From the release of the final rule on meaningful use to the launch of the temporary electronic health record certification program to the establishment of 62 Regional Extension Centers aimed at helping physicians become meaningful users of EHRs, there was a flurry of health IT activity in 2010.
Much of the activity centered on implementing policies and programs related to the meaningful use incentive program included in the 2009 economic stimulus package's HITECH Act. Under the program, health care providers who demonstrate meaningful use of certified electronic health records beginning in 2011 can qualify for incentive payments through Medicaid and Medicare. Beginning in January 2015, health care providers who are not meaningfully using EHRs will face penalties equal to a 1% reduction in annual Medicare payments per year up to 5%.
In an interview with iHealthBeat, National Coordinator for Health IT David Blumenthal discussed the biggest challenges the Office of the National Coordinator for Health IT faced over the last year, his office's game plan for 2011 and concerns about current EHR adoption rates. Blumenthal also discussed the importance of health IT to the implementation of the federal health reform law, the role of the government in overseeing EHR safety and why other countries have expressed interest in the U.S.' meaningful use program.
A transcript of the interview follows.
iHealthBeat: At the 2010 ONC Update meeting in December, you outlined the progress ONC and HHS have made in implementing policies and programs related to the HITECH Act, including the final rule on meaningful use Stage 1, the final rule on standards and certification criteria and the temporary certification program. What were some of the biggest challenges in implementing these policies?
Blumenthal: I think probably the biggest challenge was doing all of this at once, and with such short timeframes and doing things that had never been done before and trying to do them in a way that stakeholders thought was reasonable and that also met the objectives of the HITECH Act and of the administration to move forward the process of adoption of meaningful use.
So I think it was just the number of activities we had to do at the same time. Not the least of which was to make sure that we had, while we were creating the rules, the infrastructure in place to support providers who want to be meaningful users. So in figuring out what we could reasonably expect from them, while at the same time making sure we were on the trajectory toward realizing the ambitions of the act, which I think were pretty far reaching. So I think it was managing long-term gains and vision against short-term increments, and doing a lot of very practical things at the same time.
Figuring out what meaningful use should consist of was a big conceptual challenge. And, one that we took on with a lot of help from our Policy Committee and a lot of feedback from the community. And, I think we had to learn a lot along the way about what the situation is out in the country, with respect to electronic health records, and what's possible and not possible, and where that line is between what you can hope for and what you can reasonably expect. I think it was in retrospect a challenging period, but one that we navigated with a lot of help.
iHealthBeat: Do you expect to alter your process at all moving forward as you prepare to release additional policies, such as criteria for Stage 2 of the meaningful use program?
Blumenthal: I think as tight as our new timeframes are, they're a lot more generous than the first set of timeframes. And, we know a lot more and have a lot more experience. So I think that we're going to have ... a more deliberative process than we had the last time.
We're also going to have the benefit of experience with Stage 1. That is going to be a big factor. One of the ways in which the process will be different will be looking at our experience with adoption and meaningful use as a source of input into our rulemaking, and that's a very, very important new element in the rulemaking process.
We also now have a certifying process, and we pretty much well know what the certifying process consists of and maybe have some sort of idea what the standards and certification regulations should look like in light of that certification process.
I also think that one of the things that's different is that we have a lot of conversations going now that weren't going on before. We have a conversation about standards that wasn't previously present in the current forums. So I think people are perhaps used to now discussing these things. We have two committees -- the Standards Committee and the Policy Committee -- that have proven, at least in my view, their worth and their responsibilities so that I hope they'll be viewed as legitimate and as important forums for discussions by the key stakeholders.
iHealthBeat: A recent CDC survey
finds that while about half of U.S. office-based physicians are using electronic health records, only 10% of office-based physicians said they have a fully functional EHR system. Meanwhile, a separate survey from the College
of Healthcare Information Management Executives finds that the percentage of CIOs who expect their organization to qualify for meaningful use incentive payments by April 2011 dropped from 28% in August to 15% in November. What are your expectations as far as providers being able to comply with meaningful use criteria in 2011 and beyond?
Blumenthal: I guess some of these numbers are a matter of half full/half empty. Ten percent [from the CDC survey] is up from 6%, so that's a 4 [percentage point] increase on a 6% base, which is not bad -- that's two-thirds. So that's how sigma adoption curves work. They suddenly go up, and the first couple of data points don't look absolutely so great, but once the slope changes, you're on a very, very steep curve. So I'm hoping that's what we're beginning to see here.
I'm not surprised that the CIOs are looking more closely at the April timeframe, but April is just April. They've got two years to become meaningful users in Stage 1. We have some other data that we hope to be releasing in not too long that's a good deal more optimistic than this data.
