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HR 1: Stimulus Package and HIT

by John Moore | January 26, 2009

cashJust finished reading/scanning HR 1, the House Stimulus bill focusing on the HIT section, to which some $20B greenbacks will flow. This Bill just went just the Appropriations Committee and will likely pass the full house later this week. The HITECH Act (HIT for Economic and Clinical Health), is massive at some 190 pages, beginning on page 395 covering everything from codifying the Office of the National Coordinator (ONCHIT), to the numerous reports that ONCHIT has been instructed to fund, to how that $20B will be spent.

HITECH Act also carries with it a legacy of the Bush era: “The utilization of a certified EHR for each person in the US by 2014.”

Following are some quick, interesting highlights:

ONCHIT budget to soar over 4x to $250M for FY09 from the $61M it received in FY08.  Guess they’ll need all that money to fund those research reports, as well as support the new version of HITSP and AHIC, which is now called NeHC.

Both HITSP and NeHC become key advising entities to ONCHIT, HITSP on standards and NeHC on HIT policy.  Quite sure the folks in both groups are happy to hear this, especially NeHC as there was some question as to their survival if the feds did not dump $$$ in their coffers.

National Institute of Standards & Technology (NIST) to take a leadership role in testing standards and implementation specifications.

Substantial amount of writing on privacy, particularly consumer notification process should their health information be compromised.  Even had a special section on notification process for PHR vendors going so far as to reference third part data repositories (e.g, Dossia, GHealth and HealthVault).  Good to see formal procedures put in place, at the federal level to guide notification process – it’s about time!

Continuing on privacy, Bill also instructs ONC chief to appoint a CPO, Chief Privacy Officer.  This individual will have the uneviable task of attempting to coordinate helth data privacy policies across this great land of ours where it seems as though every State has their own unique twist.  Without some reconciliation on these privacy policies, the whole NHIN is nothing but a pipe dream.

A whooping $300M or RHIOs.  All those small RHIO software vendors must be licking their chops as this is a significant amount of money (about double the market size in 2008).  Expect to see consolidation and acquisitions as bigger HIT players look to get into this lucrative market.

Establishing an Extension Program for HIT.  Much like the existing Land Grant and Sea Grant programs and their extension services for agriculture and marine industries, the Bill proposes the establishment of a similar program for  HIT.  At one point in my career, I actually worked for Sea Grant, thus I know the model intimately and have mixed feelings.  Yes, it can be a very good model to reach out to small business and assist them in adopting best practices in the adoption and use of HIT, but often these programs, while well-intended, are not terribly efficient.  There is a universal benefit, however, in that often these extension services are located in academic institutions and thus can foster undergraduates and graduates to pursue research/careers in this field and right now, we can’t have too many.

trainFor the most part, we are comfortable with the above, but where the Bill really flies off the tracks is with the term:

“Certified EHR”

This term is used throughout the HITECH Act and refers to an EHR that is “certified” as:

‘‘(5) CERTIFICATION.—
‘‘(A) IN GENERAL.—The National Coordinator, in consultation with the Director of the  National Institute of Standards and Technology, shall develop a program (either directly or by contract) for the voluntary certification of health information technology as being in compliance with applicable certification criteria adopted under this subtitle… (want to dig deeper – go to page 407)

Basically what this states is that any reimbursements, payments, anything coming out of that $20B largess towards the support for adoption of HIT will only go to those instances where a “certified” EHR has been adopted or used.  And what it implies is that funding/reimbursements/incentives will onlygo to those who adopt nd use a CCHIT certified EHR.

This is a MASSIVE MISTAKE for the simple reason that it results in technology lock – technology locked to specific, “certified” criteria/standards resulting not in new innovative products, but actually retarding their introduction.

Need evidence?

Turn to the EPA and the Clean Air Act (CAA) (I did quite a bit of research at MIT for EPA on technology adoption in regulated markets, hmm, is healthcare much different, surprisingly no). The CAA when first promulgated specified specific technologies to be used to control and measure stack gases.

Benefit: Clear articulation of what technologies industry needed to adopt to comply to the CAA.

Outcome: Rapid adoption and use of these technologies leading to dramatic reductions in air pollutants.

Unintended consequence: When new and better technologies arrived on the scene, the EPA had no ready approach to get industry to adopt better technologies (without an Act of Congress) and as for diagnostic techniques for measuring stack gases, they were stuck as well.

Result: This stifled the US market for technology developers and subsequently, new technologies, once the regs were changed to incentives (trading emission credits) came from overseas, where the market was structured to advance their development and use.

Unfortunately, it does not appear that today’s legislature, nor those in HHS remember what happened at EPA with the CAA and have created an incentive program within this Bill that will result in exactly the same outcome as we saw in the environmental sector, rapid adoption, widely deployed HIT, technology lock-in with archaic standards such as HL7’s CCD and ultimately a technology frozen wasteland with other countries beginning to take the lead in HIT development, deployment and use.

Rather than follow this path, the Senate, in negotiation with the House, can strike the term certified from this legislation and instead encourage the adoption of HIT in support of scenarios that are based on information sharing and not just within an IDN but across a more expansive network.  For example, information sharing could be demonstrated by a physician being able to export of a health record, at a customer’s request, to that consumer’s personally-controlled online health account using CCR, CCD or other standard. Is that not in support of the objectives of data portability?  Of course, there is also the example of sharing health information within the context of an HIE or RHIO or other, more loosely formed network.

Therefore, it is not so much requiring that an EHR comply to specific criteria to be certified and thereby, the adoption of only certified EHRs will be reimbursed, rather it is to provide incentives that encourage what is our ultimate goal, putting health information into a digital form factor that can be securely shared among all relevant stakeholders in support of a healthier public.  After all, at the end of the day, is this not what we are all trying to accomplish?

Stay up to the minute.

“As biometric data becomes cheaper and easier to collect through smart sensors, devices, and mobile apps, expect to see more innovations in consumer health.”

-Alicia Vergaras