Wednesday, February 12, 2014

Time for a New Optimism

Readers of my blog know that over the past year, I've written several posts warning about the burden of 2014 certification, the  timing overlap of numerous federal programs including ICD10, and my observations that IT professionals/providers are at the breaking point.

However, I have reasons to be optimistic and it's not just the approach of Spring.

1.  There is a new national coordinator who is a great listener

I have every expectation that Karen DeSalvo will gather input from stakeholders and adjust the trajectory of national HIT policy within the limits of regulatory process constraints.  She understands the impact of the current federal programs and the challenges providers face getting through each day.  She knows there is a balance between appropriate regulation and over regulation.   She knows that cultural change, even driven with stimulus and urgency, requires incremental progress over time.   We've already seen a few timeline extensions (an extra year of Stage 2, extra time for hospitals and EPs to attest to 2013 reporting periods) and I expect more to come.

2.  There is an opportunity to rethink certification

With CCHIT's closure, delays in 2014 certified product availability, and significant stakeholder discussion about the certification process, all are aware of the need to revise certification.    I envision a day when ONC and its Federal Advisory Committees formulate policy goals for certification (i.e. quality improvement depends upon measurement), but then those actually doing the front line work (vendors, providers, payers, patients) develop practical certification scripts that ensure software supports the policy goal.

3.   The Sustainable Growth Rate (SGR) bills consolidate PQRS, Meaningful Use and the Value-Based Payment Modifier into a single program, eliminating penalties.

Meaningful Use has been a remarkable program, achieving rapid adoption of EHRs in hospitals/professional offices and fundamentally changing the cultural expectation of automation in healthcare.    The SGR bills transition the Meaningful Use construct from a special program to an operational part of value-based purchasing.    Making IT performance part of operational activities related to reimbursement will even out the pace of work.

4.  Meaningful Use might become a stretch goal instead of a floor

If Meaningful Use moves into a “Merit-based Incentive Payment System”, eliminating penalties, the program becomes a way for early adopters and innovators to be recognized for their efforts.    It was very appropriate that Meaningful Use Stage 1 and 2 set a floor and became a tide that floated all boats.  Going forward, it will be very challenging, if not impossible in a resource constrained world, to ensure every healthcare organization performs on the bleeding edge of innovation.   Merit based incentives enable organizations to evolve at their own pace.

5. Meaningful Use is not the solution to every problem and there are signs that other approaches may be used

It's been an honor to work on Meaningful Use, but by 2016, we need to declare victory to avoid having an ongoing special program through which every interested party inside and outside government sees an opportunity to accelerate their own priorities, creating meaningful use fatigue.   Pilots, grant programs, datapaloozas, pay for performance incentives, and competitions all enable us to move forward the technology agenda with a better balance of benefit/burden than an everlasting Meaningful Use program. 

Finally, as ONC and its committees focus more on interoperability that empowers innovation instead of prescriptive functionality (the EHR must do X, Y, Z), we need a roadmap.   I'm very optimistic that the schedule below (which I sense is developing organically among vendors, SDOs, and policy experts) will lead to much more data liquidity, care coordination and patient empowerment in a timeframe that enables us to overcome cultural resistance and policy barriers:

1.  CCD - unified CCR and CDA, first time vendors began exporting a summary, ad hoc device interoperability  (2011)
2.  CCDA - much more constrained, first time vendors began importing a summary,  Continua Alliance IEEE 11073 products emerge, FDA guidance issued (2014)
3.   FHIR/REST - much easier to implement, will result in a substantial increase in modular products connecting to monolithic EHRs, Continua Alliance IEEE standards recommended, no device data transport standards specified  (2017)
4.  APIs - will expand the number of shared data elements from hundreds to thousands and enable read/write workflows, Continue Alliance IEEE standards required, device data transport options recommended (2020)
5.  Detailed Clinical Models (ie. Clinical Information Modeling Initiative) which will begin to standardize the schemas underlying EHRs and then interoperability can happen via APIs linked to standard schemas, ensuring data integrity from point of origin to point of use, device data transport standards required (2023)

In times of struggle, there is opportunity.   2014 is the most stressful time in healthcare IT in our generation.   From that struggle will come a reasonable path forward we can all support.

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