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Enter the Internet

The community health information movement was in serious jeopardy.

CHMIS, the public sector, and CHINs had all sounded great in their promises

and then failed to deliver much of substance. The intra-enterprise advocates

were saying, “I told you so.” The movement was at best moribund. Most

604 Part V. Case Studies: Applications of Information Systems Development

community stakeholders did not see a need for a community health information

infrastructure. Those that did see the need could not see a way to make it

happen. Then, a new trend emerged that changed everything—the Internet.

The Internet revolution has been thoroughly documented and chronicled.

This chapter will not revisit this subject. Suffice it to say that the importance

of the Internet revolution to the community health information movement

cannot be overstated. The rapid deployment and adoption of Internet technology

rescued the movement from the brink and offered immediate benefits:

Taking the “Why” Question off the Table

Community health information advocates spent much of their time on “missionary”

work. They needed to convince increasingly skeptical healthcare

communities that connectivity would and should happen. As long as the

debate raged around the why question, little concrete progress could be made

on implementation. By the end of 1997, the long-running debate of interenterprise

versus intra-enterprise had been decisively resolved in favor of

inter-enterprise. It was clear that simply connecting up within the four walls

of the enterprise would not cut it in a “wired” world. The Internet was demonstrating

the benefits of the seamless network the “community” missionaries

had always described.

Providing the Means

Although the primary struggles of the movement to date were more political

than technological, the absence of a means to execute the vision, even for

those who were convinced of the need, was problematic. Internet technology

offered a relatively cheap, increasingly ubiquitous, standards-based means to

link community stakeholders. The Internet answered the most important aspect

of the “how” question. It was clear that some form of Internet technology

was going to be the ultimate community health information network.

Leveraging Investment

For a community health information initiative to succeed, there had to be a

supporting infrastructure. Individual enterprises had to invest in automation,

move data from paper to electronic form, and train and provide incentives for

users. The lure and the promise of the Internet brought forth significant levels

of information infrastructure investment. Hospitals, health plans, physicians,

and government began to see health information technology as a key strategic

investment. Similarly, on the commercial side, risk capital began to flow

to the healthcare information technology (IT) vendor community.

This convergence of the Internet and the community health information

movement spawned a new breed of initiatives. Tyler Chin, of Faulkner &

Gray, described them as “CHINInternets” (T. Chin, personal communication,

27. The Community Health Information Movement 605

1997). These initiatives have seized on the promise of the Internet in many

different ways to meet the shared health information needs of their communities.

In many cases, the sponsors of these efforts explicitly acknowledged the

problems of the past and sought to build their new models on a firm foundation

of lessons learned. Before reviewing specific initiatives, it is helpful to

consider the key lessons learned.

Lessons Learned in the Community

Health Information Movement

As can be seen from the history described, there were many lessons to learn

from the CHMIS, CHIN, and public sector experience. Although the learning

experience varied across markets, it is possible to distill a set of the most

salient lessons that seem to predominate in all settings:

The need to differentiate between needs and wants and to target needs. A

want is defined as something nice to have. A need is something that someone

will pay for. Targeting needs is critical. Even in the not-for-profit

environment, someone has to pay in order for progress to be made. Many of

the community health information initiatives that failed never adequately

appreciated the distinction between needs and wants. They generated

considerable excitement by discussing all the functionality that frustrated

health industry stakeholders had long wanted but were largely unwilling

to invest in. Then, when the call came for funds, the sponsors heard the

refrain, “I assumed someone else would pay for it.” These initiatives ended

up trying to fulfill big dreams with small budgets, a recipe for failure.

Savvy community health information operators have learned to cut through

the wants and to focus on the needs.

The need to build the business case for a concept . Much of the early work

in the community health information movement was related to sharing the

vision. The need was so profound that it seemed more important to solve

the systematic problems rather than quibble over how to fund the solutions.

This ignored the day-to-day reality faced by the enterprises participating

in the community endeavor. These enterprises faced demands for IT

solutions well out of proportion to the budget dollars available to fund

them. The enterprises tended to prioritize those solutions that addressed

urgent needs and could be justified on a business basis. To secure

community investment required a clear delineation of the benefits that

will be generated. Long-term vision might inspire, but a good return on

investment is more likely to engender support and participation.

