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Controversies about building the IT network

A couple of days ago, Brian Ahier, blogger and Oregon-based health IT evangelist, started a ruckus on Google+.

The spicy discussion centered on an article in the Journal of the American Medical Informatics Association, "Shifts in the architecture of the Nationwide Health Information Network."

Lead author of the article is Dr. Leslie Lenert, professor of medicine and biomedical informatics at the University of Utah School of Medicine in Salt Lake City. Lenert previously headed the National Center for Public Health Informatics at the Centers for Disease Control and Prevention.

Both Lenert's article and the dialogue that it catalyzed are worth reading.

Lenert wrote about the shift in direction by the federal government in guiding development of the Nationwide Health Information Network.

Most folks reading this will remember that the original NHIN envisioned a “network of networks” formed from linked Regional Health Information Organizations. The Obama administration has adopted a more diffuse approach, funding state-based health information organizations through the American Recovery and Reinvestment Act, but also supporting a future NwHIN schema with more Web in its DNA.

This alternative vision was validated by the President's Council of Advisors on Science and Technology in late 2010. But the PCAST report threw the industry and even some federal health IT planners a curve.

One Lenert gripe is that any shift away from a RHIO-based system should have been prefaced by a campaign for national consensus and it wasn't.

“It's kind of good for the country to agree on the vision,” Lenert said in a telephone interview.

“They threw the PCAST report out there and their hand-picked advisers said, ‘Hmm, it doesn't move me.'” By hand-picked, Lenert was referring to members of the HIT Policy and Standards Committees and their ad hoc PCAST workgroup, who were, in fact, in somewhat of a quandary about the PCAST shift.

“It's not something you commit the country to if you haven't proved it works,” Lenert said.

The trouble with RHIOs, of course, is that many struggle financially. Lenert said that's because many RHIOs take on “public utility” responsibilities that are good for the community, but can't impose a mechanism to fund them. That's a flaw the government ought to fix, he argues, and I agree with him.

Lenert's chief, but not only, antagonist on the thread is Arien Malec, a vice president at Relay Health, a McKesson HIT subsidiary. Malec worked for the ONC, heading its Connect and its Standards and Interoperability Framework projects.

Malec describes some, but not all, RHIOs as “rent seeking” monopolies, including those that Lenert proposed that would socialize the costs of utility services.

Market-driven exchanges “could therefore be seen as undermining the rent-seeking utility RHIO model, because results delivery is often a bread-and-butter exchange transaction and making exchange and interoperability cheaper makes it harder to collect monopoly rents,” Malec wrote.

There's a lot of ponder in this debate, and I encourage you to read the arguments for yourself.

Follow Joseph Conn on Twitter @MHJConn.

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