Kolodner Brings an Implementer's Perspective to ONCHIT

In April, Robert Kolodner was finally appointed the nation's permanent health-IT chief. He'd served as interim director since David Brailer, the first U.S. national health information technology coordinator, stepped down roughly a year ago.

Brailer's legacy is well-known. He served for two years, launched the Department of Human Services health-IT strategy from scratch, and promoted a vision in which a national health care network would link hospitals, clinics and physicians nationwide. He worked towards establishing standards and a product certifications process to form the foundation for digital patient records and health computer systems.

When Brailer resigned, he told reporters that the next coordinator's job would be not to establish a vision but to keep the process moving forward. Kolodner generally agrees. He is the former chief health informatics officer for the Department of Veterans Affair, and brings experience overseeing development of the VA's VistA program and healthcare information system -- he knows what it takes to implement big projects. Last week Kolodner spoke Digital HealthCare & Productivity about his hopes and plans.

DHP: As permanent national coordinator for health information technology, what are your main objectives?
The overall goal is moving forward and accelerating the progress we have made in the last few years. Since the President's executive order in 2004 (for most Americans to have EHRs by 2014), we've made more progress than in the prior decade or two. David Brailer did a terrific job establishing the [office] and framework for [HIT] activity. My role is to make sure the deliverables and outcomes we hoped would occur, do in fact occur, and then to set into motion new activities.

DHP: What are you hopes for this year?
We are looking at the establishment of the organization that will follow AHIC (consultative, American Health Information Community) and be a public-private entity in the private sector. In our meeting next Tuesday we'll spend a couple of hours discussing the activities and concepts of this entity that doesn't have a name yet. It is a concept that's evolving and would provide overall governance for activities with a broad base of participation. We're looking forward to an active discussion by the AHIC members at the June meeting and will see this organization take shape over the next few months.

We'll [also] be taking NHIM (National Health Information Model) to the next step, providing funds to the communities and to local and regional health information exchanges. We'll actually begin to have recognized standards that will form the basis of certification of federal systems and contracts.

DHP: Healthcare has long been working towards interoperable standards for HIT. What obstacles remain?
There are no insurmountable barriers. We need to continue to put sufficient funds into the effort. That's not a huge amount of dollars but we need to make sure we have a sufficient budget for the activities next year. The issue of privacy is also one that we have to come to grips with."

DHP: But doesn't cost remain an issue - it's expensive for physicians to invest in these systems, and many are reluctant to invest in technology that is perhaps still in its infancy.
There have been areas where we started to address the cost of systems for physicians. There are Stark exemptions and anti-kickback safe harbors, regulatory changes that allow larger providers to contribute the vast majority of cost for smaller providers for the purchase of EMRS. We have pay-for-performance projects underway and we're exploring other funding options as well.

We've also made terrific progress with certification with over 80 ambulatory health records certified in the first year - that's much higher than we thought would be achieved. We are delighted to get that level of participation. With our phased implementation of certification, each year the bar will raise and products will get better and be more interoperable and cover a broader range of data and standards that support more of the scenarios and use-cases outlined as part of the priorities.

"I agree that [health information] technology is in its infancy compared to where we will be 10-20 years from now, but that's true when you're talking about any technology. To say the technology in its current state cannot bring improved care when used properly is certainly not true. There are examples, the VA being one of them, which show how much better care can be when EHRs are used as an adjunct.

DHP:  One issue that health care has not yet recognized is vulnerability to the network core. As traffic rises, the IP network can break down. Can you talk about provisioning for huge increases in network traffic? Also, how will an increasing number of diverse wireless devices be managed?
: Your questions are excellent and are the types of questions that need to be asked and answered throughout the continuing development of the NHIN. The many ONC (Office of the National Coordinator) workgroups working to move the NHIN forward recognize that these are the questions that must be addressed into the future. They are on the radar and will be evaluated throughout the NHIN development efforts.

DHP: You were chief health informatics officer for the Department of Veterans Affairs and instrumental in laying the ground for the VA's healthcare information system. What best practices have you brought to your current role?
I see the wealth of good ideas, innovation, and creativity that is present in all levels of the health sector. This is not a top-down approach. What we're trying to do is change the environment so that the market forces work, because the problem has been they don't work. Part of this is that patients don't have the information they need to make value-based choices.

What we learned from the VA is that health-IT by itself is not sufficient to improve the system, although it is a necessary component. You need additional activities to monitor the quality and to provide incentives for that quality to improve while at the same time containing costs. All of these together describe the value-driven healthcare that Secretary [Mike] Levitt has been talking about and that also provides a nice parallel to how the VA moves forward in improving its healthcare system as well.

DHP: You say that market forces haven't been working?
: We have a system of perverse incentives. Individuals do not have the information they need in order to make informed choices for healthcare; consumers don't know the quality of providers they have to choose among or the cost of procedures for care; without these two, you don't know what the value is. Part of our activity is not only to place the health-IT infrastructure that is used at the care site and the interoperability required as well as measuring and reporting the quality and cost as we move forward. That's not in place today.

DHP: To show measurable progress in the e-health arena, we need stronger collaboration among federal agencies and a greater partnership between the government and doctors. How do you plan to help speed the move toward a national health information network, shifting from planning to action?
: It's very important to understand we are not on a linear progression of progress. We are three years towards a 10-year goal; that doesn't mean we are 30 percent there. It is a sigmoid-shaped curve, so that at first there is slow movement while progress is being made and there is not a lot of evidence for it above ground, and then, when enough of the conditions have been achieved, then there really is a rapid intake, a rapid adoption. Whether that [inflection point is] going to be the EHR or Personal Health Record (PHR) or some other approach is [still] on the horizon for the few years.

We need to do what it takes to get momentum, to provide incentives for capable EHRs to be used that are interoperable. As we start providing the means for communities to connect with each other and a variety of stakeholders, that will show the ongoing value that health-IT tools can bring.

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