Four leading members of the House Ways and Means Committee tore away last Thursday at the polite, cautious, incremental approach that the Department of Health and Human Service has been taking toward key goals of HITECH act that was meant to drag health care into the 21st century.
Specifically, the House leaders signaled their disappointment at the Stage 2 Meaningful Use rules, promulgated last August by the Office of the National Coordinator and the Center for Medicare & Medicaid Services. The Congressmen isolate certain rules that appear to be less stringent than Stage 1, point out that the key goals of interoperability and data exchange are weak, and most notably ask for a total stop to payments made to health care providers under Meaningful Use.
There’s a lot of pushback from the health care community against this letter, including speculations that the Republican affiliations of the committee chairs indicate some political agenda. I do find it strange that it took them nearly two months following the release of the rules to write the letter (particularly since the Stage 2 rules were being designed in a very public fashion for months earlier). But I find all that a pointless distraction. Let’s look at the substance of the complaint.
The ONC and CMS have been crafting the Meaningful Use rules in a very consensual, open fashion, which has benefits and drawbacks. They have been running every detail, down to the last percentage point, by their stakeholders, while trying rather heroically to keep the original goals of the HITECH act in mind and to pressure the industry to improve year after year. Forcing rules down the throat of an industry that is not technically capable of implementing them would merely have rewarded a few institutions that are already well-endowed and motivated to move forward. The ONC also has to decide where to ask the industry to invest its limited resources–and limited staff. The strategy of giving a bit in one place while upping the requirements in another is a delicate one, hard to second guess from the outside.
The attitude in the letter suggests that the Ways and Means leaders have not been following the loquacious debates over Stage 2 as the community slogged its way through the requirements. Nor do the leaders seem to have looked at the considerably more ambitious Stage 3 rules, which would be much more relevant to a discussion of whether the ONC and CMS are instigating progress.
But many of us following health care are just as frustrated as the Ways and Means members with the industry’s inability to exchange records, share them with patients, and make use of their own data to improve care. The core of the problem, as I see it, is the unique control that the medical industry has over the practice of medicine. You can’t get care without a doctor.
For a bit of wild metaphorical experimentation, let’s look at a familiar industry that has succeeded in undergoing immense change: computers. This industry was one of those highlighted in The Innovator’s Dilemma. Christiansen described it through the lens of disk drive manufacturers, but he was really chronicling the entire sweep of innovation from mainframes through minicomputers and personal computers. (Now, of course, we’ve reached another stage with mobile devices and do-it-yourself computer systems.)
Taking computers as our focus, let’s rewrite history. Suppose that a forward-thinking federal government in the 1960s had decided that the domination of computing by a few banks and other major companies was causing the economy to stagnate, as well as holding back personal creativity among ordinary people. The government therefore designed a “Meaningful Computation” program with sagacious rules such as these:
Computer owners will provide docks for removable media and demonstrate that 10% of computer users have uploaded or downloaded data to the computer.
Computer users will be able to install any application of their choice by searching for the application’s name and selecting from the resulting list.
What would happen in this scenario? The owners of the mainframe systems–bankers, factory managers, and so forth–would roll their eyes and toss the papers over the wall to the computer manufacturers. The manufacturers would dutifully tack on each new requirement, producing gawky systems at ever increasing costs. Owners would then cash in on Meaningful Computation payments without ever considering the massive changes to their ways of handling employees and the public that the rules imply.
While celebrating that the computer field took a different route, let’s remember that life is not perfect in the new computing society. A digital divide still plagues most of the world. Furthermore, the long-held dream of computer scientists, that every child would learn to program and that every adult would be able to generate and manipulate data for whatever purpose, is far from being achieved. And it took decades for the personal computer revolution to pay off in cost savings.
But other industries have changed over time; electronic health records lag. There simply isn’t any other industry where the institutions that enshrined the old way of doing things are responsible for smashing their idols. Or where third parties (insurers and government agencies) reinforce the current system in their payment structures.
Health IT expert Shahid Shah says there’s a good deal of truth in the Ways and Means letter. The ONC let the health providers water down the requirements in both Stage 2 and Stage 3 of Meaningful Use till they are “mostly useless.” He continues, “If we’re going to pay billions of dollars in incentives, we should be getting more out of our investment. Vendors can easily non-interoperable systems and still get certified. The certification isn’t exactly trivial, but it’s not very difficult either–and the certification bodies don’t possess the technological depth to ferret out interoperability problems. They basically approve vendors on the honor system.”
Shah points out that the electronic submission rules designed under HIPAA in 1997 led to conformance by more than 90% of practice management software. The government didn’t have to bribe anyone to make it happen. Thus, he counsels enforcing new business models instead of focusing on the technology.
Health reform leader Brian Ahier pointed out to me that the health care field is unique in getting billions of dollars in government money to (supposedly) make a technical transition that other industries did on their own thirty years ago. In a sense, this just perpetuates the dependency on third-party payments that has characterized the industry since World War II, and particularly since the creation of Medicare and Medicaid. Ahier also points to the skewed rewards: “The EHR vendors are making records billions in profits, while hospitals and physician offices usually can’t even cover costs of implementation with their payments.”
The revolution in consumer appliances did not require gas companies to string electrical wires, nor did the spread of automobiles require the railroads to pave the streets. But these advances didn’t take place in a free market either. Both electrification and the national highway system were funded by bold government action.
Christiansen has a prescription for health care. He anticipates that treatments will gradually shift from the institutions whose business model involves charging fifty dollars to administer an aspirin to low-cost centers such as pharmacy clinics and primary care physicians.
But again, the industry is not responding to the need to change. Instead we’re experiencing a crisis in the supply of primary care physicians. Insurers restrict patient choices. The fee-for-service model still reins, so insurers and government payers can help the situation by switching to a pay-for-value model.
What should we do with Meaningful Use? It’s a reasonable model for the reform of health care, but not the “ways and means” by which that reform will happen. Patients and their allies, including innovators who make new devices and bring the practice of medicine into everyday life, will drive the adoption of flexible, interoperable, patient-accessible records and data exchange. As I’ve shown, the history of electrification and roads also suggests a government role.