Now that the Supreme Court has upheld the substance of the Affordable Care Act (ACA), a collective sigh can be heard, of relief by some and frustration by others, but certainly of avoided tumult.
The focus of ACA attention will turn to results or repeal. And while a different decision could have had ACA become a weight on HITECH and health information technology, the principally bi-partisan nature of the HIT agenda should now refocus attention almost exclusively on results for it.
It is from this latter perspective, though, that there may still be HIT tumult to come. HITECH was constructed from a health IT orthodoxy (set of tightly-held, common beliefs) that has shown a few cracks of late. And some of these cracks have to do directly with the population health IT needs of health reform from a program (HITECH) that is principally built around individual patient transaction technology.
Through the EHR looking glass
Specifically, cracks have developed in the view, which HITECH shares, of EHRs as the center of the HIT universe. EHRs, and not other aspects of HIT, are the overwhelming focus of the incentive funds. The meaningful use criteria, tied to those funds, look at almost everything through an EHR lens. Either as cause or effect, criteria and leverage are pinned to EHR certification.
Taking this EHR focus to an extreme, recent policy discussion has even gone so far as to suggest that almost all health data, including even patient experience data, must be made to flow through EHRs. It is almost as if all the other health IT systems in hospitals, much less other health related organizations, never existed and EHRs need to carry the entire burden of HIT expectations.
Interestingly, a recent commentary by Ken Mandl and Isaac Kohane, in the New England Journal of Medicine, has strongly criticized EHR software for its complexity and lack of flexibility. The authors have been trying to develop app-like health IT capabilities for an ONC grant and no doubt are frustrated by current EHRs as a platform. They put the blame for these issues squarely on EHR software vendors. But while EHR software may be complex right now, even at the "app store" you get what you pay for, and the current orthodoxy has the country paying specifically for EHRs.
It is not clear that EHR vendors should be blamed for creating them or creating them with increasing complexity to meet all of the MU expectations. This is exactly what their clients are asking for because of the incentive structure.
Not about the technology
One way to build more flexible EHRs would be to specify and standardize more detailed EHR transactions. Currently, modular certification exists as an appeasement to existing software rather than to drive the creation of more modular, connectable systems. Here too, though, the current orthodoxy is challenged. It says that we should not pay undue attention to technical architecture that could make EHRs more modular lest we be "led by technology" or "stifle innovation."
Instead, the orthodoxy says we should focus on clinical outcomes and the technology should simply conform. Increased strategic specification of core transactions could be accomplished through the existing certification structure.
Or why not change the orthodoxy that has the country only funding increasingly complex EHRs? Alternatively, we could orient the funding more to the digital data themselves. The latter could establish an ecosystem around high-quality, standardized data in exchangeable summary records, problem lists and care plans, etc. with whatever software was needed to get to them.
Small industries might also develop to record and manage digital data for providers. But, at minimum, there would be comparable, accessible digital data for continuity of care and population needs like comparative effectiveness and accountable care. In some emergency departments, a component of an approach like this exists with scribes who take the electronic data entry chores out of the providers' hands. Not everyone could or should have scribes, but this approach is more fundamentally challenged by the orthodoxy that requires providers to be the ones recording the data so that they can then receive alerts and reminders from clinical decision support.
Now this is an alert!
And this is exactly where the last orthodoxy crack we will mention resides. It seems that clinical decision support is not really changing outcomes right now. A recent article in the Annals of Internal Medicine, by Tiffani Bright, David Lobach and others reviews 148 clinical decision support trials. While it finds that clinical decision support is "effective at improving healthcare process measures across diverse settings," it also finds that "evidence for clinical, economic, workload, and efficiency outcomes remains sparse."
So, unwinding this, if clinical decision support will at least take a while to have productive outcomes, perhaps we can tolerate providers getting help inputting and managing good quality digital data now. And if we can focus on the data more, perhaps we can focus on the EHR software less. And if we focus less on the EHRs perhaps we can focus more on broader health IT systems and population health outcomes that are the more fundamental connection with health reform.
A new orthodoxy
The collective breath holding for the Supreme Court ruling on ACA can now be exhaled. But it is an opportune time to examine the current HIT orthodoxy and see if it needs refinement moving forward. There are lessons from the immediately visible cracks that need to be considered.
First, we need to expect outcomes from health IT to be more long-term than short-term and we should anticipate that we would need to have a robust infrastructure to fully get there. Second, since many of the needs for, and benefits of, health IT seem to relate more to population than to individual patient care outcomes, the orthodoxy should prioritize population health IT to a greater extent than the focus on EHRs alone will allow. And third, the orthodoxy should focus more on good quality data and less on software. This focus may not be comfortable for those who fear talking about data aggregation and trusted data users, but it will be a more resilient direction that is less likely to get hung up in specific software issues.
It looks like the Affordable Care Act may be here to stay for a while - and now we probably need to consider a HIT orthodoxy 2.0 to better support health reform goals.