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1、A Critical Review of:“A Call to Arms: Why the NHII is Critical to Our Nations Security”David RobbinsKarin Lindgren5 November 2007MEDINF: 407 Legal, Ethical and Social Issues in Medical InformaticsDave Roberts is the Healthcare Information and Management Systems Society (“HIMSS”) director of public p

2、olicy and staff liaison to the HIMSS Advocacy and Government Relations Roundtable Committees. In his article, “A Call to Arms: Why the NHII is Critical to Our Nations Security”, Mr. Roberts advocates the creation of a nationwide health support system called the National Healthcare Information Infras

3、tructure (“NHII”). The article was published in the Journal of American Healthcare Information Management, Volume 17, Number 3. His approach in writing the article is that of supporter and lobbyist. The article covers why he believes the NHII should be created, the scope of its functions, how it sho

4、uld be developed, how much it will cost and the role of HIMSS. While Mr. Roberts clearly communicates that he is an advocate for a national healthcare information infrastructure, he does not effectively establish a need for the system, his vision of the end product is unclear, and his opinions may b

5、e prejudiced because his employer has a financial interest in the system.In the article, Mr. Roberts begins with the assumption that the US healthcare infrastructure is a critical component of the American economy and an enabler of a good quality of life for US residents. He suggests that closing ga

6、ps and maintaining that infrastructure will allow it to remain a positive contributor. He provides examples of gaps in the infrastructure such as a disconnect between caregivers and what happens with a patients medical information if that patient receives care in a new environment. He proceeds with

7、the assumption that very few healthcare facilities can transact healthcare information, which has created a gap in the US healthcare infrastructure. After laying that foundation, Mr. Roberts suggests that the inability to get medical information to people who need it quickly has been detrimental to

8、our ability to provide care during regional and national disasters such earthquakes, anthrax, the World Trade Center bombing, and West Nile virus outbreaks. He suggests that the need for medical information in these situations establishes a broader need for a national healthcare infrastructure capab

9、le of rapidly providing information to all who need it to make sound decisions about health. He calls this the NHII.Mr. Roberts begins describing his vision for NHII by citing statistics about the current state of the US healthcare system. He asserts that while our delivery system is the finest in t

10、he world, we need to continue making improvements because of rising costs, reduced benefits and the growing number of uninsured Americans. He also discusses medical error rates and potential bioterrorism as additional concerns that establish a need for NHII. He then proceeds to outline his vision fo

11、r what the NHII will look like as an end product. Mr. Roberts envisions a system that will serve public, local, state and federal healthcare providers. The system will be composed of a set of technologies, standards, applications and systems that will work in harmony to more quickly transact and mak

12、e available medical information to all users. This increased access to data will serve the public interest by supporting initiatives related to disease prevention and health promotion. Mr. Roberts continues describing his vision for the system by providing a general timeline for its creation. He env

13、isions a 10 year development time frame. The first two years would begin with the creation of an implementation plan and incentive development to encourage participation of vendors, government agencies and clinicians. The first two years would also include establishing the requirements, instituting

14、an accelerated standards process and securing resource commitments from the involved parties. The next five years would encompass the full development effort followed by three years of implementation activities. After providing the high level scheduling estimate, Mr. Roberts cites a study that estim

15、ates, in total, the creation of the NHII would cost about $14 billion dollars. Mr. Roberts concludes the substantive portion of his article by outlining the role that he believes HIMSS should assume in the creation of the NHII. HIMSS created a task force in October of 2002 to help the industry creat

16、e and adopt the NHII. The focus of the task force is to work with other organizations to provide education to its members and lobby the government for funding. The committee is composed of providers, suppliers and consultant organizations along with a number of government agencies such as the CDC, D

17、oD, HHS and VA. There are three areas of the article that undermined Mr. Robert vision for the NHII:1. Mr. Roberts first failed to establish a need for the system he is advocating. The article included a high level overview of general problems in the US healthcare system, but Mr. Roberts failed to p

18、rovide an explanation for how the NHII would improve on those problems. He pointed out gaps, but then didnt detail what NHII would do to fill the gaps. 2. He outlined an end state vision for the system that was short on details and long on assumptions. He provided a set of characteristics he believe

19、s the system should have, but did not articulate what the system would look like as a final product or how it would operate. 3. He posited a methodology for creating the system that at its core is self serving to his organization and more generally lacking in disciplined cost and effort scheduling.

20、Mr. Roberts first failed to effectively document a need for the creation of the NHII. He started building his case by listing a number of recent US disasters as evidence that an NHII must be created. He suggested that when disasters occur, federal, state, local and public health organizations need t

21、o respond effectively and rapidly. While this generality is inarguable, Mr. Roberts stopped his explanation there and provided no evidence that a nationwide information system would enable a more effective, rapid response. Mr. Roberts mentioned the attack on the Oklahoma City Federal building in his

22、 list of disasters. This attack occurred in a regional location where regional people used regional medical services. No details were provided on what sort of data would need to be transmitted nationally that would have improved the quality of emergency care for the bombing casualties. He furthermor

23、e never established that there was a problem communicating medical information quickly during the response to this disaster. Disaster preparedness guidelines for bombings and blast incidents do not include a requirement that hospitals plan to transact information rapidly to and from other facilities

24、. Preparedness focuses on capacity and emergency department planning which should receive funding before an NHII if the goal of the program is to more readily respond to disasters (Kalemoglu 2005). A second, more national scenario he cited was the Anthrax scare of 2001. In this scare, Anthrax spores

25、 were mailed to several news media offices and two US Senators. Five people were killed and seventeen others were infected (ANTHRAXinfo 2007). Again, no explanation for how a comprehensive, knowledge-based national information system would have improved the medical response to this scare was provide

