THE QUEST FOR JOHN DOEP. 22

WILL PHRS BETRUSTED?P. 28

EMRS WITHOUTTEARSP. 31

GOVERNMENT

HEALTHIT

Letters from healthIT innovators onhow to build a

health care systemthat saves health

and wealth PAGE 12

PUBLIC/PRIVATE HEALTH CARE CONVERGENCE FEBRUARY 2009 • VOLUME 4 NUMBER 1

‘Dear Mr. President’

FCW 01 1/16/09 5:47 PM Page 1

Workwith InterSystems.

Partners Healthcare works with InterSystems.

Not separate systems.

Read the case study about Partners Healthcare at InterSystems.com/HIMSS18MM© 2009 InterSystems Corporation. All rights reserved. InterSystems Ensemble and InterSystems Caché are registered trademarks of InterSystems Corporation.

© Copyright 2008 Partners HealthCare System, Inc Other product names are the trademarks of their respective vendors.1-09 Work18GHIT

The IT group at Partners Healthcare System in New

England is an innovator in connected healthcare. They

work with InterSystems Ensemble® software to deliverbetter care at lower costs to over four million patients.

Ensemble is a rapid integration and development

platform that makes it much easier to connect

applications, processes, and people – and to

develop composite applications.

Ensemble includes InterSystems Caché®, the

world’s fastest object database. Caché’s lightning

speed, massive scalability, and rapid development

environment give Ensemble unmatched

capabilities.

For 30 years, we’ve been a creative technology

partner for leading enterprises that rely on the high

performance of our products. Ensemble and Caché

are so reliable that the world’s best hospitals use

them for life-or-death systems.

Wewill be at HIMSS 2009

in Chicago – booth #2451

4Editor’s LetterChange — and then some

6NewsWeb roundup; Hospital on a chip;Naval maneuvers; Wiki expandsAIDS.gov reach; Australia’s newhealth IT chief is on the hot seat

28 The feds and PHR privacyThe outcome of the government’sPHR trials will have profound effects on public trust of the newtechnology

31 EMRs without tearsRemotely hosted EMR systemsattract doctors who don’t want the expense and headaches of in-house solutions

34 MeasuresEmployment impact of health IT stimulus

Contents

‘Dear Mr. President’Letters from health IT innovators

on how to build a health care

system that saves health and

wealth

12The search for John DoeScientists and policy-makers

seek ways to maintain patient

anonymity and tap the data

treasure trove of personal

medical records

22

22

10 11 28

C O V E R I L L U S T R A T I O N / K I M B E R LY C O N W A Y 12

TOC 03 1/16/09 5:56 PM Page 3

4 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

In this issue, we invited 21 leaders

from the health care industry to

write letters to the new president, of-

fering their best advice on how to

use information technology to

achieve his vision of a smart and eco-

nomical health care system.

We chose the writers using two

criteria: they have persistently called

for practical management reforms,

and they understand the govern-

ment’s role in creating a financial en-

vironment in which innova-

tion can thrive.

The result is a set of

some familiar ideas and

some new ones that, alto-

gether, provides a simple

road map to health reform.

For example, the writers

share an urgent belief that

the federal government must create

more powerful incentives — and

more painful disincentives — for

providers to integrate electronic

health care systems into their

practices.

In the words of one writer, “First,

recognize that the government is the

health care market,” he wrote, point-

ing out that the government ac-

counts for 60 percent of all health

spending.

“The government needs to be a

smarter buyer and a smarter investor

if the health care market is going to

act more like a market” the letter’s

author wrote. All indications are that

the incoming administration takes

that idea seriously.

I want to recommend another arti-

cle in this issue that I consider a must-

read for anyone interested in heath IT

reform. In “The Search for John Doe,”

senior editor Nancy Ferris dives into

the issue of whether organizations

can truly scrub electronic health

records of personal identifiers so that

the health care research community

can use the records. Scientists and

policy-makers are working

furiously to come up with

solutions to this problem,

which is a hurdle to health

IT adoption.

Speaking of change, I

want to note the announce-

ment that Government

Health IT was recently ac-

quired by the Healthcare Information

and Management Systems Society.

HIMSS acquired Government Health IT

magazine, its Web site and the Health

IT Summit conference from the 1105

Government Information Group.

The purchase will bring HIMSS’ con-

siderable educational resources in the

health IT community to bear in the

magazine. The result will be a richer

mix of stories, analysis and reporting

to help cover what will be a year of

enormous and fascinating change in

health IT.

Paul McCloskey

Editor-in-Chief

Government Health IT

Change — and then some

Editor’s Letter

Government Health IT (ISSN 1559-2553) is published bimonthly by the Healthcare Information and Management Systems Society

(HIMSS), 230 East Ohio Street, Suite 500, Chicago, IL 60611-3270. Periodicals postage paid at Chatsworth, CA 91311-9998, and at

additional mailing offices. Complimentary subscriptions are sent to qualifying subscribers. Annual print subscription rates for non-

qualifying subscribers are: U.S. $100 (U.S. funds); Canada/Mexico $125; outside North America (airmail) $165. Annual digital sub-

scription rates for non-qualifying subscribers are: U.S. $75 (U.S. funds); Canada/Mexico $75; outside North America $99. Subscrip-tion inquiries, back issue requests, and address changes: Mail to Government Health IT, P.O. Box 2167, Skokie, IL 60076-9285,

e-mail GHIT@1105service.com, or call (866) 293-3194 for U.S. & Canada; (847) 763-9560 for International; fax (847) 763-9564.

POSTMASTER: Send address changes to Government Health IT, P.O. Box 1267, Skokie, IL 60076-9285. Canada Publications Mail

Agreement No. 40612608. Return Undeliverable Canadian Addresses to Circulation Dept. or Bleuchip International, P.O. Box 25542,

London, ON N6C 6B2.

Paul McCloskey

WWW.GOVHEALTHIT.COM

VOLUME 4, NO. 1

EDITOR-IN-CHIEF / Paul McCloskey

VICE PRESIDENT, COMMUNICATIONS / Fran Perveiler

SENIOR EDITOR / Nancy Ferris

SENIOR EDITOR / Matt Schlossberg

CONTRIBUTING WRITERS / Peter Buxbaum, Heather B. Hayes,Brad Howarth, John Moore

COMMUNICATIONS COORDINATOR / Cari McLean

MANAGER, PUBLICATIONS / Nancy Vitucci

SENIOR MANAGER, CORPORATE COMMUNICATIONS /Joyce Lofstrom

PRODUCTION MANAGER / Jane Reiling

WEB DIRECTOR / Resa Hoeller

SENIOR DIRECTOR, EXHIBIT SALES / Kelly Laidler

SENIOR MANAGER, ADVERTISING SALES / Randy Knotts

VICE PRESIDENT, SALES / Jeff Kenjar

PRESIDENT & CEO / H. Stephen Lieber, CAE

HIMSS BOARD OF DIRECTORS

CHAIR / Charles E. Christian, FCHIME, FHIMSS

VICE CHAIR / Liz Johnson, RN, MSN, FHIMSS

CHAIR ELECT / Barry P. Chaiken, MD, MPH, FHIMSS

VICE CHAIR ELECT / Liz Johnson, RN, MSN, FHIMSS

John H. Daniels, FACHE, CPHIMS, CHPS, FHIMSSDavid FinnC. Martin Harris, MD, MBA, FHIMSSJoy G. Keeler, MBA, FHIMSSHolly D. Miller, MD, MBA, FHIMSSCarol R. Selvey, MHSA, FHIMSSJay Srini, FHIMSSJonathan M. Teich, MD, PhD, FHIMSSCharlene S. Underwood, MBA, FHIMSS

HIMSS ADVISORY BOARD MEMBERS

Mike McGill, PhDHoward A. Burde, EsquireA. John Blair, III, MDSunny Sanyal

CONTACT USEmail: Editor-in-Chief Paul McCloskey can be reached atpmcloskey@himss.org. GHIT and HIMSS staff members canbe reached by using the naming convention of first initialfollowed by last name @himss.org. So John Smith would beJSmith@himss.org.

Healthcare Information and Management Systems Society230 East Ohio Street, Suite 500Chicago, IL 60611-3270Phone: (312) 664-4467Fax: (312) 664-6143

Washington, D.C. OfficeHIMSS4300 Wilson Blvd., Suite 250Arlington, VA 22203-4168Phone: (703) 562-8800Fax: (703) 562-8801

Ann Arbor OfficeHIMSS3800 Packard Road, Suite 150Ann Arbor, MI 48108Phone: (734) 477-0850Fax: (734) 973-6996

Subscription inquiries, back issue requests, and address changes:Mail to Government Health IT, P.O. Box 2167, Skokie, IL 60076-9285,e-mail GHIT@1105service.com, or call (866) 293-3194 for U.S. & Cana-da; (847) 763-9560 for International; fax (847) 763-9564.

HEALTHITG O V E R N M E N T

GHIT 04 1/16/09 5:59 PM Page 4

What would healthcare delivery look like if yourpersonal health information were fluid-accessibleat any time and any point in your care? Imaginea future where your critical health information is

readily available to your clinician during your visit, thenflows to the other members of your care team after eachvisit, and you can access and update your own informationwhenever and wherever you want.

Health information and communications technology(health IT) have tremendous potential to makethe healthcare delivery system more consumer-centered. IT makes healthinformation portable so it can followpatients from setting to setting andprovider to provider. IT makes it possiblefor informed and collaborative decisions tobe made in real time at the point of care.But health IT alone will not dramaticallyimprove care and reduce costs. Even whenhealth records are electronic, information isnot automatically shared outside of the organizational or network firewalls, or acrossorganizational boundaries and there is no guarantee that information, once received, will be utilized.

A recent study by Booz Allen Hamilton, a leading strategy and consulting firm, explored the ways healthinformation and communications technology can accelerateprogress toward a truly patient-centered healthcare system.Most proposals promoting the use of health IT aim atincreasing investment in EHRs and, to a lesser extent, e-prescribing. While these technologies are often necessary,they are not sufficient to drive the type of change in healthcare delivery that is required to realize the qualityimprovements and cost savings desired.

A shift is needed away from a “big bang” or “magic bullet” strategy that articulates EHR adoption as the endgoal. A more effective strategy is to drive delivery systemchange through an incremental focus on widespread healthinformation exchange and patient-centered outcomes.Pharmacy, lab, and medical imaging data were the recom-mended focus for the near future since they are largely electronic and have big potential to improve outcomes.

The study concluded that consumers, clinicians, andproviders all will derive greater benefits when electronic

health information flows faster and more freely, or becomesmore “liquid.” Those changes are not about the technologyitself, but about the organizational, cultural, and legal structures that need to be transformed to support a trulypatient-centered healthcare system.

There are two basic accelerators that can help us achievethis goal: intensify the focus on information flow and communication; and take bold steps toward a patient-cen-tered healthcare system. These steps might include granting

patients consistent, secure, and timelyaccess to their personal health information,or better defining how health information isto be received, used, enhanced or processed,and passed along to others.

Growing evidence indicates that liquidhealth information can accelerate improvements in healthcare access, quality, safety, efficiency, convenience, and outcomes. It can open the door to innovation and provide a foundation for a new standard of patient-centered care in which healthcare teams who are comfortable and proficient in the use of

information and communications tools interact with thepatients through videoconferencing, e-mails, mobile phone,web portals, and other means.

Our national health IT strategy can build on the currentinfrastructure and successes to bring full interoperability.By focusing on information flow and the needs of patients,we have the opportunity to accelerate progress toward thegoal of a consumer-centered system of care.

About Booz Allen HamiltonBooz Allen Hamilton, a strategy and technology consultingfirm, works with all major agencies of the U.S. federal government with health-related missions. Booz Allen is arecognized leader in informatics and data analytics, publichealth, healthcare quality, interoperability, food safety,coordinated care and service to wounded warriors, andhealth preparedness. The report, “Toward Liquid HealthInformation: Realization of Better, More Efficient CareFrom the Free Flow of Information,” is available atwww.boozallen.com/health.

Vendor Sponsored

Picture a Future with Liquid Health InformationVision

Vision

For more information, please visit.www.boozallen.com/health

Authors: Margo Edmunds and Kristine Martin Anderson

Vision_BAH.qxd 1/14/09 3:15 PM Page 1

Congress might commit to spending$20 billion on health information tech-nology over the next few years.

