Monday, June 7, 2010

This is not a Black Swan

I am aghast, angry, and depressed over the events in the Gulf of Mexico that began with the catastrophic, tragic fiery destruction of the British Petroleum Deep Water Horizon oil drilling platform and the unimaginably horrific deaths of eleven of its workers.

This will very likely turn out to be far and away the most severe man-made environmental calamity of my lifetime. The Gulf of Mexico (and perhaps far beyond) faces biological and economic ruination that may well be at this point beyond human capacity to truly remediate.

"Act of God"? As more than one fatuous politician has lamely proffered? No "God" that I would care to consort with or submit to. Forget it. This was the culmination of a series of acts by identifiable men (All of them by now all suitably lawyered up).

WELL, PERHAPS A "BLACK SWAN" EVENT?

Citing Nassim Nicholas Taleb:
What we call here a Black Swan (and capitalize it) is an event with the following three attributes. First, it is an outlier, as it lies outside the realm of regular expectations, because nothing in the past can convincingly point to its possibility. Second, it carries an extreme impact. Third, in spite of its outlier status, human nature makes us concoct explanations for its occurrence after the fact, making it explainable and predictable. I stop and summarize the triplet: rarity, extreme impact, and retrospective (though not prospective) predictability...

Notwithstanding my extreme affinity for the philosophical/theoretical/empirical insights and works of Taleb, I would have to seriously demur were anyone to argue Black Swan here. To wit:
  1. First, it is an outlier, as it lies outside the realm of regular expectations...
  2. Second, it carries an extreme impact.
  3. Third, in spite of its outlier status, human nature makes us concoct explanations for its occurrence after the fact, making it explainable and predictable.
Only the second of these proffers legitimately obtains here.

"Black Swan" is an analogy, perhaps to the point of metaphor. So, let me offer another.

RUSSIAN ROULETTE

Six chambers, one live round. Place your bet, load the weapon, spin, place the business end of the barrel against your temple, pull the trigger. The probability of blowing your brains out in the wake of each attempt is one in six. Would you do it?

Of course not (unless you're suicidal). The negative "expected value" (obliteration) -- i.e., probability times the "payoff" -- remains essentially "infinite" irrespective of the well-below 50/50 (1/6th) nominal, non-accruing independent "chance" (a concept which utterly explains fear of flying).


Now, assume the revolver has not six, but, say, 10,000 chambers. Moreover, the barrel is pointed not at your temple but at beaches, marshes, pelicans, turtles, shrimp, shrimpers, and the rest of the inhabitants of a region writ large.

Place your bet. By the time you "lose," you will have made plenty of bank. Unlike those uninvolved in the game.
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"Years of Internal BP Probes Warned That Neglect Could Lead to Accidents"
A series of internal investigations over the past decade warned senior BP managers that the company repeatedly disregarded safety and environmental rules and risked a serious accident if it did not change its ways...

No, this horrific event fails Black Swan postulates 1 and 3 above. It may indeed have been "outside the realm of regular expectations," but only to the conveniently, expediently dilettante executive mind. And (3), there is nothing to "concoct" here. There exists a record -- one that points to criminal negligence. (see 2 - "extreme impact").
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For now, consider an earlier post of mine. We have alternatives. BTW, I am in fact a "Drill, Baby, Drill" kind of guy.

No need to idle all those drillers. There's plenty of heavy industrial work to be done.

UPDATE

This is hard to watch.


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MORE TO COME

Tuesday, May 18, 2010

Opportunity for collaboration? ASQ and the RECs

On March 2nd, 2010 I returned to work with my twice former employer HealthInsight, the highly regarded long-standing not-for-profit Medicare QIO (Quality Improvement Organization) serving the states of Utah and Nevada in the wake of their being awarded a federal "Regional Extension Centers" (REC) contract by the U.S. Department of Health and Human Services (HHS) as part of the Obama administration's stimulus funding initiative to spur the widespread adoption and "meaningful use" (MU) of health information technology (HIT).

It is a most ambitious, pedal-to-the-metal, high-velocity program (unrealistically so, say some of its critics), one whose goal is to bring the vast majority of medical providers into the digital information world, a world the rest of commerce finds at once unremarkable and indispensable.


Above, the still-predominant information storage and retrieval model for medical information. It is functionally untenable. Prohibitively expensive in ways significantly under-appreciated. It is dangerous. It could cost you your life in an exigent circumstance. It cries out for extinction. Yes, conversion will be difficult, and exasperatingly rife with logistical and legitimate, vexing policy problems.