26、d in the article. Hospitals would be more effective at responding to disasters by using the estimated $14 billion dollars to directly prepare for disasters than to make indirect improvements through the creation of an NHII. By mentioning national disasters that illicit emotion from readers, the arti

27、cle successfully got the readers attention then moved on without providing a good justification for name dropping the disasters.Mr. Roberts continued to cite other circumstantial statistics about the US healthcare system without explaining how those areas would be improved by the NHII. The article n

28、oted that the US healthcare system accounts for about 14% of GDP then failed to note that this is a disproportionately high percentage and failed to discuss how the NHII would reduce this spending. HIMSS actually has a white paper on how healthcare costs can be reduced by digitizing information but

29、Mr. Roberts fails to provide a reference or explanation for his assertion (Noffsinger and Chin 2000). He then noted that health insurance benefits are declining and a growing number of Americans are uninsured. By including these statistics, he implied that the NHII would help solve these problems, b

30、ut did not provide an explanation for how. Mr. Roberts began closing his arguments about why the US needs to develop the NHII by noting that there are 98,000 medical errors a year then not explaining what NHII would do to increase quality of care. The Agency for Healthcare Research and Quality has a

31、 publication on how facilitating information transfer can help reduce medical errors, but Mr. Roberts doesnt provide one example, explanation or reference (AHRQ 2007). Included in Mr. Roberts final conclusion on establishing a need for NHII, he asserted without explanation that the system would help

32、 prevent bioterrorism. The reader can make inferences about how NHII would address each of these issues, but Mr. Roberts would have more successfully advocated his position had he correlated gaps in the US healthcare system to features of the proposed NHII.The articles second broad weakness was the

33、end state vision for the system. Mr. Roberts provided a number of high level characteristics of a national healthcare infrastructure, but failed to provide detail on the scope of the system, the user base and the requirements. While the primary goal of the article was to address why we need NHII, co

34、mmunicating the end vision of NHII is important since Mr. Roberts is trying to convince the reader its the right solution to address the gaps he documented. Mr. Roberts does a good job informing the reader what the system is not (a centralized database of health records), but then provides little in

35、 the way of requirements to document what it actually is and what it will do. Mr. Roberts cites the National Committee on Vital and Health Statistics (NCVHS) explanation of the NHII as a “comprehensive knowledge base that is capable of providing information to all parties that might need it to suppo

36、rt sound healthcare decisions” and notes that it is composed of a set of “technologies, standards, applications, systems and networks”. Even considering that the target audience of this article is professionals who read the Journal of Healthcare Information Management, and many readers will be able

37、to make inferences about what he means, Mr. Roberts undermines the urgency he is trying to create in his article by leaving readers unsure of exactly what he wants to help build for $14 billion dollars. The article continues to present a weak end state vision for the system as he covers the target m

38、arket for the NHII. Mr. Roberts specifically mentions routine and emergency care, personal health, clinical research and public health then goes on to say that the system should generally provide information to anyone who needs it. In order to build usable systems, it is essential to understand the

39、system users needs, goals, and expectations (Pruitt 2006). A system that is built with a virtually unlimited user base is unlikely to be high performing for any user. Mr. Roberts vision of a system available to all who need it is followed by the assertion that the NHII will enable significant improv

40、ements in the security of health records and therefore privacy. Creating a system with a virtually unlimited user base, that connects previously unconnected entities, to transact private health information, is not a certain step towards increased privacy. Mr. Roberts may have meant that the way that

41、 we currently share clinical information isnt as secure as how we would in his vision for NHII, but he does not articulate that point. Mr. Roberts states that security will be improved then leaves it up to the reader to make the determination of how that will be implemented. The article would have b

42、een better served with several quick sentences on HIPAA and NHII compliance with HIPAA. The HIPAA privacy requirement requires that covered entities only use or disclose medical information for treatment, payment, healthcare operations or when compelled by law. This guideline would provide the funda

43、mental operational boundary for how covered entities use the NHII but it goes unmentioned in the article. Given the potential penalties for HIPAA infractions, the readers of this article probably have a great interest in how the proposed NHII would help them remain compliant. Mr. Roberts would have

44、furthered his case had he spent the time noting that a single, integrated platform may provide less possible infraction points than the current myriad ways that covered entities transact data. The third area the article could have been improved on was Mr. Robertss discussion of how the NHII should b

45、e created and the role that HIMSS should play. It becomes clear that not only is Mr. Roberts advocating the creation of the NHII, he is advocating that HIMSS play a funded roll in its creation. In fact, the closing third of the article is devoted to explaining how HIMSS has arranged a committee that

46、 they would like to see funded by the federal government. Mr. Roberts further discusses an additional existing initiative, Integrating the Healthcare Enterprise (IHE), that they would like to see funded as part of the NHII package as well. I think Mr. Roberts undermined his promotion of NHII because

47、 he is advocating funding for a system his organization has a financial interest in. Furthermore, the Journal of Healthcare Information Management, which this article was published in, is a publication of HIMSS. Even though the journal is peer reviewed, this particular article should be approached b

48、y readers with doubt since its author is a lobbyist for the publisher and the article is advocating funding for his own organization. In his article, Mr. Roberts articulated the creation of a system with characteristics that have few industry detractors. His vision is marked by heightened security a

49、nd privacy, tighter integration of information systems, and advanced applications to more quickly provide medical data to clinicians nationwide. These characteristics are broadly appealing and a natural evolution of existing information systems. Mr. Roberts, however, failed to demonstrate that the NHII would actually be a