That figure is in the economic recov-ery bill the House drafted and the Ap-propriations Committee released Jan.15. Committee action on the bill wasexpected soon after.

“It’s exciting that our time hascome,” said Rep. TimMurphy (R-Pa.), alongtime advocate ofhealth IT.

The bill wouldappropriate $2 bil-lion for the Office ofthe National Coordi-nator for Health ITin the Health andHuman Services De-partment “and $20billion overall forhealth informationtechnology to pre-vent medical mis-takes, provide bettercare to patients andintroduce cost-saving efficiencies,” ac-cording to the committee report accom-panying the draft.

There were reports at press time thatat least some of the remaining $18 bil-lion would be spent on health IT grantsto states because the national coordi-nator’s office is too small to managesuch a large program, some expertssaid.

Although the House is responsiblefor originating spending measures, theSenate is said to be drafting its own lan-guage for the health IT portion of thebill.

At two Capitol Hill meetings onhealth IT, one theme that emerged wasthe need to give doctors incentives forgoing beyond acquiring electronichealth record systems and other forms

of health IT to actually using them.“Linking the implementation of

[health IT] to health system reforms isessential,” Dr. Jack Cochran, executivedirector of the Permanente Federation,told a Senate committee. “To promoteappropriate and clinically effective usesof [health IT] over the mere acquisi-tion of technology, the secretary of

HHS should developa n d i m p l e m e n tmeasures for [healthIT] connectivity anddata exchange, aswell as measures forEHR-based qualityreporting.”

At the same Sen-ate hearing, JanetCorrigan, presidentand chief executiveofficer of the Nation-al Quality Forum,said health IT “in-vestments and incen-tives should be tiedto the effective use of

[health IT] to improve patient safety,outcomes and experience of care” ratherthan linking them to simply having thetechnology.

Sen. Barbara Mikulski (D-Md.), whopresided over the hearing, expressedconcern that health IT could be “anoth-er technology boondoggle” like past ITfailures in the federal government. “Wecan’t afford to go there again,” she said.

At a meeting sponsored by the In-stitute for e-Health Policy and others,Claudia Williams, director of healthpolicy and public affairs at the MarkleFoundation, said, “Health IT shouldachieve measurable health and deliv-ery system improvements.… Health ITon its own will not result in desiredoutcomes.”

— Nancy Ferris

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News

The National Association of State MedicaidDirectors is asking federal officials to bringMedicaid reporting in line with the datastandards the government has endorsed forhealth information technology.

In a letter to Kerry Weems, acting admin-istrator of the Centers for Medicare andMedicaid Services, association members saidthey are required to file data on nursinghomes and Medicaid recipients that uses“vocabularies and standards which do notconform with current industry standards.”

The letter pointed to the Medicaid Sta-tistical Information System and the NursingHome Quality Initiative’s Minimum DataSet as being out of sync with PresidentGeorge W. Bush’s 2006 executive order thatdirected federal agencies to meet recognizedinteroperability standards when they devel-op or acquire new health IT systems.

“At a time when states and CMS are look-ing for ways to save taxpayer dollars, the re-sources currently being used to develop andimplement systems that do not meet theseinteroperability standards would be betterspent on upgrading the systems to meet rec-ognized industry protocol,” the letter states.“While we understand and support data ex-changes, we believe that diverting resourcesfrom the long-term goal of standardized in-teroperability in order to update nonstan-dard interfaces is counterproductive.”

The letter proposes that CMS work withstate agencies to establish data definitionsand formats that follow industry standards.

Ann Clemency Kohler, the association’sdirector, said CMS had announced plans toupgrade its systems last November. But inthe meantime, states are being forced to cre-ate new interfaces to make their data sys-tems comply with CMS’ unique standardsand vocabularies.

— Nancy Ferris

State Medicaiddirectors objectto nonstandarddata formats

Sen. Barbara Mikulski (D-Md.)

House tees up $20B health ITinvestment for feds and states

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Medicare launched its personal healthrecords pilot program last month in Utahand Arizona.

The program allows patients coveredby fee-for-service Medicare plans to havetheir claims data downloaded to PHRs of-fered by one of four participating vendors.HHS officials hope 5,000 people will signup for the service during the one-year pi-lot program.

At a press conference announcing thelaunch last month, Scott Barlow, chief ex-ecutive officer of Central Utah Clinic, de-scribed how he began to experience backspasms during a trip with his family to afootball game in California. Because hehad had back spasms before, he knewthat a strong painkiller and other medi-

cines would remedy the problem.But the emergency physicians who

treated him were reluctant to prescribethe painkiller without testing to ensurethat he really needed the powerful drug.They insisted on giving him a battery oftests, including an expensive MRI, before

prescribing the drugs he had suggested.“It was $6,000 of wasted care,” Barlow

said — and he missed the football game.If he had had a PHR with his previousMRI images and other health carerecords, much of that waste could havebeen avoided, he said.

HHS’ Centers for Medicare and Med-icaid Services and contractor NoridianAdministrative Services will advertise theprogram in the two states, and all fee-for-service Medicare beneficiaries there willreceive letters from HHS Secretary MikeLeavitt urging them to take part.

If the program proves successful, itcould be extended past the one-year termor expanded to other areas.

— Nancy Ferris

Medicare test of PHRs gets under way

Scott Barlow

DOD launching mobile telehealth in AfricaThe Defense Department is working on anumber of projects in its new Africa Com-mand area that depend on cellular tech-nologies to transmit health informationto and from medical trouble spots.

In one project, DOD is developing a wayto send periodic text messages to Tanzania’smilitary. The project, which will launch thisyear,“targets HIV knowledge and attitudesamong military personnel in remote areas,”said Col. Ron Poropatich, deputy directorof the Army’s Telemedicine and AdvancedTechnology Research Center.

Another telehealth project on thedrawing board seeks to provide medicaltraining to members of Liberia’s militaryand allow them to consult with hospitalpersonnel in the capital of Monrovia. Mil-itary forces in that country do not employdoctors or nurses, Poropatich said.

Mobile phones will play a key role inthose projects because of their relativelyhigh use among the population of Africa.

“There are now 70 million cell phoneson the African continent, 10 times the num-ber there were in 1999,” said Poropatich at

a recent symposium in Washington, D.C.“Fourteen percent of the population hasmobile phones, more than have fixed lines.”

By contrast, only 3 percent of Africanshave access to the Internet, he added.

Poropatich expects mobile phone-based telehealth applications to includeclinical consultations, education, research,biosurveillance, health surveys and dis-ease management.

He said he believes text messaging willplay an important role in the command’stelehealth efforts because texting is cheap-er and more reliable than voice commu-nications in Africa.

“We need applications that make useof the cell phones they already have, thatrequire minimal training and that tacklelow-hanging fruit,” Poropatich said.

The command’s missions include med-ical support operations, capacity buildingand disaster relief, said Col. SchuylerGeller, a command surgeon based inStuttgart, Germany.

— Peter BuxbaumSouth Africa

News_6-7 1/16/09 5:23 PM Page 7

B Y P E T E R B U X B A U M

In the near future, U.S. warfighters mightbe wearing devices that automatically de-tect injuries and begin treatment well be-fore they are evacuated to a field hospital.

Last fall, the Office of Naval Researchawarded a $1.6 million grant to a team ofresearchers at the University of California,San Diego, and Clarkson Univer-sity to develop such a device, calleda field hospital on a chip.

The goal is to create an auto-mated system that would contin-uously monitor a warfighter’ssweat, tears and blood for bio-markers that signal common bat-tlefield injuries, such as trauma,shock, brain injury and fatigue.Once the system detects a medicalproblem, it would automaticallyadminister medication.

“The long-term goal is to de-velop and test autonomous devicesthat detect and respond to battle-field trauma or insult,” said LindaChrisey, a program officer at theOffice of Naval Research’s Biolog-ical and Biomedical Division.“Thesupporting research objectives are to iden-tify and improve detection of robust bio-markers for battlefield injuries and stres-sors and to develop interfaces between thesensors and device-control systems that in-crease the reliability of the diagnosis.”

Led by nano-engineering professorJoseph Wang, engineers at UC San Diegowill build a minimally invasive system thatmonitors multiple biomarkers simultane-ously and processes that information to di-agnose conditions.

“Since the majority of battlefield deathsoccur within the first 30 minutes after in-

jury, rapid diagnosis and treatment are cru-cial for enhancing the survival rate of in-jured soldiers,” Wang said.

He helped develop the first noninvasivesystem for treating diabetes by monitoringglucose levels in patients’ sweat. However,that type of system is not advanced enoughto function as a field hospital on a chip.

“Today’s insulin and glucose manage-

ment systems don’t include smart sensorscapable of performing complex logic op-erations,” Wang said. “We are working ona system that will be different. It will mon-itor biomarkers and make decisions aboutthe type of injury a person has sustainedand then begin treating that person accordingly.”

The project will build on Evgeny Katz’sresearch into enzyme logic systems. Katz, aprofessor in Clarkson University’s Depart-ment of Chemistry and Biomolecular Sci-ence and a member of Wang’s researchteam, has shown that enzymes can be used

to measure biomarkers and perform thelogic necessary to make limited diagnoses.

One of the team’s challenges and the ex-pected focus of the first two years of re-search will be integrating enzyme logic withsensing devices people can wear. Researcherswill work on developing electrodes with en-zymes that serve as sensors and perform thelogic necessary to convert biomarkers suchas lactate, oxygen, norepinephrine and glu-cose into data that would trigger the releaseof appropriate medication.

“We just want the ones and zeros,”Wangsaid.“The pattern of ones and zeros will re-veal the type of injury and automaticallytrigger the proper treatment. This is bio-computing in action.”

For example, if an injuredwarfighter goes into shock, en-zymes on the electrode would senserising levels of lactate, glucose andnorepinephrine. Those, in turn,would cause changes in the con-centrations of biochemicals gener-ated by the enzymes and promptthe built-in logic structure to out-put a digital signal that indicatesthe patient is going into shock. Thatsignal would trigger a predeter-mined treatment response.

The researchers expect to havea working prototype of the prod-uct in four years.“We are just at thebeginning of this project,” Wangsaid. “During the first two years,our primary focus will be on thesensor systems. Integrating enzyme

logic onto electrodes that can read biomark-er inputs from the body will be one of ourfirst major challenges.”

“Achieving the goal of the program is es-timated to take nearly a decade,” Chriseysaid.

Developing an effective interface be-tween complex physiological processes andwearable devices could have a broader im-pact, Wang said. If the researchers are suc-cessful, they could pave the way for “au-tonomous, individual, on-demand medicalcare, which is the goal of the new field ofpersonalized medicine,” he added. ■

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Hospital on a chipResearchers are working on a device to monitor

warfighters and administer medication on the battlefield

News

A project funded by the Office of Naval Research seeks to

speed delivery of medication to injured or ill service

members by monitoring and analyzing certain vital signs.

News_8-9 1/16/09 5:39 PM Page 8

B Y P E T E R B U X B A U M

The Navy doesn’t have a chief medical in-formation officer, but the man who actsin that capacity thinks it should. “We al-ready have CMIOs at the regional level,”said Dr. Bob Marshall, director of clinicalinformatics at the Navy’s Bureau of Med-icine and Surgery. “We need a central po-sition to coordinate regional activities andto have an official representative to tri-service initiatives.”

To a certain extent, Marshall’s quest issymbolic: He already performs most of thefunctions of a CMIO.“I am the primary li-aison among medical staff, [informationtechnology] and the senior leadership,” hesaid. “My office assesses changes to infor-mation systems and performs performanceassessments on inpatient and outpatientsystems. I also interface with the MilitaryHealth System and serve on tri-serviceboards.”

But he wants the Navy to catch up tothe other military services. The Army ap-pointed Lt. Col. Hon Pak as its CMIO,while the Air Force recently created a sim-ilar position and is about to fill it.

And, he believes, matching the otherservices in matters of health informationpolicy would help the Navy compete forresources.

“A central CMIO would be the primarychampion for the clinical needs of the Navyas a whole and the regions, without micro-managing the regions,” Marshall said.“Thisincludes providing adequate resources,training and reference materials to clini-cians, improving their workflows and alsoadvocating for a decent quality of life.”

