GAO's Latest ONC Report

The considerable progress in health information technology correlated with the HHS Office of the Network Coordinator is summarized in the most recent GAO report on this office. This report describes a "numerator" of programs funded by ONC, but fails to include the "denominator" that would include the far greater degree of innovation congruent with the Secretary's vision but equally the product of thousands of professionals and consumers across our country who - on their own and without strong government mandate - have concluded that a more effective health care technology infrastructure is essential to any improvements in our ailing health care system.

A "coordinator," one could argue, should address how the growing momentum created by all of these myriad programs can be harnessed to a greater social good. This writer remains a cautious optimist in this regard.

In testimony before the Senate Committee on the Budget on February 14, Valerie C. Melvin of the GAO summarized the overall HHS efforts, urging again for a national strategy.

• Follow this link to the report (GAO-08-499T)

The report describes the considerable progress achieved . And it concludes with mention of the strategic planning process underway by the relatively new leadership at ONC.

The report states:

The National Coordinator ...told us that HHS intended to release a strategic plan with detailed plans and milestones in late 2006. Nonetheless, today the office still lacks the detailed plans, milestones, and performance measures that are needed. According to its fiscal year 2009 performance plans, the Office of the National Coordinator has prepared a draft health IT strategic plan, which it intends to release in the second quarter of 2008. If properly developed and implemented, this strategy should help ensure that HHS’s various health IT initiatives are integrated and effectively support the goal of widespread adoption of interoperable electronic health records.

The current GAO report builds on previous reports cited and provides a high-level overview of budgets, progress, and challenges. The report repeatedly makes statements like "HHS has not yet defined detailed plans and milestones for integrating the various initiatives, nor has it developed performance measures for tracking progress toward the President’s goal for widespread adoption of interoperable electronic health records by 2014. "

Since 2002, ONC has received about $200 million and has made considerable progress along several critical areas. Cited in the report are details on the progress made in:

• Advancing the implementation of both outpatient and in-patient electronic health records
• Recognition by the Secretary of some interoperability standards
• Trial "NHIN II" implementations
• A toolkit and report on the extensive privacy and security efforts at the state and national level

One could challenge the impact of some of these efforts. This writer is of the belief that the NHIN I initiate was conducted in too much haste over too short a time to achieve its true impact. The GAO report states (p 10) that "according to HHS, in early 2007 its contrators delivered final prototypes that could form the foundation (emphasis added) of a nationwide network for health information exchange. The NHIN I summary report cited 24 "core services" 12 "common transaction features," and 14 "annexes on common themes like identity arbitration, consumer data-sharing permission, and data routing. Among these 50 "things" (not counting the many other features and specifications decried by the use cases, one hopes that some immediate and fundamental high priority steps will emerge as initial steps in the road map. This writer believes that about 12 of the core services lists are "must do" high priorities, but that many others may best be left for later consideration.

The report later states (p 11) that at the end of the first contract year (September 2008), "HHS intends for the nine organizations and the federal agencies that provide health care services to test their ability to work together and to demonstrate real-time information exchange based on the nationwide health information exchange specifications they define." The specifications and test materials will be placed in the public domain so that "they can be used by other health information exchange organizations to guide their efforts to adopt interoperable health IT." These documents will be valuable. (One hopes that the NHIN I materials will someday be more easily accessed as well.)

But how should - and how can - even an organization as talented as ONC develop a national strategy. This writer has a few suggestions:

Look to the successes, not just NHIN contractors. A lot is going on in health care delivery organizations, health plans, and exchanges that are funded by AHRQ, private resources, and other sources. Indeed, many of the largest and most vibrant exchanges have chosen not to participate in NHIN at this juncture.

• Build on the idea - first raised by the Commission on Systemic Interoperability - that strongly suggested the availability of a medication history for every American as a top priority
• If a second "quick win" is desired, focus the same approach on clinical laboratories
• Create guidelines for identity management. This is a critical topic for consumers, for e-prescribing, and for other applications. If e-prescribing is expanded to include controlled substances, identity management will become even more pressing
• Focus on simple core guidelines for confidentiality and privacy that transcend applications that that can serve as a basis for new and revised legislative and policy remedy
• Focus - as HHS is - on incentives to adopt helpful technologies that foster a more effective system of care
• Table or adjourn 50% of the discussions taking place on topics that are not "foundational." To paraphrase Governor Phil Bredesen's remarks at the 2007 HIMSS meeting, don't try to build version 6.0 before you've got version 1.0 working.

The literature - and our experience - are full of examples of successful approaches to strategy. Such a strategy is possible in a way that transcends the transfer of power at the executive branch of the federal government and the ongoing changes in states and communities. Central to every approach is a realistic set of expectations, focus, and incremental steps.