Every now and then, I am asked to give an overview of the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA, also known as the “economic stimulus bill”). The centerpiece of HITECH is a plan to vastly expand the adoption and “meaningful use” of electronic health records (EHRs) [1], based on a growing body of research demonstrating that EHRs, especially when combined with clinical decision support (CDS), can improve the quality, safety, and coordination of healthcare [2, 3]. Similar to other areas related to technology and/or healthcare, the US has become a laggard in the adoption of EHRs, falling behind most other developed countries [4].
HITECH provides up to $27 billion for eligible professionals and hospitals to receive incentives for achieving the meaningful use of EHRs [5]. Meaningful use is a critical concept. The goal of HITECH is not just to put computers into physician offices and on hospital wards, but rather to use them toward five goals for the US healthcare system: improve quality, safety and efficiency; engage patients in their care; increase coordination of care; improve the health status of the population; and ensure privacy and security. As such, every criterion in meaningful use (e.g., drug-drug interaction checking) must tie back to a healthcare goal (e.g., improve quality, safety and efficiency).
Government funds for HITECH incentives will be distributed through the public Medicare and Medicaid reimbursement systems. Depending on choice of funding through Medicare or Medicaid, eligible professionals can receive $44,000-$63,000, while eligible hospitals can receive $2-9 million between 2011 and 2018. The main purpose of these incentive funds is to cover the costs of investment in EHR systems. It is anticipated that further costs will become part of the "costs of doing business" for healthcare.
The HITECH legislation recognizes that incentives alone will not be enough to achieve all the goals of meaningful use. As such, HITECH allocates an additional $2 billion for various human and organizational infrastructure elements to attain its mandates. A critical portion of this infrastructure is the ability to achieve health information exchange (HIE), which is the secure flow of data to wherever it is needed for patient care, including across traditional business and other boundaries in the healthcare system [6]. About $547 million is allocated to states for HIE development.
Another critical piece of the infrastructure is the provision of technical support to achieve meaningful use. This is done with the allocation of about $677 million to 62 regional extension centers that are providing a variety of forms of assistance, mainly to small primary care practices [7].
An additional portion of the required infrastructure is a competent professional workforce to develop, implement, and train users of EHR and related systems. It has been estimated that the HITECH agenda will require an additional 50,000 professionals trained in fields such as biomedical informatics and health information management [8]. About $118 million has been allocated for both short-term training programs in community colleges as well as longer programs mostly at the graduate level in universities. My institution, Oregon Health & Science Univeristy, is playing a major role in this program.
The HITECH legislation also recognizes that additional research and development is required. As such, $60 million has been allocated to establish four collaborative research centers focusing on the topics of security and health information technology, patient-centered cognitive support, health care application and network design, and secondary use of EHR information. A related funding initiative is the Beacon Communities Program, which has funded about $250 million for 17 advanced demonstration projects “shine the light” forward.
Just as meaningful use connotes that EHR adoption is not just about installing computer technology in clinical settings, there are related initiatives in the United States that will synergize with the substantial HITECH investment. One initiative from the Institute of Medicine aims to develop the “learning health care system” that learns from the growing volume of captured data what does and does not work in healthcare [9]. This is closely related to the growing push for “comparative effectiveness research” that aims to compare tests, treatments, and other medical activities in head-to-head studies carried out in real-world settings [10]. This infrastructure will also likely contribute to the growing push for translational research, as exemplified by funding for the Clinical & Translational Science Award (CTSA) program of the National Institutes of Health [11].
Taken collectively, all these programs from HITECH to ACA, the learning healthcare system, and CTSA provide a vision of a new healthcare system that learns from its successes and changes based on its mistakes. This vision uses data as the critical enabler of coordinating, measuring, and researching care. HITECH is indeed a grand experiment, and it is likely be that some elements of this experiment will succeed whereas others fail. But in the end, the healthcare system should benefit this unprecedented investment in information systems, human capital, and goals for improving health.
References
1. Blumenthal D, Launching HITECH. New England Journal of Medicine, 2010. 362: 382-385.
2. Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al., Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Journal of the American Medical Association, 2005. 293: 1223-1238.
3. Goldzweig CL, Towfigh A, Maglione M, and Shekelle PG, Costs and benefits of health information technology: new trends from the literature. Health Affairs, 2009. 28: w282-w293.
4. Schoen C, Osborn R, Doty MM, Squires D, Peugh J, and Applebaum S, A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences. Health Affairs, 2009. 28: w1171-1183.
5. Blumenthal D and Tavenner M, The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 2010. 363: 501-504.
6. Vest JR and Gamm LD, Health information exchange: persistent challenges and new strategies. Journal of the American Medical Informatics Association, 2010. 17: 288-294.
7. Maxson E, Jain S, Kendall M, Mostashari F, and Blumenthal D, The regional extension center program: helping physicians meaningfully use health information technology. Annals of Internal Medicine, 2010. 153: 666-670.
8. Hersh W, The health information technology workforce: estimations of demands and a framework for requirements. Applied Clinical Informatics, 2010. 1: 197-212.
9. Eden J, Wheatley B, McNeil B, and Sox H, eds. Knowing What Works in Health Care: A Roadmap for the Nation. 2008, National Academies Press: Washington, DC.
10. Murray RK and McElwee NE, Comparative effectiveness research: critically intertwined with health care reform and the future of biomedical innovation. Archives of Internal Medicine, 2010. 170: 596-599.
11. Zerhouni EA, Translational research: moving discovery to practice. Clinical Pharmacology and Therapeutics, 2007. 81: 126-128.
Nice overview!
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