13 Experts Reflect on 2013 Health IT Progress, Frustrations and Hopes for 2014

by Kate Ackerman, iHealthBeat Editor in Chief

2013 marked significant growth in the adoption and meaningful use of electronic health records, as well as some key changes that could affect the future of the program.

As of the end of October, CMS has disbursed nearly $17 billion in incentive payments to eligible hospitals and medical professionals participating in the meaningful use program. CMS reported at that time that more than 430,000 eligible hospitals and professionals had achieved meaningful use of EHRs, while 93% of eligible hospitals and 80% of eligible professionals had registered for the program.

Despite the progress, both lawmakers and health care stakeholders urged federal officials to make changes to the timeline of the meaningful use program, citing a limited number of Stage 2 certified EHR vendors and a host of competing federal health IT priorities. Federal officials listened, and in December CMS proposed delaying the start of Stage 3 of the meaningful use program, while the Office of the National Coordinator for Health IT proposed adjustments to its certification process.

Under CMS' revised meaningful use timeline:

  • Stage 2 would be extended through 2016; and
  • Stage 3 would begin in 2017 for health care providers who have completed at least two years in Stage 2 of the program.
While many health IT stakeholders commended federal officials for tweaking the timeline, calling it a "welcome reprieve," not all were pleased by the changes.

Some health care provider groups still are pushing for a delay to the start of Stage 2 and added flexibility for Stage 2 of the program, while some patient advocacy groups called the delay of the start of Stage 3 "disappointing," arguing that it could stall progress.

Meanwhile, Farzad Mostashari in August announced that he would step down in the fall after serving two years as the country's health IT chief. The following month, the Office of the National Coordinator for Health IT named Jacob Reider, director of ONC's Office of the Chief Medical Officer, as the agency's acting national coordinator.

In December, HHS Secretary Kathleen Sebelius announced that Karen DeSalvo, city of New Orleans' health commissioner, will be the next national coordinator for health IT. As an ONC outsider, DeSalvo is an interesting -- and somewhat surprising -- pick to take the reins as the country's fifth national coordinator for health IT. DeSalvo joins ONC on Jan. 13.

Other notable events in the health IT space in 2013 included:

For the third year in a row, iHealthBeat asked a variety of stakeholders to weigh in on health IT progress, disappointments and hopes for the future.

Each health IT expert answered via email three questions about the most significant health IT development in 2013, the biggest disappointment in the past year and how the remaining barriers to widespread health IT adoption should be addressed in 2014.

We received responses from:

  • Russell Branzell [@CHIMECEO], president and CEO of the College of Healthcare Information Management Executives;
  • Jennifer Covich Bordenick [@eHealthDC], CEO of the eHealth Initiative;
  • Dave deBronkart [@ePatientDave], keynote speaker and advocate for patient engagement widely known as "e-Patient Dave";
  • John Halamka [@jhalamka], CIO of Beth Israel Deaconess Medical Center and Harvard Medical School;
  • David Harlow [@healthblawg], principal of The Harlow Group LLC;
  • Leonard Kish [@leonardkish], principal and co-founder of VivaPhi;
  • Tom Leary [@TLearyHIMSS], vice president for government relations at the Healthcare Information and Management Systems Society;
  • Jonathan Linkous [@AmericanTelemed], CEO of the American Telemedicine Association;
  • Michele McGlynn [@SiemensHealth], chair of the Electronic Health Records Association and senior director of strategy & operations at Siemens Healthcare;
  • Randy McCleese [@McCleeseRandy], vice president of information services and CIO at St. Claire Regional Medical Center in Morehead, Ky.;
  • Jacob Reider [@Jacobr], acting national coordinator for health IT and director of ONC's Office of the Chief Medical Officer;
  • Mark Savage [@NPWF], director of Health IT Policy and Programs at the National Partnership for Women & Families; and
  • Jeff Smith [@jefferyrlsmith], director of Public Policy at CHIME.

