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The array of national health programs in the United States is dizzying. They range from the Affordable Care Act with its health insurance exchanges and Accountable Care Organizations, to Medicaid and Medicare, disease surveillance, health monitoring, networks of health centers and labs, all the way to drug monitoring, regulation and more. All of these programs have been, or are now, becoming electronic, just as health records are. Indeed, many of these programs will play major roles in either incenting or conflicting with efforts to advance the electronic health care infrastructure. And as with other industries, becoming electronic changes the way these programs can and should be carried out themselves. With the advent of cloud computing and other approaches, these changes can have a large impact on the most effective and efficient use of large amounts of taxpayers’ dollars as well as the achievable outcomes.
Funding the stovepipes
Health programs frequently start with a perceived need. Eventually, sometimes with the support of advocacy groups, the need achieves a degree of congressional funding. Congressional funding, tied to the goals of that program, flows through one of several health-related federal agencies and operational divisions. As an example, although there are less now, the Centers for Disease Control and Prevention once had over 120 different congressional funding lines. For the CDC, the funding lines were mostly organized around individual diseases or conditions. Most federal agencies are themselves organized around such funding lines. They develop staffs that are oriented to achieving those specific missions. Not only does the amount of funding limit the number of staff, there is a rough expectation that the program will be sized as a branch, division, center or more, depending on the amount of funding there is.
The federal employees are required to use the funds to achieve congressional intent. Their career advancement and even their passions (many of these programs have truly inspirational individual missions) are tied to those specific objectives as well. Needless to say, the strong alignment in these program “stovepipes” can be both powerful and difficult to overcome when necessary. While others may increasingly reuse infrastructure, code and services, these dynamics have made it very hard for federal health programs to do so. Much of the technology needs seem similar, but program differences tend to be emphasized because of the funding and other dynamics.
Some federal programs carry out direct activities with funds, but many also pass these funds onto state and local jurisdictions to move closer to direct execution.
Many times more
There is more variation at the next level, but frequently “50 states” or “56 states and several large metropolitan city-states” are the next stop on the health programs’ progression. Not surprisingly, each of these jurisdictions is frequently organized to match the federal programs that fund them. Funding cross-cutting infrastructure, like IT frequently can be, is also difficult here because the funding lines don’t encourage, and frequently have precluded, even the perception that funds are being used for something different than the intent of the grant or other funding vehicle that transfers the congressional intent onto the state. Data sharing can also be a particular problem between jurisdictions and with the federal government.
As with federal agencies, some health program activities are carried out directly by the states, but others fund activities in health care.
“Meshing” with healthcare
Healthcare, on the other hand, is principally organized around the provision of care, the different types of providers, and the needs to be internally financially productive. Whether it is interfacing with the states or directly with the federal agencies there is an interesting meshing of “stove-piped” health programs and the somewhat conflicting organization of healthcare responsibilities (hospital admissions, differing levels of care, medical services, laboratory, radiology, etc.).
This is your health program on IT
Information technology, however, does not “care” much about the differentiating specifics of these health programs or jurisdictions. From the perspective of the technology, many of these activities share a great deal and “look” the same. The many congressionally funded disease programs the CDC, for example, have historically had very similar technical components. From a technology perspective, the difficult task of securely and reliably getting data from providers in numerous diverse healthcare organizations to public health agencies can overwhelm the differences in the data needed for different diseases.
Despite the many differences between Medicaid processes in different states, the technical needs of those systems share a great deal. There are huge political obstacles, but limited reuse at the federal and state levels is conspicuous at a time of federal retrenchment and dire state financial circumstances. As most technology implementations move to the cloud, there are also models for reuse that can maintain suitable isolation, individual variability, and appropriate data ownership, while minimizing unnecessary costs. When one looks at the entire health system, the complexity of the many EHR and other vendors – times - many healthcare sites – times - many state programs – times - many federal programs in some ways defines the huge interoperability and health information exchange problem that is still ahead of us.
Implementing multiple but similar cloud-based instances at any point in this math can greatly suppress the otherwise exponential exchange complexity. It does so by minimizing the number of interfaces and also by driving what are then, at least, de facto standards implementations. The cloud enables not only the “virtualization” of different instances, it also allows for the technology enablement of organizations, like public associations, that can be trusted systems stewards for many but have not historically had the technical wherewithal to be operational system homes.
One has to look no further than the political decisions about whether health insurance exchanges will be run by the state or the federal government to see that there are frequently non-technical circumstances that trump technical commonalties. With the advent of cloud and other approaches, however, there should be ways for leadership to drive models for more reuse in order to save healthcare dollars, achieve better outcomes, and focus on additional areas of critical need.