More on MACRA, Interoperability and the Post-Meaningful Use World


Screen Shot 2016-03-04 at 11.34.56 AMTHCB is pleased to feature acting CMS administrator Andy Slavitt’s comments during a panel appearance at this week’s HIMSS conference. We encourage you to read them closely and with an open mind and add your own thoughts on the steps you think the government should take to improve the federal quality measurement program and improve and promote health information technology. For more on the topic of EHR incentives and the transition from the Meaningful Use program, go read Andy’s last THCB post “EHR Incentive Programs: Where We Go From Here.”

I love working with Karen De Salvo. She can talk in half sentences and I can finish them. We’ve naturally been working together for months on some of the initiatives we’re talking about here, and always check in to compare facts, see if we’re seeing the same thing. We went into these speeches in perfect harmony on what needs to be done.

True story. We exchange drafts and she sends me a note “Andy, I think your speech comes across as very negative. Why don’t you reread with that lens?” I erased the email I’d been writing to her– she’s always too positive for me anyway – and I think I sent her an emoticon of a happy face instead. Now one interpretation is she works with the technology community who by all accounts and from looking around the floor are generally happy. I hear more from docs trying to use technology and that may affect my moods a little bit.

We are now seven years in to the concerted launch of a truly national health information technology platform. Always a good time to see how it’s going.  I’ve been to HIMSS with a few different hats on and have been talking fairly publicly about Meaningful Use and about moving technology to a place where it becomes a more flexible tool to support physicians so they can improve patient care.  I’m certainly not bashful about what we need to do better and I’m not going to be bashful, even in the face of some very good reasons for optimism, to point to where we all need to take our game up.

We’ve all made a great start but we’re still at a stage where technology often hurts, instead of helping, physicians provide better patient care. And we are committed to taking a page out of consumer technology playbook and taking a user-centered approach to designing policy.  I’m asking you to redouble your efforts to do the same.

The Consumer

Understanding what we want from technology means first understanding how we provide and receive care today in America where the consumer is more diverse, more mobile and more demanding than ever before.  The consumers CMS serves are a good representation of all of our care needs– 140 million Americans– most on fixed or low incomes– in every type of care situation–

  • The Medicare patient leaving the hospital with five prescriptions to fill and 2 appointments to book;
  • The marketplace customer who will have coverage for the first time and finally be able to have his wife’s chronic fatigue looked at;
  • The daughter who has made the difficult decision to move her father in a nursing home and wants to know staffing ratios and quality ratings;
  • The family with a child with disabilities on Medicaid that requires 24 hour care and is watching every dollar and interviewing every home care worker.

Because of the way people get care today– on the go, on their own terms, often not anchored in the system – their information needs are ever more vital and yet so basic. Am I recognized when I show up? Are my needs, preferences, and history available?

And today’s technology at its best is ideally suited to meet these needs – the cloud, social media, one-click purchases, information at our fingertips, everything wired, convenient devices, expert systems, intelligent agents. We know what we need to do and the technology is available.


Let me talk about the user-centered policy design approaches we’ve been using to implement the new bipartisan MACRA legislation – legislation intended to bring value-based care to the everyday physician practice. We have created a new playbook at CMS by making our most concerted effort ever at listening to front-line physician and patient input upfront.

After first collecting feedback from across the health care sector, we launched our work with a four day session with physicians and technology companies and sought more comment through a public Request for Information (RFI). But the bulk of our work has been directly with front line physicians. We have completed 8 focus groups with front line physicians in 4 separate markets and have many more coming. And I’ve been on the road meeting with a number of physicians in their offices to see how they interact with technology directly. Our questions have been simple? What needs to work better with so the technology in your office can support you in delivering better patient care?

Let me show you a few of the more representative things we are hearing.

“It does put too much of a burden on us and it does take away our time from caring for patients.  It seems like most of what I’m doing during the daytime is entering data into the electronic record.” (Primary Care Provider, Atlanta)

 “…nobody’s EMR talks to someone else’s EMR.  And that’s the big mess that people put out there.  Like if you’re going to find out someone’s information, it’s going to be snail mail or somebody’s going to fax it or you have to walk over and get it.” (Primary Care Provider, Atlanta)

 “I think that the one thing that this really could’ve added to patient care is the one thing that hasn’t happened, and that’s the systems don’t talk to each other.  It’s actually the opposite.  If one of the EMRs I used, I can’t even access it at the hospital because of the firewall.  I can’t even get into the EMR at the hospital to look at patient records.” (Health Care Specialist, Chicago)

 “To order aspirin takes eight clicks on the computer.  To order full-strength aspirin, 16. . .That’s not patient care.  It’s clicks.” (Primary Care Provider, Atlanta)

 “The problem I have is I can see less patients in a day based on all of the stuff I have to do with a computer and that’s really killing me.  ” (Primary Care Provider, Los Angeles)

“There’s too much information, finding information in an EMR is difficult.  …  It’s just too much.  A certain level is good, but they’re going beyond that.  These aren’t the greatest on things all that, we just click and click and click.  It’s very hard to, it’s a very busy screen on the EMR now.  There’s a lot of other information that you don’t need now, you just have to click, click, click, and it’s too much.” (Primary Care Provider, Atlanta)

I have hundreds of these if you’re interested.

