Part two of a two-part series (Access part one):
There will be some major changes in the way the federal government oversees its health information technology program apart from the whopping increase in funding for IT system acquisition, according to the 300-plus pages of health IT-related language in the $787 billion, 785-page American Recovery and Reinvestment Act of 2009.
The massive stimulus bill, signed into law Tuesday by President Barack Obama, does not specifically name another Bush administration era IT body, the not-for-profit Certification Commission for Healthcare Information Technology. CCHIT was created by the American Health Information Management Association, the Healthcare Information and Management Systems Society and the National Alliance for Health Information Technology, but was promptly awarded a contract by HHS to carry out its work.
However, the new law does say that the national coordinator, in consultation with the director of the National Institute of Standards and Technology, “shall keep or recognize a program or programs for the voluntary certification of health information technology as being in compliance with applicable certification criteria under this” law.
It remains to be seen whether federal support for all three of these holdover organizations—the American Health Information Community’s successor group, the National eHealth Collaborative, the Healthcare Information Technology Standards Panel and CCHIT—in addition to the two newly created ones, is to be forthcoming.
Next to cost, arguably the second most commonly cited barrier to IT adoption is the difficulty in installing, configuring and maintaining these complex systems and the disruption installations have caused to clinical workflow and financial operations. A third, oft-named barrier is the lack of technical know-how, particularly among smaller outpatient clinics and physician groups.
To address those problems, the bill establishes a Health Information Technology Extension program at HHS to be run under the Office of the National Coordinator “to assist healthcare providers to adopt, implement and effectively use certified EHR technology.” In addition, the law calls for the creation of a number of regional IT extension centers, which will be affiliates of not-for-profit institutions or organizations, to assist with “the implementation, effective use, upgrading and ongoing maintenance of health information technology, including electronic health records, to healthcare providers nationwide.”
The regional extension centers will focus on helping public or not-for-profit hospitals, critical-access hospitals, federally qualified health centers and provider organizations in rural areas and those serving the uninsured, underinsured and medically underserved individuals as well as individual and small group practices.
HHS can fund only up to 50% of the cost and expenses of the capital and operating of the regional centers, although the local cost-sharing requirement can be waived “in an instance of national economic conditions, which would render this cost-share requirement detrimental to the program.”
Another intriguing program—to fund development of healthcare IT—may be couched in language under the heading of “Federal Health Information Technology.” It said that the national coordinator “shall support the development and routine updating” of certified EHR technology and authorizes the ONC to charge “a nominal fee” for its use, taking into account “the financial circumstances of small providers, low-income providers and providers located in rural or other medically underserved area.” The ONC shall “make available” these systems, “unless the secretary determines through an assessment that the needs and demands of providers are being substantially and adequately met through the marketplace.”
Multiple studies have shown that in both the physician office and the hospital markets, the smaller the office or hospital, the less likely they are to have IT systems.
In 2004, the CMS funded adaptation of the Veterans Affairs Department’s VistA clinical IT system, which is software in the public domain, for use by physicians in solo and small group practices, work that has since been handed over to the not-for-profit WorldVistA organization that offers an open-source version of VistA.
Earlier versions of the IT portion of the stimulus bill made specific mention of the VistA system and open-source software to address this market failure resulting in weak EHR adoption at small offices and hospitals, but those direct references were dropped in the final bill.
“I’ve watched the transformation of that from early versions, and I think the way it’s written it leaves the onus on the private sector to create the systems that will get us where we’re trying to go,” Rod Piechowski, senior associate director for policy at the American Hospital Association, said. Whether the private sector, with federal funding now available, will fill the gap is “a little bit difficult to predict, because the parameters to determine whether the needs of the market being met haven’t been laid out,” he said.
Joseph Dal Molin, the vice president of business development for WorldVistA, said traditional IT business models “have failed to encourage or facilitate the widespread adoption of EHR technology across the entire health system. Cost and other barriers whose roots are in the 'legacy' business models of the healthcare IT industry are both creating and reinforcing a digital divide in the U.S. health system.
“It is very encouraging that stimulus legislation appears to have opened up a window of opportunity for practical and fundamental innovation in how software is developed, sold and supported in health systems. This could be the first step to establishing evidence-based software evolution in the healthcare industry, something the Veterans Administration has practiced for many years, a paradigm shift that will be essential to spending money effectively and fostering real change ... not just a lot more money spent on the same paradigms that haven't worked.”
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