Friday, March 12, 2010

David R. Hunt, MD, FACS ~ ONC and HITECH

David R. Hunt, MD, FACS the Medical Officer at the Office of the National Coordinator for Health IT gave a presentation to the Secretary’s Advisory Committee on Genetics, Health, and Society on February 5, 2010. The rough draft transcript is below the slides.

Dr. Hunt is here from the office of the National Coordinator for health information technology. He's in the office of the health information technology adoption. As you know, we heard from Dr. Blumenthal last June and we provided comments at that time. Since then, the proposed regulations on the meaningful use of electronic health records have been disseminated and we are going to hear an update about the process from Dr. Hunt and then what we will need from this group is to see how we might respond, so Dr. Hunt, thank you very much for joining us. If you had been here yesterday you would have heard keen interest in this topic. It has continued to be -- has been a topic of high interest for many years. So thank you for joining us.

Dr. Hunt: Oh, thank you. I have to give my sincere apologies for running late. As most of you in the area, and some not from the area know, the mid Atlantic region, we are the official weather weenies of the entire country, the red line of the metro was having their apoplexy this morning, later than I expected.

Dr. Howell has been extraordinary to adapt to our weather and other challenges.

Dr. Hunt: I bring you greetings, Dr. Blumenthal who spoke earlier, sends his greetings. I am thrilled to be here, the exciting issues you are discussing are coincident with one of the most transformative moments in American medicine. 2010 will be among the most interesting years we have seen, we hope. Our office, office of national cooer Nateor is charged to describe what can make this year and the next five or six here after more meaningful with regards to health IT. Dr. Blumenthal referenced this, a reasonable assumption is that I am here to talk about health IT, but you are wrong. That's not the primary focus of our office at all. Sounds like I con tray directed tray directed myself, but associated with information technology, more prompt way to describe our mandate from the president and Congress is to say the office of the national coordinator has been be given unpress dented resource and authority to effect an improvement in the value and the efficiency of healthcare services through the meaningful use of information technology.

The need for that improvement is pretty clear. Sir Cyril Chantler pointed it out, medicine used to be safe -- now it can be very effective but almost everything about the practice is more complex, and potentially dangerous. Understanding that at ONC, we have a firm conviction that properly applied information technology, properly applied tools can help me as a sur Jon be more mindful of my patients and the quality of care I provide. I spend a lot of time managing expectations to make sure we are careful not to fall into the trap of thinking everything will be just fine when we get the guys at Google and eBay to apply their skills to our domain.

I think you all better than most perhaps appreciate the fact that health IT or technology is really just one piece of a much much larger solution. The compelling solution for 2010 and beyond pivots around the simple question: Can we use information technology as a vehicle to change our culture and in turn our methods in 21st strch American healthcare. I mentioned earlier our Congress gave Dr. Blumenthal and the Secretary the mandate. To look at the text of the mandate, I have highlighted key words and phrases. It starts with security. Goes on, quality and cost. Further along you see we have a clear direction to facilitate the meaningful use of electronic records nationwide.

We also see throughout that the overarching subtext is to improve the quality of care while making sure the information remains secure and supports our institutions of public health.

So, we are talking about improve, ensure, reduce, protect, facilitate, promote. It's a pretty formidable list of challenges, but I ask you to take note the transcendent goal is not to acquire cool hardware, have the latest software. The infrastructure is a means to an end or it is nothing at all. Don't let me get too far ahead of myself. I have it on very good authority that I have to bottom line you. I always recount the public speaking advice my daughter once gave me, she says dad, don't take this the wrong way, but you have to tell your audience very early on, within five or ten minutes, what you are going to talk about, because after that time you have become very boring and tedious.

Who could take that wrong at all? I don't know.

The first thing I want to tell you to take home is that this moment is time, possibly more than any other is the time for clinical leadership. Next, while we lead, I think the essence of this conference and this group actually points to the fact that we must be the very first to acknowledge this work is a team sport and any success we have is wholly dependent on the strength of our partnerships. You see, our current circumstance is not due to a lack of technology, and therefore technology alone cannot be the entire solution. Above and beyond all else, we must form strong partnerships in that regard.

That brings me to my final point, and I always tell my audiences to rest assured that no direction beyond this point will be easy. While I can't stand up here and promise only blood, sweat, toil and tears, you have to understand the path forward requires a system, tremendous resources and no small amounts of courage. With those acknowledgments and looking at all the promise health IT holds, I will say that at ONC our first and steepest challenge is spurring the adoption of electronic health record and clinical practice. Here you will see pretty newly published and preliminary numbers on the state of adoption. This came out a little less than a month ago from the CDC, looking at practicing physicians we see in 2008 only 4% were using an electronic health record that can do the work we need. Handle progress notes, labs and -- we may have increased today by 2 points, still leaves us a long way to go. Why is that? Why are we still in single digits for adoption? The answer is pretty clear.