Three themes have emerged that have shaped the agenda you are hearing from Secretary Burwell, Karen and me.

  1. First is that physicians are hampered and frustrated by the lack of interoperability. It’s more practical than that. I don’t think anybody but us policy people actually use the word interoperability– it’s usually– I can’t track my patient’s referral, I don’t know what happens when they’re in the hospital.
  2. Second, regulations in their current form slow them down, create documentation burden and often distract them from patient care.
  3. And third, they find their EHR technology hard to use and cumbersome. It slows them down, doesn’t speed their path to answers.

So, let me summarize our agenda within these three themes before Karen and I take some questions.

The first area we are addressing is the documentation overhead associated with the Meaningful Use program. Since we are a few months away from having details available with the proposed MACRA rule that we will be open for public comment, let me share our approach.

Job One has been to try to close the gulf between our public policy work and what’s happening in the reality of patient care.

Second, what we are we hearing from all of our sessions with physicians? Stop measuring clicks, focus instead on allowing technology to become a tool and focus on the results technology can create. Give us more flexibility to suit our practice needs and ultimately more control.

Third, where possible, we favor “pull” vs. “push” incentives. What I mean by this is to let outcomes rather than activities drive the agenda. We can take advantage of how the landscape has changed over the last five years with the proliferation of programs that depend on care coordination and population health.

Roughly 25 million Medicare patients are now in Medicare Advantage or an ACO; April 1st, close to half of the hip and knee replacements in the country will come together in an impatient-outpatient full bundle. Medicare, Medicaid and commercial health plans are fast approaching a tipping point when more than half of all payments will be tied to improved care and cost outcomes.

Interoperability is the second area. It is an essential ingredient not only for better patient care, but as the President said last week, to the precision medicine that will unlock an entirely new future of better health.

As you know, yesterday Secretary Burwell announced that companies representing 90 percent of EHRs are committing to three vital steps to real interoperability that Karen just talked about. I thank the many who have made this commitment. It has the potential to set us on a new course, but we all need to be more committed than ever to making sure that the substance of this pledge translates to reality.

Why is a pledge important? There has to be a private sector commitment to the greater good. Regulations, like those requiring open APIs can help, but frankly there are just too many ways to step in the way of true interoperability that no regulation can anticipate – legal clauses, commercial impediments, documentation access, IP, “security” concerns, hidden documentation. The companies who live up to their commitments will be recognized. And I strongly encourage you to recognize those that don’t.

I’m also excited that on the interoperability front, today we are announcing funding to connect many of the remaining parts of the system that are not part of the EHR incentive program but serve our neediest Medicaid patients every day – long-term care, behavioral health and substance abuse providers.

But we can’t forget that interoperability is a means to an end. Ultimately it needs to open up a path to give physicians and patients what they want from their technology, so called bottom-up interoperability. We need to focus on the use cases that matter and have agreed that we will help facilitate building around two that have physicians have identified: closing the referral loop and patient engagement.

That leads directly to the third component to getting out of the EHR doldrums – to give the physician better tools that help them with patient care. It’s not only Meaningful Use that concerns physicians, they want better technology. With interoperability and open APIs, it’s time to finally create the improved workflows and the apps that physicians are looking for.

Shifting from MU-oriented design to developing certified technology that is user-centered is a big and necessary opportunity. Flexible EHR incentives should give tech companies new products to develop.

The open APIs requirements in the ONC CERT rule will allow new innovators, in addition to traditional EHR vendors, to break the current desktop lock that early EHR decisions created and create analytic applications, plug-ins, and other tools by securely moving data in and out of the EHR. Competition and innovation are a missing ingredient. So what am I most excited about? As Karen mentioned, ONC is launching an App Discovery Site, or what I call the FHIR Cloud, as an EHR-neutral place for new apps that can securely move data in and out of an EHR. We now have an opportunity to make it tangible.

