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ONC Chief Defends Interoperability Rule

WASHINGTON — Proposed regulations aimed at barring information blocking and increasing interoperability of electronic health records (EHRs) are quite reasonable, Donald Rucker, MD, head of the Office of the National Coordinator (ONC) for Health Information Technology, said here Monday.

“We spent the better part of 2 years making the provisions precise and in the public good and enforceable,” Rucker told MedPage Today during a session of the AcademyHealth Annual Research Meeting. “There has been a ton of work on the regulatory precision of all of the instruments, most notably things on allowable costs … There is a vast amount of prior legal work over the decades that goes into these things.” However, he added, “different people have different interests here; some people may have not wanted to do this. We defer to the will of Congress, who said, ‘This is what you should do.'”

Don Rucker, MD, National Coordinator for Health Information Technology (Photo by Joyce Frieden)

The proposed rule, whose comment period ends Monday, has come under criticism from the health information technology (IT) industry for being too vague and unworkable. “We think at a core level, the rules do not work,” Joel White, head of the Healthcare Innovation Alliance — a group representing patients, providers, employers, insurers, and health IT startups — said during a conference call Thursday morning; he said that the rule had some exceptions “you can drive a Mack truck through … They should be rescinded and ONC … ought to go back to the drawing board.”

But Rucker disagreed, as did David Blumenthal, MD, who served as ONC administrator under President Barack Obama. “All of the previous national coordinators have gotten together and submitted a letter as a comment on these regulations; it is extremely supportive,” said Blumenthal, who is now president of the Commonwealth Fund, a left-leaning charitable foundation in New York City. “There are a few suggestions for modifications, but I’d say on the whole [we would rate it] an ‘A minus’ … I think that in the realm of the possible, this was a very important set of steps forward.”


David Blumenthal, MD, president of the Commonwealth Fund (Photo by Joyce Frieden)

Rucker also spoke about other ways provider burden can be reduced. “The first is [a reduction in] Level 4 and Level 5 [Medicare visit] documentation requirements,” he said, noting that the requirements were initially added “as a speed break on code creep back in 1995.” However, the requirements “made most of the EHR into just a sea of boilerplate, and [made it] very difficult to find information. There is clearly work to be done to get documentation to be of help to clinicians as opposed to this boilerplate.”

A second big area is prior authorization — the business of getting insurer approval in advance for particular procedures or treatments, he continued. “Something we’re interested in exploring is how to combine modern computing and modern data. … Right now, our financial data and clinical data are absolutely disconnected, and quality data is also disconnected from financial data and clinical data. So how can we get those three data streams integrated? Prior authorization may be the battlefield to do that.”

In addition, “we have to rethink quality measures,” Rucker continued. “Having narrow point values for measuring quality from a fiduciary point of view made a lot of sense [before], but we have a lot of machine learning in all kinds of [areas], and we now have electronic data and we can rethink the business of quality and instead of clinicians [sending] hand-curated quality measures out to payers, think about machine learning attached to standards-based API [application programming interfaces] and getting large amounts of data and having a vastly more accurate picture of quality of care and improvements.”

Christine Stock, MD, professor of anesthesiology at the Feinberg School of Medicine, Northwestern University, in Chicago, discussed the ways that EHRs are contributing to physician burnout. She gave an example from her own institution of the complicated moves required to do simple things on the computer. “If I want to order an [anti-nausea drug] for a patient in the recovery room who is nauseated, I have to go through seven screens and 12 clicks,” she said. And that doesn’t even count physicians who are on their work computers during their off-hours. “The rate of burnout is probably tied somewhat to use of EHRs not during working hours,” she added.

Part of the problem comes from the costs involved in making the switch to EHRs, she said. For example, even switching to a new EHR system within Stock’s hospital — a case in which the hospital owned the software and the hardware already — “was still a $300 million undertaking,” she said. As a result of having these large costs to make up, “hospitals are pushing physicians to be more productive when they’re groaning under the weight of an administrative burden already … We have Meaningful Use, licensure, billing rules, documentation rules, and ICD-10 [codes]. All of these things are crushing the physicians of the United States.”

Stock said her own EHR “wish list” would include steps to promote EHR usability and reduce its administrative burden. “And could we get voice-activated typing so we wouldn’t have to have all those clicks and keyboard strokes?”


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