WASHINGTON – Electronic health records are only a beginning of sorts. Although a top priority for providers, the meaningful use of EHRs is not the end goal – rather, the health data that EHRs make more accessible stands to unleash a wave of applications, products and services that ultimately catalyze improvements in health care, delivery and outcomes for both individual and population health.
That is ONC’s ambitious vision, which means that National Coordinator Farzad Mostashari, MD, is essentially responsible for leading the charge. He spoke with Government Health IT Senior Editor Mary Mosquera and Editor Tom Sullivan on June 15 at the Government Health IT Conference here about the areas in which he sees innovation blossoming, the contentious nature of EHR usability, how overwhelmed providers should plan for all the incentives and unfunded mandates and why the healthcare industry will keep moving forward even if the White House administration should change next year.
Q: ONC is credited with unfreezing the market for EHRs. What other areas or tools besides EHRs do you expect to see markets grow around to support meaningful use and other healthcare efforts?
A: An innovator said that data is oxygen for us, and there is a lot more oxygen in the environment now. Electronic health records are creating more and more electronic information and we’re creating more and more liquidity with that information, and the innovation potential is even greater in all of the different applications that can come around those EHR transactional systems than even in the EHR space itself.
So what I expect to see innovation in are things that help organizations, accountable care organizations or practices for the first time the healthcare providers to purchase services that can help them do population health management, help them identify patients at high risk, predictive analytics, reaching out to a patient and effectively communicating with the patient and helping bringing those lost to follow-up back into care, helping induce and support behavior change, those are where I see tools to help monitor and enforce medication adherence, those are the things that I see the most potential for innovation. Not the clinical system per se, in terms of transactional clinical system, but all the things you can do once the information is in electronic format and once you have the motivation to do population health management.
Q: Are you seeing anything from the Health Data Initiative Forum, and all the applications they presented, that can be connected with meaningful use?
A: I think a lot of those will ride on top of the capabilities that are enabled through meaningful use. If you want to have an application that will help people to stop smoking, to have the systematic collection of smoking status in the EHR feeds that. If you have quality measurement for blood pressure control, and you want to improve blood pressure control, then you’re going to have applications that build on top of the EHR, whether it’s medication adherence or dietary counseling or weight loss control.
Q: Some vendors promise an EHR that meets all the criteria of Stage 1 but is still not really usable. What is ONC doing to foster some sort of usability?
A: We hear this all the time and we’ve had a couple of public hearings on usability by the Health IT Policy Committee. It was fantastic getting all the perspectives. For providers, this is a top priority for them, not just that you have a system, but systems that make it pleasurable, make it efficient and make it safe to take care of patients. My predecessor Dr. David Blumenthal used to say that his dream was for providers to be excited to boot up their EHR when they come to work the way that you enjoy, say, lighting up your iPad. It’s not true that doctors are late adopters of technology. I saw some incredible statistics around iPad and smartphone adoption by physicians. It’s clear that the provider community and from the research that improving the usability of systems is an important goal. The question is how do we do it?
But you can’t fix something that you can’t see. So we have to have some common sense measures and metrics for how we’re going to agree what are the most important dimensions of usability that can be reliably measured. I think that’s the first step, to get together folks in an open process that includes providers, academics, vendors, and [determine] what makes sense in terms of usability. Two, bring transparency to the decision making process. There are lots of ways once you have the measures that that can be implemented, anything from voluntary testing to challenges. If you have a usability framework, maybe you can have a challenge that will highlight the award winners for usability. That will drive the market to value and compete on the measures of usability. The option for regulatory action is, I suppose, there. But it’s premature to talk about. First, we have to make sure that we have measures, and second bring transparency, and then we’ll go from there.
Q: ONC’s Doug Fridsma said in a session at the conference that the main way of exchanging health records, even electronic ones, is still print-fax-scan. So how can ONC lead the industry over that hump to electronic exchange?
A: I think what we want to do in the first place is to improve over print-fax-scan. The ability of EHRs to be able to export summaries of care records in structured format, the ability to send that securely over the Internet using Direct protocols and the ability to incorporate that, either as human readable or in the future computer readable, those are going to be key building blocks that we’re going to make measurable progress toward this year.
Q: Many providers feel overwhelmed by having to meet requirements in so many programs at the same time, including meaningful use, accountable care organizations and ICD-10. How do providers prioritize what they need to do to meet so many mandates at the same time, and where do they start?
