10 years af­ter the revo­lu­tion

Health IT co­or­di­na­tors look back at the na­tion’s progress

Modern Healthcare - - NEWS - By Joseph Conn

On April 26, 2004, Pres­i­dent Ge­orge W. Bush for­mally launched the federal drive to widely dis­sem­i­nate health in­for­ma­tion tech­nol­ogy to im­prove pa­tient care. In a speech in Min­nesota, Bush set a goal that within 10 years, “ev­ery Amer­i­can must have a per­sonal elec­tronic med­i­cal record,” adding, “The federal govern­ment has got to take the lead in or­der to make this hap­pen.”

The next day, by ex­ec­u­tive or­der, Bush cre­ated the Of­fice of the Na­tional Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy within HHS. A few days later, HHS Sec­re­tary Tommy Thomp­son named Dr. David Brailer the first ONC leader.

Bush said the ONC should work with pri­vate sec­tor health­care or­ga­ni­za­tions as well as all federal agencies with a hand in health­care.

He or­dered the co­or­di­na­tor to be­gin work on a na­tional HIT strat­egy to pro­mote the adop­tion and use of in­ter­op­er­a­ble elec­tronic health records to en­hance clin­i­cal de­ci­sion­mak­ing, im­prove qual­ity, lower costs, re­duce er­rors, im­prove co­or­di­na­tion of care and en­sure the pri­vacy and se­cu­rity of pa­tient data. He said the of­fice should “not as­sume or rely upon additional federal re­sources or spend­ing” to do its work. And in fact, later that year Congress ze­roed out the ONC’s $50 mil­lion budget re­quest for 2005, forc­ing Thomp­son to fi­nance the agency by reshuf­fling HHS’ ad­min­is­tra­tive funds.

The ONC was started “be­cause Amer­ica was clearly be­hind a lot of other de­vel­oped coun­tries with a health in­for­ma­tion in­fra­struc­ture,” said Dr. Paul Tang, chief in­no­va­tion and tech­nol­ogy of­fi­cer at the Palo Alto

(Calif.) Med­i­cal Foun­da­tion who serves on sev­eral ONC ad­vi­sory pan­els.

In its first decade, the ONC has had “an ex­traor­di­nar­ily im­por­tant” im­pact on health­care, said Dr. John Halamka, chief in­for­ma­tion of­fi­cer of Beth Is­rael Dea­coness Med­i­cal Cen­ter, Bos­ton. “Over the 10 years of ONC, we have tripled adop­tion of EHRs and brought health in­for­ma­tion ex­change into the com­mon vo­cab­u­lary,” Halamka said.

Brailer was suc­ceeded as ONC co­or­di­na­tor by Dr. Robert Kolodner, Dr. David Blu­men­thal, Dr. Farzad Mostashari, and now Dr. Karen DeSalvo. “Each of the co­or­di­na­tors has had a unique role to play,” Halamka said. “I would say each per­son was op­ti­mally cho­sen for the era in which they served and each had a to­tally dif­fer­ent per­son­al­ity.”

There have re­ally been two ONC eras—the lit­tle-money Bush era, in which the ONC ran on $50 mil­lion an­nual bud­gets, and the big-money Obama era start­ing with the 2009 Amer­i­can Re­cov­ery and Rein­vest­ment Act, with its $2 bil­lion for ONC grant pro­grams. The in­cen­tive pay­ment pro­gram for adop­tion of EHRs has paid out $21.6 bil­lion so far.

In the be­gin­ning, the ONC was “a very strong idea” that was al­most to­tally with­out fund­ing, said Glen Tull­man, a man­ag­ing part­ner of 7 Wire, a Chicago-based in­vest­ment firm, and a for­mer CEO at Allscripts Health­care So­lu­tions. He cred­its Brailer and his top aide, Missy Kras­ner. “They sin­gle-hand­edly went around the coun­try and used the bully pul­pit to ca­jole and con­vince people that this was vi­tally im­por­tant.” But Tull­man added, “there is only so much you can do from the bully pul­pit.”

There are crit­ics of the strong federal role in HIT de­vel­op­ment, in­clud­ing Brailer him­self. He de­scribes the EHR in­cen­tive pro­gram as a mar­ket-dis­rupt­ing “Franken­stein.”

Ross Kop­pel, a pro­fes­sor of so­ci­ol­ogy at the Univer­sity of Penn­syl­va­nia med­i­cal school, said federal pol­i­cy­mak­ers erred in think­ing that “more HIT equals bet­ter care and safer care. That as­sump­tion has been de­feated by their de­sire to push the tech­nol­ogy long be­fore it was ready.” What has re­sulted, he said, “is a cap­tured mar­ket in which ven­dors cre­ate in­fe­rior prod­ucts that the clin­i­cians are obliged to pur­chase.”

