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: Carol Diamond does so below, and Mark Frisse provides his 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.
The new National Coordinator for Health Information Technology will take over a vastly different office from the one that David Blumenthal, MD, assumed in March 2009.
Blumenthal faced a challenge comparable to a start-up CEO suddenly infused with large amounts of venture capital for an idea with great potential and long in the making. Of course, in this case the injection of billions of dollars came from the appropriation of taxpayer money under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009, and with it also came very aggressive implementation deadlines, public scrutiny and congressional oversight.
At a dot-com pace and with vigorous public input, Blumenthal had to build the Office of the National Coordinator (ONC) staff, stand up infrastructure such as regional extension centers, develop a certification process for “qualified” health IT, create demonstration programs such as the Beacon Communities, and, most importantly, establish ambitious but achievable targets for “meaningful use”—the rules by which new federal financial incentives under HITECH will be paid to doctors and hospitals for using health information technology (IT).
We owe him our gratitude and respect for the steady and inspiring leadership he provided while vital groundwork of government’s health IT efforts was planned and brought to scale. His successor will have very big shoes to fill, but a different and equally important challenge—to preserve “meaningful use” gains by finding ways to make them sustainable in broader health care reforms.
Now that we are in the throes of implementation, the tactical debates are in full force—including debates about where to set the bar on the next stage of meaningful use requirements and about how to balance a sense of urgency with the very real day-to-day challenges providers face in implementing health IT. These debates, although important, should not become our singular focus, causing us to lose sight of the larger opportunity at hand. It’s critical that leaders make sure that HITECH is not narrowly defined as an exercise in adopting technology, measured by the number of pieces of software installed or the number of electronic health records certified. This was never the intention, as made clear by the conceptual framing written into the law requiring that health IT paid for with federal incentives be “meaningfully used.” In many ways, HITECH has been one of the first real large-scale efforts to change the way health care is delivered and paid for in terms of placing value on outcomes that improve health. To be successful, the larger goals of these investments must always be at the forefront and made clear and tangible for patients and providers alike: improving health, saving lives, reducing errors, and increasing the cost-effectiveness of care while encouraging innovation and protecting privacy.
Why is this so important? Because it will be how the public judges success. In a survey fielded in August 2010, at the outset of the program and during a time of continued debate over health care reform, we asked American patients and doctors what they want from federal subsidies for information-rich health care..
The results were striking: Roughly 80 percent majorities of both the public and doctors agreed that requiring participating hospitals and doctors to share information to better coordinate care, cut unnecessary costs, and reduce medical errors were important criteria. By the same overwhelming margin, the two groups agreed on the importance of requirements to protect privacy.
To fulfill these high expectations of the public and medical professionals, it seems there are four critical tasks at hand. Each must be met head-on, and with steadfast determination.
1. Make the Goals Crystal Clear
Clear health goals will bring meaning and context to the HITECH investments, and are necessary to align and prioritize the array of federal activity already under way. In the Meaningful Use Incentive Program, for example, each activity—from documenting structured data to implementing decision support— must be carefully and iteratively implemented with the health goals clearly in mind so that necessary process and care delivery changes are considered at each step.
Many goals are already implied by the clinical measures for Stage 1 of Meaningful Use, including:
- Reducing hospital readmissions;
- Improving medication management (safe medication use and effective medication management for heart disease, diabetes, asthma, mental health conditions, and hospital procedures);
- Improving care coordination and reducing gaps in care;
- Improving chronic care management, including blood pressure; diabetes, and cholesterol control;
- Improving preventive care, including healthy weight and smoking cessation;
- Improving patient safety;
- Reducing disparities;
- Increasing efficiency and appropriate use of resources;
- and Improving active engagement of patients in their care.
The Patient Protection and Affordable Care Act (ACA) also sets the groundwork for establishing health objectives. The law calls for HHS to articulate health priorities based on a number of criteria, including those that can demonstrate the greatest potential to improve health outcomes as part of the National Quality Strategy.
Moving forward, it will be critical for ONC’s leader to make explicit the health goals and targets for HITECH investments and how they align with health reform efforts.
2. Trust is Essential for Public Support
It is a pivotal time for privacy. There is broad consensus on the need to implement fair information practice (FIP) principles across government and the private sector. The FIPs approach is central to ONC policy advisory recommendations and recent reports by the President’s Council of Advisors on Science and Technology (PCAST), the US Department of Commerce, and the Federal Trade Commission (FTC).
But this broad consensus on FIP principles is not where the work is. The principles must be translated into a trust framework of clear policies, practices, and technology approaches that, when taken together, comprehensively protect privacy and data security.
For privacy protection, there will never be one magic bullet. As seductive as an innovative technology capability or a novel infrastructure “solution” may sound, technology has never been able to fully address a complex policy challenge on its own. Nor can privacy be dealt with on a piecemeal basis, a little piece or an isolated policy at a time, though this concept has equally seductive appeal. The reality is that FIPs inherently must be implemented as a full framework, a process that by design requires contemplating a set of complex moving parts.
Determining how to handle an issue like consent, for example, can only be done in the context of the other privacy and security protections in place. As those other protections are applied or change, so might the appropriate level of consent. Considering one policy area in isolation, rather than as part of a whole framework, can undermine the objective of the policy itself. The objective of consent, for example, is to give individuals greater control over their information. But if to achieve this objective all you consider is whether the individual will consent—the net result, often unintentionally, is weakened protection. Here’s why: Too frequently, the result is an implied pass on other components of FIPs because the individual has “consented,” and the hard work to formulate a balance of protections seems less needed.
