Health IT in 2013: A Year in Review

This past year has been a big year for health information technology and sets the stage for 2014 to be a pivotal time as IT plays an integral part in healthcare transformation.

One of the biggest stories of the year was the disastrous launch of healthcare.gov. I think this has been more than adequately covered elsewhere. I actually do not believe that despite the massive failures at both the federal and state levels (including my home state of Oregon) this is going to be a long-term issue. Websites will be fixed and we will still face a host of other issues as we continue to try to provide the right information to the right clinician at the right time.

2013 has seen some great progress, with still a lot of work yet to do.

EHR Adoption

2013 started with some great success in EHR adoption and strides towards meaningful use. Over $10 billion had been disbursed early in the year as more than half of all doctors and other eligible providers received Medicare or Medicaid incentive payments. EHR adoption continued to climb and actually tripled during the past four years in hospital settings with significant increases in ambulatory markets as well—even the NFL adopted an EHR this year.

However, there were concerns that EHR vendors faced a year of possible client ultimatums and revolts as customers considered switching platforms and the market continued to shake out. Still, according to the Robert Wood Johnson Foundation’s annual report, “Health Information Technology in the United States: Better Information Systems for Better Care, 2013,” over the last several years, hospitals, physicians and other providers have made significant strides in the adoption of health information technology. The latest figures show that the U.S. will likely exceed $17 billion dollars in incentive payments by the close of 2013.

Meaningful Use Changes

In May some Senators published a whitepaper “Reboot: Re-examining the Strategies Needed to Adopt Health IT” where they outlined their concerns with current health IT policy, including the costs, interoperability, the potential for waste and abuse, patient privacy, and sustainability, and suggested there might need to be a delay in the meaningful use incentive program. This was followed by Senate Finance committee hearings where the issue was discussed, and then a chorus of cries from stakeholders that providers and vendors needed more time to prepare for future stages of meaningful use.

On December 6, 2013, the ONC and CMS announced some changes to the timelines for meaningful use. This change added a third year to Stage 2 of the EHR meaningful use program and has delayed the start of Stage 3 until 2017. Providers with at least two years of participation in Stage 2 would be able to start Stage 3 in 2017, while providers who have started in either 2011 or 2012 will have an additional year of Stage 2. ONC also intends to publish a proposed rule for a 2015 Edition of certification criteria that would be completely voluntary and improve on the 2014 Edition certification criteria.

While these changes do not yet provide the flexibility that many had hoped for, it is a sign that they are listening to the community and adapting to the environment.

Changing of the Guard

Obviously the changing of the guard at the Office of the National Coordinator for Health IT (ONC) has been quite a significant event this year. On August 6, HHS Secretary Kathleen Sebelius announced that Farzad Mostashari, MD, would be stepping down as National Coordinator. In her e-mail, Sebelius wrote, “Farzad has been a leader in the Office of the National coordinator for Health Information Technology (ONC) for the last four years. Farzad joined the office in 2009 as Principal Deputy National Coordinator and took over as the National Coordinator in 2011. During his tenure,” she wrote, “ONC has been at the forefront of the designing and implementing a number of initiatives to promote the adoption of health IT among healthcare providers. Farzad has seen through the successful design and implementation of ONC’s HITECH programs; linked the meaningful use of electronic health records to population health goals; and laid a strong foundation for increasing the interoperability of health records—all while ensuring the ultimate focus remains on patients and their families.”

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Karen DeSalvo, MD, the new National Coordinator for Health Information Technology at the ONC

In a letter to ONC staff, Dr. Mostashari said “There are formidable challenges still ahead for our community, and for ONC. But none more difficult than what we have already accomplished.”

It was announced that Jacob Reider, the CMO at ONC, would serve as Acting National Coordinator and also that Principal Deputy National Coordinator David Muntz would be leaving the ONC. Dr. Reider served in this interim capacity while a search was made for a permanent replacement. On December 19 it was announced that Dr. Karen DeSalvo, who currently serves as the City of New Orleans Health Commissioner and Senior Health Policy Advisor to Mayor Mitch Landrieu, will be the next National Coordinator for Health IT.

So quite a bit of change in leadership, as well as the beginning of some changes in direction in policy and flexibility in the EHR Incentive Program.

Health Information Exchange

Health information exchange has become more widespread and is showing itself to be a key enabler of both health system transformation and improved care coordination. However, while EHR adoption has seen a steady a increase, HIE still experienced growing pains.

The Robert Wood Johnson Foundation’s annual report, co-authored by Mathematica Policy Research and the Harvard School of Public Health, “Health Information Technology in the United States: Better Information Systems for Better Care, 2013,” showed that 27% of hospitals are now participating in HIE initiatives, up from 14% in 2010. While most of the current exchange is happening using a query (or pull) model, the direct (or push) model is picking up steam. Since the Direct Project protocols are baked into the standards and certification criteria for certified EHR technology as part of the meaningful use program, there has now been a huge uptake in the use of direct secure messaging. I expect this trend to continue.

In March the ONC established cooperative agreements with DirectTrust and the EHR/HIE Interoperability Workgroup as part of  the Exemplar HIE Governance Program. DirectTrust and EHNAC also launched an accreditation program aimed at enabling trust between senders and receivers using the Direct Project protocols. In August the ONC hosted a Direct Boot Camp that built on ONC’s 2012 Direct Scalable Trust Forum with a clear focus on helping providers accelerate the scalability and interoperability of their implementations to support meaningful use stage 2. There has been significant progress in establishing governance, as the National HIE Governance Forum continued its work throughout the year.

