In responding to catastrophes, sustained and systemic change requires federal and state policy that establishes long-term infrastructure. This was evident in the aftermath of Hurricane Katrina (2005), which displaced more than 1 million Louisiana residents. Despite political activation and public outcry for cloud-based health information at the local level, little was accomplished on a national scale to advance widespread care delivery innovations. Conversely, the 2008–2009 economic recession impacted the nation as a whole, resulting in the 2009 stimulus package, which established Health Information Technology for Clinical and Economic Health (HITECH), a program that provided funds, accountability, and infrastructure to support the spread of electronic health records (EHRs). Because of this structured investment, HITECH achieved—and in some cases exceeded—its goals of nationwide EHR adoption and changed patient medical records for the long-term.

Because of physical distancing requirements, the novel coronavirus outbreak of 2019–2020 is increasing flexibility, payment, and demand for the use of telehealth. Unlike HITECH in 2009, telehealth policies are largely being implemented on a plan-by-plan and state-by-state basis, resulting in a patchwork of policies by payer and locale. Moreover, coordinated efforts to support or educate providers who may be new to using telehealth platforms have been lacking. During this time, policymakers may look to HITECH for lessons to support the long-term sustainability of telehealth.

Overview of HITECH

HITECH provided financial incentives to eligible professionals (EPs) and hospitals for the meaningful use of certified qualified EHRs and delivered a wide range of technical assistance via federally funded programs and grants.

Medicare and Medicaid EHR Incentive Program (Meaningful Use)

HITECH authorized $27 billion in Medicare and Medicaid payments to eligible providers who adopted, implemented, and used certified technology and attested to meeting meaningful use requirements. With guidance from the Office of the National Coordinator for Health IT (ONC) and in collaboration with the advocacy community, the Meaningful Use Program, as it is commonly called, was designed to improve quality, safety, and efficiency while reducing health disparities, engaging patients and families in their care, and improving care coordination, population health, and public health while emphasizing privacy and security.

The program, which was rolled out in 3 stages, required EPs and hospitals to attest to core objectives and optional or “menu” objectives, and report on clinical quality measures. Program requirements increased with each stage of the program, and incentive payments were awarded to those who successfully met program milestones and objectives. Since 2015, meaningful use requirements have been rolled into the Merit-Based Incentive Payment System, and the program is now referred to as Promoting Interoperability.

ONC Programs

In recognition that many providers were unfamiliar with EHRs, HITECH provided more than $1.7 billion in funds for grant-supported programs (run by ONC) to support EPs, build community capacity for change, and encourage a smooth transition from paper-based to electronic-based records. Key initiatives were:

• Regional Extension Centers (RECs) funded local organizations to provide customized, ground-level technical assistance to small and solo provider practices. RECs had the opportunity to collaborate through national meetings coordinated by the Health IT Resource Center, which provided an opportunity for best practices to spread nationally.
• The State Health Information Exchange (HIE) Cooperative Agreement Program awarded funding for states to build capacity to exchange health information within and across states. Early evaluations found that exchange increased over the course of the program, but there was a wide degree of variation in HIE penetration across and within states.
• Federal Health Information Modeling and Standards Program coordinated the efforts of other partner agencies who were developing EHRs or technology standards.
• Beacon Community Cooperative Agreement Programs shared lessons from 17 communities that had made progress towards EHR adoption and HIE prior to the introduction of HITECH to demonstrate how health IT investments can support achievement of the Triple Aim.
• Workforce Development Programs updated and expanded health IT instructional material to educate healthcare workers on the changing healthcare environment.

There is no doubt that HITECH programs successfully drove widespread adoption and use of EHRs and transformed care delivery. Prior to implementation, less than 10% of hospitals and around 20% of office-based physician practices possessed certified EHR technology. Today, the overwhelming majority (87% in 2017) of healthcare providers utilize certified EHR technology for patient medical records. Providers are comfortable using their EHRs for patient alerts, data intake, patient communication, and other administrative functions.

