10 years on from meaningful use, major progress despite the challenges

Ten years ago today, on December 30, 2009, the Centers for Medicare and Medicaid Services published the proposed rule outlining how hospitals and physician practices could qualify for Medicare and Medicaid payments from the EHR incentive program.

Meaningful use, as the program became known in the months and years ahead, was a transformative event for the health IT sector – for better and for worse.

The introduction of $27 billion worth of federal subsidies (the number would soon rise to more than $35 billion) as part of the HITECH Act was not something to be taken lightly, of course. 

Over the past decade, that kind of money couldn't help but have a fundamentally transformative effect on how healthcare is delivered in the U.S. 

The incentive dollars were part of the American Recovery and Reinvestment Act, which infused some $800 billion into an economy still reeling from the great recession. 

By most accounts, the financial impact of the larger ARRA package was a net positive, giving a badly damaged economy a much-needed jolt of capital.

But as this year and decade wind down, it's a fair question to ask what HITECH and meaningful used have accomplished for healthcare in particular.

There have been many complaints about the legislation and subsequent policy-making over the past decade. Some said the rules weren't tight enough, and allowed too many providers to saddle themselves with expensive but inadequate software. 

Even more complain that the regs were too stringent, and hamstrung what could have been a decade of healthcare innovation by demanding health systems adopt a select range of certified EHRs and spend countless hours documenting and attesting to voluminous and exacting meaningful use criteria.

But it's worth remembering where healthcare was with regard to technology at the end of 2009.

Yes, the challenges that exist today are many: relentless and complex cybersecurity worries; biased AI algorithms; an epidemic of clinician burnout, exacerbated by the daily demands of less-than-ideal electronic health records. 

But the strides U.S. health systems have been able to make, generally, toward better patient outcomes, healthier populations and more efficient care delivery are just as real – and they wouldn't have occurred using the sagging shelves of manilla folders that were the norm for many hospitals just a decade ago.

Let's not forget, after all, that it was barely 15 years ago that then President George W. Bush put forth the novel idea, in his 2004 State of the Union Address, that, “by computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care."

Five years later, in his own 2009 speech before Congress, President Barack Obama pledged the U.S. would "make the immediate investments necessary" for health record digitization, with the goal to "cut waste, eliminate red tape and reduce the need to repeat expensive medical tests."

It may be edifying to remind ourselves that, at the time of that speech, barely 15% of hospitals had either a basic or comprehensive EHR in use. Today, inpatient systems are ubiquitous, even if there remains a "digital divide" between larger hospital and their small and rural counterparts.

By 2012, just two years after the start of meaningful use, more than 77% of U.S. hospitals had reached at least Stage 3 on the HIMSS EMR Adoption Model.

Meaningful use has been controversial from the start, of course. In July 2010, when the 800-page final rule for Stage 1 was released, the American Hospital Association, among others, was airing concerns that it posed "unnecessary administrative burdens."

But, on the whole, the response from hospitals and practices to the EHR incentive program was immediate and enthusiastic. In January 2011, we reported how then-National Coordinator for Health IT Dr. David Blumenthal ushered in the "age of meaningful use." 

Just two weeks after registration opened for providers to attest, some 13,000 had signed up to qualify for incentives, and ONC was receiving "hundreds of calls a day from providers asking questions."

The allure was obvious. For all the attestation box-checking – and complaints about same – that would ensue, the appeal of large incentive checks, as much as $64,000, was hard to argue with.

As Michael Grunwald, author of "The New New Deal: The Hidden Story of Change in the Obama Era" – which chronicles ARRA and makes the case that President Obama's 2009 stimulus bill may be more transformative in the long run than Roosevelt's New Deal – told us in 2012, "$27 billion really did focus the mind."

But did it pave the way for lasting and transformative change for the better?

Not everyone is convinced.

Kaiser Health News reported this month that the EHR incentive program enabled A "New Era Of Health Care Fraud." And certainly, False Claims Act settlements paid out by eClinicalWorks and Greenway in recent years show that the system was ripe for gaming.

And then there's the issue of usability. Famed health technology pioneer Dr. Eric Topol didn't mince words this year when he offered Healthcare IT News his dim assessment of EHRs– laying much of the blame squarely with what he said was a misbegotten meaningful use program.

"I think electronic health records have been the singular biggest disaster in the last two decades of healthcare," said Topol. 

"The idea was right, but the execution has been pitiful," he said. "They're set up for billing purposes. They couldn't care less about the patient-centric vision. They're pathetic. They're the worst software in existence that I know of. They've really taken us astray, and have given the whole digital era in healthcare a bad name. They're uniformly hated by patients and doctors, because they involve such poorly-performing user interfaces, and are the single worst part of the deteriorating doctor-patient relationship."

Today, meaningful use is history, having been superseded by CMS' Promoting Interoperability Program in 2018.

But its legacy this past decade depends upon who you ask.

Some say the stimulus payments artificially boosted the market, or cheer-led products that weren't well-suited for the demands of quality improvement and value-based care, or held back more free-flowing and transformative innovation in favor of government-mandated best practices. They argue that technology would have come to healthcare – a laggard compared to other industries, by any measure – eventually, and more effectively.

But others say that's not so. That too many healthcare organizations would have been fine with paper files and CD-ROMs until they were forced to think differently. That the $35 billion shot in the arm was exactly what the doctor ordered to drag this sprawling and complex corner of the American economy into the 21st Century.

Yes, the fax machine is still used far too often (that is to say, at all). Yes, interoperability is still a problem yet to be truly solved. Yes, EHRs are still often aggravating and suboptimally designed, with too many clicks and alerts.

But healthcare data is now digitized and near-ubiquitous, and able to be harnessed and put to work for population health and QI projects that wouldn't have been possible just a few years ago. That digitization, for all its ongoing challenges, has been mostly good – not just for clinical and operational improvements but for patient engagement and experience, ushering in this new age of healthcare consumer empowerment.

As Michael Grunwald told us in 2012, "it really is a no-brainer, right? We've got online banking. We've got online dating. It's preposterous that you have to fill out the same 20 forms every time you go to the doctor's office. And that two doctors who aren't in the same room can't look at the same file. And that if you show up at a hospital on the weekend they have no way of seeing the test that you took on Wednesday and you have to retake it. And that your doctor could kill you with his chicken-scratch handwriting."

Including health IT investments as a big part of ARRA "appealed to Obama, who really is this sort of rationalist, pragmatist, sort of policy guy," he said. The billions doled out as part of the stimulus bill represented a chance to force the issue and finally make some progress on a topic where people had been "squabbling over the details for several years," he said. "Here was this opportunity to spend all this money, well, why don't we just do it?"

(For those who think the EHR incentive program was too prescriptive, by the way, it may worth remembering, as Grunwald reminds us, that at least one Democratic pol, former California Rep. Pete Stark, "basically wanted to force everybody to adopt the VistA system." Nowadays even the VA is transitioning away from VistA.)

Back in 2012, after I spoke with Grunwald about his thoughts on ARRA and HITECH, I dialed HIMSS' then senior director of congressional affairs, Richard Hodge, to get his.

"Clearly, the nation would not have made the significant progress toward electronic health records adoption and health information exchange that it has without the Medicare and Medicaid EHR Incentive Program authorized by the HITECH Act," said Hodge. "The public dialogue, open consensus-building process, standards-based approach, and phased implementation provided by the meaningful use process have been critical to bringing the country to achieve the current level of accomplishment and rapidly increasing adoption rates."