When it comes to health IT policy mandates, provider organizations have long questioned what’s behind the rulemaking process, with many showing further concern regarding federal leaders’ expertise levels and their lack of willingness to change based on public opinion. At the Centers for Medicare & Medicaid Services (CMS), senior technical director of Medicaid health IT Jason McNamara pays no attention these criticisms. “Those types of comments are tied to the old 1970s and 1980s way of thinking about the government, which was slow and hard to move, which sort of like a battleship in the ocean, took time to change. That’s not part of the government I’m with now,” McNamara says.
McNamara has a wide variety of skills and projects he works on at CMS, ranging from Medicaid electronic health record (EHR) incentive programs to meaningful use rule development to health information exchange (HIE) strategies to consulting on state health IT development under the state innovation model (SIM) grants. McNamara, who focuses on the Medicaid side at CMS, recently spoke with HCI Associate Editor Rajiv Leventhal further about the perception of the government in the health IT landscape, as well as current trends and challenges he’s seeing in the industry from a policy perspective. Below are excerpts from that interview.
Tell me about how you got involved with CMS and what your current role there is?
I work in the data systems group, and if you think about the data systems group, in the context of Medicaid, we essentially work on anything IT related as long as it touches the administration of a Medicaid program or Medicaid beneficiaries. So I like to loosely interpret that as the IT arm of Medicaid. I am a technologist by trade; I spent five years in the Marine Corps, and have trained in communications and technology. I set myself up for a public safety IT focus, which evolved into health IT over the years, and 15 years later, here I am. I also did work as a consultant implementing EHRs, building proprietary systems for large hospital systems, eventually moving over to the Department of Defense (DoD) and Veterans Administration (VA), having worked on their clinical applications as well. I was clinical operations director for ALTA, the DoD EHR system. Then in 2012 with HITECH legislation coming down, I have been managing EHR incentive programs ever since.
What are your insider thoughts on the DoD EHR contract bid?
Well it’s needed, it’s time to modernize that infrastructure. If you look at the infrastructure that’s in place, it’s antiquated. Some of those legacy systems were developed in the 1970s and 80s. Clearly it’s time to change the way they’re deploying their clinical technologies. This proposal will give us an opportunity to modernize a much needed environment. I have to maintain vendor neutrality here, but folks know some of the largest vendors that have partnered to help develop interoperable solutions, and it’s good that they have come to the table here.
What are the biggest priorities right now for you at CMS?
We have been very focused on Affordable Care Act work; we spent a lot of time deploying that, and now we’re breathing easier and are more focused on modernizing our systems on the Medicaid side, moving them into a real-time, progressive, shared-service model across Medicaid states. We are also heavily focused on data, deploying systems both at the state and federal levels to help analyze the massive amounts of Medicaid data we have. That is huge for us over the next 12 months. And then we are of course continuing to work on health IT an HIE, an area that has lot of area for growth both from a policy and deployment perspective.
Ideally, in a perfect world, what would be the role of the government in this industry?
It depends on the topic. If you look at the National Health Information Network (NHIN), that was an Office of the National Coordinator for Health Information Technology (ONC) program, and they managed it 100 percent at the federal level. As time progressed, they changed that and it got run over to a non-profit, Healtheway, who has since taken it over. In that regard, the government was widely used as a kickstarter to deploy that program, which is now self-sustaining in the private market. So I think it was important to push that forward. We took a step back and let the market drive that, and it’s been successful.
Standards are an interesting topic as to what role the government plays, and we’re still trying to figure that part out. There has been a lot of conversation around open source products, as we have been playing with this idea in the Medicaid space. But how do we administer those open source products? What is our role? We have started to dabble in that market, but how do we translate that back into the community and let them market-ize the platform?
Basically, there isn’t one answer to this question. Everyone would agree that government has an important role, and we have to figure out what that looks like in each separate scenario.
How would you respond to the criticism that federal leaders aren’t appropriately apt to make such impactful health IT policy decisions?
In our government, these are folks who are industry experts who gave up lucrative positions and high paying jobs to help do good. They come from the smartest universities such as Harvard and Johns Hopkins, they were CIOs in large hospitals, and data geeks form get go with three or four computer degrees. So I don’t see this in the world I live in. It is true that it’s difficult for policy makers to keep in touch with where the rubber meets the road. We have to understand the impacts of the policy decisions and how it translates, and we’re getting better at it. We are receptive to public reception and very perceptive into how folks see the program. I’m a technologist, I started by implementing EHRs, so when someone tells me I don’t know what I’m talking about with EHRs, it is offensive. The government is made up of people who want to do good and are here for good reasons. They are underpaid and overworked. I know colleagues that haven’t had a day off in two or three months. So I can’t really associate with those types of comments.
