Tuesday, October 8, 2013

Advice to the Next National Coordinator

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.


Anonymous said...

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 carrots and sticks 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 under utilized by all of the National Coordinators, but could be leveraged as "fiscal pressures" continue in the future during the "expansion era".

Anonymous said...

Great list, but I would add one more: extend the Stark Exemption allowing for hospital to donate up to 85% of the cost of EMR applications to physicians.

Will Ross said...

John, Great suggestions. From the perspective of an operating HIE services provider and Healtheway participant, I second your last three suggestions, especially the converging points about poorly optimized legacy EHRs and over-utilization of clinical data reporting requirements that are, frankly, poorly suited to an emerging era of pervasive interoperability. I highly value the recent increase in adoption of EHRs, but their silo database schemas and thicket of overpriced interfaces not so much. Finally, I'd like our FACA teams to consider slowing or reversing the growth of certification and accreditation schemes, which to date add to operating expense and deployment complexity, which are surely the opposite of their intended impact. Keep up the great work! [wr]

Anonymous said...

I am guessing the next National Coordinator for HIT will spend more time in Congressional hearings as national organizations for physicians and hospitals sweat the imminent "payment adjustment" phase of the EHR Incentive Program that begins in 2015 and go to their legislative champions. Thus, the next National Coordinator will need to be a master politician; or minimally, a master at communicating complex topics to politicians.