Micky Tripathi is president and CEO of the Massachusetts eHealth Collaborative, a nonprofit consulting firm that helps ambulatory providers of all sizes successfully adopt healthcare IT. It also owns and operates the regional extension center of New Hampshire. Tripathi also serves as chair of the ONC HIT Policy Committee’s Interoperability Workgroup, and as co-chair of its JASON Report Task Force. Look for his regular “Pretzel Logic” posts on HIStalk Practice in the coming weeks.
Your experience in the realms of RECs, HIE, consulting, and on-the-ground implementations likely means you have spent ample time listening to the wants and needs of physicians. At this stage of healthcare IT maturity and the timeline for Meaningful Use, what are physicians most concerned about with regards to technology?
They just want it to live up to the hype, or even to just half of the hype. I think that the vast majority of clinicians see healthcare IT as inevitable, and that’s not just because of Meaningful Use. There are other, more powerful market forces that are pushing in the same direction, such as:
- Higher standards of care
- Risk-based purchasing
- The growing consumerism of patients, including demand for retail service levels and emerging cost-consciousness
- The need for greater efficiency in the face of competition and cost-pressure
- The generational change to tech-savvy providers and
- Pressure for cost and safety transparency.
The healthcare delivery sector has held out for a long time, but no sector of the economy can remain paper-based, and the vast majority of providers now recognize that. However, the bad news is that healthcare IT systems are still very immature from a usability perspective, especially with respect to interoperability. The biggest provider concern that I hear is that healthcare IT all too often still gets in the way of care provision, rather than enhancing it.
MU is increasingly being managed as a “check-the-box” exercise because it has requirements that are seen as more beneficial to the “healthcare system” (whoever that is) than to the day-to-day, point-of-care needs of patients and providers. The only way for systems to really get better is through more feedback from more users, and as with every other industry, that takes time. Steve Jobs didn’t invent the iPhone and iPad on day one – it took the insights gleaned from millions of customer-hours of experience to develop what in hindsight seem like simple and obvious breakthroughs.
Do you think federal groups like the HIT Policy Committee truly understand these perspectives enough to act on them?
I would say that the HIT Policy Committee is becoming increasingly aware of the complexities of the healthcare delivery market and the healthcare IT market. Stage 1 of MU was tremendously successful in terms of creating an imperative for change and catalyzing rapid adoption of EHR systems as tools to help facilitate such change. However, moving beyond basic EHR adoption is exponentially more complex because of the fragmentation of our healthcare system both on the supply side (i.e., providers) and the demand-side (i.e., payers, purchasers, patients).
As we get deeper into it, we see that it’s more complex than anticipated, not less. Just look at the Stage 2 requirements for Direct transport – a seemingly simple technology, yet it still doesn’t work for the vast majority of providers because it takes time and experience to iron out all of the wrinkles in workflows, business conventions, technology, and industry infrastructure.
Earlier this year, the HIT Policy Committee rejected many of the initial Stage 3 recommendations from its Meaningful Use Workgroup and asked them to scale back and simplify their approach. I see that as a good sign that the message is starting to bubble up to the top.
What was your reaction to the ONC’s 10 year interoperability vision statement? Do you think this plan reflects the goals of the physicians you work with?
I think the industry needs a concrete vision statement from the federal government. Not because the government can or should dictate how interoperability unfolds across the industry, but because the industry needs to understand what the government intends to do so that the market (providers and vendors) can take that into account as they make their investments in future technologies and infrastructure.
It’s great that ONC is putting out a vision, and I understand that ONC is going to flesh it out further over the next few months. I highly commend Dr. DeSalvo and her team for actively seeking market and stakeholder input. As a high-level view, the 10-year vision is certainly inspirational, but based on what we’ve learned about the complexity of the market, I fear that many will see it as somewhat unrealistic as well. For example, the three-year agenda is to be able to “send, receive, find, and use health information to improve healthcare quality.” Right now, we still aren’t even close to having the ability to easily send and receive, so “finding and using” in three years seems like an especially large challenge.
In a similar vein, having a “learning health system” in 10 years will also be very difficult to achieve. We shouldn’t be too critical at this stage though. Once we get more details on how ONC defines and anticipates achieving these objectives, we’ll be in a much better position to fully evaluate it. I’m sure we’ll see pockets of activity that achieve these goals. As William Gibson said, the future is here, it’s just not equally distributed. I assume that the 10-year vision is speaking to goals that are achieved across the market. As the market leverage of Meaningful Use draws down, the government’s source of influence in the healthcare IT market will be less about how much it pays and more about how it acts.
I think that the upcoming ONC plan will be helpful to the market if it clearly articulates what role ONC sees the government playing in shaping interoperability in the future, and how that translates into specific actions that the government is going to take.
Was it surprising to learn that only between 1 and 2 percent of EPs have attested for MU in 2014, with fewer than that attesting for Stage 2? What do you think will help accelerate this process?
We work pretty deep in the trenches and have seen first-hand the difficulties that providers and vendors have faced with Stage 2 of MU. However, it is surprising to see how profoundly those difficulties are being felt across the entire industry. Some of that I’m sure was the result of people phasing their ICD-10 and MU efforts. Now that ICD-10 is delayed, I think we’ll see the numbers pick up since there are still significant dollars on the table at this point of MU. That said, I think the message couldn’t be more clear that Stage 2 requirements have tried to push too much change in too short a time, and CMS, ONC, and the HIT Policy and Standards Committees need to take that to heart as they lay out the future of the MU program.
What advice do you have for physicians playing catch up with Meaningful Use?
For most providers, I don’t see how you can practice medicine in the future without an EHR, for all of the reasons noted above. If you want to get Medicare to cover some of the cost, you’re about to miss the payment bus and you’re going to get run over by the penalty bus if you don’t act fast. You’ve missed the opportunity to get the full incentive ($44K), but you can still get $24K if you act now. After this year, there will be no incentives available and you may start getting penalized 1-3 percent of your Medicare billings. Medicaid incentives are larger, last a lot longer and have no downstream penalties, but it’s harder to qualify for them.
I think you’ve got to do the math, though, even if you’re already in the program, and decide whether it’s worth it to keep going. When you do the math, make sure you take into account the penalties that could begin starting in 2015 (and don’t forget to take into account the time value of money – if you don’t know what that is, have someone else do the math for you!).
The reality is that the incremental payments for Stage 3 will be relatively small, but the hard and soft costs of achieving Stage 3 once it’s defined could be quite large, given what we’ve seen from the Stage 2 experience. You don’t want to make hasty decisions that end up costing you more than you gain from the MU program. I know of large and small providers who have done the math and decided to drop out of the program and take their lumps down the road. Remember, it’s not a mandate, it’s an incentive – you don’t have to do it.