1. History of Health Information Technology in the U.S.
The HITECH Act
Welcome to History of Health Information Technology in the US, The HITECH Act. This is lecture B, Meaningful Use, Health Information Exchange and Research.
Lecture b – Meaningful Use, Health Information Exchange and Research
This material Comp5_Unit3 was developed by The University of Alabama Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000023

2. Meaningful Use, Health Information Exchange and Research Learning Objectives
Discuss the barriers to adoption of Health IT that the HITECH Act is designed to address
Discuss how the following ARRA/HITECH requirements relate to previous developments in health IT:
Certified electronic health records
Concept of meaningful use including e-prescribing, clinical decision support, interoperability and HIE, structured documentation of quality measures
Incentives to providers
Education of clinicians
Workforce development
Give examples of how the HITECH provisions support healthcare reform efforts
Discuss the overall vision for the effects of the HITECH Act
The Objectives for this unit, The HITECH Act are to:
Discuss the barriers to adoption of Health IT that the HITECH Act is designed to address
Discuss how the following ARRA/HITECH requirements relate to previous developments in health IT:
Certified electronic health records
Concept of meaningful use including e-prescribing, clinical decision support, interoperability and HIE, structured documentation of quality measures
Incentives to providers
Education of clinicians
Workforce development
Give examples of how the HITECH provisions support healthcare reform efforts
Discuss the overall vision for the effects of the HITECH Act
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

3. Barriers to Improving Quality and Reducing Costs
Low Adoption
Cost
Impact on productivity
Manpower
Adoption is not enough
Must be used appropriately
Information must be shared
Standards
Lack of agreement
Privacy and Confidentiality
Public and professional concerns
Although the HITECH Act provided funding for health IT workforce development, if you remember, an inadequate workforce was only one factor leading to low adoption. There were also concerns about the cost of EHRs.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

4. The HITECH VISION
To address some of the financial burdens, HITECH provisions include financial incentives from the Centers for Medicare and Medicaid Services also known as CMS (pronounced C-M-S), for adopting EHRs. Please refer to the slide, and the circled third item from the top in the left hand column. CMS is a major payer for healthcare for people over 65, for the poor and for the handicapped. Most healthcare providers have patients who are covered under Medicare, so incentives from Medicare will have a widespread impact.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

5. Incentives Why incentives are needed Cost savings with health IT Cost
Productivity loss
Cost savings with health IT
Reductions in length of stay if medication errors are prevented
Savings from sharing information
prevent duplicate test ordering
prevent errors from drug interactions
save clinician time in gathering information
As we said, financial incentives are needed to motivate healthcare providers to spend the money and time to invest in EHRs (pronounced E-H-Rs) and learn how to use them. Although EHRs offer the possibilities of cost-savings from such things as preventing costly errors and avoiding duplicate tests and other cost savings, there is clearly an up-front cost and many of these savings may not be automatically realized.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

6. Incentives Carrot and Stick Better incentives for being early adopters
Decrease over time
Eventually penalties for non-use
The approach taken by CMS is to provide higher incentives for early adoption. That is, beginning to use the EHR in 2011 with decreasing incentives over time until After that, the intent is to penalize non-users of EHRs. The expression “carrot and stick” for those of you unfamiliar with it, is used when you use a combination of rewards and punishments to get someone to do something. In this case, the carrot is the adoption incentive and the stick is the threat of the penalties for not adopting.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

7. Incentives Carrot and Stick Better incentives for being early adopters
Decrease over time
Eventually penalties for non-use
Adoption not enough
Must be used appropriately
But remember that one of the barriers was not just adopting EHRs, but using them in a way that can lead to improved quality of care.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

8. The HITECH VISION
To assure that the incentives would be tied to using the EHRs for improved quality, the incentives are tied to the concept of Meaningful Use of EHRs. What this means is that physicians who use EHRs in a meaningful way will be paid more by CMS for their services.
(Courtesy Office of the National Coordinator for Health Information Technology)
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