ONC sup­port­ers ac­knowl­edge some im­por­tant short­com­ings. “If I were to look at mean­ing­ful-use Stage 2, I think we have tried to do too much, too fast,” Halamka said.

“The govern­ment could have pushed in­ter­op­er­abil­ity a lit­tle harder,” Tull­man said.

Still, ONC lead­ers point to an im­pres­sive list of achieve­ments.

Be­fore the ONC, caveat emp­tor ruled for EHR buy­ers. To­day, vir­tu­ally all EHR sys­tems sold are tested and cer­ti­fied against a list of func­tional cri­te­ria de­vel­oped by the ONC.

Be­fore the ONC and the EHR in­cen­tive pro­gram, fewer than 4% of non­fed­eral U.S. hos­pi­tals had EHR sys­tems with com­put­er­ized physi­cian-or­der en­try. To­day, 90% of hos­pi­tals have CPOE. Pre­vi­ously, less than 20% of of­fice-based physi­cians had any kind of an EHR; to­day, more than 78% do.

Pre­vi­ously, only a few re­gional health in­for­ma­tion ex­changes ex­isted. To­day, af­ter $548 mil­lion in grants have been dis­trib­uted by the ONC from the federal stim­u­lus pack­age, there are 315 statewide, re­gional and lo­cal HIEs. There used to be no na­tion­wide net­work of HIT re­gional ex­ten­sion cen­ters. To­day, 62 RECs have helped 150,000 physi­cians and crit­i­cal-ac­cess hos­pi­tals pur­chase and use EHRs.

There pre­vi­ously were many HIT in­ter­op­er­abil­ity stan­dards, but no con­sen­sus on which to use for what pur­pose. The ONC led the de­vel­op­ment of the Di­rect pro­to­col for elec­tron­i­cally trans­mit­ting pa­tient-care sum­maries be­tween providers and pa­tients, which is soon to be in wide­spread use un­der Stage 2 mean­ing­ful-use re­quire­ments.

By the time of his ap­point­ment in 2004, Brailer had been at work ad­vis­ing the Bush ad­min­is­tra­tion about HIT for more than a year. “It just be­came more and more in­tense,” he said. “By Novem­ber (2003), it was non­stop. I spent a month alone on the draft in the State of the Union ad­dress. On Jan. 20, 2004, the ef­fort pro­duced the Bush sen­tence heard round the health IT world: “By com­put­er­iz­ing health records, we can avoid dan­ger­ous med­i­cal mis­takes, re­duce costs and im­prove care,” Bush said.

On April 16, Brailer gave the Bush ad­min­is­tra­tion his 54-page pol­icy op­tions brief, which be­came the guide to the ONC’s de­vel­op­ment. EHRs had the po­ten­tial to trans­form health­care, Brailer wrote, “into a more mod­ern and con­sumer-driven in­dus­try.” But, he said, EHRs deliver only a small frac­tion of their po­ten­tial ben­e­fits be­cause of the frag­mented and vol­ume-based model of health­care fi­nanc­ing. He listed 20 pol­icy op­tions to over­come the prob­lem, in­clud­ing re­duc­ing the fi­nan­cial risk to po­ten­tial EHR buy­ers.

Some of his rec­om­men­da­tions were im­ple­mented, such as arm’s-length test­ing and cer­ti­fi­ca­tion of EHRs with the launch in

2004 of the not-for-profit Cer­ti­fi­ca­tion Com­mis­sion for Health In­for­ma­tion Tech­nol­ogy. Other rec­om­men­da­tions, such as “re­im­burse­ment for EHR use at the point of care” via Medi­care through spe­cific billing codes, were not. Brailer said he asked for $17 bil­lion in federal fund­ing to pro­mote EHR adop­tion and in­ter­op­er­abil­ity, but that re­quest went nowhere.

Brailer spent two years soldier­ing on with­out call­ing again for such sub­stan­tial federal sub­si­dies for HIT. He was suc­ceeded by Kolodner, whose ten­ure bridged the Bush and Obama eras. Kolodner, who had served 28 years at the Depart­ment of Vet­er­ans Af­fairs and helped de­velop its widely ad­mired VistA EHR, said his govern­ment ex­pe­ri­ence helped him un­der­stand the dy­nam­ics of change in large or­ga­ni­za­tions and also the im­por­tance of in­ter­op­er­abil­ity.

Blu­men­thal started as a health pol­icy ad­viser to the Obama cam­paign soon af­ter Obama an­nounced his can­di­dacy for pres­i­dent in 2007. Be­fore the ONC, “I never was a tech­nol­ogy per­son,” Blu­men­thal said. As a pri­mary-care physi­cian, though, he had started us­ing an EHR in 2002 and “found that it had many, many ben­e­fits for me and my pa­tients.” Then, as an aca­demic, he had done na­tional sur­vey work un­der con­tract with the ONC, mea­sur­ing the qual­ity of EHRs adopted by physi­cians and iden­ti­fy­ing bar­ri­ers to faster EHR adop­tion.