In terms of health IT, the Navy is incritical need of wireless systems, Marshallsaid. One of his priorities is to install wire-

less local-area networks at all Navy med-ical facilities.

“In the Navy, we have installed onlythree wireless LANs,” he said. “The Armyhas almost completely rolled them out. Wewant to make major progress on that frontin 2009.”

That progress would enable Navyproviders “to have theability to use tablet com-puters as they movethrough clinical care,” headded.

Marshall said he alsowants to see progress onthe latest version ofAHLTA, the military’selectronic health recordsystem. He is aware ofcomplaints about thesystem but said he viewsits capabilities as a netgain for military healthproviders.

“AHLTA is too slow,”he said.“Most people arepretty happy with it eventhough they don’t like theslowness. The function-ality is reasonably good.A patient can be evacuat-ed from Iraq to Italy, andthey can see his entiremedical record in Italy.”

AHLTA has also nearly eliminated theneed for paper.“The value of being able tosee a patient’s entire medical record is notto be underestimated,” Marshall said. “Weused to have to access paper charts around50 percent of the time. Now, unless AHLTAis down — which is highly unusual — themedical record is in our face 100 percentof the time.”

Still, he said AHLTA is “not where itneeds to be. We need to move to a thinclient and to upgrade the ability to add un-structured text.”

Marshall said he has high hopes for theupcoming version of the system, which hasbeen available to some installations on alimited basis.“The latest version is movingin the right direction,” Marshall said.“Thepeople who have been using it have beenhappy with it.”

He said he would like to see AHLTA dofor medical records what picture archivingand communications systems have donefor radiology. AHLTA “would include theentire inpatient and outpatient medical

record, case manage-ment functionality, andcomputerized order en-try,” he said.“It would beinteroperable with Vet-erans [Affairs Depart-ment] and civilian elec-tronic health records,and it would be availablein theater.”

In-theater availabili-ty is still a problem forAHLTA, even on Navyships, because of thecontinued constraints oncommunications band-width. “AHLTA Theateris configured to operatein a disconnected envi-ronment,” Marshall said.“It is arranged so that theClinical Data Reposito-ry is updated every 24hours or whenever satel-lite communications be-come available. But on a

ship, nothing is more important than thecombat control center. The captain isn’t go-ing to let that go down so that the CDR canbe populated.”

Still, Marshall said he dreams of the daywhen in-theater medical care could beavailable globally in real time.“That wouldbe a great thing to have,” he said. “Thatwould be a killer app.” ■

9G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

“A central CMIOwould be the

primary champion for

the clinical needsof the Navy as a whole…without micromanaging

the regions.”

BOB MARSHALL , NAVY BUREAU

OF MEDIC INE AND SURGERY

Naval maneuversNavy’s clinical health IT boss envisions the day when

in-theater medical care will be available in real time

News_8-9 1/16/09 5:40 PM Page 9

B Y H E AT H E R B . H AY E S

A wiki is often described as a Web site withan edit button. But despite benefits thatinclude speed and ease of use, the tech-nology suffers from an identity crisis. Toomany people confuse it with Wikipedia,the popular Web-based encyclopedia thatallows anyone to contribute to any of 12million topics — and counting.

“If you start talking about using wikioutside the domain of Wikipedia, peo-ple’s eyes gloss over,” said Miguel Gomez,director of AIDS.gov, a Web portal forfederal resources on HIV/AIDS hosted bythe Health and Human Services Depart-ment’s Office of HIV/AIDS Policy. “Thename is not helpful at all.”

The AIDS.gov Web site, launched inearly 2008, is trying to help its users over-come any confusion they might haveabout wikis or other social media. Thesite features a weekly blog that educatesthe HIV/AIDS community on the latest

social media technologies and how theycan use those tools in their public healthwork. The tools include text messaging,virtual worlds, podcasts, social networks,and photo- and video-sharing sites.

The AIDS.gov wiki is already a popularsubject on the blog. Readers can click onlinks that provide basic information on thetool’s benefits and potential uses or view avideo tutorial with step-by-step instruc-tions on participating in a wiki. Gomez saidthe public health community can use thetechnology to collaborate with other groupson AIDS-related tasks, maintain global con-tact and resource lists, and develop calen-dars of World AIDS Day events.

Gomez said he knows the wiki is easyto use and beneficial because he and theblog’s seven far-flung contributors — in-cluding participants at HHS’ Centers forDisease Control and Prevention, Officeof Minority Health and Office onWomen’s Health — rely on the tool tocreate their weekly posts. They decided to

move to the wiki after trying to write thefirst few articles using Microsoft Wordand e-mail to collaborate.

“It wasn’t very efficient,” said Jennie An-derson, AIDS.gov’s communications direc-tor.“So we decided it would be a lot easierif we had one document where everyonecould put their changes into a single place,and with a wiki, changes are always madeto the latest version because only one per-son can go into the wiki at a time.”

By relying on the wiki, the AIDS.govteam improved accuracy, transparency andcredibility. “For senior government offi-cials who wanted to sort of monitor whatwe were doing, it eliminated the need towrite up and forward a memo,” Gomezsaid. “We can just direct them to the wiki,and they can see our progression and thehistory of contributions and edits.”

The wiki also added security to the col-laboration process. Because it requires asecure log-in, the AIDS.gov blog team cancontrol who is allowed to read and makechanges to documents. By contrast, send-ing a Word document via e-mail is fraughtwith opportunities for unauthorized usersto copy or read it, Anderson said.

Although it doesn’t endorse productsamong the many good wiki options thatare available, the AIDS.gov blog team willsometimes suggest that more skepticalusers consider a product called PBwiki,which the team used to create theAIDS.gov blog.

Gomez said it’s not because PBwiki hasmore functionality than other products;rather, its memorable moniker and slo-gan — “It’s as easy as making a peanutbutter sandwich” — grab the attention ofusers and help them overcome their aver-sion to trying the technology.

“When we’ve gotten people to startwith PBwiki, they get stuck on the cutename and away from the whole topic of‘what the heck’s a wiki?’” Gomez said. “Ithas actually secured some buy-in.” ■

AID

S.G

OV

10 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

Wiki expands AIDS.gov reachHHS office taps the social media tool to collaborate

with public health organizations

News

“If you start talking about

using wikioutside thedomain ofWikipedia,

people’s eyesgloss over.”

MIGUEL GOMEZ ,

A IDS .GOV

News_10-11 1/16/09 5:47 PM Page 10

B Y B R A D H O WA RT H

Peter Fleming is either an optimist or amasochist. As the recently appointed chiefexecutive of Australia’s National E-HealthTransition Authority (NEHTA), he leads anorganization that has been widely criticizedfor its lack of progress in developing a uni-fied electronic health record framework forthe country.

But Fleming might have stepped intothe job at just the right time. NEHTA re-cently received a commitment from Aus-tralia’s federal and state governments to al-locate $218 million in Australian dollars(about $150 million in U.S. dollars) to fundthe agency through June 2012.

“We now have guaranteed funding forthree years, which ensures we can continueto develop the essential infrastructure proj-ects necessary to support an individual elec-tronic health record in the future,” he said.“This is a strong endorsement of e-healthas an essential component of health reform.”

His appointment followed a lengthysearch after the departure of previous chiefIan Reinecke in early 2008. NEHTA’s chiefinformation officer and chief finance offi-cer also left the agency last year.

Fleming joined NEHTA last Septemberand has a background in delivering largeinformation technology projects in the re-tail, financial services, telecommunicationsand health sectors. He said he has a stronggrasp of the issues of process engineering,training and change management that ac-company NEHTA’s task.

His most recent job was with the Aus-tralian health and diagnostic company Sym-bion Health (formerly Mayne Group),

where he said he became aware of the idio-syncrasies of using technology in the healthcare sector.

“Within Mayne, I got a very good un-derstanding of how important relation-ships are in the health in-dustry,” Fleming said.“It’s not a simple indus-try, and people are pas-sionate about it. Youdon’t join the health in-dustry unless you arepassionate and want tomake a difference.”

In creating a nationalhealth IT network, “wewill make a difference topatient care, we will em-power the consumer andthe patient, and we willremove a lot of duplica-tion from the system,” hesaid. “There are very fewjobs where someone withan IT background canmake a big difference.”

Health care groups, including the HealthInformatics Society of Australia, have crit-icized NEHTA’s slow progress in develop-ing and deploying health IT standards andsystems. Fleming said he believes much ofthe criticism overlooks the backgroundwork that has been done to put standardsin place.

“Most of that is under the covers, andwe haven’t done that good a job of gettingthe visibility out there,” Fleming said.“This[funding] gives us a really wonderful start,so what I bring to this is an absolute focuson making a difference.”

With the funding situation now clari-fied, Fleming said the agency’s focus willshift to defining the stages of delivery forNEHTA projects, with an emphasis on de-livering benefits quickly. “There is a focusnow of getting some deliverables on thetable, and that is the message I am gettingfrom clinicians and the board,” Flemingsaid.“More importantly, the government is

extraordinarily serious”about health IT.

His goals includecontinuing to act on rec-ommendations made bythe Boston ConsultingGroup, such as improv-ing accountability andtransparency within theorganization. Flemingsaid he believes it is alsoimportant for NEHTAto be aware of the healthIT initiatives occurringin the private sector, sothe agency can encour-age the right develop-ment and stop duplica-tive efforts.

“One of the keys forus is bringing all those

groups together and sharing what’s goingon,” Fleming said.“I don’t think in any jobthat you can make everyone happy. How-ever, all of our stakeholders are focused onthe benefits of e-health and the need to im-plement it. Within that, there are clearly dif-ferent perspectives on how to go about it.And one of our jobs is to clearly bring thosegroups together. We won’t have all the an-swers, but as we work through with the keystakeholders on our board, the clinicians,the vendors, the consumer advocates andso on, I have no doubt that we will come upwith an appropriate consultation.” ■A

ND

RE

W L

LO

YD

11G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

“The government is extraordinarily

serious” abouthealth IT.

PETER FLEMING, AUSTRAL IA’S

NAT IONAL E -HEALTH

TRANS IT ION AUTHORITY

Australia’s new health ITchief is on the hot seatPeter Fleming vows to reduce duplication and empower

patients while building a national health IT system

News_10-11 1/16/09 5:48 PM Page 11

‘Dear Mr.President’

Letters from 21health information

technology leadersto the new

president portray a road map for

building an electronic health

care system that rewards productivity,

retains knowledgeand supports

effectiveness of care.

Feature 1_pp12-15 1/16/09 6:00 PM Page 12

ILL

US

TR

AT

ION

/KIM

BE

RL

Y C

ON

WA

Y

13G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

Reward physicians for using health ITYou enter office during a time

of unprecedented growth and

opportunity in the field of

health care information tech-

nology. Health care is an issue

that goes beyond party affilia-

tions and affects every citizen,

and as you begin your term as

president, we urge you to con-

tinue building on the momen-

tum this industry has gained in

the past decade.

Investing in health IT, such

as the adoption and advance-

ment of electronic health

records, will help bring about

an interoperable health care

system, which studies have

shown can save upwards of

$150 billion to $300 billion an-

nually to numerous stakehold-

ers, including the federal gov-

ernment and, thus, taxpayers.

Furthermore, EHR adop-

tion improves the quality of

care that physicians and other

caregivers are able to provide.

In times of disaster and crisis,

properly constructed EHR net-

works enable health care pro-

fessionals to access a patient’s

medical records at a moment’s

notice, whereby they can

quickly and effectively admin-

ister the proper care.

The benefits of widespread

EHR adoption are hard to ig-

nore. Yet many physicians re-

main reluctant to use these

solutions to their fullest po-

tential. A key step in advanc-

ing the adoption of EHRs is

the creation and support of

legislation and regulations

that provide monetary incen-

tives to physicians who suc-

cessfully deploy health IT sys-

tems at the point of care. EHR

adoption furthers the ability

for physicians to perform

more accurate and wide-

spread clinical research that

can unlock new medicines and

treatments that benefit the

greater good, from treating

common illnesses to curing

chronic diseases.

We urge you to continue

supporting legislation and reg-

ulations that advance health

care information technology.