A: I think it is incumbent upon us to align our programs so that we minimize the burden, but also maximize the signal to providers. What we are asking them to do is nothing less than put in place structures that provide higher quality, more efficiency for care at higher value. Everything we do has to be aligned with that goal. I think we certainly have the fire in the belly to do that at HHS, where we really want meaningful use to be aligned with and supportive of, if you want to deliver higher quality care, if you want to reduce heart attacks and strokes, if you want to deliver safer, more patient-centered care, more coordinated care.
Meaningful use, literally, I believe, is the roadmap for what they have to do to succeed with health reform and the delivery of more-coordinated higher-quality care no matter what the prescription for health reform is, whether it is health savings accounts, accountable care organizations, or bundled payments or capitation or shared savings, whatever your model is for doing that, it’s going to need some basic information supports. My hope for health IT is that we are absolutely the answer for the provider who says, 'what should I do to get ready for delivering accountable seamless care?' The answer should be meaningful use.
Our hope is that if we have done our job right that meaningful use will be the roadmap for succeeding in 2016 and 2017 and 2018 with what hospitals and doctors have to do to be able to thrive.
Q: NCVHS suggested in an open letter to HHS Secretary Kathleen Sebelius that ICD-10 be pulled into meaningful use. What does ONC think about pulling it into stage 2?
A: As CMS’ Tony Trenkle has made the point in policy committee meetings, we shouldn’t think of meaningful use as the be-all, end-all, that we have to hammer every nail with it, that there are other perfectly good levers out there. ICD-10 hardly needs more levers. If people don’t adopt ICD-10, they don’t get paid. It remains to be seen what the added value is for incorporating ICD-10 into meaningful use. If there is added value to that, then we’re certainly open to doing it because ICD-10 is on the critical path to a lot of the risk adjustment, payment reform, all the other things we need to do. There is no greater incentive than being able to get paid, starting Oct. 1, 2013. It’s tough to think of an incentive better than that.
Q: How does ONC plan, and how do you advise providers to plan for 10 years out when in 2012 there could be a new administration – and even if changes aren’t cataclysmic, surely there would be some?
A: I think we have to move ahead. I don’t think that we can sit on the sidelines [because] it’s possible that there might be a dramatic shift in administration policy in 2012. We have a law, incentive payments in place, and we have a structure in place. And most importantly, we have broad bipartisan support that health IT, there is one thing that I see agreement on, it’s that health IT makes sense no matter what your prescription is for getting more value out of healthcare dollars across the board.
I was at the Bipartisan Policy Center with former Sen. Robert Bennett (R-Utah), and the message came across loud and clear. I testified before the House Small Business Committee, the committee members on both sides could not have been more urgent, more supportive in their message to us that we get this right, that we move forward on effective implementation of health IT across all settings small and large.
Another interesting example was what happened in Montana. When the Medicaid EHR incentive program funding was held up, the funding for the administration of the incentive program was not appropriated initially, the governor went to the senate to make a strong case why health IT is going to be the foundation for how they to get more value out of Medicaid. And in Montana, the senate voted, I think, 45-5 in favor. I think we have broad support so that no matter what your prescriptions for getting more value out of our healthcare dollars are that we need better information and better information systems. This is a bipartisan issue.
Q: A lot of providers still don’t know a lot about meaningful use. How are you going to market meaningful use to providers, who are just too busy to even think about it?
A: I’m pretty pleased with the level of awareness and interest so far in the concept of meaningful use. If we look at hospital CIOs, for example, and even large practices, in many cases it is their number one strategic priority. And again, it’s not because it’s so much money for a hospital. It’s because it’s strategic. It’s all the right things that they know they need to do to succeed in the future. I think the framework I’m talking about has been very effective. It’s not, 'You jump through these hoops and you get money.' It’s about achieving higher quality, safer, more efficient, more coordinated care.
To get the message out even further, I think we need to call upon all of our partners. We need the medical societies, the professional societies, the state associations, the plans, the purchasers, obviously CMS, which has been hugely effective in their campaign working with their regional directors. We need to get the word out more. We’re going to look at earned media, but we’re also going to look at some paid media, highlighting some of these success stories and helping providers and patients see themselves in health IT.