Russell Branzell, CEO of the College of Healthcare Information Management Executives

What was the most significant health IT development over the past year?

The successful attestation for meaningful use Stage 1 by a majority of the nation's hospitals and physicians. This represents a major milestone in the overall adoption of health IT across the entire nation and continuum of care. It will serve as the foundation for next level advancement and outcome achievement for improved quality, improved safety and affordable care. This level of adoption is truly a testament to the hard work and dedication of the clinical and technical teams serving in health care systems, physician offices and federal/state agencies. We have come a long way in a short time, but we have so much farther to go in even less time.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

The lack of flexibility in implementation timing, with the convergence of so many critical initiatives in 2014, truly is a disappointment for this year. Although there [are] positive and hopeful discussions continuing, the reality is the workload-associated risk colliding in 2014 creates great concern for me and the members of CHIME. The concern is both for patient safety and the quality of outcomes from so many competing initiatives.

Looking forward to 2014, 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?

Barriers that still need to be resolved include clear, specific and enforced standards; patient matching approaches that are consistent across the entire country; flexibility through the adjustments of the timing of 2014 initiatives, specifically the start of Stage 2; and aligned quality metrics across all incentive and governmental programs. All of these are either achievable or major advancements that can and should be accomplished in 2014.

Jennifer Covich Bordenick, CEO of the eHealth Initiative

What was the most significant health IT development over the past year?

Transition, consolidation and change were significant this year in the private sector. Mergers, acquisitions and personnel changes were rampant amongst all different sectors in health care. 2013 was not just business as usual. It is clear that health IT organizations are taking stock of their financial, operational and strategic options. In the public sector, the recent decision from the federal government to extend the timeline for meaningful use stage 2 and 3 was critical. It was a nod to the private sector that our concerns are being heard. Finally, the selection of a new national coordinator for health IT sent a clear signal that a new direction is imminent.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

The launch of the new online insurance exchanges was a missed opportunity to demonstrate to the world the value of health IT. While nobody expected a seamless launch, we missed a chance to show the grace and ease that technology offers. That said, several of the state programs were extremely successful, and I am optimistic that the recent successes over the last few weeks have helped the federal program rebound.

Looking forward to 2014, 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 HITECH and meaningful use program made significant strides in the last several years. We have increased adoption, made enormous financial investments and expended significant policy resources. It is important to remember that the program was conceptualized in 2009, almost five years ago -- before the prevalence of smartphones, mobile health apps, analytics and the cloud. That does not mean it is outdated, but it is imperative that we revisit our approach to ensure our infrastructure and policies still make sense. In 2014, eHealth Initiative will work closely with our members to assess our current state and help set a path forward.

Dave deBronkart, keynote speaker and advocate for patient engagement widely known as "e-Patient Dave"

What was the most significant health IT development over the past year?

OpenNotes, the multiyear study that proved the benefits of patient access to visit notes, is going deep and wide really fast. (When was the last time you saw a new method spread like wildfire?) It's significant because although 2013 saw a slew of advancement on the product side, it'll stall without culture change. And for culture change, nothing beats evidence combined with widespread endorsement from leading authorities.

Big names are going OpenNotes at large scale: MILLIONS of patient have access now, as large systems like the Department of Veterans Affairs and the Cleveland Clinic have joined the study participants (Beth Israel Deaconess, Geisinger, Harborview) and pioneer adopters like M.D. Anderson. Importantly, the concept is no longer limited to primary care -- Beth Israel Deaconess and others are extending it to all specialties.

Messaging in the most trusted journals rolled out too. At year-end, a Perspective in the Dec. 4 issue of the New England Journal of Medicine discusses OpenNotes policies as a likely standard of care(!), following a Viewpoint in the November Journal of the American Medical Association by Consumers Union President James Guest, accompanied by a piece in the December issue of Consumer Reports (direct to the citizen).

