CMS Dr. Thompson talks challenges of Meaningful Use implementation IHT2 Editor Joseph F. Jalkiewicz
As chief medical officer for the Centers for Medicare and Medicaid Services (CMS) Regional Office in San Francisco, Dr. Thompson serves as the chief CMS clinician for Region IX. She is also the principal liaison with professional organizations in the region with respect to quality improvement and healthcare reform.
In advance of the HIT Summit, IHT2 Editor Joseph F. Jalkiewicz spoke with Dr. Thompson about Meaningful Use and how providers can meet the challenges of implementing MU as quickly and efficiently as possible.
Can you tell us about how your role as Chief Medical Officer at the CMS, positions you as a leader in the health IT transformation?
One of the major roles I play is to serve as a liaison to health care professionals for a variety of our quality initiatives, and that means both outreach and education. But not only am I taking our initiatives out to our providers, but I’m also in a good place to get feedback back into the central office on various initiatives, and doing some environmental scanning for the agency. That’s one part of it, but the other part of is that I really see HIT as a necessary foundation for where we need to go in terms of health reform. HIT is really a basic foundation for almost all of the work I do at the agency related to quality.
How big of a role does HIT play in your overall responsibilities?
We have a major health care problem in this country. We are on an unsustainable trajectory, and health information technology is the foundation on which we can transform the system. It’s a central, critical role getting us to where we need to be in a fairly short order of time
With your background at the CDC and in the payer industry, what are your thoughts on how HIT can impact issues like population health management? Can you share an example or two?
I think it depends a little on how you define population health management [but] it harks back to that little phrase, “what gets measured, gets done.” You can’t manage population health without data. There are a number of ways to collect data, but HIT is the most efficient way to get data. And without that you just can’t do the work. In terms of a concrete example from the clinician’s perspective, [they’re wondering] “How do I manage my diabetic patients’ health? How do I make sure all the women who should have Pap smears have gotten them? Without information technology you’re kind of stuck. You can do some kind of work around with registries or something else, but really you need EHRs; you need a good technology platform. I can tell you about numerous doctor’s offices I’ve worked with in the past where they were great docs giving really good care, but it wasn’t until they implemented electronic medical records that they realized there were a whole lot of patients who weren’t coming into the office, and while [the doctors] thought they ordered mammograms for 90 percent of the women for whom they were indicated, it was really only 50 percent. And where they thought they ordered A1C’s for every diabetic who needed them, they found it was only 30 percent.
You really do have to measure things to know where you are. I’m giving a very clinical perspective, but you can also look at it on a more global scale. What is going on in San Diego, or San Francisco? Without a data system it’s just extremely difficult to know what’s going on, much less what to do about it.
From a national perspective, what do you view as the biggest challenges in implementing the changes in health policy as related to Meaningful Use.
I happen to have a fond spot in my heart for small practices and the numerous clinicians who are still not associated with larger, perhaps more sophisticated, systems with more infrastructure. I continue to be very concerned about small practices from both the HIT Meaningful Use perspective as well as from a policy perspective.
With Meaningful Use Stage 2 just recently announced, can you share some of the initial feedback (both pushback & positive) from the various stakeholders groups with which CMS works?
I can’t say a lot about this at this point because we’re still in the process of gathering comments, but a couple things I do want to mention. Remember, these are proposed rules and the reason we put proposed rules out is because we want to garner comment; we want to hear from everyone. We really value the input. It will help us make a much better final rule. [Having said that,] you can group these into two groups: the “too much” group versus the “too little” group. There’s always a group that says,”It’s too much, too fast, and we can’t do this. You’re going to push some people out.” And then we have another group that’s just as vocal—and it’s hard to say which [group] is larger—who say, “It’s not enough. You need to do more, faster.” At the end of the day, that’s the major tension that we’ll see.
We have worked hard to provide more flexibility for specialists in the stage 2 proposal. There are a number of exclusions for providers whose scope of practice wouldn’t permit them to meet certain measures. There are new objectives for imaging and cancer reporting registries and other specialist registries. Some of the comments we heard in the past led us to incorporate some of the things you’ll see in the proposed rule. We hope there will be some positive comments about those changes, but we know there will also be many others that want to see additional changes.