Justin Barnes

Vice President of Marketing

and Government Affairs,

Greenway Medical

Technologies

Jump-start state HIEsMr. President, give us light!

It’s not hard to imagine all

the physician’s offices, all the

labs and pharmacies and hos-

pitals and nursing homes

across the country finally con-

nected — strung together in a

living, pulsing network to ex-

change information. Even the

most rudimentary version of

this would save lives, reduce

errors, cut down on waste and

save money.

But like America in the

1930s, when Franklin Roo-

sevelt established the Ten-

nessee Valley Authority to

bring electricity to one of the

poorest regions of the nation,

we need leadership and galva-

nizing legislation to light up all

the nodes on this urgently

needed network.

Only a few vital pieces of

enabling legislation will bring

this network to life. First and

most important, we need to

jump-start the development of

state-based health informa-

tion exchange (HIE) organiza-

tions. The federal government

can do this by making an ini-

tial investment of capital allo-

cated to each of the states.

The states would be author-

ized to distribute the funds to

not-for-profit, public/private

partnerships responsible for

developing HIE capabilities

within the state — either a

single operating HIE for the

entire state or an umbrella or-

ganization linking regional

and local exchanges.

This initiative needs some

accompanying support, such as

definitions of acceptable priva-

cy and confidentiality protec-

tions and tax-exempt financing

allowed for the relatively short-

lived assets of information

technology investments. But

for states that have established

early prototypes of HIEs or are

close to bringing up opera-

tions, this will ensure rapid de-

velopment and full deploy-

ment. For other states, it will

provide assurance that [an] HIE

is not only possible but in-

evitable. It is time to light up

all the nodes across the country

with the digital equivalent of

electricity utilities.

Dr. Molly Coye

Chief Executive Officer,

Health Technology Center

Train more health informaticiansYou have proposed spending

$50 billion on health informa-

tion technology to improve

health care. To achieve that

laudable objective, this invest-

ment must include more than

funding for electronic health

records implementation and

clinical data exchange.

Many more health care

professionals, especially bio-

medical and health informati-

cians with strong health IT

knowledge and skills, are

needed. These individuals will

serve in hospitals and physi-

cian’s offices to educate oth-

ers, integrate patients elec-

tronically into their own

health care and records, devel-

op systems for the future,

streamline clinical processes,

and harvest medical knowl-

edge buried in the growing

volume of clinical data.

In addition, much more re-

search is needed to determine

how best to design, imple-

ment, and use health IT to

strengthen clinical decision

support, knowledge manage-

ment, data security, and public

and population health [while]

advancing the frontiers of

’ Justin Barnes Dr. Molly Coye Dr. Don Detmer

Feature 1_pp12-15 1/16/09 6:04 PM Page 13

14 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

translational bioinformatics. In

short, informatics education

and research are essential.

In 2008, Rep. David Wu

(D-Ore.) introduced legislation

that provided support to the

National Science Foundation

for informatics training. The

bill, which passed the House

but not the Senate, must be

revived in the new Congress

with additional monies made

available for the National

Library of Medicine, the Cen-

ters for Disease Control and

Prevention, and the Agency

for Healthcare Research and

Quality.

[Allocating] $500 million

for each of the first four years

would greatly enhance the

likelihood of achieving our

goal of using health IT to im-

prove the health of individual

citizens and populations

through improved safety,

quality and satisfaction while

reducing costs.

Dr. Don Detmer

Chief Executive Officer,

American Medical

Informatics Association

Set health information standards One area where we have

broad agreement in health

care reform is on the need to

improve care, reduce medical

errors and cut costs by pro-

moting widespread use of

cutting-edge health informa-

tion technology.

We must speed the imple-

mentation of a system that

will improve health care value

by allowing doctors across the

country to have all the infor-

mation they need to deter-

mine the best courses of

treatment, cut down on ad-

ministrative costs and elimi-

nate repetitive testing. The

technology is already available

— we need to apply it. But

first, we need to set uniform

standards to bring health care

into the 21st century.

Doctors who use health IT

are very satisfied with the im-

provement in the quality of

care they can provide for their

patients. However, most doc-

tors are waiting for Congress

to establish uniform standards

before they take advantage of

the many benefits of health

IT.

Simply throwing around

taxpayer dollars as an invest-

ment in health IT is not a solu-

tion. We need to establish

consensus standards so that

doctors don’t have to worry

that the IT investment they

make today will be obsolete

tomorrow. Purchasing the

wrong software could be like

investing in compact discs the

day before iTunes launched.

Uniform standards will en-

courage doctors to invest in

health IT and drive innovation

in the health IT sector.

Sen. Mike Enzi (R-Wyo.)

U.S. Senate

Build Version 1.0 first Don’t automate until you

achieve a consensus on what

our health care system — as a

real system — should look like.

If you merely automate our

current ineffective and com-

plex system, you may make it

harder to effect real change.

As Chicago’s Richard Daley in-

famously misspoke in 1968,

“The police are not here to

create disorder; they are here

to preserve disorder.” Do not

pay for systems that preserve

disorder.

There are steps that can be

taken now. Build on Tennessee

Gov. Phil Bredesen’s admoni-

tion to build Version 1.0 first.

Focus on areas where technol-

ogy can reduce complexity.

These include providing a se-

cure medication history for

every American in every care

setting [and] providing federal

Medicaid funds for health IT

only for those systems that can

ensure availability of informa-

tion across systems through

health information exchange.

Charge America’s computer

scientists to rethink health IT

as an informatics effort aimed

at more effective knowledge

management. Teach those

who maintain computer sys-

tems to understand medical

technology and privacy. Work

with banks and other knowl-

edgeable groups to address

identity management and

data security.

Remember that the archi-

tect Louis Sullivan said, “Form

ever follows function.” If you

foster the creation of a func-

tional, effective, equitable

health care system, good in-

formatics will follow.

Dr. Mark Frisse

Professor of

Biomedical Informatics,

Vanderbilt University

Engage government in standards-makingThe U.S. health care system

has always been under signifi-

cant strain, with skyrocketing

costs, expanding ranks of

uninsured individuals, and lag-

ging quality and safety meas-

ures plaguing the system. Al-

though incremental

improvements have been

made in some areas, the cur-

rent economic environment

will force decision-makers to

rethink our approach.

Recently, the Healthcare In-

formation and Management

Systems Society released rec-

ommendations for the new

administration and the 111th

Congress. Two are particularly

critical, especially for the gov-

ernment IT space. First is the

call for $25 billion in incen-

tives for the adoption of elec-

tronic medical records. Nearly

every significant type of

health care reform requires

availability of clinical data by

electronic means.

The other is the recommen-

dation for Congress to further

Sen. Mike Enzi Dr. Mark Frisse Dr. Harry Greenspun

Feature 1_pp12-15 1/16/09 6:05 PM Page 14

15G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

the significant gains made

through public/private collab-

oration on standards and in-

teroperability. Unless the fed-

eral government remains

actively engaged, issues of pri-

vacy, security and standards

harmonization will overwhelm

what progress has been made

to date.

Dr. Harry Greenspun

Chief Medical Officer,

Perot Systems

Ask payers to finance CPOE in hospitalsHealth care costs per capita in

the United States are the high-

est in the world, yet we lag in

leading quality indicators and

universal access to health care.

Depending on how you de-

fine electronic health records,

physicians and hospitals in the

United States have between

2 percent and 20 percent

adoption of those systems,

compared to more than 80

percent in the United King-

dom, Scandinavia and Canada.

Lack of alignment of incen-

tives for technology adoption

is a major issue. He who in-

vests in technology is not nec-

essarily he who benefits. I rec-

ommend a three-point plan

for your administration.■ Provide incentives through

Medicare/Medicaid for the

adoption and use of EHRs. Tar-

get those incentives so that

cost savings are shared with

clinicians.

■ Encourage insurers to provide

incentives for hospitals to

adopt computerized physician

order entry. The technology,

which lets physicians communi-

cate treatment instructions

electronically, is the most im-

portant tool hospitals can in-

troduce to improve their safety,

quality and efficiency of care.■ Continue to provide federal

funding for technology and

policies that encourage inter-

operability among health care

providers.

If we coordinate the care of

all Americans and ensure that

every person has a lifetime

electronic record, we will enjoy

safer care at a reasonable price.

Dr. John Halamka

Chief Information Officer,

Harvard Medical School

Provide incentives for medical homesIf there is one action that can

ensure that our health care

system’s balance is restored, it

[would be] to provide finan-

cial incentives for patient-cen-

tered medical homes to flour-

ish as places where care is

coordinated and continuity is

established for every patient

who wants one.

Financial incentives are re-

quired because the health in-

formation technology neces-

sary to connect medical homes

with other participants in the

health team — such as special-

ist physicians, pharmacies, hos-

pitals and the patients them-

selves — is costly to purchase

and maintain. Without that IT-

enabled connectivity, informa-

tion will remain isolated and

fragmented, and the opportu-

nities for improving quality

and reducing unnecessary

costs will be much more diffi-

cult to achieve.

Family physicians have

proven their willingness to

adopt health IT to enhance

patient care. What we need

now from the Obama adminis-

tration are the payment re-

forms that will promote coor-

dination and continuity of

care at the primary care level

and make it possible to trans-

form our system and achieve

new levels of health quality

and cost-effectiveness for

every American citizen.

Dr. Douglas E. Henley

Executive Vice President,

American Academy of Family

Physicians

Increase Medicare incentives for e-prescribingEach year, nearly 1.5 million

people are injured and 7,000

killed due to drug errors.

E-prescribing can prevent

these tragedies and, in doing

so, save U.S. health care $27

billion per year. But, ironically,

the biggest barrier to realizing

the savings is cost.

The Centers for Medicare

and Medicaid Services have

taken a first step, offering a 2

percent e-prescribing incentive

starting in 2009. But as the

largest purchaser of health

care, the federal government

must do more.

I urge you to leverage fed-

eral health IT investments to

revise Medicare reimburse-

ments to reward improvements

in quality through health IT uti-

lization. That will help improve

the return on investment for

physician adoption. Insurers ad-

ministering Medicare Part D

(prescription drug) payments

should also be encouraged to

offer e-prescribing programs

that help eliminate the physi-

cian cost burden.

For Medicare and Medic-

aid, e-prescribing can gener-

ate $3 billion per year in sav-

ings. And insurers that do

offer such programs should be

allowed to classify e-prescrip-

tion transaction fees as a med-

ical — not administrative —

expense [because] the benefits

of e-prescribing are directly

tied to better medical care.

These investments will help

dramatically reduce costs, save

lives and create a feasible path

to nationwide e-prescribing

adoption. With your support,

2009 can be the year when

health IT makes more effi-

cient, cost-effective care a

reality.

Kevin Hutchinson

Chief Executive Officer,

Prematics

Dr. John Halamka Dr. Douglas E. Henley Kevin Hutchinson

Feature 1_pp12-15 1/16/09 6:06 PM Page 15

here, at work.

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18 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

Streamline insurance enrollment systemsOne in four people who lack

health coverage in the United

States are eligible for publicly

financed insurance programs

but are not enrolled.

In considering the expan-

sion of Medicaid, the State

Children’s Health Insurance

Program (SCHIP) or any new

program, use of the same In-

ternet tools your campaign

successfully deployed to mobi-

lize millions of Americans

should be required to make it

easier for working families to

access and retain health care

coverage.

The current system of cate-

gorical programs — each with

its own application forms, eligi-

bility rules, document require-

ments and physical locations —

makes applying in person a

timely and confusing maze for

most families. It’s also costly

and inefficient.

And although a few states

have made progress, most lack

a unified enrollment approach,

which makes it impossible to

determine the full range of

services a family might be eligi-

ble to receive. The lack of more

integrated systems also pre-

cludes families from taking ad-

vantage of existing flexibilities

in federal law that permit

agencies to use information

provided by a family to main-

tain eligibility for one program

— for example, Food Stamps —

to also renew the family’s Med-

icaid coverage automatically.

Technology on its own will

not bring reform. Yet today in

California, more than 30 per-

cent of SCHIP applications are

submitted electronically. That

experience and similar efforts

in a few other states indicate

that by making enrollment

publicly accessible over the In-

ternet, greater numbers of eli-

gible but currently uninsured

families might find it easier to

enroll.