What comes next for us? If all do our work right– and it will take all of us, physicians will at some point be talking about patient support tools, not EHRs or Meaningful Use. I don’t have illusions that anyone is ever going to enjoy being measured and evaluated– those systems are always imperfect, human biology too heterogeneous, government too far away from the judgments needed inpatient care. And frankly I never have and hope never to meet a physician that cares more about an incentive payment than doing what they think is right for their patient. So our policies need to communicate what’s important– improved patient care, better spending, and healthier people– without invading the space of how to get there. A challenging goal, but one made easier by talking about it publicly and listening to input.

It takes all of us to turn this around. We will do our part and for us, it is not a one-time fix or a single regulation that will change things – it is an ongoing process and commitment to closing the gap between on the ground care delivery and policies that promote the tools for better care. Most important for us is to commit to change how we work to listen and improve. Connecting to what happens in daily patient care is vital to our policy-making as we seek a better, smarter healthier system and a better patient outcome.

 We are committed to making real progress that makes a real difference. So let’s get to work.

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10 replies »

  1. Great article. Clearly shows why bureaucracy should stay out of the metric business. Too slugish, too inept, too corrupt. It will take 50 quarterly meetings to change the innapropriate surrogate endpoints they developed. Just considering your point on LDL, I imagine that the pcsk9 crowd is stuffing our “representatives” with all the wine and lobster they can stand trying to get this guideline to stick. CMS will continue to do what its masters tell it to do, in spite of evidence, and in spite of what is right for patients.

  2. I posted this on Twitter, but I am going to repeat here.

    I think what we need is a little more high concept than a simple reboot and a time out.

    I think we need to look closely at what we’re asking and what we’re trying to accomplish. The fact is that digital policy initiatives that rely on technology are too easy to authorize and difficult to manage and understand.

    I think we need a “Digital Paperwork Reduction Act” to establish a process by which new rules are developed, tested and authorized. New ideas should be tried and tested, absolutely. But we need more control over the system.

    We need to know what works and what doesn’t and how much it costs. And most importantly what trade-offs are involved.

  3. I echo what Dr. Rob and Dr. Hans have to say.
    Indeed, you have to stop punishing doctors unless they have done something unethical or wrong. Not using a poorly functioning computer does not qualify.
    There has been so much contamination of the whole IT phenomenon, it has ruined patient care. The swamp needs to be drained, and the focus needs to be on improving patient care. Not data mining, not facilitating someone’s pet project or special interest lobby.
    I appreciate your attention to this.

  4. Andy,
    You appear to coming to our side. The front line provider. You are getting strong headwinds from ONC (Karen) and others, we can all see that. You want to hear from front line providers? OK then listen up.
    1. Stop all the nonsense complicated regulatory schemes. Massive complicated formulas that penalize physicians are doomed to fail. I cannot believe you said, ” And frankly I never have and hope never to meet a physician that cares more about an incentive payment than doing what they think is right for their patient. ” Then Andy, stop penalizing physicians for not doing what we feel is right for our patients. MU is a complete disaster along with all the other complicated silly programs of PQRS, CQM, MIPS, MACRA, etc.
    2. Stop excessive measurement. Stop making physicians data entry people, we are terrible at it, and you will not get good data, ever. We are care givers and you are removing us from the most important part of that equation.
    3. Let the EHR market work for providers, NOT for policy. Right now, all EHR vendors want more policy to prevent innovation into the market. Its a terrible market. All vendors do at this point is develop products that meet complicated regulations from CMS. Stop that madness. Let EHR vendors work directly with providers to give us what WE need, not what you THINK we need.
    4. I want to throwup in my mouth, every time Karen or you talk about interoperability. You have NO idea what that is. Its not some CCD that gets blasted to an HIE. Its my ability to review a patients record without hassle, multiple complex logins, and with extreme efficiency. Otherwise, its useless. Thats why we still fax records and make patients pick up CDs of images of X-rays/etc. Its just not happening now, nor anytime in the near futures. Karen says we should note a difference by fall 2016…excuse me while i laugh myself silly.
    4. Stop shaming physicians about our performance and data entry and tolerance to all these extra burdens.
    5. Continue to listen and listen closely to front line providers. NOT to policy DC types. If you lose us, we leave Medicare, we are not coming back. And you are in danger, grave danger of losing many of us forever. And that would be you and Karen’s legacy. Karen, put you rose colored glasses on, because you have been the leader through the most detrimental disastrous, awful period in the history of patient care. Count all the EHR numbers you want, but costs have gone up, patient care and safety has gotten worse, efficiency and usability is a nightmare, and you have lost the hearts and minds of physicians. Put a positive spin on that Karen.
    6. Yes we are angry. We are not going away. We are going to start fighting you every step of the way. AMA may have sold us out with MACRA, but we can continue to ignore your stupid MU programs and all the complicated penalizing PQRS, MIPS and MACRA programs. I wonder how many of us have to quit, retire, move on, kill ourselves or stop accepting Medicare, for you to realize you are the harbinger of this travesty.

