The following appeared in the New England Journal of Medicine over the holidays.
Launching HITECH
Posted by NEJM • December 30th, 2009 • Printer-friendly
David Blumenthal, M.D., M.P.P.
Information is the lifeblood of modern medicine. Health information technology (HIT) is destined to be its circulatory system. Without that system, neither individual physicians nor health care institutions can perform at their best or deliver the highest-quality care, any more than an Olympian could excel with a failing heart. Yet the proportion of U.S. health care professionals and hospitals that have begun the transition to electronic health information systems is remarkably small.1,2
On December 30, the government took several critical steps toward a nationwide, interoperable, private, and secure electronic health information system. The Department of Health and Human Services (DHHS) released two proposed regulations affecting HIT (www.healthit.hhs.gov and http://www.federalregister.gov/inspection.aspx#special). The first, a notice of proposed rule-making (NPRM), describes how hospitals, physicians, and other health care professionals can qualify for billions of dollars of extra Medicare and Medicaid payments through the meaningful use of electronic health records (EHRs). The second, an interim final regulation, describes the standards and certification criteria that those EHRs must meet for their users to collect the payments. In addition, between August and December 2009, my office — the DHHS Office of the National Coordinator for Health Information Technology (ONC) — announced nearly $2 billion worth of new programs to help providers become meaningful users of EHRs and to lay the groundwork for an advanced electronic health information system. All these actions were authorized by the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the American Recovery and Reinvestment Act of 2009, also known as the stimulus bill (see table).3
The provisions of the HITECH Act are best understood not as investments in technology per se but as efforts to improve the health of Americans and the performance of their health care system. The installation of EHRs is an important first step. But EHRs will accomplish little unless providers use them to their full potential; unless health data can flow freely, privately, and securely to the places where they are needed; and unless HIT becomes increasingly capable and easy to use.
Understanding this, Congress and the Obama administration structured the HITECH Act so as to reward the meaningful use of qualified, certified EHRs — an innovative and powerful concept. By focusing on the effective use of EHRs with certain capabilities, the HITECH Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters.
The effort to achieve meaningful use provides the best lens through which to understand the government’s actions in implementing the HITECH Act. The administration is trying to do four basic things: define meaningful use, encourage and support the attainment of meaningful use through incentives and grant programs, bolster public trust in electronic information systems by ensuring their privacy and security, and foster continued HIT innovation.
The full and detailed article is available (freely) here:
http://healthcarereform.nejm.org/?p=2669&query=TOC
For e-Health in the US, and by some considerable trickle down to us I suspect, this is the biggest and most important policy statement I have seen!
If the turkeys who run Australian e-Health had anything like some brains they would be reading closely and working out how they can use similar Government policy levers to achieve similar results.
It is really pretty much all here in my view. Incentives, incremental improvement, clinician driven and the list goes on.
We have wasted a decade and it has taken the Obama administration a little less than a year to legislate funds and start serious work.
It would be real fun to be in US Health IT right now.
Go read the article closely to see just how much is being done in all the right area (training, standards etc).
This is the biggest thing in e-Health since the UK Government launched Information for Health a decade ago and kicked off the National Program for Health IT. This is genuine e-Health history in the making I believe.
David.
15 comments:
Yes - it is a very important statement.
And, yes - incentives, incremental improvement, clinician driven, are all fundamental to the philosophy of approach to e.health. The Big Bang approach is, as the name implies - big bang then fizzle - nothing.
Unfortunately I think the cost saving measures now being introduced to offset the impact of the GFC will see any incentives already in place being cancelled because it is a quick and simple cost saving measure when chops are being called for.
I agree. I think the most important words are:
- that all efforts should be directed towards achieving “MEANINGFUL USE” as it “PROVIDES THE BEST LENS THROUGH WHICH TO UNDERSTAND” and
- FOUR BASIC THINGS DEFINE MEANINGFUL USE: “encourage and support the attainment of meaningful use through 1. incentives and grant programs, 2. bolster public trust in electronic information systems by ensuring their 3. privacy and security, and 4. foster continued HIT innovation”.