Sam Karp

Vice President of Programs,

California HealthCare

Foundation

Maintain the health IT czarI suggest that your single most

important task is creating a

sound health information man-

agement and technology infra-

structure as a central element

to accomplishing comprehen-

sive health care system reform

that expands coverage, raises

quality and controls costs.

There are several objectives

involved in this goal. The most

significant of these include

maintaining an Office of the

National Coordinator for

Health Information Technology

as a sort of health information

management and technology

czar. This person would serve

to coordinate the govern-

ment’s strategies and engage-

ment with the private sector,

supporting consumer-managed

personal health records, pro-

moting health information ex-

changes and expanding Ameri-

ca’s health information

workforce.

In recent years, we have

seen substantial gains made to-

ward establishing a nationwide

network for health informa-

tion management. Continuing

this public/private collabora-

tion can only further progress

already made. As you have

pointed out on several occa-

sions, there is an emergent

need for additional skilled elec-

tronic health record and health

information network profes-

sionals that must be resolved

quickly in order to accelerate

and maintain the successful

adoption, implementation and

effective use of health informa-

tion management technology

systems that improve care.

Linda L. Kloss

Chief Executive Officer,

American Health Information

Management Association

Build on established trust and leadership Health information technolo-

gy can’t solve all our health

care challenges, but I believe

it’s the critical first step in solv-

ing any of them. The currency

of a 21st century health sys-

tem will be health information

— delivered instantly and se-

curely to individuals and their

care providers and accumulat-

ed and analyzed for constant

improvement and research.

In the past four years, the

federal government stepped

forward to lead a broad-based

public/private movement ad-

vancing health IT. Although the

funds allocated were modest,

the industry responded with a

nonpartisan outpouring of vol-

unteer support that amplified

the effects. I lead an organiza-

tion that has been part of that

initiative. Along with comple-

mentary efforts, together we

have developed mechanisms to

build consensus on health IT

priorities, harmonize standards,

certify health IT products and

services for compliance with

those priorities and standards,

and begin organizing an elec-

tronic network connecting pa-

tients, doctors and hospitals.

So my advice is simple: The

change we need is one of scale

and dedication, not a disorient-

ing change of direction. As you

develop policies for a public in-

vestment in health IT, we invite

you to build on the momen-

tum, trust and leadership that

has already been painstakingly

established. I know my fellow

health IT leaders join me in

pledging our wholehearted

support to your inspiring lead-

ership, and we look forward to

great achievements in improv-

ing the health of our nation.

Dr. Mark Leavitt

Chairman,

Certification Commission

for Healthcare IT

Sam Karp Linda L. Kloss Dr. Mark Leavitt

Feature 1_pp18-19 1/16/09 6:11 PM Page 18

Hold White Househealth IT summitThe Healthcare Information

and Management Systems So-

ciety and its members stand

ready to help you and the

111th Congress bring health

care into the 21st century. Here

are our recommendations to

help accomplish that goal. ■ The administration and Con-

gress should invest a minimum

of $25 billion to provide in-

centives for electronic medical

record adoption to those who

contract with Medicare and

Medicaid. ■ Congress should ensure that

any funding appropriated for

the purchase or upgrade of

health information technolo-

gy products by federally fund-

ed health programs be allo-

cated only for the use of

health IT products that apply

interoperability specifications

approved by the Healthcare IT

Standards Panel and are certi-

fied by the Certification Com-

mission for Healthcare IT.■ The Health and Human Serv-

ices Department should ex-

pand and make permanent

the current Stark exemptions

and anti-kickback safe harbors

for EMRs to cover additional

health care software and re-

lated devices. ■ Congress should codify a

federal-level health IT coordi-

nating body [and] a senior-

level administration official to

oversee health IT and HITSP,

which will ensure continuity

of the significant gains that

have been accomplished in

the past several years. ■ Within the first 90 days of

the administration, you

should hold a White House

summit on health care reform

through IT to develop consen-

sus and propose solutions to

critical national health IT is-

sues within the context of the

larger economic issues facing

our nation.

Steve Lieber

Chief Executive Officer,

Healthcare Information and

Management Systems Society

Make a public/private road mapThe U.S. health care system

has great challenges, includ-

ing those related to quality,

safety, efficiency and access,

and we applaud your leader-

ship and recognition that

health information technolo-

gy plays a critical role in

health care reform.

A secure electronic health

information infrastructure will

not only transform care deliv-

ery but also enable us to more

effectively measure and im-

prove quality, better manage

chronic conditions, monitor

safety and public health

threats, and help us better un-

derstand which treatments

work best for specific diseases

and conditions.

We are excited about your

commitment to substantial

federal investment in health

IT. Such an investment —

which should cover not only

those who adopt health IT

and deliver higher-quality

health care but also health in-

formation exchange across or-

ganizations — will fast-

forward the development of

a higher-quality, safer, more

effective health care system

for all Americans. Collabora-

tion across the public and pri-

vate sectors — involving every

stakeholder, both nationally

and locally — to develop a

shared road map for accom-

plishing these goals is also a

necessary element for success.

Janet M. Marchibroda

Chief Executive Officer,

eHealth Initiative

Create a flexible privacy framework You’ve pledged to spend bil-

lions building a health infor-

mation technology network

that will become the back-

bone of a reformed health

care system. But there’s an-

other critical element to the

success of this network that

can’t be bought, no matter

how much money is put on

the table: trust. Patients won’t

allow their health information

to be part of this system un-

less they trust [that] it will be

protected.

How do you make that

happen? Use existing authori-

ty — and work with Congress

to fill gaps in the law — to es-

tablish a comprehensive, flex-

ible privacy and security

framework that sets clear

rules for access, use and dis-

closure of personal health in-

formation by all entities en-

gaged in e-health.

That includes strengthen-

ing the [Health Insurance

Portability and Accountability

Act] Privacy Rule for electronic

records kept and exchanged

by traditional health system

entities and backing it up

with vigorous enforcement. It

also means working with Con-

gress to ensure that all enti-

ties that handle personal

health information are re-

quired to comply with a base-

line of privacy protections.

Approach privacy as a goal

that requires consistent effort

as our revitalized health care

system continues to evolve.

Privacy is not a one-shot deal

or a single set of rules that

will sufficiently protect infor-

mation in each and every con-

text. Building trust requires

ongoing dialogue about the

right set of rules and techno-

logical solutions to meet the

information-sharing chal-

lenges raised by the new

e-health environment. Let’s

get the conversation started.

Deven McGraw

Director of the Health

Privacy Project,

Center for Democracy

and Technology

19G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

Steve Lieber Janet M. Marchibroda Deven McGraw

Feature 1_pp18-19 1/16/09 6:13 PM Page 19

Don’t boil the oceanWhat one thing could you do

that will have the most im-

pact on improving the value

of health care in the United

States? Don’t boil the ocean,

as recent federal approaches

have done. Rather, keep it

simple and focus on what we

can get done in today’s cur-

rent technological environ-

ment. Devise a plan and strat-

egy with reachable steps

that can be measured and

provide meaningful results to

patients.

One way to do that is to

provide a medication list to

every provider for every pa-

tient for every encounter. This

information, for the most

part, is already available

through national prescription

networks. Linking those

sources together can give the

provider a comprehensive

snapshot of past and current

medications, along with med-

ication allergies, potential

drug/drug and drug/disease

interactions, and other poten-

tial drug safety issues.

Adverse drug events result

in more than 770,000 injuries

and deaths each year. The

cost to treat those patients

could reach more than $5 bil-

lion annually, which doesn’t

include lost wages and pro-

ductivity or additional health

care costs that result from

these events.

Providing access to timely

and relevant prescription

medication information is a

simple, effective and measur-

able effort to improve the

value of health care in the

United States while positively

impacting the safety and

quality of care patients

receive.

Dr. Marc Overhage

Chief Executive Officer,

Indiana Health Information

Exchange

Build privacy firewallsProtect jobs. This is the first

action you and your adminis-

tration can take to truly im-

prove health care and the

overall quality of life for

Americans.

Information is powerful. It

can be used for good or ill.

The potential benefits of

health IT are immense. But

we will never achieve them if

patients do not control access

to personal health informa-

tion and we fail to build a

firewall between employers

and employees’ private health

information. It should be an

enforceable wall that is pro-

tected by meaningful penal-

ties for abuse. Protect em-

ployees and their families,

and you will stimulate and

maintain trust in a health IT

system.

The last place any Ameri-

can wants to be is in the un-

employable or uninsurable

lines. Unfortunately, the two

are often connected. Our sen-

sitive health data should nev-

er be used to put us in either

category. There are far too

many people in these lines al-

ready. In order to reap the

many potential benefits of

health IT, treat this endeavor

no different than the goals

professed in your transition

to the presidency: ensuring

transparency [and] accounta-

bility and protecting workers

and their families.

Dr. Deborah Peel

Founder,

Patient Privacy Rights

Focus on a nationwide solutionOur dysfunctional health care

system costs too much and re-

turns too little. As much as

one-third of our health care

spending does nothing to im-

prove our health.

To help fix that, we need a

nationwide health informa-

tion technology system, which

has the potential to improve

both quality and efficiency.

You have correctly said we

need health IT to provide a

short-term stimulus and lay

the groundwork for long-

term economic growth. Help-

ing doctors and hospitals pur-

chase health IT will provide

an immediate, valuable in-

vestment that our economy

needs.

To do health IT right, the

new administration needs

to focus on three things.

First, we need financing

and incentives to make sure

doctors, hospitals, and other

providers buy and use health

IT.

Second, we need national

interoperability standards so

records can be accessed wher-

ever they’re needed to pro-

vide optimal care. That will

also help us analyze care

that’s provided to weed out

waste and promote best

practices.

Third, we need clear priva-

cy and security rules that are

strictly enforced. Consumers

must be able to trust that

their sensitive personal health

information will be safe in an

electronic world.

This isn’t easy, and it isn’t

cheap. But it will cost more in

the long run — in both mon-

ey and lives lost — if we don’t

act.

John Rother

Executive Vice President

for Policy and Strategy,

AARP

Build institute for health care effectivenessBlue Cross and Blue Shield

supports creation of an inde-

pendent institute to develop

credible clinical information

on the comparative effective-

ness of new and existing med-

ical procedures, drugs, devices

and biologics.

20 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

Dr. Marc Overhage Dr. Deborah Peel John Rother

Feature 1_pp20-21 1/16/09 6:14 PM Page 20

The new institute should

be independent, nonprofit

and governed by a board rep-

resenting diverse interests, in-

cluding public and private

payers, providers, consumers,

and other industry stakehold-

ers — and protected from

outside pressures so it can

truly be a credible source for

evidence-based information.

It should support a broad

range of research to evaluate

the clinical effectiveness of

different procedures, drugs,

devices and biologics — and

clinical trials.

The institute should work

collaboratively with clinicians

and medical societies — maxi-

mizing research dollars by en-

couraging collaboration and

efficiencies across all institu-

tions, and disseminating

reports and comparative

information widely among

providers and other

stakeholders in easy-to-use

formats.

Medical societies would

need to take this research

into account when develop-

ing practice guidelines, and e-

prescribing and electronic

health records should incor-

porate agreed-upon guide-

lines into provider clinical de-

cision support systems.

Blue Cross and Blue Shield

stands ready to work with

you and the new Congress to

make the institute a reality to

improve the quality and value

of our health care system

while expanding access to all

our citizens.

Scott P. Serota

Chief Executive Officer,

Blue Cross and Blue

Shield Association

Wire the safety netWe realize that the current

health care situation in the

U.S. has to be addressed im-

mediately across all facets —

cost, quality, access and pre-

vention. Technology is crucial

for this transformation, which

can be architected through

the choice of right processes,

methodology and appropriate

workflow.

The medical home concept

or other similar models will be

successful in ensuring that the

right coordination of care is

provided through our primary

care physicians only when

health care information tech-

nologies are implemented ap-

propriately. Incentives will be

required that reverse the per-

verse economics that exist to-

day that rewards payers, em-

ployers and patients instead of

physicians.

