As a special from the New England Journal of Medicine, which is celebrating its 200th year this year we have a 2 parter from the just departed head of the Office of the National Co-ordinator for Health IT in the US.
Given Dr Blumenthal is from the Boston / Harvard Medical School axis where better than the NEJM for this to appear?
Wiring the Health System — Origins and Provisions of a New Federal Program
N Engl J Med 2011; 365:2323-2329 December 15, 2011
PART ONE OF TWO
Presented as the 36th annual Joseph Garland Lecture of the Boston Medical Library on October 25, 2011. Dr. Garland was editor-in-chief of the Journal from 1947 through 1967.
In February 2009, the U.S. government launched an unprecedented effort to reengineer the way the country collects, stores, and uses health information. This effort was embodied in the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of a much larger piece of legislation, the so-called stimulus bill. The purpose of the stimulus bill, also known as the American Recovery and Reinvestment Act of 2009 (ARRA), was to stimulate the economy and prevent one of the worst economic recessions in modern history from becoming a full-fledged depression. Congress and the Obama administration took advantage of the crisis to enact programs that might spur short-term economic growth as well as promote scientific and technical advances with potential long-term benefits for the American people. In the health field, one such program involved a commitment to digitizing the U.S. health information system. The HITECH Act set aside up to $29 billion over 10 years to support the adoption and “meaningful use” of electronic health records (EHRs) (i.e., use intended to improve health and health care) and other types of health information technology.
Such large, targeted public investments in any particular type of health technology are rare in U.S. history. Indeed, it is difficult to think of a precedent for the HITECH Act, which encourages millions of health professionals and thousands of health care institutions to adopt and use health information technology. Now that more than 2 years have passed since this historic program began, a review of its original rationale, its accomplishments, and its considerable challenges seems timely. This report discusses the original justification for the HITECH Act, its major provisions, and some of the early challenges associated with its implementation. In interpreting this report, readers should be aware that I served as national coordinator for health information technology in the Obama administration from April 2009 until April 2011.
Arguments for HITECH
Two basic arguments justified intervention by the federal government in 2009 to promote the adoption and meaningful use of health information technology. The first was a conviction that information technology could improve health and health care for the American people. The second was that major problems inhibit the spread of health information technology in ways that create the need for government remedies.
Value of Health Information Technology
As the first decade of the 21st century came to a close, a variety of considerations appeared to support the expanded use of new forms of information technology in health care. One rationale was intuitive. Information technology was revolutionizing every aspect of human affairs, but U.S. health care seemed peculiarly immune. As of 2008, only 17% of physicians and 12% of hospitals had basic or fully functional electronic health records.1,2 This level of use contrasted with widespread adoption of EHRs in many other industrialized nations, including the United Kingdom, the Netherlands, Scandinavia, Australia, and New Zealand.3 Surely, the U.S. health care system — by far the most expensive in the world — should be capitalizing on one of the most fundamental technological breakthroughs in human history.
