Advice to the new National Coordinator

Two and a half years ago, John posted an entry with this title – and I recall that it was a good summary of the state of the industry.  While I didn’t agree with all of his suggestions, I enjoyed the review and it offered a good set of guiding principles.  Since I was Acting National Coordinator for about the same duration as Vindell will serve, (Fall of 2013 – after Farzad Mostashari departed, and before Karen DeSalvo arrived) I’ll offer some thoughts from one who has been in his position.


  1. Certification.  The health IT certification program is the core of ONC’s responsibility to the nation.  While some have called for the eradication or reduction of the certification program, I would argue that this would be akin to scaling back Dodd-Frank.  Yeh – crazy.  As a product of ONC’s certification program, we now have health IT systems that do what their developers claim they do.  Before this program existed, creative health IT salespeople would assure customers that systems had functionality that simply didn’t exist, or was nonfunctional.  The program, like certification programs in other industries (telecommunications, transportation, etc.) is in place to assure the purchasers of products that these products do what developers claim.   Is the certification program perfect?  No.  Of course not.  The program needs to iterate with the evolution of the industry and the standards that are evolving.  Revisions to the certification program must therefore continue, so that the certification requirements don’t point to obsolete standards.  A focused “2015R2” certification regulation would therefore be an appropriate component of ONC’s fall work – so that something can be “shovel ready” for a new administration for ~ February release – with final rule in ~ April/May of 2017.

  2. The 2017 Spend Plan.  The 2017 federal budget appears to be on track to pass @ some point soon – and ONC’s appropriation for 2017 is looking like it will land at a steady ~ $60M ($65M if the extra $5M for narcotic abuse prevention lands).  The National Coordinator defines the “spend plan” for how the organization allocates this money – and the plan needs to be developed and executed at the beginning of the fiscal year: October, 2016.  The new National Coordinator is therefore making decisions now about how the funds will be spent over the next 12 months.  Office Directors are preparing proposed budgets for the year:  new FTEs, new projects that they want to launch.  Every year, it’s the same – just as it is in any large organization – proposals are submitted and the proposals represent 2x-3x the $$ available.  Tough calls need to be made.  The NC makes these calls. It’s hard to do this when you don’t know who your successor will be in January – or what their preferences will be.  When I was in this position, I worked closely with the Office Directors and the ONC Chief Operating Offer (Lisa Lewis), to identify the components of the organization’s work that were essential, and which were not.  We delayed decisions on about $2M to give Karen some flexibility to fund programs that were important to her.  As I mentioned in my response to Politico’s request for comments on the next phase of ONC’s path, my view is that it’s time to wind down ONC’s grants and health IT evangelism activity.  Perhaps it’s just my personality coming through here – as I am a well-known introvert, with little interest in quadrant 1 of the sizzle-substance 2 x 2 matrix (kudos to Janhavi for its invention), but I am concerned that it’s not government’s role to convince the public of the value/need for health IT.  If health IT has value (and I believe it does) then this value will be tangible and self-evident to the public.  If not, then no annual conference, blog post, or challenge grant will change this fact – or anyone’s perception of it.  ONC’s annual meeting – an event that costs several hundred thousand dollars and attracts the same participants every year – adds rather little to the nation’s progress toward improved health through the strategic use of health IT.  Kill the conference.  Kill the health IT flag-waving.  There’s already plenty of that to go around, and the taxpayer need not pay for it.