The increased prevalence

of chronic disease and an ex-

panding aging population

that benefits from advances in

modern medical technology

are placing an increasing bur-

den on our limited clinical re-

sources. To immediately ad-

dress this issue, we need to

ensure we leverage the wide

range of telemedicine and

telehealth capabilities, so that

we can ensure all our citizens

can have the same quality of

care regardless of whether

they live in rural areas or ur-

ban areas. Additionally, high-

quality care in many cases can

be provided at the patient’s

home, [offering] convenience

for the patient while reducing

the overall cost.

Finally, we must ensure

these technology solutions are

made available to our safety-

net providers to ensure no one

is left without adequate

health care. Reimbursement

for telehealth and telemedi-

cine initiatives will be the key

to ensure broad adoption.

Jay Srini

Chief Innovation Officer,

Insurance Services Division,

University of Pittsburgh

Medical Center

Make the governmenta smarter buyerHealth care today is a cottage

industry that fragments patient

care into a thousand pieces but

doesn’t put them back togeth-

er again. As a result, we have

the best doctors and hospitals

in the world, but we pay more

for less quality than any of our

industrialized peers. We need

to turn the health care sector

into a health care system. What

should we do?

First, recognize that the

government is the health care

market. Sixty percent of all

health spending comes from

the government, but that’s

only part of the story because

[the government] influences

the market in so many other

ways, such as policy-maker,

regulator, insurer, provider,

purchaser, standard-setter and

infrastructure-builder. The gov-

ernment needs to be a smarter

buyer and a smarter investor if

the health care market is go-

ing to act more like a market.

Second, orchestrate these

roles to make basic health in-

formation sharing a standard

of care. Require all hospitals

and specialists and primary

care physicians to provide

patient-specific post-visit re-

ports to one another, and re-

quire all providers to routinely

report standardized quality

and public health data to gov-

ernment-sanctioned data-col-

lection entities. We have a lot

of data in health care delivery,

but we have little information

and even less knowledge.

Third, invest in health infor-

mation technology to turn this

data into knowledge. Hold us

accountable by making fund-

ing contingent on the ability

to demonstrate that we’ve

used technology to make pa-

tients’ lives better.

Micky Tripathi

Chief Executive Officer,

Massachusetts eHealth

Collaborative

21G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

Scott P. Serota Jay Srini Micky Tripathi

Feature 1_pp20-21 1/16/09 6:15 PM Page 21

“Every time somebody comes up with stronger protection, somebody else comes up with a better re-identification method.”

BRADLEY MAL IN ,

VANDERB ILT UN IVERS ITY ’S SCHOOL OF MEDIC INE

Feature 2 1/16/09 6:14 PM Page 22

23G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

A new era for medicalprivacy dawned in 1997, when a comput-er scientist named Latanya Sweeneyshowed she could identify then-Gov.William Weld of Massachusetts on a listof patients discharged from a hospital,even though the data had been strippedof identifiers such as names, addressesand Social Security numbers.

Using a publicly available list of regis-tered voters, Sweeney zeroed in on Weld’sZIP code in Cambridge, Mass., andmatched dates of birth and genders ontwo lists downloaded from the Internet.Weld emerged as the only match.

Sweeney said 87 percent of Americanscould be similarly identified in a dataseteven if it reveals only their birth dates,genders and ZIP codes. Lawmakers tookher comments into account when theycrafted the Health Insurance Portabilityand Accountability Act’s Privacy Rule,which took effect in 2003, nearly sevenyears after Congress passed HIPAA.

Today, medical data is increasingly be-ing stripped of identifying information

and sold to the highest bidders. Howev-er, a growing number of mathematics andcomputer science experts are saying thatsuch de-identified datasets lend them-selves to re-identification with today’s ad-vanced data-mining techniques.

Sweeney told a workgroup of the Na-tional Committee on Vital and HealthStatistics in 2007 that the chances of re-identifying someone through data thatcomplies with HIPAA’s requirements forde-identification are 0.04 percent.

“Actually, that doesn’t feel that bad,”said Dr. Kevin Vigilante, a physician andprincipal at consulting firm Booz AllenHamilton. In other words, he believed thatrisk of re-identification was acceptable.

“Unless you’re one of those people”whose medical records are identified,Sweeney said.

In the years since Sweeney pluckedWeld’s record out of cyberspace, the tech-niques that can be used for re-identifica-tion have gotten more powerful, saidBradley Malin, assistant professor of bio-medical informatics at Vanderbilt Univer-

sity’s School of Medicine. “It’s a little bitof a cat-and-mouse game,” Malin said.“Every time somebody comes up withstronger protection, somebody else comesup with a better re-identification method.”

“Things are changing very fast,” agreedCynthia Dwork, a principal researcher atMicrosoft Research.

Seeking scientific solutions That rate of change is a key reason whybiomedical researchers are chafing underthe constraints of the HIPAA Privacy Rulesix years after it took effect. In an era inwhich an increasing number of medicalrecords exist in digital form, ready to beanalyzed for insight into health issues andthe practice of medicine, it can be diffi-cult for researchers to get their hands onthat data.

In a survey of epidemiologists report-ed in the Journal of the American Med-ical Association, two-thirds said theHIPAA Privacy Rule had made researchsubstantially more difficult and added tothe costs and uncertainty of their proj-A

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Scientists and policy-makers seek ways to maintain patient anonymity and tap the data treasure

trove of personal medical records

B Y N A N C Y F E R R I S

The searchforJohnDoe

Feature 2 1/16/09 6:16 PM Page 23

ects. Only one-quarter said the rule hadincreased privacy and the assurance ofconfidentiality for patients.

Meanwhile, databases of clinical andgenomic information are increasinglyhosted on the Internet for researchers toshare. “Developers haveintegrated privacyshields in today’s data-bases, but these arenaïve and ad hoc firstattempts with no prov-able and little (or no)real-world privacy pro-tection,” Sweeney wrotein a description of a re-search project she isleading at Carnegie Mel-lon University.

Malin, Sweeney,Dwork and others aretrying to devise tech-niques that will allowresearchers to use datathat has identifying in-formation while pro-tecting the privacy ofthe individuals whoserecords are being used.

Malin, who is under-taking a project with re-searchers at prominenthealth care centers,wants to determinewhich features of individuals’ medicalrecords can be identifying and what canbe done to reduce privacy risks whilemaking the data readily available to researchers.

“If you de-identify information, youhave to ask what is still existing withinthat information that could still be ex-ploited by people,” Malin said in an inter-view. “De-identification has a focus onthe explicit identifiers — the names, thephone numbers, the Social Security num-bers — and the residual information isstill there because we don’t know how itcould be exploited.”

Based on his work, 18 data elementsthat are typically eliminated for HIPAA-

compliant de-identification might remainin the record, while other elements couldbe further suppressed.

For example, one of Malin’s students,Allison Beck McCoy, recently showed thatlaboratory test results such as blood sug-

ar values could belinked to individuals inde-identified records.McCoy used a de-iden-tified dataset availableto researchers at theNational Institutes ofHealth and matched itwith de-identified labdata from a DNA data-bank at Vanderbilt.

Malin described hiswork as “trying to givesome indication ofwhat the risks are in thereal world as opposedto just the worst-casescenario.”

Robots and sensitive dataSweeney is working ona project that, amongother things, seeks todevelop what she de-scribed as “a new re-search paradigm inwhich software agents

— not humans — access sensitive data.”Those agents, which might be thought ofas virtual robots, would dive into a data-base and return with results to a scientist’squery, such as how many patients with Xcharacteristic have Y disease.

At Microsoft Research, Dwork and hercolleagues are pursuing a different line ofinquiry. They are trying to use mathemat-ical techniques to modify data so that anyindividual’s inclusion in or exclusion froma dataset does not affect the likelihood ofhis or her identity being revealed. In addi-tion, the results of queries would be onlyslightly affected, so a researcher could trustthe results.

“Our approach will completely rule out

linkage attacks,” such as Sweeney’s detec-tion of Weld, Dwork said.

The work includes defining privacy andsecurity in mathematical terms. “Our no-tion of privacy is called differential priva-cy,” Dwork said. “We look at the ratio ofthe probabilities for any given answer,” thenintroduce tiny, random inputs to reducethe likelihood that an individual can besingled out.

The downside is that answers to thesame query would vary somewhat, shesaid. But at the same time, exact answersare risky when a researcher asks a questionsuch as, “How many people in this data-base are named Cynthia and are HIV-pos-itive?” The technique works best with largedatasets, but the amount of distortiongrows with each query, so “there is a limiton what you can safely extract from thesystem,” Dwork said.

Another approach involves encryptingthe identifying data on records in severalrepositories, then matching the encryptedrecords to create longitudinal patientrecords that can be used in research. ScottSchumacher, senior vice president andchief scientist at Initiate Systems, said atleast one company offers a software prod-uct for accomplishing that task.“But thereare not very many people doing this,” headded.

Policy prescriptionsBesides those and other research efforts,many people are looking at potential pol-icy remedies for the re-identificationproblem.

One of the most common suggestionsis extending the reach of the HIPAA Pri-vacy Rule, which now applies only tohealth care providers, health plans andcompanies that process health care claims— categories that are collectively knownas covered entities.

Some have proposed applying the ruleto every individual and organization inpossession of personal health information.That would not necessarily stop peoplefrom re-identifying data, but it would lim-it their uses of it once they did so.

24 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

“Some of themost commonquestions I get

are from entitiesthat aren’t even

covered byHIPAA who

want to knowhow HIPAA

affects them.”

FRED CATE ,

IND IANA UNIVERS ITY

The search for John Doe

Feature 2 1/16/09 6:16 PM Page 24

25G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

Malin has a relatively simple sugges-tion: States should raise the prices of thevoter registration databases they sell andconsider removing some of the identify-ing data.

Residents of some states are more vul-nerable to re-identification because dataabout them is more readily available, hesaid. For example, in Tennessee, the voterlist costs about $2,000 and includes dateof birth, gender and ZIP code for eachname. In other states’ lists, only the vot-er’s year of birth appears.

What’s more, Malin said, the voter listfor Wisconsin costs $12,000, while NorthCarolina’s list is free. Clearly, someone try-ing to match those lists with other datawould be more likely to start with theNorth Carolina list.

Officials at the Coalition for PatientPrivacy, which comprises more than two-

dozen organizations, said they are seekinglegislation to ensure that health “informa-tion disclosed for one purpose may not beused for another purpose before informedconsent has been obtained.” The effectcould be to make sales of health data andunauthorized re-identification illegal.

Another proposed policy would requirethose who hold health data to account forall disclosures of patient information. Thatmeans a patient could request a reportshowing who had received copies of hisor her records. Technically, patients alreadyhave that right under HIPAA, but it’s notclear that the provision applies to the du-plication and sharing of databases.

Many privacy concerns center on howinsurance companies and employersmight use health data to discriminateagainst people who seem likely to incurhigher health costs. For that reason, Fred

Cate, a law professor at Indiana Universi-ty and director of its Center for AppliedCybersecurity Research, said he advocatestougher enforcement of laws that prohib-it discrimination on the basis of disabili-ties or genetic makeup.

Cate also said the complexity of theHIPAA rule and other relevant laws andregulations can confuse those responsiblefor implementing them, creating a climateof fear about medical privacy. “Hospitalssay, ‘No, we can’t provide you that data,’even when under the law they probablycould,” he said.“Because the law’s so com-plex, they are hesitant” to make any dataavailable.

“Some of the most common questionsI get are from entities that aren’t even cov-ered by HIPAA who want to know howHIPAA affects them,” Cate said. Simplify-ing the laws could alleviate researchers’

Under the Health Insurance Portabil-ity and Accountability Act’s PrivacyRule, biomedical researchers havefive ways to obtain medical records,although they say none is ideal.

1. Obtain patient authoriza-tion. Not only is this approach po-tentially time-consuming, but if re-searchers want to review recordscompiled over a period of years,they will have trouble contactingsome patients because they willhave died or moved away. Other pa-tients will decline to participate inthe study, and the result will be askewed sample, as research at theMayo Clinic has shown.

2. Use de-identified data. Underthe Privacy Rule’s so-called safe-harbor provision, researchers canuse records that have been strippedof 18 kinds of identifying informa-tion, including the last two digits ofZIP codes or entire ZIP codes insparsely populated areas, Social Se-

curity numbers, and dates related tomedical care. However, it can be dif-ficult to learn much from recordsthat contain so little informationabout patients.

