Marla Roberts, Dr.P.H., is senior delivery manager at the Buffalo, N.Y.-based CTG Health Solutions, where she consults on process redesign, organizational capability, and analytics for patient care organizations. Since the American Recovery and Reinvestment Act/Health Information technology for Economic and Clinical Health (ARRA-HITECH) Act was signed into law in 2009, she has been working with client organizations on process issues around meaningful use. Roberts spoke recently with HCI Editor-in-Chief Mark Hagland regarding her perspectives on the proposed rule, released Feb. 23, for Stage 2 of meaningful use. Below are excerpts from that interview.
What is your overall critique of the Stage 2 proposed rule?
Well, I think what they’ve done [at the Office of the National Coordinator for Health IT, or ONC] with Stage 2 is to weave a picture, if you will. The elements of Stage 1 were seen as so basic, some people didn’t understand why they were doing things. Now you can start to see the ‘why’ of this: weaving in the ACO [accountable care organization] goals, harmonizing metrics, and so on. So they’re really weaving together a picture of where we’re going.
Marla Roberts, Dr.P.H.
Have they been largely successful in creating harmonized goals?
I think they are beginning to be successful. And in listening to and reading things produced directly from CMS [the federal Centers for Medicare and Medicaid Services], I believe they understand that all that is important. And I believe they are beginning to understand how important communication is. And actually, that goal of harmonization is actually part of the statute, a requirement. Now, I don’t believe it’s an easy task, but their working towards reaching that goal has really improved significantly.
Is there anything that really surprised you in the proposed rule?
There weren’t really a whole lot of specific changes from Stage 1 except in the quality measures. But one of the surprises was actually the flexibility they’ve built into this stage [Stage 2]. For example, they said that we can stay in a stage for two years, regardless of when we start; because they had said that Stage 1 was two years but if you waited a year, it had required you to do Stage 2 in one year. So that kind of flexibility is really coming across. And even though in their initial public announcement they had said they would be flexible, now they’re actually becoming more flexible.
And it seems as though in Stage 2, the officials at ONC have taken the opportunity to more explicitly address the issues around medical specialists.
Absolutely. They went from a few measures that weren’t really specialist-relevant, to 125 quality measures. So that was meant to address specialists’ participation. So I think the clinical quality measures are going to help a lot, because they genuinely had primarily focused on primary care before this.
They’ve also more specifically addressed the involvement of images in the sharing of clinical information as well.
The fact that they’ve included different types of exchange that should be done—for example, cancer registries—that’s meant in part to accommodate specialists and bring them in more. Also, the specialists use more images. So the explicit addressing of images means that specialists’ participation will be addressed more. That’s especially true when we get to Stage 3 and we say that measuring outcomes is part of that path.
Are there any elements in the proposed rule that concern you?
I think there are some challenges ahead of us, and I’m not sure that I’ve heard CMS address them. One is competition for staff, which has been there since the beginning. But as we get more into issues around interoperability, for example, there will be more competition for IT staff. And no one’s said how we’ll address all these requirements with the clinicians; I’m talking about the implied need for more quality [improvement] professionals. A lot of quality departments are very small; the same thing is true for case management. And in a lot of physician practices don’t even have a single case management person. And with the coordination of care and exchange of data elements, we’ll need more of those people, because the coordination of care between hospitals and physician practices will require more of them.
The other thing is that we haven’t yet quite gone from payment for volume to payment for value. How will physicians be able to support some of these extra staff, more processes, training for patients in helping them to use their portals? How are we going to support that as reimbursements go down? And we haven’t yet gone to a hybrid model so that reimbursement can be included for some of those responsibilities. It’s almost as though the tail is wagging the dog, in some cases.
Would you agree that the leaders of some organizations that weren’t driven before to move ahead on meaningful use, will feel even farther behind now?
Absolutely. In terms of just the exchange of data, if you haven’t begun to create a robust infrastructure for that, you’re behind already. So yes, some of those who hung back really are going to have to scramble. In some cases, there has been a wait-and-see attitude; but the other obstacle has been around cost and budget. For example, among our IDN [integrated delivery network] clients, even if they get upwards of twenty million dollars, that won’t even cover the cost of the IT, much less other elements, such as process, patient engagement, and so forth. So budget remains a big barrier to aggressively moving forward.
What would your key advice be for CIOs and other healthcare IT leaders?
Assuming that people have been working on Stage 1, interoperability remains a challenge. We only had to test it and didn’t even need to be successful, in Stage 1; so interoperability will be a big focus going into Stage 2. And that’s also because we’ll really have to work on care coordination. So they really need to look at that process and how technology will be used to support processes such as readmissions reduction. And the other thing is the clinical quality measures: do we have processes not only to report the measures, but also, do we have the analytics to monitor those measures, and to help us correct course if our outcomes aren’t where they should be. I don’t see many of our clients having gotten very far in that area.
Indeed, on the healthcare reform side, they’ll be measured in many of those areas.
Absolutely. And the competition to obtain the quality professionals will increase, as it will in the IT area.
Would you like to add anything else?
Overall, even with the challenges, I think it’s beginning to look like we’ll be able to accomplish this. And there’s an opportunity to improve outcomes. The Commonwealth Fund just published a new study, and it’s rather sad, the actual performance. You should look at it, because it shows how our access to care and care coordination are not what they should be. So this is an opportunity for us to embrace it.
And that certainly is a goal of health care reform?