Then, in Septem­ber 2008, Wall Street’s Lehman Bros. col­lapsed, touch­ing off the Great Re­ces­sion, which prompted Pres­i­dent Barack Obama’s eco­nomic stim­u­lus pack­age. Work­ing as di­rec­tor of the In­sti­tute for Health Pol­icy at Mas­sachusetts Gen­eral Hospi­tal, Bos­ton, Blu­men­thal wrote a five-page white paper, pub- lished by the Com­mon­wealth Fund in Jan­uary 2009, which hinted at many of the HIT pro­vi­sions in the stim­u­lus pack­age.

His paper en­vi­sioned di­rect grants or loans to providers to sup­port EHR pur­chases, as well as ex­tra Medi­care and Med­i­caid pay­ments for adop­tion, and penal­ties for providers with­out them. It called for fund­ing com­mu­nity-based “geek squads” to help doc­tors im­ple­ment and main­tain their sys­tems. And it called for pay­ments to in­cen­tivize im­prove­ments in qual­ity and ef­fi­ciency.

Blu­men­thal said he was not di­rectly in­volved in draft­ing the EHR in­cen­tive pro­vi­sions of the stim­u­lus bill. But he did talk to Capi­tol Hill staffers and fielded calls on tech­ni­cal is­sues from the Obama tran­si­tion team.

The most im­por­tant work per­formed on his watch, he said, was defin­ing what Congress meant by the term mean­ing­ful use. But “the more far-sighted hos­pi­tals and health sys­tems quickly un­der­stood that mean­ing­ful use was not their end goal, that they needed sys­tems that could do much more than what mean­ing­ful use was ask­ing of them,” he said.

Mostashari came to the ONC as a deputy un­der Blu­men­thal af­ter serv­ing as a deputy health com­mis­sioner in New York City, where he es­tab­lished a pro­gram that helped more than 3,000 physi­cians in­stall and use an EHR. He be­came ONC chief just as the EHR in­cen­tive pay­ment pro­gram was tak­ing off. “One of the things I’m proud­est of is how we ac­tu­ally de­liv­ered value from the stim­u­lus” money, he said. One of his most im­por­tant roles, he said, was “con­tin­u­ally try­ing to raise peo­ples’ eyes from what we’re do­ing as a reg­u­la­tion to why we’re do­ing this. The greater goal is to save lives.”

DeSalvo said she’s spo­ken with all four of her pre­de­ces­sors. Al­though “they were deal­ing with dif­fer­ent stages,” she said, “it’s in­ter­est­ing to me that some of the gen­eral themes of what they were look­ing to do were sim­i­lar. Ev­ery­one is try­ing to solve these same three is­sues—cap­tur­ing data, free­ing it ap­pro­pri­ately and then putting it to use.”

Dr. David Brailer

ONC TEN­URE: May 2004 to May 2006

CUR­RENT PO­SI­TION: CEO and founder, Health Evo­lu­tion Part­ners, San Fran­cisco, a health­care pri­vate-eq­uity firm

PRIOR PO­SI­TIONS: Se­nior fel­low, Health Tech­nol­ogy Cen­ter, San Fran­cisco; CEO, CareS­cience, Philade­phia


Helped the pub­lic and govern­ment agencies “un­der­stand that health in­for­ma­tion tech­nol­ogy would fun­da­men­tally change the way health­care is de­liv­ered”; pre­vented the na­tional health IT ini­tia­tive from be­com­ing an overly cen­tral­ized, “top down,” bu­reau­cratic pro­gram.

ONC’S FU­TURE: He orig­i­nally thought the ONC should be phased out, but now sees a con­tin­u­ing role for the agency. “ONC needs to be out there say­ing, ‘Holy cow, we’re five years away from ge­nomics be­ing com­monly used in treat­ment.’ It needs to go out and ask, ‘What are the is­sues—with con­fi­den­tial­ity, with work­flow, with tech­nol­ogy? We’re go­ing to see more and more mo­bile health­care. What are you go­ing to do about that?’ ”

Dr. Robert Kolodner

ONC TEN­URE: Septem­ber 2006-April 2009

CUR­RENT PO­SI­TION: Vice pres­i­dent, chief med­i­cal of­fi­cer, Vi­Tel Net, McLean, Va., health/pa­tient com­mu­ni­ca­tions de­vel­oper

PRIOR PO­SI­TION: Chief health in­for­mat­ics of­fi­cer, Depart­ment of Vet­er­ans Af­fairs


Took the “in­spi­ra­tion, as­pi­ra­tions and en­ergy” that David Brailer and HHS sec­re­taries Tommy Thomp­son and Michael Leav­itt gen­er­ated and laid the foun­da­tion for health IT to take off; en­hanced pub­lic par­tic­i­pa­tion in the pub­lic/pri­vate ac­tiv­ity and brought the other federal agencies into a sin­gle ef­fort; pushed through the first fully ap­proved HIT strate­gic plan.