Theoretical arguments offered a further rationale for the use of health information technology. Experts agreed that the U.S. health care system was not realizing value for the money invested.4-6 The health system's waste and inefficiency weighed particularly heavily on policymakers, who contemplated the effects of relentlessly increasing health care costs on the U.S. economy and federal deficits.6 But eliminating waste and improving quality are difficult if health professionals are uninformed about the care their patients are receiving elsewhere in the health care system. Better coordination of care lies at the heart of improved performance of the health system, but coordination implies sharing information, and information sharing is difficult in a paper-based world. Electronic health information systems thus seemed a necessary foundation for realizing many other short-term and long-term health policy goals.7
Still another rationale was empirical. Experience was demonstrating the ability of health information technology to improve the quality and efficiency of care, especially in the large health systems that were early adopters of this technology. Relying heavily on health information technology, the Veterans Health Administration transformed itself in the 1990s from a much-disparaged health care organization to one of the best in the United States.8 The Kaiser Permanente Health Plan was making major strides in improving the care of patients with chronic illness using its systemwide electronic health records.9,10 Ninety percent of physicians using EHRs in 2008 reported that they were satisfied or very satisfied with them, and large majorities could point to specific quality benefits.1 After a review of the existing evidence, the Institute of Medicine called repeatedly for increased use of health information technology in health care.11,12 Studies were not uniformly positive. Some showed possible safety problems associated with health information technology.13-17 Others raised questions in particular about whether the benefits realized by early adopters and large institutions with self-developed EHRs were generalizable to commercially developed products and later adopters and smaller institutions.18 But, on balance, studies provided support for the wider adoption and use of health information technology.19
Barriers to Adoption and Use of Health Information Technology
Despite the attractions of health information technology, at least four barriers have slowed the dissemination of EHRs and other electronic information systems. The first barrier is economic.1,2,20,21 The fee-for-service payment system in the United States does not financially reward the improved quality and efficiency that health information technology makes possible. When such benefits occur, they accrue to patients and payers as much as or more than to the health professionals and institutions that bear the often considerable costs of installing EHRs and other forms of information technology. Thus, left to their own devices, private U.S. health markets are unlikely to take full advantage of health information technology. Economists generally agree that when markets fail in this way, government has a legitimate role in helping to correct those market failures.22
A second barrier to the adoption and use of health information technology is logistical and technical. EHRs in particular are complex products that are difficult to evaluate and understand. The market's diverse offerings vary enormously in capability and usability, and new products are burgeoning. Lacking resources and expertise, providers are legitimately concerned about making big investments in systems that may not meet their needs.1 They also face technical hurdles in installing, maintaining, and upgrading EHRs over time. These concerns can reinforce the natural reluctance of health professionals to make the major changes in their daily work that new health information systems often require. Such logistical and technical barriers suggest that many providers may need assistance in adopting and using health information technology, and a successful effort to propagate EHRs in New York City indicated that government can facilitate such assistance.23
Problems with the exchange of health information create a third obstacle to the dissemination and use of health information technology. The ability to effectively transfer electronic health information between different information systems in various institutions and practices is underdeveloped in the United States at this time.24,25 Thus, providers are appropriately concerned that their electronic health information systems may not be able to exchange health information about their patients with other caretakers. This concern creates a rationale to wait until some uncertain future time when systems for exchange are working well. However, with thousands of health information technology products and hundreds of thousands of users of health information technology, developing such exchange solutions and getting them to work seamlessly are huge challenges. Overcoming these challenges requires collaboration among vendors and users of health information technology, but these organizations are often fierce competitors in local and national markets; so collaboration is unlikely to occur naturally. This lack of collaboration creates a rationale for government to be an honest broker in facilitating technical and policy approaches to the exchange of health information.
Still a fourth problem inhibiting the adoption and use of health information technology is concern about the privacy and security of digital health information. Paper-based systems are not completely private or secure,26 but digital systems create new challenges. The media report almost daily breaches in public and private electronic information systems, both health- and non–health-related.27 Entire new industries have arisen using personal health information for purposes that were never anticipated by existing privacy statutes, and these uses are not currently regulated. An example is the growing personal health record industry, which is not currently regulated under the Health Insurance Portability and Accountability Act (HIPAA). Public fears about the loss or misuse of personal health information could undermine efforts to disseminate health information technology.
Taken together, the case for more rapid adoption and use of health information technology, the considerable barriers to its spread, and the rationale for government intervention to overcome those barriers created the justification for federal legislation to promote electronic health information systems. Congress had made several bipartisan attempts to pass such legislation during the administration of President George W. Bush, but the political will for a major federal investment in health information technology did not exist at that time. The economic crisis of 2008 broke the logjam, and the HITECH Act emerged.
The much longer full free article is here:
Here is the beginning of Part 2
Special Report
Implementation of the Federal Health Information Technology Initiative
N Engl J Med 2011; 365:2426-2431 December 22, 2011
PART TWO OF TWO
Presented as the 36th annual Joseph Garland Lecture of the Boston Medical Library on October 25, 2011. Dr. Garland was editor-in-chief of the Journal from 1947 through 1967.