So I do believe that achieving meaningful use is becoming a marker of excellence for hospitals. As I talk to hospital leaders around the country, none of them are proudly proclaiming that they don't think they're going to be meaningful users any time soon. I think the leading hospitals in the United States, the leading systems, have taken this on as a serious responsibility. I [recently] saw a PricewaterhouseCoopers survey ... that shows that most hospital executives expect health IT to be their leading investment over the next year.
So I think we've sort of passed a point of no return. Admittedly, there will be some hospitals that are out ahead of other hospitals, but I'm quite confident that the president's agenda will be successful. Now will it be six months more or less, I can't predict. But, I think we're at the point of change, and I think the Congress' initiative under HITECH will be seen in retrospect as a fundamental turning point in laying the foundation for changing the delivery system in the United States.
iHealthBeat: How important are federal health IT efforts to the implementation of the health reform law?
Blumenthal: I think on both a theoretical and practical level, health reform cannot achieve its goals without a vibrant health information technology infrastructure. And, I say that because as I say often, information is the core resource for change in our health care system. It's essential to changing clinicians' behavior, it's essential for managers to change the behavior of their organizations, it's essential for policymakers to change the direction of policy and policy priorities. And, we don't have and haven't had adequate information to do any of those things in the past.
The only place I can see that kind of information coming from in a timeframe that's meaningful is from electronic sources. So I don't think there's any way of realizing our accountable care organization agenda, our medical home agenda, our bundled payment agenda, our readmission reduction agenda, our hospital-acquired infection agenda, you name it. I don't see a way to get there reliably on a systemwide basis without a strong health information system, and in the 21st century, that means an electronic system.
iHealthBeat: HHS and the European Commission recently signed a memorandum of understanding promoting a common approach on the interoperability of electronic health records and education programs for health IT. You've noted before that the U.S. lags behind several countries, such as Denmark, in health IT adoption. What kind of response has ONC received from the international community about the meaningful use program and recent U.S. efforts to accelerate health IT adoption?
Blumenthal: I, personally, have found an enormous amount of interest in our framework. Lots of countries -- even those that are well ahead of us in adoption -- are interested in our meaningful use framework because it sets expectations for the use of information and information technology, which have only been implicit in the plans of many other countries. ... I was in France [in November]. The French are actually adopting a version of meaningful use to promote health information technology adoption in their hospital sector. And, I think there's interest in the U.K.; there's interest everywhere in how you link expectations and goals to the use of health IT.
Now, most European countries are focusing on exchange because they've already accomplished adoption. And, so they're very interested in what we're doing to promote exchange, and they're very interested in the standards that we're setting around exchange. The idea that you would not just promote adoption but that you'd promote use of certain types, I think is seen as an important new contribution to the international conversation.
iHealthBeat: What kind of role do you think the U.S. government should play in overseeing the safety of EHRs and other health IT systems?
Blumenthal: Well, we've asked the Institute of Medicine to give us their advice on that. I think there are a number of ways that we could go, and they all have consequences for both innovation and safety. We attach a lot of importance to both innovation and to safety, and we want to get the right balance. This whole process of policy development at ONC over the last 18 months, 20 months has been a balancing act. This is another one of those.
It would be a lot simpler if there were easy generalizations here. We know on the one hand that promoting the spread of electronic health records improves the safety of care overall, but we also know that safety of the use of individual pieces of equipment and the safety of implementation needs to be assured as well. So I think that's a conversation that the Institute of Medicine can give us a lot of perspective on so we're waiting to hear what their advice would be.
iHealthBeat: Because of federal rulemaking regulations, I know you cannot comment on the specifics of Stage 2 of the meaningful use program, but when can we expect that rule to be released and what is your office hoping to accomplish with the next stage of the program?
Blumenthal: Well, we are hoping that we will give the field at least as much warning and time to prepare for Stage 2 as they had for Stage 1. I hope we can give them more because our Policy Committee has already put out for comment a set of proposed Stage 2 concepts and measures. So I think the conversation is already well under way. We don't want to rush the field, we don't want to get too far in front of Stage 1 and complicate the implementation of Stage 1 with discussions about Stage 2. But we also want to have a long, deliberate, deep conversation about Stage 2.
So I think that throughout the spring into the summer, there will be a very robust, open conversation about what Stage 2 ought to include. And, I think that'll give a lot of information to vendors and other stakeholders about what may be expected of them in Stage 2. I think it will probably be the following winter before a formal notice of proposed rulemaking comes out and then somewhere in the next spring or summer before the final rule is issued. Those are guesses at this point. You know these timetables have a way of changing.
What we are going to be most adamant about in Stage 2 is improving the processes of care through the use of information and decision support. That's point one. And, point two will be increasing the amount of information that is exchanged in response to patient needs, assuring that that information is crossing organizational and commercial boundaries as it must because patients don't restrict themselves to single organizations for the most part for their care.