C A L I FOR N I A H EALTH C ARE F OU NDATION Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field January 2008 Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field Prepared for California HealthCare Foundation by Bruce Merlin Fried January 2008 About the Author Bruce Merlin Fried is a partner in Sonnenschein Nath & Rosenthal LLP’s national health care and public law and policy strategies groups. During the course of his career serving both the public and private sectors, Mr. Fried was the chief coordinator of the 1992 Clinton/Gore campaign’s health care advisory group. After the election, he was a member of the president’s transition health policy team. Additionally, Mr. Fried was a senior executive at what is now the Centers for Medicare and Medicaid Services (CMS). He is a founder of the eHealth Initiative, is on the board of SureScripts, and is counsel to the Certification Commission for Healthcare Information Technology. About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information about CHCF, visit us online at www.chcf.org. ©2008 California HealthCare Foundation Contents 2 I. Introduction 6 II. Findings Achieving the President’s Goal: More Potential than Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 The Four Cornerstones: A Conceptual Foundation . . . . . . . . 7 The Nationwide Health Information Network: Mixed Feelings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Interoperability Standards: Easier Said than Done . . . . . . . . 9 Certifying EHRs: An Early Success. . . . . . . . . . . . . . . . . . . . . 10 Reconciling State and Federal Privacy Laws . . . . . . . . . . . . 11 A Larger Role for the Federal Government. . . . . . . . . . . . . . 12 HIT’s Price Tag: Not So Affordable . . . . . . . . . . . . . . . . . . . . 13 Data Exchanges Face an Uncertain Future . . . . . . . . . . . . . 15 . Congress Is Not Doing Its Part . . . . . . . . . . . . . . . . . . . . . . . 16 . Advice for the National Coordinator: Be Pushy and Spend More. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 . EHRs, the Perpetually Emerging Technology. . . . . . . . . . . . 18 2 2 III. Conclusion Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 2 4 Appendix A: espondents and their Professional R Categories 25 Endnotes I. Introduction “ HS is focusing on several key actions: H Four years ago, President Bush outlined a plan to harmonizing health information ensure that most Americans have electronic health records within the next ten years. As part of a larger agenda to advance the use standards; certifying health IT products of technology, the president told the public that he believed that to assure consistency with standards; better health information technology was essential to his vision of addressing variations in privacy a health care system — one that puts the needs of patients first and and security policies that can hinder helps them make clinical and economic decisions in consultation with their physicians. His administration’s health information interoperability; and, developing an technology (HIT) initiative would address longstanding problems architecture for nationwide sharing of of preventable errors, uneven quality, and rising costs in the nation’s electronic health information.” health care system. — David Brailer On April 27, 2004, in announcing the executive order launching the initiative, President Bush called for the majority of Americans to have interoperable electronic health records within ten years. His plan created the new position of National Health Information Technology Coordinator within the office of the Secretary of Health and Human Services. The national coordinator was made responsible for the development and implementation of a strategic plan to guide the nationwide implementation of interoperable health information technology in both the public and private sectors. The plan’s goals are to: K Advance the development, adoption, and implementation of health information technology standards; K Ensure that key HIT issues are addressed; K Evaluate the benefits and costs of interoperable HIT; K Address privacy and security issues; K Avoid assuming additional federal resources or spending to accomplish adoption of interoperable HIT; and K Set targets for measuring progress in implementing HIT. In conjunction with the launch of the federal HIT effort, the President appointed David Brailer, M.D., Ph.D., as national coordinator. Dr. Brailer identified two crucial elements to achieving the President’s vision for HIT: interoperability and the secure portability of health information, and electronic health record (EHR) adoption. As he testified before the Senate Subcommittee 2  |  California HealthCare Foundation Towards a Nationwide Health Information Structure: A Brief History Under his Health Information Technology Adoption Initiative, President Bush has called for the widespread use of electronic health records (EHRs) by 2014. Among the benefits stemming from the use of EHRs are improved quality of care and greater efficiency. Despite the demonstrated improvements in care delivery, however, studies have found that adoption rates for the technology remain low among physicians, hospitals, and other health care providers. The new initiative is aimed at better characterizing and measuring the state of EHR adoption and determining the effectiveness of policies aimed at accelerating the proliferation of EHRs and achieving interoperability. Key Components The initiative calls for: • Convening an expert consensus panel on HIT and EHRs; • Conducting an environmental scan of the current state of EHR adoption measurement and making the gaps in adoption measurement data publicly available, along with the known adoption patterns; • Developing consensus-panel-driven guidelines for EHR adoption measurement and making these guidelines publicly available; • Designing a set of EHR adoption surveys that use the guidelines to measure adoption in multiple settings of care across diverse populations; and • Synthesizing multiple EHR adoption measurements into an annual report on the overall state of EHR adoption, synthesizing multiple surveys using the methodologies developed under the HIT Adoption Initiative. Historical Timeline April 27, 2004 Health Information Technology Adoption Initiative launched by Executive Order of the President May 6, 2004 David Brailer, M.D., Ph.D., is appointed the first national health information technology coordinator. July 21, 2004 HHS publishes report, The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care, prepared by David Brailer, setting out ten-year plan to achieve always-current, always-available electronic health records (EHR) for patients, physicians, and health professionals. October 13, 2004 Grants totaling $139 million to promote the use of health information technology (HIT) are awarded by Health and Human Services announcements through the Agency for Healthcare Research and Quality (AHRQ). March 15, 2005 The Centers for Disease Control and Prevention (CDC) finds that less than a third of the nation’s hospital emergency and outpatient departments use electronic medical records, and even fewer doctors’ offices do. June 6, 2005 A private-public collaboration, the American Health Information Community (AHIC), composed of federal and state executives, company CEOs and representatives of the health care industry, is chartered by Health and Human Services to spur nationwide transition to electronic health records. Also on June 6, 2005, HHS issues a request for proposals to create processes for setting data standards, certification, and architecture for an Internet-based nationwide health information exchange, as well as to assess patient privacy and security policies. HHS says it will spend $86.5 million on health IT in fiscal year 2005, and President Bush requests $125 million for health IT in fiscal year 2006. Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  3 Towards a Nationwide Health Information Structure: A Brief History, continued Historical Timeline, continued November 10, 2005 HHS awards contracts totaling $18.6 million to four groups of health care and health information technology organizations to develop prototypes for a Nationwide Health Information Network (NHIN) architecture. May 17, 2006 AHIC approves its first set of 28 recommendations on how to make health records digital and interoperable while protecting patient privacy and the security of those records. June 28-29, 2006 The first of three (to date) Nationwide Health Information Network Forums is held, with additional forums on October 16–17, 2006, and January 25–26, 2007. These forums highlight the efforts of NHIN consortium members in their health care information technology projects. August 1, 2006 Final regulations that support physician adoption of electronic prescribing and electronic health records technology are enacted by the Centers for Medicare & Medicaid Services (CMS). Regulations cover transmission of a prescription electronically, and enable physicians and pharmacies to obtain patients’ eligibility and medication history. Fall, 2006 The first of five annual reports by George Washington University and the Massachusetts General Hospital/Harvard Institute for Health Policy to assess EHR adoption status and set baseline levels is published in the fall of 2006. April 18, 2007 Robert M. Kolodner, M.D., takes over leadership of the office of the national coordinator (ONC) for health information technology at HHS. November 11, 2007 Charles P. Friedman, Ph.D., is appointed deputy national coordinator for health IT in Kolodner’s office. November 13, 2007 CMS proposes rules to adopt new standards to advance the use of electronic prescribing (e-prescribing) for formulary and benefit, as well as medication history transactions used under the Medicare prescription drug benefit. on Technology, Innovation, and Competitiveness in pursued other initiatives, the four cornerstones June, 2005: remain fundamental to the federal HIT strategy. “ o address these challenges, HHS is focusing T on several key actions: harmonizing health In order to assess how much progress has been information standards; certifying health IT made, the California HealthCare Foundation products to assure consistency with standards; commissioned interviews with nearly two dozen addressing variations in privacy and security leaders and experts in the HIT community. policies that can hinder interoperability; and Individuals were selected from the full spectrum developing an architecture for nationwide of stakeholder groups, including health care sharing of electronic health information.”1 provider organizations, payers, physicians, health information exchanges, consumers, technology These mandates came to be known as the “four vendors, philanthropies, and business associations. cornerstones,” the foundational strategy upon which Respondents include the current national public policies would be built. While America’s coordinator, Robert Kolodner, M.D., his predecessor, Health Information Community (AHIC),2 which Dr. Brailer, and the director of the Agency for was organized at the direction of HHS Secretary Healthcare Research and Quality, Carolyn Clancy, Michael Leavitt, and the national coordinators have 4  |  California HealthCare Foundation M.D. A complete list of respondents appears in mean that data exchanges and regional health Appendix A. information organizations must evolve within new and uncertain frontiers. Research Methodology K Despite exceptionally strong bipartisan support, The interviews for this report were conducted Congress has yet to produce enabling legislation. during the summer of 2007 by telephone, personal interview, and written questions. All interviews K The national coordinator should be drumming were recorded, transcribed, and submitted to the for more federal involvement, more federal respondents for review. All respondents are identified funding and economic incentives, and more except in those instances where they requested federal guidance in developing standards that anonymity. protect privacy. K The ten-year goal would be achievable with Findings in Brief the right purchasing incentives and regulatory K The President’s HIT adoption agenda has raised conditions in place. However, this has yet to consciousness about HIT and EHRs. Beyond the occur. laying of a conceptual foundation, however, there is as yet no measurable increase in HIT or EHR adoption. K The four cornerstones are of more symbolic value than strategic value, with pilot projects failing to evoke a coherent vision. K Though it represents a worthy goal, the National Health Information Network is impractical and cannot be implemented. K Creating HIT interoperability standards is a slow process, and implementing them is difficult. K Certification of EHRs, which was expected to be the hardest step, has turned out to be the easiest. K State and federal health privacy laws need to be harmonized, possibly requiring a new federal standard that balances ensuring privacy and easing data portability. K The federal government should exert more influence as a purchaser in encouraging adoption of HIT. K As in the past, smaller physician practices lag behind larger providers and payers in making HIT investments, given that cost remains a significant impediment. K The lack of a standard business model and shifting levels of leadership at the state level Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  5 II. Findings “ HS is focusing on several key actions: H Achieving the President’s Goal: More Potential harmonizing health information than Progress The question “Where have you seen the greatest progress toward standards; certifying health IT products the President’s goal?” elicited widespread agreement. Respondents to assure consistency with standards; singled out the effective use of the bully pulpit by the president and addressing variations in privacy and his administration in raising the quality of discourse and the level security policies that can hinder interop- of expectations among policymakers, the health care community, and consumers. erability; and developing an architecture for nationwide sharing of electronic As Carol Diamond, M.D., managing director of the Markle health information.” Foundation, said, “When the President made his announcement and other federal leaders, members of the executive branch, and — David Brailer Congress started talking about the importance of HIT to the overall improvement of health care [and] health care quality, safety, [and] efficiency, that was a real turning point.” Or, as Janet “ he most progress has been made T Marchibroda, chief executive officer of the eHealth Initiative, put it, “The most progress has been made around general awareness.” around general awareness.” Added John Glaser, vice president and chief information officer of — Janet Marchibroda Partners HealthCare System, “The IT discussion in the boardroom of provider organizations or plans or life sciences is a much more prominent conversation within a larger number of organizations and associations devoting energy and time to accelerating the “ e have laid the foundation for W effective implementation of this technology. There’s more making progress.” discussion, there’s more focus, there’s more energy surrounding it — Robert Kolodner today then there was four or five years ago.” Federal efforts to encourage the adoption of HIT were perceived to have had an impact on the physician community, particularly in larger practices. Said John Tooker, M.D., executive vice president and chief executive officer of the American College of Physicians and president of the eHealth Initiative, “Some of the progress is obvious and quantifiable, and other progress much more subtle… What is quantifiable is that physicians are acquiring EHRs.” Installing an EHR, however, does not guarantee its adoption, and it is difficult to tell how physicians are actually using EHRs once they are acquired. “Physicians really are talking seriously about the need and opportunity for electronic medical records,” noted Donald L. Holmquist,. M.D., J.D., chief executive officer of the California 6  |  California HealthCare Foundation Regional Health Information Organization. the Veterans [Health] Administration, Geisinger However, while larger physician groups are [Health System], and to some degree, the Kaiser increasingly using HIT, the vast majority of [Permanente] system. Beyond that, the progress is practicing physicians, those who practice alone or in spotty.” small groups, are no closer to using HIT now than they were three years ago. At least, as national coordinator Kolodner noted, “We have laid the foundation for making progress.” Vendors, employers, and providers have also embraced the Bush administration’s HIT initiative. The Four Cornerstones: A Conceptual “The number one thing is the attitude of the Foundation vendors and the attitude of the industry to actually The four cornerstones — the proposed foundation collaborate to make this happen,” said Kevin for a digitized health care system — envision not only Hutchinson, chief executive officer of SureScripts not only the proliferation of EHR systems, but the and an AHIC member. efficient use and access to the data that they contain. The cornerstones are designed so that EHR data Added Ned McCulloch, J.D., manager of could be captured, shared, communicated, used, and government and congressional relations for IBM, relied upon by clinicians, patients and appropriate “The biggest progress has been in the private sector others. The four cornerstones are: by employers acting on their own to try to deal with K Create a Nationwide Health Information their own employees’ health care quality and costs.” Network (NHIN). Make grants to four information technology companies and their partners to demonstrate different approaches to “ he number one thing is the attitude of the T the operation of an NHIN; vendors and the attitude of the industry to K Adopt interoperability standards. Develop actually collaborate to make this happen.” a process under the banner of the Healthcare — Kevin Hutchinson Information Technology Standards Panel (HITSP) by which various technological and informatics standards could be identified, assessed, and recommended for adoption by HHS as necessary The president’s move has created a sense of for permitting interoperability of competing HIT inevitability. “The greatest progress is that there systems and platforms; is an acceptance by health care providers and K Certify EHRs. Identify a mechanism by which facilities that we are going to be moving toward an EHRs and, over time, other HITs, could be electronic medical record. It’s not a question of ‘will certified as being functional and interoperable we?’ but [of ] ‘when?’” said Helga Rippen, M.D., (applying the standards adopted by HHS based vice president of clinical informatics and analytics, on HITSP recommendations); and Hospital Corporation of America. K Reconcile laws. Uncover impediments to the free None of the HIT leaders interviewed for this report flow of digital health data created by varying state could point to substantial, real advances in the and federal medical privacy statutes and a means adoption and utilization of HIT since the president by which those laws can be harmonized while launched his initiative. John Rother, group executive protecting personal health information. officer of policy and strategy at AARP, said, “There’s been some progress in a few large systems such as Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  7 So, what do HIT leaders and experts think about practical value which helped to accelerate certain the cornerstones and the various projects that investments,” said Glaser. The idea of the projects is were launched to implement them? Areas of encouraging to HIT proponents, but as yet they do concern included the specific projects as well as the not represent any significant achievement. appropriateness of the cornerstone approach. The Nationwide Health Information Projects flowing from the cornerstones lack a Network: Mixed Feelings comprehensive approach to the challenge