Friday, February 27, 2015

What is the Optimal Future Role for ONC?

As Meaningful Use winds down and incentive dollars are fully spent, what is the optimal role for ONC going forward?

Some pundits have suggested that ONC step aside and return all aspects of HIT policy and technology to the private sector.   Others have suggested top down command and control of HIT including centralized governance to ensure interoperability.

Harmony is when all parties feel equally good about the path forward.  Compromise is when everyone leaves the table equally unhappy.   Here’s my view about the future of ONC that includes points from both sides.

The Argonaut initiative is a good exemplar of the private sector working to enhance interoperability in response to the market demands of accountable care organizations, which depend on data to succeed in a risk contracting world.    There is clearly a role for the private sector to lead innovation and standards adoption, and this role will continue to grow as demand for richer interoperability increases and technology matures.   However, even the best innovations require a regulatory and ecosystem context to enable the marketplace to blossom.   The health care sector is the most fragmented industry in our complicated economy, both on the demand side (patients, insurers, employers) and on the supply side (physician practices and hospitals).  ONC can be a focal point for the discussion of regulatory barriers to data liquidity, novel workflows, and alignment of incentives.

In Massachusetts, opioid abuse is a critical public health problem.   We believe that collecting all opioid prescriptions at a state government level and sharing that data with licensed caregivers is appropriate.   Yet, right across the border in New Hampshire, it’s illegal to share such data with government entities.  Similar prohibitions exist on sharing immunization data to prevent measles outbreaks or syndromic survellience data to detect Ebola.   Extrapolate this problem out to the various combinations of 56 states and territories and it's an interoperability nightmare for patients, providers, and vendors.  ONC can provide national frameworks that enable regional variation but can suggest guardrails so that a federated national network of interoperability and functionality is not impeded.

Canada has 35 million people.   Sweden has 10 million.   Healthcare IT policymaking that takes into account stakeholder opinions in these countries is easier than resolving the difference of 320 million US residents.   Someone needs to be a convener to give voice to the myriad stakeholder priorities of a country that glorifies individual freedom.   ONC can be such a convener.

The US government is a large player in the health care market, even aside from any oversight role it might play.  Medicare and Medicaid are the largest health insurers in the country.  The US government has over 20 million employees whose health benefits it covers.  The DoD, VA, and Indian Health Services are large providers of care.  The number of federal agencies and the many and varied ways that they affect health care delivery and health information technology is hard to quantify.   There is no single front door in the federal government for HIT related strategic planning across agencies.    ONC can serve as government agency harmonizer.

Although Accountable Care Organizations now have economic incentives to accelerate interoperability, they do not have specific incentives to focus on healthcare IT usability and the safety of IT tools.   We are now at a point where everything that happens in a hospital is somehow tied to information technology.  ONC can provide funding to study issues that lack a specific private sector market force, just as NHTSA and NTSB do with auto and airline safety.

Finally, although there are many federal and state laws that protect privacy and security, it is challenging to know how to measure the security of an EHR.   By working with other federal agencies to identify best practices, ONC can foster data integrity and promote respect for patient privacy preferences.

Thus, although the private sector can lead innovation and accelerate standards development, the combination of government, industry and academia is needed to optimize our journey.     I recently spoke with a cabinet secretary in the Massachusetts government and the person told me “the Baker Administration does not believe in less regulation or more regulation, it believes in right regulation.”    The same can be said of the balance between ONC and the private sector.   The list of tasks above seems like the “right regulation” to me.


Anonymous said...

One opportunity might be to leverage (or move over) ONC staff to assist OCR with data security enforcement. With all of the systems ONC has helped propagate, assisting in "securing the HIT HIE borders" might make sense.

Anonymous said...

Hi John,

Love your posts. Great points here. What about the potential negatives of having the ONC move in a different direction outside it's initial scope? Any concerns about mission creep?