Washington's strange love-hate relationship with health IT policy

By David Kibbe

With less than loud fanfare -- barely a peep, really -- the Office of the National Coordinator for Health IT (ONC) finally last week released its ONC-Coordinated Federal Health Information Technology Strategic Plan.

The plan is more than two years overdue and came only after scolding from a Government Accountability Office report in 2006 and an internal, semi-secret review of ONC's doings by the Institute of Medicine late in 2007. The IOM criticized ONC for the lack of a viable strategic road map almost four years after President Bush's call for interoperable health information technology and personal health records. A lot has happened since 2004 in this area, though you'd hardly know it reading the ONC Plan.

ONC is a top-down, heavily bureaucratic, large-medical-enterprise-centric, and large-IT-vendor-led juggernaut that has always been out of touch with what goes on down on the ground where consumers, patients, nurses, and primary care doctors live and work.

By out-of-touch, I mean completely oblivious to the impact that the Internet and the Web have made in virtually every other information intensive industry, profession, and realm of social interaction outside of the stilted world of health care. Out-of-touch as in asking military defense contractors to bid on a separate and wildly expensive National Health Information Network in order to make it possible for "interoperable" exchange of health information between Harvard and Stanford, and similar large institutions; a plan that caused former Intel chairman Craig Barrett to comment drily, "We already have a NHIN; it's called the Internet."

But there is something eerily obsolete and downright weird about a strategic plan offered up by ONC in the dying days of the current administration that proposes sometime in the next four years to "achieve an interoperable health IT architecture for the nation in support of patient-focused health care and population health." While at the same time, the report ignores -- and I mean completely ignores -- the progress being made in the private sector to enable personal health information to travel safely and securely on the Internet using the same IT and communications networks that most information for commerce, and an increasing amount of health data, already employs.

What time zone have these folks been lost in?

It's as though the last four years never occurred. It's as though these people and institutions never heard about medical search, health social networking, wikipedia, Google Health, Microsoft HealthVault, or the Continuity of Care Record standard. To read the ONC Strategic Plan you would never know of the existence of HealthGrades and the other quality and transparency reporting sites on the Internet; the SureScripts network that was used for 100 million ePrescriptions last year,; the hundreds of  thousands of lab results delivered to medical practices over the Internet using Web applications every day; or the thousands of medical practices that have deployed Web-based technology for billing and claims administration, Web portals for communications with their patients, and clinical systems for helping with care management. 

The biggest misstep (other than the RHIO fiasco) that occurred at ONC's inception was the emphasis on developing new standards, based on the erroneous assumption that a lack of health data and IT standards is the root cause of the unwillingness of doctors, medical practices, and hospitals to adopt health information technology, or the failure to adopt at a rate fast enough to satisfy Drs. Brailer, Kolodner, and the most expensive IT vendors (see Extormity and Seedie for a refreshingly satirical commentary on why EMRs aren't jumping off the shelves in the US of A.)  As Adam Bosworth has said on several occasions, the standards for data exchange always work themselves out when the incentives within an industry or economic sector reward efficiency through market forces. Absent those incentives and market forces, standards are all anticipatory and largely useless -- or worse.

The second biggest misstep taken by ONC has been to entirely remove the consumer from the equation, and to ignore the force of the analogy that is powering consumer/patient impatience, even anger, at the calcified hairball our health care industry has become. That is the analogy with consumer experiences of convenience, affordability, and service excellence from companies across a wide spectrum of industries that have effectively integrated the Internet and the Web into their DNA, from FedEx to NetFlix, from Southwest Airlines to L.L. Bean, and from CNN to iTunes. Education, commerce, banking, the financial services, and personal communications are all online.

Too much of health care is still offline, and nothing in ONC's obsolete strategic plans reflects this reality or recognizes the progress that is being made despite ONC's befuddled time warp.

Will somebody, please, push the "reset" button on health IT policy inside the Beltway?