The Health Information Technology for Economic and Clinical Health Act was included as a component of last year’s American Recovery and Reinvestment Act. The HITECH Act includes the use of financial incentives and subsequent penalties to accelerate the adoption and optimal use of health IT such as electronic health records. This optimal use of health IT, where optimal is defined by the use of health IT to enable measurable improvements in health care outcomes, was termed “Meaningful Use.” Meaningful Use attempted to script this policy goal—enabling measurable improvements in health care outcomes—into iterative metrics within five key domains: quality, safety, and efficiency; care coordination; patient engagement; public health; and privacy and security.
There was initial excitement from within the health IT and provider communities about seeing real dollars to help spur electronic health record adoption. But that faded quickly as attention shifted to details. The intent of HITECH is far more than a “dollars for IT adoption” program, so questions arose such as: How exactly was the Centers for Medicare and Medicaid Services, or CMS, going to define use metrics for success? Would these metrics be robust enough for the government to feel confident that their investment was making health care better? Would the metrics be too robust—asking providers to do too much too soon, such that few if any providers would actually qualify for those incentive payments?
The last year has seen much comment and debate, culminating with over 4,000 responses to the Meaningful Use Notice for Proposed Rule Making. And we will (hopefully) see within the next few weeks how CMS achieves that appropriate middle position—positioning Meaningful Use as an attractive on-ramp for both new and veteran users of health IT, but also setting clear and achievable staged expectations for using that health IT to improve care.
We have also witnessed a torrent of articles questioning the demonstrated potential for health IT to make care better as well as articulating the potential for health IT to cause medical errors. And several recent articles have been published questioning the value of health IT in improving care delivery in new care models, such as the patient-centered medical home. These criticisms are on target, but the new financial viability around electronic health records should soon make these complaints obsolete
Putting the brakes on the “vicious cycle”
Exactly one year ago, Todd Park (currently the chief technology officer of the Department of Health and Human Services) and I wrote a paper for the Center for American Progress, “A Historic Opportunity: Wedding Health IT to Care Delivery Innovation and Provider Payment Reform.” Park and I stated in that report that there is great potential for care improvement with health IT, but that we were currently stuck with less than ideal health IT, and health IT (at many levels of maturity) was used suboptimally because of a “vicious cycle.”
We posited that as long as the provider payment model in health care only encouraged procedure and visit volume over health information management and quality outcomes, there would be little market for health IT that supported better health information management and quality. Further, without payment to providers for those essential non-visit associated care activities, there would be only casual interest in implementing health IT, and health IT would be used sub-optimally where there was interest.
The virtuous cycle of business stimulating better health IT has begun
The enactment of the HITECH Act and the subsequent release of the first draft metrics for Meaningful Use sent a clear message to the electronic health record vendor community: enhance the way your EHR works such that it will meet Meaningful Use, or risk market irrelevance. Where then is the good news? Health IT vendors are responding to this market pressure. It was next to impossible to find an off-the-shelf EHR that came bundled with useable and actionable quality reporting a scant year ago, six months from now it will be hard to find one that doesn’t.
I heard the executive management of one major EHR company at a recent national EHR conference describe how their next version would contain a new dashboard, displaying how providers were doing with their meaningful use metrics and quality metrics. A CMO of another major EHR vendor told me how their next version will allow providers to readily see what their metrics submission to CMS would look like prior to submitting them. Conversations with other EHR executives have revealed similar enhancements. To be in the EHR business starting in 2011, one has to include highly useable and actionable tools that allow providers to see and improve quality as a normal part of their day. This profound and sweeping change is huge, and points toward a direction in health IT maturation from which there is no stepping back.
HITECH is stimulating other components of the virtuous cycle
Meaningful Use data submission is not required until the later part of 2011 to qualify for first year Meaningful Use bonus payments, but some providers and health systems that have begun to prepare for Meaningful Use have found unexpected benefits. At my health system, for example, providers have begun to look at quality reports for a variety of conditions. These reports presume accurate and consistent use of many of the draft foundational measures of Meaningful Use, such as a problem list and medication list.
The initial response to viewing quality reports by many providers is disbelief, followed by denial (“no way…the data is wrong”). And prior to this point in time, that was often the end of the exercise—distrust of the report followed by no further action. But we are asking providers to be specific in their comments because this is a mandatory preparation in the attempt to meet Meaningful Use criteria and the data and reports come from our own information systems. We then have our report writers fix whatever is wrong and then re-issue improved reports. Providers then are given these new reports and asked to check again for accuracy. This cycle continues until providers can say the reports are accurate enough portrayals of their quality, and good enough to take action upon.
It is at this point that the optimal benefits of health IT can emerge. There is no requirement that providers act upon these reports to improve quality now, but many have decided not to wait once they were shown reports that they could trust—they are beginning the journey toward higher quality now. How are providers doing this? Some have starting using reminders. Others are also using the EHR in ways that they did not previously—meaning not just as a documentation tool, but rather to help them consistently use information at the point-of-care to improve quality. Others are asking for additional help in the form of more intuitive and actionable data displays coupled with relevant, actionable decision support prompts.
The most interesting part of this provider response has been uncovering best practices that were heretofore unknown. For instance, we are attempting to get all of our primary care providers qualified for the Diabetes Physician Recognition Program, which requires getting quality scores above a minimum threshold for 10 diabetes-related measures. It is certainly important to get all providers at or above those thresholds—when we looked closely at our quality scores, we found that some of our providers had scores that were 200 percent to 300 percent higher than the thresholds. We have begun to uncover what these providers are doing to get such high scores, and where possible, generalizing those best practices across our provider base.
We have just started on the path of health IT maturation and care delivery innovation
Several excellent papers have been published recently that question the usefulness of current EHRs to enable improved quality and successfully support new models of care, such as the Patient-Centered Medical Home and Accountable Care Organizations. Their findings are indeed correct, but they should come as no surprise considering that the business case for EHRs to improve quality is only now beginning to emerge. And as mentioned above, the enhancement in EHR functionality to imbed quality reporting within the EHR is something we are not likely to see in most EHRs until sometime later this year or into the beginning of 2011. It would then make sense to look for better data on EHRs and quality improvement one to two years after this functionality is in place.
The lack of mature EHR functionality to support the Patient-Centered Medical Home and Accountable Care Organizations should come as even less of a surprise. PCMH’s operational details and metrics have been described, but those for an ACO have not, except in the most general of terms. The business case for these two models of payment reform have been described and are both encouraged by the new health reform legislation, but their occurrence in practice is still in limited pilot mode, which means that customer demand for further enhancing EHRs to support these care models is still in its infancy.
Care improvement stimulated by HITECH is evolutionary
HITECH has already shown its effectiveness as policy by breaking the current vicious cycle of dysfunctional provider payment leading to immature health IT and its suboptimal use. It has also proven to be good policy in that it requires providers—who want to be successful in Meaningful Use—to go through a process of preparation, which can lead to unanticipated early benefits of quality and safety improvement. HITECH must tread that middle ground of accessibility and reasonableness coupled with appropriately staged and iterative metrics in order to prove itself successful in the long term. And it must be followed by long-term payment reform that creates a sustainable business case for health information management and quality outcomes.
Peter Basch, MD, FACP, is a Senior Fellow in Health IT at the Center for American Progress.