  5. I was initially one of the early champions of EMR (installed in 1996) because it allowed me to give better care more efficiency. This was not only good for my care, but it was good for business. My hope with MU and other programs of that time was that the use of EHR by the larger population of docs would enable sharing of data and more efficient systems. I was even part of a team (including ONCIT honcho Farzad) that presented EHR to the CDC prior to meaningful use. But obviously the story took a tragic turn as EHR vendors dumped usability and patient care quality for MU certification.

    I’ve come to believe that the problem was not MU itself that caused the total malfunction of EHR as a clinical took, but it was the system itself that broke things. MU was but one more message consistent with previous messages touting data over outcomes, checkboxes over care, and a centrality of the record over the person whom the record supposedly existed.

    Our system will corrupt good intentions and clever plans, because our system is not about care, it is about codes and data submission. When the whole of how a doctor is paid is not based on the quality of service and care the patient sees, then the patient quickly goes to the back seat and becomes nothing more than the raw material on which our system runs.
    I know this because I experience the transformation first-hand, where a decent EHR product became useless because of the corrupting power of our payment system. I also know it because I left that payment system three years ago and have none of these problems with my EHR system any more. Since I am paid based on the quality of service and care my patients feel they are getting, I am motivated to center the record on communication and accuracy and accessibility of the data. I am increasingly using the most logical interface with the rest of the system there is: the patient, who happens to be present and pretty much all of their own care. I put their records in their hands, using mobile technology to bring their records wherever they go.

    The difference could not be more dramatic, both in the record system I use and in the care I use it for. While I applaud this effort to take back the mayhem caused by MU and the other document-centric parts of our system, I don’t think this will be enough course alteration to keep the Titanic from hitting the iceberg. Some of us are betting on the re-alignment of primary care with the patient (DPC) through high access and transparent pricing. I now have nearly 700 patients and it is working well so far. Changing records without changing the system itself is like putting icing on a pile of dirt.

  6. Now, I’m just a country doctor, but after years of trying to make a couple of very primitive, yet “certified”, EMRs document all the things I do for my patients so fast and so automatically that a non-medical observer couldn’t even begin to perceive what’s going on, I can’t believe there are people who hope to measure quality by analyzing the documentation in today’s medical records.

    We have the computer technology to analyze how a bird flies, how a dog’s tongue laps up water and how an athlete’s every joint moves. But we make doctors hunt, peck and click in systems that remind me of my first Atari home computer.

    Why can’t our EMRs accept input in any format and then digitize and store it where CMS and the insurance companies need it instead of making the flying bird slow down long enough to explain what it is doing? Will its flight get better that way?

    The other day, conducting a complex Transition of Care Management Visit (Hospital Follow-Up in Olde English, now 99596), I lamented to myself:

    Why does anybody make doctors scroll their way through a simple lab report instead of viewing it in one screen shot? Why do we have to read hospital reports in formats that require a 10 cm focal distance and whose idea was it to require closing out the “read” window entirely in order to get to the “type” window (Microsoft solved that issue in the 1980’s with ALT+TAB, but our EMRs don’t have it today). And on and on and on…..

    Why punish or incentivize doctors when the technology essentially isn’t mature enough for everyday use yet?

    All this hoopla is truly a case of putting the cart before the horse. Give us and our overseers the adequate technology to properly record our work first, then we can talk about assessing the quality and value of what we do!

  7. Dear Mr. Slavitt,

    In the early 1870’s, Menger, Jevons, and Walras independently elaborated the so-called Subjective Theory of Value (SToV) which has become the basis of modern economic theory and is disputed only by minority heterodox schools of economics, such as the Marxian school. (see, for example, https://en.wikipedia.org/wiki/Subjective_theory_of_value).

    According to the theory, economic value is inherently subjective and can only be determined by the consumer of the good and service. In a healthcare setting, the theory would entail that third-party payers would be incapable of making sound value determinations. Do you think that this limitation accounts for the out-of-control healthcare price inflation that has occurred since the advent of third-party payment, and in particular since the government took on that role 60 years ago?

    The theory would also imply that no amount of information technology could overcome the knowledge deficit of third parties since value knowledge is subjective and resides in the mind of patients. Would that render any plans to overcome this gap with more spending on technology counterproductive or even futile?

    Your comments would be truly appreciated.


    Michel Accad