9. Meaningful Use Focus on improving outcomes of care
HIT Policy Committee and public comments influenced final rule
Escalating expectations
The focus for the requirement for meaningful use of the EHR is to implement features of the EHR that will improve the outcomes of care. There will be escalating expectations for actually getting the incentives. What this means is it will be easier to qualify for incentives early on and the bar will continue to be raised over time as to what qualifies for meaningful use incentives. Other agencies involved with defining and monitoring meaningful use include the Office of the National Coordinator for Health Information Technology and the groups that certify electronic health records.
And while the idea of meaningful use can have many meanings, CMS is defining it to mean some very specific things.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

10. Meaningful Use Focus on improving outcomes of care
HIT Policy Committee and public comments influenced final rule
Escalating expectations
Criteria for (Stage 1)
Released in July 2010
Later stages expected in 2012
To arrive at the final decision, CMS proposed a rule with specific recommendations as to what constitutes meaningful use and asked for comments from the healthcare community in January 2010.
The final criteria for 2011 and 2012 were released in July 2010 after a review of comments. These are the Stage 1 criteria. The 2010 criteria included most of the same elements as the January rule but they took into account the comments that said the expectations were too difficult to meet for most healthcare providers.
For instance, in the January proposed rule, it was expected that five clinical decision support rules would be implemented, but in the final recommendation, clinical decision support was still expected, but only one rule was required. It is expected that the criteria may also change over time as experience with them occurs. For instance, criteria that are optional in stage 1 are likely to be required in later stages. The criteria for the later stages were drafted and commented upon during 2011 and they are expected to come out in If they still seem too difficult, they may not increase as quickly over the years as initially expected.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

11. Meaningful Use Major current Stage 1 criteria
Computerized Provider Order Entry (CPOE)
Clinical Decision Support (CDS)
Electronic Prescribing (E-prescribing)
Structured documentation of quality measures
Up-to-date Problem Lists and Diagnoses
Provide patients with health information electronically
Information exchange
Report clinical quality measures to CMS
The current Stage 1 meaningful use criteria include the following elements, as listed on the accompanying slide:
Computerized Provider Order Entry or CPOE (pronounced C-P-O-E)
Clinical Decision Support, often abbreviated as CDS (pronounced C-D-S)
Electronic Prescribing, also known as E-prescribing
Structured documentation of quality measures
Up-to-date Problem Lists and Diagnoses
Provide patients with health information electronically
Information exchange
And finally, reporting clinical quality measures to CMS
While the details of how these elements become part of the criteria for meaningful use will change over time (either escalating as intended or being modified if there are problems), it is very likely that these elements will be part of the definition in one form or another because they are key to improving quality. So let’s explore what they are in detail.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

12. Computer-based Provider Order Entry
Orders for medications, laboratory tests, referrals etc.
Replaces paper order slips
Takes longer for the physician, but can speed the overall process of fulfilling the order
Increases legibility, reduces ‘call backs’
Can prevent some errors, but without decision support, will not do as much
Computer-based provider order entry is sometimes referred to as computerized or computer-based physician order entry because most of the time it is the physician who decides on orders for medications, laboratory tests, referrals etc., but the abbreviation CPOE is used for any of these meanings.
Many physician practices and hospitals, even if they have EHRs, still have not replaced the process of the physician ordering tests or medications on slips of paper that somebody else has to enter into one or another system to complete the ordering process.
Although CPOE takes longer than scribbling an order on a piece of paper, it can speed the overall process of ordering. In addition, it can increase the legibility of the orders, preventing call backs from pharmacists and others who might need help deciphering the physician’s handwriting. Increasing the legibility will improve quality by reducing errors due to hard-to-read handwriting, but clinical decision support is needed to really improve the quality of care.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