2013 was a very good year for HIE, and has laid a strong foundation that will be a good springboard for activity in the coming year.

Patient Engagement

Patient engagement was a big theme in 2013 and we may have reached a tipping point in empowering patients with health information and truly making them a part of the care team.

The OpenNotes project, which began in 2010, was one effort that made a big splash this past year. It involved Beth Israel Deaconess Medical Center in Boston, the Geisinger Health System in rural Pennsylvania, and Harborview Medical Center, a county hospital and safety net provider in Seattle. The project invites patients to read the notes written by their primary care physicians following office visits. They are able to view these notes via the portals where other portions of their medical records are posted.

Another measurement of patient engagement and empowerment comes from the Pew Internet’s Health Online 2013 research by Susannah Fox and Maeve Duggan that shows, among many interesting data points, significant growth in patients accessing health information using the Internet. Information is power, and access to health information gives patients and consumers power over their own healthcare.

The new rules under HIPAA also expanded patient rights to access their own health information. As Deven McGraw, Director of the Health Privacy Project at CDT, said in Congressional testimony, “HIPAA’s provisions by design enable the sharing of health information, including mental health information, for both patient care and public health and safety. However, frequently these provisions are not fully understood and are too often misinterpreted, which may have a detrimental impact on both policy goals.”

The Office of Civil Rights (OCR), which is the agency within HHS that enforces HIPAA, made efforts to educate consumers and healthcare entities alike about the rules. “There is a clear right [under HIPAA] not only of patient access, but patient control over everything in their records,” OCR Director Leon Rodriguez said at the ONC’s Consumer Health IT Summit that was held during National Health IT Week.

blue_buttonDuring this year’s Consumer Health IT Summit the ONC also began an outreach campaign to encourage patients to download their own medical records through the Blue Button Plus initiative. Blue Button is also becoming a verb in healthcare instead of only a noun. Blue Button has continued to scale in 2013 and we are poised for explosive growth ahead. As Lygeia Ricciardi, the Director of the Office of Consumer eHealth at ONC said, “With more than half of Americans using smart phones today, and an abundance of popular health apps and tools such as digital pedometers, glucose monitors, and sleep sensors, consumers are becoming an undeniable part of the equation for better health and healthcare through health information technology.”

The 2013 WEDI Report had a strong focus on patient engagement. Patient engagement was defined as a dialogue between patients and key healthcare stakeholders (e.g. physicians, health plans, care coordinators, and public health). However, the issue spanned several key areas of focus for the purposes of the report. Among the findings were recommendations to standardize the patient identification process across the healthcare system, expand health IT education and literacy programs, and to leverage mobile devices to provide secure and appropriate access.

Conclusion

We have made some great progress in 2013 on EHR adoption, which is really all about data capture and the digitization of health data. Technologically speaking, we are finally beginning to drag the healthcare industry kicking and screaming into the 21st Century. And we’re making strides in interoperability, or data sharing. HIE infrastructure is in place and the policy framework will continue to drive adoption – the business case for sharing data is even more pressing as new payment and care delivery models continue to spring up.

The third piece that has started to emerge this year is health data analytics. This will enable healthcare organizations to realize some significant returns on their IT investments and thrive in the healthcare marketplace of the future.

Whatever your vision for health reform (and I think we can all agree that our system is broken), there is little doubt that the smart use of technology tools are what is going to make us successful. Todd Park, the U.S. CTO, once said that, “”There’s no problem America has we can’t invent our way out of, if we really try.” However, it is claimed that Winston Churchill once opined “The United States can always be relied upon to do the right thing — having first exhausted all possible alternatives.”

There is at least a grain of truth in each of these sayings, and we may have reached a point where they collide.

Brian Ahier

Brian Ahier is a national expert on health information technology with a focus on health data exchange. He is President of Advanced Health Information Exchange Resources, LLC, which has provided consulting services to a variety of industry clients as well as the Office of the National Coordinator at HHS. Brian sits on the Consumer Technology Workgroup of the HIT Standards Committee which makes recommendations to the National Coordinator on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information consistent with the implementation of the Federal Health IT Strategic Plan. Brian is a founding Board member of DirectTrust, and also serves on the Board of HIMSS Oregon and Q-Life., an intergovernmental agency providing broadband capacity to the region. Brian helped found Gorge Health Connect, Inc. (GHC) a health information exchange organization in the Columbia River Gorge where they implemented one of the first Direct Project pilots. Brian worked at Mid-Columbia Medical Center for eleven years, most recently as Health IT Evangelist. He served four years as a City Councilor in The Dalles, Ore., and on the Board for Mid-Columbia Council of Governments. Brian helped develop the Oregon strategic and operational plans for implementing State-Level HIE under the State Health Information Exchange Cooperative Agreement. After the plan was approved by the ONC he was appointed by the State of Oregon Health Information Technology Oversight Council (HITOC) as Chairperson of the Technology Workgroup responsible for developing a framework and providing input for technology goals, including deliverables and objectives, standards, and definition of central services. Brian has worked on a number of workgroups and committees within the Standards and Interoperability Framework and continues to work on the Direct Project.

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