HHS Secretary Mike Leavitt, a fan of historical analogies, used one to explain his proposed transition of the American Health Information Community—a government-appointed, -dominated and -funded information technology advisory panel—to a private-sector successor organization he wants to put in its place by early next year.
Leavitt said at a public forum Friday that he was looking for a person or organization to be a modern day George Washington and serve as a "convener of stature" to call together another group of founding fathers to be the architects of what he called AHIC 2.0.
"We need to bring the James Madisons and the Alexander Hamiltons of the world together," Leavitt said. "Can we create a George Washington here? If we could even have two or three organizations step up, that would be OK."
Meanwhile, several critics counter that the move to privatize the AHIC is a move in the wrong direction, with one opponent suggesting it would pre-empt Congress, which has legislation pending that would make the AHIC a needed, permanent part of government.
As AHIC chairman, Leavitt has played a high-profile role in leading the federal government's efforts in pushing adoption of healthcare information technology standards with an eye to developing an interconnected national health-information network. When he announced the creation of AHIC in 2005, he likened the needed work by the healthcare industry to adopt IT standards in creating the network to the concessions on rail gauges made by the railroad industry in the 19th century. That initial collaboration on a standardized rail gauge, the former Utah governor reminded, was a necessary first step toward the creation of the transcontinental railroad and the pounding of the golden spike connecting the converging rail lines in his home state.
One of the questioners at Friday's forum, Todd Smith, director of the strategic action group at the American Health Care Association, said that members of the new AHIC might want to stray from the path set for them by the current AHIC, but would be constrained by the work already in the pipeline.
"A lot of the process may well be set in stone for maybe a year or two," Smith said. "You bring new, creative minds to the table but they will work off an agenda that was set in the previous year."
While Leavitt noted the two organizations will run in parallel at first, the exiting AHIC has "a full agenda" that he won't abandon, but rather hopes to "drive that as far and as fast as we can." So, the successor organization will be inheriting that agenda, which Leavitt sees as a good thing. "I don't want the new entity to have to remake all the work groups and priority selections (that we've made). I'm hopeful that the new entity doesn't lose any momentum."
Leavitt said the government won't be completely withdrawn from the successor organization or its goals. For example, Leavitt said adherence to standards must be linked to payment, and as the single largest healthcare payer, government can do that.
"That's one of the ways that the government needs to play its legitimate function," Leavitt said. In addition, "I'm going to play my role as a regulator."
But government should not impose standards on the entire industry, he said. "I could as HHS secretary go out and set these standards but I'd likely get them wrong." A formal request for
grant proposals was published Aug. 13 allocating $13 million to support an AHIC successor organization for two years. The grant winner will "convene a planning board; design and establish the AHIC successor governance, business and operating models; and elicit members such that the resulting organization is a balanced, effective, public-private collaboration of organizations and individuals in all sectors of the health community."
Sabrina Corlette, director of health policy programs at the National Partnership for Women & Families, picked up on the analogy of the Constitutional Convention, noting that "there were huge swaths of people who were not represented and as a result we had huge upheavals such as the Civil War and the equal rights movement."
Ensuring that all interests are represented in the new AHIC will be a challenge, Corlette said. One problem that consumers and consumer groups have is "they don't have the resources to stay engaged," she said. The highly technical issues that will be discussed, the thin staffs of many of the not-for-profit groups, and the dues to the successor AHIC that are being proposed to make the new organization self-sustaining pose "huge problems for consumer groups, local public health organizations and local governments," Corlette said.
The government's proposed dual role of payer and regulator was too narrow for questioner Brent Gendleman, president and chief executive officer of 5am Solutions, a Reston, Va.-based consulting and software development company working with the life sciences industry.
"You've limited the role of government to one of regulation, that carries a big stick and pays the bills," Gendleman said. "The government also represents the people and carries the weight as arbiter." Gendleman said he, too, fears that the small patient-advocate organizations "are not going to have the right kind of seats at the table.
"That George Washington is going to be a tough role to fill, and my guess is it's going to be empty," Gendleman said in a telephone interview after the meeting. "The government has a greater role, which I think they're shirking, by saying, 'Let the market push us.' No. The market led us here, and if you just let the market do it, you're not going to get the results you want. I realize that is a philosophical difference, especially with this administration. But government has to play a role bigger than the one that they're envisioning.
