VI. Key Issues: Financing and Delivery >> A. Health Spending >> Health Cost Containment >> Improve Administration >> Health IT (last updated 11.23.15)
Lead Editor – Dana Beezley-Smith, Ph.D.
The adoption of various forms of health information technology (HIT) may have disparate impacts, including improvements in access/continuity of care, quality, patient satisfaction or privacy of medical information. However, a principal motivation for pursuing HIT is the expectation that it will lead to system efficiencies that result in net savings in the short run or long run. Because most HIT innovations have multiple effects, this section examines the benefits and costs of a full range of HIT innovations for which there is real-world evidence even if their purpose or impact might be quality improvement at the expense of cost containment. Discussion of health reform policy proposals related to HIT (i.e., policy options under discussion and not yet adopted or implemented) is contained at Health IT under Health Reform, Components of Reform, Cost Containment.
Health IT News and Analysis
- Over 90% Of Cloud Services Used In Healthcare Pose Medium To High Security Risk. “According to cloud security vendor Skyhigh Networks, more than 13% of cloud services used in healthcare are high‒risk and 77% are medium risk ‒ as measured across 54 different security attributes (like data encryption and “two factor” authentication).” Munro, Dan. (Forbes, 9.1.14)
- Fifteen Game-Changing Wireless Devices to Improve Patient Care. Cardiac electrophysiologist David Lee Scher, MD, clinical associate professor of medicine at Penn State University, director of a digital health consulting firm, avid blogger on mobile health issues, and chairman of the Healthcare Information and Management Systems Society (HIMSS) Mobile Health Roadmap Task Force, points to 15 potential game changers in mobile health technology that hold the promise of revolutionizing patient care in hospitals, in nursing homes, and at home. (Medscape, 10.23.14)
- Federal Health IT Strategic Plan 2015 – 2020. “Health information technology (health IT) allows individuals and health care entities and providers, home- and community-based supports, and public health entities to electronically collect, share, and use health information. The term “health IT” includes a wide range of products, technologies, and services, such as electronic health records (EHRs), mobile and telehealth technology, cloud-based services, medical devices, and remote monitoring devices, assistive technologies, and sensors. Federal agencies provide direct care and health insurance, protect public health, fund health and human services for certain populations, invest in infrastructure, develop and implement policies and regulations, and advance groundbreaking research. Given this range of activities, the federal government is also positioned to improve health, health care, and reduce costs through the secure use of information and technology. The Federal Health IT Strategic Plan 2015-2020 (Plan) identifies the federal government’s health IT priorities. While this Plan focuses on federal strategies, achieving the vision and goals requires collaboration from state, local, and tribal governments.” (Office of the National Coordinator for Health Information Technology [ONC], December, 2014)
- Feds Release Strategic Health IT Plan. “The document, now open for public comment, presents the broad federal strategy which sets the context and framing of the Nationwide Interoperability Roadmap to be released in early 2015. With the first national health IT interoperability roadmap imminent, the 2015–2020 Federal Health IT Strategic Plan is doubling down on making incompatible information systems collect, share and use health data with each other.” (Health Leaders Media, 12.9.14)
- Feds Plan for 35 Agencies to Help Collect, Share, Use Electronic Health Info. “The Department of Health and Human Services (HHS) announced the release of the Federal Health IT Strategic Plan 2015-2020, which details the efforts of some 35 departments and agencies of the federal government and their roles in the plan to ‘advance the collection, sharing, and use of electronic health information to improve health care, individual and community health, and research.’ The plan is illustrated with the following graphic:
“The report includes a comprehensive list of all departments and agencies involved.”
