About: Where Has Consensus Not Been Reached?

The most challenging issues that arose during the development of the Blueprint centered on two key areas: the design of financial incentives to support improvements in healthcare and policies for information sharing.

Regarding financial incentives, individuals offered many different perspectives about the design of incentives, including how these incentives should be structured and paid for, and what behaviors to incentivize. For example, debate occurred around incentivizing improved patient outcomes versus incentivizing or supporting information technology adoption.

While stakeholders agreed that the end goal is improving healthcare quality, safety and efficiency, they employ different approaches for arriving at that goal. Some preferred to incentivize quality outcomes only, while others preferred also to support the adoption and effective use of health IT as an efficient infrastructure for quality improvement and measurement. There was no consensus regarding the best approach to this question, and there was no consensus that only one approach will work. More study is needed to examine initiatives that have employed both approaches to identify their benefits and drawbacks.

In addition, the question of who benefits from the adoption and effective use of health IT, and therefore who should be asked to share in the cost and at what levels, was also discussed and debated at length. Many believe that incentives cannot be meaningful or appropriately aligned without objective information quantifying the benefits of health IT adoption and identifying the stakeholders to whom those benefits accrue. The Blueprint recommends that payors and providers work together toward meaningful discussion, research, and demonstration projects that can convincingly measure these benefits.

Issues surrounding policies for information sharing spanned multiple focus areas—particularly the Engaging Consumers area and the Improving Population Health area. In the Engaging Consumers focus area, the two actions that generated the most dialogue were the following:

Consumers should be able to limit which of their health information could be shared with which providers, in a manner compliant with HIPAA, when applicable.
Consumers should be able to limit how their personally identifiable medical information is used outside of care delivery (e.g. for research), consistent with all applicable federal, state and local law.
When it comes to consumer control of personally identifiable information, some stakeholders are concerned about giving more control than HIPAA currently requires, primarily because of the risk that withholding key information could pose to the ability of providers to deliver safe care. At the same time, others believe that consumers should be educated on the benefits and risks of information sharing and have control. While there was consensus that mobilizing patient data in order to improve the quality, safety and efficiency of healthcare delivery is important, questions arose such as which providers should have access to what types of data, under what circumstances—for both identifiable information and de-identified information. HIPAA was not designed to address the more robust, detailed clinical information sharing that flows from health information exchange. More agreement is needed on the details of these particular areas.

Similarly, the Blueprint section on Improving Population Health calls for consensus processes regarding policies for information sharing, including the following issues specifically:

• Privacy and consent issues with regard to both identified and de-identified data use for improving population health
  
• Appropriate uses of de-identified, identified and re-identified data
  
• Standard methods to monitor and communicate compliance with consensus principles and policies to the public

As a result, the eHI Blueprint launched in October 2007 represents Phase I of a two-phase process. During Phase II, eHI will encourage a national dialogue to reach agreement on the areas for which there is not yet consensus—in particular, those areas described above.