Thursday, December 31, 2009

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.

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