ONC’S FU­TURE: “It’s re­ally im­pos­si­ble to pre­dict what is go­ing to be needed five years from now, or three years from now, or whether it’s even go­ing to be needed at 10 years out. So I don’t know whether or not it should ex­ist 10 years from now. But cer­tainly, Dr. DeSalvo needs to fo­cus on some things. What we care about if we’re look­ing at that im­proved health and well­be­ing is… how do we do in­ter­ven­tions ear­lier to in­crease preven­tion and have less chronic ill­ness.”

Dr. Farzad Mostashari

ONC TEN­URE: April 2011–Oc­to­ber 2013

CUR­RENT PO­SI­TION: Vis­it­ing fel­low at the En­gel­berg Cen­ter for Health Care Re­form, Brook­ings In­sti­tu­tion, a Wash­ing­ton think tank

PRIOR PO­SI­TIONS: Deputy na­tional co­or­di­na­tor of ONC from July 2009. Be­fore that, New York City as­sis­tant health com­mis­sioner

MY TOP ONC AC­COM­PLISH­MENTS: “The first was, just ex­e­cute. One of the things I’m proud of is how we ac­tu­ally de­liv­ered value from the (2009) stim­u­lus law” that funded the EHR in­cen­tive pay­ment pro­gram; main­tained an en­tre­pre­neur­ial and ac­tivist ap­proach; ex­panded the scope of health IT to in­clude con­sumer e-health and ad­vo­cacy for pa­tients’ rights.

ONC’S FU­TURE: “The of­fice (even­tu­ally) may no longer be the Of­fice of the Na­tional Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy. They may drop the tech­nol­ogy part and (be­come) the Of­fice of the Na­tional Co­or­di­na­tor for Health In­for­ma­tion,” pro­mot­ing in­for­ma­tion flows, pri­vacy and se­cu­rity. “I be­lieve the of­fice and the na­tional co­or­di­na­tor will be in­dis­pen­si­ble in that role.”

Dr. David Blu­men­thal

ONC TEN­URE: April 2009–April 2011

CUR­RENT PO­SI­TION: Pres­i­dent, Com­mon­wealth Fund, New York

PRIOR PO­SI­TION: Di­rec­tor, In­sti­tute for Health Pol­icy at Mas­sachusetts Gen­eral Hospi­tal


De­fined the first stage of mean­ing­ful use of elec­tronic health records; cre­ated a cred­i­ble agency with lead­er­ship ca­pa­bil­ity for the mean­ing­ful use and reg­u­la­tory pro­cesses; over­saw grant pro­grams that built an in­fra­struc­ture to sup­port the im­ple­men­ta­tion of mean­ing­ful use.

ONC’S FU­TURE: “There are all kinds of gov­er­nance is­sues once we have a real na­tional health in­for­ma­tion in­fra­struc­ture. The Na­tional Health In­for­ma­tion Net­work, which never quite took shape, will take shape at some point. Some­one needs to con­tinue to take own­er­ship of the trust and se­cu­rity is­sues and no one else in the federal govern­ment be­sides ONC has that front and cen­ter. I think the mon­i­tor­ing of mean­ing­ful use and how it should evolve over time re­mains an im­por­tant func­tion. The cer­ti­fi­ca­tion func­tion can be much more ef­fec­tively used to im­prove us­abil­ity. So I think there is plenty of work to be done.”

Dr. Karen De Salvo


ONC TEN­URE: Jan. 13, 2014, to present

PRIOR PO­SI­TION: New Or­leans city health com­mis­sioner


For­mer ONC chiefs have dif­fer­ing views “about the role of govern­ment and the ONC in a na­tional HIT strat­egy gen­er­ally. Ev­ery­one is try­ing to solve the same three is­sues, which are cap­tur­ing data, free­ing it ap­pro­pri­ately and then putting it to use. And ev­ery­one sort of sees a dif­fer­ent way to do it.” She has been im­pressed with the reach that the re­gional ex­ten­sion cen­ters have in com­mu­ni­ties.

ONC’S FU­TURE: A top pri­or­ity by the end of this year is to up­date the na­tional health IT strate­gic plan and in­clude pro­vi­sions for pa­tient-gen­er­ated data. “The tech­nol­ogy in that area, be­cause it is so con­sumer- and mar­ket­driven, is ad­vanc­ing fast.”

Growth in EHR adop­tion by of­fice-based physi­cians 2004-13

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