The Office of the National Coordinator for Health IT received 96 comments on the draft 2020-2025 Federal Health IT Strategic Plan during the public comment period. While most organizations found a lot to praise about ONC’s approach, commenters stressed the need for better patient matching and consent for data sharing, EHR onboarding for critical providers left out of Meaningful Use, and improved provider-to-provider data exchange.
The draft strategy focuses on four goals:
• Promote Health and Wellness;
• Enhance the Delivery and Experience of Care;
• Build a Secure, Data-Driven Ecosystem to Accelerate Research and Innovation; and
• Connect Healthcare and Health Data through an Interoperable Health IT Infrastructure.
ONC received comments from a wide range of stakeholders, including health professional societies, providers of health services, public health entities, health information technology developers, hospitals, health care payers, health care quality organizations, state entities, health care suppliers of services, health care accreditation organizations, and patient advocates.
In its comments, the University of California, San Francisco’s Center for Digital Health Innovation recommended that the 2020-2025 Strategic Plan should include an interoperability measurement framework, developed and vetted by ONC and the National Quality Forum in 2017, to measure the quality, gaps, and impact of interoperability across key settings and users of health care. “We cannot improve what we do not measure,” it said.
‘Write Access’ to EHRs
In addition, UCSF said, the 2020-2025 Strategic Plan should include an explicit program and timeline for bi-directional exchange and “write” access to people’s electronic health records. “Stakeholders such as developers, doctors and hospitals, patients, researchers, and policymakers need to begin preparing now so bi-directional exchange and access can become a reality well before 2025. Bi-directional exchange and “write” access are essential for better patient outcomes, to begin integrating patient-generated health data, patients’ social services, and social and environmental determinants of health.”
Perhaps not surprisingly, the comments from Epic Systems urged caution on that front, noting that the potential for third-party applications to “write” data into EHRs through APIs also presents risks to patients and healthcare organizations. “We strongly encourage ONC to engage in in-depth discussions with health care organizations and EHR vendors before establishing policies regarding ‘write’ access to EHRs. There are serious patient safety, data integrity, and consistency issues that must be addressed before applications reach into and seek to modify systems of record.”
NAACOS, an association of accountable care organizations, praised work ONC has done on its interoperability rules, but added that those policies won’t fully solve our nation’s interoperability challenges. “While important, much of ONC’s focus in recent years has shifted to enabling payor-to-payor exchange or provider-to-payor exchange, which diverts needed attention from getting the necessary patient data into doctors’ hands. ONC should use its convening power and bully pulpit to further advance the need for improved provider-to-provider data exchange.”
NAACOS also stressed that interoperability and data liquidity are more than just getting data into the hands of patients. “Patients should not be the conduit for interoperability. Instead, interoperability should enable patients to access their records for their needs and uses, and it should allow providers to share records with each other to provide high-quality, well-coordinated care. We can’t expect patients’ access to their own records to fully solve our interoperability problems.”
The Minnesota Department of Health suggested that ONC add health equity as a federal health principle. “In addition, health equity and health disparities should be defined and factors that influence health acknowledged as including, but not limited to, race, ethnicity, location, sexual orientation, gender identity and others as identified in the social, psychological and behavioral data of the ONC 2020 Interoperability Standards Advisory.”
Like many commenters, the Minnesota DOH also recommended that ONC advance patient matching to ensure safe and high-quality care. “Patient matching is currently an area that could be significantly improved upon and as interoperability expands this need will only grow. As disparate systems, that may know people slightly differently, we will need to get significantly better at identifying and agree upon who we are talking about as accurately, confidently, timely, and as automated as possible.”
SHIEC, the Strategic Health Information Exchange Collaborative, also mentioned patient matching, requesting that ONC support research to identify effective matching methodologies and implement national standards. “With significant experience applying patient-matching methods in HIEs across the country, SHIEC welcomes the opportunity to provide real world data and expertise to further the goal of unifying the ways in which stakeholders match patients.”
Providence St. Joseph Health wrote to support continued efforts to establish a Universal Patient Identifier. “Without a UPI it makes it very difficult to ever achieve true interoperability,” it wrote.
The New York eHealth Collaborative (NYeC) argues for a nationwide consensus on consent. “While the draft plan places a strong emphasis on patient empowerment and streamlining processes to reduce barriers to sharing health information, it does not adequately address strategies for streamlining patient consent in a manner that ensures the right health information is flowing when and where it is needed. NYeC believes current proposals have failed to sufficiently address the topic and much more work needs to be done to ensure alignment.”
SHIEC also stressed that the Trusted Exchange Framework and Common Agreement (TEFCA) should “build upon, rather than scrap and replace the existing HIE infrastructure and should capitalize on the successes of the many high-functioning HIEs across the country.
SHIEC noted that HIEs received less than 5 percent of federal dollars spent on health information technology over the past 10 years, yet today SHIEC members serve nearly 92 percent of the U.S. population and push real-time data for improved clinical decision making. “HIEs have played a critical role when patients have been displaced by natural disasters, such as hurricanes and wildfires, and they are playing a critical role today in the COVID-19 crisis. One of the immediate lessons learned in the COVID-19 response is the need to collect, standardize and distribute data swiftly. As we learn from this pandemic and develop a national emergency infrastructure, we should build on and support the proven work of America’s HIEs.”
Full EHR Onboarding for Critical Providers
Portland, Ore.-based nonprofit health IT company OCHIN said ONC should work to extend EHRs to all providers who play a critical part in the system. “During this pandemic, we have seen that skilled nursing facilities, state laboratories, public health agencies, and community health centers still need support to acquire 2015 EHR platforms and interoperability to transmit data not only to allow patients to always access safe and informed care, but to help improve the national data on the impacts of COVID-19.”
OCHIN also noted that state and many hospital labs don’t support bi-directional orders or results, and are operating using fax or paper. “Without laboratories connected to EHR systems, providers are operating with missing information, making outbreaks such as COVID-19 more difficult to track. Similarly, nursing homes having been a hot spot for outbreaks all over the country. With this level of interoperability, we may have prompted other similar homes to lock down knowing they were at a higher risk, and better protected the nation’s most vulnerable citizens. For these reasons, we must resolve these gaps within our health care system.”
The Medical Group Management Association urged ONC to avoid pushing physician practices too far, too fast. “The risks of moving too quickly include additional administrative and financial burdens on practices, weaker privacy and security protections for sensitive health information, an increased level of physician burnout, and the potential of compromised patient care,” the MGMA wrote. “ONC has set out an extremely aggressive framework and goals to achieve over the next five years. We support many of the Administration’s health IT goals, particularly putting patients at the center of the care delivery process by arming them with the health information they need. However, we believe the Strategic Plan should be modified to ensure that physician practices and other care providers gain quicker access to more accurate and pertinent health information that directly improves the patient care delivery process. This transformation could lead directly to enhanced efficiency and improved clinical performance.”