I can't stress enough that OpenNotes policies are really important. I nearly sputter when I think about the human impact: patients and their caregivers have the most at stake in the accuracy, completeness and availability of the medical record, yet in two recent examples from my own social circles, we were told we could check the chart AFTER the patient was discharged.

This is Russian roulette with health IT: whether any mistakes will hit the bedside is left to chance. And it's not just a risk to patients -- it's a disservice to the clinicians: they can't possibly perform to the top of their training and experience if the chart is wrong or incomplete.

Please, my data geek brothers and sisters, be not shy! Say to thy colleagues: "I bring thee data that might improve health. Let us share it with the most affected stakeholder -- our patients and their families. Let patients help!"

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

Same [answer] as last year: all missed opportunities are just next year's agenda.

Looking forward to 2014, 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 "next big thing" opportunity to lock in adoption, for both users and vendors, is to fix usability.

This year I got an X-ray at an independent radiology shop, just as they were learning their new small-practice EMR. The number of clicks for simple tasks was hideous. Usability like that creates user hatred. Vendors, you got your money; now fix it.

Be assured, in the next two years some providers will ditch and switch, as Cedars Sinai did years ago in their famous "cream of the crap" episode. (Google it.) When that happens, you don't want to be the unresponsive vendor -- you want to be the one people flock to!

In 2013, policies took effect and this vast, vast industry made the gigantic first step, moving the whole industry up the mountain. In 2014, our job is to lock it in: smooth out what works and fix what doesn't. And please, everyone -- let patients be your active partner. Let patients help.

John Halamka, CIO of Beth Israel Deaconess Medical Center and Harvard Medical School

What was the most significant health IT development over the past year?

The Affordable Care Act is leading to more care management and collaboration, aligning incentives for the adoption of health information exchange.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

The meaningful use Stage 2 Certification process is so cumbersome that many niche EHR vendors and innovators have closed their doors.

Looking forward to 2014, 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 number of programs being executed simultaneously -- ICD-10, meaningful use Stage 2, the Affordable Care Act and the HIPAA Omnibus Rule -- has removed discretionary project planning from health care IT departments. They will spend 2014 on regulatory compliance, leaving no time for local innovations in quality, safety and efficiency.

The HIPAA Omnibus Rule is causing organizations to enhance spending on security which is a good thing for the maturity of their processes, policies and technology.

Patient and family engagement is being driven from the bottom up (consumer demand) and top down (ONC/HHS). It's highly likely that we'll see more innovative applications within and bolted onto EHRs.

David Harlow, principal of The Harlow Group LLC

What was the most significant health IT development over the past year?

The release of the HIPAA Omnibus Rule. The rule affects all sectors of the health IT ecosystem -- providers, vendors, analytics, research, marketing, developers and, of course, patients. The newly firmed-up right to patient-directed flow of information ("zap me my entire medical record now, please") and the data segmentation that patients are permitted to require ("don't send this information to my insurance company") pose significant implementation challenges for some -- both technical and cultural.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

The fact that Direct is not being used more widely in order to make patient portals less vendor-specific and more patient-centric. Providers should see that openness as a benefit to patients and as something patients would be grateful to have. By making information more open, providers may be able to command greater patient loyalty than by keeping information bottled up.

Looking forward to 2014, 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?

Are we talking about meaningful use as defined by the HITECH Act and related regulations, or about "true" meaningful use? The two are not necessarily the same thing. If the former, the barriers are the technical and cost barriers which may be somewhat ameliorated by the longer lead time recently afforded Stage 3. (To a certain extent, there is continued generational resistance at the private practice level, and there isn't much one can do about that.)

If the latter, then the barriers are the standards and measures that create the check-the-box approach to health systems improvement and health status improvement that are not necessarily optimized to create the health care system of the future or the best outcomes for the most patients. True meaningful use requires higher levels of patient engagement than are required by the regulations in order to enable health care providers to help patients help themselves (ourselves!) make better lifestyle choices (diet, exercise, etc.) that are the key determinants of health status. Much of chronic disease is preventable, and chronic disease care accounts for a disproportionate share of our health care spend. Care for injuries and acute disease may be optimized through population-based analysis of EHR data.