13. Clinical Decision Support
Systems designed to provide support to the clinician making clinical decisions
Usually at the point of care when the decisions are made
Examples: references, drug interactions, alerts, reminders, order sets
Can be helpful at all stages of care
Clinical decision support systems are systems or tools designed to provide support for the clinician making the decision. In some cases, the physician can seek out the support and in other cases it is provided automatically. Examples of the former include references on treating a given disease that the physician can seek.
An example of automatically providing decision support would be to display alerts to physicians about possible drug interactions when they are ordering medications.
Order sets can also be considered decision support. Order sets might be for example, a list of all the recommended tests that should be done each visit on a patient with diabetes. Clinical decision support tools can be helpful at all stages of care including the diagnostic stage, treatment and follow-up and as reminders for preventing disease.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

14. E-prescribing Some or all of the following:
Electronic order entry by physician for medications
Clinical Decision Support (formularies, drug dosing, drug interactions, guideline recommendations)
Direct transmission to pharmacy
Stand-alone or integrated into EHR
E-prescribing is specifically for medication ordering and is often referred to in the context of outpatient, as opposed to hospital, medication orders. At a minimum, e-prescribing has traditionally referred to electronic order entry for medications, but also includes transmission to the pharmacy. A complete e-prescribing system would also include clinical decision support, such as guidelines on appropriate choice of drugs, alerts for drug interactions, and formularies, that is, preferred drugs for a given patients’ insurance coverage and transmission to the patient’s preferred pharmacy. E-prescribing systems are often integrated into electronic health record systems, but there are also stand-alone systems that just focus on the prescription process.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

15. Structured Documentation
Physicians document electronically
Lab data captured in structured form
Quality data extracted
Structured documentation is currently one of the real challenges because even in places where electronic records are used, many physicians still dictate their notes. Even when these notes are stored electronically, which of course is helpful, it is difficult to extract data from them. Meaningfully using electronic health records means that not only can you store the data so it is viewable, but you can get the data out so you can study it and analyze it for ways to improve care. And to do that the data need to be entered in a more structured way than simple dictation can do. In particular, the requirements for meaningful use are that data on patients’ laboratory tests be captured in structured form and that data for certain quality measures can be extracted. Providers are required to capture data on blood pressure, smoking, and obesity and report these to CMS. They also have some choice in other quality measures. To do this, data have to be entered in a more structured form than currently used.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

16. Structured Documentation
Physicians document electronically
Lab data captured in structured form
Quality data extracted
Challenges in capturing and/or extracting
Different systems
Unstructured text files
Non-standard definitions of terms
Variable technical standards
Takes more time than scribbling a few notes!
The challenges of capturing or extracting data to get consistent measures of quality across different providers are many. Different electronic systems often capture and store data in different ways. As we said, much data today is currently in unstructured text files that do not lend themselves to easy analysis. Even the definitions of many of the terms are not standard and as we said earlier, even if the data are captured well in a single physician’s EHR there are often different technical standards used among providers, hospitals and laboratories.
Probably one of the biggest barriers is that capturing structured data takes more time than scribbling a few notes, which is another reason the incentives for meaningful use are needed.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

17. Other Parts of Meaningful Use
Up-to-date problem lists and diagnoses
Providing patients with health information electronically
Information exchange
Reporting quality measures
Core and Menu Objectives
15 core measures
5 of 10 menu objectives
The electronic health records need to contain up-to-date problem lists and diagnoses and healthcare providers have to have a way of providing patients with their own health information electronically. One way to do this is to set up a personal health record (or PHR) for each patient. Another requirement is for "information exchange" which will be limited at first but gradually escalate as more and more providers adopt EHRs. The final major requirement is to use the various tools to improve quality and to report quality measures back to CMS.
In addition to keeping the basic elements that had been originally proposed, but lowering the expectations somewhat on the criteria that must be met, the final rule included a set of what are called core objectives. All providers must address these core objectives. In addition, there is a set of what they called a menu of activities or objectives, where providers had some choice in what they selected to adopt.
There are 15 core objectives for physicians, 14 of which also apply to hospitals. There are 10 menu objectives and healthcare providers can choose which five they choose to implement. Similarly, while certain core quality measures were required, there were others where there was a choice. This was another way that the final rule kept to the original aims, but tried to be responsive to the need for greater flexibility.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