The Government will be looking for savings everywhere in the leadup to the budget and incentives will surely get plenty of attention. But there are different kinds of incentives already in place - some will get hit others will survive. ePIP is a good example in that some aspects of it may survive whilst other parts could easily be cancelled. Which and what is hard to tell. Medicare Easyclaim payments were under threat at the end of 2009. I'm sure there are others.
We can all dream - but hey don't waste your energy trying to get to get bureaucrats and politicians to understand what is meant by meaningful use.
It all sounds pretty sensible but even more important is the question:
How can a culture which is based on that philosophy get traction in Australia?
David,
A set of critical success factors for effective health IT were proposed by the Markle foundation to David Blumenthal recently that seem to be carried forward into the principles of HITECH. Those principles are just as valid here, but unfortunately are not often evident in the current work of NEHTA.
(As a disclaimer, Microsoft is part of the Markle Foundation, along with a variety of industry and healthcare provider organisations)
A couple of points are very directly relevant to the standard setting / conformance / compliance role that NEHTA is seeking to adopt.
"... In setting metrics, HHS should resist the temptation to impose too many prescriptive technology requirements. The most constructive part of the rule will define what needs to be achieved as opposed to precisely how systems must behave to achieve it.
... At minimum, the individual’s ability to request and obtain personal health information
electronically should be supported in the requirements for “qualified or certified EHR technology” under the Recovery Act. The success of these investments will hinge not only on whether consumers have access to their personal health information but also on the extent to which consumers are engaged in meeting the broad health improvement and cost-effectiveness goals.
The requirements should not require a narrow process or deployment of a particular tool. Rather, technology and care redesign innovations should be encouraged to engage consumers more fully in planning and managing their care through a variety of approaches.
"The approach to standards must enable a wide array of providers with varying levels of IT adoption and support, from sophisticated integrated delivery systems to the physician in solo practice, to achieve the goals of Meaningful Use. Technology or standards requirements that are unnecessarily complex, or that fail to take into account the diverse needs of a wide spectrum of health care providers, can have the unintended consequence of narrowing participation. Care must be taken to avoid stifling alternatives or innovations that
would otherwise propel more widespread adoption of health IT to improve health care quality and costeffectiveness."
"The underlying objective is to put useful information into the hands of providers and patients to improve care, and not to create a compliance exercise.
System requirements for “qualified technologies” must give providers the capabilities to calculate how individuals and groups of patients are doing based on actual clinical information at the point of care and longitudinally, so that the information can drive process and care improvements, as well as actively engaging patients as partners in planning and managing their care. Clinicians should be able to visualize the data they report and compare it with benchmarks as well as look at and assess patient-specific information and trends. Electronic systems will also need to support basic registry functions to trend populations of patients, easy-to-use mechanisms providers can use to populate specialty or chronic care registries or share information electronically with consumers or other providers, and tools to support the myriad reporting requirements providers face: including to public health agencies for reportable conditions and to support board certification.
It will be critical to foster innovation for how electronic systems organize, display and share detailed patient information in dashboards, decision alerts, clinical summaries and population health management tools for provider and patient use. But these tools and approaches do not need to be standardized. What does need to become more “conforming” and standardiSed over time are the elements and methods (if not mechanics) for how summary statistics are calculated and reported."
A great commentary from Shahid on the Healthcare IT Guy blog is at:
http://www.healthcareguy.com/2009/12/15/markle-gives-sound-advice-on-meaningful-use-of-health-it-to-policy-makers-again/
A new culture won’t get traction unless there is a change of leadership. It all depends on getting the right leadership. Does anyone disagree?
David, the US has been working on creating a viable HIT strategy and framework for years, it's not something plucked out of the air by the Obama administration. I've seen some earlier recommendations and it reads almost as a blueprint for much of NeHTA's role. All credit to Obama for getting this going and including it in his health reforms.
If one takes effective and relevant leadership as a precursor to success, then I assert that DoHA have filled this role already, by recognising that HIT is just not going to happen without standards that drive interoperability and therefore setting up NeHTA. The cultural change is happening as we speak.
