What Can Meaningful Use Learn From Healthcare.gov?

Fred's HeadThe US has spent several billion dollars on medical records, as part of the HITECH program. The goal of that spend was simple: portable medical records for patients. On our current path, we will have medical records, but without that magic word: “portable.” Ironically, the reason for this is identical to the root-cause of the problems with healthcare.gov

The root-cause of the initial failure of healthcare.gov was a lack of accountability and empowerment. There was no one person who was in charge of the operation, and those who were presumed to be in charge did not have the skill-set or political clout needed to make decisions about the project.

The result was the healthcare.gov train wreck. Thankfully, healthcare.gov was turned around.

That turn-around was the result of decisively fixing these exact issues.

Accountability restored, disaster averted.

You would think that the Obama administration and HHS would have learned the “accountability with empowerment” lesson well, if not for IT projects generally, then at least for projects involving Health IT.

Yet we are repeating this mistake with Meaningful Use. For those who are living in a cave with regards to healthcare reform, Meaningful Use is a set of standards designed to ensure that the money that the federal government spends on Electronic Healthcare Records (EHRs) for doctors results in clinically productive outcomes.

If the Federal government did not have some kind of standards for EHR systems, then  doctors might choose to install some Microsoft Word macros and claim that they should be counted as EHR systems, and qualify for funding. (I wish this was a joke. I make such good jokes usually… but this is not one of them.  I have heard doctors claim exactly this.)

You would think that after the Healthcare.gov disaster, there would be one person whose job it was to make sure the deployment of EHRs by doctors in the United States was going to work. A person who had no other job responsibilities but to make sure that records were “portable”. Someone who had all of the authority and skills needed to make EHR adoption, including “portability”, a reality.

Currently, there are two “versions” of Meaningful Use. One of them is managed by the Office of the National Coordinator of Health IT (ONC for short) and the other by the Centers for Medicare and Medicaid Services (CMS). For those unfamiliar with these agencies, ONC is regarded as being “in charge” of Health IT matters in the Federal government and CMS is primarily tasked with paying doctors for work under Medicare and other federal insurance programs.

The ONC version of Meaningful Use applies to EHR software vendors. This component of Meaningful Use dictates what standards must be implemented by EHR vendors in order to have an EHR software product certified. The CMS Meaningful Use components apply to doctors and hospitals, who must prove that they use certified EHRs in a “meaningful” way. Both CMS and ONC are part of Health and Human Services (HHS).

Guess what? The two programs at CMS and ONC don’t actually work that well together. The process works as an uneasy collaboration between two “cousin” agencies within HHS, rather than two arms of a single effort.

Meaningful Use and the funding of EHR systems more generally have been soundly criticized elsewhere, but this interoperability issue is a central problem. Meaningful Use was intended to fund interoperable EHR systems. In fact the supposed difference between Electronic Health Records and Electronic Medical Records (EMR) is that an EHR is interoperable, at least according to ONC. We have spent billions of dollars on digital medical record systems and for the most part they don’t talk. Which is to say, we were sold EHRs, but we got EMRs.

I am one of the architects of the Direct Project (or just Direct for short), which was expected to help resolve the problem of interoperable Health IT systems. The Direct Project created the Direct Protocol, which is a standard that was created by an Open Source community specifically for inclusion in the second version of Meaningful Use. Direct is one possible solution to the interoperability problem.

Recently, I asked “Why isn’t Direct being adopted?” as part of an ONC townhall at a Health 2.0 conference. The answer was basically “That’s a good question, we wonder the same thing…” I took it upon myself to figure out the answer.

Since then I have been digging into the root causes of the failure of the EHR marketplace to adopt Direct (or some other compelling interoperability solution). I have spoken to dozens of people in the Health IT industry about this issue. I think I have discovered most of the major problems, which are all complex technology and policy interaction issues. Who should I give my findings to? No one is a position to rescue the roll out of interoperable EHR systems.

In order to jump-start interoperability, both EHR vendors and healthcare providers are going to have to adjust how they operate. Because ONC works with vendors, and CMS works with doctors, there is no one person capable of addressing all of the issues that have crippled interoperability efforts.

Technically the words “National Coordinator of Health IT” imply that person who holds that title should be in a position to manage precisely this process. But the people who run Meaningful Use incentive payments at CMS do not currently report to the ONC.

As far as I can tell (from this org chart), the first place that the chain of command that the two agencies in charge of billions of dollars of Meaningful Use incentive payments meet is the office of the secretary of HHS, currently Sylvia Mathews Burwell. Unless Secretary Burwell is the right person for people like me to discuss the pros and cons of FHIR vs HL7v2 (which sounds like geek-speak because it is) … then we have an accountability problem that is essentially identical to the one we had with Healthcare.gov. This is so high up the command chain that one might continue one step higher and involve Obama himself to sort out the issue. That is not actually that far fetched, since that apparently did happen with healthcare.gov. Can you imagine? At one point the President of the United States was in the Oval Office pressing “refresh” on his browser to sort out what the problem with healthcare.gov was. We are not yet there with EHR systems, but we are on the way.

