March 25th, 2011
Editor’s Note” As David Blumenthal prepares to step down as the National Coordinator for Health Information Technology, where does the United States stand in the continuing effort to promote widespread adoption of electronic health records? What are the challenges that the next health IT coordinator will face? Health Affairs Blog asked two leading experts to address these questions: Mark Frisse does so below, and Carol Diamond provides her analysis in another post.
You can find more on the adoption and impact of electronic health records in the current issue of Health Affairs, which contains articles by Melinda Buntin, Brian Bruen, and Neil Fleming (and colleagues in each case). These articles were discussed at the release event for the issue, which you can listen to on the Health Affairs website.
Dr. David Blumenthal’s tenure at the Office for the National Coordinator for Health Information Technology (ONC) is without precedent. Never in American history has the public experienced such an aggressive and deliberate effort to introduce health information technology (HIT) into clinical settings with such a deliberate goal of producing a safer, more efficient, more reliable, and more effective health care delivery system. Following the script of the HITECH Act of 2009, Blumenthal’s ONC implemented: consensus-building processes to develop financial incentives for EHR adoption (Meaningful Use); more flexible EHR certification methods; regional extension centers to support EHR adoption; HIT workforce training and education programs; state-level health information exchange programs; simpler and more widely accepted communication standards; new health information technology research grants; and many other initiatives fostering widespread HIT adoption. Through ONC, HITECH has evolved from a stage of words and ideas to a time of action. Appropriated funds have been spent. A massive machine has been set in motion. And all has taken place over only two years.
The challenge facing Blumenthal’s successor is to harness the momentum of the HITECH machine as goals, methods, and public perception change. ONC must continually balance the noble aspirations of policy-makers with the realities of both providers and patients who ultimately realize the gains or suffer the consequences. ONC’s future will be determined by three factors: the strengths and limitations inherent in HITECH’s aggressive timelines; the impact of innovation; and the changing political and economic stage on which the Meaningful Use drama is played.
HITECH’s Aggressive Timelines
Care transformation is a product of cultural transformation. Methods for transforming care within large health care organizations have been put into practice in leading institutions, but for many other peers, such methods are applied sparingly and inconsistently. HITECH incentives will undoubtedly accelerate progress in institutions with sufficient size, work force, and financing. Care transformation in most medical practice settings is encumbered by circumstances foreign to a Kaiser Permanente or a Vanderbilt University Medical Center. Clinicians across the country share common aspirations but differ greatly in their ability to mobilize a transformation effort.
Provider EHR adoption is based on local decisions guided by national specifications, rewards, and penalties. The very ambitious nature of Meaningful Use (MU) and the pace of deliberation leads to uncertainty that in turn delays purchase decisions. Demand for the Nation’s 62 regional extension centers is therefore not increasing as quickly as was anticipated. Although 45,000 of an anticipated 100,000 providers have requested assistance, the speed with which requests can be filled is uncertain; to ONC, the cup is half full; to skeptics it is half empty. The experienced commercial workforce supporting HIT adoption is heavily engaged; although 3,400 junior college trainees will complete ONC-funded training this Spring, ONC estimates an annual goal of 10,000 through its programs. Training will take years, not months.
Meaningful EHR adoption is a multi-phased and iterative process that begins with deliberation and ends with HIT embedded into transformed clinical operations. Every step through the process adds latencies that when compounded across the entire chain lead to delays that may be far greater than anticipated. And both delays and inefficiencies decease patient throughput and practice efficacy. Delays and inefficiencies, therefore, are extremely costly. Attention must be focused on root causes. Culture – and not money – might be the critical limiting factor to EHR adoption. A doubling of funding rarely if ever halves the time required to achieve a goal.
Disruptive Innovation in Care Delivery
The HITECH Act is a marriage of recent and relatively untested care delivery models with more mature electronic health records (EHR) systems. HITECH seeks to encourage and coerce delivery systems to adopt EHR and care delivery models that in the hands of some pioneers have resulted in stunning clinical improvements. While larger and more mature organizations should be able to replicate the results of EHR pioneers, smaller or less sophisticated settings face greater challenges. The knowledge, time, and resources required to transform these practices is not widely available or in reach of many clinicians. The latter groups may initially seek piecemeal adoption of services rather than comprehensive solutions. Newer and more “light weight” systems more responsive to the care delivery and coordination needs of small practices may be necessary. Recent trends in certification processes suggest a higher ratio of EHR Modules (131) to complete EHRs (219) than was the case in the past. True innovation encompassing a broader swath of our health care delivery system may require more disruptive approaches.
HITECH and the Patient Protection and Accountable Care Act (PPACA) give consumers unprecedented rights of both access to and control of their health information. Integrating consumer preferences into a complex network of personal health records, web portals, remote sensor devices, and traditional EHR requirements with both traditional EHRs and emerging personal health record models presents a challenge. The Blue Button Initiative – a collaboration of the VA and HHS – allows Medicare and VA beneficiaries access to their medical information. Entrepreneurs are responding to this initiative by introducing novel personal health records based on Blue Button data. The impact of joint federal and private-sector efforts affords rapid innovation.
