10 years after the revolution

On April 26, 2004, President George W. Bush formally launched the federal drive to widely disseminate health information technology to improve patient care. In a speech in Minnesota, Bush set a goal that within 10 years, “every American must have a personal electronic medical record,” adding, “The federal government has got to take the lead in order to make this happen.”

The next day, by executive order, Bush created the Office of the National Coordinator for Health Information Technology within HHS. A few days later, HHS Secretary Tommy Thompson named Dr. David Brailer the first ONC leader.

Bush said the ONC should work with private sector healthcare organizations as well as all federal agencies with a hand in healthcare.

He ordered the coordinator to begin work on a national HIT strategy to promote the adoption and use of interoperable electronic health records to enhance clinical decisionmaking, improve quality, lower costs, reduce errors, improve coordination of care and ensure the privacy and security of patient data. He said the office should “not assume or rely upon additional federal resources or spending” to do its work. And in fact, later that year Congress zeroed out the ONC's $50 million budget request for 2005, forcing Thompson to finance the agency by reshuffling HHS' administrative funds.

The ONC was started “because America was clearly behind a lot of other developed countries with a health information infrastructure,” said Dr. Paul Tang, chief innovation and technology officer at the Palo Alto (Calif.) Medical Foundation who serves on several ONC advisory panels.

In its first decade, the ONC has had “an extraordinarily important” impact on healthcare, said Dr. John Halamka, chief information officer of Beth Israel Deaconess Medical Center, Boston. “Over the 10 years of ONC, we have tripled adoption of EHRs and brought health information exchange into the common vocabulary,” Halamka said.

Brailer was succeeded as ONC coordinator by Dr. Robert Kolodner, Dr. David Blumenthal, Dr. Farzad Mostashari, and now Dr. Karen DeSalvo. “Each of the coordinators has had a unique role to play,” Halamka said. “I would say each person was optimally chosen for the era in which they served and each had a totally different personality.”

There have really been two ONC eras—the little-money Bush era, in which the ONC ran on $50 million annual budgets, and the big-money Obama era starting with the 2009 American Recovery and Reinvestment Act, with its $2 billion for ONC grant programs. The incentive payment program for adoption of EHRs has paid out $21.6 billion so far.

In the beginning, the ONC was “a very strong idea” that was almost totally without funding, said Glen Tullman, a managing partner of 7 Wire, a Chicago-based investment firm, and a former CEO at Allscripts Healthcare Solutions. He credits Brailer and his top aide, Missy Krasner. “They single-handedly went around the country and used the bully pulpit to cajole and convince people that this was vitally important.” But Tullman added, “there is only so much you can do from the bully pulpit.”

There are critics of the strong federal role in HIT development, including Brailer himself. He describes the EHR incentive program as a market-disrupting “Frankenstein.”

Ross Koppel, a professor of sociology at the University of Pennsylvania medical school, said federal policymakers erred in thinking that “more HIT equals better care and safer care. That assumption has been defeated by their desire to push the technology long before it was ready.” What has resulted, he said, “is a captured market in which vendors create inferior products that the clinicians are obliged to purchase.”

ONC supporters acknowledge some important shortcomings. “If I were to look at meaningful-use Stage 2, I think we have tried to do too much, too fast,” Halamka said.

“The government could have pushed interoperability a little harder,” Tullman said.

Still, ONC leaders point to an impressive list of achievements.

Before the ONC, caveat emptor ruled for EHR buyers. Today, virtually all EHR systems sold are tested and certified against a list of functional criteria developed by the ONC.

Before the ONC and the EHR incentive program, fewer than 4% of nonfederal U.S. hospitals had EHR systems with computerized physician-order entry. Today, 90% of hospitals have CPOE. Previously, less than 20% of office-based physicians had any kind of an EHR; today, more than 78% do.

Previously, only a few regional health information exchanges existed. Today, after $548 million in grants have been distributed by the ONC from the federal stimulus package, there are 315 statewide, regional and local HIEs. There used to be no nationwide network of HIT regional extension centers. Today, 62 RECs have helped 150,000 physicians and critical-access hospitals purchase and use EHRs.