  3. Focus on quality.  No – not quality measures.  Quality of health, quality of care, quality of decisions.  Do these need to be measured?  Of course they do – and with the growth of value based payment in federal programs upon us, measurement of quality is imperative.  But we have conflated the concepts of quality and measurement.  As many know, I’ve long been concerned that the way that we use clinical quality measures in health care is fundamentally flawed.  Indeed, it was my concern about these flaws that led me to join ONC in the first place:  as the CMIO at Allscripts, I was responsible for helping our EHR development teams meet the requirements of Stage 1 of the EHR incentive programs (“meaningful use”) and it became clear that the accuracy of quality measure reporting would be terrible across the industry.  Why was this?  Because the 2011 certification criteria and Stage 1 meaningful use requirements were too vague about the data that would be used to measure quality.  For example, a quality measure might express that patients with “severe congestive heart failure” would be expected to be on a certain class of medications.  But there was no clarity for how “severe” was to be assessed, and many EHRs didn’t even formally capture ejection fraction, which would be an imperative component of an assessment of the severity of one’s CHF.  For Stage 2/2012 certification, we changed all of this, and while most readers don’t know or care about the details, these quiet changes represent the first important step toward improved quality measurement:  the data elements that are required for quality measures are explicitly identified in the certification regulation, and no measures are required that exceed the scope of these data elements. Read the last sentence again if you need to – as it’s very important and this guiding principle remains ignored by NQF, by many commercial health plan quality measures, and by many state Medicaid programs that are trying to implement quality programs.Simply put:  it’s impossible to report on data that was never captured.  A “quality measure” that assumes the presence of information in an IT system that is not present will be an invalid quality measure.  Period.  I thought / hoped we solved this problem in 2012.  Unfortunately, we did not.  Quality measures are still proposed without consideration for the data that EHRs have captured.  It’s now easy to know what the EHR can capture (what it can capture and what it has captured may of course differ).  Start with the NLM’s Data Element Catalog (Jesse James won the naming competition).  If the concept that you want to measure isn’t in here, then re-design your measure, because the EHRs don’t capture the data in a uniform manner.   If it is there, then the likelihood is high (but not certain) that the data can be captured, queried, and transmitted.

    Recall that I said our method of measuring quality is flawed.  Why is it flawed?  Because all of our focus is on quality measures rather than quality improvement, and improvement is a product of measurement and decision support.  Let’s parse this statement, beginning with the difference between measures and measurement.  A measure is an explicit logical statement about care delivery and its alignment with a very specific expectation.  For example, there is some evidence that individuals with diabetes will live longer if their blood sugar is well controlled, so there is a quality measure for this:  IF (individual has diabetes) AND (blood sugar is well controlled) THEN (quality measure satisfied).  Each of the logical expressions can be defined explicitly.  This measure can then be applied to thousands of care providers and their “scores” on the quality of care they presumably offer can be compared.  But what if blood sugar control isn’t so important?  What if there becomes a better way to measure individuals’ optimal health?  Measuring care quality with a list of measures is like having a speedometer in your car that measures 10, 15,25, 37 and 55 miles-per-hour and nothing in between.  It’s a set of measures -hard-coded into the system rather than measurement:  a fluid, adaptable system that enables us to see how we are doing and therefore enabling us to adjust our work dynamically if necessary.   How do we adjust?  With clinical decision support (CDS)!  As you will read in the chapter I wrote for Eta Berner’s just-published book on CDS, the federal government has done a great deal of work to enhance CDS capability in health IT systems, and to align it with quality measurement.  We’re not there yet – but we are well on the way.  Keep this on the front burner, and the path to the triple aim will be shorter and much less bumpy.

  4. As my friend Jerry Osheroff always says – focus on the most important things:  TMIT.  Are we helping improve the health of people?  That’s most important.  Don’t lose sight of it.  Karen DeSalvo taught me many things – but the one I’ve internalized the most was something that she taught me very early in her time at HHS:  we need shift our conversation from how to improve “health care” to how we improve health.

It’s not about the technology

I got a call from a friend last night.    He's the CMIO for a large hospital.  He's smart, works 80 hour weeks, and he's passionate about getting his EHRs to work right, the providers trained right, the order sets configured right, and (most importantly) the patients treated right.

He's been in the role for a number of years – and he's good at his job.  Very good at his job.  He knows the systems (from two EHR vendors – an inpatient system from company A and an ambulatory system from company B) better than many employees of the companies.    He's memorized the criteria for Meaningful Use down to the section and subsection numbers.  It's amazing.  I had a similar role once – about ten years ago – and I vividly recall mentoring him into his new position back then – thinking that his hospital would do so much better than mine – as he'd see the puddles we had already stepped in.  .. 

