HITECH: Improving Healthcare Through Data and Action

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.

Reflections at the End of Another Amazing Year for Informatics

Last year, in wrapping up the first year of the Informatics Professor blog, I marveled at how amazing the year of 2009 had been. I noted that the year started with both uncertainty and hope; the former fueled by the recession and the precarious financial state of Oregon Health & Science University (OHSU) due to that recession and the latter driven by the excitement of the election of President Barack Obama and (at least for me) the hope for real change. By the end of 2009, it was clear that profound change had indeed occurred, if not generally then at least in the biomedical and health informatics field.

The hope and change, of course, were driven by the HITECH program with the president's economic stimulus package. At the end of 2009, the path forward was clear: health information technology would be driven by the concept of "meaningful use," and the part nearest and dearest to my heart, education and training, would be driven by the ONC Workforce Development Program, which itself was driven by Section 3016 of the HITECH Act that I played a role in influencing.

I spent the latter days of 2009 and early part of 2010 writing proposals, in particular for the curriculum development program and the university-based training program. With the Funding Opportunity Announcements (FOAs) for these and other programs, such as Beacon, SHARP, and regional extension centers, released in December and due in January, many in the informatics field lamented that ONC stood for the "Office of No Christmas." I spent a good part of my winter break last year working on these proposals. The only enjoyable aspect of the process was that they allowed us to envision how we could implement the educational programs we always dreamed of if we ever had the money, which now it looked like we did.

The most harrowing part of the year was the time between the submission of the proposals and receiving word about funding. As well-positioned as we were to receive these competitively awarded proposals, there was an undercurrent of fear that perhaps we forgot to address some required aspect of the program or that some reviewer felt we had taken the wrong approach. In all honesty, it would have been quite an embarrassment to not be selected for funding, since OHSU's program laid the groundwork for some of the thinking that had emerged surrounding health IT workforce development.

All the agony came to an end on Friday, April 2nd, when I awoke in the morning to find out that both OHSU proposals had been funded. For the curriculum development project, we were not only funded as one of the five curriculum development centers, but also chosen as the lead National Training and Dissemination Center (NTDC). For the university-based training program, we were one of nine programs selected for funding tuition assistance in our graduate program. A common quip in academia is that the downside to getting grants funded is that you then have to do the work. However, this was literally a dream come true. Between both grants, we were funded for $5.8 million to do what we always envisioned we could do if we had the funding. While the short-term emphasis of the funding (due to their being stimulus funds) required us to make some decisions we might otherwise not make, it was still a great position in which to be.

Also on the second to last day of 2009, the preliminary meaningful use rules were released. These were followed by a 60-day comment period, modification of the rules, and the release of the final rules on July 13th. I happened to be in a hotel room in Singapore (10 pm local time, 10 am Eastern time) when listening to their unveiling. While everyone had qualms with this criteria or that criteria, I believe that the majority of people were content with the approach to meaningful use taken by ONC.

With our own projects, we hit the ground running. Out of the gate, the curriculum development project required the most work up front. After a two and a half day workshop in Washington, DC the second week of the grant, we began our long quest that would result in the first version of the curriculum being developed and handed off to the community colleges by the end of October. Being the NTDC, OHSU also had to organize a training event for community college faculty in August and launch a Web site for dissemination of the materials around that time, both of which we did. We even added an aspect to the project of creating an educational version of the VA VistA electronic health record system.

The university-based training grant project was a little slower to get started, but not by much. With funding for 135 Graduate Certificate and 13 master's degree students over three years, our plan was to use the funding mainly as a form of tuition assistance for new students entering the field. We started providing support for students in the summer academic quarter and really ramped up in the fall. The main regret is that we have received two to three times as many qualified applicants as we having funding to accept. A decent proportion of those individuals have enrolled as self-funded students.