States and state-designated entities fostering health information exchange under HITECH would be well served to learn the lessons of the NHIN Direct initiative. When David Brailer’s ONC was created, the terms “exchange” and “RHIO” were largely synonymous. State-level HIE seemed to require specialized organizations controlling both policy and technology. Anchored in work in Santa Barbara, Indianapolis, and a few other communities, fairly monolithic and controlled methods of exchange seemed to be the only way to bring aggregate data to the point of care. This mental construct led to a view of data transmission that was hierarchical: from the clinic to the RHIO to the State and to a nationwide health information network.
In practice, exchange of health information seldom follows hierarchical paths. A good part of the Nation’s health care information economy is the result of “point-to-point” transactions among clinical laboratories, health plans, claims clearinghouses, pharmacy networks, pharmacy benefits managers, and many other organizations. With the HITECH stimulus, these organizations are finding new ways of leveraging their ability to communicate nationwide with providers and payers to provide additional messaging services at very low marginal costs. ONC’s NHIN Direct project is designed to ensure that a uniform set of secure transaction capabilities is available to all providers.
Both state and regional health information organizations will play important roles in measuring quality across care transitions, supporting Medicaid programs, and communicating public health data. At present, only 35 states have approved plans to participate in ONC’s state HIE program and these programs differ greatly in technical maturity, available capital, and likelihood of operational sustainability. Clearly, the exchange requirements necessary for Meaningful Use will require more than state HIE.
The Politics of Meaningful Use
The HITECH Act’s Meaningful Use provisions present the greatest challenge to ONC. Meaningful Use criteria have been defined through three successive phases – each more prescriptive and demanding than its precedent. Blumenthal’s vision for MU is three-fold: as a driver for the creation of an HIT infrastructure; as shorthand for creation of an evolving and dynamic means of supporting health care improvement; and as a means of creating incentives for EHR adoption. A more restrictive interpretation would limit MU to the criteria for adoption and let both infrastructure development and the dynamic use of HIT to be guided more directly by our deliberation over developing incentives for proper care. In this restrictive interpretation, the form of our infrastructure would follow the functions we chose to emphasize in our health care system. Technology would be driven by policy. The MU carriage would not be placed before the health reform horse.
At present, the debate is between those who believe MU is a means to an end and those who believe MU is an end in itself. The debate is between those who believe most good ideas should be incorporated into the regulatory complexity of Meaningful Use and those who believe that the current momentum set in place by Phase One criteria is sufficient to chart the right course without MU further specification. It is a debate among those seeking a regulatory “push” through Meaningful Use and those seeking a market “pull” through less coordinated application of technologies in response to health reform initiatives only beginning to see full definition. It is a debate between those who seek to push the process even harder and those who do not believe they can realize all of the proposed phases within HITECH’s aggressive time frames.
Past HIT adoption efforts have stalled because of conflicts over health care reform similar to those we see today. Health care information technology initiatives during the Clinton administration faltered as the will for health care reform abated. In contrast, provisions for pharmacy electronic claims incorporated into the Medicare Catastrophic Coverage Act of 1988 persisted after the law’s repeal and were sufficient to foster incremental progress towards more comprehensive medication management over the ensuring decade. Arguably, the momentum achieved simply by Phase One MU could achieve broader aims no matter what happens to health reform and funding for subsequent MU phases.
As ONC’s leadership changes, it would be wise to re-examine the means by which ONC will address three major challenges. First, ONC must balance free-market innovation and federal regulation. Meaningful Use may be a test bed for how ONC balances these tensions. Looking toward Phase 2 and Phase 3 of Meaningful Use, controversy is certain to grow as proponents seek to codify advanced functionalities beyond the current capabilities of many provider organizations. Meaningful Use rules could set the bar very high by a process of informed enthusiasm, or they could express the minimal regulatory requirement necessary to ensure providers work through the details in their own manner. The latter more conservative approach does not mean that the impact of EHR adoption will be attenuated. It merely suggests that impact is ultimately dictated by the extent to which care reimbursement incentives are aligned.
Second, ONC must continually adjust the balance between local autonomy and federal control. Although this tension is most prominent in debate between some states and the federal government over the Patient Protection and Accountability Act’s health reform provisions, states differ as well in their attitude toward HIT regulation and EHR adoption. No matter what the position of a state, State HIE groups can make a significant contribution if they focus their efforts on applying national standards and governance models to vital state government activities – Medicaid and public health. Regional HIE efforts may become essential for care coordination, measurement of readmission rates and other quality indicators, and as a trusted source for health information exchange services.
Finally, large sectors of the American health care industry suffer from “HITECH Overload” precipitated by an overwhelming barrage of initiatives. Across America, organizations are trying to plan for HIPAA changes, Meaningful Use, ICD-10, health insurance exchange formation, revenue cycle enhancement, advanced clinical decision support systems and many other pressing needs. ONC must shift attention from how to spend stimulus dollars to how to support this broad array of health care activities in an era of growing fiscal restraint. ONC must continue to foster innovation but should avoid the temptation to transform too much innovation into regulation. ONC should ensure that health care information technology plans are aligned not only with the current provisions of the Accountable Care Act but also with alternative models for health care reform. ONC must continue its efforts to move conversation from the Beltway to American communities. ONC must align even more closely the ideals espoused by its programs with the practical realities of every American providing or seeking health care services.
Under Dr. Blumenthal’s leadership, ONC effectively harnessed decades of HIT effort and innovation. But the task of transforming our health care system has only begun. The application of HIT to affect widespread systemic change is in its earliest stages. The difficult work lies ahead.Email This Post Print This Post
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