Calling Dr. Berwick

On April 27, 2004, President George Bush signed Executive Order 13335 establishing the position of the National Health Information Technology Coordinator. Six years, a recession, a change of administration, a couple of major legislations and a multitude of billions of dollars later, the Office of the National Coordinator for Health Information Technology (ONCHIT) is finally on the road to delivering on the original vision behind that executive order.

The stated mission of ONCHIT, as reiterated in the HITECH Act, was the creation of a nationwide interoperable health information technology infrastructure that makes pertinent information available at the point of care, improves health care quality and coordination, reduces health care costs and disparities and does all that while protecting privacy and security.

While the 2004 executive order did not go into much operational detail, the HITECH Act provided instruction on the structure and strategy for building the HIT infrastructure. It is interesting to note that the HITECH Act is comprised of two Titles; Title XIII in Division A which outlines the activities expected from ONCHIT and Title IV in Division B which creates the Medicare & Medicaid stimulus incentives to eligible providers. The notorious “Meaningful Use” term appears only in Title IV and only as a prerequisite for stimulus incentives from CMS and is loosely defined by certified technology, electronic prescribing, information exchange and reporting on clinical quality measures.

Additional guidance is provided on the selection of clinical quality measures to be in accordance with Section 1890(a) of the Social Security Act, which awards CMS $10 million every year for contracting development of such measures. Meaningful Use seems a rather benign litmus test for CMS to administer prior to dispersing any stimulus incentives. So why is it that “Meaningful Use” became the defining substance of the ONCHIT mission?

From the first meetings of ONCHIT (or ONC for short), Meaningful Use was seen as the centerpiece for the definition of a roadmap to that elusive nationwide interoperable health information technology (HIT) infrastructure. Meaningful Use Stage 1, Stage 2 and Stage 3 were presented as the milestones on the roadmap to success and, as such, ONC assumed an active role in defining the various Meaningful Use stages. Basically, the interoperable HIT infrastructure is not defined according to the capabilities it must have, but instead it is defined in terms of what users of the emerging infrastructure must achieve in order to obtain incentives. This was largely hailed as a wonderful approach. Instead of just building standards and tools to facilitate a nationwide information exchange, we first mandate what we want to exchange, how it should be recorded, who should record it and where it should be reported, and only then do we build the infrastructure to support our mandates. We then throw in some cash and some penalties just to be sure that if we build it, they will indeed come. Sounds very reasonable, except who is “we”?

Now that Stage 1 of Meaningful Use has been largely put to bed (a few minor adjustments not withstanding), ONC is turning its attention to Stage 2 and perhaps Stage 3. Presumably there will be more of what Stage 1 required, many of the capabilities required in Stage 1 will morph into requirements for actual execution, more data will need to be captured and actually exchanged, more standards will be defined and more clinical performance measures will need to be reported. And just like Stage 1, it seems that ONC is leading the charge for Meaningful Use, instead of CMS who will end up just publishing the requirements. No surprises here, except a brand new workgroup of the Health IT Policy Committee chaired by Dr. Blumenthal himself – a Quality Measures workgroup. There is already a Clinical Quality workgroup in the Health IT Standards Committee, so I was intrigued by the policy aspects of quality measures and ONC’s need to address them.

From listening to the first meeting of the Quality Measures workgroup, it seems this is a group of well-intentioned and very talented folks trying to figure out what clinical indicators should be required for Meaningful Use Stage 2 and Stage3 reporting. The main considerations cited in this meeting were parsimony and HIT-sensitivity; parsimony, in the sense of few broadly applicable measures and HIT-sensitivity in the sense of measures best enabled by EHR technology. The entire conversation (transcribed here) is most interesting. The ONC workgroup is aiming at thoroughly examining work done by traditional quality measures builders, such as NQF, and coming up with its own recommendations to support various health care and health care policy goals. The discussion ranged from how clinical measures should support sustainability goals of federally funded Health Information Exchanges (HIE) to their ability to enable operations of Accountable Care Organizations (ACO) to the fact that lipids measurements should be stratified by risk factors.

It seems that ONC is not solely in the business of providing tools and standards to enable the practice of quality medical care as defined by CMS, but it is actively engaged in deciding how medicine will be practiced in the future. I am not entirely certain how this transformation occurred or whether the initial intent was indeed to have Health Information Technology drive the practice of medicine. And where is CMS? By all accounts, the most experienced and knowledgeable visionary leader when it comes to quality of health care is the new CMS Administrator, Dr. Donald Berwick. From his position as Vice President of Quality-of-Care Measurement for the Harvard Community Health Plan, to the Quality Improvement in Health Care demonstration project, and finally to the Institute for Healthcare Improvement (IHI), one would be hard pressed to find anyone better suited to guide health care quality improvements and shape the meaning of Meaningful Use.

So why is it that health care quality improvements and measurements are left to the technology folks? Isn’t this where Dr. Berwick was supposed to provide unrivaled leadership for the entire nation?

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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8 replies »

  1. Margalit, you perhaps are attempting to use “logic” when defining the ages old, chess match that is politics. ONC had the political capital and the money. Politics isn’t necessarily an exercise in logic so much as it is emotion and “favors”. Though…I suspect you know this.

  2. MD as HELL (welcome back) – It seems that one way or another there will be “use”. May as well make it useful…
    Dr. Techner, I am just surprised that CMS in general, and Dr. Berwick in particular, are not taking this singular opportunity to significantly affect quality of care. It almost seems that ONC got the job by default.

  3. Blumenthal rarely took care of patients. His NPs and PAs did the work. Funny he thinks he knows how to take care of patients.
    The insidious transformation is obvious. The HIT policies are for domination and control of patients and their lives. Big brother lives.

  4. Believe it or not, the “technology folks” actually know how to structure information, use algorithms, ask the ontological questions, convert/interchange data, migrate/merge systems and , best of all, design and create the human/computer interface. This is also why healthcare in this country has no need of such people.