"Yeah, I'm a CEO. I encourage business and I think there will be plenty of business, but it's different when you're talking about something that supports the common good," Gendleman said. "A narrow bottom line is what is driving the industry today. This is my piece and I'm going to protect it and I'm not interested in interoperability unless it raises my bottom line. They have 100,000 dying every year in hospitals. It's a no-brainer. That's a technical problem we know can be solved.
"I don't think a consortium of companies alone is going to be enough to be the stick to say I think we can meet your individual industry needs to the bottom line and meet the goals of improving quality and decreasing costs," Gendleman said. That role, he said, is the government's to play.
Gendleman's thinking was echoed by the AARP, in an Aug. 10 letter to Leavitt from David Sloane, AARP's senior managing director for government relations and advocacy, who said the proposed new AHIC "lacks essential public oversight and accountability."
Developing consensus on key policy issues for the national network, including privacy and security issues, "must be
addressed in order to ensure that consumers have confidence that the network will not compromise their own sensitive personal health records," Sloane said. "The pivotal and sensitive nature of this task requires a strong, inclusive, open and accountable decisionmaking body. The business models suggested to
replace AHIC would not meet this requirement. In fact, we believe AHIC's current structure needs to be strengthened as it would be under the AARP-endorsed bipartisan Senate Wired for Health Care Act (S. 1693). This legislation would guarantee accountability, ensure meaningful consumer participation, and
give AHIC a specific mandate to address key concerns on privacy and security in a clear and public process."
"While the private sector clearly needs to be 'at the table,' we feel strongly that
AHIC should continue to function with active oversight by the federal government
to ensure that policy recommendations reflect the full national interest," Sloane wrote.
"Replacing AHIC with an entity that is governed and operated without federal
oversight would have serious shortcomings, which include:
- No assurance of inclusion of all stakeholders or transparency in operations.
- No assurance that funding for the entity does not create potential conflicts of
interest.
- No clear accountability to Congress or the public at large.
We therefore urge you to withdraw proposals to remove AHIC from public
oversight and accountability and instead work with Congress to enact legislation
to strengthen AHIC's accountability, inclusiveness and mandate."
Technology consultant Gary Dickinson said AHIC needs to slow down and see what standards it and the Health Information Technology Standards Panel have anointed that actually work in the real world.
"AHIC has no track record of success. HITSP has no track record of success validated in real world implementations," said Dickinson, who works with CentriHealth, of Nashville, a personal health record system developer. "Why not validate these recommendations, without taking on additional use cases? Otherwise succession seems moot. Let's be sure we're successful with the seven use cases we have under our belt. We have limited evidence we have any of this stuff implemented in any meaningful way."
Dickinson also serves as a member of the HITSP, an HHS-funded organization working to harmonize health IT standards to "use cases" developed by AHIC.
Robert Kolodner, the head of the Office of the National Coordinator for Health Information Technology, closed the forum by outlining the timetable for succession. Kolodner said a
public notice has been posted spelling out how much federal money is available for the new organization during a two-year transition period. Forms to apply for a grant of up to $13 million are available online. ONCHIT will conduct a public meeting for potential applicants on Sept. 5.
Kolodner said ONCHIT wants to receive a letter by Sept. 15 from applicants expressing their intent to apply. Applications will be due Oct. 5 with the award slated on or before mid-November, he said. And it will be HHS, not AHIC, that chooses the AHIC successor, Kolodner said.
Earlier this year, HHS contracted with three organizations to develop potential plans for a successor to AHIC. Their work has been synthesized by the government and published as a white paper that was put out for public comment Aug. 6. The
comment period on the white paper ends Sept. 10.
Those comments "will be gathered together and provided to the awardee for them to use as they design their process," Kolodner said.
Linda Kloss, chief executive officer of the American Health Information Management Association, asked the extent to which the work of the collaboration that produced the white paper will be called upon in the next round of creative thinking about the model for the successor AHIC.
Kolodner said the government thinking is "there is a lot of strength" in the model outlined in the white paper, but a "vendor could say, 'I have a better way to do it.' Nothing is off the table. But you need to make the case why that is the better way. Bring your best ideas to the table, the best people to the table."
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