State eHealth Leaders Offer ONC Some RFP Advice

In a letter distributed through the Internet and dated July 2, representatives from several states expressed their concern over the current round of NHIN RFPs and provided some positive suggestions.

• Follow this link to the letter.

To this writer - who has spent untold days weaving through these documents - the overall aims of the NHIN proposal are laudable but the comprehensives scope suggests attaining results through even a multi-year contract will be a challenge. Core infrastructure issues are addressed and are essential, but the devil is in the details, and woven through the many guideline documents and complex uses cases, there are plenty of details.

The problem, it appears to this writer, is an inability to distinguish clearly between the interesting and the acutely important features of a nation-wide health information infrastructure based on the political and technical realities of Year 2007 health care.

At the same time, it is equally unclear what a "state health information exchange" really is, since like the NHIN RFP, these are aspirations more than realities. Ironically, the state health information exchange group representative of this note got its start as part of an ONC-funded AHIMA project that wanted to study the best practices of the self-sustaining state-level RHIOs. Again, this concept is laudable aspiration more than a reality.

In short? There is much work to do, and focusing on the immediate, vital needs seems to be the best strategy.

Portions of the PDF letter (addressed to an ONC contracting officer) are quoted herein verbatim.

This letter is forwarded to you as written documentation of issues and comments offered to the National Coordinator for Health Information Technology by several leaders of state level health information exchange entities and initiatives. The individuals offering this input are members of the State Level Health Information Exchange Consensus Project (SLHIE project) Steering Committee who participated in a teleconference with the Coordinator’s office during the SLHIE project’s recent meeting on June 27, 2007.

The SLHIE Steering Committee consists of representatives from 11 states, two of whom were not represented during the teleconference. As leaders of state level HIEs, those who participated in the call are committed to the vision for achieving a national health information network and appreciate the leadership of the ONC staff as it works toward realizing a national network of networks. At the same time, the group is very concerned that the current ONC NHIN contract RFP does not effectively align the national agenda with what states need most at this time to move health information exchanges from their current formative, development stage to production information exchange operating units. Of the nine states participating in the call, six indicated that they would not be submitting proposals for the NHIN contract, one stated that it will finalize a decision within the next 24 hours and two are going forward with the development of proposals.

The core concerns with the current NHIN contract RFP that were highlighted during the call as driving factors in the decision to not go forward with statewide proposals include:

1. The development of health information exchange remains a bottom up process that will grow in to a nationwide network over time. The focus of the current NHIN contract RFP on demonstration of the federally defined use cases does not meet the immediate needs of local, regional and statewide exchange initiatives still struggling with more fundamental issues of how to exchange data, how to accomplish process interoperability, how to develop consumer and other stakeholder buy-in, and how to build out sustainable business models.
2. The focus of the RFP on demonstrating the use cases now does not provide the flexibility to individual health information exchanges to focus on what they deem to be their critical path requirements to becoming operational.
3. The use cases do not translate into products and services for health information exchanges that generate sustainable business solutions and the growth of state level HIE.

The objective of this letter is to offer a series of recommendations for ONC to consider as it manages the current NHIN RFP process and looks forward toward future funding opportunities. The state health information exchange representatives appearing as signators on this letter stand ready to help ONC in any way possible to better align the federal agenda to promote health information exchange with the priorities and needs of statewide exchange initiatives. Recommendations are as follows:

1. Funding the growth of health information exchange at the local, regional and statewide levels is the correct focus of priority for ONC to accomplish implementation of a national health information network. To assure the highest probability for success going forward, we believe that ONC should consider expanding the pool of money committed to this funding on an annual basis and enlarge the flexibility of contract terms determining how individual HIE initiatives might creatively work toward a common federal goal. While prescribing strategic objectives and rendering interoperable standards are extremely valuable, prescribing tactical details can be counterproductive and met with unintended and predictable local and state objections, despite Grantee goodwill. The RFPs and Grants should have “play” built into them allowing individual HIEs space for community customization.
2. Expand the federal HIE development timeline and funding plan. The current NHIN contract is too aggressive in terms of scope of deliverables and time to delivery to assure the time needed for developing HIEs to mature and solidly address basic exchange challenges.
3. Consider defining optional near term minimum clinical data sets as the focus for health information exchanges in their initial development that encourages incremental growth toward the broader use case data sets over time.
4. Focus funding on promoting the adoption of concrete tools that increase the probability of HIE initiative success such as use of the e-Health Initiative Value and Sustainability model as a foundational strategy for developing an HIE.
5. Focus funding priorities on HIEs achieving business sustainability in how they approach data exchange, develop legal frameworks and encourage stakeholder investment and develop sound business models. Consider incubation grants that require Value and Sustainability Model based community business cases.
6. Review and address the incompatibilities of the federal contracting requirements with state contracting requirements for multiple bidders on state sponsored projects.
7. Harmonize the federal HIE agenda with the practical needs of statewide health information exchange projects. Consider using a group like the State Level Health Information Exchange Consensus Project Steering Committee as a resource for reviewing and commenting on draft contract proposals and funding priorities.
8. Harmonize the development and timing of federal contracts and grants focused on promoting health information exchange. Currently there does not appear to be a common federal vision for health information technology adoption and health information exchange priorities shared between federal departments and agencies. This lack of harmonization has resulted in multiple, unaligned grant and contracting RFPs being issued at the same time over the past ninety days.
9. For the current NHIN contract cycle, consider holding back a portion of the total funds available to explore promoting some near term trial implementations that address demonstration of some of the basic start up HIE objectives outlined above.

The signatories represented The Rhode Island Quality Institute, the Tennessee eHealth Council, the Massachusetts Health Data Consortium, the Maine HealthInfoNet, the Colorado Regional Health Information Organization, CalRHIO, Florida’s Agency for Health Care Administration, and the Utah Health Information Network