In the spring of 2009, the Department of Health and Human Services (DHHS) faced a daunting project: to lead the creation of a nationwide, interoperable, private, and secure electronic health information system. The DHHS and its two key agencies that were responsible for this task — the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) — were in many ways unprepared to undertake it.1 But, as national coordinator for health information technology at the time, neither I nor my CMS colleagues had any choice. The Health Information Technology for Economic and Clinical Health (HITECH) Act was the law of the land. This report reviews how the DHHS responded to the challenges it faced in implementing the HITECH Act, what has been accomplished to date, and some of the major issues that remain to be addressed.
Responding to the Challenges of the Hitech Act
The very size and scope of the HITECH Act mandate could have proved paralyzing if the DHHS had tried to address all its goals and requirements at the outset. However, the legislation itself helped to avoid this outcome. Its ambitious, congressionally determined deadlines made clear that the CMS and ONC had to act quickly. They should start by defining the “meaningful use” of electronic health records (EHRs) (the level of use that providers would have to attain to qualify for incentive payments under the HITECH Act). They should also set standards, define implementation specifications and certification criteria for EHRs that would support meaningful use, and build a national infrastructure to help willing providers attain meaningful use by January 2011, or as soon thereafter as possible. Tight time frames also made it unrealistic and unwise to specify a final, permanent definition of meaningful use and associated technical requirements in the few months that Congress had allowed. The only practical strategy was to do so in stages; this would permit continuing consultation with stakeholders and learning from experience.
The limited administrative resources of the ONC and CMS and the sheer complexity of the policies that they had to develop also argued for assembling the best minds in the nation to assist with defining and implementing the HITECH Act. However, consultation with outside experts poses surprising challenges in the federal government. Federal officials must conform to the Federal Advisory Committee Act, which requires that they obtain nongovernmental input through an open and transparent process that is accessible to the public. Here again, the ONC and CMS were fortunate that the HITECH Act created two new federal committees to advise them: a Health Information Technology Policy Committee (HITPC) and a Health Information Technology Standards Committee (HITSC). The former was to provide general policy advice, and the latter to help with developing standards, implementation specifications, and certification criteria for EHRs. In hundreds of open meetings of the HITSC, the HITPC, and its many working groups, scores of experts contributed tens of thousands of free hours to helping DHHS make the HITECH Act work.
In still another way, the HITECH Act helped the DHHS make critical early choices about implementation. The law provided the ONC with $2 billion to support development of a nationwide electronic health information system. The ONC had wide discretion concerning how to allocate these funds, but the statute provided important guidance. First, it said that whatever else the ONC decided to do, it had to fund regional extension centers for health information technology, programs for states to organize the exchange of health information within their boundaries, and training programs for health information technology professionals.2-7 Second, the HITECH Act created a clear unspoken requirement to put supports in place well before providers became eligible for meaningful-use payments on January 1, 2011, so that the programs could assist the first wave of potential users. For both legal and practical reasons, therefore, it made sense to get these three mandated congressional initiatives up and running as soon as possible.
The early pragmatic focus of the DHHS on meaningful use and on having the ONC fund particular initiatives did not obviate the need to develop a broader strategic vision and a more extensive set of programs for achieving the overarching goals of the HITECH Act. The ONC produced a first installment for such a vision in the summer of 2009.8
The Record to Date
Meaningful Use
On December 31, 2009, under the leadership of CMS, the federal government produced a proposed rule defining meaningful use and its associated incentive programs. A number of provider groups commented that they found the proposed rule too demanding and inflexible. CMS published a revised final rule on July 13, 2010. Described in detail elsewhere,9,10 the final rule was generally better received by providers, although some still warned that small practices and health care institutions would be unable to meet its demands. The rule defined stage 1 of meaningful use, and it promised that additional stages would be specified in 2013 and 2015. Stage 1 focused on defining the data that should be collected electronically in EHRs. Later stages of meaningful use would be more demanding and would emphasize the uses of EHRs that would improve processes of care (stage 2) and outcomes (stage 3).
