An important aspect of President Obama’s health plan (partly funded through this year’s stimulus package) is health technology. As noted in a prior blog post, section 4101 of the ARRA provides qualifying health providers with Medicare reimbursement incentives for implementing Health IT that meets the statutory criteria set out in that section: meaningful use, participation in a health data exchange, and clinical outcomes reporting. By setting standards and providing incentives, the federal health policy will have a substantial impact on health care technology over the next five years, as billions of dollars are poured into health IT investment.
The question presented here is where will all of this public and private investment lead Health IT in the next few years?
Data Exchange And Availability
One of the areas of major emphasis in the ARRA is the ability of health care providers to more easily share information with other providers, patients, and others who have a legal right to receive such data. In particular, emphasis has been placed on the ability to transmit data to health exchanges, and to be able to produce data for the Feds on health outcomes (such as reporting hemoglobin a1c’s values over time to evaluate if a diabetic patient is responding positively to the care provided). Health data exchanges today are on the rise, according to ihealthbeat.org, up to 57 operational exchanges from 42 the year prior. These health exchanges are being used to exchange data between individual providers in an effort to improve care coordination and to improve care quality.
More specifically, for patients with several doctors who may specialize in a variety of treatments or health conditions, health exchanges have the potential to ensure that lab data ordered by one physician is made available in a secure and reliable manner to all the physicians involved in providing health care. Health exchanges also can ensure that a patient’s medical history (particularly their prescription history) is available in a consistent format to all care providers, saving time at each visit and reducing risks to patients that might forget a prescription or past medical procedure. Sharing lab results also has the potential to reduce costs and patient injury by reducing the number of duplicative tests ordered for the same patient by different providers. This is a common problem for patients with a coordinating care provider who end up in the hospital and the attending physician is stuck ordering duplicate tests.
Looking into the future, I would expect that health data exchanges (HDE) would become more prevalent so long as the total cost to implement and maintain the HDE are less than the costs saved/avoided by the data available in the HDE. One of the other factors that will impact the growth of HDEs is the number of peer-reviewed studies of their efficacy. Today, there is relatively little information on this topic because most HDEs are new or still under development, but in the next few years more definitive information should be available for analysis and review by eager technologists and researchers.
One of the great challenges for the HDE movement is maintaining patient privacy. HIPAA was originally implemented in part to specifically address patient privacy, as have a number of other state laws on this topic (for example, the Maryland Medical Records Act, See Md. Health-Gen. Code Ann. § 4-301 et seq.). And other states are getting in on the action to protect consumer privacy, including Massachusetts, Minnesota, and Nevada, just to name a few.
However, laws alone may not be enough to effectively regulate and protect the availability of health data. In the present HIPAA enforcement regulations (which were modified by ARRA this year), the top fines (where the act in violation of the security regulations was a negligent rather than an intentional one) are relatively low compared to the potential size of an HDE (for example, if a company like google or Microsoft was to become a dominant HDE) because the fines are a flat rate per incident rather than being scaled according to the company’s gross revenue or the severity of the breach or finding. The ARRA did move in the right direction this year by implementing a four-tiered approach to violations from the original enforcement authority under HIPAA, but further scaling may be required for this to become an effective deterrent to lax security practices.
Furthermore, having a patchwork of privacy laws increases the overall cost of compliance for HDEs, which increases the cost to implement these systems without necessarily improving the actual security of the information stored at the HDE. This is caused by regulatory requirements of overlapping but also potentially conflicting laws, along with the need to respond to multiple authorities with the right to audit or investigate the HDE (as larger HDEs will undoubtedly operate across state lines). Sadly, I imagine that this problem will probably get worse before it gets better, given the number of relatively autonomous sovereign powers within our country (5o states + the federal government) and the scope and scale of the privacy issue being considered.
Attitudes Towards Privacy
Our future privacy policies may also be impacted by the attitude of our youth to privacy today. Social networking sites, for example, allow for the exposure of a lot of information about the youngest among us, but the predominant users of these systems don’t seem to mind very much. Now, of course, facebook is not known for the health data available on its users, so who knows whether college kids would be posting their latest hemoglobin values as readily as they do about the parties they were attending and pictures snapped of them by the college paparazzi, but it stands to reason that the next generation’s attitudes towards privacy will be substantially different than the present one that has been called to govern the nation.
The result may be a reduction in the concern about privacy with an increasing criminal penalty for those that engage in theft of information. For example, perhaps instead of worrying as much about whether health data is squirreled away in an underground bunker with Dick Cheney, the future leaders of the nation will make this data generally available via the internet, ultimately reducing its value to would-be thieves. For myself, I can’t say it matters much if others know than I have high cholesterol and a family history of diabetes, but I also don’t think there is much stigma attached to either of these conditions as there might have once been (or might still be for other health issues).