While a good proportion of my year was spent around these ONC initiatives, there were other achievements as well. Due to ONC and other funding, the Department of Medical Informatics & Clinical Epidemiology catapulted to second among the 25 departments at OHSU in external funding. We have many other initiatives in comparative effectiveness research, bioinformatics, and related areas. The big challenge for the department in 2011 and beyond is how to consolidate and build upon the success of the stimulus-era funding. I am confident we will find ways to do this, as the need for our disciplines to advance healthcare, personal health, and biomedical research will not diminish even as the federal budget tightens.

The coming year will also be an interesting one for the informatics world. How many eligible professionals and eligible hospitals will achieve meaningful use? What unforeseen bumps in the road will emerge? How will healthcare reform impact the use of health information technology? What will happen to healthcare reform itself? One thing is certain: we will live through exciting times!

I have now been writing this blog for almost two years. I have been pleased to have this type of forum to share my views on various aspects of my work. I am also pleased that others have noticed, not only the 129 people who follow the blog, but also winning awards like being on the list for the 2010 Top Math & Science Professor Blogs Award.

I plan to keep running the blog pretty much like I have been, with a fewer number of more substantive posts than the stream of consciousness approach used by many other blogs. I do hope to branch out a little bit more this coming year beyond workforce and education, as I occasionally did this year.

More Information Available on Meaningful Use

In my initial post on the final rules for meaningful use, I mentioned a number of other resources to describe the rules. Since last month, a number of other new readable sources of information have appeared.

Dr. Blumenthal's overview of HITECH in the New England Journal of Medicine has been officially published.

Readers of this blog know of my enthusiasm for the Geek Doctor, HITECH Answers, and Mr. HIStalk sites, but another source of information on meaningful use I value highly is Computer Sciences Corp.. They have not only issued "updates" on a variety of topics, including meaningful use, certification, and others, but also have established a Meaningful Use Community.

The Health Affairs blog has a post by the Obama Administration's two major leaders for health IT, Drs. Blumenthal and Berwick.

Another interesting post in that blog comes from Kevin Weiss and Sheldon Horowitz of the American Board of Medical Specialties. They note that the five healthcare goals for meaningful use overlap significantly with the six core competencies for physician maintenance of certification developed several years ago. They advocate that the meaningful use goals be aligned with maintenance of certification for physicians. I would agree that being able to use information and IT systems is an essential skill for the 21st-century physician (or any healthcare professional for that matter, and even for patients, researchers, policy makers, and others).

Naturally, during a monumental time like this, there are some express concerns. As typically happens, some argue the adoption of EHRs is moving too fast (American Hospital Association, Huffington Post Investigative Fund, and the Washington Times [the full breadth of the political spectrum!]) while others advocate it is moving too slow (The Leapfrog Group).

I maintain that no one really knows the right pace to move forward. We need to maintain flexibility, adjusting our plans when necessary. But inaction is not an option either. I do agree this has elements of a grand experiment whose outcome we will know only many years, lives, and dollars from now. But just as a I feel about healthcare reform, the status quo is not tenable, and action is required. Translating ideals among competing financial and other interests is always a messy task, but it is not reason for inaction.

Core competencies of meaningful use for people, organizations, and systems

As an educator, I often think of competencies, which are the knowledge, skills, and attitudes we hope that students obtain from the education we deliver. As I think about competencies related to meaningful use (MU), I see that there are competencies not only that people must have, but also organizations and even the information systems they are deploying. The final MU rules make it clear that there are a number of competencies that people, organizations, and systems must have to succeed with the HITECH agenda.

The list of MU criteria and what must be done to implement them are a veritable textbook of clinical informatics. They also include some additional competencies from other sub-areas of biomedical and health informatics as well.

Clearly the major competency area for MU is clinical informatics. Individuals, their organizations, and their information systems must have a thorough understanding of most of the tenets of clinical informatics. A list of what competencies are needed and why includes the following:

• Clinical data, e.g., demographics, vital signs, problem lists, medications, structured data, advance directives
• Clinical decision support - rules, drug-drug and related checks, medication reconciliation
• Computerized provider order entry
• Health information exchange
• Privacy and security
• Healthcare quality
• Organizational and project management
• Standards and interoperability - e.g., HL7, ICD-9, SNOMED, LOINC, CCR/CCD, etc.

