HIT, Meaningful Use and Population Health

The U.S. health system’s lack of progress in adopting health information technology (HIT) and electronic health records (EHRs) can lead to unnecessary and duplicative services. It can also lead to poor care coordination, burdensome administration and missed opportunities to improve doctor-patient communication. Barriers to speedier HIT adoption range from the high cost of investing in EHRs to the huge task of developing and enforcing interoperability standards, not to mention concerns about information security. But the adoption of EHRs is key to health reform efforts around improving care and lowering costs and, ultimately, improving population health and achieving health equity.
The 2009 stimulus bill gave a major boost to HIT by allocating $29 billion in Medicare and Medicaid incentive payments for EHR adoption in the Health Information Technology for Economic and Clinical Health (HITECH) Act.  It also set up a network of state-level policy and technical assistance supports including health information exchanges andRegional Extension Centers. To qualify for incentive payments, hospitals and physician practices have to satisfy a series of tests known as “Meaningful Use” criteria.  Stage 1 of Meaningful Use was introduced in 2010 and established basic EHR standards covering data capture and patient access. Stage 1 appears to have been reasonably successful, with hospitals now embracing EHRs. Meaningful Use Stage 2 begins in 2016 and strengthens technical standards for information exchange and care coordination. Stage 3 of Meaningful Use will bring public health into the picture as population health and health equity are added to the reporting requirements. In Stage 3 the focus moves frominputs to improving quality and health outcomes.
Meaningful Use Stage 3 will impact the work of all public health departments. The National Association of County and City Health Officials highlighted several issues that health departments need to consider.  These include public health surveillance, community analytics, expansion of quality measures for public health, and bi-directional communication between clinical providers and public health departments. The Institute of Medicine (IOM) has acknowledged that quality measures for population health are critically dependent on data availability at the state and local level.  Another IOMdiscussion paper sees the State Innovation Model initiative as an opportunity to move away from a payment system that mainly responds to individual sickness towards one that aims for health for all—what we like to call ‘population health’.
There are several barriers to achieving the goals of Stage 3.  First there are technical issues, like data standardization so public health registries can accommodate new data reporting flows. Then there are data security and privacy issues, which include appropriate management of sensitive social and behavioral data in health equity analyses, and constitutional restrictions on what private health data may be collected.  The National Coordinator for HIT recently acknowledged a tension between population health management and personalized, individual health care. Aware of these concerns, the IOM set up a committee to address the question of what social and behavioral data should be included in EHRs.
Stage 3 won’t be implemented until 2016 at the earliest, which gives the public health community a chance to think about the data collection and exchange standards that Stage 3 should put in place. The Centers for Medicare and Medicaid Services wants to identify core EHR standards for behavioral and social determinants of health data; for example, to help pinpoint links between these factors and the onset and progression of disease. The National Coordinator is already starting to consider what to include in the final Stage 3 criteria and is facing some difficult choices, such as whether electronic lab reports can be included.
What do you think needs to be included in the stage 3 criteria? What kind of opportunities for public health and health care collaboration to improve outcomes might be fostered by Stage 3 data? Let us know in a comment below.