He's an incredibly gifted physician too – and continues to see patients at least 20 hrs a week – with a full call schedule.  

But tonight he called me because he wants to quit his IT job and go back to being "just a doctor."

Because the politics of the IT world have been too much for him.

"The analysts didn't finish the order sets and blamed the doctors for not reviewing them."

"And the doctors insist that they WANT to review them, but the analysts tell them that they're not ready to be reviewed!"

"We're behind schedule and all they do is blame someone else."

"Why are they lying?  Why do they get mad at me when I point out what's going on?" 

I listened.  And listened.  It sounds dreadfully challenging.  He's implementing TWO EHRs, and getting CPOE up and running in an outlying hospital, and migrating a community of physicians to new workflows, new processes and new habits.  This is no simple task – and he's got the technical details down cold.  

And he's done a great job with all of it …

Except his relationship with the IT team.    

This is not uncommon.  But there is a solution.  An easy one, in fact.  

"Your should pretend you're a doctor."  I said.

    "I am a doctor!"

"You're a doctor when you are with your patients. But it doesn't sound like you're a doctor when you're with the IT team.  It sounds like you are an angry parent!"

We talked about this for a while.  He wasn't sure where I was going – but he was intrigued.  He knew that somehow I have found it less difficult to navigate the political mine fields of hospitals, academia, industry and government.  Indeed – his minefield is my Fenway Park!  Am I serious that I want him to treat the IT team like they are his patients?

Yes!

"If your patient tells you that they have been dieting and exercising but they are still gaining weight – what do you say?" 

    "I would say that I believe them 100% – that they are dieting and exercising and that I want to find ways to help them."

"Do you really think they have been dieting and exercising as much as they say?"

    "No.  Of course not."

"So why do you not challenge them?  Why don't you point out how wrong they are – and that they are fibbing?"

    "Because it's not important if I am right.  That won't help them."

"So why is it important that you are right that the analyst streched reality a bit about doing the order sets for Dr PooBah?"

    "Because they didn't do what they are supposed to do.  I need to point that out."

"Why?"

    "OK – I can see what you are saying but it still doesn't make sense.  How will my NOT judging them make them get their work done?"

So this is the key leap of faith for him.  It seems like these are different settings, different goals, and he should use different skills.

But it's not necessary.  The same skills that make a great empathic physician will also make a great empathic results-oriented CMIO.

He's built a (medical) career of great habits that we can leverage.  The habits he'd built are the ones he uses every day to care for his patients in a collaborative, meaningful, non-judgemental way.

The key to his success in the IT world is to say (to himself) just what he says to his patients:

  "Because it's not important if I am right.  That won't help them."

The focus shifts from blaming them for being lazy, lying IT enemies – to "folks who need my support."

Dr CMIO – you already know how to do this!

I could tell he was interested – but still wasn't quite at the point where he could make the leap.  We talked about the dysfunctional team of IT analysts, how they gossip and argue and sidestep work.

"It sounds like they are very unhappy"  I say.

He got quiet.

"Yes – they are – and they make everyone else unhappy."

"So what do you think would happen if they felt like you were an ally?  Like you wanted them to be successful?"

We went on like this for an hour or so.  It's a hard shift – but quite powerful.  He remarked that I was soundling like a buddhist – and I pled guilty – but pointed out that this is not just a buddhist principle to avoid judgment – it's a core component of many of the "success in management" books too – most of which avoid invoking religeon or spirituality.    A few good ones to consider – probably required reading for any CMIO:

Energy Leadership

Five Dysfunctions of a Team

7 Habits of Highly Successful People

I'm giving a talk to a bunch of CMIOs in a few weeks.  Maybe I'll leverage this vignette into a little sermon powerpoint.

 

12 years of blogging .. about medicine, technology and their intersection …

This post from November 26th, 1999 – was the first on this blog.  There were a few months of previous posts, but due to several platform changes back then – these seem to be lost.  