3. Ask for a limited dataset. Thedata will have more identifying in-formation than data that has beende-identified, but it won’t haveenough detail for many researchers’needs. Furthermore, researchersmust enter into an agreement withthe source of the records specifyinghow they will use them and agree-ing not to re-identify them.

4. Obtain the approval of theresearch or privacy board at theinstitution where the researchproject will take place. Such boardsare composed of volunteers, usuallyfaculty members, who review re-search plans. They can determinethat access to protected health datais required for a project and that theappropriate safeguards will be in

place. At some institutions, theprocess runs smoothly, but at others,it causes delays and can be a highhurdle for researchers.

5. Use statistical methods tode-identify records instead of re-moving the 18 identifiers speci-fied in the Privacy Rule. For the re-sulting dataset, the rule states that“a person with appropriate knowl-edge of and experience with gener-ally accepted statistical and scientificprinciples and methods for render-ing information not individuallyidentifiable” must certify that thereis a very small risk of the records be-ing re-identified.

Although experts say the methodis not often used, it provides an op-portunity for de-identifying datawithout re-writing the Privacy Rule.On the other hand, privacy advo-cates decry the lack of specificityabout statistical experts’ qualifica-tions and the lack of provisions forreviewing their decisions.

— Nancy Ferris

5 ways researchers can get medical records

Feature 2 1/16/09 6:17 PM Page 25

and patients’ privacy concerns, he added.Cate also suggested that different lev-

els of protection might be warranted fordifferent kinds of data, depending on theimpact of disclosing the information. Forexample, one’s HIV status should be tight-ly held, while one’s daily blood pressurereadings are less consequential, he said.

Is there really a problem?Patient Privacy Rights, the organizationled by Dr. Deborah Peel, has been partic-ularly concerned about the sale of healthdata, even when it is de-identified.

Such sales are common these days, andthe data’s use in marketing is one of thethings that troubles privacy advocates likePeel.

No reporting is required for healthdata sales, and there are no laws or regu-lations limiting the uses of de-identifieddata, so nobody really knows what buy-ers are doing with it.

When data is de-identified, “there areabsolutely no strings attached to that,”said Deven McGraw, director of theHealth Privacy Project at the Center forDemocracy and Technology.

“Unless the recipient of the data is it-self a covered entity, the chain of account-ability is completely lost,” she said. “Therecertainly aren’t any federal parametersaround the use of de-identified data, sothere’s a huge market for it. It’s of mini-mal privacy risk if in fact it can’t be re-identified, but certainly some of the moresophisticated statisticians out there” haveconcerns.

Malin described the legal environmentas “a little bit of cowboy country.” Hewouldn’t speculate on how much re-iden-tification is taking place, but, he said, “Ifthe data’s available and the data can bedownloaded or collected and pinpoint-ed…with relative ease, then you will seecompanies or individuals do this just be-cause it can be done. And it will be valu-able because people will buy it.”

On the other hand, he cautionedagainst assuming the worst. “I’m not try-ing to say that people are going to go off

and nefariously try to identify individu-als or health insurance corporations aregoing to try to find out what diseaseseverybody has,” he said. “It’s just that therisk exists,…and we have to control theinformation accordingly.”

Besides the uncertainty about howmuch data mining andre-identification are oc-curring, another barri-er to policy-making isthe difficulty of under-standing the issues.

Although scientistscan quantify things suchas the risk of re-identi-fication, how serious isa 0.04 percent chance ofre-identification?

And although re-search organizationslobby for access to dataso they can study dis-eases and advance thepractice of medicine,privacy advocates makea forceful case in Con-gress for their positions.Finding the right bal-ance isn’t easy.

“I sympathize withthe lawmakers in thatthe privacy argument isvery, very clear and very[persuasive] to them,and sometimes the [re-search] use argument isn’t so [persuasive],”Schumacher said. “I think we can do abetter job of explaining and calculatingthe risks.”

No privacy absolutes“After five years, given the increase in pub-lic databases that are available out there,is that [HIPAA] safe-harbor method stilla reliable one?” McGraw asked.

“I think it’s a little unknown. Some-thing that’s static, that specifies certaincategories of data, is by nature going tobecome outdated as more and more in-

formation becomes more publicly avail-able,” she added.

“This is an area that requires furtherstudy,” said Dixie Baker, chairwoman ofthe Privacy and Security Advocacy TaskForce at the Healthcare Information andManagement Systems Society.

The task force hascalled for the Healthand Human ServicesDepartment, which is-sued the Privacy Rule,to continually reviewthe standard for de-identifying data.

“I don’t think it’s re-alistic to assume thatthat standard will beadequate forever andever,” said Baker, who isa senior vice presidentat Science ApplicationsInternational Corp. “Itdoes need to be re-ex-amined. There are veryfew absolutes when itcomes to personal pri-vacy. It’s a fact of lifethat there will be trade-offs. It’s always a risk-management question.”

“The current situa-tion doesn’t seem to meto satisfy either the pri-vacy side or the re-search side,” Schumach-er said.

Despite researchers’frustration with the HIPAA rule, it’s intheir interest to work with HHS to main-tain privacy protections, Malin said.

“I think it would only take one famouscase in order to lose the public trust inthese types of research endeavors,” headded.

Those issues have been around forsome time, but it’s possible that a resolu-tion is in sight. Health care reform is onthe horizon, Cate said, and “there is noway they’re going to do it without con-fronting these privacy issues.” ■

26 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

“After fiveyears, given

the increase inpublic databases

that are available outthere, is that

[HIPAA] safe-harbor

method still areliable one?”

DEVEN M C GRAW,

CENTER FOR DEMOCRACY

AND TECHNOLOGY’S

HEALTH PR IVACY PROJECT

The search for John Doe

Feature 2 1/16/09 6:17 PM Page 26

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B Y J O H N M O O R E

The U.S. government is the largest pro-vider and payer of health care services inthe world. So how it approaches obstaclesto providing personal health record sys-tems to the public is likely to have a bigimpact on whether the new technologygets widely adopted in this country.

PHRs promise to give patients un-precedented control over who has accessto their health records and what thoserecords contain. The information cancome from a variety of sources, includinghealth facilities, health plans, independ-ent service providers such as health databanks, or information technology firmssuch as Google or Microsoft.

Given the many delivery options andthe complex handoffs involved in linkingconsumers and physicians to health recordrepositories, experts say PHR privacy andsecurity must be nearly foolproof before

the public will accept the new technology.“I think a foundation of trust is ab-

solutely essential for people to start usingPHRs,” said Dr. Jody Pettit, strategic leaderof the Certification Commission forHealthcare IT’s PHR work group. “Thattrust includes really good privacy policiesand really strong security protections.”

To help spur adoption, CCHIT is de-veloping a certification program for PHRs,which is set to launch this summer. Al-though security criteria fall within thescope of the effort, the organization won’tconduct some identity management testsuntil the 2010 certification cycle.

Among the most important techniquesfor verifying people’s identities are iden-tification proofing and authentication.

ID proofing creates a foundation oftrust from which an organization can is-sue credentials for authenticating a per-son’s right to access a system — in thiscase, a PHR. A user name/password com-

bination is the most common example;more stringent credentials include secu-rity tokens and biometrics such as finger-prints or vein scans.

But there is no standard approach forgovernment agencies seeking to establishID management processes for PHRs.“There has not been a universally accept-ed standard in this area,” Pettit said. “Inthe areas that are new like PHR, wherestandards may not be complete, it makesour job more challenging.”

Medicare approachesThe novelty of PHRs means they do notfit neatly into existing privacy frameworks.For example, the Health Insurance Porta-bility and Accountability Act (HIPAA) in-cludes language that relates to PHRs butonly those offered by certain providers andhealth plans. Therefore, HIPAA rules donot apply to independent providers suchas Microsoft or Google.

Officials at the Centers for Medicareand Medicaid Services have experiencedthat dichotomy firsthand as they preparedto conduct PHR tests for Medicare recip-

28 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

The outcome of the government’s PHR trials will have

profound effects on public trust of the new technology

PERSONAL HEALTH RECORDS

The feds and PHR privacy

For Microsoft’s HealthVault, con-sumers can open an account andcreate a personal health recordwith the same Windows Live IDthey use for other Microsoft onlineservices, such as Hotmail, or theycan create a distinct Windows LiveID for HealthVault.

Users can also sign in withOpenID accounts, which offer second-factor authenticationthrough the use of physical tokenssuch as USB keys. In addition,Microsoft is adding support for In-

formation Cards in HealthVault. PHRAnywhere, a payer-based

PHR, uses smart cards in its authen-tication process. Members receivethe cards when they sign up withan insurance company or employerthat offers PHRAnywhere. When amember registers on the portal forthe first time, PHRAnywhere elec-tronically verifies user-entereddata, such as smart card number,insurance card number and date ofbirth, against information providedby the insurance company or em-

ployer. Members are then issued auser name and password, whichthey use for subsequent log-ins.

Some companies use biometrictools to secure PHRs. Fujitsu Com-puter Products of America’s Palm-Secure technology is being used toprotect electronic medical recordsbut has not yet been directly inte-grated into a PHR system.

PalmSecure captures an imageof the vein pattern of a person’spalm. Software takes the imageand creates a template that is digi-tized and encrypted.

— John Moore

Authentication paths

Policy 1/16/09 5:57 PM Page 28

ients in South Carolina, Arizona and Utah.CMS is in charge of the South Caroli-

na program, so it falls under HIPAA andthe Federal Information Security Man-agement Act. In contrast, participants inthe Arizona/Utah test can sign up withone of four commercial vendors: GoogleHealth, HealthTrio, NoMoreClipboard orPassportMD.

The companies are not covered enti-ties under HIPAA and “operate in a spacewhere there are no standards that apply,”said Elizabeth Holland, a health insurancespecialist at CMS.

Against that backdrop, governmentagencies are taking steps to move PHRsforward. Although CMS cannot requirevendors to adhere to the terms of HIPAA,the firms participating in the Arizona/Utah program, which is expected to getunder way early this year, have signed adata-use agreement, Holland said.

The agreement calls for vendors to es-tablish appropriate administrative, tech-nical and physical safeguards to preventunauthorized use of and access to records.The data that will populate Medicare re-cipients’ PHRs will come from CMS con-tractor Noridian Administrative Services.

The agreement also specifies Office ofManagement and Budget Circular A-130as a guideline for IT security. A-130 re-quires government information systemsto have security plans, provide securitytraining to users and adhere to federal in-formation security laws.

In addition, Holland said, vendorsmust agree to certain controls describedin the National Institute of Standards andTechnology’s Special Publication 800-53.That document’s user identification andauthentication policy calls for “the use ofpasswords, tokens, biometrics or, in thecase of multifactor authentication, somecombination” of those tools.

How vendors meet those requirementsmight vary slightly, Holland said. CMS hasleft it to vendors to decide details such aswhether they will assign user names or al-low participants to select their own, shesaid.

Once a participant signs up with aPHR vendor, he or she will be passed backto CMS. The agency will ask for five piecesof information: Medicare number, lastname, gender, date of birth and ZIP code.Once CMS validates that information, itwill release the person’shealth data to the PHRof his or her choosing.

Military solutionsThe Veterans Affairs De-partment offers PHR-like services through itsMy HealtheVet Web por-tal. The site offers healtheducation and benefitinformation withoutregistration. However, anupgraded account letsveterans store elementsof their health records inMy HealtheVet’s eVAultfeature.

Thus far, the dataavailable for eVAult islimited to a combina-tion of self-enteredmedication data anddata from VA’s electron-ic health record system.More health informa-tion will be made avail-able in an upcoming release of MyHealtheVet, said Theresa Hancock, theprogram’s director.

In-person ID proofing has been therule for obtaining an eVAult account. Vet-erans typically went to a VA medical cen-ter for a face-to-face validation. In June2008, VA’s Health Information Manage-ment Group approved a policy that letshome health care nurses, legal guardiansor individuals with power of attorney han-dle the validation task. VA also providesin-person ID proofing at veterans events,such as American Legion conferences.

Once the ID proofing is complete, theveteran is issued a log-on credential con-sisting of a user name and password.However, VA officials are exploring other

authentication mechanisms to augmentexisting approaches. For example, voicebiometrics would provide greater assur-ance of veteran authentication than sim-ply a user name and password, said John“Mike” Davis, a security architect at VA’s

Office of Informationand Technology.

