Three health record bank (HRB) pilots in Washington State have been operational since March and the Health Record Bank in Oregon (HRBO) is scheduled to go live in early 2010. Both efforts were well developed long before the American Recovery and Reinvestment Act (ARRA) was signed and $564 million was allotted for health information exchanges.


Health record banks can be the foundation for health information exchange (HIE) and therefore qualify for those federal stimulus funds, according to William Yasnoff, MD, PhD, managing partner of NHII Advisors, and advisor to the HRB efforts in Washington State and Oregon. Indeed, the November 2008 Health Information Infrastructure Advisory Committee report (pdf) to the Oregon Health Fund Board considered the HRBO as “a fundamental building block in developing health information exchange in Oregon.”


Two years ago, the Office of the National Coordinator (ONC) for Health IT required distributed models to be deployed in order to receive one of the Nationwide Health Information Network prototype architecture contracts. HRBs have a centralized architecture or infrastructure. In this year’s Funding Opportunity Announcement for the State Health Information Exchange Cooperative Agreement Program, ONC is not dictating the HIE architecture. In a recent AP interview, ONC head David Blumenthal, MD, said, “We’re very committed to innovation and we’re very aware that the government is not the repository of all wisdom, especially in a field as dynamic as health information technology. So we fully expect there will be a lot of different solutions to the exchange problem.”


The “architecture neutral” position “represents a significant shift in ONC from the past,” Yasnoff pointed out. Under the American Recovery and Reinvestment Act (ARRA), states or the state-appointed entities reserve the right to propose whatever architecture they choose. ONC must approve, however, the state’s strategic and operational plans before releasing the funds for HIEs. “It will be interesting to see what states propose,” he said.


Yasnoff believes the acceptance of a centralized architecture is based on two things: distributed architectures are extremely expensive, inefficient and unreliable to operate and privacy issues are paramount. A distributed model that must deal with more than 10 data sources is a “logistical and operational nightmare,” Yasnoff contends. It’s impossible to have all stakeholders in a community to cooperate and agree to a data-sharing agreement, he said.


As for the privacy problem, there are only two options, he said. Either you adopt a uniform privacy policy for everyone, which Yasnoff points out is not feasible in this country, or each person gets his or her own privacy policy, which is possible in the HRB model, he said. “As the privacy issue is being considered, it’s becoming clearer: Having patient control solves the privacy problem,” Yasnoff said. Deborah Peel, MD, founder and chair of the Patient Privacy Rights, agrees. In her written testimony (pdf) before the HIT Policy Committee dated September 18, 2009, she supports HRBs because it gives patients control over their electronic data.


During the public commentary on “meaningful use,” the Health Record Banking Alliance made two recommendations. One, clinics should be required to transmit electronic health record (EHR) data created from an encounter in a standardized e-format to a destination of the patient’s choosing within 24 hours and at no cost to the patient. And two, no other EHR data should be sent anywhere without patient consent. “It’s all about patient control,” Yasnoff said.


HRBs have other things going for it besides dealing with the privacy and consent issues. Although meaningful use hasn’t been defined in more detailed to date, “health record banks meet the general requirements in every way in terms of complete patient record, improved outcomes, efficiency and patient safety,” he said.


While the funding is welcome, Yasnoff said it hasn’t changed the fundamental problems in the community, namely privacy and stakeholder cooperation. “These are very difficult to deal with unless you’re a health record bank,” he said.


“In all the excitement with the funding, we need to maintain a sober realization that all this funding is temporary,” Yasnoff said. “People should not lose sight of the ultimate goal. At the end of the day, we need a sustainable, working infrastructure.”