of systemic HIT leaders and experts are mixed in their reform, said the Markle Foundation’s Diamond, assessments of the value of the Nationwide Health “The way I see it, it would be more logical to take Information Network, its execution, and its lessons. those four pieces and talk about them as a whole Most had little praise for the project, characterizing first… I think it plays out tremendously when you it as either ill conceived or poorly executed. start to talk about a health information sharing environment that enables information to move for “NHIN was a disaster from the beginning because the care of patients, between doctors to patients, there was no integration. It was four companies each what have you. Our view is that you can’t uncouple pulling together a consortium, going off and doing those pieces. Policies that define how information their thing and then coming back with four different is used and handled and shared are as important answers,” said William R. Braithwaite, M.D., Ph.D., as the standards for the network definition.” The the treasurer of HL7 (Health Level Seven) and vice pilot projects might be viewed as standing alone, chair of the Healthcare Information Technology unconnected to the others, and lacking shared Standards Panel. context or vision. Glaser added, “I’m of two minds on this thing. For many HIT experts and leaders, the cornerstones One is, as a practical matter, that [NHIN] are of symbolic — not practical — value. “Clearly is unsustainable and is unlikely to get past they [the cornerstone projects] are good things to demonstrations in the next multiple years, and so I have done and the industry will be a better place don’t think what one is seeing is the first phase of a because they were done, even if we’re not quite sure multi-phase effort to build this out, because I just yet what the permanent contributions of those things don’t think it will fly. On the other hand, it had a are to the industry… I think they have practical lot of symbolic value. Real work has gone on and it’s value as a portfolio. They also have symbolic taught us a lot about how to deal with identification value as a portfolio, which is above and beyond issues and authentication issues and how one might rhetoric… For a lot of the movement, it was more put systems together… So, we have learned a lot the symbolic value of those [projects] than the actual technically about how to have interoperability between organizations even if the use of that interoperability for the next multiple years is likely between trading partners — and highly unlikely to be “ think NHIN probably is the one [cornerstone] I a national infrastructure.” where most would agree you have not seen the amount of progress seen… in the other areas. Glaser continued, “I think NHIN probably is the one [cornerstone] where most would agree you have I think it’s primarily because the other three… not seen the amount of progress seen”… in the actually feed into NHIN.” other areas. “I think it’s primarily because the other — john Glaser three… actually feed into NHIN.” 8  |  California HealthCare Foundation Reflecting on Dr. Brailer’s statements to Congress, releasing an RFP calling for trial implementations. Hutchinson said, “…really what NHIN is, is The focus will not be on the technology companies policies, standards, security requirements, a lot of the but on the health information exchange entities, necessary things needed to build…a sound structure. including RHIOs [Regional Health Information But unless you take the local market into account Organizations]. Instead of giving the money to within that structure, it will fail.” the technology companies, it will be given to the users. We want to help those users work with Perhaps the most positive conclusion mentioned the technology companies to provide working by respondents was the idea that barriers to the solutions for the health information exchange within NHIN are not technological but political and real communities. Now we have the technology organizational. Said McCulloch, “I think there has companies competing for the business in the been some progress on the NHIN. The prototypes… funded communities, and we’ve also provided the all worked and I think there’s something to be companies the criteria that they need to adhere to for said from that. I think that was helpful because it functionality and interoperability. These capabilities demonstrated that it wasn’t a technical problem, it will need to be delivered by those technology was a will problem.” suppliers to the communities participating in the trial implementations.”3 Dr. Kolodner, Dr. Brailer’s successor as national coordinator, argued that the lessons learned from the While respondents were doubtful that lessons NHIN projects will benefit local and regional health learned from the NHIN projects can be applied information exchanges (HIEs). “We succeeded in the in community level HIE activities, most saw the first step that we wanted to accomplish, which was development of standards for interoperability, an to develop the NHIN prototype architectures. This essential criteria for HIEs to succeed, as painful, strategy allowed us to draw upon the creativity and slow, and limited. innovation in the private sector to rapidly advance this effort. The four consortia we funded came up Interoperability Standards: Easier Said with different enough solutions, but with similar than Done enough end points, that we were able to identify If EHRs and the other cornerstones of HIT are critical elements from these deliverables. to be capable of sharing health data reliably and efficiently, a host of technical and clinical standards “In conjunction with NCVHS [National Committee must be identified, assessed, tested, adopted, and on Vital and Health Statistics] activities that we used — either as a result of regulation, or of market requested, this allowed us to extract the functionality forces. Without standards to assure systemic needed for future NHIN phases,” Kolodner interoperability, the benefits of sharing health continued. “The prototypes demonstrated that there care data through HIEs and other avenues will be were technical solutions compatible with a network unobtainable — whether for research, biosurveillance, that met our functional requirements for patients to ready access to relevant patient data, or otherwise. have control and input as to how their data flowed The national coordinator created the Healthcare over the NHIN. We had said from the beginning of Information Technology Standards Panel to develop the four contracts that we were not intending to find and execute a process which ultimately recommends a single solution to move forward; [the idea] was to standards for adoption by the secretary of HHS (the learn from all of the consortia. standards are then incorporated into the certification process, discussed below). “We did that, and we’re now going to Phase Two,” Kolodner continued. “Very shortly we will be Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  9 While the panel has made progress in recommending ask this question of a lot of people, every time I standards, the speed of the process has been meet with a health IT person, ‘How are we doing frustrating and limited. As Braithwaite said, “It’s on standards? Is HITSP doing what it needs to do? going slowly. Getting consensus across an industry Are we making progress? Is the process what it needs about a particular standard for a particular use case to be?’ I think that probably there could be some is very, very difficult for a whole bunch of different tweaks to the process. I think that we could have an reasons. But, let’s say there are two major reasons ongoing approach to standards development and right now: one is that, in this country, it’s done maintenance and updating that is perhaps a little bit totally by volunteers. Nobody’s paid to do that… more transparent, that is better isolated from politics, It takes a very, very long time to reach consensus and that hopefully is a little bit quicker to fruition. on what the right answer is or you end up with But by and large it seems like we’re making some what we’ve done for the last 20 years: a “standard” headway.” that is so loose that everybody can continue doing what they’ve been doing, or something very close to it, and you end up with non-interoperable, non-computable data exchanges. It only works “ rom where we sit as non-technology people, it F point-to-point because those two people really want just seems like we should be able to get this done to exchange data and they get together and figure and just decide, come up with some standards out all the little decisions that have to be made and just decide.” before that data transfer could be meaningful. But, you can’t do that across a hundred thousand actors. — Michael Zamore You’ve got to set a standard that’s detailed enough that everybody can write to the same standard.” While agreeing on interoperability standards is Said Linda Kloss, chief executive officer of the one thing, implementation is another. Said Glaser, American Health Information Management “They’ve done a nice job of taking what appear Association, “I think that’s been a painful launch. to be zillions of standards and narrowing it down Not that they [HITSP] haven’t done it as well as significantly, and of creating a process by which they could, it’s just the difficulty of the mission various [standards development organizations] get of bringing together organizations that have together and hammer out some form of consensus. worked independently and competitively to work The step that needs to happen now is that the harmoniously.” Added Mark Leavitt, M.D., chair market embraces and insists on those [standards] so of the Certification Commission for Healthcare people like me who buy [HIT] can require [vendor] Information Technology, “HITSP has such a hard conformance to those [standards].” job — to harmonize the standards while focusing on the use cases. That fills their plate.” Certifying EHRs: An Early Success The consequence of certification — one of the Members of Congress also acknowledge the slow cornerstones — has had important implications pace of the standard-setting process. As Michael for the HIT market. Nonetheless, there is broad Zamore, J.D., policy advisor to Rep. Patrick agreement that the certification process has been Kennedy (D-RI), said, “From where we sit as a success. That process was developed and is now non-technology people, it just seems like we should being implemented by the Certification Commission be able to get this done and just decide, come up for Healthcare Information Technology (CCHIT), with some standards and just decide. I understand the only certification body recognized by the HHS that it’s obviously more complicated than that. I secretary. 