2011 was a big year for health IT. Farzad Mostashari took over as the country's fourth national coordinator for health IT. The Office of the National Coordinator for Health IT launched pilot projects in which health care providers and public health agencies began exchanging health information using specifications developed by the Direct Project, an "open government" initiative. The first graduates of federally funded health IT training programs hit the job market. CMS issued proposed rules designed to improve consumer access to laboratory testing results. HHS Secretary Kathleen Sebelius gave health care providers who met Stage 1 meaningful use requirements in 2011 an additional year to comply with Stage 2 criteria. More than 100,000 primary care providers -- more than one-third of primary care providers nationwide -- signed up with the 62 federally designated regional extension centers to move forward with electronic health record adoption. Medicare and Medicaid each distributed nearly $1 billion in incentive payments during the first year of the EHR system doubled from 17% in 2008 to 34% in 2011.
However, much of the U.S. health care system still exists in a paper-based world. The majority of health care providers have not yet made the leap to EHRs, citing cost, workflow and privacy as major barriers. Some health care stakeholders have raised concern that the meaningful use incentive program requirements might be unachievable for many health care providers, while others argue that the criteria do not go far enough in promoting patient-centered care.
2012 is sure to be a crucial year in the country's shift toward health IT. We asked a variety of stakeholders -- including providers, vendors, patient advocates and government officials -- to weigh in on health IT progress, disappointments and hopes for 2012.
We asked each health IT expert to answer three questions about the most significant health IT development in 2011, the biggest disappointment in the past year and how the remaining barriers to widespread health IT adoption should be addressed in 2012.
We received responses from:
- Brian Ahier, health IT evangelist at Mid-Columbia Medical Center and president of Gorge Health Connect;
- Jennifer Covich Bordenick, CEO of the eHealth Initiative;
- Jeff Donnell, president of NoMoreClipboard;
- Bruce Lisanti, CEO of Medical Informatics Engineering;
- Farzad Mostashari, national coordinator for health IT;
- Eva Powell, director of Health IT Programs at the National Partnership for Women & Families;
- Dave Roberts, vice president of government policy at the Healthcare Information and Management Systems Society;
- Steven Stack, American Medical Association chair-elect; and
- Brantley Whittington, CEO of Extormity.
Brian Ahier, Health IT Evangelist at Mid-Columbia Medical Center and president of Gorge Health Connect
What was the most significant health IT development over the past year?
Singling out the most significant health IT story is very difficult in a year filled with some incredible developments. I am choosing the launch of Direct Project pilots in February. Less than a year from the birth of the project, having real world implementation is lightning speed for a government-sponsored effort. The Direct Project has been a remarkable success story and will have long-lasting impact on health information exchange. Second place would go to General Electric and Microsoft announcing a joint venture aimed at using real-time information to improve health care quality. These two behemoths combining their intellectual property and massive R&D capabilities will make a big splash over the next few years, especially in the area of managing chronic conditions.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
I can't answer this without putting health IT in the context of the greater health care system. The linchpin of efforts to reforming our health care system is technology enabled. And my greatest disappointment by far in 2011 was the departure of Don Berwick from CMS. He cast a vision for investment and research in information technology leading to accountable care organizations, medical homes and other innovations in delivery and payment models. However, I am hopeful that he may actually be able to accomplish more released from the bonds of government service.
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
Some barriers to EHR adoption include funding (meaningful use incentives are not paid until achieving the measures, which leaves a large upfront cost burden); inadequate workforce to provide the human resources needed for the future of health care; and the inability for Rural Health Clinics to qualify for Medicare incentives. These barriers could be addressed through federally backed loans to providers and hospitals to acquire the technology, continued investment in workforce development and congressional action to allow RHCs to qualify for Medicare incentives, as well as Medicaid.
