As ONC’s Policy and Standards Committees get off the ground, there is little time for pleasantries and much work to do. Under such circumstances, HCI will endeavor to interview as many individuals involved in the process as possible. In the past, we have spoken with Epic’s Judy Faulkner and InterMountain’s Marc Probst (Policy Committee); along with Harvard Medical School’s John Halamka, M.D.; Cleveland Clinic’s C. Martin Harris and Gartner’s Wes Rishel (Standards Committee). In this interview, HCI Editor-in-Chief Anthony Guerra talks with Standards Committee Member and Cerner VP David McCallie about how the industry moves forward from here.
AG: What do you expect to come from the meeting on Friday (the 15th)?
DC: We simply haven’t met yet and our formal charter is rather sparse. I don’t have specific expectations, so it’ll be a little bit of wait and see. What I would expect to happen, maybe not in the first meeting, but over a relatively short period of time, is identification of the steps that we can participate in – we the Standards Committee – to help define what a certified EHR is so that meaningful use can get defined and we can get moving with all of this. That’s pretty much what our charter is. I am pleased with the makeup of the Standards Committee, of the folks that I know, and I know half of them probably, they strike me as pragmatic people who have a strong interest in seeing this move forward, and so I think we should be able to get a lot done.
AG: You listened to the Policy Committee meeting, which took place on Monday. Tell me your impressions.
DC: I was only able to listen to the last half, so unfortunately, I missed Dr. Blumenthal’s initial challenge. I think the meeting was a little disorganized because it wasn’t clear what the committee assignments were, it wasn’t clear what the subcommittees were. That took longer than maybe one would like to see to those get formulated, but I believe they settled on some good choices. And the issues are so cross cutting, everyone is going to have to deal with everything anyway.
What’s unclear to me, and that meeting didn’t necessarily help clarify it, is what the role of the Policy Committee is as compared to the recommendations from NCVHS as compared to what Dr. Blumenthal himself will do. It remains to be seen how these various inputs will coalesce to a specific set of recommendations to the secretary.
AG: It should be fascinating, to say the least.
DC: Well, it will be Byzantine perhaps.
AG: I think that’s a fantastic word to describe what I’ve observed so far. From what I understand, the Standards Committee meeting was scheduled for the 15th basically to be in compliance with the requirement that it meet by a certain date. And then essentially the Policy Committee saw that date, realized that they had to give you direction and just scheduled their meeting a few days before. Is that your impression?
DC: I don’t really know how the timetable was set. I know that there is a great sense of urgency in all of these processes because the deadlines for producing the recommendations are short, and given that it takes the vendors a long time to respond to anything that would be a change, and a long time for physicians to purchase and implement these systems, and we have only a short period of time before the first year of measured reimbursement kicks in, everybody is feeling very pressured to move quickly. So some of the chaotic start may just be due to the intense time pressure.
AG: Whatever is ultimately formulated still has to be put out for formal comment, unless I’m incorrect, and you would imagine that would have to be a minimum of 30 days, which would have to be followed by a period of time when those comments would be examined and possibly the guidelines revised based on those comments, so there’s some major steps here.
DC: Yes. I think the interim final is due by the end of the year. I’m not an expert on government policymaking, but my impression is that the interim final can be treated as a final even though it’s still open for downstream revision. So they have a little bit of an out that would allow them to satisfy the law and move forward, yet come back and tweak it later.
AG: The goal, I believe, of the Policy Committee holding their meeting on Monday was to give you direction. Have you received any direction yet from the Policy Committee? Do you expect to get anything before Friday, and, if so, do you have any idea how that would come to you?
DC: A carrier pigeon, I think. Maybe Twitter. No, I think that the Policy Committee will provide direction. I don’t think all of that direction has to be provided between their first meeting and our first meeting. So I anticipate that direction will emerge from the Policy Committee’s subsequent deliberations and will guide the Standards Committee. It will happen quickly, but it won’t all happen in the first week.
AG: Does it make sense to you to have two separate committees, one focused on policy and one on standards? If you were setting it up, is that how you would have done it, or would it have made more sense to have people together because these things are so intertwined?
DC: That’s a good question. I think, in an ideal world, perhaps they would have been combined, but then you might be talking about 30 or 40 people, and the deliberative process is just so hard when you have that many smart and opinionated people in the room. So separating it out where one group focuses on the goals they’d like to see achieved, and the other group focuses on the details of how to get there, it seems like a pretty good compromise.
