In 1991, the Institute of Medicine (IOM) called the electronic health record (EHR) “an essential technology for patient care.”[i] Although this early report spurred considerable action and some progress in the 1990s, it was the subsequent report, To Err Is Human,[ii] from the IOM in 1999 that really focused the attention of the nation on the pervasive problems of safety and quality in our health care system, largely traceable to the limited application of modern information management. That report estimated that medical errors result in between 44,000 and 98,000 preventable deaths each year in hospitals alone. A more recent study showed that only fifty-five percent of U.S. adults with common chronic diseases were receiving recommended care.[iii]
This was further elucidated and emphasized in subsequent reports from the IOM[iv],[v] and other national expert panels including the President’s Information Technology Advisory Committee[vi],[vii] and the Computer Science and Telecommunications Board of the National Research Council.[viii] In 2001, the National Committee on Vital and Health Statistics (NCVHS), a statutory advisory committee to the U.S. Department of Health and Human Services (DHHS), explicitly recommended development of a National Health Information Infrastructure (NHII).[ix] By then, it had been recognized that EHR systems alone were not enough - the systems would need to interconnect and communicate to ensure that patient information dispersed among the various places where care had been given were assembled into a complete record immediately available at any point-of-care. It was also clear that modern information management was an essential prerequisite to improving all aspects of health care, leading the IOM Committee on Patient Safety to conclude in 2003 that “establishing this information technology infrastructure [NHII] should be the highest priority for all health care stakeholders.”[x]
In response to the 2001 NCVHS report, the DHHS began to focus on this issue by adopting health information standards for use by the Federal government and licensing the controlled vocabulary SNOMED for use at no charge by anyone in the United States. In 2003, the first NHII conference developed a consensus national action agenda.[xi] The following year, the President created the Office of the National Coordinator for Health Information Technology (ONC) in the DHHS and a Strategic Framework was announced espousing the goals of informing clinicians, interconnecting clinicians, personalizing care, and improving population health.[xii] Besides improving safety and quality, it has been estimated that the annual national savings from NHII (now also known as the NHIN or the Nationwide Health Information Network) could exceed $130 billion, about 8 percent of current health care spending.[xiii]
A key implementation strategy emanating from the IOM, the 2003 NHII consensus national agenda development meeting,11 and the DHHS Framework for Strategic Action12 is the concept of building local or regional health information infrastructures (HIIs) to implement the organizational, financial, legal, and technical capabilities needed to interconnect all sources of health information.[xiv] Since health care itself is a local activity and the difficult sociopolitical issues related to sharing health information are best addressed at the local level, this approach seemed both pragmatic and feasible. This view has been reinforced by the early successes of a few community HII projects, such as Spokane, Washington, and Indianapolis, Indiana.
While widespread application of HIT is not a panacea for all the complex and difficult problems of our health care system, it is a critical prerequisite to addressing many, if not most, of the key issues such as higher quality care, increased access, more effective chronic care delivery, and the ability to empower active consumer participation in their own health care. The ability of HIT to both measure and directly impact the everyday processes of health care will enable ongoing design, development, implementation, and evaluation of policy initiatives to improve the quality and efficiency of care.
Recognizing the potential value of HIT, efforts are underway in communities throughout the nation to promote adoption and use of EHRs, as well as the connectivity required to integrate the information to provide complete medical records for each person whenever and wherever needed. The experience of communities that have been pioneers in the development and implementation of HIIs demonstrates that the application of health information technology to improve health care can be both feasible and practical. However, such efforts are also complex, difficult, and risky. At least five major categories of issues must be addressed:
- obtaining the buy-in of the community;
- developing appropriate governance mechanisms to ensure fair and equitable sharing of power;
- dealing with each stakeholder’s concerns about ownership of data;
- developing appropriate and sustainable financing arrangements that match costs with benefits; and
- acquiring, implementing, and maintaining effective, secure, and reliable technology.14
A consensus about how best to approach the challenging problems of developing such health information infrastructure has not yet emerged. Nevertheless, there is general agreement in the health information technology community that we do not have sufficient numbers of trained personnel to implement the NHIN regardless of the approaches that ultimately prove successful. If this generally accepted premise is correct, our nation could soon find itself in the unfortunate position of knowing how to build the NHIN but lacking the workforce needed to accomplish the task.
The strong tendency of community health information infrastructure projects is to engage the best available personnel, regardless of whether those individuals meet an objective standard of competence (which is admittedly difficult to define). If there is a shortage of qualified personnel, much of the NHIN work in communities is likely to be done by inexperienced and inadequately trained individuals who, as they rediscover well-known informatics principles, will inevitably make expensive and time-consuming mistakes. Such errors not only have a negative impact on an individual project, but also could be misinterpreted by others as evidence that the NHIN itself is not a viable idea. This might jeopardize projects across the nation, including those being effectively implemented by capable and experienced informaticians. This same scenario was observed in the 1990s with the development of community immunization registries, where inexperienced leaders repeatedly made costly errors leading to project failures, disillusionment, and substantial waste of financial and other resources. Compared to immunization registries, the NHIN work is even more complex and involves more stakeholders in a much greater level of change. Therefore, it is reasonable to anticipate that, absent effective intervention to improve the availability of needed informatics personnel, the implementation problems will be even worse.
This workforce problem has been recognized for several years. In 2001, before the current surge in NHIN development activity, the Department of Labor was already projecting a forty-nine percent growth in the demand for health information management workers by 2010.[xv] The recommendations developed at the 2003 NHII meeting included increased clinical informatics training for both health professionals and clinical informatics specialists.11 In 2005, the American Medical Informatics Association (AMIA) announced its intention to facilitate the education of 10,000 informatics specialists by 2010 with its "10 x 10" program.[xvi] More recently, this workforce issue was the subject of a joint report from AMIA and the American Health Information Management Association (AHIMA) entitled Building the Workforce for Health Information Transformation.[xvii]
The recommendations of the AMIA-AHIMA report include the following:
- Create incentives for health care professionals to acquire and maintain informatics skills.
- Develop a stronger health information specialist workforce.
- Define workforce competencies.
- Engage a wide group of stakeholders to develop a vision for expanding health
- information education in the future.
- Increase awareness of the need for expanded public- and private-sector funding of HIT training.
- Develop and apply tools for assessing and projecting workforce needs.
Specifically addressing this last recommendation from the AMIA-AHIMA report, the current research project aims to develop and apply tools to estimate the specific workforce needs for building the NHIN. While there is widespread agreement about the need for additional personnel, there are no existing tools that focus specifically on quantification of NHIN personnel needs. Availability of such estimates would greatly assist policymakers, educational institutions, professional societies, communities, and others to help address the expanding needs for trained personnel as the work on health information infrastructure across the nation continues to develop and expand.