Here we see the top six barriers to adopting electronic health record. In short, for many it has not been worth it. Collectively, we in the clinical community have been very clearly saying that to embrace electronic health records our needs have to be met. I use this slide everywhere I go because I find it such a wonderful construct to frame our challenge as well as our solutions. This is a diagram from the work of Abraham Maslow, who described the theory of human motivation, dividing need into's growth needs and deficiency needs. Deficiency needs are physiologic, have to be met first. Once met the individual seeks to satisfy the needs of growth.

We can apply Maslow's hierarchy to our current circumstance and the foundational need is privacy and security. Beyond that, moving up the needs of growth the components of usability, basic functions, a strong business case, and finally, at the top, a most fulfilling achievement. One that many of us often gather to discuss, information exchange. Now, let's look at how the requirements will translate into action from our office. I mentioned earlier that privacy in the foundation for moving forward. The reason is obvious and you probably better than virtually any group understand this. The tenets of privacy are old in my profession, the Recovery Act clearly speaks to this point. To help us build the infrastructure the that would support that fabric of trust and all our other programs, Congress provided we have more than a policy of good intentions.

I point this you out to say this is a serious endeavor and our intent at HHS is to durable, measurable, reliable improvement in healthcare. One of the first issues is how to help providers choose and effectively implement this technology. Our department released a framework regarding how to give technical assistance to health IT regional extension centers and within the next few weeks I anticipate we will be able to announce the first of those organization that will be out of the chute to provide that assistance. The goal of these centers will be to provide hands-on technical assistance in implementing the technology.

They will do this for more than 100,000 physicians. Our office is dedicating over $600 million on this assistance. That assistance will be specifically directed at providers that are least likely to be able to do this on their own.

Here you can see those awarded grants must prioritize assistance to those in historically underserved areas with the ultimate goal of reducing health disparities. Reducing disparity you is a primary goal and explain this is recent head line. There is becoming evermore evidence of a growing digital divide. You see, if we believe that information at the point of care can make a difference in the quality and value and safety of that care, and this information can go on to support institutions of public health and social priorities, then the imperative of these findings become much more critical crit and are easily understood. This begs the question, what is the meaningful use of information technology?

Well, I have to give a little bit of a disclaimer here. Right now we just published the rules, a little more than a month old, proposed rule for the meaningful use of health IT. Because of that, we have officially entered the comment period for that propose which means I can't provide interpretations other than what's published. The greatest import is that we are collecting comments. Clearly we believe the proposal meets the requirements established by Congress in the statute. That statute gives pretty clear contours for the meaningful use. For example, the EHR must be certified, must be on a trajectory that includes exchange of information of real value to the patient such as care coordination.

Let me get back to the most important thing I can offer, namely, that as a published proposed rule we are desperately asking everyone and anyone who has thought about us moving forward, to please submit a comment. I invite everyone on this panel to submit a comment. Let me say that again. We are begging everyone to submit a comment; because you will see that for many groups, many -- particularly very interested groups, the proposed rule landed sort of flat. We took a tremendous amount of testimony, and obviously we are working on a very, very aggressive timeline, and some were a little disappointed some of the thought and ideas within their testimony weren't fully fleshed out within the proposed rule. There are a Jean-Bertrand a number of reasons for that -- the aggressive timeline not the least. The thought was if we can put up a reasonable proposal, we definitely can per nect rule with comments. The comment period lasts from now, ends can March 15. The gift of this tiewp the to speak to you really has the price that this is a brief presentation, doesn't provide a opportunity to provide more than a cursory acknowledgment of a lot of the other programs launched for information exchange, workforce development and beacon communities.

Beacon communities are quite interesting, hold the greatest promise because in those communities we are looking to see the full flower of what this technology can achieve. We are providing grants to about 15 communities, the grants can range from 10 to 20 million-dollars and the thought is that these grants will go to communities a little further along, advanced in terms of health IT, particularly that they probably have higher adoption numbers already, much higher than the 4% national average we have, and the thought is that they will provide a way for them to fill in the gaps and really, really demonstrate the full potential of what health information technology can do in one complete community.

We all recognize the essence of that is to see real exchange. Finally, I would be remiss if I don't highlight one other area, not involved in the high tech act at all, but I think this is, along with the beacon community program, probably one of the most exciting areas of all. That is comparative effectiveness research. This investment will obviously benefit all Americans, but it is clear that some of the greatest value will be in commune uponnities and groups not traditional used in research protocols.

I will wind up answering questions you have, just by restating my central thesis, namely, our current circumstance is not solely due to a lack of technology, and therefore it can't be solvedded by technology alone. It is no small matter that two of the stat criteria for meaningful use involve information moving, information exchange. The whole point is to provide a means to facilitate communication, and the transfer of information, and possibly even the transfer of knowledge. In the right hands at the right time, information can be transformative. The full, complete rapid and regular exchange of medical information will represent a singular change in our culture and I can think of no better way to increase the value of our services than to make their provision fully informed.

The alternative is equally remarkable. To continue, each of us in our own silo, putting one new innovation on top of another with no real consideration of how one piece of information informs, supports or confounds another means we will keep our haphazard care of patients. Means we will recreate the experience of babel. I hope you understand data are not the whole answer. The question is not how much technology do we need. The question is how do we improve the quality of care for all Americans, and in turn effect that elusive, yet supposedly self-evident truth that among our unalienable rights are life, liberty and the pursuit of happiness.