18. ONC Beacon Communities
Communities with strong health IT infrastructure
Funding to expand and strengthen capabilities
Quality and cost focus
Model communities
to demonstrate
meaningful use
In addition to providing incentives to individual hospitals and physician practices to promote the meaningful use of health IT, HITECH also provided funding for what were called “Beacon Communities.” These are communities that already had demonstrated strong health IT capabilities. The funding was to strengthen them so that they could become models in using information exchange to promote meaningful use to improve quality and reduce costs. The name “Beacon Communities” comes from the idea of a beacon or lantern that lights the path for others to follow.
(Photo by Andrew Bossi)
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

19. Barriers to Improving Quality and Reducing Costs
Low Adoption
Cost
Impact on productivity
Manpower
Adoption is not enough
Must be used appropriately
Information must be shared
Standards
Lack of agreement
Privacy and Confidentiality
Public and professional concerns
We said earlier that the barriers to smooth information exchange among healthcare providers are still a problem.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

20. The HITECH VISION
Health information exchange by itself is an example of meaningful use, which is why it is one of the requirements for the meaningful use incentives. But health information exchange is also a means to promote even more meaningful use of health IT. For these reasons, the HITECH Act includes some specific methods to promote health information exchange.
Courtesy Office of the National Coordinator for Health Information Technology
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

21. ONC-Funded Health Information Exchange
To share information, systems need to “talk to each other” and “be understood”
Interoperability
Lack of agreed-up on standards
Demonstration projects for interoperability
Grants to states for information exchange
Sharing information requires that information systems be able to talk with each other and be understood. This is called interoperability (pronounced inter-opera-bility). To be able to talk to each other requires common technical standards so that a message sent can be received. To be understood also means that not only must there be common technical standards but the vocabulary must be common as well. There are still many standards where there is lack of agreement, which has inhibited information exchange up to now.
The HITECH Act includes funding for activities to promote information exchange. In addition to the Beacon Communities’ funding, there is funding for demonstration projects for identifying models for interoperability and information exchange. As well, there have been grants provided to states to set up statewide information exchange processes.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

22. Standards Privacy and security issues Certification of EHRs
Standards “harmonization”
Technical
Vocabulary
Health Information Technology Standards Panel (HITSP) HIT Standards Committee
Privacy and security issues
Strengthening of current rules
Certification of EHRs
There are also efforts at what has been called standards “harmonization” that will include reconciling the different technical and vocabulary standards. This process began with the Health Information Technology Standards Panel, and is being continued under HITECH with the formation of the HIT Standards Committee.
Other issues we mentioned were the privacy and security issues. Under HITECH, the existing rules for privacy and security are being strengthened.
Finally, as these changes are implemented they will become part of the requirements for a certification process for EHRs, since the rules for meaningful use require practitioners to use a certified EHR.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

23. Certified Electronic Health Records
Certification
ONC Authorized Testing and Certification Bodies (ATCBs)
Certification Commission for Healthcare Information Technology (CCHIT)
Five other approved ATCBs as of December, 2010
Focus on functions for meaningful use
The requirement that payment for meaningful use requires certified electronic health records is important for two reasons. First of all, it is a sort of seal of approval that can help assure purchasers that the systems that they are getting have had some review. The second reason is that the certification requirements are set up to include functions that meet the requirements for meaningful use and facilitate health information exchange.
The certification bodies are called ONC (pronounced O-N-C) Authorized Testing and Certification Bodies or ATCBs (pronounced A-T-C-Bs). The Certification Commission for Healthcare Information Technology or CCHIT (pronounced C-C-H-I-T) was formed before HITECH, but is now recognized as an ATCB. As of December 2010, in addition to CCHIT, there are five other ATCBs. The ATCBs focus on the functions that are required for meaningful use, not directly on the usability or use in practice of these systems.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

