Thursday, September 20, 2007

Institute of Medicine and the Office of the Network Coordinator

Review of the Adoption and Implementation of Health IT Standards by the DHHS Office of the National Coordinator for Health Information Technology

Remarks: Mark Frisse, September 17, 20007

In response to a request from the Office of the National Coordinator for Health Information Technology in the Department of Health and Human Services, the Institute of Medicine (Board on Health Care Services) in collaboration with the National Research Council (Computer Science and Telecommunications Board) are undertaking a fast-track study to examine the standards activities of Office of the National Coordinator.

From this writer's correspondence, it appears the mission is broader and will "examine the processes of the Office of the National Coordinator, determine how effectively they are working to advance the national Health IT agenda, and make recommendations for improvement as warranted." In a note sent on September 13, the charge is stated to include examination of "how effectively the ONC processes (HITSP, AHIC, CCHIT, NHIN and related efforts)." Asked to speak briefly before the group, the following questions were submitted.
Question topics for consideration


The summary report, written by the Gartner Group, has little data but an abundance of desired features and other characteristics. The contractors no doubt were charged with producing extensive technical reports and a financial analysis as well.
  • Where are the complete data from the NHIN I contractors?
  • What are the lessons learned from NHIN I?
  • What did the financial analyses performed by the contractors show about the costs and benefits of operations?
  • To what extent were the contractors able to deliver the contract specifications within the time allotted?
  • To what extent have the communities who participated in these initiatives carried on with the contractors or their prototype architectures? The experience of AHRQ's state-regional demonstration projects suggests that a true demonstration takes many years.
  • How were the lessons learned translated into the 20 tasks as well as the functional specifications and requirements for the NHIN II solicitation? More specifically, what did the demonstration projects teach about audit logs, standards, record merging, clinical utility, federated identity management, consumer authentication, and the many other issues raised in the NHIN II request for proposals?
  • How should the lessons learned about the contracts guide a timeline for clinical decision support and other long-term aims?
  • To what extent can complex, accelerated contracts actually resolve complex social issues surrounding consent, authentication, privacy, consumer access, and integrated adoption? To what extent is ONC, to paraphrase Governor Bredesen, pushing for adoption of "Version 6.0" before the requirements of "Version 1.0" are understood and accepted?
  • When compared to other agencies with a longer history of such work, how successful has ONC been in creating clear rfps and managing complex projects? What additional support and collaboration do they need to become more effective and more widely accepted?
National / Federal coordination
  • How successful has ONC's strategy been in engaging states?

  • How should ONC participate with other groups to establish guidelines to accelerate effective adoption of health care technologies in clinics, pharmacies, nursing homes, hospitals, and other provider settings?
  • In the area of policy and regulation, to what extent did the HISPC effort lead to greater awareness of the enormous differences in interpretation of HIPAA, consent, and other matters?
  • How did the outcome of HISPC match up with the expectations set forth in the RFP? (Linda Dimitropoulis of RTI has written an excellent summary report.)
  • What role did ONC play in the Medicaid Transformation Grants? These grants to states exceeded $100 million and address fundamental issues in information technology. Should these grants not be part of a coordinated federal or national effort? Is there any coordination between the CMS MITA platform and the technology initiatives of ONC?
  • What was the initial intent and the outcome of the AHIMA / FORE contract to examine the best practices of self-sustaining state-level RHIOs? How were the participants from 9 states selected?
  • Why were many of the same participants in the AHIMA / FORE process critical of the NHIN II solicitation in their public letter?
  • What lessons were learned from this process and report (written largely by Vicky Prescott) and how were these lessons learned translated into subsequent activities?
  • What role has ONC played in e-prescribing? To what extent are the many documented lessons learned from the AHRQ/CMS pilots incorporated into ONC's agenda?
  • Why, over the past two years, has ONC restricted its view of the "Nationwide Health Information Network" to include only the NHIN contractors and not other HHS efforts like the AHRQ-funded state and regional demonstration grants, HRSA initiatives, and independently-funded initiatives? Are these initiatives not part of the NHIN?
  • To what extent do individuals from other federal or non-profit agencies (or those who collaborate with these agencies) believe ONC eases the overhead of working with the federal government; to what extent does ONC actually add further complexity? What positive suggestions would these groups add to improve even further ONC's effectiveness
  • The creation of AHIC has generated an every wider array of committees, initiatives, and proclamations.
  • What is ONC's role in this effort? How does this role compare with that of other agencies and groups with a long history of activity in health information technology, including CMS, NCVHS, NIST, FDA, AHRQ, NLM, DoD, and many others?
  • Given the enormous amount of time and activity, it is hard to understand what the most critical issues facing AHIC are. What are the three most important initiatives that ONC is addressing in the context of AHIC?
  • Are there issues for which standardization is premature? How much should any federal body do at present to assure the public interest where personal health records and health information exchanges are concerned? How much should be regulated?
  • In his HIMSS address, Governor Phil Bredesen suggests that much work has to be done on standards. What has been ONC's contribution to these efforts and to what extent should this be coordinated by NCVHS or other groups?
  • What is ONC's roles in executing the Executive Orders concerning health IT. What are the intellectual and policy initiatives that must be addressed to realize a truly "transparent" health care system?
  • To what extent do we have meaningful definitions of terms like "transparency" or "quality." How can a body be asked to execute on an executive order when no clear consensus exists on such critical terms?