Former National Coordinator for Health IT: "Even though EHRs have proliferated, we have yet to achieve the interoperability, usability and full utility of them."
To say that a lot has changed in healthcare since last year’s HIMSS conference is an understatement. Right now, a new Congress and a new Administration are wrestling with how to repeal and replace the Affordable Care Act, the signature health reform law of the Obama Administration.
Despite all that's changed, one thing has not: the move from fee-for-service to value-based care. Not only is this a transformation that pre-dates the Obama years and the ACA, but thanks to the overwhelmingly bipartisan Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, the shift to value is enshrined in our law, and will survive any changes to the ACA.
To make value-based care work, however, we need data – lots of it, and free flowing. When doctors are on the hook for the full cost of care, they need to know: what interventions work and which do not; who has been to the ER and needs follow-up care to prevent a costly readmission; who has not been in the office in a while and may be at risk for a complication; and the list goes on and on.
Harnessing all of this data and making it useful has been a huge undertaking for physicians and hospitals, for health IT developers, for regulators, for us all. While at times it may be frustrating, we have seen significant progress in health IT since I started working on its dissemination as part of the Office of the National Coordinator of Health IT in 2009.
Thanks to the massive investment in health IT as part of the American Recovery and Reinvestment Act, the percentage of office-based physicians with an EHR system more than doubled from 2008 to 2015, and more than three-quarters of these doctors have certified EHRs. Prescribing errors have decreased, provider and patient access to clinical information has improved, readmission rates have fallen, and — perhaps coincidentally — health care cost growth has been at its lowest level in decades.
Unfortunately, even though EHRs have proliferated, we have yet to achieve the interoperability, usability, and full utility of them. Part of that is due to a compliance mindset on the part of many vendors and providers who "check the box" to comply with the letter of the law, but fail to embrace the spirit of the law. The result has been EHRs that work in the lab, but not in the field, and practices that focus on fee-for-service billing while bemoaning software systems that slow them down. But there is a new driver of change in the healthcare system that is far more compelling than mere compliance with meaningful use regulations.
At Aledade, for instance, we work with more than 200 independent primary care practices who have committed to taking accountability for the total cost and quality of care of their patients. We interact with more than 50 different EHR systems and patients who use more than 400 different hospitals across 15 states. There are many ways in which the health IT infrastructure built in the past 8 years is pivotal to our ability to succeed in new value-based payment models, but I will highlight two key areas where more needs to be done to make true, functional interoperability a reality.
First is the use of real-time hospital event notifications to improve care transition for patients. Many health information exchange organizations are finally beginning to deliver true value by leveraging simple admission, discharge and transfer messaging to help reduce readmissions. But too often, we find hospitals or health systems who refuse to share this basic information, or make it more difficult than necessary because they see that data as a "strategic asset" — in the words of one hospital executive — instead of as a central part of making interoperability work for patients.
We try to work around these roadblocks — even digitizing faxes and "scraping" data from them, but this behavior is putting patients at risk. The Department of Health and Human Services should use new authority given to it in the 21st Century Cures Act signed into law last December to impose tough penalties on information blocking, and state and federal officials should look into these anti-competitive behaviors from an enforcement point of view.
Second is the use of EHRs to reduce the burden of quality measurement. A decade ago, I led a federally-funded research project to show that data routinely collected as a part of delivering care could be used for automated reporting of quality measures. We now have EHRs on every desk, and collection of most of the data elements needed. But clinicians are increasingly frustrated with box-checking and EHR systems that can't produce reliable quality measures and that won't export standardized data to outside registries and quality reporting intermediaries.
We need EHR vendors to hold themselves accountable for their customers' success in the full cycle and not just for the calculation of quality measures in the certification lab. They need to focus on producing successful workflows to efficiently capture key data, correct configuration and mapping in the back end, and standardization of the data payload when exporting data. Customers need to demand more from their technology partners, and my former colleagues at ONC need to use their new authorities to enforce the certification program in the field.
These steps will help accelerate the transition to value as well as the new IT tools we see emerging. However, to fulfill the promise of value-based care, to get data flowing, and to make interoperability a reality, we will need a true partnership between all of those working in health care and health IT. We need developers to talk with doctors, doctors talking to regulators, and regulators listening and responding to them all. If we do that, I have no doubt that in HIMSS conferences to come, we will celebrate a smarter health care system powered by technology and, thus, delivering better care for less money.