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Healthcare IT advances are pulling together to manage an expanding universe.
REGIONAL NETWORKS - by Charlene Marietti

The goal is clear: to improve patient safety and the quality and efficiency of care through sharing of health information. The clock started ticking in the race toward that objective last spring when President George W. Bush issued his executive order calling for widespread deployment of healthcare IT and electronic health records (EHRs) for most Americans by 2014.

The National Health Information Infrastructure project was already in motion at the time, but as strategies evolved, it has been redefined and renamed the National Health Information Network (NHIN). Basically middleware, the NHIN is a collection of technologies, business frameworks, financing arrangements, legal contracting and other mechanisms, policy requirements, organizational issues and related components that support nationwide implementation of interoperable health IT. And underpinning the NHIN will be regional health information organizations (RHIOs).
Lori Evans, senior advisor to National Health Information Technology Coordinator David Brailer, M.D., Ph.D., and head of his RHIO program, describes them as nongovernmental organizations charged with governance of business and legal issues necessary to facilitate the exchange of health information. Specifics are unavailable since RHIOs are still being developed. But eventually every American will be covered by a RHIO, just as every American will ultimately have an EHR.

Local workhorses
Although the NHIN architecture is still conceptual, the need for it is real, and urgent. The network has to be ready by the time EHRs are deployed, and preferably sooner, Brailer says, "so that we can bind the way the central middleware works, so we know how to specify what it takes for an electronic health record to connect to that or another information appliance."

RHIOs, which have taken the place of the earlier local healthcare information infrastructures and, for reasons of financial and technical scalability, are expected to cover larger geographical areas, will provide much-needed support and services to small physician offices as they adopt EHRs. But they will not be responsible for developing components needed for interoperability. "RHIOs will support deployment of applications that we hope will be plug-and-play and be integrated and implemented with the NHIN," says Evans.

Nobody really knows what will work best, but experts are fairly certain that RHIOs cannot be built with a cookie-cutter approach. This is the discovery phase and thinking is extremely fluid, notes Holt Anderson, executive director, North Carolina Healthcare Information & Communications Alliance, Research Triangle Park. "What we define today may change tomorrow," he says. Right now, the only absolute is keeping the patient and quality as the central focus.

There are currently two basic network models--distributed and centralized--defined by where the data resides, explains Steve Steindel, Ph.D., senior advisor for data standards and vocabulary at the Centers for Disease Control and Prevention in Atlanta. A distributed model, which has been selected for a project in Santa Barbara, Calif., allows members to store data at each site and uses a locator system to find and access it. A major disadvantage with this model is that a translation system must be installed in each location. In a centralized model, a single repository accepts data from members and uses transformation tables to convert and store it in standard formats. Data is then accessible to the community. The RHIO in Indianapolis is moving some types of data under this model.

Haven't we done this already?
Remember CHINs (Community Hospital Information Networks)? Don't confuse that '90s failure with this initiative. This is very different. "CHINS were largely an HIT initiative, with no federal, no state, no big employer, and modest insurer interest," says John P. Glaser, Ph.D., vice president and CIO at Partners HealthCare System in Boston. This approach has broader national interest, involvement from insurers and physicians' professional organizations and bipartisan legislative support, and it benefits all stakeholders, including big, Fortune 50 and 100 companies. Plus, the federal level of interest is not going away, he adds. But this is still the learning phase, emphasizes J. Michael Fitzmaurice, senior science advisor for IT, Agency for Healthcare Research and Quality (AHRQ), Rockville, Md. To learn what works and what doesn't, AHRQ is funding--at $1 million per year over a fiveyear period--state and regional demonstrations in Colorado, Indiana, Rhode Island, Tennessee and Utah.
Evans is hopeful the demonstrations will emerge as prototype RHIOs. But, says Fitzmaurice, "There are a lot of questions to be answered," including what incentives are required to maintain data sharing. "A lesson we learned from CHINs is, if we don't pay attention to incentives, we don't have everybody playing in the game."

At this early stage, people are beginning to confront the core operational issues behind RHIOs. How will they be governed and funded? What kind of policies, including privacy and security, and standards are necessary? What architectural model is most appropriate? Where should initiatives start, and with what data types? In Indiana, they started with lab information in the emergency department; in Boston's New England Healthcare EDI Network, they started with claims. "It is still very early. We have a molehill of experience, as distinct from a mountain," says Glaser.

Federal leadership is crucial in this effort--and the feds could play any number of roles, according to Glaser. For example, they could force boards and leadership to talk, much as the Washington, D.C.-based Leapfrog Group is doing, or set standards and models of clinical data exchange across regions. Legislatively, laws that impede progress need to be adapted. A prime candidate is the Stark Law, also known as the federal self-referral law because it prohibits referrals for federally insured patients to services between parties who have a financial relationship. Perhaps most important is increased funding, which will make the difference between progressive growth and stalled projects. However, even with a lot of money on the landscape, this undertaking will not be a slam dunk, notes Glaser.

Shepherding the flocks
With little solid experience upon which to build, most providers and payers are likely to want more concrete plans than currently available before committing. To meet this need, the Washington, D.C.-based Foundation for eHealth Initiative, through government and philanthropic money, is compiling a knowledge base of various communities' work products. This includes charters, mission statements, pricing approaches and architecture documents.

Watch for regional workshops through such professional groups as the College of Healthcare Information Management Executives, Ann Arbor, Mich., to stimulate the exchange of experiences and working strategies. They will likely address practical issues, such as how much to charge physicians, what level of support to provide and whether vendors will allow extension of licenses to physicians. Lack of experience in collaboration and data sharing--not to mention building and managing a shared clinical information systems infrastructure--is a big problem. Few regions have a history of organizations sitting down together and solving complex problems. Learning how to govern themselves and developing trust will take time.

The Healthcare Information and Management Systems Society (HIMSS), Chicago, perceives itself as uniquely positioned to take a leadership role. The HIMSS RHIO Task Force has proposed a HIMSS RHIO federation in which HIMSS would use its reach to support RHIOs, says Pete Palmer, task force member and principal security analyst for advanced patient management at the St. Paul, Minn., division of Guidant (recently acquired by Johnson & Johnson, New Brunswick, N.J.).

What's not to like?
The degree to which each of the 80 to 100 projects nationwide will conform on standards remains in question. Lack of a common medical vocabulary, and thus difficulty in getting the important concepts mapped to each other, is a major barrier. There aren't enough standards and they're not put together well enough or consistently enough to allow interoperability and seamless data handoff, says Steindel. To what degree these regional networks conform to standards depends somewhat on the role the feds play, says Glaser. Without incentives, there is little hope that stakeholders will move. The resounding success of the Centers for Medicare and Medicaid Services' strategy--using a 0.4 percent differential reimbursement to encourage hospitals to report quality data--indicates that even small financial incentives will promote formation of data-sharing networks. However, financial incentives remain elusive, with nearly all proposals still in the early planning stage.

The driving force, and the one that won't go away, is patient safety. Will these efforts be enough to support significant improvement? "Nobody knows," says Fitzmaurice. "What we're hoping to do is light a spark. Is the spark enough? We don't know, but there has never been a better time than now."

As leaders seek a sustainable financial model to achieve quality-improvement goals, IT also needs to pay off economically. A real market is developing, notes Steindel. "The large vendors smell money in HIT, and when people smell money, they tend to fill [the market] pretty quickly," he says. "President Bush says he wants an EHR in 10 years. I think it will be five."

(extraído da publicação Healthcare Informatics, focada no estudo de TICs para Healthcare) Fevereiro 2005