Frisse is the director of Vanderbilt’s regional informatics programs and has helped efforts to develop a statewide health information infrastructure to support Tennessee Medicaid patients. He is also helping to spearhead a demonstration project in the Memphis area and is actively involved in activities sponsored by the Markle Foundation and the eHealth Initiative. Frisse recently spoke with Digital HealthCare & Productivity on the need to align policies and incentives for health information sharing.

DHP: Is ONC’s attempt to reach a consensus on HIT terms a step in the right direction?

Frisse: Clarification seems essential if external entities are going to certify products and tie compensation for services to the use of a certified product. But how exactly should you define an emerging technology or functionality within a technology? If it’s done well, such definitions can educate and foster the public debate. Done poorly, or done with the intent to gain a near-term advantage, such deliberations can lead to obsolescence and anachronisms. It’s important to get this right. Some terms, such as EMR, beg for at least an interim characterization, while other terms, such as RHIO, may help clarify thinking or simply lead to an endless morass of irrelevant debate.

DHP: Is it also harmful to certify prematurely what is not yet clearly understood?

Frisse: I think the certification of ambulatory care systems is a central task, and I applaud the certification commission tackling such systems. I think it has provided reassurance to the public and the healthcare community. But somehow we have gone from ambulatory care systems to 10 working groups that are certifying everything but the kitchen sink.

There’s discussion of certifying personal health records even though we don’t yet clearly know what they are. There is talk of certifying health information exchanges and [there are] claims that there are 150 to 200 of these [exchanges]. I dispute that number. We don’t know what health information exchange is. It is bureaucracy run amok. I simply don’t understand why HSS [U.S. Dept. of Health & Human Services] cannot focus on doing several things well rather than creating a plethora of communities and working groups that literally consume everyone’s time.

DHP: What do you think they should focus on?

Frisse: Three clinical themes: ambulatory systems, electronic medication history, and laboratory information. In order to solve these, you must address the issues of how do you authenticate identity, and how do you communicate in a secure and easy way.

DHP: You’ve been advocating for some time for electronic health records [EHRs]. Is Medicare’s latest plan to offer financial incentives to 1,200 practices to use EHRs a step in the right direction?

Frisse: At first glance, the numbers may appear small: 1,200 physician practices over several years, or 3 million patients affected, is less than one percent of population. One may think that is relatively small, but it is important to note that this is an extension of some current pilots and telegraphs a signal that more small practices are adopting information technology. I think it’s a very good thing.

This plan is not giving any particular group a grant or buyout to invest in technology but rather provides an additional financial incentive for healthcare practitioners to finance technology on their own means. It’s very important in my mind that practitioners maintain control over their capital and the tools of the trade.

[The] only negative I can see is that e-prescribing and safety are considered central drivers, and if that is the case, one hopes that similar incentives will be provided to retail pharmacies, particularly small rural pharmacies, for conductivity and adoption of technology as well. To expect a small medical practice to be involved in bi-directional electronic prescribing with a pharmacy without any support is unrealistic.

DHP: What about the proposed CMS changes for DRGs [drug-related group]/hospital-acquired complications? What impact will these have on how hospitals and other organizations manage health information?

Frisse: The short-term implication is the awareness that one should not profit from one’s errors. One does not expect a negligent auto mechanic to charge you more money to fix what he has broken. Poor care leads to higher cost.

But in its implementation, we’ve gone from a sincere intent -- “Let’s pay for better care” to “Let’s do a lot of finger pointing; you started it, I didn’t it” -- because we’re talking about who gets the blame, and who gets paid and who doesn’t.

And if you read the additional regulations, the amount of additional coding that will be required to differentiate all these things is not [clear] yet we [already] have how many thousands of codes. How much more complexity do we need? There’s a new study that says we should be looking at ICD-10 [international classification of diseases], which will have many thousands of more codes, adding new labels and classifiers. I keep saying, what’s wrong with ICD-2? All that complexity comes with higher cost of delivering service

DHP: You’ve said that ROI [return on investment] may not be the right question -- or the only question -- to ask when it comes to healthcare.

Frisse: I’m an oncologist by training, and I can tell you when you’re facing death, ROI is not the first thing that comes to your mind. ROI is not a futile area of inquiry, but this consideration has to be part of a broader set of values that places healthcare in a context appropriate to its social mission.

We’re trying to build nirvana on a swamp. You can’t expect to build a totally coherent information technology system superimposed on an incoherent healthcare delivery system.

Our healthcare system pays for complexity in volume rather than for simplicity in results. It doesn’t surprise me in the least bit that there’s a lot of controversy in aligning incentives, because you will have that [controversy] as long as there are fundamental differences in the public eye about how healthcare should be paid and financed. The central theme through all of this is payment reform.

DHP: You are helping develop a statewide health information infrastructure. What are some best practices and lessons learned, and what’s the status of this state infrastructure?

Frisse: In Memphis, we now have a system that involves the exchange of information from every competing major hospital in the region, covering about 1 million lives. The operational cost is about $2 million a year -- that’s $2 per person. It is a group of bitter competitors who have decided that when it comes to making information available for healthcare, they are committed to doing this. They didn’t try to solve the whole world’s problems and try to do P4P [pay-for-performance] and research.

They understood that by working together and making more data available, they would gain more power over their future than if they let a third party, whether it be a health plan or government agency, take control. We have strong, formal, data-sharing agreements and contracts that limit use and outline policies and procedures. It’s a story of Memphis, Tenn. It’s not my story, and it’s one of several models all over the U.S. -- they’re happening all over the country. I just think we are further along than most.

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