During a small gathering with health IT trade press on Sept. 19, Vindell Washington, M.D., newly-appointed National Coordinator for Health IT, reiterated the Office of the National Coordinator for Health IT’s (ONC) overarching goal to improve healthcare interoperability through a variety of initiatives.
Dr. Washington, who previously served as the president of the Baton Rouge, La.-based Franciscan Missionaries of Our Lady Health System (FMOLHS) Medical Group and as the health system’s CMIO, and who just recently took over for Karen DeSalvo, M.D., as National Coordinator for Health IT, spoke for the first time to about a dozen members of the trade press, some in person in Washington, D.C., and others via teleconferencing. While Washington answered a myriad of questions covering various health IT issues, the main takeaway from the session was that most of the federal agency’s core goals are centered around improving health information sharing across the care continuum.
Washington noted that ONC primarily focuses on three major areas regarding interoperability: using national, federally-recognized standards that come up through the environment; changing the way care is paid for, which involves work the agency is going doing with its partners at the Centers for Medicare & Medicaid Services (CMS); and third, working towards cultural changes around the sharing of health data, which involves work with the government’s Office for Civil Rights (OCR) as they look to make sure that patients know their rights around information exchange. “These initiatives fit under that [interoperability] effort, and we are focused on them as they are most likely to move forward the information sharing that’s desired in the health ecosystem,” Washington said.
Washington touched further on standards specifically, as healthcare leaders continue to look for a common language to enable interoperability between systems and devices. In the past, ONC has gotten criticized for having regulations that deter marketplace innovation. But Washington pointed to a testimony he gave to the Senate Health Committee, in which he recommended a public/private approach, with the Interoperability Standards Advisory being the best example of that. “If you look at the Standards Advisory that was recently released, it’s organized about the use case,” Washington said. “So this depends on what information is being passed, for what usage it’s being passed, and what the standards should be. You see areas of evolution in the Standards Advisory. As the government moves forward and as those standards mature, you have a move in that direction that underscores the specificity of standards that are necessary for passing information. You draw a line in road but allow enough room for innovation in our sector,” he said.
Health IT’s new National Coordinator say went on to say that the work ONC is doing around data sharing goes hand in hand with a number of the Obama Administration’s priorities. “[Data sharing] is important for delivery system reform, for the Precision Medicine Initiative, and for the Cancer Moonshot. Even though those are large and in some ways longer-term strategies, the work in the short term is around increasing this flow of information, empowering patients in this space to be able to use information and send it forward for purposes they choose. The work we are doing is in particular aimed in those areas,” he says.
Washington also stated that ONC is working with CMS to provide technical help for the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) final rule and working with OCR around the concept of patient information, meaning what data should be available and clarifying Health Insurance Portability and Accountability Act of 1996 (HIPAA) rules. “We want to get that word out, and pushing that forward in the last few months [of the Obama Administration] is very important,” he said. He also mentioned funding opportunities where the agency is funding folks to do work on the patient-facing side, meaning apps using Fast Healthcare Interoperability Resources (FHIR} application program interfaces (APIs) with the goal of demonstrating an ecosystem or app store environment. “Standards will always be a whiteboard exercise until they are in wide and deep use,” Washington attested. “We are particularly interested in having relatively specific use cases, and some of that catalyst work helps us get to standards,” he said.
To this end, when asked about current interoperability initiatives in healthcare such as CommonWell, Carequality and the eHealth Exchange, Washington said that ONC approves the commitment in those sectors to move interoperability forward. “Our general approach is to applaud the sharing of information to be available when and where patients need it. We are also focused on making sure the playing field is level and that folks are not left out,” he says. “We have encouraging evidence in the field about exchange that’s working either by these efforts or by a local HIE [health information exchange]. There is an opportunity to do it more broadly, and that’s our focus.”
Overall, Washington believes there “is great promise and opportunity in interoperability.” He talked about a recent trip to Oklahoma in which competing health systems—Hillcrest HealthCare System and St. John Health System in Tulsa—as well as a Blue Cross Blue Shield vendor all worked together on CMS’ Comprehensive Primary Care federal initiative. “I dropped by [to talk to] one of the doctors at Hillcrest, and he told me that he’s never had this kind of information on patients he was caring for. So there are clearly areas where this is going well,” he said.
But, Washington also brought up a situation at his health system before he joined the government that points to data sharing struggles. He said he has had shifts in the ED where he has managed critical care patients with doctors who were remote and writing orders. “We both were reviewing charts at the same time, and then an hour or two later I would have to get a fax from the hospital down the street to continue the care for the patient. So I would say in some instances, it is about how broad and deep the exchange is.”
Addressing Docs’ Concerns
Meanwhile, Washington had other interesting comments regarding quality measurements and documentation for physicians—often sore points for doctors who complain that these requirements impede their ability to practice medicine. While the ONC chief couldn’t speak directly to CMS’ portion of setting up federal programs about payment, Washington attested that there “is a need to make sure care is provided is within guidelines,” adding that when he was a CMIO, “we had questions about where we stand about quality.” He said, “If you close the door with no payers in the room and discuss with providers how they will demonstrate the level of care they’re providing and improve upon that care, it becomes a complicated situation. You have limited ability in some instances to measure true outcomes such as quality-adjusted life years, improvement, and the overall health status of individuals. Those are the end goals but they are also difficult to measure.”
So, Washington pondered, what is needed in healthcare to lead to those outcomes? “Maybe I can keep my diabetic patient from having a bad complication. The best guess is to measure [the patient’s] Hemoglobin A1c in a certain range, so you are measuring that but what you really want is to have them not lose a limb or eye sight. There is a juxtaposition of what you can measure easily versus what the ultimate outcome is,” he said, adding, “This idea of quality measurement generally is not an easy scenario. It’s also multifactorial. Whether or not I had an asthmatic patient with multiple visits may be related to him or her living in a polluted area, or if the patient took medicine or used an inhaler. So we are operating in an imprecise environment while trying to reach these laudable goals of measurement,” Washington said.
Washington was also asked about a recent study published in the Annals of Internal Medicine which found that during office hours physicians spent nearly 50 percent of their time on electronic health record (EHR) tasks and desk work, and outside office hours, they spend another one to two hours of personal time each night doing additional computer and other clerical work. To this, Washington noted that there are pockets where technology is evolving well in physician practices, and pockets where it isn’t. He said he has had providers who implement their systems, do well with them, have great patient encounter times, and go home on time or even early, but he also knows instances of providers who document at home rather than spend time with their families. He did say, “I don’t hear stories anymore about ineligible orders from physicians or [documentation] with missing information as we used to hear. My impression is that when the picture is so diverse, it means we are in an evolutionary phase when it comes to the ultimate usability of the record,” he said.
In the end, Washington is pleased with ONC’s role as its name implies—a coordinator. “Some of the best work we do is around coordination and collaboration among different movers in the environment,” he said. He lauded the effectiveness of the Meaningful Use program, as some 98 percent of hospitals and three-quarters of doctor practices are now digitized, noting that foreign delegators have asked the ONC how it has gotten such high levels of adoption.
“Now we need to pivot more to information sharing,” he said. “When I was a provider, one of the things I valued the most about being digitized was the support I got from my EHR to help me avoid errors but also the information I could get on fingertips to provide better care. Broadly speaking, [focusing on] information sharing—termed interoperability—is the right place for ONC.”