The need to focus on more than a network . Prior to the Internet revolution,

most of the community health information initiatives focused most of their

energies on developing a network capability. The emergence of Internet

technology as a network solution allowed community organizers to expand

their vision. Whereas some community groups leveraged Internet

606 Part V. Case Studies: Applications of Information Systems Development

technology to deploy private networks (Intranets or Extranets), many other

groups focused their energies in other complementary areas—for example,

development and implementation of standards, security and privacy

practices, education and training, applications, etc. The presence of Internet

technology has freed the community health information movement to go

beyond CHINs and offer more than just a network.

The need to use the competitive versus the collaborative model . Idealists

in the community health information movement cherished the hope that

much of the health information infrastructure would be built on a

cooperative basis. The growth of the commercial IT sector has proven this

belief false. In addition, many of the enterprises that comprise the local

health services community have their own electronic strategy. These

enterprises are not looking to either a community group or a commercial

entity to meet their needs. Rather, they plan to do it themselves. In fact,

many of these enterprises explicitly reject a collaborative strategy because

they see their electronic-health (e-health) initiatives as a means to

competitively distinguish themselves. This has forced community health

information groups to acknowledge a fundamental truth: most of the health

information infrastructure will be built under the competitive model. The

challenge for community groups is to prioritize those limited collaborative

components of the overall infrastructure that most effectively leverage

and support the competitive investments being made.

The need to define roles . The early community health information

initiatives perceived the need to “do it all.” They saw few ready partners at

hand and assumed that if they did not address a key component of the

community infrastructure, it would not get built. To some degree, this

perception placed community groups into a competitive situation with

others working to achieve similar objectives. As the movement matured,

community groups recognized that they could not and should not attempt

to build the entire health information infrastructure. There are roles for

many different types of players. Linking and leveraging the amalgam of

talent and resources devoted to improving the health information

infrastructure makes far more sense then working at cross-purposes. The

community groups need the enterprises, and vendors to be successful in

their work. The vendors and enterprises can accelerate what they are trying

to achieve with the help of the community groups. Clearly defining roles

and constantly seeking to build and strengthen partnerships are now seen

as crucial aspects of the work of a community health information group.

The need to narrow project scope and to avoid creeping incrementalism .

Trying to live down the claim of being “too big to be true” has dogged

many of the more ambitious community health information efforts. Focus

has become an important element of success. Most current community

health information initiatives have narrowed the scope of their work

considerably from the halcyon days of CHMIS. Taking slow, measured,

clearly defined steps that address urgent business needs of key stakeholders

27. The Community Health Information Movement 607

is widely seen as the most likely path to success for community health

information initiatives.

The need to address privacy matters . The concerns about health information

privacy first encountered by CHMIS have continued to proliferate. The

gradual automation of the health industry, coupled with highly publicized

security failures, have sensitized many policy makers, media people, and

ordinary consumers to the need to protect the privacy of personal health

information. For many people, their health records are the most sensitive

data they have. Although the community health information movement

has always seen itself as a force for social good, privacy advocates see any

aggregation of health information as a potential threat. Privacy and security

concerns are here to stay, at least for the immediate future. Addressing

these concerns is both an obligation and an opportunity for the movement.

The Community Health Information

Movement in Action

The lessons described are best understood in the context of specific initiatives.

Listed below are six leading community health information initiatives.

Together, these six organizations illustrate the past, present, and future of the

community health information movement.

Minnesota Health Data Institute

The Minnesota Health Data Institute (MHDI) is a unique public/private partnership

in the state of Minnesota. MHDI operates as a private, not-for-profit

organization; yet, it was created by the Minnesota legislature in 1993. The

21-member board, comprised of purchasers, providers, payers, the public sector,

and consumers, works closely with the Minnesota Commissioner of Health

to accomplish its mission:

To design and implement an integrated state wide health care data system to support

the information needs of health care consumers, purchasers, providers, payers, policymakers,

and researchers in measuring and improving the quality and efficiency of

health care services in Minnesota.”2

MHDI has programs in quality measurement, electronic commerce, and

privacy. MHDI has lived through the evolution of the community health

information movement. It was originally a CHMIS site, and it sought to execute

its mission on the comprehensive scope of the CHMIS vision. However,

early on, the community leaders recognized that the full-scale CHMIS approach

would not work in Minnesota. They sought instead to create a CHINlike

approach. Their solution was a private Intranet called MedNet.2

MedNet sought to match the community governance of CHMIS with the

“network-of-networks” CHIN concept.

