Lessons from America

It has been said that the NHS National Programme for Information Technology (NPfIT), which initially took cues from the publicly funded US Veterans Health Administration, now serves as a model for a planned interconnected healthcare data infrastructure in the US. From the American perspective, lessons seem to be flowing in both directions.

“We’re learning how from them and they’re learning why from us," explained Dr David Brailer, national co-ordinator for health information technology in the US, a newly created office within the Department of Health and Human Services (HHS).

Brailer said that the involvement of private enterprises in the American system helps breed innovation in care delivery. Conversely, the government-run NPfIT in England is an exercise in volume, being just about the largest, most ambitious IT project in history.

“This is one of the few times [in healthcare] where America falls behind Britain," Brailer conceded.

The US plan differs from the NPfIT because the NHS actually is managing and paying for the implementation. “We’re not running an IT project," Brailer said.

“There will not be a government network," according to Brailer. The administration of US President George W. Bush is dead-set about the need for market-based healthcare. Government does need to play a role, Brailer said, but the exact parameters have yet to be determined.

Brailer also said that the NHS essentially has split the function he plays into three separate jobs, that of NPfIT Director General Richard Granger; the recently appointed head of NPfIT service implementation, Alan Burns, whose role is to rally physicians and the public; and John Bacon, group director of health and social delivery.

While the NHS plan to automate healthcare information for 52 million people across England is well underway, the Americans still are shaping policy.

Last January, Bush challenged government policy-makers and private entities to bring electronic medical records to the majority of Americans within 10 years. In May, he tapped Brailer to lead the effort.

Brailer since has identified a four-pronged “framework" for meeting the president’s goal: inform clinical practice, interconnect clinicians, personalise care and improve population health.

Brailer wants to have the building blocks for a proposed National Health Information Network in place by the end of 2005. With this in mind, HHS last month issued a formal request for information from healthcare stakeholders, in hopes of ascertaining the industry’s current and future capabilities.

Brailer said it is critical to have the foundation of the national network in place within two years or the 10-year goal may be unattainable.

The plan suffered a setback late last month when the US Congress quietly eliminated a proposed $50 million (£25.9 million) appropriation from the 2005 federal budget to encourage standards adoption and provide incentives for private investment in health-IT.

Also on Friday, Brailer’s boss, HHS Secretary Tommy Thompson, announced that he would step down in February.

While expressing disappointment that the funding line item fell through the cracks as lawmakers scrambled to pass a budget ahead of a long holiday weekend, Brailer said that the lost money is little more than an inconvenience. “$50 million is not going to change America’s adoption of health information technology, and this is a multi-billion-dollar endeavour," he explained.

Brailer also talked of the fact that healthcare IT has become part of the debate on spending priorities. “This is a national issue that’s now on the national radar screen," he said.

Still, the reality is that healthcare stakeholders in the US still are grappling with how to change the market so that insurance companies, health plan sponsors and consumers are buying value. “You fundamentally alter the economics to give consumers what they want, which is more pain-free, disease-free days," Brailer said.

Patients — the consumers of healthcare — will help bring about transformation, but not until they have trustworthy information about physicians and hospitals so they can make informed choices about where to spend their healthcare money. In the US, employers, the traditional sponsors of health insurance for most Americans, are fighting double-digit inflation in premiums by increasingly asking employees to bear a greater share of the costs.

“This is a vital piece," Brailer said of consumerism.

Brailer highlighted an element of consumerism last Friday at Evanston Hospital, just outside Chicago. Parent organisation Evanston Northwestern Healthcare (ENH) recently completed a $30 million (£15.5 million) implementation of clinical IT across three hospitals and scores of physician offices.

ENH just launched a Web portal for patients to view their medical records, communicate with physicians, book appointments and request prescription refills.

Changing attitudes

And that is the fundamental challenge Brailer faces, breaking down barriers that keep information confined to single institutions. Brailer says that the healthcare industry still is a long way from having a universal, patient-centric electronic health record, even though there has been talk of setting standards for data interchange for a quarter century.

“I’m worried most about interoperability because I don’t see any native force that drives that," Brailer lamented.

“It is not enough for each business to automate itself," Brailer said. Patients have multiple care settings and often choose providers in an a la carte fashion, so health IT systems must be interoperable. “We need portable information that follows patients," he added.

“I want you to go beyond your walls when you’re able to do that," Brailer told Evanston Hospital officials.

“This is not about the technology,” he insisted. “Technology is the easy part." Changing institutional cultures predisposed against sharing information and empowering consumers to make informed healthcare choices is much trickier, Brailer said.

But he remains upbeat in the face of a daunting task because there finally exists the political will to fix the broken US healthcare system. “Things don’t happen very fast in healthcare, but I’ve seen very few issues with so many interests aligned," Brailer said.

“I think that the talk around Washington about change in healthcare, particularly around health information technology, is simply stunning,” Brailer said. “This is the beginning. It’s not the end."