- Omnibus Bill Keeps ONC Funding at Same Level as 2014. “In its ‘Congressional Asks’—formal requests to Congress to accomplish specific goals to advance health IT–HIMSS urged lawmakers to fund ONC at the higher level. It calls this fourth year and Stage 2 of Meaningful Use a ‘critical juncture’ for the adoption and effective use of EHRs, citing the need to maintain the momentum achieved so far.” (Fierce Health IT, 12.15.14)
- The Tyranny of the Should. “In the UK, it appears the NHS will have a ‘huge rollout‘ of wearable technology as part of a ‘revolution in self care.’ Being able to monitor patients remotely, especially those with a chronic condition, is admirable. If entities in healthcare will be able to monitor us remotely, surely that’s always going to be a good thing? Perhaps not. Given the huge financial pressures facing the NHS over the next 20 years, we may have to ration access to care. In the future, could all this data collected about our behaviour be used to ration or even deny care? I’m not the only one who is asking that question. In a great article by Hamza Shaban examining the impact of sensors collecting data about our health on the pricing of health insurance, one sentence stands out, ‘Imagine a pricing scheme that would punish sleep-deprived single parents or the dietary habits of the working poor.’ A world where our health insurance premiums decline when we behave within the guidelines, and rise when we deviate from the guidelines…Today, the National Institutes of Health announced it’s searching for a wearable or otherwise discreet device capable of measuring blood alcohol level in real time. There is a fine line between ‘Digital Nudges’ and ‘The tyranny of the Should’ – and it’s not clear to me that we’re having the right conversations in the right places.” (Juneja, Maneesh, 3.2.15)
- Roll Back the Federal 10-Year Strategic Plan for Health Information Technology: Statement for the Record. “A 2014 report for the RAND Corporation also concluded the federal [HITECH] money was invested poorly: ‘Unfortunately, the rules that the U.S. Department of Health and Human Services (HHS) issued to guide implementation of HITECH watered down the requirement for connectivity. The practical effect was to promote adoption of existing platforms, rather than encourage the development of interconnected systems. Although large vendors and many health care systems welcomed this decision, it was criticized by others. By subsidizing “where the industry” is rather than where it needed to go, HHS rule-makers allowed hospitals and health care providers to use billions in federal subsidies to purchase EHRs that did not have the level of connectivity envisioned by the authors of the HITECH act.’…As HIT expands in unpredictable directions, the federal government should exert a humble and light regulatory touch; and refrain from the temptation to spend more money to encourage the types of technologies preferred by the government, instead of patients and providers. The billions of dollars in capital being invested in HIT must be allowed to find their own course to success.” Graham, John R. (NCPA, 3.17.15)
Electronic Health Records (EHRs)
Meaningful Use Program
CMS (Update, 10.6.15): The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub.L. 111–5) was enacted on February 17, 2009. Title IV of Division B of ARRA amends Titles XVIII and XIX of the Social Security Act (the Act) by establishing incentive payments to eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs), and Medicare Advantage Organizations to promote the adoption and meaningful use of interoperable health information technology (HIT) and qualified electronic health records (EHRs). These incentive payments are part of a broader effort under the HITECH Act to accelerate the adoption of HIT and utilization of qualified EHRs. Meaningful Use (MU) is a Center for Medicare & Medicaid Services program that pays an incentive for “meaningful use” of an electronic health record (EHR). It is a separate program from PQRS (Physician Quality Reporting System). Those eligible for the Meaningful Use include doctors of medicine or osteopathy, dental surgery or dental medicine, podiatry, optometry, and chiropractic. Meaningful use is defined as use of certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities; Engage patients and family; Improve care coordination, and population and public health; Maintain privacy and security of patient health information.
Stages of Meaningful Use
2011-2012 Stage 1: Data capture and sharing
2014 Stage 2: Advance clinical processes
2016 Stage 3: Improved outcomes
Stage 1 EHR Meaningful Use Requirements
- Use of a certified EHR in a meaningful manner (e.g. e-prescribing)
- Use of a certified EHR for electronic exchange of health information to improve the quality of health care
- Use of certified EHR technology to submit clinical quality measures (CQM).
Qualifying for Stage 1 Meaningful Use of an electronic health record (EHR) means that:
- The EHR meets all 20 objectives for meaningful use.
- Six clinical quality measures are reported.
- The EHR and has been in use for at least 90 days during the first year and 12 months for all subsequent years.
- Three core measures plus three additional measures must be reported. If the provider does not qualify for the three core measures, three alternate core measures must be reported. List of core and alternate measures.
