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.