Of course, MU is not limited to clinical informatics. People, organizations, and systems must understand elements of public health informatics, since of the "menu" criteria must include the exchange of information with state or local public health agencies. Likewise, these entities must have competence in consumer health informatics, understanding the ramifications of the requirements to provide patients with summaries of their care and, in the long run, exchange information with personally controlled health records.

There are more competencies that one must have across for all uses of health information technology and the even-larger field of biomedical and health informatics. Nonetheless, competency in MU is something that all people, organizations, and systems that deal with health must know about. Many must master it, not only to achieve the short-term objectives and funding of HITECH, but also to provide a patient-centered, evidence-based, and cost-effective healthcare system for the 21st century.

Meaningful Use Rules Finalized!

July 13, 2010 was, at least for those of us in the informatics field, a historic day: the release of the Stage 1 meaningful use rules by the Office of the National Coordinator for Health IT (ONC) and the Center for Medicare and Medicaid Services (CMS). These rules define explicitly what healthcare professionals and hospitals must do to quality for the incentive funding under the HITECH Act. As I have written before, the meaningful use framework is an excellent construct, enshrining the notion that HITECH is not just about adopting technology, but rather insuring it gets used in ways that benefit human health. As much as we love technology, we can never lose sight of the notion that, at least in healthcare, the goal of its use is to improve the care that people get. We do not always succeed at that, but it should always be what motivates us.

The final rules also demonstrate some other positive attributes about people, organizations, and governments. Most critical of these was that ONC and CMS listened, recognizing that the initial proposed rules were a little too much, too soon. So they dialed back, but not to the point of making the criteria too easy, which could have effectively turned the program into a government boondoggle, i.e., a subsidy for healthcare organizations. The whole ONC process has been very open and deliberate, involving many thoughtful people and organizations.

So what do the rules actually say? Before we get into the details, let's step back and look at the big picture. It is estimated that if every eligible professional and hospital meets the criteria, the cost of the program will be about $27 billion. When you add in the additional $2 billion invested in infrastructure (regional extension centers, HIE funding for the states, SHARP research projects, Beacon demonstration projects, and workforce development), the total cost will be $29 billion. That is no small sum of money, but is one of the those situations where the market would be unlikely to bring about this change. True to the American Recovery and Reinvestment Act (ARRA) from where it was legislated, the program certainly has created jobs and will likely create more.

As always with health IT, you can find a great deal information about the rules on the Web. One place to start, especially if you have a lot of time on your hands, is the full text of the final meaningful use rule (officially called the CMS Electronic Health Record Incentive Program, which also has an official Web site) and the final standards rule (officially called the Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology). However, for those of us with other things to do than read federal rules documents hundreds of pages long, concise early summaries are available from a number of places, including:

• An article in New England Journal of Medicine (NEJM) by Dr. David Blumenthal, National Coordinator
  
• Postings by Dr. John Halamka (Geek Doctor) on the meaningful use and standards rules, along with the beginnings of a frequently asked questions (FAQ) list
  
• A succinct overview from the Mr. HISTalk blog

The overall requirements from the ARRA legislation are of course still intact. The overall requirements for meaningful use involve:

• Use certified EHR technology in a meaningful manner
• Use certified EHR technology connected in a manner that provides for health information exchange to improve the quality of care
• Using certified EHR technology, the provider submits information on clinical quality measures

A certified EHR is a qualified EHR approved by an ONC- recognized certifying body. A qualified EHR is 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 and has the capacity to:

• Provide clinical decision support
• Support physician order entry
• Capture and query information relevant to healthcare quality
• Exchange electronic health information with, and integrate such information from, other sources

The incentives will be provided through increased Medicare or Medicaid reimbursement to eligible professionals (EPs), who include:

• Medicare: Physicians, Osteopathic Physicians, Dentists, Podiatrists, Optometrists, Chiropractors
• Medicaid: Physicians, Pediatricians, Dentists, Certified Nurse Midwives, Nurse Practitioners, Physician Assistants operating at an FQHC/RHC

