ONC focus on new targets exemplifies evolution of its purpose 

With the industry now widely using electronic health records, ONC shifts attention to information blocking, interoperability and supporting other federal agencies.

ONC National Coordinator, Micky Tripathi

This article is part of the January 2023 COVERstory.

Nearly 20 years ago, the Office for the National Coordinator for Health Information Technology came into existence, and today, the healthcare world is in a far different digital place than it was when President George W. Bush called for its creation. 

In 2004, many hospitals were still in the early stages of implementing technology; only a small percentage of pioneers were using systems for clinical information, and rare was the physician office that used electronic clinical records. CIOs – if health organizations had one – were techie experts who were more likely to be grounded in running Cat 5 cable than understanding the interface of IT and medical care. 

ONC’s impetus received a jump start in 2009 when billions of dollars in incentives, through the Health Information Technology for Economic and Clinical Health Act (HITECH), as part of the American Recovery and Reinvestment Act. Spurred by the incentives, digitization is widespread in healthcare – more than 95 percent of acute-care hospitals and nearly 80 percent of office-based physicians are using an ONC-certified EHR system. 

Now, the agency is getting an expanded remit to achieve benefits from the digitization of health records and to interoperate with other federal agencies to derive information to support important initiatives that depend on access to health information. 

ONC is still addressing gaps in industry capabilities, such as ensuring the free flow of health information to all entities, improving health information exchange and achieving basic health equity goals. But with most of the industry using digital clinical systems, agency leaders believe that its vision is clearer and well-communicated, enabling the industry to better know what to expect and how to shape IT strategies. 

Trying to bring order to a fragmented industry 

It made sense for the federal government to intervene and begin calling on the industry to implement EHRs, says Micky Tripathi, national coordinator for health IT. As a purchaser of healthcare, it wields enormous leverage, because its payments through federal Medicare and Medicaid programs represent nearly half of what the U.S. annually spends on healthcare. 

Additionally, federal agencies have interests in and financially support public health, research and safety activities, and national initiatives because of the highly regulated and fragmented nature of healthcare, Tripathi adds “Fragmentation on the supply side makes it hard to drive change,” he explains. 

The more than $30 billion in federal incentive payments under HITECH helped tip the scales toward EHR implementation, overcoming provider concerns that digitization “didn’t accrue benefits to them,” he adds. “That led to the rapid transformation and kind of the landscape of EHR adoption in a relatively short period of time.” 

The federal incentive program used a three-phase sequence program that emphasized the meaningful use (MU) of EHRs for specific, quantifiable goals, such as for clinical decision support, provider order entry and patient access to information, among others. Providers also were required to use certified EHRs, assessed for functionality by contracted certifying organizations. Before MU requirements were established, they were vetted as proposals for industry review, often resulting in back-and-forth adjustments to requirements – at times, final requirements were published without sufficient lead time for technology vendors to make changes and for providers to install and test updated applications, and then train users on functionality. 

The quick turnaround of MU sequences, coupled with the industry’s rapid pace of EHR implementation, often left the industry feeling surprised by requirements that stretched it technologically and in its ability to manage the underlying change, Tripathi admits. 

“There was a rapid transformation in the landscape of EHR adoption in a relatively short period of time – it was very fast,” he says. “If you think about how complex it is, what we were doing and what we were trying to accomplish in arguably the most complicated part of the economy – we were using large investments from the federal government to get the industry to break through the log jam.” 

Delivering the coming attractions 

HITECH helped put in place a solid technology infrastructure, bolstered by the EHR certification program, and now ONC is looking to build deliverables on that infrastructure, says Steven Posnack, deputy national coordinator for ONC, who has worked in the agency since 2005. 

“I have described this as ‘the coming attractions,’ that we’re always talking about - the coming attractions for this next great blockbuster movie that isn’t going to come out for three years, but just stick with us, because it’s gonna be awesome,” Posnack says. But he contends that the base foundation of IT now makes this future focus achievable for ONC. 

