How ONC’s experience can apply to reform efforts

It was an interesting assignment—reviewing the roles that the six national coordinators have played in leading ONC.

The current transition from Karen DeSalvo, MD, to Vindell Washington, MD, seems like an apt time to take stock of the role that this important office has played in getting electronic health records widely deployed in healthcare organizations.

The role has only been in existence for a dozen years, and even that seems hard to believe—hasn’t it always been there? It’s equally hard to remember how ecstatic the healthcare IT industry was when President George Bush briefly mentioned electronic health records in his State of the Union address in 2004, which was the forerunner of the call to create ONC.

Much ground has been covered since then, with federal incentives fueling broad implementation of EHRs by both hospitals and physicians. In only 12 years, the use of records systems has advanced to the point that they’re now called “table stakes” by Adrienne Edens, long-time CIO and now vice president of education for the College of Healthcare Information Management Executives. EHR systems are now an assumed starting point for any provider.

Whether by planning, fortune or divine intervention, each of the leaders of ONC came to the position with a certain set of skills, experiences and personalities that matched the industry’s need at that time. For example, David Brailer, MD, had an entrepreneurial bent that coincided with the Greenfield project of starting a new agency from scratch. David Blumenthal, MD, had the analytical mind and research background to lead the crafting of the meaningful use program. Farzad Mostashari, MD, offered a warm and engaging personality that helped build consensus and support for tough transitions.

None of the ONC heads were perfect; each made mistakes and had flaws. But collectively, they’ve brought the industry a long way in 12 years.

Just as President Bush’s call for widespread use of electronic health records in 10 years posed a significant industry challenge, the industry now faces an even more profound change—moving from a volume-based system to one based on value. Perhaps the ONC experience in leading the transition to EHRs can provide some wisdom for this second, more expansive, shift.

Currently, much of the shift to value-based care is being led by federal agencies responsible for Medicare and Medicaid reimbursement. As the federal government is the largest payer for care in the country, it’s hoping to lead the way and provide an example that other payers can follow. The Department of Health and Human Services has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.

Toward this end, HHS is deploying pilot projects, new reimbursement initiatives and payment strategies that are coming at providers at a dizzying, confusing pace. Case in point: Consulting firm Deloitte recently released a survey that found that half of physicians are unaware of the significant payment changes coming in 2017 through the 2015 Medicare Access and CHIP Reauthorization Act (MACRA)—in fact, 50 percent of physician respondents said they had never heard of it.

Meanwhile, providers struggle with being at the fulcrum of this transition. Until the industry fully transitions to value-based payments, providers will struggle with having their feet on two diverging boats—one requiring value, the other based upon volume. There are risks and challenges involved in supporting two such wildly different reimbursement systems.

And at its essence, this is not just a discussion about changing reimbursement systems. It involves the very core of how we look at healthcare, what we perceive to be good results, and the information technology, data and other changes that need to be mixed together to land safely in a new, better world of care delivery.

While I don’t want to be the one calling for more bureaucracy, the importance of making this shift effectively—with adequate coordination and planning and with a minimum of suffering—cries out for a federal coordinating office with someone serving as a czar of healthcare transition. Truth be told, there’s not a lot of understanding of the cross-currents of economic forces that can be unleashed by current initiatives, and without coordination and planning, no one can be sure how things will play out, and if effective change will really occur.

One only needs to look back 30 years, when diagnosis-related groups were devised as a cost control measure. That didn’t work out as planned, and volume of services still drives healthcare costs today, as it did then. We’re 30 years further down the road—we need the current set of changes to work, and to do so for the good of patients and providers. Let’s make this someone’s sole responsibility.