In this U.S. election year, and on the eve of the Health Information and Management Systems Society's HIMSS 2012...
conference, it seems that pure politics, not practical or technical considerations, are shaping health IT adoption policy -- especially as the Centers for Medicare and Medicaid Services agrees to postpone ICD-10 implementation at the American Medical Association's behest.
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Yet Harvard School of Public Health professor, former Health IT Standards Committee co-chair and current Veterans Health Administration senior advisor for quality and safety Ashish Jha, M.D., said that the HITECH Act -- arguably the biggest HIT political gambit -- is accomplishing what it set out to do three years ago: expedite health information exchange (HIE) and electronic health record (EHR) implementation.
Delivering the keynote address for Massachusetts Health Data Consortium's recent HIT '12 conference, Jha broke down recent National Center for Health Statistics figures, which showed that 35% of U.S. physicians now are using either a basic or comprehensive EHR system. While he was not allowed to comment publicly on hospital HIT adoption figures due to be released next month, Jha did reveal that they will also show a dramatically upward trend compared to a year ago.
"That's pretty impressive when you're thinking about the whole country. In 2011, there's starting to be real growth. If you go back to 2010, this [was] depressing," Jha said. "My sense is that what we'll see over the next three years is this really taking off on the hospital and ambulatory side."
However, since Jha's keynote, HHS secretary Kathleen Sebelius revealed that the percentage of US hospitals that adopted EHRs spiked to 35% in 2011.
Slowly but surely, health care providers are adopting basic systems, and the HITECH Act's meaningful use provisions are driving more robust EHR use for a smaller subset of users. He sees those trends continuing as meaningful use stages 2 and 3 approach.
Health information exchanges are, in fact, on their way
"In stage 1, all we're trying to do is get data in a common format, it's supposed to be a somewhat low bar," Jha said. "Obviously, most providers don't necessarily feel it's a low bar, but the idea is that you can't really use this information to drive improvement in health care if a lot of the information is still paper-based."
But the adoption of health records is only a first step toward the HITECH Act's main objective of driving health care quality improvement through technology. Promoting data exchange between providers will be where the gains are made, Jha said.
CIO surveys tell different health IT adoption story
Two surveys likewise released on the eve of the HIMSS 2012 conference also take a look at health IT adoption in the United States, with figures that differ dramatically from Jha's.
First, a report from CDW Healthcare due for release on Feb. 27 will indicate that 56% of hospitals with 200 or more beds have deployed an EHR system in the last 18 months, with more than 90% of such hospitals now having an EHR system in place. Over the same time period, nearly one-third of surveyed hospitals have rolled out HIE technology, with nearly 60% of hospitals now participating in health information exchange.
Meanwhile, data from the Optum Institute for Sustainable Health, which surveyed CIOs at 301 hospitals, paints a similarly rosy picture. This survey suggested that 87% of hospitals have an EHR system in place, with 70% of those facilities in turn having met meaningful use stage 1 criteria. Roughly 70% of all hospitals surveyed are participating in health information exchange as well.
The discrepancy stems in part from what is being measured. CDW and the Optum Institute both looked at instances of EHR adoption, whereas Jha look at actual EHR use. The federal government, it should be noted, also has the benefit of a much larger pool of data -- the thousands of U.S. hospitals submitting data to it, as opposed to the hundreds of hospitals voluntarily participating in a survey.
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To that end, he said the 75 health information organizations, or HIOs (formerly referred to as RHIOs, with the "R" standing for "regional"), which predate the HITECH Act, cover about 5% of hospitals and ambulatory physicians. Most states building statewide health information exchanges (HIEs) are working with HIOs to build their patient data networks -- but it's moving much more slowly than EHR adoption.
The barriers to health information exchange are many, Jha said, specifically citing cost, privacy and security, technical considerations and pure market considerations. The last obstacle takes on added importance now that the accountable care organization (ACO) has entered the picture. Competitive issues -- as well as ACOs' need to keep patients within their networks to control cost and keep quality high as possible -- may play into future HIE growth.
HITECH sets foundation for larger health reforms
There's also a general perception that, at the end of the day, all this technology can actually drive better, lower cost quality health care. "So far, we have relatively little evidence that HIT adoption is really driving big changes in care delivery -- so far," Jha said. The much bigger story isn't the tech itself driving care quality, he said, but rather its ability to enable broader health reform initiatives.
"[Can] this stuff work? I think we have overwhelming evidence that it does. Electronic health records can make dramatic improvements in quality and efficiency," Jha continued. "Health IT is the infrastructure that allows health care systems to change. You basically can't do ACOs without a really robust EHR system and without information exchange. You can't do the patient-centered medical home. You can't do this stuff without health IT. Increasingly, providers are going to be asked to manage populations. You can't manage populations without health IT; it's a mess trying to do it on paper."
Health IT is the infrastructure that allows health care systems to change.
Ashish Jha, senior advisor for quality and safety, Veterans Health Administration
If the HITECH Act on its own might not bring quality improvements, then what has it accomplished to date? Jha believes the law has taken the resistance to health IT out of the health care system and accelerated adoption much more quickly than if it hadn't been enacted.
The next challenges for the Office of the National Coordinator for Health IT, he predicts, will be similarly removing the health care system's resistance to HIE, and finding ways to include providers who were left out of the HITECH Act, chiefly nursing homes as well as long-term care and psychiatric facilities.
Those providers will probably remain mired in paper for the next five to seven years despite a steady flow of patients between hospitals and those facilities. It's not an insignificant number, Jha said. One-third of Medicare patients don't go home after they're discharged from a hospital; they go to nursing homes or long-term acute care or rehabilitation facilities.
"They're not getting much focus from policymakers. Policymakers will say 'Oh no, no, no, we care about them' but nobody in Washington is being graded by what happens in terms of EHR adoption in nursing homes," Jha said. "And they're getting no love from vendors."