AG: You touched on the number of people and that’s one of the things that struck me at the Policy Committee meeting, that there were too many people and the meeting was too short, and overall the timelines are too tight to hear from everyone. You can’t physically give everyone a chance to speak. So there were people, I believe, that didn’t speak at all, some people spoke more than others, and there was no allotment of time for each individual. The Policy Committee had 19 people plus the chair. Your committee has 21 people plus a vice chair and the chair, which is a total of 23 people. Do you have any idea how this will be managed, can you see this working where all these people are heard from?
DC: I think, over time, not necessarily all in the first meeting, but over time, I think that could be done. Dr. Halamka, who I know fairly well, is pretty good at getting a lot of people to participate in a fast-paced process and respecting the input of all of his committee members. I look for him to bring forward a lot of learning from his experiences dealing with aggressive timelines at HITSP.
AG: You were mentioning John Halamka, have you worked with Standards Committee Chair Jonathan Perlin before?
DC: No, I don’t know him, I look forward to meeting him.
AG: In light of the deadlines, are you optimistic that meaningful use can be a defined as something which seriously moves things forward?
DC: I think we will see some good progress, and the reason is the ARRA or HITECH spells out, in the law, the major categories for what they consider meaningful use, that what the legislators consider meaningful use to be, and you could simplify it, but essentially it’s e-prescribing, progressing onto physician order entry, exchange of clinical information, initially point to point perhaps, and in the long run, via health banks or patient controlled health records or regional health exchange, depending on which of those is the best strategy. And then clinical quality reporting, quality metrics.
I think the details will be around, technically, what does it take to become a certified EMR and what’s the staging of the timetable of the deliverables from those EMRs over the five-year period that the money can be awarded. I don’t anticipate that it’ll start with the full definition on Day One for 2010 because that would exclude too many people from participating, and one of the goals here has to be to get as many providers to participate as possible.
AG: At a basic level, many say the tools are simply not user friendly enough and the financial incentives are not lined up for widespread adoption of EMRs amongst physicians, especially one to three doctor practices, even up to five doctors. It’s argued that it simply doesn’t make sense to them, from a dollars and cents point of view. Isn’t adoption an uphill battle until that problem is solved?
DC: Certainly my company’s expertise is with the other end of the spectrum, the large hospitals and larger provider groups, and we have users who don’t like everything about our software, but we have many, many thousands of physicians who use the software to run their entire patient process every day. I know that the problem can be solved and it can be done. I do agree with you that on the small practice side, with one to three physician practices, the software choices may not be so clear cut. There’s a certain amount of overhead in establishing an EMR system, and we may not have reached the point – or we may just now be getting to the point where it’s feasible to put such a system in.
One of the advances in information technology in general, over the last few years, has been an understanding about how cloud-based services or software-as-a-service providers can work, whereby if you're going to use a complicated piece of software, and all you do is sign up for it and start using it; you don’t have to install anything locally in your office. I think that will be the way we see the small practices integrated into the EMR world, at least for a large number of physicians, and that will make more sense than the old days when you had to have a file server under your desk and reboot it every so often and back it up at night and do stuff that you just shouldn’t be doing if you're running a practice.
AG: If you go to the CCHIT site, there is one inpatient certified system, and that’s Epic. Cerner does not have a certified 2008 system. What are your plans for getting certified, do you think CCHIT should be the sole certification source for products, or should there be some other method, or do we need certification at all?
DC: I’ll work backwards. I think we do need some form of certification simply to relieve the physicians of the burden of trying to figure out if what they’re buying is going to meet the criteria. I would like to see a certification process that does not become either a bottleneck for the vendors or a barrier to innovation for the industry as a whole. We don’t want to clamp down too tightly because that would stifle innovation. I think that CCHIT has served a valuable role. I think we can learn from that process and revise it and improve it going forward. I’m optimistic. (Cerner has applied to CCHIT for 2008 Certified Status)
AG: You might have a number of vendors sitting out there waiting to see if CCHIT is deemed the sole certification body which determines who can get HITECH monies. If that is the case, they may get flooded with applications.
DC: I don’t think we want to see a bottleneck emerge where they can’t handle it. I agree, that would be a problem.