Time for hard HITECH reboot

10-point plan from former ONC official may surprise you
By John W. Loonsk, MD
08:03 AM
Reboot button

So, you dropped a huge chunk of change on a new IT system. Now you are frustrated and have buyer’s regret. The “installation requirements” are very complex. And although you just bought it, the system already needs to be updated. It only seems to run one application – “EHR version 1.0,” but you want to do many other things too. EHR v1 is not very user friendly and sure makes you do your work differently. And there is more. This expensive new system doesn’t seem to connect to anything. Sure, there is a basic email application available, but you also want to look for information and get what you need when and where you need it. Isn’t that what the Internet enabled years ago?

[See also: Thrill is gone as meaningful use strains.]

If this is the metaphorical world of HITECH, here’s to giving Karen DeSalvo, the new national coordinator for Health IT, all the support she needs to do a full and hard HITECH reboot. More than 30 billion dollars have been spent. And while it is reasonable that many HIT outcomes are still unfulfilled, the path forward seems murky. EHR adoption has surged, but much of what has been broken about health IT in the United States still remains. And the leverage of the HITECH funds is dwindling fast.

Now there is yet another independent report, this time from the JASON group which, like the report from the President’s Council of Advisors on Science and Technology before it, suggests the need for a major architecting effort for health IT nationally. The Government Accountability Office reports that there is a lack of strategy, prioritized actions, and milestones in HITECH. HIT interoperability is recognized as being limited at multiple levels. And resultantly, the benefits of HIT that depend on a combination of adoption, interoperability, and health information exchange as table stakes are elusive.

[See also: Commentary: What about interoperability?]

Meanwhile political resistance has reached a frenzied pitch. Entrenched interests are back on top and aggressively lobbying to advance their respective positions. Very few hospitals and providers have achieved Stage 2 of meaningful use, Stage 3 concepts have received substantial push-back, EHR certification is under fire, and ICD-10 has been pushed back yet another time.  Dr. DeSalvo has initiated a reorganization of the HIT Policy and the HIT Standards Committees, but has much more work cut out for her. So, here we offer our unsolicited top 10 list of HITECH reboot priorities:

10) Divide and conquer - Separate healthcare provider adoption angst and frustration from EHR vendor complaints about standards implementation and certification. Although these two things are frequently conflated during political push-back, they should be addressed very differently…

9) Meaningful relief - Providers need to be left alone for a while. They were already under incredible strain from many non-HIT related pressures. HITECH added to these pressures (necessarily) by fostering EHR adoption. But meaningful use added much more strain through sometimes aspirational criteria that demand workflow and process changes well beyond simply adopting an EHR. Give providers meaningful relief from many of these new business requirements. It is not clear that there are incentives to sustain them after HITECH and the infrastructure needs attention before many are viable.

8) Double down on interoperability - Don’t give in, on the other hand, to push back against standards and certification. In fact, the entire standards, implementation guidance, and certification process needs a boost to achieve just a strategic sample of the transactions needed in health. There needs to be a broader, more inclusive, standards process. The ONC Standards & Interoperability Framework has good ideas, but there are many more needs than ONC alone can promote. There are also needs for broader standardization and specification of technologies beyond just data and messages. Constructively re-engage the industry to help make this happen.

7) Certify more, not less – Certify more systems not less. Hang more government incentives on certified HIT. Use CLIA, the DoD EHR investment, TRICARE, all federal contracts and grants – whatever it takes.  Standards, interoperability specifications, and certification that includes conformance testing is the recognized path to interoperability. Certification needs to be specific enough for robust conformance testing and interoperability certification needs to be applied to all HIT participants not just EHRs. Identifying business outcomes, even when incentives are aligned, will not suffice for interoperability. But by all means make certification as minimally burdensome as possible by focusing only on interoperability and security.

6) Maximize network effects - Does anyone remember how important the network was to making PCs useful? No one may want to fund separate Health Information Exchange organizations, but there is much that can be done to advance networking anyway. There must be interoperable directories, functional indexing, security infrastructure and application programming interfaces / standardized transactions beyond “push” email to support HIT nationwide. Build a named network that providers want to join because it provides tangible value for them to do so. If we are to get past data hoarding and business proprietary interests, we need to enable, not frustrate, network effects. Providers will want to join a network, or a network of networks, if they can go to it to pull down the information they really need.

5) Build up infrastructure - We need to build some of this HIT infrastructure “up,” architect it, instead of expecting that somehow business requirements will suddenly align to make a coherent architecture appear below them. If one only follows outcomes or business requirements “down” to technology implementation, inefficient silos of activities are developed instead of shared infrastructure. Are the technical needs of population health management really that different from registries, public surveillance systems, and quality reporting systems? By “architecting up” we can more readily build components to serve multiple functions.

4) Organize for technology leadership too - Rearranging the HIT Policy and HIT Standards committees was overdue. But it is also critical to address the relationship between them. As was stated at the last HIT Standards Committee meeting, the perception is that “the Policy Committee has high-level policy thinkers and the Standard Committee has implementers.” As per the JASON and PCAST reports, we need high-level architecture thinkers who can help design “up” the strategic interfaces and components to meet multiple business needs and make for a coherent complex system. Where is the strategic technology discussion?

3) Emphasize managed data - Providers want value in the information that they get. The paper-based medical record has frequently been a detailed recording of care. EHRs can compound this sometimes overwhelming information accumulation or they can help provide up-to-date, managed information like current and well-maintained problem, medication, care plan, allergy, and immunization lists. Current, succinct information needed for care is valuable to providers.  A record of care is also important, which is why providers will always “own” certain aspects of the record need, but it is not the only one.

2) Make quality reporting help HIT - HIT has been pitched as critical for quality reporting, but why has quality reporting taken such a heavy portion of the limited HTECH leverage? Quality reporting can always be incented through differential reimbursement. With the HITECH leverage evaporating, let’s think about how quality reporting can help the more general HIT agenda.  Instead of having a quality reporting “silo,” have quality reporting standards serve multiple purposes including supporting health information exchange, continuity of care and population health needs.

And the number one recommendation for rebooting HITECH and advancing health IT nationally is…..

1) Stop talking only about EHRs! - EHRs are part of a much bigger HIT ecosystem. They are like the leaves on a tree. There must also be branches, a trunk and roots. There are networks and hundreds of other HIT systems that support ancillary organizations and activities, population health and healthcare.
Progress has been made. We may be now entering the post-HITECH period, but it is not the time to regress. Clear leadership and resolve can build on the HITECH investment and put broader HIT outcomes into reach.

John Loonsk, MD, served as director of interoperability and standards in the Office of the National Coordinator for Health Information Technology from January 2006 to December 2009.