10  |  California HealthCare Foundation HIT industry leaders were uniformly positive decrease the risks that they would steal information. about the progress made in the certification of And I’m now starting to see actual financial and EHR systems. Certification “would have been the regulatory relief incentives that tilt to certification.” thing that would have been the hardest one [of the cornerstones] to do and the slowest to do but it Some in the HIT community worried that the surprisingly has probably been the one with the most certification process and its costs would pose a progress,” said Hutchinson. disadvantage to smaller and newer EHR companies. While it is essential that certification assure Another leader described the HIT certification compliance with interoperability standards, the process as “laudable. The real spirit of certification certification process might raise barriers to the kind is to allow the health care delivery organization to of innovation that is critical if HIT is to become know that that business is at least technologically, if more common and inviting. To this, Leavitt replied, not financially, stable. And the certification process “Well, it’s a fair question. And we were worried in principle allows that to be done. The certification about it ourselves as we got started. But we said, process adds a certain amount of leverage and ‘Let’s look at the data as it emerges rather than listen consensus to purchasing decisions that’s very healthy. to people complaining about something.’ And after The challenge for the certification process is you a year of certification of ambulatory EHRs, CCHIT can have a vendor that’s certified, and have older certified 87 products. We surveyed the vendors, versions of the vendor software out there that are not [their] annual revenues, and what size practices they certified, and that’s a bit of a problem, but a minor serve. It turns out that three quarters of [all] vendors one. The broader issue, though, is to restrain the have revenues of $10 million a year or less. And, in impulse to certify everything. I think most recently fact, 16 percent have revenues of $1 million or less. this notion of certifying personal health records is That is a garage kind of shop. Only a fourth were an example of perhaps trying to certify something the large vendors with $10 million or more, and before we even understand what it [is].” some of them were huge companies. So that data laid to rest this concern that it was going to squeeze The certification process requires extreme vigilance, out small vendors. It actually seems to have done the said one leader. “The only problem is can we, on opposite. It’s created a level playing field.” the certification side, keep up with all the changes. The pace of change that’s occurring in technology is One respondent suggested streamlining the process. going so rapidly that it’s outstripping the ability of “If there’s anything I would recommend it’s probably certification programs to keep pace. I pay attention creating one continuum that goes from standards to this stuff, and I’m having a hard time keeping development through to certification in a highly up,” said Kevin Fickenscher, M.D., chief medical coordinated, tightly coupled kind of way, and officer and executive vice president of health care that’s not what we have currently,” said Charles transformation for Perot Systems. Kennedy, M.D., vice president of health information technology for Wellpoint, Inc. CCHIT’s Leavitt reflected on his organization’s achievements around certification. “I am proud of Reconciling State and Federal Privacy what [CCHIT has] accomplished. That these people Laws from all walks of health care came together, had the Regulatory impediments must be lowered if health debates, and came up with a reasonably balanced set care data is to flow freely between EHRs and other of requirements that we could rigorously attest to HIT applications. On the other hand, privacy and decrease the risk of buying the systems, decrease must be protected and data secured if EHRs and the risks that they wouldn’t be interoperable, and other HITs are to enjoy the trust of consumers and Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  11 clinicians. The HIPAA privacy standards were a first they all learned a lot and actually, you’ve had that attempt to strike a balance between these objectives. experience when you’ve talked to those who’ve HIPAA established minimum federal privacy been part of those planning groups. It’s been a real standards, allowing more stringent state laws to eye-opening experience. That grass-roots learning preempt the federal standards. Many believe that the will pay dividends down the road. Coming to some resulting series of state and federal privacy policies conclusions that we can really get lawmakers and hinders the flow of personal health information. others to rally around…could be the backbreaker.” In response, the national coordinator launched a process intended to harmonize individual states’ It’s not likely that state and federal policy on data policies, and state and federal policies. The initial flow can be harmonized without addressing issues phase of that process, recently completed, identified of privacy. Lawmakers at all levels and the public those policies which create impediments to efficient at large oppose the loss of personal privacy. If this sharing of health information data. policy disconnect is to be addressed, a much broader public discussion must occur. Otherwise, clinicians The interviews included discussion about these and researchers will have difficulty gaining access to conflicting imperatives: protecting privacy, and data they need to advance medical care. allowing free flow of sensitive health data. Each of the respondents was invited to comment on A Larger Role for the Federal the difficulty of harmonizing these objectives and Government whether progress was being made toward that end. When asked whether the federal government is doing enough to achieve the president’s objectives, Rother said, “It is unlikely that a state-by-state effort most respondents said that it could throw more will address the regulatory barriers that currently weight as a payer and purchaser. “No surprise, but exist.” Instead, he said, a federal standard will be I think that payment reform is the primary issue necessary if health care privacy regulations are not to that needs to be addressed… We’re seeing lots of impede the flow of patient medical information. experiments and interest and policy stuff floating around changes in payment policy. I think that is the Added Jeffrey Kang, M.D., chief medical officer most important thing that could happen now,” said for Cigna, “Typically, [the federal authorities] set a Marchibroda. minimum and then states can go higher. On this one, in order for the free flow of information to As the big spender in health care, the federal improve quality, you actually want to set a maximum government could exert more influence, said which states can’t go above because you want to be McCulloch. “The government is responsible for able to guarantee some level of free flow.” buying the bulk of the health care in the country. People will respond to whatever incentives that they Incongruities between state and federal privacy laws send out and right now they’re asking people to must be carefully assessed to resolve the privacy provide high-volume, low-quality products and so issue. Kloss said, “Well, I think we’re at a really that’s what people are providing. We’ve done some pivotal point on the [state privacy law] analysis. thinking, we’ve done some test deployments, and The solution set is really now just beginning to be none of that would have happened without the looked at. I think it was also pretty important to government’s involvement. And it’s now going to go out to the communities to look at this issue. be up to either this Congress, more likely the next It was quite a complicated project in getting all president, to decide whether they’re going to move these groups convened in all these states and doing to product deployment. And I don’t see anything all these reports and machinations, but I think happening unless they make that change.” 