Nonetheless...

I have been writing a bit about this on one of my other blogs. See "Irrespective of national health care policy reform legislation, the medical sector is going full-steam-ahead HITECH," initially written prior to the passage of the Obama "Health Care Reform" legislation (with updates still to ensue, mostly pertaining to the complex data security issues bearing on patient privacy).

ASQ

The American Society for Quality. My wife and I have been members since the mid-1980's. We live and breathe "quality" concepts and issues, having both come together out of the same legacy-era "quality control" paradigm. We have both served as Examiners for our Nevada state-level Baldrige Award assessments (ASQ administers the national Baldrige program). My friend and ASQ colleague Fred Schwager and I co-founded the Nevada Quality Alliance (NvQA.org), which administers the Nevada Baldrige model program.

When I returned to work, I renewed my optional special interest sub-membership in the ASQ Health Care Division. Shortly thereafter, I had the fine fortune to strike up an internet and phone conversation with the Chair-Elect of the Division, Dr. Joseph Fortuna. Joe is an enthusiastic supporter of the REC effort, and was intimately involved in DC legislative support for health policy reform.

We share some concerns, which we have by now discussed at some length; e.g.,
  • Critics bemoan a lack of prior HIT deployment and QI experience among some REC awardees (as well as the heterogeneity of business models);

  • While 60 REC contracts have thus far been awarded, with the newly chartered RECs frantically ramping up to meet the rather compressed Stage One Meaningful Use incentive payment timelines, both the requisite Meaningful Use reporting criteria and the EHR (Electronic Health Record) certification regulations remain unresolved at this writing. The cart is seriously out in front of the horses in many respects;

  • Notwithstanding that HHS is spending hundreds of millions of dollars on REC contracts, physicians and hospitals are not required to engage REC services in order to qualify for federal incentive payments. Consequently, RECs are having to spend significant time and money hawking their services (the polite term being "enrollment." I did not know when I signed on that I would be required to do what amounts to hastily and minimally trained cold-call sales). Moreover, REC services are not fully subsidized, the upshot of which is often skeptical "we'll pass" pushback, especially in light of the hyperbolic claims of virtually all major EHR vendors "guaranteeing" that their products will get the provider to MU (with the glossed-over disclaimer, well down in the fine print "When Used As Directed");

    • At this writing, the aggregate Final Rule for MU criteria is still under HHS consideration, with myriad professional stakeholder groups arguing for relaxation of both the compressed compliance timelines and the all-or-nothing approach, countered by a broad array of equally vocal consumer/patient advocacy organizations arguing for MU criteria adoption "as-is" as set forth in the Interim Final Rule.

      I would have added another MU criterion: require working with the RECs as a condition of incentive money eligibility;

  • The relatively sparse per-provider federal REC funding may force the RECs to focus simply on assisting their client physicians with hitting the MU criteria in pursuit of the incentive reimbursements -- to the practical exclusion of broader and more sustainable, internalized quality improvement efforts;

  • There is to be a "Health IT Research Center" funded by HHS and intended to "gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Extension Centers (RECs) collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support. The HITRC will build a virtual community of shared learning to advance best practices that support providers’ adoption and meaningful use of EHRs."

    It is not even slated to be up and running until FY2012.

Notwithstanding our concerns, we see potential opportunities for win-win synergistic REC-ASQ collaboration via which to help improve health care.

THE ASQ HEALTH CARE DIVISION "MARSHALL PLAN"

Dr. Fortuna is a Champion of the ASQ "Marshall Plan."
"...In different areas of the country, ASQ members, under the leadership of the ASQ Healthcare have teamed up with the local healthcare community and medical organizations to help improve healthcare delivery. Being that we are all stakeholders in this system and that there is much opportunity to apply quality and lean methodologies, this is a great place for ASQ members to use their skills for the betterment of the system. The focus is on primary care doctor offices..."
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Click the link, Read all of it. An extremely worthy volunteer effort with the potential to deploy a large number of experienced QI professionals in pro bono service to the healthcare community in a manner complementary to and reinforcing of the work of the RECs.

The Regional Extension Centers could certainly benefit from the help, and ASQ in return would be made visible to a large source of potential new members, given the projected HIT-related and health professions employment growth across the decade.

I would also favor inviting several other ASQ Divisions to collaborate: Biomedical, Software, and Service Quality.