While I am frequently prone to exaggeration, in this case I am not being hyperbolic. Preventible cancers separated far too many of our people their right to life, and life and liberty is not apparent to those who rise every morning with a disability, Alzheimer's or HIV. A computer won't make that right, but information technology can assure that a pediatrician sees a list over morning of the patients coming that day that aren't up to date on immunizations, as well as the names of their brothers and sisters who will probably pow in to with mom. Can ask and answer the questions, what treatments work best for a 48-year-old Latino with cancer, or an African-American with prostate cancer, what are the portfolio of services to effective implement that treatment. A computer won't rid the world of AIDS, but will afford well-meaning people the liberty of having their care coordinated in it such a way that every one of their doctors knows the results of all of their tests.

Nine years ago the Institute of Medicine got it right. Quality care is efficient, effective, safe, patient-centered, equitable and timely. But just saying that won't make it real, and it only begins to describe NASUA we need to do to reform healthcare. With information systems we can see the true choices and the balance that must be preserved. That balance is highlighted in my reality as a 21st Century American surgeon. That reality stands in indeed juxtaposition that no country, no national enterprise has fully and successfully implemented what we are attempting to deliver. Now, I used to end my implementation presentations with a quote from Voltaire that basically said doubt is unseveral, but certainty is ridiculous. While that is very true, and while we stand on the cusp of this new year I appreciate Mr. Twain's observation more. We in the office of the national coordinator are willfully, purposefully grabbing this cat by the daily. And in doing so we are about to understand things that can be learned in no other way. Essentially, every where I go, I want to point out we are here to ask -- for that result.

Appreciate it. Marc?

Thank you very much for that presentation. I would have two comments. One is that our committee certainly was active in providing comments on the first go around of meaningful use, and I anticipate that we probably should involved in the second. I would propose that.

Please. Please.

The second thing that struck me as you were going through the presentation and the things you referenced, so much of what you are doing intersects with things we talked about here. I am interested in the possibility, and I have been told by Sarah this is not out of bounds, would it be -- it would seem reasonable to have a liaison from your office that would be an ad hoc attendee of this committee.

I think that will be fantastic and I can't step over my bounds, have to clear through leadership, but I believe we will be very receptive to that.

I propose invitation be made officially.

We can do that. We will figure out what the channels are.

If you send a note with me I can forward to Dr. Blumenthal, he will take it under consideration and I am almost sure it will be favorably -- we are low maintenance, bring our own water.

I am sure we have our own bureaucracy too, we will figure out what it is and move it forward. That would be very constructive.

I do want to respond, though, to the -- some logistical challenge similar to what we discussed with Rod. This is out for a 60-day period

Comment period ends on May 13.

That's before our next meeting --

March 15, sorry.

It's before our next meeting, but we would like to get comments there. Mark, you drafted the -- right? The comments sent in before.

Yes, I can do that.

Can you send those, scan to be specific to that. I don't know if othersment to specifically work -- but we can share with the committee here --

Sarah is suggesting we take what we did, expand with what we have already done, more complete, responsive to needs, and move it forward. We aren't going to reconvene. We can share with all of you. Obviously everybody can respond individually, and obviously we have an open invitation to do that.

Please, please.

That we can do on behalf of the committee.

Dr. Hunt: Two things. First, the NIH -- there is competition in HHS, and the NIH have been Crowing around for I don't know how long that they got 50,000 comments for their stem cell research rule. We are aiming to top that, okay. Individually and collectively we really want you to provide comment and I am not stepping out of bounds. This is not an interpretation ever the rule, but in the proposal we have three basic periods of development in the meaningful use. 2011 is first, individual practices will be able to qualify for meaningful use incentive payments. And as many of you know, 2011, in terms of the federal government is like next Wednesday. Our thoughts are to have just, to start this off. The next period begins in 2013, and we are actively thinking on how to really ramp up. In the statute it was very clear there's the expectation meaningful use will progress in terms of requirements. In 2013 there are tremendous more process things for meaningful use incentives. 2015, that's the peak, literally and figuratively, where we are seeing the full flower again of what we can achieve in terms of meaningful use. That's the peak because after that period you can incur, the statute incurs penalties for Medicare providers that don't meaningfully use electronic health records. I hope that will help frame some of your comments.

That's triferric. These are of keen interest to us. A flood of information in genomics, information needs to get out and get used well.

We realize it's not going to happen without an organized system of care that can get the information out in a imaginable and intelligible way.

Dr. Hunt: Clearly very few groups would have a sensibility about the privacy issues around the exchange of information, and so I am sure that thoughts around -- because you have grappled with this external to any discussion of health information exchange for are a while and have a tremendous amount of -- I know well considered thought on the issues of privacy, and that will be very, very welcome.


It remains a topic of keen interest. Thank you very much for joining and particularly for your eloquent comments. They were delightful.