The discipline of biomedical and health informatics has had an increasingly important and visible role in individual health, healthcare, public health, and biomedical research in recent years. But HITECH will impact virtually every aspect of our field. It will certainly define the path and set the implementation priorities for hospitals and physician offices implementing their electronic health records (EHR). HITECH will drive the standards agenda for health data and information. It will also set the bar for privacy and security matters. Finally, HITECH will drive the academic informatics agenda through its impact on research programs (the SHARP program), demonstration projects (the Beacon program), and education (the health IT workforce funding initiatives).
There will, of course, be some activity outside the confines of HITECH. More fundamental research and training of future researchers will continue to be the purview of the National Library of Medicine (NLM). Informatics will continue to play a key role in the Clinical and Translational Science Award (CTSA) program of the National Institutes of Health (NIH). Likewise, the Agency for Healthcare Research and Quality (AHRQ) will likely continue its quality and comparative effectiveness research agendas with the heavy utilization of health IT. But even all of these programs will be impacted by HITECH's provisions and regulations concerning EHR data, its driving of the research agenda, and its influence on curricula in educational programs.
There has been much written in detail about various aspects of HITECH. Probably the best big picture overview is the New England Journal of Medicine article by the National Coordinator himself, Dr. David Blumenthal. This paper lays out the vision of "meaningful use" of health information and the ONC's planned path for achieving it. There are also a number of Web sites and blogs that maintaining ongoing information and commentary about the programs. These include:
- Geek Doctor blog - I have to commend Dr. Halamka for keeping us up to date with a very readable overviews of the emerging programs, regulations, technologies, etc.
- HIMSS - Also has a nice site, some of which is limited to members only, that also is kept up to date well
- AHIMA - Also starting to provide materials on meaningful use and related topics as well
- HISTalk - this more eclectic blog provides other interesting perspectives
It is important to remember that the goals of HITECH are ultimately rooted in improving individual health, healthcare, and public health. The goal is not adoption for the sake of technology. All HITECH rules, regulations, incentives, programs, etc. are linked to one of five underlying goals for the healthcare system:
- Improving quality, safety and efficiency
- Engaging patients in their care
- Increasing coordination of care
- Improving the health status of the population
- Ensuring privacy and security
- The Notice of Proposed Rule-Making (NPRM) - the rules for how incentives for meaningful use will be funded through Medicare and Medicaid reimbursement by the Centers for Medicare and Medicaid Services (CMS)
- The Interim Final Rule (IFR) standardizing what will be required to achieve meaningful use of EHRs by ONC
- Use of certified EHR technology in a meaningful manner
- Utilize certified EHR technology connected in a manner that provides for the electronic exchange of health information to improve the quality of care
- Using certified EHR technology, the provider submits information on clinical quality measures
The stages of adoption and their key features are as follows:
- Stage 1 - electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes, implementing some clinical decision support tools, and initiating the reporting of clinical quality measures and public health information.
- Stage 2 - expand on Stage 1 to focus on continuous quality improvement at the point of care and the exchange of information in the most structured format possible.
- Stage 3 - focus on promoting improvements in quality, safety and efficiency by encouraging decision support, patient access to self-management tools, access to comprehensive patient data, and improving population health.
- Use computerized provider order entry (CPOE) for orders (any type) directly entered by authorizing provider. One of the differences between hospitals and professionals is that the former are required to use CPOE for 10% of all orders whereas professionals are required to use it for 80%.
- Implement drug-drug, drug-allergy, and drug-formulary checks.
- Maintain an up-to-date problem list using ICD-9 or SNOMED.
- (Professionals only) Use electronic prescribing for 75% of all prescriptions.
- Exchange key information electronically among providers of care and other patient-authorized entities.
- Provide summary care record for 80% of care transitions.
- Provide electronic syndromic surveillance data electronically to public health agencies.
- (Professionals only) Provide patients with electronic access to their information for 10% of all patients.
- Protect electronic health information created or maintained by certified EHR technology through the implementation of appropriate technical capabilities.
The NPRM also lists the quality measures that meaningful users must report on in Stage 1. There are listed 35 clinical quality measures in nine categories for which hospitals must report to meet the meaningful use criteria (pp. 152-162). All of the measures have been endorsed by the National Quality Forum, and 25 have been adopted by the Hospital Quality Alliance. However, only nine of the measures are currently in use in Medicare's pay-for-reporting program, meaning that hospitals may face significant challenges in implementing the new measures if they are all adopted in the final rule. Hospitals will be required to report on all quality measures for which they have any applicable patients, not just for measures applicable to their Medicare patients.
For eligible professionals, the NPRM has a list of 90 quality measures that are grouped into 15 categories by specific medical specialties (pp. 143-151). Professionals must only report on measures for the category of professional in which they fall.
The IFR provides a definition of certified EHRs and an initial set of standards, implementation specifications, and certification criteria for EHRs. It creates standards for certified EHRs in four categories: content, vocabulary, transmission, and privacy/security. Certified EHR Technology is defined by the IFR as consisting of a Qualified EHR that has been certified by an authority designated by the Department of Health & Human Services (in a process to be determined). A Qualified EHR consists of an electronic record of health-related information on an individual that:
- Includes patient demographic and clinical health information, such as medical history and problem lists.
- Has the capacity to provide clinical decision support; support physician order entry; capture and query information relevant to health care quality; and exchange electronic health information with, and integrate such information from other sources.
One substantial supporting program will be the Health IT Regional Extension Centers (RECs). About 70 RECs will be funded with $643 million to provide guidance, mainly to small primary care practices, in achieving meaningful use. Because there will be 70 programs, some larger states will have more than one REC while some smaller states will participate in multi-state RECs. These programs will have some similarity to the long-standing agricultural extension service that farmers have relied on for years to improve the capabilities of their farms.
Another key component to achieving meaningful use, likely familiar to readers of this blog, is development of the health IT workforce. The details of these programs have been described in previous postings, but essentially two types of programs will be funded. One will be the funding of five regional community college consortia to achieve 51,000 trained workers over five years (10,500 per year, starting in the fall of 2010) in six specific job roles. The other program will be the funding of universities to train another 1000-1500 individuals per year over three years for six additional higher-level job roles. Also funded under this initiative will be Curriculum Development Centers, mainly to assist community colleges, and a certification examination for graduates of the community college programs. A total of $118 million will be funded under these programs.
Additional funding will go for the following programs (and some additional ones in Dr. Blumenthal's paper and not listed here):
- State-based health information exchange (HIE) - $564 million in grants to the states to develop HIE programs.
- Beacon communities - $235 million to fund up to 15 communities that provide exemplary demonstration of the meaningful use of EHRs to bring out measurable improvement in the quality and/or efficiency of healthcare and/or public health.
- Strategic health information advanced research projects (SHARP) - $60 million for four collaborative research centers in the areas of: Security for Health Information Technology, Patient-Centered Cognitive Support, Healthcare Application and Network Platforms, and Secondary Use of EHR Data
Some ONC leaders have stated that HITECH is a "down payment" on health care reform. Of course, given the state of the health care reform debate as I write this in mid-January, I am not sure what the final payment will be or what healthcare will be in place as these programs are implemented. I do hold the opinion that HITECH is more likely to succeed if we transform our healthcare system to one that better values quality and efficiency, but even under the present system, it is likely to result in some positive improvement.
This is a defining moment for the informatics field. Never before has such money and attention been lavished on it. HITECH provides a clear challenge for the field to "get it right." It will be interesting to look back on this time in the years ahead and see what worked and did not work. Whatever does happen, it is clear that informatics lives in a HITECH world now.