ONC – from a small office to key support agency 

The technology office gained significance in 2009, when it helped establish the EHR incentive program. Billions of dollars later, heavy lifting still remains.

ONC's history is tied into executive orders and providing regulatory guidance and leading EHR initiatives.

This article is part of the January 2023 COVERstory.

The Office of the National Coordinator for Health Information Technology had its beginning in 2004, as a result of an executive order from President George W. Bush. The President electrified health information technology proponents when he set a goal for every American to have an electronic health record by 2014. 

But in its early years, the office – a staff division within the Department of Health and Human Services – was limited in scope, lacking budget and regulatory authority to encourage healthcare organizations to implement electronic medical records systems. Instead, health organizations were expending more dollars to improve financial and administrative functions, with only a few pioneers using the bleeding-edge technology to address clinical concerns. 

Among office-based physicians, only about 20 percent were reported to be using any form of electronic health records in 2004. Challenges were even higher at complex health organizations, of which fewer than 2 percent were reported to have comprehensive electronic records systems present in all clinical units, with an additional 7.6 percent having basic systems in at least one clinical unit. 

Lighting the fuse 

However, in response to a deep national recession, the American Recovery and Reinvestment Act was passed in 2009, and part of that included the Health Information Technology for Economic and Clinical Health (HITECH) Act, which established the creation of a short-term funding program for eligible physicians and hospitals. The program used incentive payments for providers that adopted records systems from technology products were deemed certified to meet minimum technical capabilities. The program gave ONC policy levers to incentivize change. 

This was seen as an opportunity for the federal government to make investments “in the economy to get us out of the recession,” says Micky Tripathi, national coordinator for health information technology at ONC. “Electronic health records were that opportunity for being ‘shovel ready.’ ” 

Over the next several years, ONC oversaw a program that poured more than $30 billion in incentives to ambulatory care offices, hospitals and healthcare systems. The incentives worked, and now more than 95 percent of the nation’s hospitals have comprehensive records systems in place, as do about 80 percent of all physician offices. 

The incentive program had three two-year segments, with healthcare organizations required to achieve certain metrics to demonstrate that they were meaningfully using the systems – for example, to show patients could access their records via portals, that clinicians could use them to enter orders via computer and more. Healthcare organizations often pushed back on proposed requirements, citing technology, training or change management challenges in achieving the targets. 

The Meaningful Use program was rebranded as Promoting Interoperability in 2018, increasing the focus on interoperability and improving patient access to health information. The ability to exchange and access this information had been challenging for providers, because of a lack of both technical and terminology standards, competitive pressures across the industry and other issues. 

Policy levers 

ONC continues to work on facilitating the exchange of information. Together with the Department of Health and Human Services, it bears responsibility for a section of the 21st Century Cures Act that looks to prohibit information blocking – any practice that impedes the flow of patients’ clinical information. 

ONC also plays a role in gaining consensus on standards. It’s an active participant in efforts to find ways to use the Fast Healthcare Interoperability Resources (FHIR) standard, among others intended to use coding that can enable the orderly exchange of health information between health organizations. Through the use of FHIR-enabled application programming interfaces, technology can enable consumers to access their health information and present them in readable formats on a variety of platforms, including smartphones. 

ONC also is playing a critical role in developing the United States Core Data for Interoperability, adopted as a standard in the ONC Cures Act Final Rule. ONC contends that USCDI sets a foundation for broader sharing of electronic health information to support patient care. The datasets represent a bolus of information that certified EHRs are required to be able to collect and exchange. 

ONC also is looking to empower information exchange through the Trusted Electronic Framework and Common Agreement, a set of rules of the road for information exchange to which large information exchange entities must agree. The program to designate qualified health information networks (QHINs) holds the promise of facilitating agreements, practices and protocols to facilitate information exchange across the country. The first QHINs are expected to be named in 2023. 

Now, ONC is providing support services to other federal agencies that are increasingly looking to gain efficiencies and economies of scale in accessing and using the nation’s vast store of electronic health information. 

“Not a day goes by that either a federal agency (has a question) … that does not involve health IT or interoperability,” says Steven Posnack, ONC’s deputy director. “Way back in the beginning, we were this kind of little office; we're still relatively little in the federal scheme of things, but we were the ones that were most passionate about health. And we started to get converts along the way." 

“Over time, the lightbulbs go off, and all of these agencies, they're like, 'Wait a second, our mission needs this data that's now in those EHRs.’ So now we're in these really important federal coordination conversations.”

More on the evolution of the ONC:

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