One of the significant challenges to meaningful use of the technology is the lack of standards. There are strong efforts to address this by ONC within the Standards and Interoperability Framework. This work is vital and must continue, and produce results quickly. Another key area is usability. The standards and certification criteria for a certified EHR do not address usability. I have long said that it would be possible to develop a software application that meets all of the criteria for meaningful use, yet is completely unusable in clinical workflow. By the looks of the some of the applications in use, it seems a few vendors have taken me up on the challenge!
Jennifer Covich Bordenick, CEO of the eHealth Initiative
What was the most significant health IT development over the past year?
Clearly, I think meaningful use was the most significant development over the past year. It helped kick-start health care to bring our industry into the 21st century. But, it was truly a double-edged sword, as providers are struggling. I think the biggest remaining barrier to meaningful use is financial. The weak economy will increasingly impact the health and technology sectors. Many providers still cannot see a positive return on the investment in an EHR. This remains a big challenge. At the end of the day, providers need money to purchase, implement and meet meaningful use. Add to that the political uncertainty about Medicare, budget cuts, ACOs and the aggressive timelines.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
For good reason, we spent a lot of time focused on meaningful use and EHRs in 2011. But, I think we missed an opportunity to look at the emerging technologies that consumers and providers can use both for treatment and preventive care. I am hopeful that in 2012 we can focus on the other side of e-health: mobile apps, tools for remote monitoring, telehealth, patient-physician email, text messaging and other tools. Focus on tools that reach patients where they spend the majority of their time -- outside of medical facilities. I think this was a missed opportunity, but I know that eHealth Initiative is one of many organizations that is going to redouble our efforts in these new areas.
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
A lack of standardization is still a standout issue. There are still too many systems that are not capable of communicating with one another. An electronic health system is only as good as its paper counterpart, albeit faster, if the information can only be shared among those that use a particular set of standards or have a system equipped to understand the information. We need a more prescriptive approach in that area.
Some of the biggest opportunities for impacting quality of care require improved data and analytics. We need to focus more on standards around how data can be used. We haven't focused enough on standards for governing patient privacy and information sharing. Privacy and security should be a fundamental component of new health policy, and the government should make it a foremost priority to carefully align new policy with a strong and clear privacy policy. Work on these issues now, while the health IT space is still young, and it will pay dividends in the future.
Jeff Donnell, president of NoMoreClipboard
What was the most significant health IT development over the past year?
For those of us who are serious players in the patient engagement space, it was the sudden and seismic shift from "electronic communication with patients is a microscopic blip on our radar" to "we need an electronic patient engagement strategy and we need it yesterday." Factors ranging from meaningful use requirements to a federal emphasis on providing consumers with easy access to health information (Putting the I in Health IT campaign) to the realization that this Internet thing might just be here to stay all contributed to the turnaround. At NoMoreClipboard, physician practices started calling to learn about our portal offerings based on inquiries from patients eager to send their personal heatlh record information electronically. Hospitals and health systems pursuing an ACO strategy expressed interest in using a PHR to communicate effectively with patients who have chronic diseases. Employers seeking to reduce health care costs, improve productivity and presenteeism, and get employees and their families more interested in managing health and wellness, wanted to know how we could help. The net result: 2011 will go down as the year we went from proving viability and building value to exponential growth and rapid expansion.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
While it's hard to believe, there are still those who cling desperately to paper charts. While care and caution in implementing health care IT solutions is certainly warranted, claims that EHRs will erode privacy, invite malpractice suits and lay waste to the ability of physicians to practice anything but cookbook medicine do little more than propagate hesitation and skepticism among hospitals and practices that are still on the sidelines. Privacy is certainly a valid concern, but paper charts laying on a practice counter or traveling around in physician trunks are clearly less secure than an electronic chart and its electronic audit trail. For those who doubt the value of embracing IT, spend a few minutes in a waiting room and watch the delight of patients who are given a clipboard full of paper forms and challenged to complete them legibly, completely and accurately. These are often the same patients who bank, book travel and buy goods and services online -- the Internet that more than 75% of all U.S. citizens use.