608 Part V. Case Studies: Applications of Information Systems Development

MedNet was not designed to be the sole network in the community. It was

envisioned as a means to link the existing networks of key health care enterprises.

MedNet enjoyed early success as some of the major market participants

connected to the network. However, usage was limited, and transaction

volumes suffered. In an effort to boost network usage and diversify its electronic-

commerce (e-commerce) offering, MHDI pioneered an eligibility application,

the central query system (CQS). The CQS was designed as a common

eligibility portal for public sector and private sector eligibility data. Minnesota

Medicaid was the initial source of eligibility content. In addition to the

CQS and MedNet, MHDI delivers educational services related to e-commerce

and recently to issues related to the Health Insurance Portability and Accountability

Act of 1996 (HIPAA).

MHDI has also grappled with the privacy issues. It played a key role in

helping Minnesota draft its health privacy laws. Since then, MHDI has expanded

its work in this area to include Public Key Infrastructure (PKI). Along

with groups in four other states (Washington, North Carolina, Massachusetts,

and Utah), MHDI participates in the national HealthKey program that is exploring

approaches for deploying PKI in health care.3

Recently, MHDI evolved its e-commerce offering in a new direction. MHDI

and the Pointshare Corporation entered into an agreement to outsource CQS and

MedNet. MHDI decided it was better able to achieve its objectives by leveraging

the capabilities of a private company. Pointshare saw MedNet and CQS as a costeffective

way to enter a market and deliver services. This type of partnership

highlights the creative approaches community health information initiatives are

taking to achieve their goals. MHDI is unique in structure, experienced in the

gyrations of the community health information movement and innovative in its

program design. Those interested in the progress and potential of the movement

will closely watch MHDI as it moves into the future.

Utah Health Information Network

The Utah Health Information Network (UHIN) is the only statewide CHIN that

really achieved success. Whereas the CHMIS sites struggled and most CHINs

never got off the ground, community leaders in Utah had the vision and

capability to organize and implement a statewide network. In 1993, UHIN

was incorporated as a nonprofit company with a mission to provide the consumer

of healthcare services with reduced costs and improved healthcare

quality by creating and managing an electronic value-added network, standardizing

healthcare transactions, and gathering and providing data to a statewide

repository. A board that is selected by the membership governs UHIN.

The UHIN membership capitalized the company and funds the operation of

the network. In addition, UHIN has received support from the state of Utah.4

UHIN understood early on the “wants versus needs” dilemma and the requirement

to make a business case. The organization focused tightly on a

limited scope of work and required anyone who wanted to play to have a

stake in the game. Although UHIN is a classic community health information

27. The Community Health Information Movement 609

network, it takes great pride in emphasizing that it runs the network as a

business. UHIN leaders know that community participation is voluntary and

predicated on the network’s capability to meet its customers’ needs.

Currently, UHIN offers an electronic data interchange (EDI) solution for

healthcare claims and remittances that serves all interested payers and providers

in Utah. As the organization looks toward the future, UHIN envisions

expanding its suite of services to include:

• Eligibility

• Referrals

• Patient records

• Lab tests

• Digital images

In the conduct of its business and in its role as community educator, UHIN

heavily emphasizes the importance of standards. UHIN has taken a leadership

role within the sate of Utah to help the healthcare community get ready for

HIPAA and the requirement to implement national standards for common

healthcare transactions. In addition, UHIN has diversified its work in two

other areas. First, like MHDI, UHIN is one of the five participating state organizations

in the HealthKey program. UHIN sees the emerging importance of

privacy and security and wants to explore ways to make it work on a costeffective

basis for all participants. Second, UHIN recently entered into an

innovative arrangement with the Utah Department of Health to collect data

that is legally required by statute. For those data sets mandated by law, members

may use UHIN to submit to the state. This arrangement highlights a

clever and efficient arrangement to meet public health information needs by

leveraging a community asset. UHIN will continue to explore creative ways

to keep pace with the changing face of e-commerce, serve its customers, and

apply its most valuable commodity—the commitment of its members.