Moreover the current ONC is not “just” the ONC. Karen DeSalvo currently acts as “assistant secretary for health” as well as her duties as ONC. Doctor DeSalvo and I share mutual friends and I have it on good authority that she is super-competent, just like all of her ONC predecessors. (Farzad still wears me out with his energy). This is why, I think, that she was tasked with being the “Ebola Czar”. She is exactly the kind of person we needed in that role, having her quickly shift into that role probably saved lives.

But as she took on that new role, Doctor DeSalvo never stopped being the ONC. DeSalvo cannot do two overtaxing jobs effectively and even if she was the ONC for 100% of her time, that role is crippled with regards to Meaningful Use. She still would not be in a position to make the needed changes. Even if she was put in that position, her strong suits are connecting clinical concepts with policy considerations, while she is technically competent, she is not primarily a technical expert.

This country may spend as much as $20 billion dollars on software for doctors. No one in Washington is going to have the political will for another round of funding for this problem. We are only going to get one shot at installing medical records.

The advertisement made for these dollars, is that healthcare consumers in the United States would be able to have portable healthcare records. But it looks like the American taxpayer is going to spend billions on systems that will not live up to the promise. Sound strangely familiar? It sounds just like Healthcare.gov doesnt it?

The Obama administration needs to get someone who does nothing but Meaningful Use and EHR interoperability. They need to put that person in charge of the process at ONC and CMS. They should appoint a new ONC and make that person report to Karen DeSalvo rather than having her try to wear two hats. Someone needs to be the Czar of “Record Portability”. That person should understand, intuitively geek phrases like “FHIR is based on RIM, but can be expressed in either XML or JSON ”, and have the power to make fast and substantial decisions about interoperability and other critical Meaningful Use policy decisions.

Fred Trotter is a healthcare data journalist and author. He is a founder of CareSet Systems and The DocGraph Journal

18 replies »

  1. Fred — Kudos. Insightful and enticing framing of the nature of this screw-up around interoperability, and possible solutions. Quite simply, Brailer was wrong, from the beginning. And other national coordinators fell too much into step…hoping the private sector and vendors would magically invent a great system. Yes, the political realities under Bush were a large obstacle. But it would have been much better if the federal government had actually been bold in the period 2003 to 2007 and established a firm regulatory standard that could be adapted over time. A technical challenge to be sure, but not an insurmountable one. When the feds wimped out, the die was cast and successive ONC regimes dithered…though certainly important advances were made under HITECH, most providers have made the transition, and the concept of meaningful use (if not its’ implementation) is sound. This will be resolved because it has to be. Because portable records and connected systems are 70% of the point of the whole thing. Time and money was wasted, though. No doubt about it. Sad but not unprecedented by a long shot. The history of DOD weapons systems is replete with poor management, contracting, execution, and timely production.

  2. Something Farzad just said in a Brookings forum I watched is relevant here: that the ONC thought the fastest way to usability was through the market. But he hastened to say the government should set a foundation for that market by requiring interoperability so providers had a choice and could switch. It seems that neither the certification proceses nor the interoperability showcases at HIMSS have been able to line up the vendors, so 6 years of MU have not found a path to a solution. As for the Federal Health Architecture, it sounds like a great idea but did not persuade the Department of Defense to work with the Dept. of Veterans Affairs–they have twice rejected the obvious solution of adopting VistA.

  3. Steve Soumerai is of course correct that the cost of HITECH — $32 B, not $20 B, BTW — is only the seed money for the HIT bill. For a large hospital system, the cost of the software can be as much as $400 million. Then implementation, training, linkages, etc etc costs about 4 times that. So, let’s say that’s for 4 large hospitals and associated clinics, labs, etc. What about the other 5000 hospitals. And now, many hospitals are installing their 2nd EHR (Penn, Partners, UCI, UCSF, and several hundred others). Yes, the total cost makes the $32 B chump change.
    Also, the article, though better than most, misses many of the dynamics in the industry that help explain with the software is so non-responsive to the needs of healthcare.

  4. I agree with the readers that these are good points but they only address part of the problem. I don’t have the time to even try to list them. But how about the unwillingness of vendors to cooperate in problems of interoperability? There is no mention of the magnitude of the medical errors being caused by EHRs. Where did $20 billion dollars come from as the estimate of physician (and hospital and ….) costs of HITECH. In my (snowy) town it is well known that Partners, just one large hospital system, is spending about $1.5 billion just to replace its EHR over a few years. I think a $ trillion is probably closer to the truth. What do we get for our money–much –of it Medicare and Medicaid–other than obscene profits for the HIT industry ? We certainly are not getting the promised “return on investment” promised to us by the CBO and the Administration. All that “switching” of systems represents waste and sunk costs. I admire the efforts like these to fix the mess (beyond my technical knowledge). But before we embark on other boondoggles it would be good to have some data first that we can really do this. The data from over 40,000 studies already existed at the time of creation of the ONC and their conclusions discounted the false promises of industry, the CBO, the Rand Corporation and the government cheeleaders.