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
I remain amazed as I talk to physicians around the country who still have not received the memo on meaningful use. Sure, most are aware of stimulus funds and have a hazy and ill-defined understanding of the program, but far too many know way too little about the specifics -- how it works, what they need to do and where to get started. Now that hospitals and practices are actually qualifying for stimulus funds and receiving checks, we need to get the word out -- making sure there is widespread awareness of the benefits of the program, the real value being derived by real providers and practical advice on what to do next. Those who are doing meaningful things with their IT solutions and realizing meaningful financial value need to be held up as evangelical foster children.
Bruce Lisanti, CEO of Medical Informatics Engineering
What was the most significant health IT development over the past year?
For Medical Informatics Engineering, the most significant development was one that went largely unnoticed by the health care IT mainstream. We are experiencing significant growth in the employer space -- with large corporations operating their own health clinics for their employees, and with small- and medium-sized organizations contracting with hospitals or outsourced providers of clinical services. These employer-based or affiliated provider organizations are interested in comprehensive health IT solutions that combine clinical, occupational health and employee engagement modules in an integrated fashion. Fed up with rapidly escalating health care costs, employers are taking matters into their own hands -- expanding health services beyond compliance requirements and offering comprehensive clinical services including primary care, chronic disease management, and health and wellness programs. Thanks to our Fortune 500 clients, our health IT solutions have been deployed worldwide in more than a half-dozen different languages.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
There are literally hundreds of certified EHR vendors providing health IT solutions to physician practices, clinics and hospitals. However, many providers are selecting an EHR from a handful of large, established vendors. While the so-called safe choice is understandable, many of these EHR solutions are costly, inflexible and difficult to implement. For those evaluating EHR options, it pays to take a deep look at the depth and breadth of available solutions. When we find prospective clients who are willing to give lesser-known solutions a fair shake, we win more than our fair share of business.
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
We have to recognize that roughly 50% of physicians are still on the sidelines, taking a wait-and-see approach. In many cases, these providers are looking for meaningful use that is truly meaningful. Many physicians are searching for real value and expect to do more than self-attest to a list of 40-odd requirements. Those of us who provide EHR solutions that do more than meet the minimum measures have to get the word out -- sharing stories of our practices that not only qualified for stimulus funds, but realized significant benefits in terms of improved productivity, reduced costs and enhanced clinical outcomes.
Farzad Mostashari, national coordinator for health IT
What was the most significant health IT development over the past year?
The most significant health IT development over the past year was "breaking the ice" on health IT adoption and meaningful use. Recent data show that the percentage of physicians who have adopted a basic EHR in their practice has doubled in just two years, rising from 17% in 2008 to 34% in 2011. Fifty-two percent of office-based physicians in the U.S. have indicated that they intend to take advantage of the incentive payments available for doctors and hospitals through the Medicare and Medicaid EHR incentive programs. We've also seen a sharp increase in the number of physicians using e-prescribing capabilities. Recent national data show that the number of providers using EHRs to e-prescribe increased from 52,947 in December 2008 to 297,036 in November 2011 -- a more than fivefold increase.
We've also begun to see early results demonstrating that the use of health IT significantly improves health outcomes when integrated into an environment that supports delivery system improvements. Published in September 2011, research by Better Health Greater Cleveland showed that physician practices that use EHRs have significantly higher achievement and improvement in meeting standards of care and outcomes for diabetes patients than practices using paper records. The study reported that nearly 51% of patients in EHR-based practices received care that met all of the endorsed standards for diabetes care, while just 7% of patients in a paper-based practice received the same level of care. Forty-four percent of patients in EHR-based practices met at least four of five outcome standards for diabetes, compared with 16% in paper-based practices.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
It took longer than we anticipated for the vendors to be ready to support physicians in moving to meaningful use. The move toward meaningful use required vendors to develop and, in many cases, upgrade their existing products to meet the meaningful use standards and certification criteria. Vendors play a critical role in supporting physicians and hospitals as they move toward meaningful use; we can't do it without them!