These higher-level capabilities now being espoused by ONC include optimizing interoperability, improving user experience, empowering patients, using artificial intelligence and machine learning, finding more opportunities for automation and improving care coordination. 

“When Micky came in as part of the Biden administration, one of the things that we’ve really doubled down on is our focus on health equity,” Posnack adds. Other priorities of the current administration include promoting competition, and federal customer experience and service delivery. 

Part of ONC’s expanded role stems from a directive issued this summer from Xavier Becerra, secretary of the Department of Health and Human Services, to work more closely to achieve shared goals for interoperability and the adoption of standards-based technology. 

A blog written by Tripathi and Posnack earlier this year notes that HHS wants to leverage data and capabilities available through EHRs for a wide range of federal activities and programs. These capabilities are becoming more possible now that EHRs are required to include elements of the United States Core Data for Interoperability, including components detailing social determinants of health. 

That data can support the Centers for Disease Control and Prevention as it aims to shore up public health reporting; the Food and Drug Administration as it increasingly seeks to rely on real-world evidence to support best practices in care delivery; and the National Institutes of Health as it aims to facilitate medical research. 

“You’ve got these other federal partners who are now starting to say, ‘Oh, the coming attractions are here,’ “ Tripathi says. “We want to get information out of these EHRs for this program and this program. The secretary recognized that we need to get out ahead of this and have us coordinate our activities better across the department so that we’re making efficient use of tax dollars and getting more effectiveness out of those programs.” 

Helping the industry anticipate 

ONC is aiming to improve communication with the industry, as well, and Tripathi and Posnack say they believe that more frequent dialogues with key industry organizations and associations will reduce the chances for surprises and augment its ability to listen to industry concerns about IT. 

ONC’s current goals are clearer, they say, as it aims to improve enforcement of information blocking provisions of the 21st Century Cures Act and pursue implementation of the Trusted Exchange Framework and Common Agreement (TEFCA). Both will take time to flesh out and will be a prime focus of the agency for months to come, and healthcare organizations can build these into their strategic visions. 

“We’re in this early stage with information blocking regulations, and we know there are going to be adjustments over time,” Tripathi notes. “The healthcare ecosystem is a complicated environment, and the amount of the healthcare economy that’s covered by the information blocking regulations is much different than what we were previously charged to oversee from a regulatory perspective. 

“Hopefully, our colleagues in the regulated space feel that we do a pretty good job in keeping pace and being responsive to their questions. We know we can work infinitely on education, but we have to pick and choose what we think is going to be the most impactful for all of the stakeholders at scale.” 

The expanded interrelationships with other HHS agencies also reveal much about ONC’s expanding influence and role, Tripathi and Posnack say. 

“We want our federal partners to think of us as a service agency to their missions,” Tripathi says. “We’re here to say let’s figure out how we can jointly solve your problem. How can we best use the things that we have in our arsenal, from an agency perspective, with respect to standards, with respect to interoperability, with information blocking rules, with all the authority that we have? I think we’re getting a lot of great collaboration with our federal agency partners … because they’re seeing us, more and more, as problem solvers to help them better accomplish their missions.” 

As Posnack describes it, ONC succeeds best when it works itself out of its original remit – when the underlying IT becomes so transparent and empowering that it just does what it’s supposed to do in the background, enabling clinicians and healthcare administrators to focus on using the data and underlying insights to effectively and efficiently improve patient care. 

“When we think about health equity, when we think about interoperability, when we think about AI and algorithms, we’re not having to explicitly think about why technology is a barrier or something that has compounded problems that exist in our healthcare system,” Tripathi concludes. “Instead, those organizations are able to count on there being an open architecture health IT ecosystem that are electronic health records, as well as interoperability mechanisms, to be able to accomplish what they want to be able to accomplish, without having to think about it.”

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