The World in 2016: MACRA, a New Era For Meaningful Use and (Yet More) Political Change to come

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THCB is pleased to introduce the 2016 Healthcare Town Hall, a special online feature brought to you in partnership with Health Catalyst. This is an experiment. The idea is to open up an ongoing dialogue around the issues that are transforming healthcare in the second decade of the 21st Century.  

We’re kicking things off with an online panel featuring THCB Editor John Irvine and the HealthCatalyst leadership including Dale Sanders, John Haughom and Bryan Oshiro. 

John Irvine: Let’s start with the recent decision at CMS to transition from the Meaningful Use the program to a new program that will be a component of MACRA.  A lot of people were extremely surprised with the news that Meaningful Use is going away. The follow up development, of course, is that CMS has agreed in principle to a new set of core clinical quality measures that will change the way doctors are evaluated. I’m hearing a lot of positive feedback about the Meaningful Use decision. Reactions?

Dale Sanders: I was surprised, yes. As I think you know, I’ve spent a lot of time in Washington. I know how government works. People in government generally do not reverse themselves, unless it is very clear that there is no other available option. That’s Washington 101. Read into that what you will.  It’s far easier to allow a program to keep on going than to admit that something isn’t working or that it has outlived it’s usefulness. I think a lot of people are missing the fact that It took political courage to do that.  I will say that I was one of the first to publicly call for the suspension of Meaningful Use, and you guys posted the blog that I wrote about it. At Northwestern, we published a one page policy entitled, “Principles of EMR Utilization” that was written and endorsed by our physicians, facilitated by me when I recognized that our EMRs were being used for little more than a multi-million dollar word processor. That one-page document is all we needed to achieve the same concepts as Meaningful Use. The last time I counted, the Meaningful Use regulations totaled over 350 pages. In typical fashion, the government turned a good concept into a mess. So, I’m cautiously optimistic that we are going to return to common sense.

Bryan Oshiro:  The intent of Meaningful Use was noble.  However, it placed a great deal of burden on physicians.  Who would not want to use technology to improve quality, safety, efficiency, and coordination of care for the purposes of improving the health of the population.  At the same time, Meaningful Use incentives made it easier for doctors to afford the transition to purchasing a technological solution.  It was also helpful that the implementation of this transition  was staged.  The first stage concentrating on data capture and data sharing.  However, this goal was only partially met.  Indeed, the medical information was being captured electronically, but there was no standard way of inputting the information and therefore analyzing this information to improve patient care was difficult to do.  Furthermore, data sharing was made more difficult due to the fact that there was no incentives for interoperability between systems.  There was enough angst and push back that there was a reconsideration to get away from  regulating a way to get to improved outcomes as outlined in stage 3. The unintended consequence was the increased time and workload burden that was placed on physicians.  

John Haughom: On the other hand, a lot of people would say yes, we spent a lot of money and sure there were some problems, but in the end we got where we wanted to go. The EHR adoption numbers have shifted dramatically. Since 2008, they’re up from 9% to nearly 60%.  

John Irvine: That’s true. It’s a very impressive jump. There’s clearly a lot of potential. I think that’s why people are so frustrated. This is not unimportant stuff.  There are so many cool things we can be doing here.

Bryan Oshiro:  Clearly things were not working as expected and something had to change.  I was encouraged from what Karen DeSalvo, acting assistant secretary for health and Andy Slavitt, acting administrator for CMS said at HIMSS. Clearly there is a renewed focus on interoperability.  This will be good for physicians, hospital systems and patients.  However, the issue of usability needs to be addressed.  The EMRs are still not easy to use.  Ordering medications is very cumbersome.  Navigation is not easy.  The EMR still adds an increased burden on a physician’s time.  And, it has not improved the physician-patient interaction.We are paying more attention to the computer screen and not on the patient.

Dale Sanders: Allow me to rant.

John Irvine: Please rant.

