Table 2. Recommendations for a Learning Health Care System—Relevant Meaningful Use Stage 2 Objectives, Cancer-Specific Gaps, and Potential Management Strategies.

Table 2 represents the authors’ view of relevant Meaningful Use Stage 2 objectives (for eligible hospitals and critical access hospitals, together “EH”, and for eligible providers, or “EP”) associated with the IOM’s ten recommendations to accelerate progress toward a learning health care system, cancer-specific gaps, and potential management strategies.^40,58

Foundational Elements

Recommendation 1: The Digital Infrastructure Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.

Relevant Meaningful Use Stage 2 Objectives Automatically track medications with an electronic medication administration record (EH) Imaging results accessible through Certified Electronic Health Record (EHR) Technology (EP/EH) Incorporate clinical lab-test results into Certified EHR Technology (EP/EH) Protect electronic health information created or maintained by the Certified EHR Technology (EP/EH) Record and chart changes in vital signs (EP/EH) Record demographic information (EP/EH) Record electronic notes in patient records (EP/EH) Record patient family health history (EP/EH) Record smoking status for patients 13 years old or older (EP/EH) Record whether a patient 65 years old or older has an advance directive (EH) Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders (EP/EH) 58

Cancer-Specific Gaps EHRs do not routinely capture oncology-specific data elements, such as tumor type and stage There is a shortage of trained health data scientists with experience in managing and analyzing large datasets and the associated infrastructure 59

Potential Management Strategies The Office of the National Coordinator for Health Information Technology (ONC) should incorporate cancer-specific objectives (e.g., capturing essential oncology data elements) in future stages of its Meaningful Use program The ONC should fund career development awards aimed at training information technology (IT) professionals in managing large health datasets

Recommendation 2: The Data Utility Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.

Relevant Meaningful Use Stage 2 Objectives None

Cancer-Specific Gaps Existing regulations (e.g., the Health Insurance Portability and Accountability Act, or HIPAA, and the Common Rule) may create unnecessary barriers to activities that advance clinical science and performance improvement, but are not research or clinical practice 1,40

Potential Management Strategies The Department of Health & Human Services (HHS) should review existing regulations that govern patient privacy and human subjects research to ensure that the prescribed level of oversight corresponds to the level of patient risk 1

Care Improvement Targets

Recommendation 3: Clinical Decision Support Accelerate integration of the best clinical knowledge into care decisions.

Relevant Meaningful Use Stage 2 Objectives Use clinical decision support (CDS) to improve performance on high-priority health conditions (EP/EH) 58

Cancer-Specific Gaps CDS tools exist for oncology, but are not widely used and lack non-clinical factors that influence treatment options (e.g., genomics and patient preferences) New knowledge is not rapidly disseminated into the evidence base or clinical practice

Potential Management Strategies The ONC should incorporate cancer-specific CDS objectives in future stages of its Meaningful Use program The National Cancer Institute (NCI) and standard-setting organizations, such as the National Comprehensive Cancer Network (NCCN), should develop strategies and standards to promote faster translation of clinical trials and comparative effectiveness research into the evidence base and clinical practice, such as through a CDS public library 1

Recommendation 4: Patient-Centered Care Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.

Relevant Meaningful Use Stage 2 Objectives Provide patients the ability to view online, download and transmit their health information (EP) Provide patients the ability to view online, download and transmit their health information within 36 hours after discharge (EH) Use certified EHR technology to identify patient-specific education resources (EP) Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate (EH) Use secure electronic messaging to communicate with patients on relevant health information (EP) 58

Cancer-Specific Gaps Many patients (and their families) lack timely access to their medical records and to patient education resources Existing data systems and payment models give insufficient consideration to shared decision-making, patient engagement, and personalized medicine

Potential Management Strategies The Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute (PCORI) should fund development of oncology-specific tools for shared decision-making The Center for Medicare & Medicaid Innovation (CMMI) and private payers should fund development of payment models that encourage shared decision-making 60

Recommendation 5: Community Links Promote community-clinical partnerships and services aimed at managing and improving health at the community level.