In short, I believe that health IT can be a significant force in improving preventive care, personalized medicine and population health; we just have to get out of our own way in order to make it work.

Leonard Kish, principal and co-founder of VivaPhi

What was the most significant health IT development over the past year?

There were a lot of developments of note, and for most we won't know the full effects of for quite some time: Commonwell, Healthcare.gov, the effectiveness (or not) of mobile apps, the rejection of many early EHR solutions, continued adoption of value-based payment models, the move toward health platforms by Aetna (Carepass) and possibly WebMD.

Another that may have a bigger impact is 23andMe, FDA relationship and the letter. Long-term, I don't think it (but mostly I hope) will have a big impact on DTC analysis (although it certainly will in the one-three year timeframe, but better technologies and analysis will emerge), but it will have a short-term impact on patient access to their data and raises a lot of interesting questions: What is a device? What constitutes a diagnosis? And, how much (if any) should a whole set of algorithms be regulated over any single algorithm? I hope to see the whole analytics market become more open rather than reducing access to data.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

The growing opportunity is still the data. I wouldn't even call it big data, just data. Giving hospitals and caregivers even minimal reporting capabilities will be a big step forward. Now with meaningful use Stage 1 underway, there's a lot of data in EHRs, and also in mobile apps, in claims data and All-Payer Claims Databases, just to name a few. There's consumer data, including [direct to consumer] tests like 23andMe.

Mostly I'm disappointed in access and utilization of all this data. I'm disappointed by the 23andMe case, not for one side or the other, because there were mistakes on both sides, but because it will slow individual access to data, and the less access to data, the less value there is. There are network effects at work. The more access there is to health data, the more valuable all health data will become in terms of our ability to do accurate diagnostics and make accurate predictions. The same is true for EHRs, most of which have convoluted reporting processes. Just giving docs access to analytics would be a huge step forward. We need the right balance.

Looking forward to 2014, 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 fewest barriers are when patients share their own data. I'm a little disappointed in the extension for meaningful use Stage 2, but I hope, independent of Stage 2, to see more widespread use of consumers using their own data in health IT. My retired mother carries a kind of personal Blue Button two-page sheet she has developed and manages on her own for a loved one. I hope that caregivers like her will have access to the same kind of dashboard that she has essentially developed herself. We need to make it easy, with docs having access to something similar and accurate that summarizes a patient's info on a dashboard. Right now, it often takes 30 to 40 minutes for a physician to sift through a patient's electronic record! That's a very expensive use of time. We need something that makes decisions quicker and more effectively, with better user experience. To do that, we need more easy-to-use tools, better access and, perhaps more than anything, increased understanding and awareness of the benefits of using our health data better.

My hope and thoughts for the New Year: Let's continue to emphasize that, yes, data is powerful medicine. But let's recognize there are some big differences in terms of risk of giving patients probabilistic data and information compared with medicines we ingest or the crisp, clean answers we've historically expected from medical devices. We have a probabilistic future, and I firmly believe we should have access to this probabilistic information with the best data available and accept the risks. Let's ask in 2014 and get close to consensus on this question: "Do we really need to regulate data in the same way we regulate medical devices?"

Tom Leary, vice president for government relations at the Healthcare Information and Management Systems Society

What was the most significant health IT development over the past year? 

The most significant health IT development in 2013 was the increase in number of eligible professionals, eligible hospitals and critical access hospitals that kept working toward becoming meaningful users and solidifying the foundation of health IT to support care coordination and health care transformation. 

