RWJF Report: Time to adjust expectations and settle in for the long term?

What started out as a sprint to better healthcare enabled by IT now looks more like a marathon
By Irv Lichtenwald
10:46 AM
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Context and perspective matter.

And it's often both context and perspective that are lacking from the daily snapshots we get of health information technology, meaningful use, interoperability and the progress we are either making or not making, depending on your perspective.

So I welcome a report like the one the Robert Wood Johnson Foundation (RWJF) released last month on the state of health information technology circa 2015 in these United States. Subtitled "Transition to a Post-HITECH World," the detailed report, created in collaboration with the University of Michigan School of Communication, the Harvard School of Public Health and Mathematica Policy Research, takes a 10,000-feet view of the ongoing digitalization of healthcare and what the priorities are as we approach the terminus of HITECH.

But before I delve into what I believe are the more interesting aspects of the RWJF report, I think it necessary to mention some other bits of information that filtered my way this past week.

It's necessary to mention these health IT-related events and reports because I think they support what I most strongly infer from the RWJF report--namely, that we can't see the finish line from where we stand. In other words, HITECH and similar legislation created an idea of a finish line that is now clearly false.

As RWJF reports, there is reason for optimism. In 2014, 76 percent of hospitals "reported exchanging data with outside health professionals … up from 62 percent in 2013 and 41 percent in 2008." Most hospitals have at least a basic EHR now, which means much of the track has been laid for a full-fledge health IT train system.

But enthusiasm is waning. Fatigue is setting in.

"In 2014, 1,826 hospitals successfully attested to meeting Stage 2 criteria (approximately 38% of all hospitals registered for the meaningful use incentive program)--far fewer than the 4,379 ever attesting to Stage 1," RWJF reports. "Moreover, overall participation in the program declined between 2013 and 2014 for eligible health professionals in both the Medicare and Medicaid EHR Incentive Programs."

As the authors of the RWJF report clearly understand, for reasons that have much to do with American society, what started out as a sprint to better healthcare enabled by IT now looks more like a marathon of gradual improvements enabled by IT as one component among several.

"Other nations--many with a long-standing history of supporting HIT adoption--are still aspiring to realize the goals which HITECH anticipated could be accomplished in three years. To compound these challenges, America faces tremendous impediments which many other countries do not have to overcome, such as competing, proprietary health care systems, the lack of a universal patient identifier, and tremendous regional variation in terms of policies, infrastructure, and culture."

While there is much to be gleaned from the RWJF report, I find chapter 5 to be the most compelling section. Here, the authors make a case for payment reform as the primary driver of health system change. With fee-for-service (FFS) and total-cost-of-care (TCOC) models, there is little incentive for separate health systems (an "archipelago" of healthcare, the report calls them) to liberally and willingly share patient data. 

"The larger vertically 'integrated' health systems are rushing to warehouse clinical and financial data, but ultimately for the wrong reason. They simply want to enhance their private holdings. Very little information emanates from these private islands unless there is a mandate compelling it … in the total wallet share game, controlling information matters, which is why the mode of payment matters."

Instead of a fee for services rendered, or reimbursement of total costs plus a profit margin (virtually impossible when most hospitals don't know enough about actual costs), RWJF re-asserts what many have already said--that we should be paying for distributed episodes of care, including outpatient visits and in-home care. Cost effective at-risk care drives coordination among nimble providers--a group that will not include most large hospitals and health systems.

"This will significantly increase the likelihood of data sharing if the health professionals co-managing the patient come from different health professional organizations … while total cost of care payments (and variations thereof) almost always call for vertical integration of health professionals; payments centered on episodes don't."

If payment is restructured, there will be an incentive to exchange data, which is the second half of RWJF's proposed solution for making HITECH work. What we must achieve is semantic, not syntactic, interoperability. In other words, the data exchanged must have unambiguous shared meaning across the spectrum of providers and facilities.

"Syntactic interoperability enables a base level of communications and information exchange … Syntactic interoperability (or information exchange) is the necessary but not sufficient condition for semantic interoperability."

While versions of HL7 have been the standard for data exchange thus far, these are largely syntactic and insufficient moving forward. Fortunately, the RWJF authors believe alternative technologies in development will enable us to achieve, technologically at least, true data interoperability BETWEEN health systems.

The report highlights these three solutions:

  • Resource Description Framework: "RDF makes it possible to build models called 'ontologies' that are more rigorous because they support automated reasoning … Ontologies are better at dealing with changing and ambiguous medical knowledge."
  • Fast Health Interoperability Resources: "The new HL7 FHIR … initiative explicitly recognizes … difficulties for developers by creating very simple and readable information structures that are not derived from an abstract information model."
  • SMART: "FHIR and SMART adopt the 'RESTful' architecture of the Web. REST stands for representational state transfer and 'is a software architecture style consisting of guidelines and best practices for creating scalable Web services.'"

Lengthy at more than 100 pages and rather technical in sections, the RWJF report is still worth a read for both the reality and the reward. No, we cannot see the health IT finish line from where we stand. Yes, HITECH and perhaps the whole reform program are in a precarious place where failure might be as likely as success. Yes, initial estimates and expectations were wildly off the mark. No, it is not true that little has been accomplished.

As former National Coordinator Farzad Mostashari said:

"'Oh, the marvels of technology that would have emerged had the government not stepped in. Oh, you should have just waited.' So, first of all, waited until when? We waited 20 years, right? Waited for what? Second of all, where's the counterfactual? You know what the counterfactual is? Behavioral health. You know what the counterfactual is? Long-term care. Show me the beautifully innovative technology that's now easily adopted by long-term care health professionals. It doesn't exist."

(If you read the RWJF report, by all means include the quotes near the end from interviews with all the national coordinators from Brailer through to De Salvo. Well worth the time.)

I get that EHRs have made life harder for physicians, and I can understand why many are displeased with the HITECH program. But we are moving away from a scenario that almost all agree was not working in terms of both cost and correct focus on the patient. Collectively, why would we go back there?

Click on RWJF report to access the report in it's entirety.