Dale Sanders: This is the sort of thing that makes sense on paper if you’re a bureaucrat sitting in Washington and never works in the real world. We have 20-something kids with brilliant IQs and wonderful intent, but no real world experience writing all of these regulations. “Oh yeah, sure that makes sense, we’ll do that. We’ll incentivize them. And then we’ll measure how well they’re doing. And yeah, it’ll be great.” And it doesn’t work out that way. And everybody stands around scratching their head wondering why it isn’t working? There’s a reason that EHRs didn’t sell on their own and required federal money to create the demand. Their value to efficiency, quality, and cost of care is simply not compelling, yet.

John Haughom: So true. That’s why I’m excited. And why I think it’s important that we move on. There’s so much potential.

John Irvine:  So, the future of MACRA. We now know a lot more about what’s up ahead than we did. Last month CMS announced core clinical quality measures in key areas, the idea being that the quality improvement process needs to be streamlined.  What can we expect to see from Washington? Are you cynical? Cautiously optimistic? Any thoughts? More to the point, what do you think we need to see?

Dale Sanders:  I’m pleased that meaningful use is going through an evolution, but having been in this game for a long time I tend to be on the skeptical side. How many quality metrics are we tracking now? There are 1,958 quality metrics in the national clearinghouse and only 7% of those have anything to do with patient outcomes. The rest are process measures, not quality measures. We are measuring what docs do, not what they achieve for patients, believing that reducing variability in process will inherently lead to a good outcome. But I could care less how physicians achieve a good outcome for me, as long as they are ethical and affordable; it’s the outcome that matters. We’ve gone nuts with measures that don’t really matter and actually alienate physicians’ sense of purpose and autonomy.

John Irvine: What do you make of the core quality measures?

Dale Sanders: As I mentioned earlier, we are not measuring quality. We are measuring processes and variability, with the assumption that reducing variability in processes will lead to better outcomes. There is some truth to that assumption, but if you think about it, personalized medicine is the antithesis of standardized medicine. We should throw all of the process and quality measures away, replace them with patient reported outcomes, and make those publicly transparent, because outcomes are all that matter. Let physicians and organizations figure out whatever process they want to use to achieve great outcomes, both clinically and financially.

Bryan Oshiro: I think we need to look very closely at what quality measurements we’re rolling out and what we’re asking of people. It’s clear that we’re asking a lot from people.

John Irvine: Sure. Bob Wachter, who is a guy a lot of people look to for leadership in this area,  had an opinion piece in the New York Times recently that basically made the point you’re making, which is that the measurement thing has gotten a little out of hand, we have to be a little more selective, perhaps a little more thoughtful about what we do with measurement. What matters? What doesn’t?

John Haughom: This is the way doctor politics work. I’ll tell you what people respond to.  They respond to things that are meaningful to them.  We need to give them data that is meaningful to them. Then they’ll get excited.

Chris Keller: We’ve done a lot of work at HealthCatalyst around this. I was part of a team that went to Europe this summer and talked to a lot of really prominent people doing work with quality measurement, which was a pretty great introduction to the field. We like the idea of user-driven quality metrics. If I’m a patient, what’s important to my life? If I’m a doctor, what matters to me?  How are my patients doing? How are my colleagues; patients doing? A lot of this stuff that matters to patients just doesn’t get measured in the medicine of today. I think we are on the cusp of seeing that change for the better with some of the interesting work being done by ICHOM and others to measure outcomes that patients care about.

John Irvine: That’s how you get people involved.

John Irvine: If there was a story of the year in health IT 2015, it was probably physician dissatisfaction with electronic health records.  The electronic health records industry has taken a lot of heat for producing products that frustrate users and that lack innovation. Do you see a light at the end of the tunnel?

Bryan Oshiro: Usability is a huge issue for not only physicians, but any health care team member.  There are some companies that have niche products that work well.  However, the industry as a whole has to fundamentally change the way their EMRs are designed.  

John Irvine: What is needed in your view?

Bryan Oshiro: Functionality is key.  A system should be highly intuitive to use.  Put the most relevant information right in front of me, at the right time, in the right place, and the proper context.  The system should also allow me to communicate information to other relevant team members.  The same information should not have to be repeatedly entered by a nurse, doctor, receptionist, etc.  Decision support tools should be easy and simple to use and be contextual.  The care team should be able to partner with patients in their own care.  Thus, there is a huge need to build systems that incorporate the patient into the system.  Messaging, alerting of potential problems, reminders, questions should easily flow between patients, providers and the care team.