Stage 1 EHR Meaningful Use Specification Sheets. The Centers for Medicare & Medicaid Services (CMS), which administers the Medicare and Medicaid EHR Incentive Programs, provides these sheets to help professionals and hospitals understand the requirements of each objective and demonstrate meaningful use successfully.
- EHR Meaningful Use Specification Sheets for eligible professionals (EPs) [PDF – 348 KB]
- Meaningful use specifications for eligible hospitals [PDF – 360 KB]
Stage 2 EHR Meaningful Use
On September 4 2012, CMS published a final rule that specifies the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to continue to participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. All providers must achieve meaningful use under the Stage 1 criteria for two years before moving to Stage 2.
To help providers better understand Stage 2 Meaningful Use requirements, CMS developed Stage 2 Meaningful Use Specification Sheets for EPs and Eligible Hospitals that provide detailed information on each Stage 2 objective.
Stage 3 EHR Meaningful Use
For Stage 3 of the EHR Incentive Programs in 2017 and subsequent years, major provisions include:
- 8 objectives for eligible professionals, eligible hospitals, and CAHs: In Stage 3, more than 60 percent of the proposed measures require interoperability, up from 33 percent in Stage 2.
- Public health reporting with flexible options for measure selection.
- CQM reporting aligned with the CMS quality reporting programs.
- Finalize the use of application program interfaces (APIs) that enable the development of new functionalities to build bridges across systems and provide increased data access. This will help patients have unprecedented access to their own health records, empowering individuals to make key health decisions.
All providers will be required to comply with Stage 3 requirements beginning in 2018 using EHR technology certified to the 2015 Edition. The Stage 3 requirements are optional in 2017. Providers who choose to begin Stage 3 in 2017 will have a 90-day reporting period. Objectives and measures for Stage 3 include increased thresholds, advanced use of health information exchange functionality, and an overall focus on continuous quality improvement.
CMS restructured the objectives and measures of the EHR Incentive Programs in 2015 through 2017 to align with Stage 3, and modified “patient action” measures in Stage 2 objectives.
CMS announced on 10.6.15 a 60-day public comment period to facilitate additional feedback about Stage 3 of the EHR Incentive Programs going forward, in particular with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which established the Merit-based Incentive Payment System (MIPS) and consolidates certain aspects of a number of quality measurement and federal incentive programs into one more efficient framework. (Center for Medicare and Medicaid Services, 10.6.15)
Health Information Exchanges
- National Health Information Exchange: Why The Delay?”A public-private consortium is putting in place a system that should provide interoperability among disparate EHR systems and HIEs. If it’s successful, it will provide plug-and-play connectivity between EHRs and HIEs and between HIEs. This initiative would drastically cut the expense of interfaces and would let more than half of the U.S population and their healthcare providers access health data shared among multiple states and systems…Healtheway, the new private-sector entity that operates the eHealth Exchange (successor to the Nationwide Health Information Network), has partnered with a consortium of states, EHR vendors, and HIE vendors to implement standards that will make it easier to exchange health information. Despite this progress, there’s at least one issue no one wants to touch: the individual patient identifier code. (InformationWeek Healthcare, 11.5.12)
- Former Senators Join Forces to Advance Telemedicine. “In their post-Senate careers, the three former lawmakers have relocated to K Street, home to lobbyists, and are working on behalf of the Alliance for Connected Care, a nonprofit collection of health care providers, insurers, pharmacies, technology firms and telecommunications companies, to pursue legislative and regulatory changes to let more Americans essentially get much of their health care remotely…All three former lawmakers said they became interested in the potential of digital technology to deliver health care when they were representing states with pockets of poverty, where access to health care can be difficult for geographic and economic reasons.” (New York Times, 5.20.14)
- Pediatric eHealth Interventions: Common Challenges During Development, Implementation, and Dissemination. “The challenges associated with eHealth interventions and their proposed solutions are multifaceted and cut across a number of areas from eHealth program development through dissemination. Collaboration with a range of individuals (e.g., multidisciplinary colleagues, commercial entities, primary stakeholders) is the key to eHealth intervention success. To ensure adequate resources for design, development, and planning for sustainability, a number of public and private sources of funding are available. A study design that addresses ethical concerns and security issues is critical to ensure scientific integrity and intervention dissemination. Table I summarizes key issues to consider during eHealth intervention development, testing, and dissemination.” (Journal of Pediatric Psychology. 2014;39(6):612-62)