The Shift Toward Telehealth

The rapid expansion of telehealth in many ways mirrors the proliferation of EHRs a decade ago. Prior to the outbreak, telehealth was expanding, albeit at a slower pace. In 2019, the Centers for Medicare and Medicaid Services (CMS) allowed Medicare Advantage (MA) plans to offer additional telehealth benefits. Avalere analysis found that almost 60% of plans offered telehealth options in 2020. Additionally, prior to 2020, the overwhelming majority of states had implemented policies expanding telehealth coverage for Medicaid programs and in the private (individual and group) markets, but access to telehealth varies widely by state and rarely provides adequate payment.

In the wake of the coronavirus outbreak and because of the urgent need for response, the federal government acted to enable access to and coverage for telehealth. As detailed in past Avalere Insights, Medicare has granted reimbursement parity with in-person visits, opened up reimbursement to more platform types, removed patient location limitations, and elected not to enforce out-of-pocket cost requirements.

The CMS also recently released a toolkit that offers resources and guidance to states interested in expanding telehealth coverage policies for Medicaid and the Children’s Health Insurance Program. Though the toolkit details considerations that states must weigh as they evaluate the need to expand their telehealth capabilities, such as eligible populations, reimbursement policies, eligible providers, and technology requirements, the onus is ultimately on states to enable widespread telehealth use, support and train Medicaid providers, and provide adequate reimbursement.

Many believe that the recent telehealth boom will change patient and provider behavior. Indeed, in an annual survey of more than 800 physicians, approximately half of the physicians reported using telehealth to treat patients as a result of COVID-19, up from 18% in 2018. However, telehealth may continue to be differentially available based on coverage source and patient state of residence absent federal action and standards and coordinated technical assistance.

Lessons to Sustain and Spread Telehealth

Policymakers can draw lessons from the HITECH experience to support the long-term sustainability and broad use of telehealth. HITECH successfully drove EHR adoption because it provided financial incentives in combination with supportive infrastructure. Meaningful Use established expectations to support program goals as well as penalties and incentives to reinforce expectations. Importantly, ONC programs also provided services and supports to prepare providers for change and, to the extent possible, minimize burdens related to care delivery innovation and workflow redesign. As policymakers develop telehealth programs, they could consider opportunities to provide not only financial support but also education and technical assistance for those who may be unfamiliar with this technology.

Despite successes, there were challenges related to HITECH implementation that also offer lessons for future care delivery innovations. For example, providers frequently expressed frustration with what they viewed as prescriptive requirements and escalating standards for meaningful use. Though designing technology standards necessitates some level of complexity, balancing inherent trade-offs between accountability and provider burden is critical in developing such programs.

Additionally, in order to maintain compliance with meaningful use reporting standards, providers were required to make ongoing investments to upgrade and optimize technology. In general, the efficiency gains were insufficient to sustain these investments. Continually assessing care delivery reforms such as telehealth to determine actual cost savings and adjust incentives and reimbursement accordingly would be an approach that reflects lessons learned from HITECH.

Finally, as noted previously, HITECH policies resulted in a wide degree of variation for data exchange capacity building, and local stakeholders called for stronger federal standards to harmonize requirements and advance nationwide interoperability.¹ This issue was later addressed in the 21st Century Cures Act and corresponding regulations.² Similarly, telehealth policies today currently vary by state and similar federal standards may be debated over time.

Reach out to Josh Seidman or Amanda Napoles to learn more about how to build momentum for telehealth and define the optimal use cases for telehealth care delivery.

Check out our  COVID-19 Intel Center.

Notes

1. Gold, Marsha, and Catherine McLaughlin. “Assessing HITECH Implementation and Lessons: 5 Years Later.” The Milbank Quarterly 94.3 (2016): 654–87. doi:10.1111/1468-0009.12214.
2. CMS. “Interoperability and Patient Access Fact Sheet” (Accessed April 24, 2020).