As evidenced by the HIMSS Analytics EMR Adoption Model percentages, we have seen a significant growth of organizations that are achieving higher levels of health IT adoption and implementation, leading to being technologically prepared to share data across their facilities and with other providers and care settings. Since the start of meaningful use, we have seen a more than 80% increase in EMRAM Stage 5 and Stage 6 facilities and more than a 60% increase in EMRAM Stage 7. Coupled with the Value of Health IT case studies that HIMSS has collected on the adoption, implementation and return on investment for health IT, these developments should be significant and encouraging for policymakers at all levels of government.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

I tend to be optimistic about the health IT space but would say that there are several components of health IT that have missed opportunities in 2013. First, given the challenges some providers, hospitals and vendors are experiencing upgrading to the 2014 certification, we are still hopeful that the government will address the timeline for Year 1 of meaningful use Stage 2 and allow at least 18 months in which eligible hospitals and eligible professionals can attest to meaningful use requirements for one quarter.

Finally, and most significantly, we still have challenges and opportunities to advance interoperability, moving away from the perceived silos of care to true care coordination that is consistent with payment reform initiatives and health care transformation.

Looking forward to 2014, 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 am looking forward to the endless possibilities 2014 will bring to health IT! The biggest remaining barriers are tied to educating consumers, providers and hospitals on why an investment in health IT is critically important to improvements in health care quality and cost containment. HIMSS and our health IT community partners can continue to work with all levels of government to ensure that all stakeholders have the tools they need to adopt, implement, and achieve a return on investment. We also need to be open to adjusting expectations in order to navigate through the Perfect Storm of Opportunity in Health IT.

Jonathan Linkous, CEO of the American Telemedicine Association

What was the most significant health IT development over the past year?

The biggest health IT development for telemedicine in 2013 has been the fact that choosing and paying for technology (devices and connectivity) is no longer the single biggest factor in deploying remote health services. Increasingly, the catch phrase for telemedicine, telehealth, m-health or connected health is that "it's not about the technology, it's about the service." The ubiquity of telecommunications, the increased reliability and ease-of-use of the technology and the increased adoption of telemedicine by rank-and-file providers and health systems have evolved the focus toward integrated work flows, practice regulations, outcome measures and business plans. It's a sign of success.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

There were several missed opportunities this year. State legislatures made a tremendous effort to adopt laws expanding reimbursement for telemedicine by private payers and Medicaid. Backers of the proposed bills came from both sides of the aisle, from urban and rural districts.  Unfortunately, not all measures passed. 

Looking forward to 2014, 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?

Two factors.

First, fee-for-service payments for health services are an anathema to the use of almost all health IT. As health systems and payers adopt alternative payment mechanisms such as medical homes, accountable care organizations and managed care, the incentives will be in place to leapfrog the use of technology throughout health care, wherever such use results in quality improvement and cost reduction.

Second, as more and more primary care practices and health systems deploy user-friendly patient portals, consumer demand will slowly grow. No one would dream of using a bank that did not offer access to an ATM. Soon consumer expectations will be the same for online appointments, test results and even consultations. Once patients start picking their care provider based on such factors, adoption will come almost overnight.

Michele McGlynn, chair of the Electronic Health Records Association and senior director of strategy & operations at Siemens Healthcare

What was the most significant health IT development over the past year?

In our view, the most important accomplishment for the health care industry was the significant growth in adoption of EHRs by hospitals and physicians' practices, with notable growth in participation and incentive qualification for the Medicare and Medicaid health IT incentive program (meaningful use). We continue to work with CMS, ONC and other stakeholders to refine and improve the regulations and their implementation and roll-out as we move into Stage 2 and begin policy discussions on Stage 3. It's clear that the program has been successful in increasing adoption and use of EHRs and related health IT and that more health care providers and their patients are benefiting from the value of these technologies.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

It's likely that some stakeholders are disappointed that we aren't further along the path toward broad health information exchange (HIE) and interoperability. Significant progress is being made and we expect to see the benefits in 2014 and 2015. We expect that HIE and interoperability will increase substantially as a result of new standards-based capabilities and associated provider exchange requirements associated with Stage 2 and the associated 2014 certification provisions, as well as continued growth in HIE organizations and new exchange models. Perhaps even more powerful will be demand for HIE created by the growth in accountable care and integrated health care systems, and creation of new business cases for HIE.