- The Cleveland Clinic: Coming to a Kiosk Near You? Health System to Offer New Telehealth Options. “The Cleveland Clinic has signed a letter of intent to partner with HealthSpot, a provider of telehealth services based in Ohio, to provide care to patients via walk-in kiosks located in non-traditional health care settings, like workplaces, universities, and retail stories. The kiosks are private, eight-by-five foot spaces outfitted with medical devices, videoconferencing capabilities, and medical devices. They allow Cleveland Clinic providers to see patients through the kiosks, and each kiosk is staffed by a medical assistant.The clinic will integrate patient data from the kiosks into its electronic health record system.” (The Advisory Board Company, 5.22.14)
- New Push for TeleHealth in Accountable Care Act’s ACOs. “NAACOS has co-signed a letter to HHS urging CMS to grant a waiver to permit all ACOs to use and bill for TeleHealth services. HHS clearly has the authority but so far has been unwilling to exercise it.” (National Association of ACOs, 6.6.14)
- Physicians Warm to Digital Communications With Patients. “Forty percent of physicians say they believe the use of digital technologies to communicate with patients can improve outcomes, and the same percentage say they have increased their use of digital tools in patient care during the past year, according to a recent Manhattan Research survey. These digital technologies include everything from the use of patient portals and emailing and texting with patients to the prescribing of mobile health apps for self-tracking and remote patient monitoring, Monique Levy, vice president of research at Manhattan Research, told Medscape Medical News.“ Medscape Medical News, 6.12.14
- Telecare Collaborative Management of Chronic Pain in Primary Care: A Randomized Clinical Trial. “The Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study was a randomized trial comparing a telephone-delivered collaborative care management intervention vs usual care in 250 patients with chronic (≥3 months) musculoskeletal pain of at least moderate intensity (Brief Pain Inventory [BPI] score ≥5). Patients were enrolled from 5 primary care clinics in a single Veterans Affairs medical center from June 2010 through May 2012, with 12-month follow-up completed by June 2013…Telecare collaborative management increased the proportion of primary care patients with improved chronic musculoskeletal pain. This was accomplished by optimizing nonopioid analgesic medications using a stepped care algorithm and monitoring.” JAMA. 2014;312(3):240-248
- New Push for TeleHealth in ACOs. “NAACOS has co-signed a letter to HHS urging CMS to grant a waiver to permit all ACOs to use and bill for TeleHealth services. HHS clearly has the authority but so far has been unwilling to exercise it.” (National Association of ACOs, 6.6.14)
- Telehealth Services Comments Letter: NAACOS has signed on to an Alliance for Connected Care letter to the House Energy and Commerce Chairman and the Energy and Commerce Subcommittee on Health Chairman addressing improvements to the availability and use of telehealth services. (National Association of ACOs, 6.16.14)
- Medicare Increases Telehealth Coverage…a Bit. “The Centers for Medicare & Medicaid Services (CMS) proposes to increase incrementally the telehealth services that Medicare will cover, including wellness visits and some behavioral health services. However, CMS continues to restrict telehealth coverage to rural areas and offers a very circumscribed definition of the telehealth technology that can serve as the basis for coverage…Years ago, Dr. Bashshur recalled, CMS refused to cover telehealth at all, and it is still taking a very restrictive approach because it is afraid of the potential for overuse. On the basis of his own research, Dr. Bashshur has estimated that CMS paid only $12 million for telehealth last year.” (Medscape Medical News, 7.16.14)
- Does Telehealth Diminish Physician-Patient Relationships? “Nonvisit care of patients is becoming a necessity in primary care, noted Dr. Scherger, who practices part-time and was a pioneer of secure email consultations. Moreover, he pointed out, the Internet has created new ways to deliver chronic and preventive care and treat minor acute problems, and those modes will be used. ‘You’ve got this new platform of communication and care that is going to be delivered, whether it’s by a continuity provider or by somebody else.’” (Medscape Medical News, 7.25.14)
- FSMB Compact Could Ease MultiState Licensing. “The Federation of State Medical Boards (FSMB) has unveiled a draft interstate compact for physician licensure that, it said, should make it easier to practice telemedicine across the country. The compact, which the FSMB expects to finalize in the next month or two, offers a ‘streamlined alternative pathway’ for physicians who want to practice in multiple states, according to a federation news release. Under current state medical board policies, physicians must be licensed in the state where a patient is located to diagnose or treat that patient, a stance that the FSMB recently reaffirmed in its model policy for telemedicine. As a result, physicians who consult remotely with patients in other states must be licensed in those states. That can create barriers to telehealth consultations, especially for on-call physicians who are not licensed in every state where patients may contact them online. The FSMB’s interstate compact would allow physicians to apply once and receive licensure in all states that are party to the compact.” (Medscape Medical News, 8.5.14)
