Just what do the terms “flexibility” and “user-centered design” mean? And what are the senior officials at the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) really thinking these days? Russell P. Branzell, president and CEO of the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) spent some time trying to find out, when on the afternoon of Feb. 23, he led a panel discussion at the CHIME-HIMSS Forum being held at the Hyatt Regency Orlando.
Under the headline of “Afternoon Keynote: Delivery on the Value of Health IT: A National Dialogue on Crossing the T’s and Dotting the I’s,” Branzell engaged one CMS official and one ONC official in a lively 40-minute dialogue around a variety of topics of importance to CIOs and other senior healthcare IT leaders.
The two federal officials—Jacob Reider, M.D., chief medical officer at ONC, and Robert Tagalicod, director of the Office of E-Health Standards and Services at CMS—cautiously shared perspectives on the challenges and opportunities facing the U.S. healthcare in general, and what providers might be able to expect from their agencies in the coming months.
Within minutes, Branzell, who has helped to spearhead a very assertive stance on the part of CHIME in asking for greater flexibility with fulfilling the requirements of Stage 2 of meaningful use under the HITECH (Health Information Technology for Economic and Clinical Health ACO, had posed a question on Stage 2 timelines. Said Branzell, “There have been recent changes in the timelines around Stage 2. Those have been beneficial. We’ve been asking, very nicely, for some flexibility, because of what we really do see as the perfect storm coming. Even during the break, people have said, we’re struggling with ICD-10, healthcare reform, and meaningful use. So,” he asked the officials, “what flexibility might you have?”
“What I’d like to say is that we’ve heard the message,” Reiter said. “We need to be explicit about our understanding of some of the challenges that many care delivery organizations are seeing ahead of them. The confluence of various demands, the vendor readiness—and we understand that certification is the first of many steps that have to happen. And we know that working with the vendors is a lengthy process, and we also have heard loud and clear that if one pushes the envelope too much, there are consequences. So we’ve heard the message.”
Tagalicod said, “We heard the word ‘flexible,’ and it was very clearly stated in many of the letters that have come to the Secretary [Kathleen Sebelius, Secretary of Health and Human Services], as well as to our Administrator [Marilyn Tavenner, R.N.], and the National Coordinator [Karen DeSalvo, M.D.]. I think that we’re pragmatic, and we’re focused on partnerships. Let me focus first on the partnership piece,” he added. “We are listening, and we have heard the message. Now, the pragmatic part is everything that comes out of the statute. And we understand the burden.” Tagalicod also offered that “We do check with our general counsel to see where there is latitude. And I’m going to make a plug: the plug is for Thursday. Marilyn Tavenner [CMS Administrator] and Karen DeSalvo [M.D., National Coordinator for Health IT] are going to be speaking, and hopefully by then, some of the things called ‘relief’ will be made a little bit clearer.”’
What about user-centered design?
Another area of the discussion had to do with usability of the clinical information system products now on the marketplace. Branzell opened that segment of the discussion by stating that “There’s still a non-intuitive aspect to most of the products out there.”
“This is why I went into this industry,” Reider pointed out. “I was a frustrated user, and was accustomed to using my 128K Apple Macintosh at the time. And I actually started working for a vendor for that reason. And what I discovered is that it’s easier said than done; it’s a long process to get folks to where they need to be. And it’s a cultural process to get to user-centered design. What we’ve discovered at ONC, after we put into the 2014 certification criteria requiring that vendors put in user-centered design, is that many vendors had no idea what we were talking about. Some knew what we were talking about, and used that requirement internally to get better testing and development in that area. The products need to be safe first, and then reliable, functional, usable, and pleasurable.
Supporting what Reider had just said, Tagalicod added, “We’re sync in terms of usability. The question becomes, how do we incent that as we look beyond meaningful use and look at payment adjustments, and our own payment policies at CMS? As we look into the future,” he said, “our question is how we get to that place, and incent and support that.
What’s more, Reider said, “User-centeredness comes from both the core technology… But there are different kinds of usability issues—sometimes, a product that is too customizable, is ruined by the patient care organization. So the issue the responsibility lies with the vendor as a developer, but also with CMS as a payer.”
Healthcare leaders’ concerns over meeting MU quality requirements cited
One other area of particularly lively interaction came around the topic of quality measures. As Branzell put it, “The thing about quality measures under meaningful use is that you can hit 99 percent, but yet you’re not there. So is it really fair to have an all-or-nothing standard for quality measures?” he asked the federal officials. “Right now, you either meet all of them and you’re meaningful user, or you’re just a little bit short, and you get nothing.”
“By regulation, it was constructed as all-or-nothing,” Tagalicod responded. “We defined meaningful user by regulation. We are listening” to provider concerns, he insisted, “to determine where do we have latitude, in terms of meeting partially some of the things we’re looking at? Is it better to at least meet some of them partially? It’s a philosophical question,” he stated. “Yes, the high performers will get 100 percent. And if smaller providers moved from 40 percent to 60 percent, does that help the industry, in terms of meaningful use and HIE [health information exchange]? I can’t give you an answer to that yet.” he said.
“Also, what are some of the burdens that CMS would experience in changing aspects of the program?” Tagalicod said further. “Those are all fair questions; we just don’t have answers at this point. But we’ve heard everybody, and have ideas. And maybe,” he said, “in terms of the statute, we can look outside of the box in certain ways and still meet the requirements of the statute. And we’re the executive branch, and there’s nothing stopping people from approaching the legislative branch,” to try to address problems and issues.”
The discussion took place in front of an assembly of the audience present, whose total number was well over 600, the highest level of attendance so far for the CHIME-HIMSS Forum, CHIME executives noted.