As well as to eligible hospitals (EHs), which include:

• Medicare: hospitals paid under inpatient prospective payment system, critical acess hospitals; within the 50 states or DC
• Medicaid: acute care hospitals, childrens' hospitals

What follows is an overview of the criteria required to achieve meaningful use in Stage 1. The text that follows is gleaned most verbatim from Dr. Blumenthal's NEJM article as well as two PDF tables sent by email (can't find them on the Web) by ONC from the final regulations with the criteria sorted by core and menu items and by method of measure. An additional table from ONC compares the preliminary and final rules.

The rules are now organized so that in order to achieve meaningful use, an EP or EH must achieve 14 (EH) or 15 (EP) core rules and then five additional menu rules. There are also some additional twists on the menu rule. For example, some of them apply only to EPs while others apply only to EHs. In addition, one of the menu items selected must be a public health measure. This means that EPs must submit data to an immunization registry or syndromic surveillance registry, while EHs must submit to either of these or a reportable lab registry. However, if a state or regional public health agency is not prepared to accept such data, the EP or EH will not be penalized.

The 14-15 core measures must be achieved by all EPs and EHs in order to qualify for incentive payments. These include:

• Record patient demographics (sex, race, ethnicity, date of birth, preferred language, and in the case of hospitals, date and preliminary cause of death in the event of mortality) data - More than 50% of patients’ demographic data recorded as structured
• Record vital signs and chart changes (height, weight, blood pressure, body - mass index, growth charts for children) - More than 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data
• Maintain up-to-date problem list of current and active diagnoses - More than 80% of patients have at least one entry recorded as structured data
• Maintain active medication list - More than 80% of patients have at least one entry recorded as structured data
• Maintain active medication allergy list - More than 80% of patients have at least one entry recorded as structured data
• Record smoking status for patients 13 years of age or older - More than 50% of patients 13 years of age or older have smoking status recorded as structured data
• For individual professionals, provide patients with clinical summaries for each office visit; for hospitals, provide an electronic copy of hospital discharge instructions on request - Clinical summaries provided to patients for more than 50% of all office visits within 3 business days; more than 50% of all patients who are discharged from the inpatient department or emergency department of an eligible hospital or critical access hospital and who request an electronic copy of their discharge instructions are provided with it
• On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, and for hospitals, discharge summary and procedures) - More than 50% of requesting patients receive electronic copy within 3 business days
• Generate and transmit permissible prescriptions electronically (does not apply to hospitals) - More than 40% are transmitted electronically using certified EHR technology
• Computer provider order entry (CPOE) for medication orders - More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE
• Implement drug-drug and drug-allergy interaction checks - Functionality is enabled for these checks for the entire reporting period
• Implement capability to electronically exchange key clinical information among providers and patient-authorized entities - Perform at least one test of EHR’s capacity to electronically exchange information
• Implement one clinical decision support rule and ability to track compliance with the rule - One clinical decision support rule implemented
• Implement systems to protect privacy and security of patient data in the EHR - Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies
• Report clinical quality measures to CMS or states - For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures

EPs and EHs must then select any five choices from the menu set. Criteria applicable to both EPs and EHs include:

• Implement drug formulary checks - Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period
• Incorporate clinical laboratory test results into EHRs as structured data - More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data
• Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach - Generate at least one listing of patients with a specific condition
• Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate - More than 10% of patients are provided patient-specific education resources
• Perform medication reconciliation between care settings - Medication reconciliation is performed for more than 50% of transitions of care
• Provide summary of care record for patients referred or transitioned to another provider or setting - Summary of care record is provided for more than 50% of patient transitions or referrals
• Submit electronic immunization data to immunization registries or immunization information systems - Perform at least one test of data submission and follow-up submission (where registries can accept electronic submissions)
• Submit electronic syndromic surveillance data to public health agencies - Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

Additional menu criteria for EHs include:

• Record advance directives for patients 65 years of age or older - More than 50% of patients 65 years of age or older have an indication of an advance directive status recorded
• Submit of electronic data on reportable laboratory results to public health agencies - Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

Additional criteria for EPs include:

• Send reminders to patients (per patient preference) for preventive and follow - up care - More than 20% or patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders
• Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, medication allergies) - More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR

In my postings ahead, I will explore the meaningful use criteria in more detail, especially from the standpoint of the competencies requires of informatics users, organizations, and systems.

