Friday, October 6, 2017

HITECH Retrospective: Glass Half-Full or Half-Empty?

Last month, the New England Journal of Medicine published a pair of Perspective pieces about the Health Information Technology for Clinical and Economic Health (HITECH) Act (both available open access). The first was written by the current and three former Directors of the Office of the National Coordinator for Health IT (ONC) [1]. The second was written by two other national thought leaders who also have a wealth of implementation experience [2]. Both papers discuss the accomplishments and challenges, with the Directors’ piece more positive (glass half-full) than the outside thought leaders (glass half-empty).

In the first piece, Washington et al. pointed to the accomplishments of the HITECH era, where we have finally seen digitization of the healthcare industry, one of the last major industries to do so. The funding and other support provided by the HITECH Act have led to near-universal adoption of electronic health records (EHRs) in hospitals and substantial uptake in physician offices. They also point to a substantial body of evidence that supports the functionality required under the “meaningful use” program.

These authors also note the shortcomings of this rapid adoption, when not only the people but also healthcare organizations and even EHR systems were not ready for rapid uptake. They acknowledge that many healthcare providers are frustrated by poor usability and lack of actionable information, which they attribute in part to proprietary standards and information blocking. They advocate moving forward with a push for interoperability, secure and seamless flow to data, engagement of patients, and development of a learning health system.

Halamka and Tripathi, on the other hand, take a somewhat more negative view. While acknowledging the gains in adoption that have occurred under HITECH, they note (my emphasis), “We lost the hearts and minds of clinicians. We overwhelmed them with confusing layers of regulations. We tried to drive cultural change with legislation. We expected interoperability without first building the enabling tools. In a sense, we gave clinicians suboptimal cars, didn’t build roads, and then blamed them for not driving.” They note that the process measures of achieving meaningful use have become an end in themselves, without looking at the larger picture of how to improve quality, safety, and cost of healthcare. They do point a path forward, calling for streamlining of requirements to insure interoperability and a focused set of appropriate quality measures, with EHR certification centered on this as well. They also encourage more market-driven solutions, with government regulation focused on providing incentives and standards for desired outcomes.

Taking more of a glass half-full point of view, I wrote in this blog several months ago that EHR adoption has “failed to translate” the benefits that have been borne out in practical research studies. I noted the success of some institutions, mostly integrated delivery systems, in successfully adoption EHRs, and also persistence in healthcare of the problems that motivate them, such as suboptimal quality and safety of care while costs continue to rise.

A few other recent pieces have painted a path forward. The trade journal Medical Economics interviewed several physician informatics experts to collate their thoughts on what features a highly useful EHR might have, especially in contrast to systems that a majority of physicians complain about today [3]. The set of features does not represent much more than we expect of all of our computer applications these days, but whose availability in EHRs continues to be elusive:
  • Make systems work together – achieve interoperability of data across systems
  • Make it easier and more intuitive – make systems easier to understand and use; reduce cognitive load
  • Add better analytics – add more capability to use data to coordinate and improve care
  • Support high-tech care delivery – be able to engage patients in through video and asynchronous communication
  • Make EHRs smarter – systems anticipate user actions and provide reversible shortcuts
  • Become a virtual assistant – assist the clinician with all aspects of managing the delivery of care
A couple other recent Perspective pieces in the New England Journal of Medicine provide some additional solutions. Two well-known informatics thought leaders from Boston Children’s Hospital lay out the case for an application programming interface (API) approach to the EHR based on standards and interoperability [4]. Although this piece has a different focus than the previous one, there is no question that the data normalization from FHIR Resources, the flexible interfaces that can be developed using SMART, and the ease of developing it all via SMART on FHIR could make those goals achievable.

In the second other piece, a well-known leader in primary care medicine calls for delivering us from the current EHR purgatory [5]. His primary solutions focus on reforming the healthcare payment system, moving toward payment for outcomes and not volume, i.e., value-based care.

I agree with just about all that these authors have to say. While the meaningful use program required some benchmarks to insure the HITECH incentive money was appropriately spent, we are probably beyond the need to continue requiring large numbers of process measures. We need to focus on standards and interoperability that will open the door to doing more with the EHR than just documenting care, such as predictive analytics and research. Continuing to reform our payment system is a must, not only for better EHR usage but also to control cost and improve health of the population.

There is also an important role for clinical informatics professionals and leaders, who must lead the way in righting the problems of the EHR and other information systems in healthcare. I have periodically reached back to a quote of my own after the unveiling of the HITECH Act: “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.” Informatics does live in this world now, and we must lead the way, not letting perfect get in the way of good, but making EHRs most useful for patients, clinicians, and all other participants in the healthcare system.


1. Washington, V, DeSalvo, K, et al. (2017). The HITECH era and the path forward. New England Journal of Medicine. 377: 904-906.
2. Halamka, JD and Tripathi, M (2017). The HITECH Era in Retrospect. New England Journal of Medicine. 377: 907-909.
3. Pratt, MK (2017). Physicians dream up a better EHR. Medical Economics, May 22, 2017.
4. Mandl, KD and Kohane, IS (2017). A 21st-century health IT system — creating a real-world information economy. New England Journal of Medicine. 376: 1905-1907.
5. Goroll, AH (2017). Emerging from EHR purgatory — moving from process to outcomes. New England Journal of Medicine. 376: 2004-2006.

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