“We have establisheda mechanism that workswhere we are today andgives us a bridge to thefuture,” he said. “Wewant veterans to gothrough this only once.”

Officials hope to fur-ther simplify ID proof-ing by taking advantageof the Defense Depart-ment’s high-assuranceprocess, Davis said. Thatstep would free VA andveterans from duplica-tive proofing.

For its part, DOD re-cently launched its Mi-Care prototype PHR.Microsoft’s HealthVaultand Google Health serveas the repositories forthe program’s patient-controlled health infor-mation. DOD officials

say they will use the Markle Foundation’sConnecting for Health guidelines to pro-tect health information. That four-step au-thentication framework uses ID proofing,tokens or identifiers, ongoing monitoring,and ongoing auditing and enforcement.

Whatever approaches agencies take,PHR acceptance will ultimately dependon the trust of health information pro-viders and consumers.

“I think the element that needs to bediscussed and understood about identitymanagement is that the PHR industry isgoing to be required to have a high levelof assurance that [users are] who theypresent [themselves] to be,” said LoryWood, co-chairwoman of CCHIT’s PHRwork group. ■

29G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

“We have established

a mechanismthat works

where we aretoday and gives

us a bridge to the future.”

JOHN “MIKE” DAVIS ,

VETERANS AFFA IRS

DEPARTMENT

Policy 1/16/09 5:58 PM Page 29

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B Y J O H N M O O R E

Physicians who have so far resisted the urgeto buy an electronic medical record systemoften cite costs, the management attentionthey would divert and doubts about theirefficacy. But now momentum is building foran approach to using EMRs that takes someof the risk out of the equation.

An increasing number of health infor-mation technology firms are offering EMRsas a hosted service, making it easier for smalland independent physicians’ practices toadopt the technology, according to somewho have taken that route.

With a hosted or software-as-a-service(SaaS) model, a third-party firm runs andmaintains EMR software for the customer.Experts say the approach lowers upfrontcosts and reduces the complexity of fieldinga system. It could also inspire greater accept-ance among physicians in smaller practices,where health IT is taking longer to catch on.

“SaaS is essential if you are going to un-

lock the low end of the market,” said MarcHolland, a research director at IDC’s HealthIndustry Insights. “The [adoption] rateamong solo and less-than-three-doctor prac-tices is really pretty dismal.”

In an October 2008 report, the Health-care Information and Management SystemsSociety pegged the EMR adoption rateamong small practices at 24 percent.A studypublished in the New England Journal ofMedicine in June found that practices ofmore than 50 physicians were four timesmore likely to have a fully functional EMRthan practices of three or fewer physicians.

Now that hosted EMR systems are an op-tion, small practices “are finally going to takethe plunge,” Holland said.

Public health organizations are also ex-ploring hosted solutions. For example, NewMexico’s Department of Health chose sucha system for its 49 public health offices.

Hosted market evolvesA number of firms that historically focused

on client/server EMRs now also offer SaaSas an option. Allscripts, eClinicalWorks andMcKesson are among the companies thatoffer both approaches.

Girish Kumar Navani, president of eClin-icalWorks, said he believes vendors that of-fer hosted EMRs will fare better this yearthan those that carry only client/server prod-ucts. The hosted model is easier and less ex-pensive for health care providers to adopt,which makes it especially appealing duringthe current economic downturn.

“You don’t have to buy a server, so cost-wise, it becomes more attractive,” he said.

With SaaS, customers typically paymonthly hosting charges and licensing feesfor using the software. Licensing fees forclient/server EMRs can run into the tens ofthousands of dollars, while monthly sub-scription fees for a SaaS-based EMR are gen-erally a couple hundred dollars per provider.

LifeSpan, a health care system in RhodeIsland that uses eClinicalWorks’hosted EMRand practice management solution, offersthe EMR service to members of its Physi-cians Professional Services Organization.

“The [hosted] approach has been ex-tremely beneficial in getting smaller prac-

31G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

Remotely hosted EMR systems attract doctors who don’t

want the expense and headaches of in-house solutions

SOFTWARE AS A SERVICE

EMRs without tears

Buying electronic medical records asa service reduces upfront costs, but isit a better deal in the long run?

Under the software-as-a-service(SaaS) model, customers typically paya monthly subscription fee that cov-ers software licensing and hostingservices. As an example, a five-physician practice that contractswith a vendor for a hosted service ata cost of $400 a month per providerwould pay $24,000 in a 12-monthperiod — a tally that might not dif-

fer that much from the upfront costfor a client/server EMR.

But total-cost-of-ownership com-parisons yield different results de-pending on the type of software in-volved and its useful life, said JeffreyKaplan, managing director of con-sulting firm Thinkstrategies.

SaaS should cost about the sameas annual maintenance fees for on-premise software, Kaplan added. Butthere’s a twist. “While some peopleequate SaaS to leasing rather than

buying a car and, therefore, [con-clude it’s] not economical over time,the reality is that unlike leasing a car,SaaS is continuously gaining valuerather than depreciating,” he said.

That’s because the serviceprovider constantly refines and en-hances the software, which alsosaves the customer from having tomake additional hardware or staffinvestments to support or upgradethe application, he said.

— John Moore

Are hosted EMRs really cheaper?

Technology 1/16/09 6:00 PM Page 31

tices to adopt the EMR system,”said Bill Flo-rio, director of information services at Life-Span’s physician organization. “The mainadvantage is that there is a dramatically re-duced start-up cost [because] the only hard-ware needed in the offices is the client PCs.”

At least one hosted EMR vendor offersits product for free. Practice Fusion doesn’tcharge for licensing, hosting, implementa-tion or training. Instead, the company gen-erates revenue from banner ads and the saleof anonymized patient and doctor data.

Ryan Howard, chief executive officer ofPractice Fusion, said his company also of-fers a fee-based, ad-free product, but mostdoctors choose the free version.

The rigors of managing an in-housetechnology deployment represent a barrierto EMR acceptance. But the SaaS approachaddresses those issues by offloading tech-nology oversight to the software vendor orapplication service provider (ASP).

Bob Mayer, chief information officer atthe New Mexico Department of Health, saidthe agency chose a hosted EMR system fromAllscripts because of the complexity of EMRapplications and skills required to managethe technology. “We weren’t confident wecould support it ourselves,” Mayer said.

Holland said the Web-based nature ofhosted solutions means that health organi-zations only need to focus on client devicesand Internet connectivity.“There’s no serv-er to worry about,” he said. “You just haveto keep the workstation up and the routerand Internet connection running.”

The SaaS approach also shields cus-tomers from the need to maintain and up-date software. Vendors handle those tasks,and subscription fees cover the costs.

New Mexico’s arrangement with All-scripts lets the health department lock inEMR software costs for the four-year termof the contract and build them into its budg-et, Mayer said. Otherwise, obtaining extrafunds to pay for software upgrades can provedifficult for state agencies, he said.

Data ownership The hosted approach has a few drawbacks.For example, its reliance on the Internet

means an EMR system’s performance is onlyas good as the available bandwidth and thereliability of the Internet service provider.

Glen Tullman, CEO of Allscripts, saidmedical records are time-sensitive and doc-tors have concerns about a hosted EMR’sability to deliver instan-taneous updates. How-ever, improvements inbandwidth and ASP of-ferings have helped al-lay those concerns, Tull-man said.

However, some ar-eas still lack adequateinfrastructure. “Somerural communitiesdon’t have reliablebroadband connectiv-ity,” said Jonah Froh-lich, senior programofficer at the Califor-nia HealthCare Foun-dation, adding thatsmall practices in someurban areas can alsoencounter bandwidth difficulties.

Lack of control is another issue, withmany clients citing concerns about datasecurity. For example, LifeSpan soughtgreater control over its hosting arrangement

with eClinicalWorks. As a result, the EMRapplication resides at eClinicalWorks’ datacenter, but LifeSpan owns the server thatgives it access to the software.

Florio said hardware ownership provides“an additional layer of security to our envi-

ronment” by ensuring thatonly LifeSpan-affiliatedphysician datasets run onits server. By contrast, mul-tiple customers typicallyshare hardware in a SaaSvendor’s data center.

Server ownership alsolets LifeSpan manage scal-ability on its own terms. Ifperformance lags, the or-ganization can add morehardware instead of askinga vendor for more capaci-ty, Florio said.

Ultimately, SaaS firmsbelieve customers will bewilling to work around thehosted model’s negatives toreduce upfront costs and

outsource technology management.Tullman said smaller practices are con-

cluding that they “want to practice medi-cine [and] want someone else to handle thetechnology.” ■

32 F E B R U A R Y 2 0 0 9 | G O V E R N M E N T H E A L T H I T

“We weren’tconfident we

could support itourselves.”

BOB MAYER , NEW MEXICO

DEPARTMENT OF HEALTH

Independent practice associationsare among the health care pro-viders embracing the hosted ap-proach to electronic medicalrecords.

Taconic IPA, which operates inNew York’s Hudson Valley region,is affiliated with MedAllies, a com-pany that hosts EMR systems.MedAllies is about 18 months intodeployments of NextGen Health-care Information Systems and

eClinicalWorks solutions for theIPA’s physicians.

Dr. A. John Blair III, presidentand chief executive officer ofTaconic IPA and chairman and CEOof MedAllies, said installing an EMRsystem can prove to be beyond theability and expertise of some IPAs.

So far, MedAllies supports 100doctors on NextGen and 150 oneClinicalWorks, he added.

— John Moore

Independent practices alsoeye EMRs as a service

SOFTWARE AS A SERVICE

Technology 1/16/09 6:01 PM Page 32

33G O V E R N M E N T H E A L T H I T | F E B R U A R Y 2 0 0 9

© Copyright 2009 by the Healthcare Information and Management Systems Society (HIMSS). All rights reserved. Reproductions in whole or part prohibited exceptby written permission. PPeerrmmiissssiioonn RReeqquueessttss: Mail requests to Permissions Editor, HIMSS, 230 East Ohio Street, Suite 500, Chicago, IL 60611-3270. MMeeddiiaa KKiittss: Di-rect your media kit requests to Randy Knotts, Senior Manager, Advertising Sales, at rknotts@himss.org, or at (312) 915-9561. RReepprriinnttss: For single article reprints(in minimum quantities of 250-500), e-prints, plaques and posters contact: PARS International at (212) 221-9595; via email at 1105reprints@parsintl.com; or viaweb at www.magreprints.com/QuickQuote.asp. LLiisstt RReennttaallss: For information on rental of this publication’s subscriber list, contact Randy Knotts at rknotts@himss.org,or at (312) 915-9561. DDiissccllaaiimmeerr: The information in this magazine has not undergone any formal testing by HIMSS and is distributed without any warranty ex-pressed or implied. Implementation or use of any information contained herein is the reader’s sole responsibility. While the information has been reviewed for ac-curacy, there is no guarantee that the same or similar results may be achieved in all environments. Technical inaccuracies may result from printing errors and/ornew developments in the industry.

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A $10 billion investment in health in-

formation technology as part of a

planned economic recovery package

would create or retain 212,105 jobs

in one year, according to the Infor-

mation Technology and Innovation

Foundation, a Washington think

tank.

ITIF’s analysis found that a $10 bil-

lion health IT stimulus program

would create or retain 43,410 jobs di-

rectly, most of them in areas such as

software and hardware sales and sys-

tem installation. Another 115,670

jobs would be created or retained in-

directly, in areas such as sales of vehi-

cles and food to those holding the

new jobs.

Furthermore, the availability of

new and improved networks and in-

formation would create 53,025 jobs,

the foundation reported.

In addition, ITIF found that a

$30 billion investment in health IT,

a smart power grid and broadband

would create 949,000 jobs, more

than half of them at small businesses.

GE

TT

Y IM

AG

ES

MEASURES

Employment impact of health IT stimulus

Jobs created or retained for 1 year by a $10 billion health IT stimulus package:

Direct jobs Indirectjobs

Network-related jobs

31,790

43,410

62,895

115,670

26,990

53,025

Source: Information Technologyand Innovation Foundation

Small-business jobs

Grand total 212,105Total small-business jobs121,675

GHIT 34 1/16/09 6:03 PM Page 34

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