What did you think about the news that Karen DeSalvo is likely out at ONC, and what would you like to see from the next National Coordinator?
I think it's a logical step for her career and her success. Karen is a dear friend and colleague and she is one who can just get things done. There's value in that mindset no matter where you are in the health system. I think the next coordinator will have to continue to push the community with health IT adoption and interoperability. More importantly, push agencies towards modernizing their various policies that have a direct or indirect impact in the use of technology. In short, the last five years have been spent laying the foundation. It's time to build something magnificent.
What are your biggest challenges and pain points right now at CMS?
The way we have done business in the last 30 years is significantly changing; helping become a change agent is a very sensitive thing around everything related to Medicaid. We are not your grandmother’s Medicaid program anymore—it’s a different environment and building that trust is something we’re very focused on. It will become more complicated and important as we liberate data and start to tell stories about our beneficiaries. We have begun to publish a lot of data, and then folks get access to it, analyze, and make connections. We need to make sure communications across systems is continual, that’s a big focal point for us.
With respect to EHRs, we are very mindful of providers who have never had technology in practice. They are a minority but they do exist, as a specific percent are struggling with that. So it’s a challenge considering that from a policy perspective. Also, from a federal perspective, figuring out what’s the value in what we pay for? The data systems group has a $5 billion IT portfolio across states, but what does that mean and how do we create an environment where we make taxpayers dollars most effective installing systems? That’s very complicated, especially when working with legacy systems.
You help write the EHR certification criteria for the meaningful use program. Can you get into detail about what’s behind that?
We create an advisory group, which comes from the private sector—doctors and CIOs—not public servants. That committee looks at the program, takes public comment, and has very intimate conversations about how it will look from a clinical and systems perspective, and how it will be deployed. So we take in recommendations, and sometimes the idea starts with a simple Word document. We’ll toss around ideas and end up with some direction. The committee acts as an objective filter for that. So once we do that, we make a notice for proposal.
For the meaningful use program, we put that on the street and take public comment. We are required to respond back—most people don’t even know that. If there’s a policy objective or measure we use and there’s a lot of comment, we can go back, change it and finalize it. We take our process from the Hill, we interpret what we think they’re trying to achieve for regulation, and then we finalize that with our rulemaking process. Then we go forward and deploy the program. When we start to hear questions from provider groups or associations, we create a sub-regulatory guidance, which provides clarity to what we intended when people have difficulty interpreting things. And we can use riders to modify and make amendments as well.
What has the Stage 3 feedback been like so far?
I think we are at a place where Stage 3 was an aggregate of comments that we have heard over the years. We have learned lot of lessons with Stage 1 and 2, and we are now seeing a much more simplified version. How is this connecting to other programs? It aims to simplify the administration process. Folks have been generally favorable—there have been some concerns about the details of the regulation, and we will publicize those as we start to finalize it. Stage 3 is a much needed policy change, generally speaking.
You have worked with a ton of EMR vendors in the past. How would you rate their willingness to be more open systems?
I think at the end of day, vendors are there for their customers. That means a few things: customers have to hold the vendors accountable, customers have to be knowledgeable, they have to know what they want, and they have to know what’s happening. Too often we see providers pointing fingers at vendors, but are you asking them the right questions and holding them to those standards? Chances are if you hold someone to a standard, he or she would like to perform to that standard.
I think vendors want to support their customers, do good by them, stay in business, and grow revenue, and the way to do that is to solve problems of customers. You can’t get answers to those problems unless you ask questions, though. The vendors are trying, some have built infrastructure around housing their data in an effort to move data within the context of their own systems. I think that’s okay for now. But when folks talk about restricting and closing access, that’s a problem for me. We meet with vendors regularly, people don’t realize that. If we’re hearing problems from providers over and over again we can go right to the executive leaders of those vendors to work those out.
If you had to give a message to the industry as they move forward in a challenging time, what would it be?
We have to keep asking questions and challenge the data. We have a data-saturated environment right now. There is a lot of noise around that data, but what does it all mean? A very important piece of all this, and this ties into interoperability, is the semantics of the data. Let’s keep challenging the data, keep asking questions, and if we have asked so many questions and challenged different pieces, then we have created this fog, but we could sift through that to find direction and truth. It’s not about you, me, a specific provider or vendor, it’s about the collective. What are we doing as the collective to move forward? Let’s have the conversation that way.