There is a lot of experience and relevant expertise upon which to draw. I would even surmise there might be interest and value adding input from and collaboration with the ASQ Quality Management and Statistics Divisions.
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"LEAN? THAT MAY BE OUT OF OUR SCOPE"


Such was a reaction from one of my skeptical HealthInsight HIT Adoption Support team members during a recent meeting in which I'd recommended that we consider deploying aspects of "lean methods" for workflow analysis and re-design, as proffered most recently in the new Quality Press book "Lean Doctors." He didn't say so explicitly, but his implication was clear: in light of our finite FTE resources and the huge scope of the project, our necessarily circumscribed task will be to drive providers toward MU and the incentive money riding on it [PDF], period. Point taken, to an extent, but, it should be equally clear that I don't regard the MU goal contractual imperative as inexorably being at odds with the utility of lean re-design tactics. Neither do I buy the implicit, gauzy HHS assumption that clinicians hitting the MU targets amid the money chase constitutes focused, adequate, and lasting healthcare QI of the kind we are incontrovertibly in need of.

This (highly recommended) book rightly points out, ever so politely, that the term "workflow" -- particularly in the medical setting, can be seen as having become something of a cliche, i.e., there's typically very little in the way of smooth "flow" in the daily "work," which is more aptly typically characterized as a series of "push" processes rife with bottlenecks caused by lack of coordination and waste. Any method that can demonstrably abate that simply has to be worthy -- whatever you choose to call it.

In the words of the publisher's blurb, Lean Doctors posits
"six proven “success steps” for implementing lean in any healthcare environment:
  1. Create physician flow
  2. Support physician value-added time
  3. Visually communicate patient status
  4. Standardize everyone’s work
  5. Lay out the clinic for minimal motion
  6. Change the care delivery model
"Why go through such a transformation? Because it works. Tell a doctor that he can see the same number of patients, offering the same high quality and personal care, and have an extra 90 minutes at the end of his clinic day – and that means something. Tell the staff that they can look forward to actually ending on time, with satisfied patients, no backlog, and having focused their attention completely on quality patient care – and they will listen..."

"They will listen." Really? Making that sale is perhaps not as easy as it might appear. But, in my view, such is our mandate, given that the elimination of process flow roadblocks and the waste they comprise cannot but provide, among other QI benefits, the availability of the requisite time for MU compliance.

A useful quote from the text for now:
Lean is a science for creating flow in a system—whether of a physical product or of a service. In healthcare, this would mean that we aim to create patient flow, without wait times, through any given area. As we focused on patient wait times in the clinic we found that no other metric brought the varied root causes of inefficiency so clearly into focus. When patients were moving through the process promptly, a lot of things were going right. However, when patients waited in the exam rooms or waiting rooms or at supplying processes, then any one of a great number of things could be going wrong...

And, one more:
As you consider undergoing a Lean transformation process at your own practice or clinic (or hospital or larger healthcare setting), you might think that a minute shaved off here and a minute saved there does not seem worth much. Change is difficult, time-consuming, and cumbersome. So why would you literally analyze every step a nurse takes? Why take the time to have technicians or nurse practitioners describe in detail the reality of their jobs, when you need them to simply get the work done? Why? [again] Because it works...

Color me a believer, based on what I have thus far learned. However, our REC reality may be that we will largely be limited to predominantly a prescriptive/advisory/auditing role. We will necessarily be developing SOPs via which to guide clinicians and their staffs toward accurately and routinely documenting in their EMR systems the structured data required for their MU Stage 1 attestations (and eventual data reporting). The current draft of MU criteria contains 25 outpatient items, many of which require numerator and denominator data for calculating percentages that must meet or exceed MU thresholds, e.g.,
  • 1.01 Computerized Physician Order Entry (CPOE): Use computerized CPOE for at least 80% all orders (e.g. medications, consultations, labs, diagnostic imaging, etc.);
  • 1.02 Medication Interaction/Contraindication Checks: Enable functionality in EHR for automated drug-drug, drug-allergy, and drug-formulary checks;
  • 1.03 Patient Problem List: Maintain an up-to-date problem list of current and active diagnoses (recorded as structured data) based on ICD-9-CM or SNOWMED CT® for at least 80% of all unique patients;
  • 1.04 E-Prescribing: At least 75% of all permissible prescriptions written are transmitted electronically (eRx) using an EHR;
  • 1.05 Active Medication List: Maintain an active medication list (recorded as structured data) for at least 80% of all unique patients;
  • 1.06 Active Medication Allergy List: Maintain an active medication allergy list (recorded as structured data) for at least 80% of all unique patients;
  • 1.07 Patient Demographics: Record demographic data (including preferred language, insurance type, gender, race and ethnicity coded by federal guidelines, and date of birth) as structured data for at least 80% of all unique patients;
  • 1.08 Vital Signs: Record and chart vital signs (including height, weight, blood pressure, calculated and displayed BMI, plotted and displayed growth charts for children) for at least 80% of all unique patients;
  • 1.09 Smoking Status: Record smoking status for at least 80% of all unique patients 13 years old or older;
  • 1.10 Lab Results: Clinical lab results captured as structured data for at least 50% of all labs ordered...