- Current Law Restricts Millions of Americans’ Access to Telehealth Services. “Several of the nation’s largest pharmacies and health-care companies are urging lawmakers to expand the types of telehealth services that can be covered by government insurance programs, arguing that an outdated federal law is limiting the number of Americans who can access telemedicine. Under current law, only telemedicine services offered through rural hospitals and clinics are covered by Medicare, according to a section of the Social Security Act that regulates how Medicare reimburses for telemedicine.” (Washington Post, 10.19.14)
- What Will You Do With All That Telemedicine Data? “(T)he growing prevalence of monitoring devices is starting to make many doctors nervous as they contemplate how they will deal with all the data they may receive. And if you work in an environment where reimbursement will increasingly be based on outcomes—a hospital, a practice owned by a hospital system, an accountable care organization (ACO), or a patient-centered medical home (PCMH)—this dilemma may affect you sooner than you may think…Many physicians fear that once remote patient monitoring becomes the standard of care, they will be deluged with patient data that they will then need to evaluate and, in some cases, act on in a timely fashion, when there already aren’t enough hours in the day.” (Medscape Business of Medicine, 12.18.14)
- ACP Supports Expanding Telemedicine in Primary Care. “Telemedicine can broaden access to care, improve outcomes, and reduce care costs, but risks and benefits must be carefully evaluated for both patients and physicians, say authors of a new position paper from the American College of Physicians (ACP). The paper, published online September 8 in the Annals of Internal Medicine, offers more than a dozen recommendations — and the rationale behind them — for successful telemedicine, which the ACP says should be held to the same standards of practice as in-person medicine.” (Medscape Medical News, 9.8.15)
- Teladoc Files Antitrust Suit Against Medical Board. “In just over a month, a new state rule is set to kick in that could undercut the business model of Dallas-based Teladoc, a rapidly growing telemedicine company that connects patients and doctors over the telephone and internet. With the clock ticking, the company is brandishing every weapon in its arsenal, deploying teams of lobbyists and lawyers to fight a Texas Medical Board rule change that it says is more about stifling competition than protecting patient health. The board’s rule, set to start June 3, would prevent doctors from treating people over the phone — making a diagnosis or prescribing medicine — unless another medical professional was physically present to examine the patient.” (Texas Tribune, 4.30.15)
- Patients Consent to Physicians Crowdsourcing for Diagnosis. “The increasing number of apps and online services that allow physicians to use crowdsourcing to make a diagnosis highlights the need for a debate on how to allow for patient privacy and consent, according to results from a new survey. When asked whether they would give permission to have their picture posted online, about 80% of respondents agreed to posting to improve their own medical care, about 80% agreed to posting to educate other doctors, and about 80% agreed to posting to advance scientific knowledge.” (Medscape Medical News, 5.1.15)
- Online Psychotherapy Gains Fans And Raises Privacy Concerns. “Some studies suggest that therapy online can be as effective as it is face to face. ‘We have a lot of promising data suggesting that technology can be a very good means of providing treatment,’ says Lynn Bufka, a clinical psychologist who helps develop health care policy for the American Psychological Association…Family therapists, mental health counselors and clinical social workers are licensed to practice by individual state boards. But it’s unclear whether a practitioner who lives in one state can or should treat someone who lives elsewhere.’ We’d like to see a little more mobility and flexibility with that, because certainly for licensed psychologists the standards are pretty similar across state lines,’ Bufka says. Perhaps, she adds, therapists could get a special certification that would allow them to practice in multiple states or countries.” (National Public Radio, 6.30.14)
- Coalition for Technology in Behavioral Science Formed (Summer, 2014). CTiBS is an inter-disciplinary group dedicated to fostering the legal and ethical use of evidence-based technology in behavioral health care and is open to members of all disciplines who share an interest in technology in improving the human experience. “Please review the many areas of technological research, development and consultation that we support; review our mission; avail yourself of our extensive and searchable bibliography; and read about the latest writings about the intersection of technology and behavioral health in our blog.”
