Yesterday, ONC published an 8pg document that provides a roadmap for the important decisions that they will make in the coming months. Over on the industry news website, Healthcare IT News, John Halamka provides a good overview on some of the highlights of this fairly important document.

Meaningful Use:

Clearly, ONC is seeking to provide some assurances to the market that they do have a clear plan moving forward giving some direction to the market as to what to expect. All well and good but what is surprising is what is not provided in the document.  For example, while timelines are given for such issues as the HHS-NIST relationship for conformance testing and milestone dates for “Standards Rulemaking” there is no timeline for definition of “meaningful use.”  Rather the document states:

Define “Meaningful Use of an EHR”: Recovery Act §4101– The Recovery Act authorizes that incentive payments may be made to eligible professionals and hospitals that are using EHRs in a meaningful way.  Specific understanding of what constitutes meaningful use will be determined through a process that will include broad stakeholder input and discussion.  HHS is developing milestones for major phases of the program’s activities with planned delivery dates.

As this has been acknowledged by many, including the new head of ONC, Blumenthal himself as the linchpin in the HITECH Act, where is the plan? In an earlier post Chilmark predicted a draft release on meaningful use by mid-June.  After reading this document, it appears that ONC may be moving slower than originally thought and we might not see such guidance until late August at the earliest. This could be a long summer.

Metrics of Success:

Another to come later statement is the outcome measures that ONC will use and measure on a quarterly basis to report on the success, or lack thereof of the ARRA funding for “certified EHR” adoption.  What those outcome measures might be is anybody’s guess.  Might they be based on “meaningful use” criteria, e.g., growth in eRx or improvement in quality outcomes? No clear signals from ONC at this time.  What we do know is that in the past, ONC has looked annually at adoption of EHR metrics, but even these numbers (at least the ones referenced in the document) do not align with adoption numbers reported by Blumenthal et. al. in a recent NEJM paper.  Chilmark’s hope is that the metrics ONC wil use has some relevancy to Joe the Plumber and Jane the IT executive for at the end they are the one footing the bill, not a hospital, not a physician and certainly not a payer.

Extension Centers:

While the ONC document outlines appropriations for RHIOs/HIEs ($300M), NIST ($20M), and Privacy and Security (~$24.3M), there is no mention of how much will be allocated towards regional Extension Centers (EC) which will be instrumental in outreach to small and single physician practices.  For that matter, ONC provides very little guidance beyond stating that by the end of 2009 ONC will publish funding availability for ECs with actually $$$ beginning to flow in 2010.

Which raises the question: If these centers won’t even see funding until 2010, how do physicians get the advice they need in the near term?  Talk to/listen to vendors?  Talk to/listen to consultants?  It would seem that getting these regional ECs in place sooner than later is prudent.

But then one gets to the last page of the document and all becomes so much clearer.

At the bottom of that page, ONC fully realizes the challenges ahead and also makes what Chilmark found to be a shocking admission; ONC only has 30 FTEs to orchestrate this monumental task!

Barriers to Effective Implementation: Staffing levels in ONC must be increased.  With the current staff of 30 FTE, plans are to use all available human resources vehicles to increase the level of staffing.  This will include term appointments for projects with short-term needs; details as permitted by Recovery Act legislation; a limited number of permanent positions for long-term projects; and other temporary and contractual agreements.

Thirty FTEs to define criteria for the distribution of over $21B in federal funding, funding that will define the HIT industry for at least the next decade, if not longer?  Maybe this ONC document needed to start with a simply staffing plan.