...and so forth. SOPs driving toward uniformly capturing such subsequently queryable information will necessarily be EMR platform-specific, and will comprise substantial work to derive and implement. Consequently, I may in fact be asking too much to insist on inclusion of "Lean" principles in our REC workflow re-design effort during this initial phase.

But, before I leave this issue (regarding which I welcome commentary/feedback), consider a few screen clip excerpts from a recent Lean project study posted on the ASQ Healthcare Division web page:


While I know that a lot of QI has gotten a sometimes deserved rep of being "soft" touchy-feely dubious flip-chart fad-of-the-moment social "science," the outcomes here are expressed in (verifiable, I assume) bottom line "hard dollar annual savings" on the order of $90k.

Annual.

Now, consider: the maximum HHS MU physician incentive payments are $44,000 over 5 years for Medicare providers and $63,750 over 6 years for Medicaid providers.

Think about that, in the context of leaning up one process at a net of 90 grand a year.

The basic issue, visually:

More to come...
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Wednesday, March 17, 2010

Irrespective of national health care policy reform legislation, the medical sector is going full-steam-ahead HITECH

While I've continued to closely follow the dismaying -- albeit admittedly "realpolitik" -- end-game developments in the increasingly acrimonious "health care reform" national political debate since I quit blogging about it in November, 2009 (with snide demagogues now largely in charge of national discourse on the topic), I'd intended to move on next to "drought and western states water policy," regarding which I've culled a ton of technical information and have some arguably value-adding ideas to proffer.

However, I've just been re-hired by my former employer (the not-for-profit Utah-Nevada Medicare QIO)
as a Project Coordinator for Health Information Technology (HIT) in the wake of their being awarded the HHS contract to become one of the CMS "Regional Extension Centers" (RECs) under Title XIII of the 2009 Obama Stimulus legislation, ARRA ("American Recovery and Reinvestment Act"), i.e., the ARRA "HITECH" Act ("Health Information Technology for Economic and Clinical Health").

So, bear with me. This is important stuff. Indulge me this coda. It bears to a significant degree on national health policy broadly going forward, given the undeniable importance of timely, appropriately available health data as a core component of effective care. And, the first round of this particular initiative has now been launched and will
go forward for at least the next four years** independently of the outcome the current contentious national health insurance reform legislation heading for its final House and Senate showdowns.
(** Assuming the Republicans don't regain control of Congress via this year's mid-terms and thereafter see fit to cripple or asphyxiate the HITECH program.)


"HITECH" - HEALTH INFORMATION TECHNOLOGY
FOR ECONOMIC AND CLINICAL HEALTH

The HITECH goals are to [1] facilitate widespread adoption of electronic medical records systems across the nation (given that health care providers still lag far behind the rest of commerce in the use of digital information technology), [2] guide clinics and hospitals toward using the systems fully, in a "patient-centered" manner (known as "meaningful use"), and [3] assist with the deployment of widespread appropriate, secure sharing of electronic health information through which to improve personal and public health.

ANALOGY

Cheryl, Nick, and I went to to the UK and France in 2004 for 16 days, mainly to go see Lance Armstrong win le Tour #6 in Paris. Which he gloriously did.

I booked and paid for the airfare, hotels, B&Bs, and EurRail passes in advance online. Without adverse incident. I used my credit union debit card multiple times while in the EU, for cash, car rentals, and restaurant meals, etc. All without incident.

Ongoing, like most of you, I routinely buy books and other products from Amazon.com and myriad other mainstream eCommerce sites. Without incident. I increasingly do most of my banking online, including most of my bill paying. Securely, without incident.

I bought my late cat Max's insulin and ancillary diabetic feline supplies online via PetMeds.com (he had a better health plan than do I, LOL). Without incident.


