Incentives remain unaligned with the use of health IT, but 21st Century Cures Act implementation is one tool in ONC's arsenal.
Lock-in of all sorts, ranging from the geographic lock-in of hospital consolidation to the vendor lock-in of electronic health records, was on the minds of former national coordinators of health IT during a panel last week at the virtual CHIME21 Summer Forum.
"I see telehealth as the next positive disrupter for improving care," said Rob Kolodner, MD, vice president and chief medical officer of ViTel Net, who served as national coordinator from 2007 to 2009 under former President George W. Bush.
Kolodner said he hopes telehealth can empower individuals to have provider choice and thus spur competition within the healthcare system, "rather than a geography lock." The COVID-19 pandemic shattered many of the barriers to telehealth adoption "and hopefully won't be reinstated," Kolodner said.
But competition extends to the very EHR systems that the federal meaningful use program funded, he added.
"Having spent over 30 years in the federal government, believing that vendors should compete on value and not on vendor lock, in order to do that, we need to get beyond the monolithic-type systems that we sometimes have to a platform-based type of approach, with modules and optional components, and be able to adapt easily and rapidly over time, and not have an 18-month cycle to get new things into place," Kolodner said.
Don Rucker MD, professor of clinical emergency medicine and biomedical informatics at Ohio State University and the immediate past national coordinator under former President Donald Trump, echoed the need for ONC to enable more choice for healthcare consumers.
"We can't, as an industry, look and say, we're providing great value for the American public and healthcare," Rucker said.
"Ultimately, the role of ONC and of any federal agency head is to be, in part, the voice for the people, the vast majority of America who's not at the table, but who has, frankly, gotten a raw deal in healthcare," he added.
Still, Rucker shares the hope of all former coordinators that new tools, including the FHIR application programming interface (API), will spur competition at all levels, including health information exchanges.
The daunting challenge of data blocking exasperated all national coordinators, leading ultimately to language in the 21st Century Cures Act, passed in the final months of the Obama administration in 2016.
"That would allow us to have a more modern approach…to achieving interoperability with an API FHIR-based system, and then addressing this increasingly important challenge of data blocking," said Karen DeSalvo, MD, chief health officer at Google, who was national coordinator from 2014 to 2016 under former President Barack Obama.
All the technology in the world won't help unless incentives are aligned to share data, said David Blumenthal, MD, president of the Commonwealth Fund, who was national coordinator from 2009 to 2011 under Obama as well.
"The implementation and use of electronic health records, and all the applications that build on them, is fundamentally a human activity," Blumenthal said. "If we don't motivate the users of those technologies to make the most of them, they won't."
The frustration of Blumenthal and his successor, Farzad Mostashari, MD, founder and CEO of Aledade, created a sense of inevitability that interoperability would happen, Blumenthal said, affording the political opportunities DeSalvo and Rucker used to pass and implement the Cures Act.
Although Mostashari's term saw the implementation rate of certified EHRs rise from 9% of hospitals to 90%, "the test of success was not functional enough, and it wasn't tied to payment models enough," Mostashari said. "It wasn't tied to the real business model. It was more compliance-oriented."
EHRs were able to meet ONC's certification standards but "you can't calculate a darn quality measure," Mostashari said. Instead, ONC would be better off "focusing more on functional tests" that demonstrate the ability of the EHR to perform a given function, he added.
The Power of Listening
Listening to public concerns about proposed ONC regulations emerged as another key topic at the CHIME forum.
"We did a lot of listening sessions with CMS," said Vindell Washington, MD, chief executive officer of Alphabet/Google Verily subsidiary Onduo, who was national coordinator from mid-2016 to early 2017. "There's no substitution for getting out, having sessions, and talking with folks that are going to be participating."
"I learned at ONC that listening is one of the most powerful policymaking and management tools that any leader in any organization can exert," Blumenthal said. "Some of my most productive meetings were meetings in which I didn't say a thing."
"Every single comment gets heard," added Micky Tripathi, the current national coordinator. "Sometimes you don't see it in a direct response, but I can assure you it's taken very seriously."
Mostashari cautioned the CHIME CIO audience that "astroturf doesn't work" in the regulation feedback process.
"If a vendor says to send in your version of this form letter, that's counted basically once," he said. "Speak in your own voice, be specific and granular about your own experiences, and be grounded in your reality."
Both public health and hospital staff received accolades for handling the COVID-19 outbreak, and a few former coordinators said that things would have gone worse without the widespread rollout of EHRs in American healthcare. Still, the leaders cautioned that more must be done.
"For years, we've been saying public health is underfunded," Tripathi said. "Public health is too fragmented. Public health has too many jurisdictional issues. We invested $40 billion in EHR systems that sent a firehose on the public health system with one-way flows of data that the public health system was not prepared to do anything with."
Despite this, "we also saw tremendous and heroic efforts to stand up stuff to help to solve that problem," Tripathi added.
Efforts to implement vaccination scheduling at a state level, exposed through EHR vendors such as Epic, and major pharmacy chains, have been a bright spot, based on an FHIR-based protocol, Tripathi said.
"It shows how, with the new technologies that we have available to us…you have the ability to say we can do things on a short cycle in the way that the rest of the internet economy works," he said.
"I do think our traditional public health organizations were in much better shape than they possibly would have been without those public health provisions that we did put in place," Mostashari said.
The proliferation of APIs enabling data exchange will lead to many new healthcare apps that won't necessarily be based upon EHRs, he added.
Scott Mace is a contributing writer for HealthLeaders.
Ultimate EHR success still requires better ties to payment models and focus on passing functional tests.
Telehealth holds promise for increasing competition to consumers' benefit, panelists say.
Former ONC chiefs recommend listening, current chief Micky Tripathi says ONC says every comment is taken very seriously.
FHIR-based vaccination scheduling at the state level was a bright spot for interoperability during the pandemic, ONC chief says.