It's been a year since the American Recovery and Reinvestment Act and the HITECH Act got the president's signature. Since then, there have been countless meetings of standards-setters, CIO experts and medical informatics pros, all opining on the meaning of "meaningful use," the criteria for certifying electronic health records and the vision for a Nationwide Health Information Network.
As they asked in "Seasons of Love" from Rent, "565,600 minutes … how do you measure a year?" The chorus's response: "In cups of coffee, in inches, in miles, in laughter, in strife." And 525,000 journeys to plan.
That's about the number of physicians who will be affected by the 2009 federal economic stimulus plan, and based on what I heard among those clinicians who haven't yet adopted an EHR, they're barely willing to Rent, let alone Buy, an EHR based on their latest understanding about what's involved with the process of adopting what seems to be a still-evolving set of rules.
Two mantras permeated the Healthcare Information and Management Systems Society conference's vendor floor: "We Can Help You Connect" (the health information exchange message), and "We'll Make It Meaningful for You." Most vendors are offering various flavors of meaningful use guarantee, this word being used in a wide range of ways based on vendors' lawyers' taste for going at-risk. As such, meaningful use still seems largely in the eye of the beholder.
This lack of consensus and crispness adversely impacts solo and small practices as they need greater clarity and comfort; the smaller the practice, the greater the risk-per-physician from a scaling perspective.
On the other hand, the connectivity/HIE scenario is something that makes manifest the old saw that all health care is local (with a nod to Tip O'Neill). RelayHealth management told me in detail of their HIE projects in over 50 communities, from Northern California to New Jersey. The drivers in these projects are physician alignment and hospital connectivity to doctors, and brand building in local/regional health markets. The relatively fast proliferation of these projects throughout the U.S. means that health providers see value in the HIE concept.
This local/regional infrastructure is enabling data liquidity and health information connectivity between physicians and hospitals. As Dr. David C. Kibbe characterized it for me, the local HIE projects are de facto "EHRs for a Small Planet." Kibbe is the senior adviser on health IT to the American Academy of Family Physicians, as well as the chair of the ASTM International E31 Technical Committee on Healthcare Informatics. He deeply understands where physicians are on the EHR adoption spectrum.
Community-Level Action
Far away from the glitz and glamour of the showroom floor is the sleeves-rolled-up reality that local and community health information exchange activity is outpacing bigger, more complex and expensive state-wide exchange building. This means that community hospitals and health centers, local medical practices, labs and imaging centers, have begun the heavy lifting of clinical integration.
The stakeholders who commit to these local projects recognize the value of collaborating in them: benefits accrue in the forms of quality improvement and care coordination for patients who, before, were poorly managed in an episodic, fragmented fashion.
The local collaborations aren't waiting for the larger national or state initiatives to percolate down. This is grassroots health care, and it's got traction.
Here's another riff on the health-care-is-local theme driving health IT adoption that I heard at HIMSS this year. GE Healthcare works closely with the Boston Medical Center. This 626-bed urban hospital is New England's largest safety-net hospital and is Massachusetts' largest provider of medical services to the poor. The institution said it would lose $175 million this fiscal year.
But the hospital remains committed to building its electronic health information infrastructure that services both inner city Boston and connects with clinics throughout the community. That's the only way to successfully affect population health, reach out to schools and improve health outcomes for some of New England's sickest citizens. BMC's investment in its electronic health information backbone and systems builds connectivity that is making a difference for healthy citizens in its catchment area. This investment will help the institution sustain itself over the longer term because it will be able to provide care more cost-effectively -- deploying the right resources to the right patients at the right time.
The message of health care/local is sustainability: while grants and incentives will flow for HIEs and EHRs, only those projects and implementations that ultimately serve the benefits of patients and the clinicians who serve them will find value in the spending. As one of my colleagues asked me as we noted the number of 'connectivity'-emblazoned banners, "connectivity for what?"
John Halamka -- chair of the Health IT Standards Panel, co-chair of the Health IT Standards Committee and CIO of Harvard Medical School -- wrote in his blog's post-HIMSS observations that many of HIMSS' nearly 30,000 attendees came to the party to "better understand how they could participate in the euphoria of HITECH stimulus dollars." But we've seen millions, possibly billions, of taxpayer dollars spent on big-vision health IT programs in the past, Community Health Information Networks (CHINs) and telemedicine pilots among them.
At the end of the day, it's the heavy lifting of patient care and health engagement that are going to be meaningful long after the HIMSS parties, colorful corporate knick-knacks and euphoria pass.