At the 2018 SHIEC Annual Conference, sponsored by the Strategic Health Information Exchange, and being held August 19-22 in Atlanta, Donald Rucker, M.D., National Coordinator for Health Information Technology, delivered the opening keynote address on Monday morning, under the title, “Reshaping U.S. Healthcare: A Progress Report on Improving Interoperability and Usability of Clinical Information.”
Dr. Rucker, who was named National Coordinator in April 2017, told the 500 attendees assembled at the national association for health information exchange (HIE) organizations, that forward progress around health data exchange has to be understood in the context of a growing demand on the part of the purchasers, payers, and consumers of healthcare for the attainment of greater value in U.S. healthcare. And while he sidestepped specific questions emerging in the industry on some of the more contentious issues of the moment—including some degree of controversy within the HIE sector around the evolution of the draft of TEFCA—the Trusted Exchange Framework and Common Agreement by the Office of the National Coordinator for Health IT (ONC)—a mechanism to promote data exchange and interoperability in healthcare, conceived in response to requirements in the 21st Century Cures Act.
TEFCA remains controversial, particularly in the HIE sector, more than seven months after its release in draft form.
“All of us have to be aware of what the broader surround is” around this discussion of interoperability, Dr. Rucker told his audience. “Obviously in this audience and in ONC’s work, we focus a lot on interoperability. But interoperability is just part of the national discussion about what we get in healthcare, what we’re paying for. You can call it the search for value, but it’s a deeply important national consumer question. So this entire meeting, these discussions, have to be in that context. How do we add value for the American consumer?”
Rucker continued, “It’s been a very funny 50 years in healthcare. In 1965, when Medicare started and we took market prices out of the healthcare economy—you know, market prices are a way we signal value in other industries. And when we took that market pricing out of healthcare, we sort of had to create an immense sea of government policies. And I think it really is time to rethink those. And part of the discussion is, how do we rethink those, while understanding that you can’t predict who will get sick? How do we do that? Now, Congress has obviously had many opinions on that. And the opinions on that that matter most for us in this room were probably legislated in the 21st Century Cures Act.”
Further, while the largest section of the 21st Century Cures Act focused clinical trials and drugs, [since] clinical trials drive the single biggest part of the American drug spend. Title IV of that law was all about interoperability. When you talk with people on the Hill, they don’t think about it as interoperability, they think about it as, I couldn’t get my MRI results out of my patient record, or I had to take off a day of work” in order to obtain care or manage personal health information. “These are members of Congress. And when you have the backdrop of the modern app economy; and everybody uses technology.”
For example, Rucker noted, most likely, most of the conference’s attendee’s probably used smartphone apps to calculate traffic to the airport, confirm flights, check out local maps upon arrival, and so on. “We have increasingly extraordinary expectations in the app world, and Congress when you look at21st Century Cures asked, how can we get that type of app economy into healthcare? The law was passed almost unanimously. And much of the same intent in terms of empowering consumers and getting to the modern economy, is absolutely in President Trump’s intention.” Meanwhile, he noted, I had a meeting just two weeks ago with Health and Human Services Secretary Alex Azar, “and he asked me the same question three times: what are you doing to get this technology into the hands of consumers? So he’s absolutely on the case. So are Seema Verma and Adam Boehler at CMS,” he said, referring to the Administrator of the Centers for Medicare and Medicaid Services, and the recently appointed director of the Center for Medicare and Medicaid Services.
Burden reduction goals cited
“Part of what’s in Cures,” Rucker told his audience, “is not just interoperability, but burden reduction.” And, he said, “As we look at healthcare data, doctors are pretty unhappy about their EMRs. You look at the amount of time they spend” in physician documentation. With regard to that, he said, “In order to really harness interoperability, we need to make the computer a tool that has more happiness in it, and more value-add, rather than a black hole into which a lot goes in but not a lot comes out. The rest of the world uses computers to dominate things; that’s not the dominant picture in healthcare.”
More specifically, Rucker said, “In listening to literally thousands of doctors, one problem is the massive amounts of boilerplate text in our notes. There was a study published last month in the Annals of Internal Medicine that showed that the average physician note involves 4,000 characters of text in the United States, but only 1,000 in the rest of the world. That 3,000 characters gives you a sense of the delta of the documentation burden. Levels 3 and 4 CPT codes generate voluminous notes. It’s daunting; it’s like a game of three-card monte, in terms of finding anything that’s not just boilerplate. So the proposal is for a revenue-neutral, specialty code-neutral merger of codes from levels 2 through 5, so there’s no incentive to do all this sort of boilerplate documentation on things you wouldn’t need to do. There’s a special add-on code for category 6 patients, the most complex patients. We believe this will leave documentation revenue-neutral” for physicians. “If implemented by all payers, we believe it will free up 5-10 percent of time for physicians. This is an absolutely dead loss to the economy.”
A bit later, Rucker noted that “There has always been tension in electronic health records, in terms of what you have in structured form, versus in freetext data. I think that over time, as computers get more powerful, we’ll see machine learning, using big data. Big data us gathering steam in healthcare. But I think we’re going to see a series of modern tools to help clinicians, patients, the whole system, be smarter. This will take time,” he added.
What’s more, Rucker said, an additional challenge that he considers significant is that, “As we look at the query part of this, it’s been pointed out that there’s not a way to look at population-level data. You can use FHIR [the Fast Healthcare Interoperability Resources standard] to look at individuals. But we have a lot of national needs to look at populations of data. Right now, there’s no standard way for anybody to look at a population of patients electronically. And that’s critical, because most American healthcare is still paid for by third-party payers. And they do not have an elegant, computational way of figuring out what they’re getting from providers on their behalf. There’s a lot of thinking to be done on how we measure value.”
Addressing the controversies around TEFCA
Much later in his speech, Rucker addressed, if somewhat glancingly, some of the controversies among providers and HIE leaders about the provisions of TEFCA. “For those of you who haven’t read the law under Cures… Congress had heard a lot of complaints about people being charged to use networks, so Congress said, there shall be this public-private network to coordinate common agreement among these networks,” he said, referring to the provisions in the draft regulation around QHINs—qualified health information networks, and the Recognized Coordinating Entity (RCE) that is supposed to be created in order to supervise the QHINs envisioned under the regulation. ONC has suggested that a private-sector organization might ideally serve as the RCE, a suggestion that has created some concern and confusion in the industry, particularly among HIE leaders. “That’s a work in progress. We’ve gotten a lot of comments” about that large element of the regulation, he noted. “We have to figure out how to put this recognized coordinating entity together. There will be notice of funding opportunity, or NoFo. We are deeply aware that these decisions impact not only policy, but also a lot of operations issues. As a matter of public policy, we want to expand the scope and permitted purposes of these networks,” he said. “And over time, we want to increase the public purposes, so it’s not just single conversations about getting my chart from one provider to another. We want discussions among payers. And there are public health issues,” as well as input from the medical research community. “So there are broader purposes to this work in progress, but that will be out there, and there will be lots of comments on that,” he said, referring to the broad goals around the TEFCA rulemaking.