Data Quality and Trusted Sources
HDEs will also need to address head on the quality and reliability of data stored in their databases. Today, data systems do not generally go beyond the initial setup of some kind of private network and the file formats that are acceptable for data to be exchanged. Inherently, one system trusts the data it receives from the other and merely re-publishes it into its own database, identifying the source of the data. Usernames and passwords may just not be enough for everyone to know that the data being sent or received is accurate and reliable.
In addition, even though HIPAA (and some other laws) have placed a small emphasis on technical encryption, the truth is that little has really been done with these technologies for most systems today to ensure that data entered is not repudiated later by the person that purportedly entered it. For example, many commercially available database systems are not natively encrypted. Local area network activity on the wire is rarely encrypted, again relying on the border security devices to keep outsiders out of LAN activity. Passwords are not consistently complex across an enterprise (especially where multiple database systems maintain their own passwords and accounts), and certainly cannot reasonably be changed frequently enough to ensure the password has not been compromised (without the user community revolting against the IT staff). And users routinely share passwords even though there is a federal law against it and in spite of the numerous repeated messages from system administrators to not share passwords.
Furthermore, data exchanged between systems relies on the initial configuration of the networking that connects the two systems to remain uncompromised. There is no further system verification to ensure that messages actually received across these systems are correct in the typical data exchange design. TCP itself was designed with a checksum in each packet, but that only tells the receiver if the packet received matches what was intended to be sent, not whether the data sent is coming from the human/system source alleged (e.g., the laboratory technician or physician that actually created the entry in the first place).
I anticipate that the future of authentication will be to move towards far more sophisticated and multi-level authentication (even though the biometric movement seemed to have lost steam, at least in the general consumer market). For example, instead of or in addition to a username/password, systems may also generally implement a token, or other physical card to grant access (such systems exist and are in general use today for some systems). Other security measures may involve thumbprints or biometrics. I would also imagine that more sophisticated encryption algorithms could be used beyond 128-bit cipher, and that encryption might occur at a more basic level than it does today (if transmissions are encrypted at all). For example, databases themselves may be encrypted at a record or table level, or application access could be managed through an encrypted socket instead of plain text as many operate now.
Beyond user access to put in data, surely there be could some additional layer of verification that could occur once data has been received from a producer system which could be, by design, independently verified before being committed to the receiving system. The alteration (or just erroneous entry) of data in transport from one system to another creates the real possibility of a bad health care decision by professionals using the data. This is certainly one of the major weaknesses of consumer level HDEs such as those from google or Microsoft which must rely on the consumer to enter their own lab and pharmaceutical information into the database when that data is not available electronically, or on data providers that rely on administrative or clerical staff to actually do the data entry without further review before distribution.
HDE Information Security
Today, a number of technologies exist that allow for data backup and redundancy to ensure that systems can be highly available and resistant to significant environmental or system disasters. One category of technology is called “cloud computing,” which is a kind of modern equivalent to what application service providers (ASP) of the 1990’s were offering, or what the ancient mainframes of yesteryear offered to computing users back in the bad old days of the 1970’s. What is fundamentally different today, however, is the possibility of having massively redundant and distributed information systems that belong to a cloud, where both ASPs and mainframe computing was often centralized into one server room or series of server rooms in one facility.
A common example of computing in the cloud today is gmail, which is an email service provided by google for free to consumers. There are still, somewhere, servers connected to the internet and controlled by google that will respond to SMTP requests, but google most likely has these servers distributed all over the planet and connected to a larger, redundant network infrastructure. Data stored on these servers are likely real-time replicated so that all gmail replication partners are up to date, regardless of which one you actually connect to when you use your web browser to navigate to your email account. Gmail has been around for some time now, and there are a fair number of users (26 million according to one article as of last September; wikipedia claims there are 146 million gmail users each month as of July 2009). Perhaps Health IT will be the next internet “killer app.”
And looking down the road, the future of Health IT likely involves some kind of “cloud computing” model where health data is not stored locally on an organization’s server. This model will provide for additional flexibility with data transfer, improved system redundancy, and higher availability than is typically possible in a single enterprise or within a single server room.
Cloud computing, however, does pose other security and privacy concerns. (See this article on CNET that addresses some of these same concerns) For example, will staff of the cloud computing service have some kind of access to the actual data entered into the system? Will these systems have a way of keeping those administrators from changing or accessing data (for example, by encrypting the data to place it out of reach of administrators)? Who is liable for loss of the data? Will the HDE seek to (and will courts and lawmakers allow it to) unreasonably limit liability for unauthorized access? Will the HDE be indemnified by a government agency? Will the HDE pay for itself by allowing advertisers access to data stored by the HDE? Will it utilize a more democratic approach (for example, as facebook has recently been employing to ratify adoption of changes to policies in place that affect its user community)?