Dale Sanders: We violated every law of common sense when we used $30B in federal money to stimulate the uptake of today’s EHRs. Imagine what would have happened if we dangled just $1B of that in front of modern software engineers in a winner-take-all competition to build a compelling, new generation EHR. The reason that physicians and healthcare systems didn’t buy EHRs with their own money is because the current design of EHRs adds little or no value to a physician’s ability to apply their skills in the best way possible, or engage patients in their own care. The entire industry sunk money into products that most physicians don’t want and we are going to live with the consequences of that multi-billion dollar decision for at least 10 years. In the meantime, there will be a new generation of EHR emerge that will finally offer what the industry needs.

Bryan Oshiro: I am starting to hear talk about all kinds of cool stuff. Lots of stuff that’s coming out for the iPad on the visual representation side. Things that people are doing to reduce the information overload, give people better hands on their data, to communicate with other members of the care team.  One of the things I’d like to get out of this exercise, I’d personally like to hear what people are using. I’d also like to hear what they want to be using.

John Irvine: I’d like each patient’s screen to be customizable, so I see the information I need. It’s going to be different each time, you know.  And tags. Something to allow me to order the information I’m dealing with in the way my brain works. Not the way a developer sitting in a cubicle works. I think essentially what you need is something that’s something like an CRM system. This is patient relationship management, after all.   

Dr. Mitra: I like that term, because it really is the doctor patient relationship we’re talking about.

Bryan Oshiro: One of the things we’re hoping to accomplish with this conversation is learn a little bit about what people are doing. What new tools they’re using. What they think the next generation of tools should look like.  This is the kind of conversation the internet is perfect for.

John Haughom: If I were a young physician today, I’d be thinking about ways to create tools to help physicians work with live data. Give people access to data that they can use in real time. Then they’ll get excited.

John Irvine: I agree. If I’m a young doctor coming up today, I thinking about all of the data in my EHR and I’m salivating. Man, give me better tools. Let me get creative.

Dale Sanders: That’’s something we already do at HealthCatalyst, to an extent. We go in and we teach people how to think about data. We call it data literacy. How to tell good data from bad, how to get a team together and understand what you have and what you can do with it. A lot of people are making really basic mistakes that limits their data’s value or distorts their findings — which obviously can be a dangerous thing. We do a lot of work around data literacy.

John Irvine: As you look in the world in 2016, what do you see? What are people thinking? What’s on doctors minds?  What are young doctors thinking? Are things starting to shift after a couple of years that saw a pessimism?

John Haughom: I think we’re starting to see the light at the end of the tunnel. People are starting to adjust. They’re getting it.

Bryan Oshiro: One word. Uncertainty. People are wondering what’s coming next.  

John Irvine: What are they talking about?

Bryan Oshiro: Meaningful Use was a big  issue. Physician reimbursement is also a major concern for us.  Repealing the SGR was huge.  But we’ll have to see what the payment reform components to MACRA is going to look like and how that will affect the way the we practice medicine.  Again, the intent is good.  It’s really going to be in the execution.  But, we still live in an uncertain world.  Depending on who is going to be governing, it may bring about significant changes to health care law.  What’s going to happen with the Affordable Care Act? We’ll have to wait and see after the elections.

Bryan Oshiro: Ha. Exactly! Exactly. Just tell me I can handle it. What I hear around the country is that this has all been a distraction, people want to get back to work. But if you tell me the Affordable Care Act may go away and we may have to do this all over again. Well, then that’s another story. That’s a pretty scary thought.

John Irvine: Which brings us to the very large elephant in the room. The 2016 Presidential election.  Many of the Republicans are pledging to repeal and / or replace the Affordable Care Act. That’s going to be very hard to do.  But there are a lot of people who think that if we have a Republican in the White House things could get very interesting.

Dale Sanders: That’s an understatement. The Affordable Care Act has major problems, no doubt about it, but it’s not going to be repealed. Too many voters are benefiting from it. But, it should be reengineered, and it should focus much more on changing the economic model of healthcare in the US that encourages so much waste. If the US government would act like the world’s largest healthcare customer instead of the world’s largest healthcare government, we’d be much better off.

