Looking Back at 2014: Thermidor for Health Care Reform?

Posted on December 29, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

As money drains out of health care reform, there are indications that the impetus for change is receding as well. Yet some bright spots in health IT remain, so it’s not yet time to announce a Thermidor–the moment when a revolution is reversed and its leaders put to the guillotine. Let’s look back a bit at what went right and wrong in 2014.

Successes in Policy and Information Technology

Although I want to focus on the IT aspects of health reform, we must acknowledge important advances on the policy front: the groundswell of sign-ups for health insurance among those who would otherwise be uninsured, and the slow-down in the rise of health care costs, however temporary that may be. One can find plenty of pessimistic news reports to balance these successes, but they remain worthy of notice.

The FHIR standard for open APIs, whose significance I covered a couple months ago, has not only been blessed by the ONC but, more importantly, has won promises from all the major U.S. EHR vendors to implement it.

Again, our joy this season must not lose its sobriety. The vendors will probably take their time implementing FHIR. If they introduce arbitrary barriers, as they have done with the open Direct project, we may be in for another exhausting round of struggle for interoperability. Meanwhile, tools to extract, interpret, and make use of the data from FHIR will have to evolve before it can have an impact on clinicians’ behavior and bottom lines.

Another news item with substantial potential to enhance openness in health care is the Open Payments program from the Centers for Medicare & Medicaid Services.

Finally, one can look at recent advances in telemedicine, the vigorous entry of Apple and other tech companies into the health market, and the formation of new Accountable Care Organizations as springboards for future advances in health.

Setbacks Abound

Aside from the items mentioned in the previous section, I saw little in 2014 to celebrate regarding health IT. The ONC was level-funded in the recent, hard-fought end-of-year budget bill. Congress also undermined the ONC’s reforms by delaying ICD-10 implementation, even though, ironically, lots of organizations are making headway toward its adoption. I consider the whole ICD standard an ill-informed, brittle structure that isn’t suited for clinical or research use, but plenty of industry analysts laud ICD-10 and bewail the delay.

Setbacks have also weakened Meaningful Use. CMS stretched out the modest Stage 1 adoption cycle, a concession that was not enough to satisfy the AMA or several members of Congress, who requested further delays. Dismal attestation rates for Stage 2 led industry leaders–naturally–to ask for yet more concessions, and doubts are being openly aired as to whether Stage 3 will ever see the light of day.

CMS can wield penalties as well as hand-outs, and it has indicated that it takes its power to punish providers seriously. Ultimately, however, no hand-out will be enough to compensate a doctor for the wrenching move required to implement evidence-based medicine and holistic health, nor can the government drive the industry like a recalcitrant donkey struck by a whip.

Change may have to come through demands from doctors, patients, and the public as a whole for easy data exchange, 24/7 health care, and usable electronic records for clinicans and patients alike. Personal fitness devices and Apple HealthKit provide technical tools for change, but they won’t have an effect on the health care system until the system itself makes the huge paradigm shift toward using their data.

A Thought Experiment: Could Meaningful Use have been rolled out differently?

Experts in health IT have been quietly groaning over the direction health reform has taken ever since the big push in the HITECH act started in 2009. It is easy to criticize the timing of incentives. But if we take a moment to hop an imaginary time machine and design an ideal roll-out, we’ll find why such a roll-out historically could not happen.

The HITECH act put reforms in the use of EHRs on a fast track. Had Congress given the ONC more breathing room, it could have followed a strategy closer to the one that the JASON team presented to the ONC just this year. Ideally, something like FHIR and SMART (which was funded by the ONC in 2010) would have been stable and ready for adoption in 2009. The ONC would then have mandated a JASON-like architecture, where data resides in databases supporting FHIR and SMART, making it available to third-party developers.

This way, Meaningful Use wouldn’t have to demand any support from EHR vendors for its complex requirements. It wouldn’t demand anything from them except to keep data secure and uncorrupted while a rich ecosystem and robust market developed for modern applications to mediate data entry needs and analytics in health care.

An open source reference implementation–that is, a functioning software program available to all that does things correctly–could also stimulate companies to compete around interoperable products, as it did in medical imaging.

The health care field, however, understood little of current coding practices in 2009 and was far from adopting simple standards such as JSON or RESTful APIs (universally used on the Web to transfer data).

David Blumenthal, who was National Coordinator when the agency first rolled out Meaningful Use, publicly acknowledged that they desired interoperability from the start and knew it was inadequately supported by existing EHRs (although there were open source EHRs that performed better in that regard). Blumenthal said the ONC deliberately staged the roll-out of Meaningful Use to encourage hospitals to buy EHRs despite their deficiencies, hoping to impose interoperability afterward.

Given the HITECH act’s aggressive schedule, this was probably the only option available. But it’s like leaving for a cross-country drive without a roadmap, and assuming you will pick up maps up as you go along from one town to another. You’ll wander down a lot of poorly chosen highways, take a long time to get where you want to go, and risk running out of gas.

The original Thermidor in 1794 led to retreat by a democratic forces in Europe that was shaken off only in the revolutions of 1848 (which by and large also failed). We can’t wait 50 years for another stab at health care reform. Hopefully, we also won’t need to borrow tactics from Robespierre to end the incumbents’ rule. Still, a little agitation from the sans-culottes among doctors and patients would help.