The 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