Protection is achieved when individuals can, for example, consider consent when they know that there are limits on the collection and use of their information, know that information will be collected and shared only for specific purposes, are able to request and receive a full accounting of disclosures of personal information, are able to request corrections of erroneous data, understand the that there are proper oversight mechanisms in place, along with remedies in the event of breach, and are confident that technical and security practices are in place.
Just within HITECH, a long list of privacy and security rules still must be promulgated by several agencies, such as the U.S. Department of Health and Human Services Office of Civil Rights and the Federal Trade Commission. As the title implies, the Office of the National Coordinator must develop the policy framework and prioritize coordination of privacy and security policies with several other government agencies—a critical task.
The ONC leader will have a key role in helping the government contemplate a 21st century policy-development model that’s not balkanized by previously defined sectoral or agency boundaries. The evolution of IT and the Internet, with a growth in the number and types of entities outside of the traditional health care sector that now handle increasing amounts of personal health data, will require policy makers to think beyond the old paradigm of “covered entities” under the Health Insurance Portability and Accountability Act (HIPAA).
ONC is not the primary writer or enforcer of privacy and security rules, but it has earned the serious responsibility to maintain strong leadership for comprehensive and coordinated protections for personal health information as a consequence of its role in helping define the requirements for the spending of billions of dollars of taxpayer money.
It’s a big challenge that will take unwavering leadership in a volatile, complex arena at a pivotal time. But ignoring it will undoubtedly undermine all the good work done to date. Headlines such as Equifax and wikileaks tell the story of large-scale data spills from both the private and public sectors, making it clear to the public that protecting information is hard. The public wants the benefits of health IT but also wants protections. We must deliver. Losing the public trust means losing the opportunity to use health IT to make much-needed improvements in our health and health care system.
3. Encouraging Innovation with an Open Approach to Technology
Health IT is in its infancy. And incentives for tools to support the use of information to improve health and health care are just now being provided. But enabling and fostering innovation requires deliberate intent when it comes to government interventions. It takes humility, agility, and perseverance to resist complexity amid a myriad of competing interests while pushing ahead and taking on “defense of the status quo.”
Technology, and how it is used, is changing rapidly. Just in the last few years, Facebook and Twitter evolved from novel ways to find an old high school friend or tell your friends what you ate for lunch into tools that connected people in ways that have shifted power and contributed to the overthrow of an oppressive regime. No one wrote the technology roadmap, certified the functions, or standardized the semantics of some of the most transformative tools of our time.
In the push for interoperability, a worthy and important goal, the new ONC leader must continue Blumenthal’s success in avoiding the pitfall of endorsing overly complex technology standards and infrastructures. To encourage a broad array of solutions to improve health and health care, we must ensure market conditions that will allow the kinds of innovations that the broadest array of users will access, value, and demand. To see that technology reaches its transformative potential in health care, we should:
- Make the health improvement goal crystal clear: Improving health and health care is job number one. Metrics must reflect health improvements to drive technical innovation in this direction.
- Place a value on this goal by emphasizing and rewarding improved outcomes rather than relying solely on technology or standardization: Improving the reasons to share data, namely achieving quality and safety goals, creates an incentive to use technology and adopt more standardization—something the mere specification of standards can never achieve on its own.
- Let IT do what it does best by making sure the conditions for innovation are right: keep the barriers to entry low for innovators and provide market certainty with clear rules for privacy and security protections.
Blumenthal’s office put ONC’s Direct Project on the right track with this basic approach. It will be critical for his successor to keep this disciplined approach to technology and certification requirements.
4. Engaging Individuals: A Largely Untapped Resource
Finally, Blumenthal’s successor will succeed by making the untapped army of patients and consumers his key ally in health care transformation.
A critical achievement of Congress’s HITECH Act, and consequently the Stage 1 meaningful use rule, was the inclusion of requirements that participating hospitals and doctors share electronic copies of key information with patients, including medication lists, lab results, and clinical visit summaries.
No one has a more vested interest in coordinated, high-quality care than patients and their families. As we continue to chart the road to interoperable EHRs for doctors to use, we must never forget that the patient goes from provider to provider, even if her medical records do not.
But this too needs the discipline of keeping requirements achievable by a broad array of participants. It may well turn out to be the case that some of the simplest starting points can be the most transformative, even if seemingly unworthy of IT luminaries or complex committee debates. The simple idea to let people download their own key health information is one such construct. Although being able to simply download your own health information can seem routine to some, it’s not routine for most people today. More than 100,000 Veterans did just that within 45 days of being given the chance to use a blue button to download their own health information.
We need ONC to plug into untapped potential of patients, consumers and caregivers so that they can create serious “pull” on the health IT “push.” Information is a foundation for individuals to be active participants in achieving health-improvement and efficiency goals targeted by these health IT investments.
We need to better understand how to further harness the adoption of social media, reliance on mobile platforms, and the use of applications to encourage better health and help individuals manage their health and navigate their health care.
The Big Picture
Perhaps most critically, the new head of ONC will also need to do the hard work of changing a start-up into a sustainable venture. Meaningful use subsidies are authorized only as short-term economic stimulus. But the clear transformation opportunity is the shift in an industry’s focus that “meaningful use” provides toward improving health and the quality, safety, and cost-effectiveness of health care. The next leader will need to maximize every opportunity to use the implementation of other health care reforms, including experiments with “medical homes,” accountable care organizations (ACOs) and even health insurance exchanges to thread this string all the way through the needle.
To add to the challenge, the next coordinator must defend the health IT investments already made in a dynamic political environment with widespread concerns over federal spending.
But the rationale seems clearer every day for sustained leadership to improve health and health care. Our economic future depends on it. So does the future of a nation of people with epidemic rates of chronic disease and a health sector plagued by unsustainable costs and inefficiencies.