NeHTA has delivered a number of standards already (plus there's the actual implementation of the UHI as an integral component for the use of those standards). You might have problems with those standards, but at least they've got something published and can therefore be worked on and improved. This cannot be said for the US. Far from being behind the US, it looks like we're far ahead. But at least they're taking the right approach. I find it hard to believe that any informatician would look towards the monolithic beast that is the UK program with envy.
James from Microsoft's comment is impenetrable. He appears to be using points (from an unknown, and rather waffly, document) to make implied criticism, which makes it difficult be certain about what he's saying. But his first point seems to be that it is wrong for NeHTA to specify with precision what should be used to get something happening. An interesting comment from an employee of a company that appears to actively undermine standards (just ask any web developer using CSS, or programmer wanting to do something useful with RTF). At some point, a decision needs to be made on what material the road will made of, what size plugs will be used, what colour the traffic lights will be, what audio frequencies will be used, etc. If James' point is to be made, then he will need to define what is meant by "too prescriptive". Is he saying that NeHTA is? If so, why?
I think you are quite wrong about DoHA leadership. In the last 10 years we have had so many people with responsibility for e-Health it makes one's head spin.
NEHTA is not meant to be developing standards - that is the job of IT-14 and it is only in the last year have NEHTA and IT-14 actually done any significant work together!
As far as your assessment of who is ahead of who when I consider where their leaders (e.g. KP, Sutter, Mayo) are and where ours are - we loose badly.
The US approach of 'meaningful use' is incentives done right compared with the joke of ePIP.
David.
I take your point about NeHTA and standards. Though, without NeHTA, national standards wouldn't be feasible.
The ePIP has had an extraordinary effect. Awareness and desire for secure messaging is increasing significantly. And vendors have agreed on the standard for secure message transport (now with IT-14). It's not the whole picture, but it's a significant step. Once again, impossible without NeHTA's leadership.
I don't understand "meaningful use". It sounds weasely. "Semantic interoperability" is a more solid concept. If more than one provider can communicate with another, then they will create their own meaningful use by themselves, based on their own needs. KP, Sutter and Mayo may be HIT leaders, but can they semantically interoperate?
Bren,
'Meaningful Use'is simple - you get paid incentives for actual use of systems productively - not for agreeing to conform to secure messaging that is yet to be sorted out.
It is central to the US strategy and I suggest you learn a bit more about it as soon as you can.
People have been chatting on about 'semantic interoperability' for a decade or two and show me the actual implemented progress - solid concept or not.
BTW I utterly reject your positive view of NEHTA. They are not leading into anything useful I can detect after now 5 years of funding. Hardly enough to inspire confidence!
Lots of documents but hardly anything beyond the pilot stage for the $200M spent so far!
David.
Bren,
I included a reference to the document at:
http://www.healthcareguy.com/2009/12/15/markle-gives-sound-advice-on-meaningful-use-of-health-it-to-policy-makers-again/
Perhaps you missed the link in your rush to retort.
It's disappointing you have such an incorrect view of Microsoft's activity in standards. I participate in many of NEHTA's specification development activities as well as with IT14, including the secure messaging work that you refer to. In fact, I wrote the proposed alternative NEHTA ELS specification that was submitted to IT-14 (one that leverages accepted international standards, rather than inventing a whole new standard for Australia, advocating for standards-based approaches rather than undermining them, as you accuse).
My point is that there is a remarkable difference in how the eHealth policy is defined in the US around achieving measurable outcomes, and how that leads to very different approaches around areas like standards and certification.
The US policy defines specific, measurable goals (for example, the number of patients discharged with electronic care summaries available to their primary carer). Incentives for technology adoption will be tied to achievement of those goals. There will of course be technical standards for certification in the US but there is likely to be significant flexibility and innovation within the health IT market to leverage those standards while delivering on the specific goals.
What are the measurable outcomes for PIP incentive for secure messaging in Australia? In Australia, we have incentives of up to $50,000 available to GP Practices simply for obtaining a HeSA key, making available electronic clinical guidance, and having a clinical system from a vendor that happens to be in conversations with NEHTA on secure messaging (and every one of those GP's already had that system in place?)There are no measurable outcomes!
Without measurable outcomes and policy around achieving them, we instead have NEHTA moving solely towards a technical certification process for software conformance.
