear in mind that health IT is a means” to improving health care performance “and not an end in itself, the progress made thus far provides a firm foundation on which to build,” say Kolodner and his colleagues. The advancement of standards has been through a harmonization process involving a broad array of public and private stakeholders, and has not been the traditional “standards by committee.” Kolodner and coauthors also say that technology choices that could affect future policy decisions can be identified in advance and structured to preserve policy flexibility.

The Health IT Planning Process Should Be Informed
By Web-Based Applications From Other Industries

In another Perspective, David Kibbe and Curtis McLaughlin call for a health IT planning process that is more open to input from outside the health care industry. “Over the past six years, expert panels and policy analysts have often ignored the analogy driving the public’s high expectations for health IT: namely, their experiences with Web-based applications in information-intensive activities such as banking, travel, finance, education, music, and interpersonal communication,” write Kibbe, a senior adviser to the American Academy of Family Physicians, and McLaughlin, a professor emeritus at the University of North Carolina. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.5.w396

The article by Diamond and Shirky will be available when the embargo lifts at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.5.w383

The Perspective by Kolodner and coauthors will be available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.5.w391

The Perspective by Kibbe and McLaughlin will be available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.5.w396


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. Web Exclusives are supported in part by a grant from the Commonwealth Fund.


©2008 Project HOPE–The People-to-People Health Foundation, Inc.