  5. Edmund,
    ” a great 60 Minutes segment or plot-line on House of Cards.” Excellent idea….the huge disaster of the mandated/coerced/incentivized/penalized health care IT is in need of some old time investigative journalism.

  6. Com’on man! MU is a much bigger fiasco than healthcare.gov. By far. Every health provider was effected and thus their patients. Tens of billions of dollars spent. Leading EHRs are flush with taxpayer dollars with little to no portability or interoperability. What is different is the media uproar. A story on “The EPIC Industrial Complex” and it’s “non-profit” health system dominance would make a great 60 Minutes segment or plot-line on House of Cards.

  7. Spending on health IT reaches far beyond HHS and MU: witness the amounts similar to what has been spent on MU that the DoD and VHA are in the process of spending on “new” EHRs. Are they accountable to HHS in any way, shape or form? Nope. How about Bureau of Prisons, The Coast Guard, NASA, SSA? Not them either.

    Long ago, OMB (Office of Management and Budget) established an eGov Line of Business called the Federal Health Architecture (FHA): “To ensure that agencies seamlessly and securely exchange health data with other agencies, other government entities, and with other public and private organizations.”

    A newly energized FHA with a strong OMB overseer could go a long way in bringing transparency and accountability to the federal health IT investments (including but not limited to EHRs).

  8. Joe,
    Great points. This kind of data protectionism must ultimately be combated with careful new incentives and Meaningful Use dollars are in important change.

    But at this point, the application of Meaningful Use has some fairly substantial tactical issues, especially regarded to how interoperability is measured. As I carefully cataloged those issues, but realized that there is really no one to submit my comments to.

    It doesn’t matter if you or I or anyone else knows how to fix things if no one is in a position to make them happen.


  9. EHRs and EMRs are yesterday’s tools to solve today’s problem tomorrow. Healthcare.gov is about money. Health records are about people. Patients and doctors, not hospitals.

    Patients and doctors will outlive the hospital as the center of sick care. $30 B spent to consolidate the market failure we have in the US is peanuts compared to $1 Trillion the customers of the EHR vendors are trying to protect.

    It’s time to move on.

  10. Key issue, and great article, Fred. What’s missing is the why? As in, why do we have to press so hard for interoperability in a world in which every other field operates on the assumption of interoperability based on standards. Try to imagine a world in which financial software companies had somehow convinced banks to buy software in which each bank had its own data standards and could not talk to any other banks.

    We headed down this road because the major companies building EMRs did not want interoperability. They wanted to use their “walled garden” approach to build market share. And they managed to convince their customers of the same idea — hospitals need market share among the physicians in their region; they can gain that in part by having compatible IT systems that shut out other hospitals. It’s a con, and much of the industry has fallen for it.

    Now in the rapidly changing world of population health management and accountable care organizations that decision comes to seem more and more stupid by the hour.

  11. “If the Federal government did not have some kind of standards for EHR systems, then doctors might choose to install some Microsoft Word macros and claim that they should be counted as EHR systems, and qualify for funding. (I wish this was a joke. I make such good jokes usually… but this is not one of them. I have heard doctors claim exactly this.)”

    MY product has done extremely well.



  12. So, do you think it is possible to get this mess cleaned up before it explodes (like healthcare.gov)? The situation in most doctor’s offices (myself thankfully not included) is that they are diverting time and resources to MU submissions coming up – time and resources that are inevitably taken from the meager time they are giving patients. The unfortunate thing is that much of the noise being made by doctors in this is construed as them being luddites who are opposed to technology and change. While there is still much of that in doctor land, this is not the root problem. The root problem is that EHR software is increasingly interfering with care, not improving it. To run the business properly, however, the care of patients is no longer the source of income; the source of income is the generation of codes, documents, and data that will get money for compliance. Whose screams are going to have to be heard to get the message that this is smothering many doctors?

    I hope people hear you, Fred, because the powers in charge of this (I use that term loosely) won’t likely listen to the cries of physicians.

  13. Excellent analysis of the issues from Fred Trotter.

    He is correct. The problem is a political one.

    It may in fact be impossible for government to oversee technology projects of this nature. We should learn from our experiences or we are going to blow a lot of money.

  14. No one is going to listen to you guys, the CMS or the ONC until there is MS= meaningful security. And the folks responsible for meaningful security should be financially accountable. If medical data is stolen, these responsible people should lose income, and the harmed patients should be paid off via a surety bond. If you can’t get it secure, there is no point in EHRs or EMRs and for all intents and purposes they do not exist.