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Interoperability Plan Underwhelms, Mostashari Resigns: Now What?

 |  By smace@healthleadersmedia.com  
   August 13, 2013

In seven weeks, providers are supposed to be implementing stage 2 of Meaningful Use. The government's interoperability plans are lacking. And a key Washington player says he's leaving the scene. It's starting to look like a calamity.

As if the turbulence of July 2013 on healthcare IT wasn't bad enough, last week things got arguably worse.

First, Farzad Mostashari, director of the Office of the National Coordinator (ONC) for Health IT at the Department of Health and Human Services, announced he is resigning, staying on just long enough for a replacement to be found.

Then, one of ONC's major projects of 2013, a strategy by CMS and ONC to promote interoperability in an industry that desperately needs it, made its underwhelming debut, overshadowed as it was by Mostashari's resignation, which hit during the same 24-hour news cycle.

How underwhelming was the ONC/CMS plan, itself a response to comments on an earlier request for information? Highlights of the initiative related to health information exchange tell the story:

  • Accelerating Interoperability and Electronic HIE through Payment Models Require electronic HIE in all advanced payment models and Medicaid waivers
  • Extend Center for Medicare & Medicaid Innovation (CMMI) efforts
  • Include Long-term care and post-acute care (LTPAC) and Behavioral Health (BH) in State Innovation Models (SIM) grants
  • Direct incentives for LTPAC and BH providers
  • Explore additional reimbursement codes for care coordination via telehealth, e-visits, radiology queries, and Evaluation & Management
  • Require electronic HIE standards as regulatory requirements for quality measurement and conditions of participation
  • Extend Regional Extension Center (REC) support
  • Extend Stark and Anti-kickback exceptions for donations of EHR software

The RECs are doing fine work, and it's all well and good for CMS and ONC to want to extend support for their work in the hopes of moving health IT interoperability forward and provide necessary training, but that will require Congress to act to extend that funding.



Russell Branzell, president and CEO of CHIME

You had to be pretty technical, and dig down deep into the 14-page document, to find anything that really impressed. I did find this:

ONC, through the HHS Entrepreneurs Program, is developing targeted, open source toolkits ("Health Information Service Provider [HISP]-in-a-box and Admission, Discharge, and Transfer [ADT]-Alerts-in-a-box") that can be rapidly and cost-effectively deployed by a wide range of health care entities including those that are not eligible for the EHR Incentive Programs (e.g., SNFs, surgery centers, and home health agencies).

Still, it was hard not to feel a sense of dashed expectations from this, the major work product of ONC's year of health information exchange.

Searching for insight or perhaps some encouraging words, I spoke last week with Russell Branzell, president and CEO of CHIME, the College of Healthcare Information Management Executives.

"I'll give kudos that they're addressing these concerns," Branzell told me. "The right people are listening. We went into meaningful use pretty quickly during a period of economic turmoil in the country, probably without the homework we should have done on the front end of what this might look like.

"Now we've got some chances to fix stuff, so I think ONC and CMS are both very strongly interested in getting the right things moving in the right direction."

Continuing the direction analogy, Branzell says "we're probably heading in the correct north direction overall. The difference is we're not heading true north yet, which is fine early in a journey, when you're only 50 miles away from your original starting point, if you're only a few degrees off.

"But if you're a thousand miles down your journey, and you start off a few degrees off, you're a long way from your target line. We're still early enough in the journey that we've got to make some of these corrections, and really a lot of this does have to do with the way the law was written, [and] the way the interpretation of standards and certification requirements come out."

Branzell astounded me at one point, noting that some providers are on not just their second, but their third electronic health record implementation.

It's actually not that inconceivable. In the initial rush for the ONC incentive money, too many organizations picked more than one EHR, one for inpatient records and one for outpatient records. That was bound to be trouble.

Not only that, but large organizations have been gobbling up practices and smaller organizations all this time. Numerous acquired facilities have been ripping and replacing their first choice of EHR to match the new parent company's preference.

Moreover, Brazell said, "a lot of people jumped in because they knew that the sand in the hourglass was running out, so they [were] slamming systems in, [and] probably didn't do the right transformation or process change, and now are going, 'okay, we got those first payments, but now we realize we should have done this a little bit differently.'"

Noting that some large organizations are acquiring multiple smaller organizations, Branzell characterizes the work underway as "not multiplicative work, but rather exponential increases in work, because each one of those small systems are pretty tough to convert. I've talked to CIOs all over the country, and that's probably one of their major pain points right now.. the ambulatory conversion factor that they're having to address."

While we try to determine just how much money might have been wasted by these multiple EHR implementations, Branzell said most organizations have not yet begun their work on meaningful use stage 2. How could they? Only a handful of certified EHRs for stage 2 are yet available. In just seven short weeks, providers are supposed to be implementing. It's starting to look like a calamity.

But perhaps we should keep our eyes on the horizon, no matter how rough the trip. One encouraging sign is that CMS is starting to consider making health information exchange part of the criteria for Medicare payment.

"We cannot have it be profitable to hoard patient information and unprofitable to share it," Mostashari said last week. I can't imagine market forces doing it by themselves.

CMS must take more action, and Branzell thinks it's inevitable. States cannot solve this problem by themselves. "My previous organization, a third of our patients came from two other states, because we were on a border," he says. In such a scenario, connecting to the HIE in one state does not solve the state-to-state interoperability problem.

"What we really need is a framework," Branzell says. "I don't think it will adapt as fast as the needs of the industry, whether the [ONC] Standards and Interoperability Framework will really give us those things that we need."

The current approach, built around flexibility and modularity, let the healthcare IT industry "kind of adapt to itself," Branzell says. "The general approach, I think, is flawed. I'm not personally a big government person, but I think there's a really strong place here for the government to much tighter rein in the guardrails of where the variation can occur, to give us a smooth path to where we need to get to."

There you have it – the dog days of summer 2013, a good time for healthcare CIOs to take a break if they can, if they believe that things will turn around when they return in September. Meanwhile, I do wish ONC and HHS leadership all the luck in the world. Losing Mostashari now is the last thing they need.

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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