Editor's note: This is the latest "HIT Happens," a semi-regular news analysis and opinion column.
Hit the button, call the crash cart: Meaningful use could be triggering a code blue.
Respected health IT leaders such as meaningful use guru Jim Tate and Beth Israel Deaconess Medical Center CIO John Halamka, M.D. may be right in painting a picture of the health IT incentive program as "in need of overhaul." Similar notions show up in letters issued earlier this year by the College of Healthcare Information Management Executives and American Medical Association calling for "flexibility" in stage 2 rules and last year's letter to HHS from six senators, who termed it a "reboot."
The word we're getting out of Washington D.C. in discussing recent events with sources on and off the record paints a far graver picture than a possible overhaul. Sources tell us that morale at the Office of the National Coordinator for Health Information Technology (ONC) has withered and Republicans will continue to call into question the existence of the meaningful use program as well as the ONC itself as election season draws closer.
David Kibbe, M.D.,CEO, DirectTrust
Meaningful use would take time to wind down. Healthcare CIOs would be pinched, trying to figure out how to spend always-limited resources as they guess what all these signs from Washington mean in regard to available incentives. Do you invest heavily in reporting for quality measures, health data interoperability, building data warehouses and documenting it all? What about stage 3? How does one plan for what the rule will require, considering the uncertainty?
Accountable care organizations probably aren't going away any time soon, and when they do they'll invariably be replaced with a 2.0 version that will require similar IT tools for managing and running analytics on large clinical data sets. We're guessing that commercial payers will also launch separate-but-similar programs, as they often follow the lead of Centers for Medicare and Medicaid Services (CMS).
This year's meaningful events
So far in 2014:
- CMS watered down meaningful use by granting physicians hardship exceptions (see Section 3.2.4) in cases where their EHR vendors can't keep up with ONC certification, after providers in many corners of healthcare complained.
- ONC's currently proposed relaxation of stage 2 rules extends some deadlines and permits incentive recipients, in some cases, to attest to stage 2 using 2011 certified EHRs instead of the previously mandated 2014 standards.
- ONC then announced a reorganization that effectively decentralizes management.
- Since the reorganization, two of what could be considered the ONC's most important patient advocates, Chief Privacy Officer Joy Pritts and Director of the Office of Consumer eHealth Lygeia Ricciardi, resigned. Our sources predict more ONC resignations will come as frustrations mount.
An ONC spokesperson said in an email that no replacements or acting replacements for Pritts or Ricciardi have been named, because it's still too early. Replacing Pritts could take a while, as the position is politically appointed.
Sky isn't falling?
Not everyone is reading too deeply into these recent ONC staff moves. Regina Holliday, one of the staunchest patient advocates in the health IT realm, said the resignations aren't particularly worrisome. She chalks it up to typical churn of federal officials and the fact that they so quickly followed the ONC reorganization was more of a coincidence. It doesn't signal to her that ONC is moving patients down the priority list.
"It's a cyclical thing. Oftentimes, people work for the government for two years and they move on and do something else for a while to refresh themselves," Holliday said. "... I think it would be good for the remaining ONC staff to get to know all of us patient advocates, because I don't think the new [leaders] coming on board have experiences meeting with us, and our wonderfully disruptive nature."
The ONC spokesperson said that some staffers who joined the office as a part of the grant-making surge immediately following the HITECH Act may move on now that American Recovery and Reinvestment Act funds are expected to expire. "You have seen a few of our colleagues do just that," the spokesperson said, "and this is a natural part of the maturation of any organization."
Storms brewing over Hill
David Kibbe, M.D., longtime health IT and policy adviser to the American Academy of Family Physicians, said that ambiguous verbiage in the ONC's recent proposal to relax meaningful use stage 2 rules and delay stage 3 point to a program in trouble. Kibbe, who is also CEO of DirectTrust, a nonprofit trade alliance that receives grant funding from ONC, sees potential strife later this year, as opponents to the current administration may target meaningful use as a program and, possibly, ONC itself.
"I think the Republicans, in the election season, are going to go after ONC and the meaningful use program and ask serious questions about how the money was spent, and what were the results," Kibbe said, citing a letter the House Energy and Commerce Committee sent ONC questioning the agency's ability to launch a Health IT Safety Center. "I think the Republicans have come out and said, 'After HITECH, we will challenge the statutory authority under which ONC does anything in terms of regulation.' We're kind of in limbo over that ... I think this introduces significant uncertainty into the picture right now."
For its part, the ONC spokesperson said the office is working with Congress to make health information technology "as safe and effective as possible."
"Health IT policy has historically enjoyed bipartisan support and we look forward to continuing to work in partnership with Congress to advance a strong platform that will bring better care and health for all," the spokesperson said.
The open-source Direct health information messaging protocol and progress made by members of DirectTrust, Kibbe said, are one of the few things that meaningful use proponents and opponents both like, because it simply and effectively enables information exchange between small practices and large hospitals regardless of EHR system they use. For his part, Kibbe said DirectTrust is asking the National Institute of Standards and Technology, ONC and CMS to strengthen Direct testing in future certification standards for EHR vendors, which in turn will make it more straightforward for clinicians and patients to use Direct for clinical data exchange.
Vendor: Focus on interoperability
A high-ranking EHR vendor executive familiar with D.C. machinations we spoke to hasn't heard anything about morale issues at ONC. This executive wouldn't be surprised, however, to hear of such problems, considering the barrage of criticism the agency endures from physicians, industry and political foes over the structure, execution and backtracking on meaningful use.
The executive believes the meaningful use program might be a hard sell to legislators for continuing through the rest of stage 2 and on to stage 3. In granting hardship exceptions to physicians and hospitals whose vendors couldn't complete EHR certification, ONC will be forced to justify the pretzel logic of "continuing to fund a hardship." Another source suggests this scenario could culminate in open hearings on Capitol Hill with television cameras rolling and National Coordinator for Health IT Karen DeSalvo, M.D. on the hot seat.
What's the executive's advice to ONC? Make stage 3 all about forcing health data interoperability, which recent advisory committee meeting chatter suggests to could be the direction ONC is leaning as it goes into the "quiet period" of writing stage 3 rules.
Even if we are stepping into a post-meaningful use world as of today, healthcare CIOs, as they like to put it, will have to keep the lights on: Data will need a place to be stored. Wi-Fi and wired infrastructure will have to work. Clinical data will need to be protected and backed up in compliance with HIPAA. Radiologists and cardiologists will keep cranking out pictures and videos at a record pace. Patients in remote areas will still need telemedicine visits. Payers will still demand that coders and billing departments create claims with ICD codes, documented just so.
In sum, health IT isn't going anywhere.
But meaningful use might be.