There previously were many HIT interoperability standards, but no consensus on which to use for what purpose. The ONC led the development of the Direct protocol for electronically transmitting patient-care summaries between providers and patients, which is soon to be in widespread use under Stage 2 meaningful-use requirements.

By the time of his appointment in 2004, Brailer had been at work advising the Bush administration about HIT for more than a year. “It just became more and more intense,” he said. “By November (2003), it was nonstop. I spent a month alone on the draft in the State of the Union address. On Jan. 20, 2004, the effort produced the Bush sentence heard round the health IT world: “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care,” Bush said.

On April 16, Brailer gave the Bush administration his 54-page policy options brief, which became the guide to the ONC's development. EHRs had the potential to transform healthcare, Brailer wrote, “into a more modern and consumer-driven industry.” But, he said, EHRs deliver only a small fraction of their potential benefits because of the fragmented and volume-based model of healthcare financing. He listed 20 policy options to overcome the problem, including reducing the financial risk to potential EHR buyers.

Some of his recommendations were implemented, such as arm's-length testing and certification of EHRs with the launch in 2004 of the not-for-profit Certification Commission for Health Information Technology. Other recommendations, such as “reimbursement for EHR use at the point of care” via Medicare through specific billing codes, were not. Brailer said he asked for $17 billion in federal funding to promote EHR adoption and interoperability, but that request went nowhere.

Brailer spent two years soldiering on without calling again for such substantial federal subsidies for HIT. He was succeeded by Kolodner, whose tenure bridged the Bush and Obama eras. Kolodner, who had served 28 years at the Department of Veterans Affairs and helped develop its widely admired VistA EHR, said his government experience helped him understand the dynamics of change in large organizations and also the importance of interoperability.

Blumenthal started as a health policy adviser to the Obama campaign soon after Obama announced his candidacy for president in 2007. Before the ONC, “I never was a technology person,” Blumenthal said. As a primary-care physician, though, he had started using an EHR in 2002 and “found that it had many, many benefits for me and my patients.” Then, as an academic, he had done national survey work under contract with the ONC, measuring the quality of EHRs adopted by physicians and identifying barriers to faster EHR adoption.

Then, in September 2008, Wall Street's Lehman Bros. collapsed, touching off the Great Recession, which prompted President Barack Obama's economic stimulus package. Working as director of the Institute for Health Policy at Massachusetts General Hospital, Boston, Blumenthal wrote a five-page white paper, published by the Commonwealth Fund in January 2009, which hinted at many of the HIT provisions in the stimulus package.

His paper envisioned direct grants or loans to providers to support EHR purchases, as well as extra Medicare and Medicaid payments for adoption, and penalties for providers without them. It called for funding community-based “geek squads” to help doctors implement and maintain their systems. And it called for payments to incentivize improvements in quality and efficiency.

Blumenthal said he was not directly involved in drafting the EHR incentive provisions of the stimulus bill. But he did talk to Capitol Hill staffers and fielded calls on technical issues from the Obama transition team.

The most important work performed on his watch, he said, was defining what Congress meant by the term meaningful use. But “the more far-sighted hospitals and health systems quickly understood that meaningful use was not their end goal, that they needed systems that could do much more than what meaningful use was asking of them,” he said.

Mostashari came to the ONC as a deputy under Blumenthal after serving as a deputy health commissioner in New York City, where he established a program that helped more than 3,000 physicians install and use an EHR. He became ONC chief just as the EHR incentive payment program was taking off. “One of the things I'm proudest of is how we actually delivered value from the stimulus” money, he said.

One of his most important roles, he said, was “continually trying to raise peoples' eyes from what we're doing as a regulation to why we're doing this. The greater goal is to save lives.”

DeSalvo said she's spoken with all four of her predecessors. Although “they were dealing with different stages,” she said, “it's interesting to me that some of the general themes of what they were looking to do were similar. Everyone is trying to solve these same three issues—capturing data, freeing it appropriately and then putting it to use.”

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