The meaningful use program has had and continues to have its challenges, but much has been accomplished, and much will be accomplished over the next two years as well; and a bold future of data-driven healthcare is ahead of us. That was the core of the keynote presentation delivered by David Blumenthal, M.D., at the Health IT Summit in New York, held at the Convene conference center in New York City’s Financial District Sep. 28-30, and sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics, under the corporate umbrella of parent company Vendome Group, LLC).
Dr. Blumenthal, who is now president of The Commonwealth Fund, the New York City-based organization whose website describes it as “a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults,” served as National Coordinator for Health IT in 2009-2011. He spoke on the topic, “Realizing the Potential of Health IT: The Policy Challenge, on Sep. 30, at the Convene conference center in the city’s Financial District.
David Blumenthal, M.D.
At the outset of his remarks, Blumenthal noted a number of statistics, including the following: $31.13 billion was disbursed between May 2011 and May 2015, to 470,000-plus unique providers, slightly under the estimate made by federal officials of $34 billion in disbursements prior to the onset of the meaningful use program under the HITECH (Health Information Technology for Economic and Clinical Health) Act.
Blumenthal, using statistics from the Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare & Medicaid Services (CMS), also noted that 95 percent of eligible hospitals and 54 percent of all office-based physicians in the U.S., have received Medicare or Medicaid incentive payments so far; and that as of July 2015, 1,836 eligible hospitals, and 60,004 eligible providers, had attested to Stage 2 of meaningful use.
With regard to the qualitative evaluation of the meaningful use program to date, Blumenthal said, “With respect to Stage 2, clearly, the hurdle is higher” than it was under Stage 1 of meaningful use. “We’ve had 1800-plus hospitals attest. It doesn’t prove that it’s easy, but it does prove that it’s possible.”
Further, he noted, “Stage 2 ended up emphasizing interoperability, decision support and consumer engagement. If you think about the value of electronic health records, they don’t lie in the capture of data, but in their use, including exchanging information, supporting clinical decision-making, and enabling clinicians to be more effective partners with patients in their care.”
Anticipating the final rule for Stage 3 of meaningful use, Blumenthal noted that “The proposed Stage 3 rule is now before OMB”—the federal Office of Management and the Budget. “It’s always dangerous to predict based on a proposed rule, what a final rule will look like.” That said, he noted that the proposed rule for Stage three “continues the emphasis on interoperability, consumer engagement, and decision support. What it will actually look like when OMB is finished with it, and ONC and CMS have finished with it, I don’t know,” he said. “But what is clear is that there will be no stages after 2017. When we were first tasked with defining meaningful use in 2009, there was no literature to go on, and no definition,” he added. “The conceptual basis for defining it was pretty much a null set. And the reason for multiple stages was to allow the definition to evolve. If we had tried to set out a final definition in Stage 1, it would almost certainly have been wrong, constraining, and impractical. So the idea that we’ve continued to redefine meaningful use has been gratifying.”
He also noted the dramatic leaps in the adoption of electronic health records (EHRs) because of the passage of the HITECH Act, with its meaningful use program. As he noted, hospitals’ adoption of EHRs went from 9 percent in 2008, according to his accounting, to 76 percent in 2014, while physician practices’ adoptions of electronic health records went from 29 percent of physician practices having adopted any kind of EHR in 2006, to 83 percent having done so by 2014.
The Challenge of Health Information Exchange
“What are the continuing challenges?” for clinical information system adoption, Blumenthal asked his audience rhetorically. “Health information exchange remains a continuing challenge,” he stated. Meanwhile, he said, “Interoperability, which is technical,” also remains to some extent unresolved. Among the challenges he sees in the forward evolution of health information exchange adoption, Blumenthal told his audience, are HIE governance, which he described as still “haphazard”; as well as data privacy and security concerns; and the fact that “Electronic health records weren’t designed effectively with [clinical] end-users in mind.”
“It takes partnerships, collaboration, and cooperation, to be successful with exchange,” Blumenthal noted. “Those issues are far more significant than the technical ones. We spent a lot of time talking about standards” during his tenure at ONC, he said. “It’s humanware, not software, that is the big issue in exchange. If we had a functioning healthcare market that worked like other markets to optimize quality and reduce cost, there would be no need for meaningful use, the HITECH legislation, or government intervention. You’d see healthcare exchange as ubiquitous as ATMs and air travel. But you don’t, because you have a dysfunctional healthcare market, and that’s why we needed to create this legislation”—the HITECH Act.
“Another way of thinking about exchange,” Blumenthal said, drawing an analogy with the automotive market, “is that [what we are doing in requiring data exchange in healthcare is that] we are asking Toyota, BMW, and Lexus, to exchange their consumer lists, their records of repair, their consumers’ preferences, and their financial terms, as though they weren’t competing for customers. That’s what we’re asking hospitals and physicians to do. The fact that it doesn’t happen shouldn’t surprise anyone. Or the fact that vendors aren’t exactly enthusiastic, shouldn’t surprise anyone. It reflects the healthcare market.”
Blumenthal noted that “Ashish Jha at Harvard did a study that the ONC has incorporated in its report to Congress on information-blocking. It turns out,” he said, “that in more concentrated, less competitive markets, and among non-profit entities, exchange is more common. It turns out that in less-concentrated markets, among for-profit entities, and in large systems that have developed their own electronic systems, exchange is less common. Market competition is not conducive to information-sharing.”
Progress Seen as Inevitable
Despite all the challenges that healthcare leaders face, Blumenthal told his audience that “We are on the road, bumpy as it is, to digitizing the great bulk of provider-based, provider-generated health information. This will happen. It’s just a matter of time. We may not get exchange exactly the way we wanted; it may still be burdensome. But it’s inevitable. And deep down, doctors and administrators understood that this was inevitable. They wanted to put the pain off as long as they could, but knew that at some point, we had to forward with this. We are now entering a new world,” he stressed; “the kinds of data that will be available will be vastly more rich, a lot of it less useful, a lot of it useful.”
What’s more, Blumenthal told his audience, “As we start to work with provider-based information, we are about to begin a process of sorting through what we do with all sorts of information. And by the way, the market is aware of this. And venture funding for digital uses of information, is soaring. There are a lot of misunderstandings” in the business world about all this, he conceded. “There’s a big gap between what Silicon Valley and Silicon Alley understand what healthcare is like, and there’s a lot of naiveté. But venture capitalists are going whole hog, investing in wearables and bio-sensing, healthcare consumer engagement, employee wellness—a lot of things that are consumer-facing, that they understand.”
In fact, Blumenthal said, “I believe that it won’t be long before each of us has the equivalent of a personal digital health advisor, that will provide us with information, both what is available from our providers, and what we ourselves have generated through biosensors and other data sources, through our purchasing patterns and habits of life and through the Internet of things. And,” he said, 10 to 15 years from now, we will see companies already existing,, others that will be totally new, that will help collect, steward, and curate information for you, 24/7, with a whole lot of personal applications that will tell you about the quality of local providers, the availability of local providers, where you stand with regard to your deductions and co-pays, what drugs and treatments are available and approved, etc., on mobile apps, before you are even ready to use them. And that would be huge in terms of making patients loyal to particular health system, because patients and consumers will want to know that their information is safe, and the providers of that information is trustworthy and useful.”