12  |  California HealthCare Foundation Kennedy offered a similar perspective. “The federal of taking care of people in the real world, how does government needs to continue to push very strongly health information technology allow you to then as a purchaser of health care for the deployment disseminate that practice? Those are the kind of real of these types of tools. I think that you don’t have world or outcomes-based research. It’s all types of to have language yet that mandates these types things that are researched around how care is actually of solutions, but the federal government needs to delivered in the real world.” be continually sending the signal [that] this is the direction the industry should be moving and there The federal government may have missed an will come a day [when] if you don’t have these kinds opportunity to foster innovation, but that chance of solutions in place you won’t be able to play with is coming again, said Fickenscher. “I think where Medicare [or] Medicaid, or you’re going to miss out we made a mistake…is that we didn’t foster the on revenue increases.” laboratories of democracy over the last four or five years. I actually think that we have the opportunity over the next three or four years to do the same thing. Because I think the environment is even “ he government is responsible for buying the T more right today than it was three or four years bulk of the health care in the country. People ago. Now we have the opportunity [to] be very will respond to whatever incentives that they intentional. Let’s foster experimentation, but then from the experimentation, let’s take the best ideas send out and right now they’re asking people to and cultivate [them] and say that at the end of four provide high-volume, low-quality products and or five or six or seven years we’re going to take that so that’s what people are providing.” knowledge and apply it at the federal level.” — ned McCulloch HIT’s Price Tag: Not So Affordable While large health care providers are increasing their HIT investments, small physician practices are not, Relying on the federal government’s purchasing posing the risk that a digitized health care system power alone to create a market for HIT will not will never be fully realized. Understanding why some achieve the president’s vision. Nor will simply make the investment and others don’t is critical to putting information technology tools in the hands expanding the presence and use of HIT. of clinicians and their patients. How practitioners use those tools and how the business of health care One reason is competitive market pressures on large evolves will be more important. systems, which include the linking of reimbursement and quality of care. “One [of the drivers of large As Kennedy said, “Once you have this infrastructure systems] is the steady drumbeat over the years by out there, you’re going to have better data, but organizations like [the] Leapfrog [Group] and people you need to know what to do with the data. [So like Don Berwick [M.D.], who have pointed out you must make] sure that protocols are in place to how screwed up the care process is and how IT allow use of the data for research purposes. And can be an answer,” said Glaser. “There’s also the I’m speaking now of clinical data, not traditional uneven but progressive movement to various pay-for- claim[s] data. I’m thinking of research in terms performance contracts where quality is exposed and of [the] variety of care paths that are used to take poor quality is increasingly penalized. So, those have care of an [individual]. What type of [clinical] had environmental pressure saying that, particularly management approaches work well and how do you, large health systems, that they’ll increasingly be once you define an appropriate or an effective way visible and there will be financial penalties unless Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  13 they clean up their act, and IT is being seen as an said, most physicians practice in and most patients important part of that. There’s also a form of herd get their care in small group and solo practices, a mentality. When I talk to my colleagues who are a different and independent culture of practice. If you part of large health systems, Baylor [Health Care have a three or four person practice, you’re likely System], BJC [HealthCare], Mayo [Health System], to have physicians who are recently entering the Trinity [Health], they’re all in a cohort and they practice, and others who have been in the practice watch each other to see what the others are doing. for many years. Culturally transforming the way There’s now clearly a critical mass of them that are that you do business by incorporation of electronic making big-time investments. Hence, if you’re a health records, after you’ve been practicing without CEO and you go to a meeting of your colleagues EHRs for a long time, is a big transition. With an and all your colleagues are out betting big bucks integrated health system, such as Kaiser, physicians you’re sitting there wondering, ’geez, what’s wrong join knowing and agreeing to participate in the with me, maybe we should be doing that too.’ So, it’s culture and mission, including around change such very clear to me… that the larger health systems… as EHR adoption.” are really ramping up their investments big time.” Its harder for independent physician practices to pay Not everyone believes the federal initiative has for HIT investments than it is for other providers. had much influence over large systems. Said “Physicians working for an integrated health system Carolyn Clancy, M.D., director of the Agency are likely salaried, with incentives. [That’s] very for Healthcare Research and Quality at the U.S. different than a three-person practice in which the Department of Health and Human Services, “I’d capital investment for the electronic health record love to say [HIT investment by large systems] is a infrastructure is not coming from the retained response to the bully pulpit but at the end of the earnings of a corporation but rather from the savings day, I don’t really believe that. I think in tightly from your practice, your personal retirement,” said organized systems, there’s been a lot of movement Tooker. “How well can your personal income and because the technology is ready or more ready than practice tolerate initial decreases in productivity it’s been to actually be deployed on a grand scale. with EHR adoption as well as the capital outlay? If there was a tipping point here, my guess is it In the end, if you can recover your costs and make was probably Kaiser [Permanente] turning to Epic the practice more efficient and certainly much more [Systems Corporation]. I think what a lot of people enjoyable professionally, the effort was worthwhile.” are beginning to see is that these investments can actually change the nature of health care to a series of transactions that are far more proactive, that can happen right now even without payment reform.” “ ow well can your personal income and practice H tolerate initial decreases in productivity with While insurers and large provider systems are EHR adoption as well as the capital outlay? In spending heavily on HIT, the typical physician the end, if you can recover your costs and make practice is not. Speaking anonymously, one physician leader described the challenge of increasing HIT the practice more efficient and certainly much utilization by small physician groups: “There are more enjoyable professionally, the effort was lots of barriers to adoption, including cost and worthwhile.” changing practice culture. Larger, integrated health — John Tooker systems like Kaiser are systems with the scale and culture to facilitate adoption — many physicians enjoy working in such an integrated system. That 14  |  California HealthCare Foundation Another barrier to implementation of HIT by small Data Exchanges Face an Uncertain practices is the absence of needed data. As Mark Future Frisse, M.D., director of MidSouth eHealth Alliance, From the earliest days of the federal HIT explained, “One of the reasons that community initiative, the national coordinator encouraged physicians don’t use information technology as the development of regional health information much is because the information they would really organizations (RHIOs), or data exchanges. A small need and want — information from hospitalizations, amount of funding was provided and grants were information about your health, your medication made for the provision of technical support. Yet, over history — just simply hasn’t been available until very time, there has been inconsistent emphasis on the recently. It’s rather foolish to require a physician, for role of RHIOs, insufficient funding, and an uneven example, to use a health care information system track record of RHIO development. Thus, the role when it’s not integrated with the billing, when of RHIOs seems uncertain and unsettled. you can’t get the medications. It’s not efficient. It’s not a matter of physician resistance, it’s a matter Kolodner believes the role of RHIOs will emerge of [having] no critical map for the community over time. “We still believe that the majority of providers. Then, there is the issue of financing. I health care activity occurs at the local, regional, and share [the] view that every other small businessman state levels, and that’s where the sharing has to begin. in the country has got to afford their information To make this happen, multiple stakeholders at the technology and that any practitioner in their right local and regional level will have to come together, mind ought to be doing the same. I think they and a balance among their differing desires and will, as soon as there’s enough to hook it to make it needs will have to be found. But this is something worthwhile for them and their patients.” that’s never been done before, and if you push it too fast when you do something that’s not been done In the years just after World War II, Congress before, you’re going to have lots of failures. What addressed the shortage of hospitals and nursing we need to do is proceed in a deliberate, stepwise homes by passing the Hill-Burton act, giving fashion and discover the good ideas — which are health facilities grants and loans for construction the things that work, and which things don’t work, and modernization in exchange for providing a or at least, don’t work in those settings and done in reasonable volume of services to persons unable that way. And we need to make sure there are sound to pay and to make their services available to all communication processes in place. That’s another persons residing in the facility’s area. Is such an suite of activities that we have to address, both with initiative program needed for physician-practice the health information exchanges and drawing out HIT? Rother thinks so. “With regard to the problem their best practices, as well as fostering a dialogue of encouraging small physician practices to obtain across the various RHIOs or health information and use electronic medical records, there needs to be exchanges — entities that cluster together for a Hill-Burton type program. In particular, it must business purposes. We also have state-level activities be recognized that while small physicians are key to such as the State Alliance for e-Health where state a successful health care information system, small governors, legislators, attorneys general, and health physicians are least able to afford the costs of such a commissioners meet together to identify and system, are least likely to realize significant benefit formulate solutions for interstate health IT barriers. from the use of electronic medical records, beyond We’ve created an environment that has been able to clinical benefits, and that those entities most likely to foster discussion across the boundaries, so good ideas realize significant benefits, in particular insurers and get shared.” other payers, should be bearing the largest burden of the economic cost of health care IT systems.” Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  15 For many of those interviewed, the viability and you willing to be so recalcitrant in your view of role of RHIOs remains unclear. As Dr. Kennedy health care finance that you’re willing to see all this observed, “The problem with RHIOs is no one has great work and energy go to its death?’ And I think figured out how to specifically connect them to the that will pose a lot of dilemmas for people as part of existing business model of health care. So they’re a broader question about where is health care going.” kind of this entity that’s hanging out there that doesn’t really have a role in what we would call the In recent months there have been several highly value chain. Meaning, member to employer to health visible failures of RHIOs. At the same time, new plan to medical group to physician to ancillary RHIO efforts are underway, and some federal providers of care. Where exactly does a RHIO fit in funding has gone to RHIO development. The there? I’m not sure the approach really works.” question remains: Where do RHIOs fit into HIT? Another question is, how do RHIOs fit in the larger Is Congress Doing Its Part? national HIT system? Frisse said, “I’ve never viewed While much of the action and attention on HIT and a RHIO as an organizational engineering entity. I EHR initiatives has been focused on the executive viewed a RHIO as an environment in a region that branch, there are two issues which only Congress would look at the underlying issues that overlapped can address. It can make the office of the national long-term care of individuals across various coordinator an official part of the federal structure settings and fundamental policy and information (it now exists by executive order), and it could management issues. So in other words, whether create incentives to accelerate HIT deployment and it’s a RHIO or something else, there are some core utilization. problems like identification, merging, consent, technology standards, that we have to take on simply to take care of us. I’m looking at what is the role of the community and the role of the community “ he big challenge for health IT so far has been T as a trust broker… There’s no argument that many that it’s everybody’s second issue.” of these standards should be federal standards. So — Michael Zamore there are some things that are federal, there are some things that are regional and there are some things that are organizational… There needs to be greater federal support for collaboration.” Although there appears to be bipartisan enthusiasm for HIT, significant HIT legislation has yet to be The role of RHIOs may even be at odds with adopted. Congressional staffer Zamore explained, the rest of the HIT infrastructure. Speaking “The big challenge for health IT so far has been that anonymously, one respondent said, “I see [RHIOs] it’s everybody’s second issue. And you’ve got all the becoming apparatuses of state health leadership as groups talking about health IT as so important and opposed to a federal network… There’s no business they’ve got their white papers, but when they come model for what they do. They can figure some out up here and they’re sitting down with a member on the margin but in terms of the core mainstream, of Congress with their membership, or with the high-octane business model, there is none because president or whoever it is at whatever level, for the value they create is adverse to the financial doctors they’re talking about how much Medicare interests in the industry. I expect a lot of them to is going to pay them. If they’re hospitals they’re face a lot of economic trouble and I think it’ll force, talking about, you know, how much Medicare frankly, the question that we’ve been trying to force is going to pay them. If they are patient groups [on] people who pay for health care, which is ‘are they’re talking about [National Institutes of Health] 16  |  California HealthCare Foundation funding… Everybody’s got their own thing and IT About the first theme, Hutchinson said, “I would is not the second one on the list or the third one finally put some meat behind what the secretary on the list and it’s not the first one on the list for has been saying for a year and a half [about] his almost anybody other than the IT vendors… So, intention to use the size of Medicare to drive the politics on health IT are at once great because change and adoption of health IT… I would make the general impression by far is in agreement, it’s sure that there is a timeline and there are concrete kind of mom and apple pie… So on the one hand recommendations…that will make sure that those it’s great, but on the other hand things move when plans and programs are, in fact, happening.” they’re demanded to move and nobody is demanding that this go. A couple of years ago, [during] the first About the second theme, Tooker said, “While I year of ONCHIT, the appropriations process was agree that the market and the business community so instructive because the president requested this are key players, I think that there is a role, including money and everybody thought ‘oh great, health IT a funding role, in the public interest for the is on its way’ and then nothing. It was zeroed. And federal government, including the development of that was sort of a wake-up call. I don’t think a lot’s infrastructure across the land for health information changed.” technology and quality improvement. This would require reform of the current payment system to Rother, one of Washington’s most experienced optimize physician participation.” consumer advocates, reinforced this view. “With regard to the politics of health care information Respondents contended that additional issues technology one need only look at last year’s requiring the national coordinator’s attention include legislation,” he said. “Significant HIT legislation the adequacy of the HIT workforce, additional work was introduced by heavyweight sponsors. Nothing needed on standards, more public displays of success, happened. This indicates that health care IT is the slow rate of HIT adoption by physicians in small not a high priority for Congress. This is in part a groups, and concerns about financing. result of the congressional budget office not scoring health care IT as resulting in savings, the concerns Kloss suggested that everyone take a breather. of providers for the cost of health care IT, and “There’s been a lot achieved in a very short time… that other issues are competing for congressional It’s classic change management… We need to go attention like the state child health insurance on and update the vision because we’re all getting program, SCHIP.” weary and we need to be re-energized. I’d take the rest of this year to re-energize and then I’d roll out Advice for the National Coordinator: this new governance mechanism and use 2008 to Be Pushy and Spend More get it in place In the meantime, I’d find some way When those interviewed were asked to stand in the to get Congress to put some real money on the table shoes of the national coordinator and share their on this, and buy ourselves the time we need to get thoughts on what they would do to accelerate the this organized so that it’s a sustainable structure. deployment of HIT, two major themes emerged. There are issues like workforce that haven’t been First, the national coordinator should make better attended to yet, there’s a lot of nuts and bolts stuff use of the federal government’s power, both as like vocabularies and classifications and data content purchaser and regulator, to accelerate nationwide standards that are really essential for interoperability. HIT adoption. Second, increased federal funding Nobody’s really getting to it yet because it’s so hard. is needed, and reimbursement reform could be an So, I’d do some change management, and celebrate. incentive to advance the HIT initiative. I’d figure out a campaign for this public and get them behind this.” Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  17 Glaser suggested that the national coordinator a patient? If you did that, then those who gather the worry more about incentives and demonstrations information would be willing to pay something to of success, and less about interoperability. “I’d keep those who stored it, and those who stored it would HITSP and CCHIT alive and I’d let the privacy say, ‘Oh, you’ll pay me to store it and give it to you,’ stuff continue and I might continue to futz around and you’ve got the economy there. And then you with demonstrations of technology and assessing could tackle this question of [whether re-use of data the successful RHIOs… I would focus on getting could] help support it, and what are the ethics of the adoption up and getting people making these that, and the policies. You’d have to do that first, and investments and making them effectively and then literally the technology problems would solve thoughtfully. I’d get to work on how to help the themselves. I think there’s been a little too much small doc, small hospital, make these investments emphasis on technology, because it doesn’t bite back. and have good partnerships along the way. I’d But the more brain power you put on it, the better continue to work with the payer community you get at technology, whereas the business issues and purchasers… to start moving them towards and the financial issues and the ethical issues, it takes incentive structures which will drive people to make more than just being smart. You’ve got to go out and these kinds of investments and feel like there’s an convince people and talk it through.” economic upside or an economic downside if they don’t. And I would also — and I realize that this The need to engage patients in issues of standards is the tough beast — really work on the federal and privacy was also raised. government both on CMS payment structures and also the OPM [Office of Personnel Management, As Zamore said, “I [would] continue to focus on the which administers the health care benefit system standards stuff. I think that that kind of plumbing for federal employees and retirees] structures to behind all of this needs to happen… I think you get the federal government to put its money where open up a privacy debate [that is] much more its mouth is. But I’d be worried much less about freewheeling, a lot more aggressive… I think that interoperability; I’d be much more worried about I’d like to see more efforts at engaging consumers. I getting adoption up and pressing the two levers of think there’s a tremendous potential in unleashing incentives and support for the small guy.” consumer demand for IT as a part of their health care experience. It’s not clear to me [what] the nexus HIT leaders and experts regularly raised the issue [is] between personal health records and RHIOs of finances, both the basic issue of the costs of or NHIN [or] how those things fit together. But I HIT, and the use of reimbursements and economic think that there’s been a tremendous focus on docs incentives to propel HIT adoption to improve and hospitals and other providers and infrastructure, delivery. One respondent predicted that by creating and people are leaving the patients out of the a market demand for a high-performing, data-driven conversation.” health care system, the technologic challenges would solve themselves. EHRs, the Perpetually Emerging Technology “I’d spend a fair portion of my time on the road out While those interviewed believed that most there with hospitals, doctors’ associations, patient Americans would have an EHR by 2014, there associations, and sectors of the industry like the was less agreement about what that means. Perhaps laboratories, talking and listening,” said Leavitt. “It the lack of clear consensus is due partially to the will get figured out if you had a business driver. So ambiguity of the president’s stated objective. Did you’d first say how do we reimburse for spending the president mean an electronic medical record, or the extra few minutes to gather the information on did he mean a personal health record? Did he mean 18  |  California HealthCare Foundation an EHR that was part of a larger, fully deployed and insurers are doing it on their own. And I haven’t national health data exchange, or did he mean a seen the government provide any of the beneficiaries stand-alone EHR? The diversity of views on the in any of the programs yet.4 I think it’s moved along prospects for nationwide EHR adoption reflects pretty quickly and I think the government could the range of interests, challenges, perspectives, and really help a lot of folks were they to do it. By the communities that are involved in the HIT effort. way, just as a global statement, it’s actually moving faster in a number of other countries than it is here As Kolodner said, “We’re well along with product in the United States.” certification; more and more standards are getting in place; communities are working together; and conversations are underway regarding the [American “ think that chances are pretty good that a fair I Health Information Community] AHIC successor. number of people will have an electronic medical While nothing is absolutely certain, I think we have an extremely good chance, and I put my money on record and I think the chances are pretty good the side that we will achieve the 2014 goal.” that it will have nothing to do with anything the government did.” Speaking anonymously, another respondent was — ned McCulloch equally enthusiastic. “I do believe they will [meet the goal]. And the reason is because my mental calculation is how far down the gradient towards size of practice will we get until the doctors who care for As for the likelihood of nationwide EHRs in ten half the American public will have it. To cover half years, Frisse said, “I’m going to say yes, but it’s not the American public you only need to go down to going to be because it was the president’s idea or about 35 percent from the top. I think it would take your idea or my idea. It’s because increasingly it’s a massive step-back in the rate of adoption increase making sense to everyone… People don’t adopt for it not to happen.” your idea. They make your idea their idea and then they adopt that. I think there is going to be a Marchibroda advised that expectations be tempered. growing trust, despite what’s going on now in the “We took a survey at one of our conferences, and digital world, there’s going to be an expectation for mostly everyone said ‘no’… In seven more years, management; the aging population, the kids, what we’ll probably see about 20, 25 markets wired. And they’re doing with cell phones and the like. I think we’ll see, with this group of national networks that we’re going to be pretty far along the way and I don’t are interoperating with those markets, probably think it’s going to be because of the reasons we think about 50 percent of our docs wired. But there will it is. I think it’s going to be the law of unintended be a big chunk that won’t be yet because they’ll be consequences and funny surrogates for this stuff. in rural areas or, for whatever reason, they’ll be left What we’re going to have in 2014 may be radically behind.” different than [what] we think is going to happen today.” Not everyone believes that the federal government’s initiative will be the primary influence in EHR The challenges of bringing HIT to small physician adoption. McCulloch said, “I think that chances are practices; reforming reimbursement to encourage pretty good that a fair number of people will have HIT; harmonizing the interests of payers, providers, an electronic medical record and I think the chances and vendors; and other challenges facing the nation are pretty good that it will have nothing to do with all suggest that achieving the president’s vision will anything the government did…because employers Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  19 be unlikely. As is often observed, a real EHR has been merely five years away for almost thirty years. A Snapshot of EHR Adoption A key component of President Bush’s HIT initiative is the synthesis of EHR adoption measurements Glaser indicated he didn’t think the U.S. was moving into an annual report on the overall state of EHR fast enough for most Americans to have EHRs adoption. In October, 2006, the first of these by 2014, unless the pace of change “...accelerates reports was produced by a team of researchers dramatically. But if you said ‘Well, what would at the Institute for Health Policy at Massachusetts cause it to accelerate dramatically?’ one [cause might General Hospital, and the School of Public Health and Health Services at George Washington be] very significant movement to reimbursement, University. The report evaluated the latest and nobody’s moving that fast, they’re all big talk. information on the state of EHR adoption in the I don’t blame them. They’re being thoughtful and U.S. health care system. careful because the worst thing in the world from The report was built on a review of existing the purchaser’s perspective is that they’ve put a lot surveys, with a focus on four questions: of money into this and nothing’s any different… • What is the current level of EHR adoption among If I believe, and I do, that [the important thing is] key provider groups; especially physicians in payment, and support for the small guys, I’m not small groups or solo practice, large physician seeing enough progress to believe that [a] tipping groups, and hospitals? point will occur in the next seven years… The other • What predicts whether or not a physician or reason is, and this could be incorrect, 80 percent of hospital will adopt an EHR? the outpatient care that Americans receive is received • Where are the gaps in adoption? Does adoption in the practice of a solo practitioner, or a two-person depend (and if so, how much) on location, group… [You] can have all the big guys off doing organization type, specialty, involvement with vulnerable populations, or EHR capabilities? terrifically on this stuff and you would’ve solved • How can precise, timely data on EHR adoption fifteen percent or twenty percent, tops, of this thing. best be collected? So where most of the care is occurring is in the place that is struggling the [most].” All available surveys of EHR adoption were included. Of 36 surveys identified, the researchers were able to gather enough information to rate the quality of both the methodology and the content of 22 surveys. Only ten surveys received a high rating for methodology. The methodological ratings were based on the survey’s accuracy in representing the population in question, the proportion of those surveyed who returned questionnaires, the questionnaire development process, and sample size. Surveys were rated on five areas of inquiry: • Whether the practice had an EHR; • The nature of the EHR’s capabilities; • Measures of incentives for EHR adoption; • Measures of barriers to EHR adoption; and • The ability to identify disparities in adoption among different vulnerable populations. No survey was rated high in all five content areas. Only three physician or physician group surveys and one hospital survey were rated as having high quality content in at least three of five