Looking forward to 2014, 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 believe we are at the point in the US, based on various studies and data on EHR incentive program growth, where we have widespread adoption and use of EHRs. As we move into 2014, the greatest opportunities involve continued alignment of payment and delivery system incentives to establish a robust business case for investment in and use of health IT, including HIE and interoperability. In addition, it is essential that federal and state implementation of the EHR incentive program move towards greater simplicity, higher quality, more timely regulations and supporting materials, transparency and clarity to reduce burdens on providers and software developers, create more room for innovation and recognize that providers face a "perfect storm" of challenges. These challenges include ICD-10, new delivery and payment models and the need to implement and use upgraded EHR versions that comply with 2014 certification requirements. Also, as we move toward Stage 3 -- which is intended to focus on improving clinical outcomes -- it will be important to coordinate clinical quality measures across all government (federal and state) agencies that require CQM reporting.

We continue to share our feedback with CMS and ONC and work with other stakeholders on the many issues. We remain optimistic that, with the right focus and priority, we'll be positioned to support our customers -- the majority of hospitals and physician practices using EHRs in the US. With respect to Stage 3, although we appreciate the CMS decision to move the start of Stage 3 to 2017, we urge CMS and ONC to adopt a final regulatory timetable that allows vendors and providers sufficient time to implement new requirements for EHRs and their use, with at least 18 months from availability of final rules and all associated guidance before Stage 3 starts. Otherwise, we will be in a similar situation as we are with Stage 2, with a very compressed timeframe. We also urge CMS and ONC to take a very focused approach to Stage 3 meaningful use and certification requirements to enable providers to realize the full value of the Stage 2/2014 certification enhancements and to prepare for emerging payment and delivery models, rather than having to take on another set of complex and prescriptive requirements and a major EHR upgrade so soon after the 2014 upgrade.

Randy McCleese, vice president of information services and CIO at St. Claire Regional Medical Center in Morehead, Ky., and 2014 chair of CHIME's board of trustees

What was the most significant health IT development over the past year?

2013 was a year that saw a significant number of happenings in health IT. The increased use of mobility is one of the trends at the top of my list as being the most significant. Consumers and caregivers alike are rapidly adopting mobile devices and want to use them in their everyday lives. This rapid adoption is outpacing the behind-the-scenes work that needs to be done by health care IT departments, so as to ensure security of data and appropriate access to electronic records.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

The biggest disappointment is the amount of time that providers are required to spend on meaningful use audits. Based on conversations with other CIOs who have been involved in these audits, a significant amount of the work that has to be done involves educating the auditors on health care processes and procedures. With the amount of work that has to be done in health care today, we have very limited time to provide education for things that auditors should already know.

Looking forward to 2014, 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 numerous initiatives in the health IT space for 2014 -- ICD-10, meaningful use Stage 1, meaningful use Stage 2, the future of meaningful use Stage 3, accountable care organizations, the Affordable Care Act, payment reform and others. So many things are happening with near-simultaneous deadlines that many CIOs see it as the perfect storm on the horizon. Additionally, many care providers are having a hard time adapting to the "new health care" in such a short amount of time. Changing to an all-digital environment is difficult for providers, especially physicians who have practiced in the same manner for 20 or 30 years. One thing that can happen to address the challenges is to postpone some of the deadlines so providers can adopt the technology and learn to tweak it (optimize) before having to change simply because new requirements demand an update.

Jacob Reider, acting national coordinator for health IT and director of ONC's Office of the Chief Medical Officer

What was the most significant health IT development over the past year?

