When it comes to the federal meaningful use program, keep your eye on the prize—not the incentive dollars, advised Doug Fridsma, MD, former director, office of science and technology in the Office of the National Coordinator. With complexity rising and dollars declining, the greater objective in your deployment of health IT should be preparation for payment reform.
Recently named CEO and president of the American Medical Informatics Association, Fridsma was a member of a panel addressing “The Future of Federal Information Technology Incentive Programs” at the annual meeting of the Radiological Society of North America in Chicago on December 3.
Fridsma provided an insider’s appraisal of the program to date, real-world perspective on what to expect next and recommendations for the radiology community on making the best of it all. His first piece of advice: Recognize that the incentive moneys were front-loaded.
“We have this paradox in that increasing requirements that come from stage 1, 2 and 3 are actually met with decreasing dollars,” he said. “It is important to recognize that, because it affects how people are going to do the business decisions around stage 2 and stage 3.”
Another cloud on the MU horizon is the current leadership challenge, with executives departing—including Fridsma—at a critical time both politically, with a presidential election cycle approaching, and operationally, with the increasing requirements of the program. “It is going to be a challenge for ONC to get ahead of the curve to be able to lead a lot of this, and that is why I think that CMS and some of these other programs are going to be important to pay attention to,” he said.
For a bellwether of where the meaningful use program will go in stage 3 and beyond, look at choices around the government’s $11 billion acquisition of a next-generation EHR. The quantity of interactions that healthcare has with veterans and the requirements that emerge from that EHR acquisition will impact development of all other EHRs, Fridsma predicted.
“I think it’s important to pay attention to that, because there are a lot of dollars going into it,” he said. “There is a requirement within that acquisition that it align with meaningful use, and certification and many of the other things that we have been talking about within the health IT policy community.”
Health records or bridges
Because the HI-TECH Act was a $23 billion segment of a $900 billion stimulus package, the emphasis was on technology adoption. “I tell you that from experience, having had the vice president call and say, ‘Unless you can spend this money, we are going to send it to build bridges, because we need to get the money out there in the economy.’”
Yet interoperability continues to be a source of frustration for many users of health IT. Stage 1 was more about adoption than interoperability, and stage 2 was more about exchange than interoperability, Fridsma said. “Exchange is really just moving the information around,” he noted. “Sending a PDF image from one place to another is about exchange, but you may or may not be able to use that information that is being exchanged.”
Moving forward, the work of interoperability will be driven by specific goals and private industry rather than government prescription, Fridsma predicted. “Interoperability is hard in the concrete, but it is impossible in the abstract: Interoperability has to be grounded in a thing you want to do,” he said—such as creating recognition that you are using decision support with ordering. “That is something concrete.”
Creating interoperability around specific needs is still hard, but it is possible, Fridsma said. “We have this abstract notion that what we want is interoperability, and all of these systems are going to play with one another, and they all are going to talk with one another—it is almost impossible,” he said.
This is why Fridsma predicts that payment reform will drive further health IT policy decisions. “To succeed under payment reform, including ACOs, medical homes and value-based purchasing, knowing your patients in the data will be critical,” he said. “I’d like to see a world in which you get paid because you have good informaticians, not because you have good accountants. The way you manage risk is by making sure you understand the risks that you have and making appropriate decisions based on that.”
Getting to interoperability
Between budget constraints and the political headwinds of a presidential election, Fridsma said private sector engagement will be of critical importance in moving the federal health IT policy forward. The ONC’s budget is precisely what it was in 2004 when President Bush established the office. “We had a little blip of going from about $60 million to $2 billion and then back down to $60 million,” he said. “Imagine trying to manage change in an organization that had that kind of effect?”
The ONC expects to issue its roadmap to interoperability, a 10-year vision statement to achieve an interoperable health IT infrastructure, early in 2015, and Fridsma urged everyone to respond with specific, concrete suggestions on how to make the plan actionable and concrete.
Do not expect MU stage 3 to push the envelope too hard because of dwindling incentive dollars and compliance fatigue. “There are difficulties with stage 2, they raised the bar and there are fewer incentive dollars available,” Fridsma said. “There is real fatigue given the pace of change.”
Not only are providers feeling the fatigue—so are the vendors and the government enforcers. “We have been going in these 18 and 24 month cycles, which is really fatiguing for the vendors, the doctors, and, quite frankly, for the federal personnel to try to do this in that rapid cycle,” he acknowledged.
Usability and interoperability will need to be driven by market forces in the private sector and not through regulatory frameworks, Fridsma said. For instance, he thinks the new web-based HL-7 standard has the potential to cause some significant change.
“I think it would be a mistake for us to have over-regulated interfaces, particularly if we are thinking about driving innovation in this space,” he said. “I think there will be a focus on application programming interfaces—or APIs—and newer technology, and we have to pay attention to the DOD EHR acquisition because that may be more important in pushing the envelope—and it may pull us back.”
In conclusion, Fridsma suggested that simpler interfaces and finding ways to correct market failures will be the key to success for the private sector, offering data portability as an example with implications for radiology.
“You buy a system, you don’t like it, but it’s going to cost you more money to take your data out and move it to a new system—that’s a market failure,” Fridsma said. “Maybe there are ways that we can leverage federal and government resources to make sure that markets work the way they are supposed to, and that can help us drive things forward. We need to hear about those kinds of stories.”
Ultimately, the patient is going to be the ultimate driver to real change, Fridsma predicted. “Access to technology will change healthcare in ways we don’t understand just yet, and I think the patient is going to be the key.”
To illustrate the latter, Fridsma reached back a century for an example of how patient access to technology drove change in healthcare. Between 1906 and 1912, an extensive series of articles was published in the Journal of the American Medical Association about the physician’s automobile, addressing whether pneumatic or rubber tires were the better choice, and whether the physician should take care of the car himself or hire a mechanic to do it for him.
Henry Ford upended the healthcare delivery model when he invented the Model-T in 1908: It was no longer about physicians getting an automobile to reach patients, it was about patients acquiring the technology and getting to the physician.
“We have a lot of conversations about [health IT] and how it is going to be beneficial to doctors, but fundamentally, the thing that is going to drive change is when patients start to get into it,” he concluded. “Then we have not 500,000 physicians, but 300 million patients who are all driving for change.”