New England Healthcare EDI Network

The New England Healthcare EDI Network (NEHEN) is a fairly recent entrant

to the community health information scene. It offers another interesting model

for how community efforts can evolve through partnership. In the mid-1990s,

the Massachusetts Health Data Consortium (another HealthKey participant)

brought together key stakeholders to explore how best to address shared ecommerce

needs. These enterprises were very clear that they did not want to

create what they deemed a CHIN. To them, a CHIN was a single network

solution for all. In contrast, they sought a means to keep their independence

and engage in collaborative activities of limited scope. In this context, the

Massachusetts Health Data Consortium created and operated the Affiliated

Health Information Networks of New England.

Initially, the affiliated group focused primarily on information and education

as it considered how best to work toward its vision of “non-CHIN” collaboration.

In 1997, the group hit on an idea for a network-of-networks model

610 Part V. Case Studies: Applications of Information Systems Development

that would meet the requirement to offer common benefits while preserving

individual discretion. This idea was NEHEN. NEHEN was created with five

key benefits in mind:

• A tool to achieve HIPAA compliance;

• Delivery of service efficiencies through EDI;

• Reduced time to implement EDI on a large scale;

• Maintenance of individual business flexibility; and

• Reduced cost of EDI implementation through coordination and

standardization.

The founding members of NEHEN included major healthcare payers and

providers in New England (Harvard Pilgrim Health Plan, Tufts Health Plan,

CareGroup, and others). The founders sought a private partner to staff the

effort, to bring it to fruition, and eventually to operate the network. They

selected Computer Science Corporation (CSC) for this purpose.5

To get buy-in, CSC embarked on an extensive communications effort with

key executives. CSC emphasized how NEHEN could address urgent business

needs and provide a positive return on investment. Once the decision was

made to proceed, CSC created the network infrastructure with a secure Extranet

and a thin layer of software at each enterprise location. The network initiated

operations with the eligibility transaction. As of 2001, NEHEN was generating

12,000 eligibility inquiries per day.5 NEHEN intends to move forward

with other HIPAA-compliant transactions, including claims, referrals, remittance,

and others.6

NEHEN is a blend of the community model and the commercial IT world.

Incubated in a community not-for-profit setting, NEHEN has now incorporated

as a limited liability corporation. The network is governed by its member

participants and is open to any enterprise that wishes to join and adhere to

common practices. CSC operates the network at the behest of the members.

NEHEN is now being seen by other e-commerce companies as a cost-effective

platform to conduct their business. The possibility exists that NEHEN will

become the common health information network for both health industry

participants and the vendors that serve them.

Wisconsin Health Information Network

When knowledgeable people talk about CHINs and describe the failure of the

concept, they may add, “except for WHIN.” Just as UHIN is seen as the one

statewide CHIN that succeeded, the Wisconsin Health Information Network

(WHIN) is often seen as the one community-based CHIN that succeeded. WHIN

began where others ended up: as a partnership between Ameritech, a large

telecommunications company, and Aurora Health Care, a major integrated

delivery system based in Milwaukee. The genesis for this partnership was the

effort Aurora made in the 1980s to connect physician offices to Aurora’s hospital

information system (HIS). In working with the physician community

27. The Community Health Information Movement 611

and other stakeholders to connect and share information, Aurora began to

sense both the need for inter-enterprise connectivity and the challenge of

bringing it about. After surveying members of the community, Aurora and

Ameritech concluded that a single hospital solution was not the right way to

proceed. It made far more sense to develop an “all-community” solution.7

In 1992, Aurora and Ameritech responded to the community’s concern by

creating WHIN. Since that time, WHIN has enjoyed steady growth and a reputation

as the most visible and successful CHIN in the country. WHIN offers a

comprehensive list of services including:

• Network access

• Clinical information

• Eligibility data

• Referral processing

• On-line document retrieval

• E-mail

• Electronic forms

Because of its hospital roots, WHIN offers a deeper level of functionality to

hospital and physician participants than most other community health information

networks. The recipe seems to have worked. WHIN currently has over 1200

physicians and 3000 total subscribers generating over 100,000 transactions a

month. It is also worth noting that as a for-profit company, WHIN is profitable.7

As the CHIN market deteriorated nationally, Ameritech got out of the business.

WHIN is now owned and operated by Aurora. WHIN has worked hard to

justify the benefits of a community health information network. In 1994,

WHIN published an independent study conducted by the University of Wisconsin.

