Is “Meaningful Use” Delivering Meaningful Results?: An Examination of Health Information Technology Standards and Interoperability

On Wednesday, November 14, 2012, the Subcommittee on Technology and Innovation of the Committee on Science, Space, and Technology held a hearing entitled "Is 'Meaningful Use' Delivering Meaningful Results?: An Examination of Health  Information Technology Standards and Interoperability" to examine progress on the development and implementation of interoperable technical standards and conformance testing procedures for health information technology (HIT). (Video archive here) The Subcommittee reviewed the activities of the Office of the National Coordinator for Health Information Technology (ONC) and the National Institute of Standards and Technology (NIST) in promoting interoperability through the development of technical standards for HIT, and will examine the implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act, including the recently announced final rule for Stage 2 meaningful use of HIT under the Act.

Witnesses included:

• Dr. Farzad Mostashari, National Coordinator for Health Information Technology, The Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services.
• Dr. Charles H. Romine, Director, Information Technology Laboratory, National Institute of Standards and Technology.
• Mr. Marc Probst, Chief Information Officer and Vice President, Information Systems, Intermountain Healthcare.
• Ms. Rebecca Little, Senior Vice President, Medicity.
• Dr. Willa Fields, DNSc, RN, FHIMSS, Professor, School of Nursing, San Diego State University.

These witnesses were asked to address the following questions in their testimony:

1. What is the goal for health information interoperability under the HITECH Act?
2. How are Stage 1 and 2 meaningful use requirements and supporting standards advancing us towards this goal?
3. How have the lessons learned from the implementation of Stage 1 meaningful use requirements and supporting standards been applied in drafting Stage 2 requirements and Stage 3 proposals?
4. How does the ONC engage Federal agencies and other stakeholders (National Institute of Standards and Technology, vendors, and providers) in developing the meaningful use requirements and technical standards?
5. How does the HIT Standards Committee balance the need for common IT standards with the diversity of the healthcare industry? How does the Committee account for technology development and innovation in its standards recommendations?
6. How effective have HHS and the ONC been in establishing long-term goals and benchmarks for HIT adoption, interoperability, and provision of care?
7. What recommendations would you make for Federal policy makers as we consider future HIT policies?

After giving an overview of the EHR Incentive program, Dr. Mostashari discussed how the ONC has been working with NIST. "In 2009 and 2010, NIST provided standards and conformity assessment technical expertise as ONC established the regulatory framework for EHR certification, a HITECH requirement designed to ensure the availability of EHR products that enable health care providers to meet meaningful use criteria. NIST continues to play a key role in supporting the design, implementation and maturation of the ONC HIT Certification Program, including the accreditation of testing laboratories, and the test procedures and testing tools/infrastructure used by them," said Dr. Mostashari. "We have also worked closely with NIST on issues of measuring and improving the usability of EHR products, including through several workshops. Experts from NIST also participate in various capacities on the Health IT Policy Committee and Health IT Standards Committee, as well as through the Standards and Interoperability Framework, a forum for stakeholders to use to identify and resolve standards-based issues impeding progress in the marketplace."

Dr. Romine stated, "NIST’s Information Technology Laboratory (ITL) and ONC are collaborating with industry, healthcare informatics-related standards organizations, consortia, and government agencies to develop consensus-based complete and unambiguous standards and to build tools and prototypes to advance the adoption of IT within healthcare systems. NIST focuses its efforts on developing the key standards that ONC needs for current and future meaningful use criteria."

Marc Probst, of Intermountain Healthcare and a member of the HIT Policy Committee, said that progress has been made as a result of the HITECH Act towards greater health information technology (HIT) interoperability, but much needs to be done. He gave an analogy of the Australian railroad to provide an example of the importance of standards. "In Australia, railroads developed independently, one by one. While trains and tracks did get built, the railroad system was constructed with many different gauges of rail, preventing railroad cars on one set of tracks from running on others. After many years of subpar train service, expensive work‐arounds, and increasing costs, Australia defined a standard gauge system. The process of standardizing the gauges was expensive and disruptive, but efficiencies continue to be realized today," he said.