No matter.  12 years is a long time.  My blog is now officially an adolescent.  I wonder what it will be when it grows up!  Long-time readers are of course observant that I've been remarkably quiet for the past few years.  This is due to my evolving work for an HIT vendor and now the Federal Government.  

So I've been operating with this in the background for the past six years:

The opinions expressed on this blog are my own and do not represent the veiws of my employer.

And there is a rough "social media policy" (google docs – you have edit rights .. feel free to steal or enhance … ) that I have in my head as well .. so in general I have done my best to observe and occasionally point to important publicly available information, but take care not to comment too deeply – for fear that others would interpret my commentary as a telegraph of my employer's next steps.  This wouldn't be appropriate for me to share – and increasingly – I am concerned that most of my public thoughts could be interpreted in this way – so I've been holding back from any public commentary.

So for now – here we are. 

I'll push the envelope a teensy bit and comment on some events of the past few months:

Tim HISTalk covered my arrival at ONC in a post about a month ago.    He asked the right questions about the topic at hand – but he didn't get to the one that I am hearing often these days – which is .. "Why did you leave your leadership role at one of the top health IT companies, choose to spend weekdays away from your family, AND (with two kids in college) take a giant pay cut?"  

The answer is easy:   It's the right thing to do.  

Health Care in the United States  is at a turning point.  It is well known that despite great advances – we don't provide the quality of care that we would.   It is also self-evident (to me) that technology – carefully applied – will improve both the quality of care – and the efficiency, sensitivity, and ease with which it is delivered.  Yes – some of those words may not be familiar to you – but why WOULDN'T we want it to be EASY to deliver great care?  Why shouldn't we deliver SENSITIVE care (sensitive to your hopes, religion, fears, preferences) – in addition to efficient, evidence-based and (of course) cost effective) care?

 So I have always tried to focus my work on helping others meet their true potential.   In my first career – as a 16 year old sailing teacher, I helped kids find the freedom and autonomy that a good breeze and a sunfish will provide.   As a teacher of junior high school kids – I witnessed breathtaking intellectual growth in a herd of 12 year olds who were otherwise distracted by adolescence and its daily challenges.  Working with (some say "caring for") patients as a family physician - I found that my most important work was not to take control and "fix" my patients (as some of my mentors had advised in medical school) but to partner with my patients – serving as a resource – without any judgment or critique.  As Bill Miller and James Prochaska have demonstrated (motivational interviewing, transtheoretical model) – people change when they choose to – and no sooner.  Can we facilitate growth in others?  Of course we can.  But "facilitate" and "cause" are inherently different.

As a leader in a large health IT software company – my role was often to help our teams align the software products we were producing with the needs of our customers.  This is not unlike the role of a good physician:  we need to listen carefully and critically so that we understand the needs (which will sometimes differ from the "wants") so that we can facilitate success.

And isn't that the role of government too?   Perhaps that's a political question.  Some would argue that government should get out of the way, while others would argue that there is an important role for government to provide an infrastructure with which success can be facilitated.  Is a healthy happy nation something that is important?  Are there ways that government can facilitate a migration toward these goals? 

I think so.  Keep an eye on my occasional tweets , g+ posts (rss), and posts here on this blog.  It will continue to be sparse here on the blog. 

EHR Incentive Program Registration Instructions

Registration opens today for the EHR Incentive Program.  The process is not so easy as one would like.  Here's an overview for how to register as an Eligible Provider.