And so forth. You know precisely what I'm talking about. Simply put, absent being "wired" across myriad domains, civilization could simply no longer function. To close the loop on this analogy, the fact that health care continues to operate largely on paper simply means that it cannot function effectively. At root, health care is about making frequently maddeningly complex decisions -- usually under intense time pressure --, based on the best and most comprehensive available information. Most clinicians today still frequently lack such fingertip access.

OK, TO BE FAIR, I'VE INDEED SUFFERED AN INCIDENT

It was relatively banal. We awoke one morning in December 2007 to find that someone had commenced a wild holiday shopping spree in Paris via our credit union debit card. It had nothing to do with our prior EU trip, but, rather owed to my a couple of years thereafter having bought a pair of shoes in Henderson, NV at the DSW "Discount Shoe Warehouse." They subsequently got hacked, with my card number acquired amid the aggregate ePirate booty.

The credit union's fraud indemnity insurance covered the bogus $600+ accruing charges, and shut the card down forthwith, promptly issuing us new ones. Without further problems.

HACKING YOUR ONLINE MEDICAL RECORDS

In the 2009 survey summary depicted above, ~3/4 of the respondents (76%) recently expressed it to be "somewhat likely" (35%) to "very likely" (41%) that "an unauthorized person would get access to your medical records" were they to go digital and subsequently become accessible "online."

Well, while that's probably a rational concern to a point, having worked in credit card risk management (where the fraudster probers were/are 24/7 relentless and insidiously ingenious), I would observe that the Bad Guys are far, far more interested in getting directly into your financial accounts -- for what ought be obvious reasons.
Yet most of us engage in a gamut of online financial transactions routinely, absent major widespread adverse consequence.
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HIT concerns


There are basically three levels of present and emergent online HIT concern. First, even in the circumstance where a particular medical practice's electronic records system (the EMR, a.k.a. EHR -- or, even simply a front/back office non-clinical "Practice Management system") may be confined totally in-house, it remains -- just like your internet account at home -- vulnerable to hacking should there exist an internet connection up and running amid the onsite network, even if not in any way directly interfaced with the clinical system.

Second, if a clinic opts to contract with an internet EMR "hosted service" -- a.k.a. the "ASP" or Application Service Provider model, wherein the practice simply avails itself of the web browser-based input/output screen array comprising the remote EMR, with transactional data being stored on and pulled from "secure" offsite servers, one still must address, among other risks (such as 'net outages), possible encryption-surmounting hacker vulnerability concerns (an endlessly moving target, that).

Finally, we come to the mostly nascent "HIEs" -- Health Information Exchanges (existing today in wildly varying degrees of planning or operational maturity, and comprising the bigger-picture end goal of the REC effort). The national goals here are twofold: [1] enabling patients to accord health care providers of any stripe authorized access to pertinent elements of their clinical histories anywhere/anytime as either exigent/acute or routine needs dictate, and; [2] the "blinded" reporting of clinical information of interest and need to various medical authorities, both for public health surveillance and outcomes research.

The "HIE"

a.k.a, the "Regional Health Information Organization (RHIO)." As I mused in my prior post:
"A fully integrated, electronic health information exchange is essential to ensuring that high-value health care is delivered to the right patient, at the right time, and in the right setting." Yes, of course... These things go the acronym "RHIO" or "RHIE" ("Regional Health Information Organization/Exchange"). The Utah Health Information Network (UHIN) stands as a fairly mature example here. During my last QIO tenure, I sat on the Steering Committee for a southern Nevada RHIO startup attempt. I recall the fractiousness of the proceedings, given the disparate interests of the various for-profit and non-profit interests. We still don't have one in Nevada. I applaud these efforts, but they remain fraught with technical and policy difficulties...

That was several years ago. It does not appear that all that much has changed. The technical (e.g., "data mapping" standards for seamless "interoperability") and policy challenges (e.g., data security, HIPAA privacy compliance) remain many and complex.

I continue to be concerned with the sometimes contentious, duplicative attributes of much of this HIE thinking and effort (i.e., primarily the potentially heterogeneous "regional" aspect).

And, that drives me back to ruminating on my bank risk management days.

THE BUREAU PULL

During my credit card bank risk department tenure, I was involved with vetting applicants for appropriate risk-assessed revolving credit line assignments, and for passing judgment on existing customers' requests for "CLIs" -- credit line increases (or a variety of account forebearances), the latter based on a mix of their current FICO scores and internal account performance histories.

