EHR usability and interoperability have become the central focus for the federal HIT agency
During a briefing with members of the industry press today, top officials at the Office of the National Coordinator for Health IT (ONC) discussed the core priorities of the agency, signaling a change in focus for the health IT branch of the federal government.
The July 11 call with health IT trade press, both in person and via telephone, included recently-appointed National Coordinator for Health IT Donald Rucker, M.D., John Fleming, M.D., deputy assistant secretary for health technology reform, and Genevieve Morris, principal deputy national coordinator for Health IT. All three top senior officials at ONC are appointees of President Trump, though Morris has worked with the federal agency in the past on various projects.
Rucker, formerly the vice president and chief medical officer at Siemens Healthcare, handled most of the responsibilities of the 90-minute call in what was his first open briefing with the trade press since taking the job this spring. The National Coordinator opened by reaffirming what Fleming had said during a keynote at a recent event—the agency’s two core priorities will largely be around electronic health record (EHR) usability and interoperability.
In prior administrations, ONC had various roles, from encouraging EHR adoption to assisting with health information exchange (HIE) infrastructure to helping with the meaningful use program, but late in the Obama administration, those priorities started to shift. And then when Tom Price, M.D., was confirmed as Health & Human Services (HHS) Secretary under Trump, federal health IT officials mainly became focused on making sure that EHRs help physicians rather than burden them—a sentiment that was a big point of emphasis in today’s briefing.
Indeed, while interoperability has been a major focus for ONC in past years, improving the usability of health IT systems is now also right up there. Rucker noted that the two laws that have been passed by Congress—MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) and the 21st Century Cures Act—together “define the ONC mission.” He said, “We have spent a lot of money on these systems and there is a widespread dissatisfaction with the level of interoperability. [Now], we are trying to use the tools that we as a country have purchased to help us with value-based purchasing and quality reporting.”
Speaking further about reducing the burden, Rucker said that the agency is looking at documentation requirements for physicians as well as the whole quality framework around value-based purchasing, and other regulations related to how systems are architected. “For a lot of practices, this has become a challenge in that we have to think about what the win is for them. The expense that [comes with] complying with the quality measures [compared with] the innate value [gained] needs to be analyzed at some point,” he said.
Rucker added that he has personally been working on EHRs for a long time and that many people assumed that usability was something that should have been figured out in Silicon Valley in the early 1990s. “Now it’s 2017, so I won’t make any more predictions since my prior ones have not been very successful,” he said jokingly. He added that in a broader sense, there is a feeling in Congress that EHRs can be harnessed. “They are right now about documentation and billing, but every other industry uses its enterprise computer software to do automation to become more efficient. We are the only business to use computers to become less efficient.”
To this end, Rucker also noted that the hiring of Fleming—for a position that has never existed before in the government—signals that there is now someone in a key leadership role who stands for the many issues that small and independent practices have with technology. Fleming, a former Navy physician who then opened his own private independent practice in the 1980s, noted that when his practice got its first EHR it all started out smoothly, but over time the practice started to have the same issues that have plagued other doctors around the U.S. “You hear complaints that doctors are so focused on the different administrative requirements in healthcare today. It reminds me of when commercial aircrafts became so complex and pilots had an overload of managing those systems. But that has become more streamlined now,” he said.
Both Rucker and Fleming said that it has come directly from Secretary Price that more attention be paid to reducing the burden that health IT puts on providers. Noted Fleming, “EHRs have become symbolic with physician burden, but by no means is it the entire cause. A physician, in an independent practice, is the CEO and must manage that practice, he or she must see the patients, and now with EHRs, he or she must be the data input person, too. We get reports from doctors that they spend two to three hours a day creating documentation.”
Interoperability and Cures
Meanwhile, another core priority of ONC will be to work on a number of provisions as outlined in the bipartisan Cures Act passed late last year. Rucker said that the top takeaways from this law are that Congress wants more explicit definitions of interoperability, open APIs (application program interfaces), and that it wants to prohibit information blocking.
When asked if the agency will have sufficient budget and resources to carry out these responsibilities, Rucker said, “We think we do have the resources and time to do these tasks. Some of these things we are not legally able to work on until Congress handles certain aspects of the budget, and some of it is [the work of] other agencies like the GAO [Government Accountability Office].” But he did add that ONC will begin hosting a series of meetings later this month with the aim to establish a trusted framework and common agreement for health data exchange, as outlined in Cures. Morris added that the common agreement should be out for the public later this year or early in 2018.
Regarding interoperability, Rucker noted that it happens in pockets of the country today, and the sharing of lab results and images works well for the most part, but he pondered if the business model as it is today could extend beyond these few areas, and if there is enough of a business incentive for a patient’s problems list to be up-to-date and meaningful for all doctors to see, for example. “On the enterprise side with hundreds of providers, these problem lists are all over the place, and they go from screen to screen to screen. There is no business model to clean that up,” Rucker said. He added that ONC’s Interoperability Roadmap is a “solid path” but said there is no ETA for when some of those data sharing challenges will indeed be solved. “A lot of this is about more than just standards; it’s about business relationships,” he said.
Overall, when asked about the future vision of ONC and its role in the industry, Rucker said that philosophically speaking, ideally all of these regulations wouldn’t be needed, since that would mean many of the problems that exist today would be solved. To this point, he was asked when the meaningful use program will wind down, to which he responded that there is no date and that much of what’s to be decided is in conjunction with CMS. He did say that the focus is “not on finding more things to apply the meaningful use methodology to.” But for now, he said, for the next few years, it will be about making sure that EHRs are working so that physicians are not data clerks, but rather they can get value from the data that’s in the systems.
Fleming added that the changing reimbursement system is also a driver for much of this change. “Rather than pay for service, we need to pay for quality and outcomes. This is where CMS is putting effort and resources into, and this goes back to last administration—to their credit—in evaluating these [payment] models so people have the same incentives.” He noted, “The hope is that as we advance into better reimbursement and care models, some of these fee-for-service issues, documentation issues and usability issues begin to resolve themselves.”