- Telepsychologist Competencies for Psychologists Practicing in Ohio. Webinar provides an overview of competencies and best practices in implementing telehealth. (Ohio Psychological Association, October, 2014)
- Cognitive Therapy Works Even by Telephone, Computer. “Cognitive behavioral therapy (CBT) for anxiety and depression, whether self-guided, provided via telephone or computer, or provided face to face, was better than no care in a primary care setting and was also better than treatment as usual (TAU), according to a meta-analysis published online September 22 in Family Practice.” (Medscape Medical News, 10.9.14)
- Federal Health Records Program Leaves Some Medical Professionals Out of the Loop. “Mental-health clinics, psychologists and psychiatric hospitals were left out of the incentive and penalty program, along with nursing homes, emergency medical services and others. It has been estimated by the consulting firm Avalere Health that including them would require an additional $1 billion…’If a broad base of health professionals had access to mental-health records that include psychotherapy notes, I am concerned about the potential for privacy violations . . . not only for the patient, but also for the others who are involved in the patient’s life,’ he said…Recent provider backlash against the current government incentive program may also be a roadblock. Earlier this year, 37 medical societies led by the American Medical Association asked federal regulators to shift direction, arguing that today’s electronic records systems are cumbersome, inefficient and can present safety problems for patients.” (Washington Post, 3.5.15)
- Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder. “Telephone-delivered CBT consisted of as many as 11 sessions (9 were required) focused on recognition of anxiety symptoms, relaxation, cognitive restructuring, the use of coping statements, problem solving, worry control, behavioral activation, exposure therapy, and relapse prevention, with optional chapters on sleep and pain. Telephone-delivered NST consisted of 10 sessions focused on providing a supportive atmosphere in which participants could share and discuss their feelings and did not provide any direct suggestions for coping…In this trial, telephone-delivered CBT was superior to telephone-delivered NST in reducing worry, GAD symptoms, and depressive symptoms in older adults with GAD.” (JAMA Psychiatry, October, 2015)
Health IT and Hospitals
- The Healthcare Chief Information Officer MindMap. “It’s a beautiful display of everything that’s happening in healthcare IT. Although, it’s also an illustration of the challenge we hospital CIOs face. Is it any wonder that so many hospital CIOs feel overwhelmed?” (EMR and HIPAA. 4.8.14)
- Expert: U.S. Hospital Breach Biggest Yet to Exploit Heartbleed Bug. “Hackers who stole the personal data of about 4.5 million patients of hospital group Community Health Systems Inc broke into the company’s computer system by exploiting the “Heartbleed” internet bug, making it the first known large-scale cyber attack using the flaw, according to a security expert…Community Health Systems, one of the biggest U.S. hospital groups, said the information stolen included patient names, addresses, birth dates, phone numbers and social security numbers of people who were referred or received services from doctors affiliated with the company over the last five years.” (Reuters, 8.20.14)
- Health Information Technology (Health Affairs topics page)
- Federal HealthIT Site: http://www.healthit.gov
- See Information Management under Health Care Delivery System.
- HealthVault (Microsoft). Health care management site.
- Blue Button. Federal protocol permitting veterans and Medicare beneficiaries to share medical history with providers.
- Kaiser Health News. Health IT.