Like any credit grantor, we had essentially instant authorized access to the financial "health histories" of both prospective and existing customers. The first step in consideration of an initial or secondary credit request was the "hard pull" (a.k.a. "bureau pull") from one or more of the three credit reporting agencies: Equifax, Experian, or TransUnion.


THE CREDIT FILE "DATA MAP"


Credit applicant bureau files arrived as legacy platform (mainframe) encrypted export data that, once unlocked, simply comprised variable-length ASCII files containing fixed-position row/column headers denoting each subsequent sequential following data element (with the respective data types and field lengths defined by a standard "data dictionary" - i.e. "data maps" guiding the import conversion specifications). Such files are necessarily "variable length" owing to the fact that every person's credit history differs, both in length of history and relative periodic intensity of activity and breadth of credit utilization.

A bit of relatively unremarkable programming, and the import "data map" routines are done.

How a person's health/medical transactional history differs materially in concept from that escapes me. For example, a core HIT industry consensus standard -- HL7 -- exists for interoperable transmission of medical information messaging. It simply specifies a "data map" wherein health data elements are identified by their relative position within an ASCII file, each datum preceded by a coded identifier readable by an HL7-enabled destination interpreter, e.g.

"HL7 messages are in human-readable (ASCII) format, though they may require some effort to interpret.

Each message consists of one or more segments. A carriage return character (\r, which is 0D in hexadecimal) separates one segment from another. Each segment is displayed on a different line of text."

This is all rather Old School, actually.

To be fair, data in individual medical files extend beyond the IT-mundane alphanumeric items comprising credit bureau compilations, principally with respect to bandwidth-intensive graphic imaging files, e.g., x-ray and other scans (PACS output), EKG graphs, and so forth. However, such imaging data might simply be be made effectively accessible via secured proxy hyperlink reference (thereupon downloadable as needed) rather than traveling pixel-by-pixel with the textual/alphanumeric data constituting the bulk of transactional health records.

In sum, there seems to exist a functionally mature mega-scale infrastructure already in place, one that securely and efficiently manages perhaps close to 200 terabytes of data ongoing, 24/7, capable of near-instant accessibility/turnaround.

PUSHBACK?


It almost writes itself. Beyond the turf-protective antipathy likely to be voiced by existing regional HIE organizations that have labored mightily to date, credit reporting firms are far from the most beloved of corporate entities. Everyone seems to have his or her pet horror story (as do my wife and I). Widespread, chronic inaccuracies in consumer financial information are bad enough. Trafficking in error-ridden personal medical data would be orders of magnitude worse, sometimes lethally so. Also, we are unhappily witness to ongoing "mission creep" as bureau pulls get used to vet people for decisions having nothing directly to do with the properly limited legitimate purpose of creditworthiness evaluation: Hiring decisions, apartment rentals, actuarial model insurance policy rate setting, etc**.
** Not to mention the poignantly hyperbolic cast of derisive Palinistas and indignant fellow traveler Tea Baggers who reflexively see "Federal Death Panels" lurking behind every tree stump, shrub, USB port, and T-1 line (particularly when the cameras are rolling), and who will no doubt breathlessly spin HIE data distribution as inexorable grist for exactly that.
Nonetheless, those are policy issues that can be reconciled legislatively and via subsequent regulation (to the sufficient satisfaction of the sane, in any event). My speculation goes to the availability of an extant but possibly overlooked yet scale-and-technology viable digital infrastructure that might expedite the goal of universal, standarized HIE.

Perhaps neither Equifax, Experian, nor TransUnion would have any interest in getting involved in HIE (What would be the viable business model? What is the quantifiable fair-market value of timely access to individual and aggregate health information?). I simply don't know. But, it's a question worth asking, in light of their long experience dealing with secure, large-scale transactions of highly sensitive data.

THE HIT DATA SECURITY/PRIVACY ISSUES

Coming shortly. Google "Latanya Sweeney" and "Deborah C. Peel" for starters. If you take everything these two prominent critics have to say at face value, you'll be anxiously aching to get off the wire (and the wireless) and off the grid and off to the far reaches of some inaccessible somewhere that no longer exists.

Stay tuned...
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DISCLAIMER: I composed the foregoing wholly on my own time and my personal computer at home. The views proffered are expressly my own as a concerned and active citizen/taxpayer, and in no way reflect any policy views of my employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the new work with which I am now charged.