24. The HITECH VISION
One of the other barriers we mentioned previously was that the technology itself still needs improvement in many areas. To address this barrier, in addition to the workforce training for new engineers and scientists, the HITECH Act provided funds for major collaborative research projects known as the SHARP grants.
(Courtesy Office of the National Coordinator for Health Information Technology)
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

25. SHARP Grants Strategic Health IT Advanced Research Projects
Security of Health Information Technology
Healthcare Application and Network Platform Architectures
Source: (Stead & Lin, 2009)
SHARP stands for Strategic Health IT Advanced Research Projects. Because the vision of HITECH includes moving toward nationwide health information exchange, there are still many areas where current systems need technological development and/or improvement for that scale of information exchange. Four awards were made to focus on several key areas that need work in order to realize the HITECH vision.
The first area, security of health information technology, will do research to develop security processes in anticipation of large-scale health information exchange. Similarly, the second area, healthcare application and network platform architectures, aims at developing new applications and new ways they can be integrated into EHRS.
In 2009, an influential report by William Stead and Herbert Lin found that most current EHR systems, even those at very advanced institutions, were inadequate in providing easy-to-use support to enhance the thinking and decision making of doctors.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

26. SHARP Grants Strategic Health IT Advanced Research Projects
Security of Health Information Technology
Healthcare Application and Network Platform Architectures
Patient-Centered Cognitive Support
Secondary Use of EHR Data
In addition to the issues connected with information exchange, the SHARP awards also funded research on how best to provide this type of cognitive support. The word cognitive means involving thinking and decision-making. Some of the research involves usability testing and developing ways to design the screens and processes to make the systems better match the way users think and work. Finally, since the ultimate aim of HITECH is to use health IT to promote improved quality, the fourth award was for developing methods to effectively use the vast store of clinical data in EHRs for quality improvement and research.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

27. Leadership
Office of the National Coordinator for Health Information Technology (ONC)
HIT Policy Committee
HIT Standards Committee
You may remember that the final barrier was that, prior to HITECH, we did not have sustained health IT leadership at a national level. A new president could undo an executive order under which the National Coordinator for Health IT was appointed.
That barrier was addressed when, as a result of HITECH, the position of the National Coordinator for Health Information Technology became protected by law. In addition, two committees were established to provide guidance on the key issues of Health Information Technology Policy and Standards.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

28. Certified Electronic Health Records “Meaningful Use” Incentives
The HITECH Act Summary
Leadership
Certified Electronic Health Records
“Meaningful Use”
Incentives
Health IT manpower
Interoperability and information exchange
Privacy and Security
This concludes Lecture B of The HITECH Act.
In summary, under the leadership of the National Coordinator, the implementation of HITECH was designed to address many of the barriers to use of electronic health records.
Providers will have the financial and human assistance they need to meaningfully use certified electronic health records to improve the quality of patients’ health outcomes. To facilitate those improvements there will be widespread interoperable information exchange through a nationwide health information network where the security and privacy of patient’s information is assured.
Although there will undoubtedly be bumps along the way, as a result of the HITECH Act, we are now on the road to realizing that vision.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b

29. The HITECH Act References – Lecture b
Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med. 2009; 360;15: Available from:
Office of the National Coordinator.  Celebrating the first anniversary of the HITECH Act and looking to the future.  2010.  Available from:
Blumenthal D and Tavenner M.  The “Meaningful Use” Regulation for Electronic Health Records. N Engl J Med 2010; 363:   Available from:
Images
Slide:  4, 8, 20, 24:  Courtesy of the Office of the National Coordinator for Health Information Technology. Available from:
Slide 6, 7: Microsoft clip art; Used with permission from Microsoft.
Slide 18: Andrew Bossi CC-By-SA-2.5, 2.0, and 1.0 Available from:
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Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the U.S The HITECH Act Lecture b