Mr. Probst added, "The vast majority of these Meaningful Use requirements deal with functions that an EHR should be able to perform and requirements for what functions or data should be shared between EHRs. The existing HIT systems, be they vendor developed or self‐developed, also were built one‐by‐one and applied differing standards (the great thing about healthcare standards is there are so many to choose from). Although very effective for each institution, heroics are required to share even basic data between them. We now essentially have our own Australian railroad and fixing it will require leadership and investment."

Rebecca Little, from Medicity said "We supply the 'plumbing,' the intelligent plumbing, rather, that allows electronic medical records, electronic health records, lab services, pharmacies, hospitals, doctors’ offices, and other providers to connect with one another. To continue with the metaphor, it doesn’t matter what Electronic Medical Record (EMR — or fixture— a provider uses. Our plumbing can connect any type of fixture to another so that health information and patient data can be safely and securely transmitted."

Dr. Willa Fields, the new Chair of the Board of Directors of HIMSS gave a description of the HIMSS Electronic Medical Record Adoption Model (EMRAM) system. She provided seven recommendations for Congress from HIMSS:

1. Continue its strong bipartisan support for the adoption and use of electronic health records and interoperability.
2. Continue to support and sustain the Meaningful Use and Electronic Health Records Programs.
3. Direct the administration to initiate an appropriate study of a nationwide patient data matching strategy with a report back to Congress.
4. Support harmonization of federal and state privacy laws and regulations to encourage the exchange of health information across health systems, payers, and vendor systems.
5. Continue to support programs and services to educate providers and provider organizations on how Health IT can and should be used to engage patients.
6. Continue to support and sponsor pilot programs addressing the collection, analysis and management of clinical data for quality reporting purposes to assist providers and provider organizations make informed decisions for public health, patient care and business purposes.
7. Preclude any additional delay in the nationwide implementation of ICD-10, International Classification of Diseases beyond the current October 1, 2014 deadline.

During the Q&A, responding to a question from Chairman Ben Quayle from Arizona, Dr. Mostashari explained how there are exemptions for specialists for requirements that are considered out of scope for their practice. These exemptions are in place for stage 2, which will allow many providers to avoid penalties. He also stated that we have made great progress on interoperability in meaningful use, but there is still work to be done. All of the panelists agreed with this assessment. Although Mr. Probst added that simply exchanging health information is not enough, but true interoperability goes to a much deeper level being integrated into clinical workflow. Everyone stressed the need for greater efforts at national standards development.

Asked to elaborate on the necessary compromises between the aspirational goals we want to achieve and the reality of where the market is, Dr. Mostashari explained that we need to be sure to allow an on ramp for small providers to meaningful use of EHR technology. When questioned on the much discussed issue of increased billing through the use of EHRs he stated that a thorough investigation is taking place and announced an upcoming summit of stakeholders to further address this issue. Dr. Romine added that NIST is exploring ways to begin conformance testing for EHR usability.

Representative Suzanne Bonamici, from Oregon asked how healthcare professionals can be included in the design of EHR technology to help ensure usability. Dr. Romine stated that NIST does not have great clinical experience, so they partner with the healthcare community, standards organizations, and the ONC. Dr. Mostashari claimed that the EHR products available now are much more usable than just a few years ago. He said the difference "is like night and day."

Dr. Mostashari discussed the need for a continued patient-centered approach, and remarked that the patient is the most underutilized resource in healthcare. He noted the critical importance of patients having access to their own health information if they are going to be engaged and empowered to participate in their care. He also highlighted the fantastic Blue Button program, which started within the Veteran's Administration, and is now being deployed all over the country. Dr. Fields pleaded that Congress allow the investigation and study of patient identification issues using a national patient identifier. Congress currently prohibits the use of appropriated funds for these types of studies and HIMSS has asked that this be reconsidered.

It was a very interesting hearing and certainly highlighted the need for continuing standards development work. While there was some opposition from certain members to the amount of money being provided for incentives, I was encouraged by the tone and tenor of the hearing and very gratified at the strong bipartisan support for health information technology. There are likely to be many legislative battles ahead, but this hearing foreshadowed what is likely to be a continued strong bipartisan support for using health information technology to improve healthcare and lower costs.