Call for HITECH reboot
John W. Loonsk, MD, CMIO at CGI and adjunct associate professor at Bloomberg School of Public Health at Johns Hopkins Center for Population Health IT, served as director of interoperability and standards at the ONC from January 2006 to December 2009. Part of his time at ONC coincided with Blumenthal’s tenure as national coordinator.

In an analysis piece Healthcare IT News published May 29, Loonsk called for a “hard reboot” for HITECH, and offered a 10-point plan for how to proceed.

“Here’s to giving Karen DeSalvo, the new national coordinator for Health IT, all the support she needs to do a full and hard HITECH reboot,” Loonsk wrote. “While it is reasonable that many HIT outcomes are still unfulfilled, the path forward seems murky. EHR adoption has surged, but much of what has been broken about health IT in the United States still remains.”

No. 9 on Loonsk’s 10-point plan is a call for “meaningful relief.”

“Providers need to be left alone for a while,” Loonsk wrote. “They were already under incredible strain from many non-HIT related pressures. HITECH added to these pressures (necessarily) by fostering EHR adoption. But meaningful use added much more strain through, sometimes, aspirational criteria that demand workflow and process changes well beyond simply adopting an EHR. Give providers meaningful relief from many of these new business requirements. It is not clear that there are incentives to sustain them after HITECH and the infrastructure needs attention before many are viable.”

No. 8 on Loonsk’s list is a call to “double down on interoperability.”

“There needs to be a broader, more inclusive, standards process,” Loonsk wrote. “The ONC Standards & Interoperability Framework has good ideas, but there are many more needs than ONC alone can promote. There are also needs for broader standardization and specification of technologies beyond just data and messages. Constructively re-engage the industry to help make this happen.”

Interoperability on the mind
“I think a lot about interoperability and whether we could have promoted an exchange more rapidly and more effectively, and I’m not sure we could have – the reason being that the standards were not adequate at the time to support it, and there was no demand – real demand – for it,” Blumenthal said, when asked, in hindsight, could ONC have done anything differently.

“When we began this process, there was very little capability, and/or demand for interoperability. It was a theoretical idea.”

 If ONC had placed a big emphasis on interoperability, there would have been pushback, Blumenthal surmised. The question, he said, would have been, “Why are you so interested in interoperability when there isn’t any information in digital form? There’s nothing to exchange.”

“So, we adopted the view that basically you had to operate before you could interoperate, and that we would have to create an infrastructure on top of the electronic health records that we were putting in place to create interoperability.”

Succeeding national coordinators, however, began to put interoperability center stage.

“Most vendors really do see it now as part of their self-interest to be as interoperable as possible,” then National Coordinator Farzad Mostashari told me in an interview in March 2013, “but we still hear a lot of complaints from providers that their vendors are putting up what they believe are artificial roadblocks to them being able to share information, to participate in health information exchange.

As Mostashari, sees it, interoperability is a shared responsibility.

“Fundamentally, we have to reduce the cost and complexity of interfaces through standards and implementation guides,” he said. “The vendors have to really be able to do Stage 2. It’s a huge step up – huge step up on interoperability. Vendors are really going to have to step up to the plate in terms of being able to achieve the Stage 2 expectations for true vendor-to-vendor coded, clinical structured, documents being able to have kind of ubiquitous protocols with security in place. That’s a big step for the industry and meaningful use Stage 2 sets the tempo and expectations for that.”

Fast forward a year, and National Coordinator Karen DeSalvo, MD, who has taken the baton from Mostashari, is gathering input from stakeholders on several topics, with interoperability at the top of the list.

“I’m in a listening phase about all of this,” she said in a February 2014 interview. What I’m hearing is that there are some technical aspects to it that are real and important. There have to be some standards to allow for that interoperability to occur. There are some business issues that relate to not just the business model, but to the marketplace itself and providers, which are themselves right now undergoing a lot of evolution and change because of quality and payment reform. It’s a dynamic place. I think from a business case standpoint, there’s been work to do to get some of that appreciation.”

A few days later DeSalvo announced at the Fourth Annual Health Care Innovation Day in Washington, DC, hosted by ONC and the West Health Institute, that interoperability would be her top priority for 2014.

In hindsight, Blumenthal believes ONC did what was possible at the time, and that meant focusing on EHR uptake. The time was not right during his tenure to press for interoperability.

“My view of the process of promoting electronic health record adoption and the creation of a national information infrastructure is that it’s a complex interaction between technology and market forces,” Blumenthal said. “And, the technology doesn’t advance very fast unless there’s demand for it, and the demand doesn’t advance as fast as you’d like unless there’s a technology to support it. So, there will be a constant interplay between the technology and the demand for technology.

“What I do believe focusing on adoption did was it proved that the government could accomplish a first step, and that was to incent adoption. I don’t think people realize how important it was for the government to establish its credibility at being able to move this process along on some dimension.”