The study was designed to assess the impact of the CHIN. Sample

findings about the impact of WHIN include8:

• Savings of $5.10 for medical record requests handled by WHIN for the

hospital

Savings of $1.00 for referral requests and $2.50 for clinical information

requests handled by WHIN for physician offices

• Benefits such as rapid response time, fewer lost charges, and decreased

patient stays in hospital

WHIN now seeks to consolidate its gains and potentially expand its offering to

neighboring markets. It endures as the role model for a successful CHIN.

Healtheon/WebMD

Many people would not consider Healtheon/WebMD as a community health

information initiative. Instead, they would see the company as a vendor or a

“dot.com.” However, an examination of the objectives of the company in light of

the evolution of the community health information movement makes it clear that

Healtheon/WebMD may be the ultimate end-state of the movement.

612 Part V. Case Studies: Applications of Information Systems Development

Healtheon/WebMD (recently renamed WebMD) describes itself as follows:

WebMD provides connectivity and a full suite of services to the healthcare industry

that improve administrative efficiencies and clinical effectiveness enabling high quality

patient care. The Company’s products and services facilitate information exchange,

communication and transaction between the consumer, physician, and healthcare

institutions.”9

Change the names and this could easily be a statement from the early days

of CHMIS. Indeed, it could be argued that WebMD has an even more ambitious

plan than CHMIS and the CHINs. WebMD seeks to wire up the healthcare

industry “end-to-end” on a national basis.

WebMD is really an aggregation of health information technology companies

that have been acquired over the years by Healtheon, the original organization.

This national conglomeration of companies includes physician practice management

systems, consumer health information sites, claims processors, network

service providers, and others. Its breadth of offering, matched with strategic partnerships,

has positioned WebMD as the dominant player in its market space.

This dominant position provided the company with enormous capital resources

after it went public. Even with current market fluctuations, the total market valuation

of WebMD is well into the billions. WebMD’s list of corporate partners and

investors reads like a who’s who of industry. The result is a war chest that most

community health information groups could only dream about. However, the

clout and scope of the company has also caused problems. Some have been

concerned by the potential for WebMD to overwhelm, dominate, and

disintermediate healthcare enterprises. The creation of a rival organization,

MedUnite, by major health plans was a direct response to WebMD. The company

has also struggled to seamlessly integrate the component companies into a single,

efficient, operating entity. As a consequence, WebMD’s fortunes and the prospects

of the e-health sector it leads have been depressed recently.

The question for the community health information movement is whether

WebMD and other e-health companies will displace the movement, push enterprises

closer to community-based alternatives in a defensive reaction, or eventually

emerge as a powerful partner and enabler. Many on Wall Street and on main

street will be watching with great interest to see how the story plays out.

Pointshare

Like WebMD, Pointshare is a commercial organization. However, it has a very

different strategy. Pointshare derives its strategy from the premise that health

care is a local service. The company believes that in order to deliver value, it

must operate at the community level. Pointshare positions itself as a national

leader in connecting healthcare communities with secure online business

services that enhance communications, improve the delivery of patient care,

and increase operating efficiency. To achieve this objective, Pointshare provides

the following offering:

27. The Community Health Information Movement 613

Connectivity

• Eligibility

• Referrals

• Clinical messaging

• Access to medical content

Pointshare also carries other value-added services on its network, including

access to an Internet-based immunization tracking system operated by

public health and a private company.10

Pointshare is smaller and more regionalized than WebMD. It is interesting

to note that Pointshare is based in Washington State and also operates in

Minnesota. These are two of the states discussed as leaders of the community

health information movement. This overlap is not coincidental. Pointshare

has long supported and participated in community health information efforts.

The company sees such community groups as blazing a trail for adoption and

use of its services. Where communities have come together to address shared

information needs, Pointshare believes it will find a more receptive market

for what it sells.

Specifically, in Washington State, Pointshare is working with a community

collaborative called the Network Advisory Group (NAG). NAG is a consortium

of major payers and providers dedicated to coordinated

implementation of HIPAA. Pointshare is the initial intermediary that links the

payers and providers together. In Minnesota, as previously mentioned,

Pointshare has partnered with MHDI to operate its network. Like WebMD and

other e-health companies, the challenge for Pointshare will be to deliver on

the promise of e-health in a less favorable investment climate. Pointshare is

trying to demonstrate that community health information networks are not

only a social good, but that they can also be good business

The Future

Using a circle as a metaphor for the community health information movement

means we come back to our starting point or near to it as we examine the

future and the implications for public health:

“Do it all together” is not going to work. The original vision whereby a

small group of community leaders in a top-down model wired up the world

and governed a unitary system is not palatable to the health industry or to

community stakeholders. Furthermore, it is not consistent either with the

nature of Internet technology or the nature of the commercial organizations

seeking to harness it. The health information infrastructure must permit discretion

at the individual enterprise level and perhaps even at the individual

user level.