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
The biggest challenge we will face in 2012 is increasing the exchange of digital health information. The promise of widespread adoption and meaningful use of health IT can only be fully realized once providers achieve ubiquitous, standards-based and affordable information exchange with public health organizations, with patients, with labs and with other providers across the spectrum of care. We are working with stakeholders to broaden agreement around the technical standards that enable information exchange. We are working with our state partners on ways they can facilitate information exchange by filling gaps in existing services, such as provider directories and identity assurance. These will complement our efforts to provide policy guidance around the governance of health information exchanges and other policies that help build a foundation of trust that is critical to the success of information exchange.
Ultimately, though, to get to where we want to be on information exchange, providers have to see it as in their interest to exchange information to coordinate care, and vendors need to respond to this market demand by making interoperable exchange not just technically feasible, but routinely implemented in practice.
Eva Powell, director of Health IT Programs at the National Partnership for Women & Families
What was the most significant health IT development over the past year?
The consumer-engagement aspects of the meaningful use incentive program are beginning to deliver tangible benefits to patients. For example, I personally have a new primary care provider whom I chose specifically because of his use of a more progressive care delivery model, which integrates technology as a tool for improving care. I have online access to my health information, communicate with him by email, make appointments and renew prescriptions online and enter my health history online prior to going to an appointment. Right now we are only seeing these kinds of benefits in the most forward-thinking physician practices, so we must ensure that all individuals have the same kind of access to information and benefits offered by health IT that I and others are beginning to see.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
We routinely hear from patients and families, "I just want my doctors to talk to each other." The proposed criteria submitted by the Health IT Policy Committee for Stage 2 of meaningful use could have gone further to advance health information exchange for care coordination and care planning. Consumer groups hope that CMS takes these recommendations and advances them further to address an area that is consistently among consumers' chief concerns about the health care system: care coordination. The value of health IT is really in the sharing of information, not just capturing information in an electronic format.
There is also tremendous opportunity to increase health IT adoption and use to improve health outcomes for underserved populations. This requires the use of health IT as both a quality improvement tool and a patient engagement tool. A major emphasis on reducing health disparities through federal efforts such as meaningful use, accountable care organizations, medical homes and the ONC consumer engagement campaign and pledge programs could have a tremendous impact.
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
There are at least two major remaining barriers to widespread adoption and meaningful use of health IT. One is the slow progress being made in health information exchange. The other is the limited types of providers who are eligible for meaningful use incentives. For example, care coordination requires other providers, such as nursing homes and home health agencies, to participate in the exchange of information. We must make a concerted and coordinated effort to ensure that these providers are also adopting technologies that enable information to move with the patient, wherever they receive care. Expanding meaningful use incentives could help. ACOs could also help by including these settings in their efforts.
Dave Roberts, vice president of government policy at the Healthcare Information and Management Systems Society
What was the most significant health IT development over the past year?
HITECH and health care reform regulations continued to be implemented to support health care transformation, including the release of final ACO regulations and the disbursement of more than $1 billion in Medicare and Medicaid EHR incentive program payments to eligible professionals and eligible hospitals.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
Matching the right patient with the right medical record is a key component of nationwide interoperability, but Congress and HHS have yet to fully address the issue. Patient identity integrity will continue to be a hot topic on Capitol Hill, and I'm hopeful that the Government Accountability Office will begin a study in 2012 to evaluate the various technology options to ensure safer patient care.
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
Resource funding restraints will continue across the board and for the foreseeable future, resulting in continued pressure on health care costs and provider reimbursement rates.
Steven Stack, American Medical Association chair-elect
What was the most significant health IT development over the past year?
There have been many significant health IT developments this year. The adoption of the Direct Project has transformed the way health information is shared, giving participants a way to send authenticated, encrypted health information directly to known, trusted recipients over the Internet. Mobile health, or mHealth, continues to grow rapidly as physicians use their mobile communication devices for health services and information.