There was a number of significant health IT developments in 2013, beginning with the increase in adoption among eligible health care providers. Between 2009 and 2012, EHR adoption nearly doubled among physicians and more than tripled among hospitals. As of October 2013, 85% of eligible hospitals and more than 60% of eligible professionals had received a Medicare or Medicaid EHR incentive payment. Moreover, 90% of eligible hospitals and 80% eligible professionals had taken the initial step of registering for the Medicare or Medicaid EHR Incentive Programs as of October 2013. We attribute some of this increase in adoption to the work of ONC's Regional Extension Centers -- RECs recruited almost 134,000 primary care providers (44% of the nation's PCPs); 85% of them were using EHRs with advanced functionality and about 50% have achieved meaningful use. About 85% of Federally Qualified Health Centers and about 80% of critical access hospitals worked with RECs.

The release of the HHS Patient Safety Action and Surveillance Plan was the first step in helping to draw attention to the importance of ensuring the safe development, implementation and use of health IT, which in itself is a tool to helping ensure that care is safe. We will be building on the plan with the release of the SAFER guides in the next months.

We have offered tools to help providers ensure that their use of EHRs and other health IT is safe and secure -- in 2013 we posted new checklists and online tools to help them make sure that they are keeping patient information secure if they are using mobile devices and ways to ensure the security of electronic health information in their practices -- all tools to help them achieve the meaningful use security assessments.

We have made steps toward health information exchange with the work conducted by the National eHealth Collaborative and Direct Trust and the comments we and CMS received in response to the request for information that was issued early last year that will allow for the use of health IT to transform the nation's care delivery system. Both ONC and CMS have seen the value of health information exchange in programs like the State Innovation Models and Health Care Innovation programs and even through the reduction of hospital readmissions.

2013 also marked the launch of our 2014 certification program for EHR technology. These criteria are much more comprehensive than previous editions of our certification criteria, presenting a "heavier lift" for technology developers, while providing greater assurance for purchasers of these products.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

2014 Edition EHR technology certification program did not launch as soon as we would have liked. Certain electronic testing tools took some additional time to get right, along with other delays (like the government shutdown), all of which set back EHR technology developers' schedules.

Looking forward to 2014, 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?

Let's be clear about our goals. Widespread adoption and meaningful use of health IT is just a means to better health for the nation. So it's always important that we view health IT as an essential part of a transformed care delivery system, and not a solution looking for a problem.

In 2014, more providers will be adopting EHRs and meaningfully using EHRs in the United States than ever before. That means more and more of them will not only be attesting to achieving meaningful use Stage 1, but also Stage 2. This will result in even more patients having access to their health information through the Stage 2 requirements for view, download and transmit, as well as interacting with care provides through secure messaging. While many patients will continue to act as their own "health information exchange," we expect that many will also begin to ask whether their providers are able to securely and safely electronically exchange information with each other.

Through our work with stakeholders from all facets of the care delivery continuum, we will see enhanced levels of interoperability as a byproduct of Stage 2 of the meaningful use incentive program and the requirement to use 2014 Edition certified products. 

We will continue to implement the HHS Health IT Safety Action Plan with the release of SAFER guides, which will give providers tools to help them safely and securely implement EHR systems and, with contract support from The Joint Commission and Mitre, we expect even broader public-private partnerships will be established to help assure the safety of health IT products.

We are also working hard on many other projects that will help care delivery organizations improve care: our clinical quality improvement initiatives are focused on improved technical standards for quality measurement and clinical decision support; we are working with industry stakeholders to create and maintain guidance for governance of information exchange; we are working with NIST and other federal partners on the National Strategy for Trusted Identities in Cyberspace initiative to improve both the security and efficiency of identity management in health care; and we continue to manage and maintain the two federal advisory committees -- the Health IT Standards Committee and the Health IT Policy Committee -- through which we plan for future policy and standards actions where indicated. Government must do what we must do -- and no more. Navigating the threshold between what we must do and what we could do is no easy task, and we are grateful to the hundreds of stakeholders who volunteer their time and effort in helping us to understand what's happening out there in "the real world."

Mark Savage, director of Health IT Policy and Programs at the National Partnership for Women & Families

What was the most significant health IT development over the past year?