John Haughom: I think doctors are used to this. There’s always something. I suspect it will have a lot to do with how the election plays out. If we get to summer and we’re in a horse race, I think people will start paying real attention.

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5 replies »

  1. Thanks for this great exchange.

    Dale, have any of you guys looked at the proposed rule yet?

    Advancing Care Information is an improvement. Meaningful Use had some unfortunate overtones that critics were quick to pick up on. Advancing Care Information is a pretty good choice, I think.

    Although there may be some confusion with ACI and ACOs?

  2. Good dialogue. I just want to second Dale Sander’s comment near the end…that if the federal government seriously leveraged its role as the world’s largest purchaser of healthcare….we’d all be better off. Absolutely!

  3. My 2 cents and in response to James Purcell: an intuitive EHR for physicians should have been the focus and very foundation of health IT. I’ve discussed this repeatedly in this blog and on my blog (http://noshemr.wordpress.com) last year. MU and now MACRA, in my view, still fails to really address this. What works for physicians is so variable from specialty and setting that it is unlikely that there is a one-size-fits all approach; however, the idea that some EHR company will be willing to address this seems to be more and more unlikely due to the lack of physician input in development of these interfaces.

    Hence that my proposal that an intuitive EHR design ought be started from an open-source project (such as mine, NOSH ChartingSystem) so that there is an open invitation for all medical providers to peek under the hood and provide feedback about how to make it better. A closed license model is both highly restrictive and unable to foster the type of environment where we truly have a peer-reviewed development of such an important tool such as an EHR. All of these dreams of utilizing the data from EHRs is moot if the data coming in is garbage or unreliable due to poor EHR interfaces.

    An accurate health record, that James and others talk about is also a dream of mine that I don’t believe will be fulfilled with the approach that MU and MACRA are focusing on. We are dealing with a fragmented system of care and subsequent fragmented health records from institution to institution with non-interoperable EHRs…forget about quality of care, we’re dealing with the risk of patient safety that also is not really given much mention.

    I’ve been working with Adrian Gropper about the idea (and this too was posted in THCB from Peter Elias) regarding the concept of the patient health record that is the one true source…a decentralized, yet distributed version of a patient health record system that at its heart works as an EHR that many physicians or care providers can input into this one patient record system. A test demonstration of this concept is already a reality. The open source EHR driving this concept is already a reality.


    With the current landscape where non-intuitive, non-interoperable EHRs is the norm, I suggest you consider this alternative where both patients and physicians really can have a voice.

  4. Rant (sorry):

    Stop trying to structure the EHR so much a let it grow from the ground up. Let the years go by. Put your energy into AI so that we are helped getting a good diagnosis (there are over 4000 inherited metabolic diseases, for example.) Computers and HI can help docs learn too, through new educational approaches. Try to recall that healthcare is partly art and that quality and outcome words don’t have meaning in art. It’s nice to think anout outcome and how to measure it but outcome for the patient–say, reduced pain and disability, give opiods–does not mean outcome for the disease–is it cured or modified?–and does not mean outcome for the family–is the patient a heavier burden?–does not mean outcome for the population–is the contagion stopped?–does not mean outcome for science?–do we now understand something deeper?–does not mean outcome for the payer. Ditto above with quality.

    If we can get a lot of diagnostic help and newer educational tools from IT, just think of the leverage we will have in using NPs and PAs; and healthcare access will zoom and prices will fall.

  5. Good discussion. What I’m hoping I’m hearing is that EHRs ARE a good thing. I know that’s a fundamental premise, but so often I think I hear physicians implying that they wish EHRs would go away. The concept of my accurate health record anywhere at anytime is so important to reduction of waste and error. And presumably with appropriate programming, tools to reduce the variability of delivery (or should I say improper variability).

    So what this really gets down to is how do he get the intuitive EHRs that Bryan described. And yes, reduce and standardize the measures so that they measure what is important to the patient–outcomes. [I suppose we need some quality of care measures since that’s how you get to better outcomes, but someone who knows more than me on the subject should limit them to wicked important ones.]

    I like the discussion format.