Pay for performance: a win for the NHIN? During a recent conversation with a healthcare CIO, the subject of the National Health Information Network and Regional Health Information Organizations came up

Healthcare Financial Management, August, 2005 by Dewey Freeman

My friend expressed skepticism that either would ever become a reality. It seems that many healthcare IT leaders at least the ones with more than a little gray hair recall the passing of the Community Health Information Networks of the mid- 1990s and see parallels to it in the present NHIN-RHIO efforts. There is growing evidence that the skeptics will be wrong.

What Is Different Today?

Recent reports from research groups and information from the Office of the National Coordinator for Health Information Technology state that significant savings could be achieved if providers, payers, patients, and others had access to a shared network of health information. These savings are driven in large part through reduction of errors, elimination of redundant and conflicting tests and treatments, streamlining of administrative processes, and proactive patient management. One might argue whether the annual savings are nearer to $100 billion or $50 billion, but it is clear that there are benefits.

The president has made healthcare IT one of his top priorities and mentioned the need to trans form healthcare delivery through the use of IT in each of his past two State of the Union addresses. He launched the role of national coordinator for health information technology in April 2004, and named David Brailer, MD, PhD, to the job. In July 2004, the Secretary of Health and Human Services announced the "Decade of Health Information Technology" as critical to transforming our healthcare system. At the same time, the Office of the National Coordinator for Health

Information Technology released Framework for Strategic Action, which describes a high level plan for how the healthcare industry will move from today to where it needs to be in 10 years. Running through the entire framework is the need to IT enable healthcare delivery and connect providers, payers, patients, and others in a national network.

HHS Secretary Michael Leavitt announced on June 6 that he would chair a commission called the American Health Information Community. The commission will focus on five objectives for healthcare IT:

* Protect privacy and security

* Define an Internet-based national architecture for secure health information exchange

* Create a process to identify and harmonize interoperability standards

* Define a process to certify healthcare IT products

* Make itself obsolete in five years

There are also at least six legislative initiatives proposed in the House and Senate with broad bipartisan support. These initiatives, among other things, propose creating incentives for healthcare IT adoption, providing loans and grants for health care IT initiatives, and modifying Stark and antikickback laws to promote healthcare IT.

Unlike the Community Health Information Networks of 10 to 15 years ago, there is intense federal attention and energy being applied to the creation of a national network, which, it is recognized, will be pieced together by interconnecting RHIOs. At present, more than 140 RHIO initiatives are in various stages of development around the country. The technology landscape today the Internet as a backbone network systems management for distributed architectures, and more robust applications--present even more opportunities for creating RHIOs.

What Has Not Changed?

A few things remain the same from the Community Health Information Network era. There is no complete set of standards for creating interoperable systems and linking the data through an RHIO. The nation is in the early stages of RHIO development, and the RHIOs will take on many forms and architectures. Some will have to be reconstructed as NHIN and other requirements become better defined.

The culture of competition among healthcare organizations still makes it difficult to bring the parties together to collaborate on creating RHIOs. Difficulties creating a working governance structure and funding model remain.

Also, electronic health record systems are not in every provider location. Although the number and functionality are improved over those present in the 1990s, adoption of EH technology by physician providers has been slow in coming. Many RHIO efforts are providing physician access to information about patients that is Created in hospitals, laboratories, and pharmacies, but will add physician generated data later.

How Will P4P Affect RHIOs?

If physicians can access information about their patients without the need to implement an EHR, then why will they bother? What is the "secret weapon" for RHIO/NHIN success? The answer is pay for performance. Many P4P programs require that physicians submit clinical data so it can be determined if they achieved the program's outcome targets. Some P4P programs also offer incentives when physicians use an EHR. Physicians who participate in a P4P program without an EHR must manually abstract the required clinical data for reporting. They also do not benefit from the automatically generated alerts and reminders that help them achieve their quality targets. P4P may well be the single biggest motivator physicians have for adopting an EHR.