content areas. Only two surveys achieved a high quality 20  |  California HealthCare Foundation A Snapshot of EHR Adoption, continued rating for both methodology and at least three of five content areas. After one year of examination of the qualifying studies, a report was published with the following key findings: • EHR adoption is not occurring as rapidly as hoped. The report estimated that 17 to 24 percent (closer to 24 percent) of physicians in ambulatory care settings use EHRs to some extent, and 4 to 24 percent (closer to 4 percent) of hospitals have adopted computerized physician order entry (CPOE), the best proxy in existing surveys for EHR adoption in these settings. • There is uncertainty about the availability of EHRs to physicians who serve vulnerable populations. The data show that 8.6 percent of the nation’s approximately one thousand community health centers and public hospitals have a full EHR and an additional 15.9 percent report have a partial EHR system. Providers who derive a smaller proportion of their practice revenue from Medicaid are more likely to report using EHRs than providers with a larger share of Medicaid patients. • Four factors drive EHR adoption. These are financial incentives and barriers, laws and regulations, the state of the technology, and organization influences. Financial barriers include the high cost of EHR systems and providers’ uncertainty about the return on investment. Legal barriers include concerns about newly created potential legal liabilities, privacy and other factors. Technology-related barriers include ease of use and obsolescence. Organizational barriers include size of practice or hospital, payer mix, level of integration of the care system, and organizational leadership. The report found that approaches to measuring the adoption of EHRs could be greatly improved through developing a standardized, widely accepted definition of an EHR and of the adoption process, and through using generally accepted survey methodologies in collecting data on EHR adoption. This sidebar is adapted from “Health Information Technology in the United States: The Information Base for Progress,” published in 2006 by the Robert Wood Johnson Foundation and available at www.rwjf.org/files/publications/other/EHRExecSummary0609.pdf. Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  21 III. Conclusion Implications The leaders and experts interviewed for this report concur that the past four years have been valuable in focusing attention on the need to create a health care system that routinely uses HIT to achieve improved patient care and administrative efficiencies. Some of this progress is manifest in public discourse. There are more HIT policies, conferences, chat-rooms, associations, online newsletters, editorials, and op-ed pieces. The expectations of the health care industry and its consumers are rising. Yet, it cannot be said that the nation is substantially closer to a ubiquitous, interconnected, interoperable HIT system now then when the president called for action in April 2004. For those who have been part of the HIT world for a while, hope for a nationwide EHR remains an unfulfilled goal, still beyond our collective grasp. How many Americans have a true electronic medical record of up-to-date, reliable information that is used by our clinicians in the provision of care? How many physicians could electronically access critical health care information in the event of a catastrophic health care emergency? How many emergency rooms can electronically access essential health care data regarding critically ill or injured patients? How many communities are sharing data among providers to facilitate the efficient provision of care? Those who grapple daily with such questions say the truth is that improvements in these and other HIT areas since 2004 have been minimal. Recommendations At the end of the day, government has two tools to implement public policy: regulation and purchasing power. The bully pulpit, leadership by example, and other implements of moral persuasion are useful. But in this case, moral persuasion has made the case but has not delivered results. At the launch of HHS’s ten-year plan on July 21, 2004, some 1,800 people participated. Attendees found the event energizing, visionary, and community building. To a reporter’s question, “Does HIT have critical mass?” the response was “Critical momentum, not critical mass.” Three years later, HIT continues to have momentum, but it has not achieved critical mass. 22  |  California HealthCare Foundation Aside from its attention to building blocks, the federal government has failed to use its clout to drive widespread implementation and use of HIT. The administration has focused on a few important issues, but has not followed through with action. Those pursuing its HIT agenda are left to wonder: Why not require that, as of a particular date, no federal funds will be spent on any HIT system that is not certified to be interoperable? Why not adopt reimbursement policies that reward physicians who use HIT for electronically prescribing? Why not move federal health care programs to performance- based reimbursement (which requires the digital collection, reporting and analysis of care data)? HIT leaders and experts have similar questions for Congress: Why has no meaningful HIT legislation been enacted? Why has Congress only funded ONC at a fraction of what is requested or what would be useful? Why isn’t Congress pressing the executive branch to more rapidly advance the use of HIT in achieving better administrative efficiencies and improved clinical performance? Absent the willing and intelligent use of regulatory or purchasing power, it is not likely that all or even most Americans will benefit from a digital health care system by 2014. Americans may be offered personal health records by insurers and HIT vendors but it is unlikely that any clinician will be willing to use them. Or some may have an EHR, so long as it is with a particular physician who is part of a particular health system’s network. And others may have a smart card or memory device that stores some personal health data but which cannot be accessed by all clinicians or providers. The goal of an HIT system that allows clinicians and their patients to reliably, immediately, and transparently gain access to our individual health data by 2014 is achievable, but only if government uses its power to achieve HIT’s critical mass. Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  23 Appendix A: Respondents and their Professional Categories Foundations/Consumer Organizations Private Sector (Vendor, Consultant) Carol Diamond, M.D., managing director, the Markle David Brailer, M.D., Ph.D., chief executive officer, Foundation Health Evolution Partners; former national coordinator for health care information technology, John Rother, group executive officer of policy and U.S. Department of Health and Human Services strategy, AARP Kevin Fickenscher, M.D., chief medical officer and executive vice president of health care Government transformation, Perot Systems Carolyn Clancy, M.D., director, Agency for Healthcare Research and Quality, U.S. Department of Health Kevin Hutchinson, chief executive officer, SureScripts; and Human Services member, American Health Information Community Robert Kolodner. M.D, national coordinator of health Ned McCulloch, J.D., manager, government and care information technology, U.S. Department of congressional relations, IBM Health and Human Services Michael Zamore, J.D., policy advisor to Rep. Patrick Professional/Industry Association Kennedy (D-RI) William R. Braithwaite, M.D., Ph.D., treasurer, HL7 (Health Level Seven); vice chair, Healthcare Information Technology Standards Panel Health Plans Jeffrey Kang, M.D., chief medical officer, Cigna Charles N. Kahn III, president, Federation of American Hospitals; member, American Health Information Charles Kennedy, M.D., vice president of health Community information technology, Wellpoint, Inc. Linda Kloss, chief executive officer, American Health Information Management Association Health Providers John Glaser, vice president and chief information Mark Leavitt, M.D., chair, Certification Commission officer, Partners HealthCare System for Healthcare Information Technology John Halamka, M.D., chief information officer, Janet Marchibroda, chief executive officer, eHealth Harvard Medical School; chief information officer, Initiative CareGroup Health System; chair, Healthcare John Tooker, M.D., executive vice president and chief Information Technology Standards Panel executive officer, American College of Physicians; Helga Rippen, M.D., vice president of clinical president, eHealth Initiative informatics and analytics; medical director of technology transformation, Hospital Corporation RHIOs/HIEs of America Mark Frisse, M.D., professor of biomedical informatics, Vanderbilt University; director, MidSouth eHealth Alliance Donald L. Holmquist,. M.D., J.D., chief executive officer, California Regional Health Information Organization 24  |  California HealthCare Foundation Endnotes 1. Testimony of D. Brailer before The Committee on Commerce, Science, and Transportation Subcommittee on Technology, Innovation, and Competitiveness United States Senate, June 30, 2005. 2. See: www.hhs.gov/healthit/community/background. 3. A request for proposals for trial implementations was posted in June, 2007, and contracts were awarded to nine health information exchanges (HIEs) to begin trial implementations of the NHIN on September 28, 2007. The trials’ purpose is to further specify the common interfaces that the national HIEs need to interoperate. Awardees are to demonstrate real time information exchange based upon the new specifications by September, 2008. 4. Subsequent to this interview, on June 20, 2007, CMS announced a pilot project to provide PHR [Personal Health Records] to beneficiaries enrolled in certain Medicare Advantage and Part D plans. Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field   |  25 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org