Now that the Supreme Court has upheld the substance of the Affordable Care Act (ACA), a collective sigh can be heard, of relief by some and frustration by others, but certainly of avoided tumult.

The focus of ACA attention will turn to results or repeal. And while a different decision could have had ACA become a weight on HITECH and health information technology (HIT), the principally bi-partisan nature of the HIT agenda should now refocus attention almost exclusively on results for it.

It is from this latter perspective, though, that there may still be HIT tumult to come. HITECH was constructed from a health IT orthodoxy (set of tightly-held, common beliefs) that has shown a few cracks of late. And some of these cracks have to do directly with the population health IT needs of health reform from a program (HITECH) that is principally built around individual patient transaction technology.

[Related: Beaufort Memorial CIO Ed Ricks on sorting emotions after SCOTUS ruling.]

Through the EHR looking glass
Specifically, cracks have developed in the view, which HITECH shares, of EHRs as the center of the HIT universe. EHRs, and not other aspects of HIT, are the overwhelming focus of the incentive funds. The Meaningful Use criteria, tied to those funds, look at almost everything through an EHR lens. Either as cause or effect, criteria and leverage are pinned to EHR certification.

Taking this EHR focus to an extreme, recent policy discussion has even gone so far as to suggest that almost all health data, including even patient experience data, must be made to flow through EHRs. It is almost as if all the other health IT systems in hospitals, much less other health related organizations, never existed and EHRs need to carry the entire burden of HIT expectations.

Interestingly, a recent commentary in the New England Journal of Medicine by Ken Mandl and Isaac Kohane, has strongly criticized EHR software for its complexity and lack of flexibility. The authors have been trying to develop app-like health IT capabilities for an ONC grant and no doubt are frustrated by current EHRs as a platform. They put the blame for these issues squarely on EHR software vendors. But while EHR software may be complex right now, even at the “app store” you get what you pay for, and the current orthodoxy has the country paying specifically for EHRs. It is not clear that EHR vendors should be blamed for creating them or creating them with increasing complexity to meet all of the MU expectations. This is exactly what their clients are asking for because of the incentive structure.

[See also: SCOTUS ruling a 'great success' for public, population health.]

Not about the technology
One way to build more flexible EHRs would be to specify and standardize more detailed EHR transactions. Currently, modular certification exists as an appeasement to existing software rather than to drive the creation of more modular, connectable systems. Here too, though, the current orthodoxy is challenged. It says that we should not pay undo attention to technical architecture like that which could make EHRs more modular lest we be “led by technology” or “stifle innovation”.

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