Let's give credit where credit is due. From where I sit, Congress took a big step toward a digital health care system by including the HITECH provisions in the American Recovery and Reinvestment Act of 2009.
Approximately $30 billion in new federal spending was authorized for various health IT activities, the bulk of which goes toward economic incentives for physicians and hospitals to be "meaningful users" of certified electronic health records. Monies were also allocated for extension services, state initiatives, loans and grants. All good.
But I should have known. It was predictable. Certainly there is no reason to be surprised. Having included HITECH and its authorized funding in ARRA, it appears Congress thought its health IT work was done. Were it only that easy.
If we are to have real health care reform, a greater health IT effort is required than what was accomplished in ARRA.
Let's take a brief digression. It is essential, in my mind, that everyone working in health IT -- from the code writers to the technology geeks to the folks in the C suite -- understand that health care reform is the business justification for building a digitized health system. What is driving policymakers to reform the health system is not an altruistic sense of moral obligation.
Sure, there is certainly some of that. But the real driver is the fear that results from a clear-eyed assessment that our current health system is unsustainable. Absent substantial reform, the way we have organized and financed health care will collapse the system (and I don't just mean the health care system, I mean THE system, the economic system of the country).
Incentives Need To Change
While a hot debate is raging on the details of health care reform, there is surprising consensus on the objectives of reform. The growth of health care costs must be constrained. We have to "bend the curve."
The only way to do that is to change the economic incentives of health care, encouraging physicians and other health care providers to work together to coordinate care, to be collectively accountable for each patient's needs, to avoid unnecessary or duplicative care, to better care for patients with chronic illnesses and to be compensated in ways that incent coordination and reward good clinical performance and efficiency. Only by capturing, storing, analyzing and using data can those objectives be met. And that, my friends, is the business justification for a digitized health care system.
So, that being the case, where is the HIT in HCR?
Well, it's not completely absent. The Affordable Health Choices Act -- the Senate Health, Education, Labor and Pensions Committee's health care reform bill -- includes a provision to "develop interoperable and secure standards and protocols that facilitate enrollment of individuals in federal and state health and human services programs."
For anyone who has struggled with enrolling in federal and state programs, this should offer some real relief. The model here is "Health-e-App", an online application for low-income families seeking Medicaid and other health coverage from the state of California.
More Can Be Done
But, come on, is there nothing more that Congress could do to accelerate the digitizing of health care? Well, I have a couple of ideas.
ARRA provided incentives for hospitals and physicians to use EHRs. But that is not enough. The ARRA mechanism by which physicians will receive their HITECH payments provides no incentive for care coordination, a primary objective for health reform. The House's health care reform bill, the so-called "Tri-Committee bill," includes two pilot programs to advance and encourage care coordination.
Among these programs are accountable health care organizations and patient-centered medical homes. Each encourages physicians and other clinicians to coordinate their clinical activities. Yet the Tri-Committee bill provides no support for the use of health IT in that regard. The experience of physician groups, which have been coordinating care for years, is that centralized data systems must be available to support the efforts of clinicians to coordinate care for patients. It's not enough for each physician's EHR to be interoperable; the effort at coordinating care requires systems that support coordination. Why not include health IT support in accountable care and medical home pilot programs?
And, if there are going to be incentives for hospitals and physicians to use EHRs, what about nursing facilities and the long-term care community in general? If there is any sector that could benefit from coordinated care, it is long-term care. The upside to coordinated long-term care -- primarily the avoidance of unnecessary hospitalizations and polypharmacy issues -- is tremendous. The margins for long-term care are sufficiently small that it is unlikely that sector will go digital without some support.
Invest in Advanced Research
But let's go a step -- or 10 -- further. Why not really invest in health IT innovation and a data-driven health care system? Let's call on Congress to create a DARPA for health care. The Defense Advanced Research Projects Agency has generated some of the most remarkable technical research in the world. Virtually every one of us has benefited from DARPA's efforts. Perhaps the most well-known of its accomplishments has been the creation and early development of what we now know as "the Internet." So why not an ARPA for health?
And as long as I'm at it, here's my reform-driven health IT research agenda for ARPA:
Let's make a serious effort at projecting the intersection of new technologies and evolving health needs. How can IT keep people healthier and more independent longer? How can IT help individuals, families and clinicians care for those with illnesses? What technologies from other sectors can be brought to bear in health care?
Let's get out of our boxes.
What new uses can be found for the volumes of data we have and the oceans of data we will be acquiring? Some see the confluence of biologic/genetic data and clinical data. What can we do with this information to predict and prevent disease?
What opportunities are there to re-engineer the process of medicine and the delivery of care once health IT is ubiquitous? How does a small but highly connected physician practice change its work flow, re-architect its office and clinical space? What about virtual examinations? With new generations of sensors and connected devices, is the standard physician office necessary? What will be the most efficient, highest quality way to deliver care, taking advantage of the health IT that lies over the horizon?
How does a digital health system support effective and efficient knowledge transfer? It is generally accepted that the quality and flow of new empirical knowledge is too great for any clinician to keep current. What tools, data flows, and decision support technologies can be developed and delivered to allow clinicians to make the best judgments about the right care for each patient?
The possibilities are endless. Sure, an ARPA for health would confront entrenched bureaucracies and the challenges of starting up. But if ARPA for health accomplished even half of what DARPA has accomplished, health care reform would take on a whole new meaning.