Meaningful Use: A Highly Useful Construct for Informatics

Whatever does happen with the ARRA/HITECH programs in the long run, one value to come out of the entire process is the construct of "meaningful use." In the next month or two, we will hear how meaningful use is operationalized in its first (2011) stage. Two more stages will follow in 2013 and 2015, and later in this decade we will know if the meaningful use of the electronic health record (EHR) has improved healthcare and people's health.

But I must give credit to whoever "invented" the construct of meaningful use. It is a brilliant way to think about the implementation of health information technology. I would also argue that it drives home the distinction between informatics and information technology (IT) that I have written about elsewhere, with the former focused on the goal of making "meaningful use" of the technology of the latter.

I have been asking around to see to whom we can attribute the invention of meaningful use. I will stand corrected if I find out the term was used before this, but it appears that it was first coined in a bill introduced in the 2007-2008 Congress, H.R. 6898: Health-e Information Technology Act of 2008. The bill was never passed but proposed the idea of "incentive payments to physicians and inpatient hospitals that meaningfully use a certified health information technology system." HR 6898 was introduced by Pete Stark, and has much verbiage from what eventually went into ARRA/HITECH. (Given the meaning that Stark’s name has in other contexts, it is indeed interesting that he could have been associated with the origination of the term!)

The idea behind meaningful use is simple: The goal is not to merely put computers and EHRs in physician's offices and in hospitals, but rather to make sure that they are implemented in ways that improve individual and population health. As HITECH has been operationalized, there are five underlying goals for meaningful use:

1. Improve quality, safety and efficiency
2. Engage patients in their care
3. Increase coordination of care
4. Improve the health status of the population
5. Ensure privacy and security

Every specific criteria that HITECH requires physicians and/or hospitals to do in order to get EHR adoption incentive funds must be tied back to one of these goals. For example, they must implement decision support rules, which are tied back to the goal of improving quality, safety, and/or efficiency of care. Likewise, they must provide care summaries in the patient's format of choice, tying back to the goal of engaging patients in their care. In the matrix of proposed criteria for meaningful use accompanying the Notice of Proposed Rule-Making (NPRM), every last criteria is tied back to one of the five goals listed above.

The definition is further modified that certified EHR technology be used, and that these certified EHRs be connected for health information exchange and able to submit information on quality measures, but that is just a modifier to the core construct. In the weeks and months ahead, we will see meaningful use operationalized, but I hope that we do not lose sight of how excellent of a construct it is for thinking about the value of HIT.

A New Year's Moment to Reflect

The year 2010 will mark my 20th year at Oregon Health & Science University (OHSU). I arrived at OHSU in 1990 as a newly minted Assistant Professor, fresh out of a three-year medical informatics fellowship in Boston that followed my medical training (medical school and internal medicine residency in Chicago). I have seen a great deal of change in our field since my tenure in it began, but I don't believe there has been anything quite like this past year, 2009.

I remember quite vividly as 2009 began. While I was excited at the election of our new president and his fresh hope for change, I was more than a little concerned about the onset of the economic recession and its impact on the finances of OHSU. Based on what we were hearing, I was having some serious doubts about the viability of OHSU and our Department of Medical Informatics & Clinical Epidemiology, as cuts to the small but essential amount of support (about 5% of our overall budget) we received from the university looked threatened. Furthermore, the potentially draconian cuts in other departments greatly threatened institutional morale.