  1. Go to the Registration Program's login page.
  2. You need a login.  This is your NPPES login.  Oh?  You don't have one?  Neither did I.  
  3.  I do have an NPI.  So do most EPs.  If you have an NPI – you can create an NPPES login here.  If you don't have an NPI – you will need to apply for one here.
  4. OK .. go back to the login page (link in #1 above) and log in.
  5. Click on "registration"  (the tab at the top) and scroll down to the bottom.  Your name is listed and at the bottom-right is hyperlink:  "Register."  Click that.
  6. Click through to the page that is going to stop most providers in their tracks.  There are several questions:  First – you need to select whether you are participating in the Medicare or the Medicaid program.  You should know.  Most providers will choose Medicare.  This next part is counter-intuitive:  you need to select the radio button - and then click "apply."  It's terrible design.  What does "APPLY" mean?  Regstep5_2Am I applying for the program?  No.  In this case – what I THINK the web designers meant was that you are APPLYing your selection of the radio button.  When you choose "Medicaid" – a drop-down list appears so that you can choose your state.  Only a handful of states have competed their paperwork – so only a handful of state Medicaid programs are open for registration.  If you plan to register for the Medicaid program in one of the states not listed here, you need to wait days, weeks or months until the program is active.  There is a link to this page (ugh! pdf – more bad web design – here's a non pdf version) that lists the state programs and their expected ETA.  Don't know which program you qualify for?  Use this nice wizard to figure it out.
  7. Once you select the program – you are asked whether you have a certified EHR – and if so, what the certification number is of that product.  This is an OPTIONAL question.  I assume that's because some products are not fully certified yet – or because in many scenarios – one needn't even have an EHR yet.  This is just registration for the program.  Note that this page requests a certification NUMBER but in fact – what they want is a "YOUR CERTIFICATION ID" – and NOT the "Certification # of the product.  Yes – this is confusing.
  8. This page directs you to the CMS website here.  But that's not the right place to go.  What you need is the CHPL – the Certified Health IT Product List.  To create your certification ID (you don't really need this – recall that it's optional)  .. go to the CHPL here .. then browse the list or search for your vendor(s).  The second column is the PRODUCT's certification #.  Not what you want.  If you have one complete EHR – click on "add to cart" and follow step #9 below.  If you have several modules – add all of them to the cart.
  9. At the top of the page – you will see a link to your "shopping cart."  Click on that link.  Now you see your list of modules.  You need 100% Certified EHR technology – so if you have modules that don't make you "complete" – you won't be able to create a certification ID.  Have 100%?  Great.  Now click.  There is your certification ID.  That's what goes in the optional field on the EHR Incentives registration page.  Let's hope they fix this soon so that it's more clear.

I didn't get past this page – (yet) as my state isn't one of the active ones – and I will apply for the Medicaid program.  If you got past this screen – please let me know if you encounter anything challenging. 

 

Mark is still dead

Last week I wrote about Mark. 

Unfortunately – the bad dream that he had died wasn't a dream – and it's been a surreal week – re-connecting with old friends, and re-living formative memories.

Mark was a passionate, thoughtful person who worked so hard to make things RIGHT – while doing his best to have fun – with a unique serene yet sardonic demeanor.

In 1982, I was Mark’s apprentice for 12 months on the 144’ sailing ship – the Barkentine r/v Regina Maris – where he was Chief Engineer (El Jefe) – and I was the Assistant Engineer (El Lacayo) – earning $1 / day.

It’s Mark’s fault that I am a physician.

As we diagnosed, disassembled (and reassembled) diesel engines, bilge pumps, de-salinators and generators together – Mark taught me the fine art of diagnosis, decision making, and careful, patient action. 

In healthcare we call this SOAP (Subjective Objective Assessment and Plan) – On Six Forks Road (and Toyota) – it’s called PDCA (Plan-do-check-adjust).

Medical Educators call it GNOME.

Regardless of the name/ framework/ religion we use – it’s about thinking carefully, calmly and strategically about where you want to end up – then having the knowledge, skill and attitude to get you there.

We're on our way to Mark's memorial service now.  Marcie sent me this last night – which does a better job than I ever will in telling a short story about our friend:

 

Informatics Comeptency Evaluation

Let's say you want to evaluate the Medical INformatics Competency of a group of students, IT staff or physicians.

I'm working on an evaluation tool that should be EASY for anyone with these skills .. and a true challenge for those without.   

Take a look at it here. It's a Google spreadsheet so you will have to log in to Google Docs to edit it .. but feel free to do so.