Six years ago, President Obama signed into law the HITECH Act, which spelled out a path to a nationwide health information technology infrastructure. The goal was simple: every doctor, nurse, and hospital in America should use electronic health records — and do it in a way that leads to better care delivered more efficiently. The Act provided $30 billion in incentives for providers and hospitals who met the criteria for “Meaningful Use”, which the Obama administration was given the authority to define. The rules were set up to be rolled out in three stages, and while the first two stages have been out for a while, the criteria for the third and final stage of Meaningful Use (MU) were finally released on March 20.
David Blumenthal, the first national coordinator under HITECH, used the analogy of the Meaningful Use program as an escalator — with the first stage focused on just getting people on board and each stage requiring a higher level of use — which would focus on demonstrating better care through advanced EHR use. Put more simply, the goal of the three stages was to first get providers to just start using EHRs, and then over time to get them to use the systems more frequently, more robustly, and ultimately, in ways that lead to better, more efficient care.
The new stage 3 rule reflects both the successes and the failures of the first two stages. It moves toward making the EHR market more open and competitive, and providing more choices, in ways that I think are helpful — but possibly not helpful enough.
Where We’ve Been
To understand where the Obama administration is going with stage 3 Meaningful Use, it’s important to reflect on where we’ve been and how far we have come. In 2008, the year before HITECH was passed, just 17 percent of U.S. doctors – and only 9 percent of U.S. hospitals – were using an EHR. That degree of computerization was abysmal, especially for an industry as information intensive as healthcare. None of us doubted the potential of EHRs, because the evidence was overwhelming: when done right, EHRs improved the safety, effectiveness, and efficiency of healthcare delivery. This was the motivation for launching HITECH.
The focus of the first two stages was to get doctors to purchase, adopt, and start using the systems. By those metrics, the program has been a smashing success. As of 2013, more than 50 percent of physicians and more than 60 percent of hospitals were using EHRs. That is an astounding increase in the rate of adoption – no other country in the world has wired up this many doctors and hospitals this fast. Although the 2014 data are not out yet, the rate of adoption has likely continued to tick upwards, and that’s a good thing.
But if the goal is better, more efficient care, simple EHR adoption is not enough. There is plenty of evidence that EHRs don’t, unto themselves, make care better. As I described above, the evidence suggests that when done right, EHRs could transform health care. “EHRs done right” probably means something a little different for each provider, but here’s a simple notion: EHRs should be intuitive and easy to use; they should align well with the way doctors and nurses work, fitting and augmenting work flow, providing needed information and avoiding unwanted clutter. And, it should be easy to share that data with other providers and patients.
That would be a good start – and by that definition, the EHRs out there, financed in part by your tax dollars and mine, have been a disappointment. Not awful, but a disappointment. Until we fix that, it is unlikely that EHRs will pay off as an investment for the American people.
Where The Stage 3 Rules Aim To Take Us
So how do the stage 3 rules help? In some important ways, I think. But before we get there, let’s talk about what stage 3 tries to do more broadly. If you skim through the 301 page proposed rule, you’ll find two words throughout: simplicity and flexibility. By the standards of complex federal rules, I think these terms are appropriate. There’s a real effort to both simplify the complex meaningful use process and to offer some flexibility to providers in how they meet the criteria.
There are three stages of meaningful use, each with different criteria, with different providers at different stages. The proposed rule moves everyone into a single set of meaningful use criteria by 2018, which is both long enough to let providers get on board, and short enough that the simplification is valuable. Beyond this, the proposed rule streamlines the requirements and objectives of meaningful use: The program now lays out 8 objectives and gives providers flexibility in how they meet many of the objectives. The objectives fall into four buckets: assure security, prescribe electronically, use clinical decision support, and share data with other providers and patients. Combined with the requirement to submit clinical quality measures electronically, it’s not a bad list – and consistent with what Congress wanted out of HITECH.
Opening up closed EHR systems …
The big deal in the stage 3 meaningful use rules is data flow. Here, I think federal policymakers are helping to fix the big problems with EHRs, though they could go further. The current EHR vendors have prioritized integration with legacy systems and complex, secure systems over ease of use and support for better care. That’s a problem. Most of these systems are closed, making it difficult to use 3rd party vendors to improve provider experience or share data with others. If you don’t like the Apple Maps App provided on your iPhone, you can use Google Maps. If you hate the electronic prescribing system in your EHR – good luck being able to use a third party system that plugs into it. By creating closed systems, EHR vendors hamper innovation and made EHRs unnecessarily difficult and painful to use.
However, by forcing EHRs to allow for sharing of data with patients, and by pushing EHRs to incorporate patient-generated data, the new proposed rule will begin to create leaks in these closed systems. And that’s a helpful start. As the data in the EHR begins to be able to break free, third party vendors will build better tools that engage patients in their care. Requiring EHRs to incorporate data generated by patients will push the industry towards greater standardization.
…. but not quickly enough.
While these are helpful steps, they may not be enough. If we are serious about addressing EHR’s poor usability and inability to support the kind of care we are increasingly demanding, then we need to open up the EHR systems in a more robust way. As part of certification, the Office of the National Coordinator could require that all EHRs publish their full application-program interfaces (APIs). The proposed rule begins to do that, but only as it relates to sharing information with patients. This is not enough. ONC should require that any vendor that enjoys federal subsidies for its products make its full suite of APIs widely available for third party products.
This may sound like a technical issue, but it’s a critically important one. If these APIs become widely available, third party vendors will build the tools that currently limit EHR utility and value. Hate the way your EHR does clinical documentation? Use the one just developed by a new vendor down the street. That kind of competition will make everyone better.
If you were locked into using the Apple map forever, they would have little incentive to improve it. That’s how the world works – and to improve EHRs, we need the kind of competitive pressure created by open ecosystems. Stage 3 meaningful use rules move us one step towards that goal, and that’s a good thing. But given how long the journey is between EHR adoption and better care, we could surely move faster.
Our nation has made a major investment in EHRs and the signs suggest that we have made good progress. As the government finalizes the stage 3 proposed rules, it should focus on fostering systems that are open, flexible, and usable. That’s the only way we will let doctors, nurses, and others provide the kind of care that Americans need and deserve.