Congress received an odd document last week from an advisory committee on Health IT. It takes an unexpectedly new–and demandingly detailed–approach to the perennial problem of health record interoperability. However, if one analyzes the authors’ reasoning, it turns out to be based on unstated principles that are widely accepted in health care:
The market is broken, and the government must intervene either through incentives or through requirements.
The intervention should be based on operational or clinical goals, not dictating the adoption of specific technologies.
Policy-makers should pick off low-hanging fruit through goals that produce potentially large benefits with relative ease.
The Health IT Policy Committee (HITPC) was established as part of the HITCH act and consists of experts drawn from a range of industries and organizations related to health care. The committee is chaired by National Coordinator Karen DeSalvo, so it is presumably not in conflict with the ONC. Strangely, though, the report says nothing about how its recommendations will reinforce, replace, or co-exist with the Meaningful Use program, which (contrary to the wishes of many) is still in full force. The Medicare Access and CHIP Reauthorization Act (MACRA) is mentioned once.
A special subcommittee called the Interoperability Task Force prepared this report, which seems to have received mostly positive reactions. Its bold suggestions will take a lot of effort to implement, however, and seem to me a striking departure from ONC efforts so far.
Of the three principles I stated at the beginning, the first is the most controversial. The report makes a good case for government intervention in sections IV.D, “Need for Synchronous Collective Action Among Multiple Stakeholders” (pp. 10-12) and IV.E, “Weak or Misaligned Incentives” (pp. 12-13) as well as the introduction to section V, “Context for New Recommendations: Financial, Business, and Cultural Barriers.” In addition to the complaints one frequently hears about the perverse incentives in fee-for-service payments, the report points out that it takes two to tango to achieve data exchange. Although disparate actors have managed to pull together and achieve interoperability in other industries, they are having trouble doing so in health care. The government can be a beneficent master here.
The second principle comes out in the committee’s creative suggestion that the government move away from requiring interoperability as a fundamental goal. (Such requirements have driven Meaningful Use from the start, of course, and particularly since Stage 2). Instead, the committee says the government should require evidence of data exchange. Reflecting the third principle, they recommend a focus on health care situations where data exchange is particularly pertinent. For instance, exchanging data between a hospital and a community clinic may be crucial to preventing readmissions, so the government can ask for confirmation in that situation that the two institutions exchanged data.
I am surprised no one in the health care field has questioned the recommendations, which would seem to take a long time to finalize and would result in very detailed requirements–and perhaps the kind of intrusive, time-consuming reports clinicians are always groaning about. Imagine having to distinguish the data exchanges you make around critical care transitions (as defined by new regulations) form those that are non-critical, and generating a report that lists the number and percentages of data exchanges. Computers are good at counting, but monitoring the process still sounds burdensome.
If I am right, all these concerns will come up during the summit that the report calls for. On the other hand, the fate of this summit may be the same as the one requested 20 months ago by the short-lived JASON committee. (For those who haven’t been paying attention, the summit never happened.) I have low hopes for the fate of this HITPC report as well. But the problems are operational–the report is worth consideration for the three underlying principles I stated at the beginning of this article.