Relevant Meaningful Use Stage 2 Objectives Identify and report cancer cases to a State cancer registry (EP) Identify and report specific cases to a specialized registry (other than a cancer registry) (EP) Submit electronic data on reportable lab results to public health agencies (EH) Submit electronic data to immunization registries (EP/EH) Submit electronic syndromic surveillance data to public health agencies (EP/EH) 58

Cancer-Specific Gaps Clinical and public health practices are poorly integrated Many community providers (particularly providers that serve vulnerable and underserved populations) lack the resources and manpower to adopt the advanced IT available to other providers

Potential Management Strategies The Centers for Medicare & Medicaid Services (CMS) and private payers should incorporate population health measures into their payment models;40 the NQF “measure incubator” could accelerate measure development The ONC should fund grants to increase EHR implementation among providers that serve vulnerable and underserved populations

Recommendation 6: Care Continuity Improve coordination and communication within and across organizations.

Relevant Meaningful Use Stage 2 Objectives Generate and transmit permissible prescriptions electronically (eRx) (EP) Generate and transmit permissible discharge prescriptions electronically (eRx) (EH) Perform medication reconciliation (EP/EH) Provide clinical summaries for patients for each office visit (EP) Provide structured electronic lab results to ambulatory providers (EH) Provide summary of care record for each transition of care or referral (EP/EH) Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care (EP) 58

Cancer-Specific Gaps Current data systems lack interoperability and do not facilitate care coordination and inter-provider communication Current payment models do not award care coordination and inter-provider communication

Potential Management Strategies AHRQ should partner with professional organizations and patient advocates to fund development of cancer-specific care transition tools CMS and private payers should incorporate oncology-specific care coordination measures in their payment models; the NQF “measure incubator” could accelerate measure development CMMI and private payers should fund development of payment models that encourage effective care coordination and transitions

Recommendation 7: Optimized Operations Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.

Relevant Meaningful Use Stage 2 Objectives Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach (EP/EH) 58

Cancer-Specific Gaps Few provider systems have executed system-level initiatives to reduce waste and variation in cancer care There is no clear mechanism to disseminate operational improvements within the cancer care community, particularly to providers that treat vulnerable and underserved populations Provider access to and experience with systems engineering tools and process improvement methods varies

Potential Management Strategies CMMI and NCI should sponsor oncology-specific projects to eliminate inefficiencies and improve patient health through operational improvements; specific funding should be directed to providers that treat vulnerable and underserved populations Professional organizations should co-develop strategies and standards to promote faster dissemination of operational improvements within the cancer care community, such as through a publicly-available best practice database or a learning consortium 40 Credentialing organizations should strengthen re-certification requirements to include demonstration of systems thinking and projects to reduce wasteful care

Supportive Policy Environment

Recommendation 8: Financial Incentives Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.

Relevant Meaningful Use Stage 2 Objectives None

Cancer-Specific Gaps Fee-for-service reimbursement does not incentivize high-quality, lower-cost care Existing alternative payment models (e.g., value-based purchasing) are insufficient to incentivize sustainable improvements in care Existing payment models do not incorporate long-term outcomes and patient-reported outcomes (e.g., survival and functional status)

Potential Management Strategies Public and private insurer payment models should incentivize high-quality, team-based care focused on patient goals, needs, and preferences 40 CMMI and private payers should sponsor demonstration projects for oncology-focused alternative payment models that incorporate outcomes that are important to patients; the NQF “measure incubator” could accelerate outcome measure development Provider organizations and health care systems should reward continuous improvement and professional development through financial incentives 40

Recommendation 9: Performance Transparency Increase transparency on health care system performance.

Relevant Meaningful Use Stage 2 Objectives None

Cancer-Specific Gaps There are significant gaps in outcome, safety, cost, and other quality data to guide patient decision-making and to guide performances improvements; timeliness is also an issue

Potential Management Strategies PCORI should fund research regarding which cancer quality data are most important to patients and when and in what format these data should be pushed to patients to aid in their decision-making HHS, private payers, professional organizations, and patient representatives should collaborate to implement a coordinated, transparent reporting infrastructure that meets the information needs of all stakeholders (in particular, patients and their families) and presents information on a real-time basis and in a way that is understandable to patients Public and private payers should promote transparency in outcomes, safety, cost, and other quality data through alternative payment models

Recommendation 10: Broad Leadership Expand commitment to the goals of a continuously learning health care system.

Relevant Meaningful Use Stage 2 Objectives None

Cancer-Specific Gaps Fragmented measure development and reporting efforts inhibit progress toward a learning health care system

Potential Management Strategies Professional societies, credentialing organizations, and accreditation organizations should incorporate continuous learning and improvement into educational, certification, and accreditation requirements Professional societies should collaborate with experts in organizational development to establish standards and strategies that promote organizational cultures that support continuous improvements and transparency Health care organizations and public and private payers should align financial incentives accordingly