Despite challenges ahead, ONC and industry more aligned than ever 

With the industry largely using electronic health records, the agency can now play a role in extracting benefits from digitization.

ONC is focusing on efforts to get advanctages from the digitization of the health industry

This article is part of the January 2023 COVERstory.

Industry groups and watchers have wide respect for the accomplishments over the past two decades of the Office of the National Coordinator for Health Information Technology. 

Despite concerns about achieving interoperability across the industry and sometimes overly optimistic expectations about the industry’s ability to manage change, there’s widespread appreciation for the amount of change accomplished by the federal office. 

“Unquestionably, ONC has changed the landscape of health IT adoption and what health IT looks like today,” says Leigh Burchell, vice president of government affairs and public policy for Altera Digital Health and a longtime executive committee member for the Electronic Health Record Association. 

The agency “has had a singular vision from the outset. They’ve gone through multiple administrations that had different perspectives on healthcare – ONC has stayed pretty consistent, driven by bipartisan legislation,” adds Rob Tennant, vice president of federal affairs for WEDI. “Americans can fight about a lot of things, but when it comes to improving patient experience and improving the flow of data, there’s been agreement across the board,” and ONC is leading that charge. 

Things done well 

ONC has a long track record of engaging stakeholders, Burchell notes. “They are really accessible; they really want to hear from the industry, from providers, patient advocates and other entities. I appreciate that – that isn’t always the case with policy makers. They have an open-door policy that’s been very consistent. They have been willing to change course in some instances and consider different approaches.” 

ONC sees the importance of communication and transparency, says Micky Tripathi, national coordinator for health IT at ONC. It’s setting out timelines that give the industry more time to make changes, because “we definitely appreciate the problem of people being able to have enough information with as much advance notice as possible … because these things don’t change overnight since the technology in these EHR systems are increasingly sophisticated.” 

ONC also maintains close relationships with stakeholder groups in the industry, such as the American Medical Association and other professional clinical associations, as well as with industry trade and standards organizations. That’s important, Tripathi says, because individual clinicians and organizations rely on their associations to provide contextual information about IT that impacts them. 

ONC “can convene and be a participant” in industry initiatives, contends John Glaser, former CIO and now executive in residence at the Harvard Medical School. “They have a great convening power – they do have the ability to summon players and get people to participate.” 

That involvement isn’t lost on HL7 CEO Chuck Jaffe. ONC and other federal agencies are active participants in initiatives to sculpt potential use cases for the Fast Healthcare Interoperability Resources (FHIR) standard, which is expected to support a variety of information exchanges in healthcare. Work with ONC “has been evolutionary, but for me, the major change was when they made a commitment to support open APIs and FHIR. Don Rucker (the ONC coordinator prior to Tripathi) was the first to say that this was the way interoperability needs to be understood, and he did everything he could to make it happen.” 

“I like what they’re doing in forcing the issue on FHIR,” Glaser adds. “They can help people implement it and set the standards.” 

ONC also has become effective at looking to supply the data needed to support industry initiatives that are important, both to the current administration and to advancing the health of the country, such as health equity, Tennant contends. “Micky’s had significant experience prior to coming to ONC with patient matching and now with USCDI (the United States Core Data for Interoperability), we can look at how to collect the data we need as an industry to address health equity and social equity needs.” 

Challenges ahead 

But the industry still lags in achieving interoperability at the scale that many expected, industry watchers note. Enabling massive change in the industry meant prioritizing adoption first, and retrofitting interoperability has taken longer than expected. 

ONC “didn’t have as many tools in their toolchest” in promoting industrywide interoperability, “and it remains a problem today,” says John Moore, CEO and founder of Chilmark Research, a health IT consultancy. “State (health information exchanges) are all over the map in terms of what services they provide.” 

Other issues weren’t addressed in the rush to modernize the industry with EHRs, Glaser notes. In addition to interoperability, he mentions usability concerns and the lack of gains in care improvement. The hope was to “put in the tool and get some value,” but data-driven insights have been slow to materialize. 

ONC is only beginning to tackle systemic shortcomings highlighted by the COVID-19 pandemic, such as the lack of data exchange capabilities and technical shortcomings in the public health system, Moore adds. He’s also concerned about the early selection of FHIR as an interoperability mechanism, saying “it’s still pretty immature, and there are a number of provider organizations that really haven’t turned it on.” 

ONC holds the potential to move the industry, because it can manipulate some incentives to cause change, Moore believes. Glaser sees the potential for ONC to provide momentum around evolving technologies, such as digital therapeutics, artificial intelligence and other emerging capabilities. Part of that may be hampered because, unlike during the incentive-powered Meaningful Use era, “they don’t have the money that they used to,” he adds. 

ONC will have a full plate in advancing current initiatives, concludes Tennant. “TEFCA will be a big test for ONC and the industry. If it achieves the promise, the industry will be able to move closer to value-based care, which is predicated on data exchange and getting up-to-date healthcare information on patients." 

“For now, ONC will be laser-focused on health equity and looking to expand its footprint in that area,” he adds. “ONC is limited in terms of staffing and budget, in comparison to CMS. But the nice thing about Micky is that he’s been down in the trenches. And he’s known as a wonderful collaborator.” 

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