Informatics and the Goals of Obamacare Barry Smith 1

David Brailer (first National Coordinator for Health Information Technology) On saving money through Health IT —$77 billion would be saved annually if patients’ information were shared across health care settings so that personal health information seamlessly followed any patient through various settings of care—$77 billion would be saved annually “Economic Perspectives on Health Information Technology”,

Obamacare: “The ‘no-brainer’ of health IT” A central pillar of [ARRA’s] mammoth, $800 billion dollar legislation … is devoted to digitizing the nation's medical records and rewiring healthcare for the 21st century, via the $27 billion Health Information Technology for Economic and Clinical Health (HITECH) Act. the most lasting, bipartisan and transformative piece of the stimulus bill health IT … has set the stage for broader healthcare reform, … may just be the most lasting, bipartisan and transformative piece of the stimulus bill. Health IT News, TIME magazine correspondent Michael Grunwald, October 1,

Electronic Health Records gaps and duplication in patient care delivery can be reduced or eliminated through proven technologies such as electronic health records, e-prescribing, and telemedicine making needed clinical information accessible to all appropriate providers and in a more complete and timely fashion than paper records health information technology improves quality by making needed clinical information accessible to all appropriate providers and in a more complete and timely fashion than paper records 4

through interoperability, EHRs will save money David Brailer, again (from 2005): Currently, as soon as a patient arrives at a hospital, a battery of tests is performed … because clinicians have no way of knowing what has already been done. It is really about obtaining data by calling it up on a computer system rather than waiting for medical records to be delivered. Eliminating this inefficiency and frustration through interoperability represents a significant challenge. It does not, however, require magical changes in the business processes or culture of health care to be realized. It is really about obtaining data by calling it up on a computer system rather than waiting for medical records to be delivered. 5

Brailer: what can go wrong? “the policy challenge is to get a critical mass of health IT adoption so that this nation can move forward. The reasoning is that once health IT adoption reaches the 40 to 50 percent range, market forces will take over, because health care IT will become a requirement for doing business.” 6

Brailer: there are disincentives to early adopters They “are like the first owners of fax machines. … there is no infrastructure to which an EHR can connect. … there are 300 electronic health record products on the market that I know of, and that does not include all the home-grown products. Health care providers buy the wrong product virtually all the time. There is no price transparency around products, …. Physicians do not know how to contract for these technologies, so they almost always take unnecessary risks in their contracts. And they do not know how to implement them. … 7

Why interoperability (combinability) is so hard Different EHR vendors have financial incentives to thwart interoperability Patients move between physicians and hospitals, who use EHR systems deriving from different vendors Even where hospitals or wards use the same EHR vendor, their EHR data may not be interoperable Even where coders in the same hospital or ward use the same EHR system, they may code in non- interoperable ways Interoperability standards are still slapdash 8

through interoperability, EHRs will save money David Brailer, again (from 2005): Currently, as soon as a patient arrives at a hospital, a battery of tests is performed … because clinicians have no way of knowing what has already been done. It is really about obtaining data by calling it up on a computer system rather than waiting for medical records to be delivered. Eliminating this inefficiency and frustration through interoperability represents a significant challenge. It does not, however, require magical changes in the business processes or culture of health care to be realized. It is really about obtaining data by calling it up on a computer system rather than waiting for medical records to be delivered. 9

Stephen T. Miller and Alastair MacGregor: Ethical Dimensions of Meaningful Use Requirements for Electronic Health Records “The need to bring clinical charting traditions into the electronic format is obvious. Anyone who works in a clinical setting knows that retrieving information from an outdated or otherwise separate chart is burdensome and inefficient. Having that information in a structured, easily retrievable format is a great boon to both health care professionals and patients.” 10

11 Stage 2 standards (130 pages) technology-standards-implementation-specifications-and-certification-criteria-for

12 3. Scope of a Certification Criterion for Certification In the Proposed Rule, based on our proposal to codify all the 2014 Edition EHR certification criteria in § , we clarified that certification to the certification criteria at § would occur at the second paragraph level of the regulatory section. We noted that the first paragraph level in § organizes the certification criteria into categories. These categories include: clinical (§ (a)); care coordination (§ (b)); clinical quality measures (§ (c)); privacy and security (§ (d)); patient engagement (§ (e)); public health (§ (f)); and utilization (§ (g)). Thus, we stated that a certification criterion in § is at the second paragraph level and would encompass all of the specific capabilities in the paragraph levels below with, as noted in our discussion of “applicability,” an indication if the certification criterion or the specific capabilities within the criterion only apply to one setting (ambulatory or inpatient). Example paragraph from the Stage 2 Final Rule

13 3. Scope of a Certification Criterion for Certification In the Proposed Rule, based on our proposal to codify all the 2014 Edition EHR certification criteria in § , we clarified that certification to the certification criteria at § would occur at the second paragraph level of the regulatory section. In the Proposed Rule, based on our proposal to codify all the 2014 Edition EHR certification criteria in § , we clarified that certification to the certification criteria at § would occur at the second paragraph level of the regulatory section. We noted that the first paragraph level in § organizes the certification criteria into categories. These categories include: clinical (§ (a)); care coordination (§ (b)); clinical quality measures (§ (c)); privacy and security (§ (d)); patient engagement (§ (e)); public health (§ (f)); and utilization (§ (g)). Thus, we stated that a certification criterion in § is at the second paragraph level and would encompass all of the specific capabilities in the paragraph levels below with, as noted in our discussion of “applicability,” an indication if the certification criterion or the specific capabilities within the criterion only apply to one setting (ambulatory or inpatient). Example paragraph from Final Rule

14 3. Scope of a Certification Criterion for Certification In the Proposed Rule, based on our proposal to codify all the 2014 Edition EHR certification criteria in § , we clarified that certification to the certification criteria at § would occur at the second paragraph level of the regulatory section. In the Proposed Rule, based on our proposal to codify all the 2014 Edition EHR certification criteria in § , we clarified that certification to the certification criteria at § would occur at the second paragraph level of the regulatory section. We noted that the first paragraph level in § organizes the certification criteria into categories. These categories include: clinical (§ (a)); care coordination (§ (b)); clinical quality measures (§ (c)); privacy and security (§ (d)); patient engagement (§ (e)); public health (§ (f)); and utilization (§ (g)). Thus, we stated that a certification criterion in § is at the second paragraph level and would encompass all of the specific capabilities in the paragraph levels below with, as noted in our discussion of “applicability,” an indication if the certification criterion or the specific capabilities within the criterion only apply to one setting (ambulatory or inpatient). Example paragraph from Final Rule What can go wrong?

Pressure on hospitals to receive meaningful use payments will cost lives Sam Bierstock, MD: There is “enormous pressure by the hospitals to force the physicians to use EHRs that are not necessarily very user-friendly and therefore disruptive to their work and to their efficiency,” hospital EHRs “are simply not yet adequately intuitive to meet the needs of clinicians.” “Most EHRs result in a percent decrease in efficiency of emergency room doctors and an increase in the people who leave without being seen due to extended wait times. “Providers also face mounting expenses as a result of HITECH regulations, which … also strengthened security and privacy requirements, “which are complex, costly to implement and poorly understood by the majority of providers” 15

Health IT and Patient Safety: Building Safer Systems for Better Care Institute of Medicine, November 10, 2011 Recommendations Current market forces are not adequately addressing the potential risks associated with use of health IT. All stakeholders must coordinate efforts to identify and understand patient safety risks associated with health IT by … creating a reporting and investigating system for health IT-related deaths, serious injuries, or unsafe conditions 16