In addition, the health care industry has recognized the growing importance of health IT, and there appears to be real growth in health care jobs that focus on the merging of clinical data and information technology.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
AMA has very serious concerns with CMS' pattern of effectively "back-dating" the imposition of congressionally mandated penalties by basing the penalties on performance before the penalty was to take effect. This first appeared with CMS' plan to base 2012 electronic prescribing penalties on whether the physician met e-prescribing requirements in 2011. CMS has decided to continue the back-dating of the e-prescribing penalty in future years of the program. The application of the e-prescribing penalty is the first of several penalty programs that include meaningful use of EHRs and Physician Quality Reporting System programs. Because there are multiple penalty programs, this approach of back-dating will become even more confusing for physicians who may be subject to multiple, overlapping penalty and incentive programs in the same year.
In order to achieve widespread health IT adoption, it is critical to pursue reasonable, achievable requirements and to align the requirements for the various incentive and penalty programs currently under way. Educational outreach to physicians and patients must also be coordinated for these health IT programs.
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
There is great interest among physicians to take advantage of the available incentive payments through the Medicare and Medicaid EHR incentive program, but according to the most recent numbers from CMS, a very small percentage of physicians have received incentives. Many specialists have expressed concerns that they are not able to meet all of the required measures necessary to be eligible for incentives. For example, radiologists do not typically collect and record a patient's medication list, a required measure.
The Medicare and Medicaid EHR meaningful use program requirements must include sufficient flexibility to increase physician participation rates in later years and stages of the program. AMA has called on HHS to fully evaluate Stage 1 of the incentive program and develop solutions to increase physician participation rates prior to finalizing requirements for Stage 2.
Brantley Whittington, CEO of Extormity **
What was the most significant health IT development over the past year?
At Extormity, we used meaningful use incentives as a literal force multiplier -- forcing each of our physician clients to multiply $44,000 by a factor of four to pay for consulting, implementation, configuration, customization, hardware, software licensing, maintenance, support, meaningful use modules and participation in our user advisory council. Our sales and marketing efforts emphasized the stick rather than the carrot, raising the specter of reimbursement penalties for those who hesitate. We also ginned up a white paper showing that practices who invest in an expensive and bloated EHR solution command much higher than average multiples when negotiating an acquisition by a hospital or health system.
What was the biggest disappointment or missed opportunity in the health IT space in 2011?
We have been sorely disappointed by our government's emphasis on interoperability, indicating a shift away from proprietary, fortress with piranha-filled moat models that have contributed to ridiculous historic valuations at companies like Extormity. Of late, this focus has expanded to include providing patients with easy electronic access to their health information -- making it simple for patients with portable data to move from provider to provider. The heresy has even been extended to collaborative and convenient solutions like Direct and Blue Button. If this keeps up, there will no longer be a need for Interoperability Showcase events where vaporware is used to great effect as a way to let CIOs glimpse what they want, but can never really have.
Looking forward to 2012, what are the biggest remaining barriers to widespread adoption and meaningful use of health IT? And, what can be done to help address those challenges?
From the lofty Extormity vantage point, we believe it's high time to reinforce the barriers to widespread adoption and meaningful use. The lofty sounding concept of electronic medical records for the masses will only serve to spur innovation and erode our sizable margins. We long for the halcyon days when only the well-funded specialty practices and health systems were investing in health care IT, and they paid dearly for the privilege. Sure, we have a locust army of salespeople infesting every mom and pop practice -- extracting $44,000, implanting barely usable solutions and moving on to the next fertile land mass. However, we are doing our best to provide shoddy support to these little guys, virtually guaranteeing a rapid de-install and a default to paper charts. As small practices revert back to their comfort zones, we will return to the sizable health systems with their overflowing war chests.
** = Extormity is a satirical electronic health record vendor with a tag line of "Expensive, Exasperating, Exhaustive." It is the brainchild of executives from Medical Informatics Engineering, or MIE, and NoMoreClipboard.