Part two of a two-part series (access part one here):
The release last week by the Office of the National Coordinator for Health Information Technology of a redrawn national plan to promote healthcare information technology is an attempt to finally address a requirement set by President Bush more than four years ago, but the national IT campaign is also encumbered by policy set out in the same presidential order, according to several industry experts.
On April 26, 2004, Bush set a national goal that every American must have a personal electronic medical record within 10 years. A day later, he issued Executive Order 13335, now well-known in healthcare IT circles for creating ONCHIT, but lesser known for its call to draft the first national healthcare IT plan.
That July, David Brailer, the first national IT coordinator, released his 178-page Framework for Strategic Action. It set the stage for much of the initial federal healthcare IT development work that followed. For example, two key federally funded but private-sector not-for-profit organizationsthe Certification Commission for Healthcare Information Technology, which tests and certifies healthcare IT software systems, and the Healthcare Information Technology Standards Panel, which anoints the most appropriate healthcare communications standards for use by IT systems on specific healthcare transactionsflowed from Brailer's first plan.
But the presidential order also said that a national IT plan should include "measurable outcome goals," and also that the plan should "not assume or rely upon additional federal resources or spending to accomplish adoption of interoperable health information technology." Both requirements would prove problematic to ONCHIT and HHS.
The Government Accountability Office, the congressional oversight agency, has repeatedly criticized HHS for failing to develop a national IT plan that contains measurable benchmarks.
In the summer of 2005, the GAO noted that after more than a year of ONCHIT operations and notwithstanding Brailer's "framework," HHS had "not made long-term plans or established milestones for the implementation of a national strategy to accelerate the adoption of IT across the healthcare industry."
In testimony before a House subcommittee as recently as June 2007, a GAO official said HHS still had failed to "identify milestones for integrating the outcomes of its privacy-related initiatives" as well as "ensure that key privacy principles are fully addressed."
Linda Koontz, director of information management issues for the GAO and the author of several of those critical GAO reports, declined to comment on the inclusion of milestones in the latest ONCHIT plan, citing a recent request by Sen. Daniel Akaka (D-Hawaii), to do a follow-up report on HHS progress in promoting healthcare IT.
"We'll eventually be reporting on that very issue," Koontz said. "We're just getting started."
Robert Kolodner, a psychiatrist with a career in informatics leadership at the Veterans Health Administration, stepped up to serve as the head of ONCHIT when Brailer stepped down in mid-2006. Charles Friedman is the national health IT coordinator at ONCHIT with a long history in leadership in medical informatics in academic research and education. Both HHS leaders spoke about their updated plan during a telephone interview June 4, the day after it was released.
Kolodner said that Brailer "used the strategic framework very effectively" in establishing a national IT development program, but a redrafting was needed because "activities have continued to evolve, like the AHIC, so there's been enough changed that it needed to be updated, and Congress has been asking for it." The American Health Information Community, or AHIC, is a key federal healthcare IT advisory panel first established by HHS Secretary Mike Leavitt in 2005, the year after Brailer's initial plan was released.
The persistent banging by the GAO also "certainly was part of it," Kolodner said of the need for a plan update. "They want milestones. We do have milestones. It runs through the framework for the plan. They were looking for the same type of thing."
In June 2007, Kolodner announced that he'd begun developing a privacy and security framework. The announcement came four months after the GAO criticized HHS for foot-dragging delays in developing comprehensive national healthcare privacy and security policies and benchmarks.
The new plan specifically says it is not setting new policy while it repeats Kolodner's earlier phraseology in saying it provides for development of a confidentiality, privacy and security "framework" by the end of this year.
"What we'll be doing is putting out privacy and security principles," Kolodner said. "That's not policy, but it is a set of principles on which policy can be laid."
The plan contains four pages of spreadsheets that set completion target years for each of the 43 "strategies." For example, under Goal 1, "Patient-focused Care," is Objective 1.1, "Facilitate electronic exchange, access and use of electronic health information while protecting the privacy and security of patient's health information." Also, the first of five measurable milestones under that objective is Strategy 1.1.1, "Develop a confidentiality, privacy and security framework," which is to be completed in 2008.
Neal Neuberger, president of Health Tech Strategies, a McLean, Va.-based consultancy, said that the cataloging of achievements and ongoing programs as well as the delineation of goals and objectives all the while ducking tough, unresolved policy issues such as privacy and security is a pragmatic approach given that time is running out on this administration.
"They clearly want to steer clear of making policy recommendations at this point," Neuberger said. "There is going to be debate about privatizing AHIC 2.0. Some of the members of Congress are having discussions about that, but we won't know until the next administration comes in."
Kolodner said that despite what critics describe as modest targets for physician adoption of electronic health records, both he and the plan said that they should be good enough to meet Bush's goal of providing personal EMRs to all Americans by 2014. "Part of this is the whole technology adoption curve," Kolodner said. "When you start gaining momentum, it goes up very steeply."
An appendix to the report pegs physician EHR adoption at 10% in 2004 and 14% in 2007. Kolodner said he expects adoption to rise by at least 5% this year.
Some experts contacted for this story faulted the plan for not specifically providing substantial federal funding for IT, an endemic complaint since Bush's 2004 order. On Capitol Hill, even the health IT bills most primed to move play coy with the actual dollars and cents.
In the Senate, for instance, the Wired for Health Care Quality Act would allot roughly $150 million over a two-year period for a federal grant program to help providers purchase and upgrade their IT infrastructures. But the total amount could double once state matching rates and other incentives are factored into the equation.
A blueprint for a House bill, released in May, includes a number of grants and loan programs, but doesn't specify a solid dollar amount.
"I hope Congress will work with (ONCHIT) and the other administrative organizations to see where we could do more than encourage, but push the envelope a bit harder," said Harris Stutman, executive director of clinical informatics at Memorial Health Services, Long Beach, Calif. "Some of that is probably allocation of dollars and cents, and some of it could be directives."
On funding, Kolodner pretty much stuck to the party line that no large-scale federal IT subsidies were looming, but the CMS demonstration project in which physicians will be paid bonuses for achieving certain benchmarks while using EHR systems will test prevailing theories that an investment in IT systems will yield a financial return.
"That's what the demonstration is about," Kolodner said. In addition, the Bush administration will continue to evaluate the impact on adoption by the Stark and anti-kickback waivers as well as reductions in medical malpractice insurance rates to physicians who use EHRs.
"Those are things that we'll be continuing to evaluate the measures we are taking and whether additional measures are needed to ramp up the adoption," he said.
Stutman said the plan mainly covers familiar ground, but one item "actually caught me by surprise, and that's an innovative idea to measure how much public health information can be derived from the information derived from patient-based EMRs" and personal health records, Stutman said. "I think it was indicative of the kinds of innovative thinking we all should see going forward. It's something I hadn't thought of as a key metric, and I thought it should be."
Friedman said that the national measurement is "doable using a survey method."
"What we envision is a fraction that has as a denominator the total amount of information from caregivers to public-health agencies, and the numerator is the information that does not require duplication of forms but comes from electronic sources," Friedman said. ONCHIT will lean heavily on population health agencies at the federal and state levels to help design specific methodologies for data they want to collect, he said.
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