Now under Stage 2 of the meaningful use program, patients can electronically view, download or transmit their health information within four business days and get summaries of office visits within one business day -- a great advance for patients and families. Consider what a major transformation this is for health care: Under the HIPAA Privacy Rule, patients had a right to inspect and copy their health data within 30-90 days of the request; regulations under the HITECH Act reduced that to 30-60 days. But imagine waiting 30-60 days for access to your bank account information! Now, patients and families need no longer wait for critical health information, either. In fact, with Blue Button, where available, patients can even get access at the click of a button. And according to a 2012 survey by the National Partnership for Women & Families, when patients have online access to their health information, 80% use it.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

Reducing health disparities remains a key gap in EHR functionality and policy. A few examples illustrate the magnitude of this problem and the urgent need for a solution. According to the 2010 Census, more than 60 million people speak a language other than English at home, yet current proposals for Stage 3 would only require that a provider deliver one patient specific educational resource to one patient in that patient's preferred language. More than 56 million people have a disability, yet current proposals only require certified EHR technology to record disability status, not to accommodate it. Significant health disparities exist for these and many other populations. We have an opportunity to build electronic health records and policy right the first time, without costly retrofitting later. We should be integrating language access and more granular demographic data collection in order to better identify and address disparities.

Looking forward to 2014, 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?

Better care, better health and lower costs require better engagement, better access and better partnership with the patient at the center. First, meaningful use requires more than access alone. In 2014, we must make electronic health information exchange truly bi-directional, adding patient-generated health data to provider-generated health data and building partnerships among patients and providers. Second, access does not mean understanding. The Spanish-speaking patient might not understand a visit summary in English. Discharge instructions written for college graduates might puzzle many with lower literacy levels. In 2014, we need much more progress toward language access and integrating electronic tools that adjust for different literacy levels. Third, the aim is better health, so we must involve patients and families in their health and care planning. In 2014, we need more progress in incorporating patients and caregivers into identifying and achieving health goals. Finally, delaying Stage 3 delays meeting these core needs, so we must use the extra time to take these critical next steps.

Jeff Smith, director of Public Policy at CHIME

What was the most significant health IT development over the past year?

In some ways, 2013 was the year that meaningful use lost its innocence. For the first time, criticisms coming from Congress and provider groups in Washington made headlines; more than that, they made an impact. The pressure began in April when several U.S. senators released a report critical of several aspects of the policy, and that was followed by hearings in the summer. A letter from 17 U.S. senators was released in September, asking HHS to give providers more flexibility to meet meaningful use criteria in 2014. This was significant because defenders of meaningful use were able shift the conversation away from what was wrong with meaningful use to one that focused on how to make it successful for the long run.

What was the biggest disappointment or missed opportunity in the health IT space in 2013?

It was hard to see the last few months come and go without an announcement on Stage 2 meaningful use from the administration. Through the rollout of Healthcare.gov, the whole country learned how difficult technology implementation can be. In ICD-10, we are looking at an event where the deadlines are firm and the scope is set. With meaningful use, we have an opportunity to provide some relief, at least on timelines. While we're disappointed the administration did not announce flexibility for meaningful use when hospitals across the country were setting budgets, we believe there is still time to make the right decision. Ratcheting down the scope of meaningful use makes little sense, but providing flexibility on timelines does.

Looking forward to 2014, 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?

Hopefully, as we see 2014 Edition certified EHR technology saturate the market, the standards promoted by the use of the technology will get us closer to interoperability. Also, there are a host of HIEs that are standing on their own, apart from government funding and providing real value to clinicians. There will be more evolution in the HIE/HIO market, but I'm hopeful that 2014 will see a maturing of business practices and further stability among health data exchange organizations. However, one of the biggest barriers continues to be the pace and volume of change. Reimbursement models, and the technology needed to support them, continue to change. Add to that ICD-10, Stage 2 meaningful use, numerous quality measurement programs and you have got a major list of to-dos. And quite simply many organizations will not be able to keep up with these market changes and government mandates.



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