National Coordinator for Health IT Farzad Mostashari and other officials involved in the meaningful use rulemaking process took to Capitol Hill to defend the interoperability standards included in the stage 2 rules and the federal funding being spent to encourage physician adoption of electronic health records.
Mostashari was called to testify before the House Subcommittee on Technology and Innovation amid growing concerns that the meaningful use incentive program is not doing enough to facilitate the interoperable exchange of medical records between electronic health record (EHR) systems. In October, a group of four U.S. representatives sent a letter to HHS Secretary Kathleen Sebelius, stating they believed the stage 2 meaningful use rules are too weak on setting interoperability standards and waste HITECH Act funds, which were appropriated to incentivize physician EHR adoption. Shortly thereafter, a group of four senators sent a similar letter asking for a meeting with Sebelius to discuss whether incentive payments are being used efficiently.
It becomes very important for us to not set [standards] so low that we are not changing the intrinsic capabilities of systems, but not set them so high that only a few can participate.
national coordinator for health IT
"We could set the standards very, very high, and only a few institutions could qualify," Mostashari said during the hearing, when asked why the stage 2 rules do not explicitly set interoperability standards. "We would not have succeeded in improving health and health care for all Americans. So it becomes very important for us to not set [standards] so low that we are not changing the intrinsic capabilities of systems, but not set them so high that only a few can participate."
In responding to the criticism, Mostashari noted that EHR adoption among office-based physician doubled between 2008 and 2011, during which time the meaningful use incentive program went into effect. He also said the meaningful use program took a fragmented EHR industry and imposed standards on it that will lead to greater interoperability. The interoperability requirements will increase in stage 2, as certified technology will have to be able to produce standardized discharge summaries and be capable of communicating with other systems.
"HITECH is working," Mostashari told the subcommittee.
But not all representatives agreed with Mostashari's assessment. Subcommittee chairman Ben Quayle (R-Ariz.) said that even though the meaningful use program has succeeded in increasing the use of EHRs, he does not believe enough is being done to ensure the technology is being used in a standardized format. This may ultimately diminish the returns the health care system can deliver on the government's investment in EHRs. A lack of interoperability may prevent improvements in quality and a reduction in cost.
"Effective utilization has the potential to fundamentally change health care," Quayle said. "While adoption of health IT products and services has increased since the passage of the HITECH Act, I have serious concerns about our progress toward greater interoperability."
Representative Randy Neugebauer (R-Texas) said standards development would be best left to private industry. He pointed out standards are starting to take hold in the mobile Internet industry without any influence from government. Trying to increase EHR adoption and direct standards development by paying out $20 billion in incentives available through the meaningful use program is unlikely to produce a more efficient health care system, Neugebauer said.
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"When people try to do everything, they don't generally get anything done," he said. "At a time when we're trying to bring down the level of deficit spending, it seems to me like an expenditure of $20 billion is an awfully high price tag."
It is true that instituting a widely accepted set of standards and facilitating EHR adoption will be expensive and could take some time, said Marc Probst, CIO of Intermountain Healthcare and a member of the Health IT Policy Committee. But he said it is necessary work that will eventually lead to increased care coordination, which will produce improved treatment outcomes and lower costs.
The reason why setting standards is difficult is because the health care industry is so complex. Probst told the subcommittee the medical industry generates more data than most other industries, and all of that information must be accurate and available in a timely manner. Putting in place a single set of regulations for an industry with this kind of complexity is challenging work. But the government has to be involved in the process, Probst said, because a voluntary, industry-led approach helped produce the fragmented system of today.
Representative Dan Benishek (R-Mich.) said more work is ultimately needed on standards and he isn't sure EHR use should be mandated until interoperability questions are answered. Benishek, who is a practicing physician, said his practice still has to send faxes to other practices because his EHR system does not communicate with others. Until EHR systems have all the functionality necessary to support improvements in health care, which include interoperability, it is difficult to justify mandating their use, Benishek said.