ONC: some hard choices

One of the hallmarks of the emerging Meaningful Use definition for Electronic Health Records (EHRs) is the ability to report data. The Meaningful Use data grid published by the ONC’s Health IT Policy Committee contains a minimum set of measures that an HHS-certified EHR is supposed to be able to report: (1) % of diabetics with A1c under control, (2) % hypertensive patients with BP under control, (3) % of patients with LDL under control, (4) % of smokers offered smoking cessation counseling, (5) % of patients with recorded BMI – and so on. The grid is 10 pages long and contains many specific data elements that an EMR should address.

The other ONC committee, the HIT Standards Committee, has taken these elements and tried to build a more specific grid of their own, The result is an even more detailed set of criteria that a certified EHR is supposed to report. The HIT Standards Committee has been composed of health IT “technical insiders” more significantly than the HIT Policy Committee, and has proceeded from a perspective that starts from legacy standards, rather than from a more simplified market-oriented perspective. The specifications have been an attempt to map Meaningful Use data points to the definitions established previously by the National Quality Forum’s (NQF) HITEP data sets – a laudable and forward-looking approach, from a theoretical perspective. There is a tie-in to several standardized data sets, such as SNOMED for clinical nomenclature, LOINC for lab data, etc. So what is the problem with this? Only a few, advanced systems in place around the country currently implement such things – institutions, very large and costly legacy EHR systems with full-time IT staffs, and very large vendors have moved in this direction; smaller practices and the health IT tools (if any) that they use are nowhere near this realm. Even some very large vendors have not implemented these standards – Quest laboratories, for example, has only mapped about half of their internal lab-test codes to the national-standard LOINC system. Some critics of this approach have likened it to asking everyone to “speak Latin.”

What is also not clear is exactly how physicians who use certified EHRs are supposed to report their Meaningful Use. Is there to be a national electronic data service (supervised by the ONC or maybe by CMS) that EHRs are supposed to connect with and report to? Or is it to be simply self-reporting (“yes, I did these things”) by attestation, with auditing – much like how reporting of many PQRI data elements used by CMS for pay-for-performance currently occurs? Or is there to be a new set of CPT codes to be added to a bill to Medicare, indicating EHR Meaningful Use, similar to current attestation reporting for use of electronic prescribing?

Clearly, the ONC has some challenges before it. There is the push by “health IT insiders” to implement very specific national-standard (but very incompletely used) approaches to Meaningful Use data reporting – which has the impact of narrowing the reach of health IT and favoring large, legacy vendors (hindering EHR adoption in smaller practices). There is the countervailing push to make certification simple and market-sensitive, favoring those who are in a position to make EHR adoption dramatically more widespread. Practice Fusion, by virtue of being a Saas-based (software-as-a-service) EHR, is such an example. The method of Meaningful Use reporting has yet to be detailed. Progress toward establishing alternative HHS Certification organizations has not visibly begun, leaving CCHIT as the “only game in town.” All these issues remain on the ONC’s very full plate. Yet they are critical strategic decisions which should emerge over the next few months. We remain hopeful that the ONC chief, David Blumenthal, will continue to make the kinds of principled decisions and recommendations we have seen to date. Remember that the larger picture revolves around how to make EHR use simple and widespread, and help rank-and-file physicians (including those in solo and small-practice settings) move from paper to electronics in their day-to-day lives.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.