In the final analysis, the meaningful-use program will be successful if it improves the quality and efficiency of health care services and the health of Americans. However, these are long-term goals that will be challenging to measure and will be influenced by a host of factors, including the implementation of the Affordable Care Act (which the HITECH Act is supposed to support). In the short term, the success of the meaningful-use provisions will be judged at least in part by whether or not sufficient numbers of providers are adopting and using EHRs in a manner consistent with meaningful-use criteria. What constitutes “sufficient numbers” at any point in time will always be open to interpretation. On the one hand, if 100% of providers met the meaningful-use standard in 2011, the rule could be fairly criticized for having set the bar too low. On the other hand, if only a few providers qualified for payments during stage 1, the regulation will be considered excessively demanding.
Stage 1 of meaningful use lasts through 2012 (although the secretary of health and human services has suggested extending it), and the program as a whole extends through 2018 for Medicare and through 2021 for Medicaid. It is far too early, therefore, to reach any definitive judgment about the regulation's success. On the positive side, providers are clearly aware of and responding to the availability of incentives. Internal CMS surveys show that as of April 2011, 78% of physicians and 96% of hospital executives were aware of the meaningful-use program (Trudel K: personal communication). As Figure 1 (Figure 1Provider Registrations for Meaningful-Use Payments) shows, more than 114,000 eligible providers, or 21%, had registered for meaningful-use payments by the end of September 2011.11 Registration is the first step in qualifying for meaningful-use payments. Providers must then complete a second step by attesting to their fulfillment of meaningful-use criteria. The pace of registrations remains strong at approximately 10,000 providers per month. CMS internal surveys have shown that 90% of unregistered hospitals intend to register. Less positive is that only 31% of unregistered physicians said they intended to register (Trudel K: personal communication).
Through September 2011, a relatively modest 3880 providers had successfully attested to meaningful use under Medicare, receiving a total of $357 million. An additional 6767 had received more than $514 million from state Medicaid programs, which do not require attesting to meaningful use in the first year.11
On a much more positive note, the HITECH Act may have spurred a rapid increase in the adoption of EHRs, an essential precondition to their meaningful use. Data released by the DHHS at the end of November showed that between 2009 and 2011, the proportion of U.S. physicians reporting that they had at least a basic EHR had increased from 22 to 34%. The percentage of primary care physicians with a basic EHR had increased from 20 to 39%, or almost doubled, during that period.12
..... (much more fascinating material omitted on what has happened in 2 years.)
Looking Forward
Beyond these three challenges to achieving the vision of the HITECH Act, many others remain. Nevertheless, over the long term, the success of the HITECH program seems inevitable, in part because its failure is unimaginable.
Information is the cornerstone of good clinical care and vital to all the objectives of our health care system. It is inconceivable that the health system in the United States will indefinitely resist a force that is transforming modern civilization and that offers almost infinite promise for improved and more efficient care. But perhaps the most convincing reason for the inevitability of the vision of the HITECH Act is that the next generation of clinicians, weaned on the Internet, Twitter, Facebook, the iPad, and the iPhone, will insist that the United States find its way to an interoperable, private, secure, and modern electronic health information system.
Source Information
From the Departments of Medicine and Health Care Policy, Harvard Medical School, Boston.
The second part is here:
What we have here, in my view, is the insider’s view of what has happened when funds, leadership, political will and governance come together. Sure Dr Blumenthal is talking his own book and legacy to a degree but I invite comparison with the capability and competence of what we are seeing in Australia.
I fear it is really pretty sad indeed. Do read the two articles - they are free and need to be read by all.
David
We need to take our hats off to David Blumenthal and ONCHIT. While they have come from a long way behind, they are certainly on the right track now. The reason they are making such good progress is, in my view, the fact that government is settling out a clear strategy and providing worthwhile incentives, rather than getting deeply involved in a single centrally-led initiative.
ReplyDeletePerhaps when Winston Churchill said "they always get the right answer, but only after trying everything else" he might have been talking about Australians.
Some day soon perhaps?
Kind regards,
Tom Bowden
The problem now Tom is that before setting out on a new 'right track' as you describe it there is very big mess that has to be cleaned up first, starting with the existing management who created the mess and the bureaucrats who so stupidly encouraged them to lead everyone into the mess all the while wasting hundreds of millions of taxpayers dollars. Perhaps the new Health Minister will have the courage to pause and reflect upon what the industry has been saying for a very long time.
ReplyDelete