Within a month or two of the new year, however, a different picture began to emerge. Something called the American Recovery and Reinvestment Act (ARRA, also known as the economic stimulus package) had just come to be, and within it, something called the Health Information Technology for Economic and Clinical Health (HITECH) Act promised unprecedented new support for health information technology (HIT). I even played a small role in the development of ARRA, contributing a few words that made it into what became Section 3016, the portion legislating support for health IT workforce development, working with the staffs of my Congressman David Wu and one of my state's Senators, Ron Wyden. (ARRA has also greatly benefited some, but not all, of the other departments at OHSU.)

In addition to new acronyms that are now household names (at least for those of us in informatics), such as ARRA and HITECH, new phrases appeared in the vernacular, mostly notably "meaningful use." As an educator and frequent speaker on the topic, the constant unveiling of new details made it a challenge to keep all my slides up to date.

The year of unprecedented activity came to a head in the last month of 2009. The trickle of funding opportunity announcements (FOAs)turned into a torrent, with the Office of the National Coordinator for Health IT (ONC) laying out its implementation of the vision of HITECH. The tight mid to late January deadlines for these FOAs released in December led a colleague to quip that ONC stood for the "Office of No Christmas" (to which I added, "Office of No Chanukah" for those of a different religious persuasion). Like many, I have spent a good deal of this year's Christmas break working on proposals for the FOAs.

On the second to the last day of the month and year, ONC, along with the Centers for Medicare and Medicaid Services (CMS), released the Notice of Proposed Rulemaking (NPRM) for the "meaningful use" criteria that will guide the distribution of financial incentives for EHR adoption under HITECH. Further released was the interim final rule (IFR) on Standards & Certification Criteria, the initial set of standards, implementation specifications, and certification criteria for the interoperability, functionality, utility, and security of health IT. A good starting point for digesting all the information associated with these is the ONC news release and overview. From these, you can link to a fact sheet on the IFR.

Readable and succinct summaries are also available from CMS about the program in general, the meaningful use standards, the meaning of certified electronic health records, and the requirements for incentive funding in the Medicare and Medicaid programs. No doubt a number of summaries will appear in the coming days; two good ones to start come from the venerable blogs HisTalk and Geek Doctor.

Also released on that day was an article in the New England Journal of Medicine by the National Coordinator of ONC, Dr. David Blumenthal, that gives a succinct, big-picture overview of HITECH. Dr. Blumenthal's article makes clear that if 2009 was the planning year, then 2010 will be the implementation year. We will see the finalization of the meaningful use criteria, the launching of the regional extension centers, the start-up of a number of other programs, and the initiation of the education and training programs to ramp up the necessary workforce to make it all happen.

Another event of 2010 will be the finalization of healthcare reform legislation. I have avoided expressing my views on healthcare reform this blog (considered out of scope!), but I agree with those who say there was more "reform" and transformation of healthcare in ARRA (courtesy of HITECH) than anything that will emerge out of the legislation due to be reconciled by the House and Senate in early 2010. I do agree, however, with those who see the imperfect legislation that will emerge from that process as a "foot in the door" to more meaningful healthcare reform in the years ahead. It will not be a smooth or painless process.

So ONC has now put its proverbial cards on the table, and it is very clear how they plan to implement HITECH. There probably is not a single person in the field who agrees with everything they are doing, but it is very clear that the health IT agenda in the US will be driven by the ONC agenda. A huge natural experiment is about to take place, and I for one am excited to be a "subject" in it!

Happy New Year to all.

The workforce for meaningful use

The discussion about health IT workforce continues to heat up as health care organizations realize that achieving meaningful use of electronic health records will require not only hardware and software, but people who have the expertise to make it happen. That expertise requires as much an understanding of information use and analysis, clinical organization and workflow, and business and management as it does IT, i.e., the substance of informatics.

One recent article describes a developing "war on talent" for health IT workers. The same publication features another article about how health care organizations are "racing" to fill CIO positions.

Finally, an IT publication describes why "your next job may be in health care."

By the way, many people ask me where they can read a succinct overview about "meaningful use," and I have found a nice 6-pager by David Classen of CSC. Of course, the "ground truth" comes from the matrix recommended by the Office of the National Coordinator to CMS, who will set the final rules in the near future.