And yes, I do believe that the NEHTA specifications are too prescriptive in a number of areas and have provided specific feedback to NEHTA in a range of forums to that effect. I don't believe the NEHTA specifications generally reflect the variety of existing standards and technology platforms that are in place in Australia and internationally, and am not convinced that they provide the framework for market-driven innovation that has been espoused by the government as the way forward.
I don't subscribe to the view that interoperability (and more importantly good outcomes) is achieved by defining a single stack of tightly-coupled immutable standards, backed up by a heavy stick of compliance and certification.
I'm simply expressing my view and belief that the incentives based model built around specific measurable goals is very attractive as a tool to drive adoption and better outcomes, and that this tool leads to specific approaches to standards setting and certification that are not sadly not prevalent in Australia.
That is my point.
Indeed James!
Well put. I have been saying ePIP is a fraud ever since it was announced!
David.
Thanks for the clarification James. I must admit I skipped over the link because it said it was a commentary.
Was your proposed alternative ELS specification based on the UDDI? If so, perhaps it was considered more complex than necessary for the relatively simple objective of the ELS? After all, there is no international standard for a web services directory in the health context...is there?
You've confirmed that you think NeHTA is being too prescriptive at times, but I'm guessing those fora you mention have no publicly available archives, so, of course, I'm still in the dark as to which specifications.
I understand the US is taking a different approach to Australia, and I agree with the strategy to incentivise. The present policy in Australia seems weighted towards developing, and certifying, workable standards for interoperability. It is perhaps now time to consider incentivisation and indeed it *is* one of the eHealth recommendations in the NHHRC report.
I don't quite follow your point about the "significant flexibility and innovation within the health IT market". You say that the market will leverage the standards. Is that not the case in Australia as well? Admittedly our government is not setting specific goals, but perhaps they're relying on our clinicians setting their own?
I think our difference in view centres on the priority of interoperability. Please point me to the US' measurable outcomes that specify *interagency* transmission of mutually understandable data. I've had a look at the link you provided, and it conveys the impression of focussing on data within a provider (and by a single system), rather than data exchanged between providers (I'm happy to be corrected). In other words, I would like to see how the US intends to create an eHealth ecosystem. I believe DoHA and NeHTA have this as their priority and I'm not surprised if the US is slow to pick up on this considering its worship of the market god. (Markets are pretty poor at encouraging standards. E.g. the length of time it's taken to agree that a standard phone charger is necessary). We need to move away from large, sacred IT artefacts to flexible, simple, modular structures that can be altered and replaced easily. (A concept I'm guessing is anathema to Microsoft).
In your final paragraph, you seem to be saying that by working towards specific targets, the standards will emerge. Of course, this is correct. After all, without experience, how can a standard be identified and defined? But for many of our objectives in eHealth, haven't we already got that experience? As can be seen in many an eHealth document, health lags far behind all other sectors in its adoption of IT. We can look at those sectors and pick out the bits needed for health and define them for its needs (considering we're only in the early stages - the really difficult challenges relating to content still lie ahead). I assume this is what NeHTA is doing and why it can afford to be quite specific about them. (Though, I've never heard they're to be immutable!).
Bren,
Go and read all the work from Markle.org on health inter-operation standards and then get back to us. The US has been developing interoperable Health Information Networks for over a decade. Please tell us about the ones that are live at scale based on NEHTA work? There are lots in the US.
The chcf.org site also has heaps that might help.
The US HITECH plan is trying to get doctors communicating and actual use of EHRs and so on is the focus.
Developing all the standards to facilitate Health Information Exchange at local and regional levels is now pretty much done - evolving the ecosystem you talk about.
They have also done lots of work in areas like getting the VA and DOD systems working together so they are more than across the issue (Note Medicare OZ is issuing separate IDs for VA patients and Medicare Patients so they are really not there at all!)
In the US, BTW, markets (i.e. commerce) are inside the tent developing standards. This is needed here but the vendor / NEHTA communication is still embryonic.
I really think you need to know a great deal more about where the US (and the UK) are up to before being too assertive about what is going on. If you are a deep expert I apologise in advance!
You may disagree but reading what you write does not give me the sense you have a good grasp of their strategies and their importance.
David.
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