“Do it all alone” is not going to work either. Those most deeply opposed

to the early vision of the community health information movement believed

614 Part V. Case Studies: Applications of Information Systems Development

there was no need for inter-enterprise connectivity or collaboration. They

expected to “own” on an exclusive basis all of their trading partners. These

trading partners would be connected directly to a single enterprise, and that

supposedly would solve the problem. The evolution of the healthcare market

place with many-to-many relationships already made this a questionable strategy.

The Internet revolution makes it a suicidal strategy. Like it or not, health

enterprises will be sharing data, customers, and trading partners for the foreseeable

future. The question is not if enterprises need to connect to others,

but how.

“Just let somebody do it for you” does not appear that it will work as a

concept. The commercial organizations moving into the community health

information space had high hopes that they would assume a role similar to the

one CHMIS identified 10 years ago. As the intermediary at the heart of the

network, they would sign everyone up, route traffic, extract data, and get rich

on the value they provided and the huge volumes of transactions they moved.

It is too soon to be definitive about this concept; however, the early returns

seem to indicate that this model won’t fly. Major health enterprises fear the

intermediary will either assume a monopoly role and mistreat them or assume

their role and disintermediate them. Furthermore, enterprises increasingly see

e-health as a means to competitively distinguish themselves. Therefore, they

are reluctant to turn it all over to a third party.

“Do it in partnership” seems to be the direction the market is currently

headed. The need for interoperability is a key driver of the partnership approach.

Health services is a many-to-many market place. This means there is

a tremendous cost to all participants if everyone does their work in isolation.

Interoperability is a critical component of any robust health information infrastructure,

just as it is in other industries. In this context, the enterprises, the

vendors, and the community groups are finding common ground. The enterprise

holds the data and sometimes the customers everyone wants access to.

However, the enterprise generally lacks the necessary capital, IT talent, and

field force to establish connectivity and get it used. The vendors have the

capital, the resources, and the incentive to execute on infrastructure development.

However, without the content and the customers, they have no way to

make the connectivity and applications valuable. The community group usually

lacks the capital, the content, and the resources. However, the community

group is often in the best position to build trust, foster collaboration, and

educate the stakeholders—all prerequisites for the successful pursuit of

interoperability. As can be seen with the examples profiled, enterprises, vendors,

and community groups are already finding exciting ways to partner.

What does this partnership approach mean for public health? It suggests

that public health needs to move aggressively to join the partnership. With

limited budgets and the requirement to assess populations, public health

organizations have wonderful opportunities to leverage the investments of

the personal health industry and the vendor community. Going it alone makes

no more sense for public health than it does for the healthcare enterprises.

27. The Community Health Information Movement 615

Specific partnership opportunities abound and are already under way in some

communities. These include:

Immunization tracking . In Washington State, public health, Pointshare,

and a company called HealthRadius are partnering with health plans and

providers to see if the same network used to transact the administrative and

clinical business of health care can be leveraged to track immunizations.

Vital statistics . UHIN and the Utah health department are piggybacking

reportable information on the same network developed for handling

administrative transactions.

Lab results . Public health is attempting to extract and aggregate

surveillance information from clinical laboratory findings. Many

enterprises and the vendors that serve them have identified clinical results

reporting as a priority for the messaging services they are building and

deploying. This suggests a cost-effective partnership could be structured

to accommodate all users.

Consumer information . Vast sums are being spent to attract consumers to

the Internet and particularly to medical content sites (WebMD, drkoop.com,

etc.). These initiatives offer public health a vehicle to disseminate

information on prevention.

As the community health information movement enters its second decade,

a different sort of promise beckons than was glimmering 10 years before. At

the beginning of the cycle, it was sharing grand visions and trying to make it

all come true at once. Now, the vision is entrenched, and the field is crowded

with those who want to help bring it about. The challenge for the community

health information movement is to make the right “picks”—pick an area of

focus, pick the right role, pick a good set of partners, and concentrate resources

to execute successfully. Over the next 10 years, the goals of the

movement’s founders can finally be realized.

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