Stimulus money heightens urgency for health IT guidance

HHS and the health IT coordinator must ramp up standards work to meet stimulus deadlines.

Imagine what would have happened in the early 20th century if the federal government had decided to give the automobile industry a boost with billions of dollars for manufacturers and buyers, even though the industry was just starting to figure out what it was doing. 

Where the money is going

The $19.5 billion in funding for health information technology in the American Recovery and Reinvestment Act is expected to save the government $12 billion in the coming years. 

Here's how the money will be spent at the Health and Human Services Department: 

  • Office of the National Coordinator for Health IT: $2 billion. The funding includes $300 million for regional health information exchanges and $20 million for the National Institute of Standards and Technology to integrate health information enterprises.
  • Centers for Medicare and Medicaid Services: $16 billion to provide incentive payments to physicians and hospitals for using health IT for Medicare and Medicaid patients.
  • Indian Health Service: $85 million for health IT.
  • Several HHS agencies: $1.5 billion in grants to community health centers to fund health IT purchases.
Source: eHealth Initiative

That is an apt analogy for the state of the health information technology sector. The economic stimulus law sets aside a net of about $19.5 billion for health IT during the next 10 years, with hopes of convincing physicians and patients to start using electronic health records and related applications that could improve the quality and reduce the cost of health care.

However, versions of the necessary technologies have been around for years. Health care organizations have been slow in adopting it, while government and industry groups have hammered out the necessary protocols and processes. Solving the policy issues around patient privacy, for example, or developing common lexicons so that health information systems can exchange useful information, has not been easy.

But now, with billions of dollars to become available over the next few years, there's a new urgency. The Health and Human Services Department is now on a tight schedule to establish the foundation for standards, governance and certification that will guide the use of health IT.

According to provisions of the stimulus law, HHS’ Office of the National Coordinator for Health IT (ONC) would oversee $2 billion of the total. The law contains deadlines for certain steps that ONC must take to begin to support the implementation of a health IT infrastructure that physicians and hospitals can use to exchange electronic health records.   

When the money will get there

The Timeline for implementing health information technology initiatives in the American Recovery and Reinvestment Act, enacted Feb. 16.

  • Early April, or 45 days after the law’s enactment: The Health and Human Services Department will appoint Health IT Standards Committee members to advise the Office of the National Coordinator for Health IT (ONC).
  • By mid-May, or within 90 days of enactment: The committee will recommend standards, implementation specifications and certification criteria for health information exchanges.
  • In early July, or within 45 days after the committee provides its recommendations, ONC will decide whether to approve them.
  • By Dec. 31, the HHS secretary, in consultation with other agencies, will adopt an initial set of standards, implementation specifications and certification criteria through interim final rules.

  • January — Grants awarded to develop loan programs to encourage adoption of certified electronic health record technology.
  • October — Report due to Congress on the availability of open-source health IT systems for federal safety net providers, with recommendations for administrative or legislative action.
  • After October — State grants awarded to implement and expand health information exchanges, with required state matches.

  • January — Reporting begins on EHR systems acquired after January 2009. Incentives for Medicare and Medicaid providers become available.
Source: John Halamka, Healthcare IT Standards Panel

The clock on the stimulus law's health IT aspects began running even before the administration appointed a national coordinator for health IT to lead the effort, said Dan Pelino, general manager of health care initiatives at IBM. Now that Boston physician David Blumenthal has been named to the position, he will provide further impetus to meeting the deadlines, Pelino said. Blumenthal is expected to start work in mid-April.

“There’s been work on standards going on in the background while awaiting the new national coordinator,” Pelino said. Many government and industry leaders have been providing their points of view, but the work needs "the coordination effort of a leader in that office,” he added.

According to the law’s provisions, ONC is supposed to form a Health Information Technology Policy Committee by early April, and then, by mid-May, the committee is to recommend which standards, implementation specifications and certification criteria are needed. The office is also to form a Health Information Technology Standards Committee, which will have its own set of deadlines.

The Government Accountability Office appointed 13 members to the policy committee April 3. HHS will appoint seven more.

“It absolutely is an aggressive schedule," said HHS spokesman Nicholas Papas. "We are working quickly and carefully to establish committees and ultimately establish a nationwide interoperable health IT infrastructure that protects patient privacy, and we will ensure that everyone has a seat at the table."

Since its inception in 2004, the national health IT coordinator’s office has developed sample cases and formed public/private groups to guide health IT development. It also awards contracts to establish the foundation for agreement on standards for many health care activities, certification criteria for electronic health records and system implementation specifications. The stimulus law imposes a timeline on some of that work.

ONC has sponsored public/private groups, such as the Healthcare Information Technology Standards Panel for broad agreement on specific standards in health IT and the Certification Commission for Health Information Technology to establish criteria for EHR systems. The National eHealth Collaborative was created in January to be the independent successor to the HHS-sponsored public/private American Health Information Community to promote agreement on achieving interoperable EHRs.

Current EHRs do not communicate with one another outside of a physician's practice or hospital network, Pelino said.

“Electronic health records need to be interoperable and be able to exchange data and provide service level that’s not as expensive as it currently is," Pelino said. "We will see new services, workflow and business processes."

Blumenthal, a practicing physician and expert on health IT, most recently served as director of the Institute for Health Policy at the Massachusetts General Hospital/Partners HealthCare System in Boston. He is experienced in many aspects of health care, Pelino said.  

His appointment "signals that the administration is ready to move as fast as they need to move in order to hit these deadlines,” Pelino said. 

In an article published in the New England Journal of Medicine in March, Blumenthal gave his perspective on the challenges and potential presented by the billions available for health IT in the stimulus law.

Only about 17 percent of physicians and 10 percent of hospitals use EHRs because of their cost, lack of financial return on investment, and technical and logistical challenges in installing and operating them, he wrote. One of the most important provisions of the stimulus law is as much as $17 billion in financial incentives to spur providers to adopt and use EHRs.

Starting in 2011, physicians can receive extra Medicare payments for the meaningful use of a certified EHR that can exchange data with other health care systems, Blumenthal said. That means the infrastructure to support health IT adoption needs to be in place before 2011 if providers want to be prepared to take advantage of the biggest Medicare and Medicaid bonuses. The incentive payments decline over time. HHS also will need to determine the definition of those terms, he said. 

According to provisions of the law, states can receive funds starting in October 2010 to assist in implementation of health information exchanges, in which groups of hospitals and physicians can share health data in regional networks. ONC has tested trial implementations for the Nationwide Health Information Network, which would be a network of networks of health information exchanges.

One of those regional networks is the North Carolina Healthcare Information and Communications Alliance, established in 1994, to foster the adoption of health IT. It has been a participant in NHIN architecture prototypes, trial implementations, governance and policy development, and security and privacy collaborations, said Holt Anderson, the organization’s executive director.

North Carolina health care will benefit from health IT stimulus funds through incentives for physicians and hospitals, grants for health information exchanges for regional extension centers and EHR adoption loans, broadband infrastructure, and workforce training grants, he said.