Over the next few months, Jacob Reider will serve as the interim National Coordinator for Healthcare IT while the search continues for Farzad Mostashari’s permanent replacement.
What advice would I give to the next national coordinator?
David Blumenthal led ONC during a period of remarkable regulatory change and expanding budgets. He was the right person for the “regulatory era.”
Farzad Mostashari led ONC during a period of implementation when resources peaked, grants were spent, and the industry ran marathons every day to keep up with the pace of change. He was the right person for the “implementation era”
The next coordinator will preside over the “consolidate our gains” era. Grants largely run out in January 2014. Budgets are likely to shrink because of sequestration and the impact of fiscal pressures (when the Federal government starts operating again). Many regulatory deadlines converge in the next coordinator’s term.
The right person for this next phase must listen to stakeholder challenges, adjust timelines, polish existing regulations, ensure the combined burden of regulations from many agencies in HHS do not break the camel’s back, and keep Congress informed every step of the way. I did not include parting the Red Sea, so maybe there is a mere human who could do this.
What tools does the coordinator have in an era of shrinking budgets?
At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.
Can resources be expanded?
Given that Medicare/Medicaid reimbursements are falling, private insurance payments are nearly flat, and costs continue to escalate, the pie of resources is a fixed size and very challenging for anyone to expand.
The new coordinator has only two levers – reduce scope or extend time. Changing the scope of initiatives already in progress may be very challenging i.e. require acts of Congress, realignment of powerful stakeholders, or compromise of the important interoperability goals we’ve worked so hard to craft.
That leaves “time” as the one lever under the coordinator’s control. However, even revising schedules will be challenging because of competing stakeholder demands.
a. ICD-10 – although some large organizations have significant sunk costs and want the deadline to remain as October 1, 2014, smaller organizations will not be ready. Some payers (including government payers) may not be ready. It’s clear we need to extend the deadline at least 6 months. Maybe encourage voluntary ICD10 transactions on October 1, 2014 but allow a 6 month grace period without regulatory enforcement for the industry to catchup with the software, training, and process change needed for ICD-10 success?
b. Meaningful Use stage 2 – Software products are still being certified, so many hospitals and professionals have not yet upgraded to Meaningful Use Stage 2 certified applications, making a 2014 reporting period/attestation somewhat challenging. Meaningful Use Stage 2 reporting periods have already begun for hospitals, so no delay is possible, but the reporting period timeframe could be extended. Maybe provide an 18 month window for Stage 2 attestation? I realize this could delay future stages of Meaningful Use, but the industry needs a breather to consolidate our gains.
c. ACA – The Affordable Care Act has motivated many organizations to focus on continuous wellness rather than episodic sickness. ACOs are building private data exchanges and outcomes registries. Progress is accelerating because every dollar spent on IT has the potential to reduce costs in risk-based contracts. ACA and private insurer equivalent programs (such as the Blue Cross Alternative Quality contract) include many quality measures. Unfortunately, these measures are not optimized for the EHR era and are retooled from a time when quality measurement was done by abstractors in health information management. Rather than escalate already burdensome quality reporting requirements (BDMC produces over 1000 measures per year for various regulatory agencies), shouldn’t we step back and ask what measures are truly important and urgent in a fully electronic era? Reducing reporting burdens temporarily while s a consolidated set of new electronic measures is developed would be very helpful.
d. HIPAA Omnibus Rule – Audits require at least 10 operational hours for every auditor hour. While hospitals and practices are in the midst of enhancing policies, revising infrastructure, and learning about the operational implications of the Omnibus Rule, it would be prudent to slow the pace of audits, just temporarily. We all want to protect privacy and reduce risk but there is a fixed rate at which organizations can integrate change. We need to focus on the long term and build a robust multi-layered defense. At times in the past, we’ve moved faster with regulations/enforcement than standards and technology maturity could support.
e. Some have suggested that if industry does move fast enough, more regulations will cause stakeholders to move faster. I really believe that more regulations will be a case of haste makes waste. Let’s integrate existing regulations into the fabric of our operations, using the market forces created by the accountable care act to align incentives, and only consider new regulations when we have enough information about the impact of prior regulations. Although challenging, maybe the coordinator could even consider polishing existing regulations to reduce the artificially burdensome aspects which are not necessary to achieve policy objectives. I’d start with taking testimony about the certification scripts for view/download/transmit, transitions of care, quality measurement, automated numerator/denominator, and clinical decision support. Jacob Reider will do a great job over the next few months and could become the permanent coordinator. I will do everything in my power as co-chair of the Standards Committee to support whatever scope and timing revisions the coordinator considers.
John Halamka, MD, is the CIO at Beth Israel Deconess Medical Center and the author of the popular Life as a Healthcare CIO blog, where he writes about technology, the business of healthcare and the issues he faces as the leader of the IT department of a major hospital system. He is a frequent contributor to THCB.
“At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.”
John, this is the first time an “insider” has belled the cat! All these well intentioned government initiatives have so overwhelmed our healthcare providers that they have no room to breathe or time to talk with their patients.
One unintended consequence you did not mention is that these initiatives also kill innovation. Providers simply have no time to try or test any innovations no matter how promising they may be.
The choice of words “consolidate our gains” may be seen as unfortunate from the perspective of both physicians and patients. The consolidation they see is of industry and vendor control over the physician-patient relationship. A lot of physicians are unhappy with their EHRs and feel powerless. Patient “engagement” seems designed to prevent leakage and obfuscate costs.
Meanwhile, the “implementation era” has consolidated institutional control over patient data by allowing days or weeks of delay before giving the patient an electronic copy of her records, by not giving patients the right to automated transmission or access of her records using Blue Button Plus, and by not mandating that the physician can white-list any Direct email address if they choose. The implementation era also consolidated managed-care era sharing practices. ONC decided not to advance patient privacy rights in health information exchange and has left us a legacy of coercive HIE practices with state databases like the HIE Record Locator Services and All Payer Claims Databases that are hidden and inaccessible to the patient.
Patients deserve a fair shot at our own personal data and, in this respect, the perfect is the enemy of the good. ICD-10, 500-page CCDA specifications, and expensive trust federations instead of a universal Direct address space are not helping patients as much as they’re paving the cow path of managed care. The market-based health reform promised by the ACA depends on patients with real-time independent advice about costs and risks, a consolidated explanation of benefits history to guide choice of plans at the health insurance exchange and a chance to ask our physician for an un-delayed copy of our health record to be sent to the Direct address we designate.
Not all regulations are alike. Some are designed to consolidate power into ever more centralized corporations. Others encourage competition and enable innovation and transparency at the local level. I hope the next coordinator can trade off a few kilopages of EHR mandates for some “meaningful choice” on the part of the physician and patient.
Unless Moses returns from the dead, I too, fear that we may be reviewing a short list of “technically” qualified individuals who can hold firm in this coordinator position. We will find someone, but if that someone can’t fulfill the requirements and meet the deadlines and delegate responisibility/communicate effectively within our elected officials…we will be in even more trouble. Again, you nailed it, friend. I’ll be keeping a close ye on this article and watching for your replies, etc. Great article, John.
There are some other levers that the National Coordinator has at hand that have not been utilized to their fullest capability. That is to coordinate the regulations, funding and incentives from other government agencies and HHS sub-ops that have both a direct and indirect stake in all aspects of healthcare for this nation. This area has been underutilized by all of the National Coordinators, but could be leveraged as “fiscal pressures” continue in the future during the “expansion era”.