Health connectivity: the global holy grail

A late scheduling change combined two sessions on Wednesday evening, bringing together officials from four national connectivity programmes for a frank discussion on the challenges the UK, US, Canada and Australia face in bringing interoperable electronic health records and other information technology to tens of millions of people.

Describing the national programme’s approach, Richard Granger, NPfIT director general, said that policy, planning and standards are just as important as cash. Granger said that the project to wire a health system for 52 million people is fraught with uncertainty, bureaucracy and complexity.

“Implementation is going to require about 380 million activities,” Granger said. A summary plan of the NPfIT contains a daunting 112,000 milestones.

Granger noted that England does have an advantage on the US in that more general practitioners in Britain are using technology in their practices. “The challenge is to get them to use systems that are compatible with others,” he said.

Canada, on the other hand, is busy putting standards in place and choosing its battles carefully before attempting to build a full-powered national health IT network.

The federal government joined with the 10 provincial and three territorial governments last decade to reach consensus on the need for an “infostructure” in health, including interoperable electronic health records. In 2000, 14 government entities founded Canada Health Infoway, an independent corporation charged with co-ordinating the transition to EHRs and other health IT.

The goal is to cover 50 per cent of the population by 2009, according to Infoway’s chief technology officer, Dennis Giokas.

With 1.2 billion Canadian dollars (£521 million) committed to it so far, Infoway is following nine strategic investment programmes, including interoperable EHRs, telehealth, laboratory systems, data repositories and standards development. “It’s focussed investment on health IT throughout the country,” Giokas said.

Canada’s universal healthcare system is funded by each province and administered by semi-autonomous health regions, through Giokas expects to have literally hundreds of regional data warehouses rather than central storage.

Although Canada has just 31 million inhabitants, Giokas estimated that Infoway has perhaps 20 to 25 per cent of the money that it will need for the next five years. Even with private industry expected to contribute another 25 per cent, leaders of the Canadian project are choosing their battles carefully.

“Don’t boil the ocean,” Giokas advised. “You’ve got to focus on what you can afford.”

For now, Infoway is limiting its work in computerised physician order entry to medications.

Canada Health Infoway is attempting to track the value of implementation based on geographic coverage, usage and adoption. Granger called those good metrics.

Far across the yet-unboiled Pacific, Australian officials would love to have Canada’s predicament.

“We have a dysfunctional federated system,” said Dr Branko Cesnik, representing the Australian Health Information Council and National Health Information Group—year-old components of Australia’s nascent national health infrastructure project.

The two organisations have the unenviable task of creating order out of chaos, according to Cesnik. Australia has a dire need for data standards in healthcare, though the country does have a general broadband initiative in progress.

Leadership in health IT was also sorely lacking, Cesnik said. “There are a lot of champions, but few of them are leaders.”

Health policy decisions for the whole country are made in Canberra rather than in each state, yet Cesnik contended that there was no real sense of authority, especially in IT. The cost of building health IT networks barely has come up, he said.

“The lack of co-ordination has led to a diffusion of our costs," Cesnik said. “We are not as organised as Canada.”

But consumer demands for wellness programs and multi-faceted pressures for safety and quality are changing the dynamic. Health officials are convening a first-ever national summit on health IT this December in Victoria.

The vision for the next three years is to develop strategy, with the notion that health IT should be an enabler of quality. “In three years, there will be a national (health IT) authority,” Cesnik promised.

If only the United States had it so easy.

“We’re really laggards in this area,” Dr William Yasnoff, co-ordinator of the National Health Information Infrastructure (NHII) project for the US Department of Health and Human Services (HHS), said.

Of the US healthcare system, Yasnoff said, “Basically, it’s a mess.” Some in the audience applauded.

The US has made some progress this year, as President George W. Bush created the Office of the National Co-ordinator for Health Information Technology (ONCHIT) within HHS and named Dr David Brailer to lead it. Yasnoff reports to Brailer.

Brailer has spelled out a four-pronged “framework” for bringing EHRs to most Americans within 10 years: inform clinical practice, interconnect clinicians, personalise care and improve population health. The plan generally has been well received.

While the NHS will save ?6 billion over the next 10 years by aggregating its purchasing, according to Granger, the US may have a difficult time realising similar savings due to the structure of its health system.

“In a government-funded health system, the government is going to have to pay for IT because the government pays for everything,” Yasnoff said. Although the federal Medicare programme covers older Americans and indigent citizens receive care through the federally funded and state-administered Medicaid system, the US model is based on employer-sponsored private health insurance.

In the US, healthcare providers generally foot the bill for technology that can prevent medical errors and reduce overall costs, but insurers reap most of the fiscal benefits. “We’re asking physicians to buy a Lexus for the health insurers,” Yasnoff explains.

“We need to re-align our financial incentives because the way things are set up now, all the incentives are to do the wrong thing,” he says.

That is not an easy task, since Medicare is the largest single healthcare payer in the US and private insurance companies usually take their cues from Washington.

Medicare can run “demonstration” programmes as long as they are budget-neutral, but Yasnoff said that government accountants do not have a good way to measure savings from health IT. Any other major policy changes require federal legislation, unlikely in the current political climate.

“There’s an awful lot of scepticism in Washington, D.C., about whether these savings are going to be real,” he said.