Matthew Holt interviewed Jacob Reider, Deputy National Coordinator for Health Information Technology and Chief Medical Officer at the ONC, ahead of his appearance at the 8th Annual Health 2.0 Fall Conference. Jacob will be participating in several panels at Health 2.0, beginning with the Monday main stage panel “Smarter Care Delivery: Amplifying the Patient Voice”.

In this interview, Jacob gives an overview of the HITECH program, the question of interoperability, and the broad adoption of technology in health care as an industry.  

Matthew Holt: So, let’s touch base on a couple of things. You’ve been in ONC some time now. Let’s talk about how the general HITECH program has gone and is going. If you were to get to rate it, the spread of EMRs and the usefulness of them, their usability, how would you say we’re doing so far?

Jacob Reider: I think we’re doing very well. Some of your readers know I went to college at a place that had no grades. So I’ll give you the narrative score.

The narrative score is that the program has been very successful achieving the goals that were defined at the outset. So the first iteration of the program, stage one, was all about getting organizations to adopt Health Information Technology, and I think all of the metrics that we’ve seen have validated that the program has been quite successful in accelerating the adoption of Health Information Technology, in both hospitals and practices. That doesn’t mean that we’re finished, but the vast majority of these organizations have now adopted Health Information Technology. Are there additional goals that we’d like to be able to meet? Absolutely, we’d like to see interoperability working better. As you mentioned, we would like the products to be more usable, and therefore, safer.

We’d like to see patients even more engaged than they currently are, so they have more access to the information in their records. We’d like to solve a problem that we’re starting to see in the industry, which I started to call hyperportalosis, which is that in any given community, there may be many portals that patients are expected to log in to. So we’re trying to think about how those problems can be solved in the next iteration of the HITECH program.

MH: That’s really fair. There are a bunch of commentators who I think will agree with you and me in that we had to kick-start this somehow.

One thing that I think you mentioned is the interoperability  question, and there have been several efforts from ONC and elsewhere to deal with this. Three come to mind: the mainstream HIEs — a lot of them were funded out of the original HITECH Act, the Direct program, and obviously Blue Button. Can you give us a sense of where you think those three are, and where we are with interoperability , data exchange, and access more broadly?

JR: Sure. So there are many HIEs that are in place in the country and they’re working, in many cases, very well. Some of the HIEs have not gone so well and we’ve learned from those projects.

The two primary use cases that we see starting to occur in the marketplace are actually exemplified by the two of the three that you discussed. The HIE supports query-based exchange really well. So, if you come into my office as a primary care physician and I don’t know anything about you and there’s an HIE in place in my region, I can log into that. I can query it for important things that I should know about you, of course, with your permission in a secured way that aligns with all of the privacy and security and from ONC and from OCR, and I can provide better care to you.

In the case where there is not an active health information exchange or for a different use case, we see the Direct is actually doing very well. We are starting, now, to see the Direct activities increasing in number, both the number of transactions and, of course, the folks who are trading with each other using Direct.

One of the metaphors that we’ve used is that until all of the kids are on the baseball field, it’s hard to play catch. So, right now, all the kids are starting to come onto the field.

Blue Button, as you know, is a way for patients to access their information through Health Information Technology, and it’s instantiated in many ways. The most common is that a patient should be able to view, download, or transmit their clinical information to a third party. I can say that I have used the Blue Button functionality in my dad’s medical record, with his permission, of course, to get a better understanding of the care that he’s receiving. He was recently diagnosed with lymphoma and is receiving very good treatment from some very good health care providers who are about a thousand miles from me.

I think on all fronts, the program is doing well, but in all those three fronts, there have been some challenges and there will continue to be just as with any new technology in any industry, it’s not always perfect with the 1.0 release.

MH: So talking about new technology, one of the criticisms — and I’m as guilty as anybody saying this — is that a lot of what we’ve been doing in health care since HITECH, is that we’ve been putting in large scale enterprise systems. But what we’ve seen elsewhere in health care — this stuff we focus on at Health 2.0, which tends to be the cloud-based, mobile solutions — have really not grown to the same extent in health care.

So, where do you think health care stands in the broad adoption you’ve seen in other industries where you’ve gone from enterprise-based tools, to a mix of enterprise and cloud-based tools, and then the third leg of that – the bring your own device piece where a lot of these tools get put onto mobile devices, which are what the employees, consumers, professional companies use in their everyday activities. Where do you think we are in that transition?  Or do you think we won’t be going to that transition because health care is different?

JR: I’ll answer your last question first. I don’t think health care is different. It is self-evident to me that health care will move in the same way that other industries have moved — toward a much more distributed, much more personal user experience for everyone. We’ve certainly seen it in — we’re all familiar with the other industries where we’ve seen it, right?  Banking is often cited as an example. I think transportation is often cited as a good example. Remember when we got airplane tickets in the mail weeks ahead of our flight. Now, we can make our reservation on our phone and never touch a piece of paper throughout the whole experience.

So we are seeing it at the fringes of health care. Lots of activity that is thrilling to see and as you know, ONC has yes, supported, encouraged, and tried to think about the developers of these tools as we craft the primary products of our organizations, which are often regulations, right?

There are certain parameters where purchasers of these systems need to be confident that the developers have followed a certain set of guidelines to develop, to deliver tools that are safe, reliable, secure and consistent.

MH: Last question, Jacob. We’re hearing a lot about clinicians and organizations changing EMR systems from one to another, and some of them from smaller systems to bigger organizations like Epic, but some of them from small companies to cloud-based companies. Do you think that the amount of churn we’re seeing while we’re seeing this big growth and uptake of EMRs from paper in the first place, is that normal?  Is that a bad thing?  Or is it a good thing?  Or was it more than you expect? Or is it less? Any combination of the above.

JR: I try not to judge things as good or bad. This is happening. I would say it is not unexpected when you have an industry where there are lots and lots of small players, and you will almost always see consolidation. We’ve seen it in almost every other industry, right?  In the automotive industry, even in the 1920s and 1930s; we’ve seen it in transportation in the airline industries. We’ve seen it in telecommunications and even in computing.

Some of this is self-evident. We don’t necessarily pick the winners. If we are to handicap these things, it’s hard to predict who is going to survive and who is not, and sometimes we see very large organizations that are not doing as well as many would expect them to. So, I don’t necessarily think that it’s size that predicts success, so much as the ability for an organization to — as they say, “See where the puck will be.”

So to be explicit and answer your question more clearly, yes this is expected. I don’t think it’s bad, although talking to a clinician who is migrating from one product to another, is painful.

MH: Yeah, I think that’s right and there was a great piece on some blog showing that in 2010, Nokia was by far the biggest smartphone company in the world, and about last year they were sold to Microsoft for a bucket of chips and two pints of beer.

JR: Yeah.

MH: Yeah. Change can happen quickly you know.

JR: It can happen although this is the challenge, right?  Maybe because of the complexity of Health Information Technology, change can’t happen as fast as Nokia changes, right?  Because where, when you implement an electronic health record in your practice, you change your workflow to meet the proclivities of that system. Your data is an octopus inside of that system and it’s not as easy to export your context as your calendar items and poof, you are on a different cellphone in 10 minutes. Migration is actually a really massive experience.

MH: We’ll touch on that topic in Santa Clara. So with that, let’s wrap this because we can talk about this stuff all day, and we’ll talk more about it in Santa Clara. I’ve been talking with Jacob Reider, who is the Deputy and the Chief of the ONC and the Chief Medical Officer. Jacob, thanks for your time. I’ll look forward to seeing you in a few weeks.

JR: Likewise, Matthew. Thank you.