Where do you think most providers will find their biggest challenge in MU2?
As I said, we’re shooting for providing more flexibility and reduced burden in Stage 2. Having said that, the new rule emphasizes health information exchange and interoperability, and frankly, those are challenging issues not just for providers but for everyone in the health information exchange world as well. There are also more robust objectives proposed around exchanging summary-of-care information with different providers that have different certified EHR technology. These will be challenges, but they are ones we have to meet. Having everyone have an independent EHR that works well in their office but doesn’t communicate with surrounding offices may be minimally helpful to the physicians or clinicians in those offices, but it’s not helpful from a systems perspective.
Do you have any guidance for those getting an early start?
Don’t just think about this as a federal regulation and what’s required. Really focus on quality improvement. That’s what this is all about: more efficient, higher-quality, and less costly care. Focus on areas where you’ll get the most bang for your buck for your practice and your patients, like bigger gains in patient health status indicators. I do want to emphasize that we’re proposing that Stage 2 kick in in 2014, not 2013, so for those who did a test for Meaningful Use in 2011, they have a little more time before the Stage 2 requirements have to be met, although we’re certainly happy for people to meet them early. The other thing that’s important for providers to know is we’re working hard to reduce the burden of reporting. The proposed rule further aligns the EHR program with some of our other quality reporting systems, such as the physician quality reporting system as well as the new ACO or shared savings program and some others. Providers can look for more of that.
At iHT2’s Health IT Summit in San Francisco, you are speaking on a Meaningful Use panel discussion focused on leveraging technology to improve outcomes & efficiency – from which criteria will we see the biggest impacts from the upgrades to Meaningful Use Stage 2?
I’m not a big one for the crystal ball gazing. I want to emphasize again that [Stage 2] is proposed rules, and they represent a big step forward from Stage 1. I think the biggest impact overall comes from the ability to truly exchange health information well as to advance clinical care processes. For example, one of the fairly simple ones that is proposed is to use the EHR to provide reminders for preventive and follow-up care. It seems like such a no-brainer, but …many people who have had EHR’s for a very long time have not been using [them for reminders], and this is something that we know can substantially increase the rate of many screening tests and [routine] vaccinations. Depending on the test, you can see anywhere from 20 percent to 40 percent increase in the percentage of people who will get that screening or vaccination. That’s a huge change when you think about an entire population. If you break down each of these and think about what that can mean on a population basis, the impact is quite significant.
What do you think will provide the biggest impact per dollar spent?
I won’t even hazard a guess. I think it’s the whole package together that’s important.
Do you have a sense of how patients are reacting to the transformation in their care environment and what the biggest issues are from their perspective?
People are starting to vote with your feet. My mother just moved to a new state and she needs a lot of help coordinating her care. When I started looking for providers for her it was very important for me to get her into a system where I knew we wouldn’t be chasing her health records down all the time. That’s not something you want to be doing when you have a loved one who’s sick or possibly dying. With that in mind, patients really do have to be at the center of all this, and I think the Stage 2 rules continue our push toward that patient-centered delivery system that we so need in this country. You’ll see new objectives centered around the patient’s ability to view, to download, and to access their own health information in a timely way, as well as to make sure their providers can communicate that [information] with one another and that [patients] can communicate with their provider using secure electronic messaging. We really mean it when we say we need to get the patient at the center of care and health information technology can help us achieve that.
Looking forward, what is your best advice for providers making the trek to achieve Meaningful Use Stage 2?I’ll go back to what I was saying earlier: Don’t focus on this as a government program. Focus on what you can do to improve, what you can accomplish, in your own practice to enhance the care you deliver and to improve the workflow in your office. The groups that take it in that vein invariably do better than the ones inclined to just check off the boxes. I think it’s also important to look at the proposed rule, if you’re so inclined, and where you think we have it wrong, tell us before the comment period expires. Stage 2 is when we want to be advancing clinical processes so think of it that way.
I started out talking about the enormous challenges we’re facing in our healthcare system as a whole, and that is very real. We really are on an unsustainable trajectory. I want to underscore the importance that we cannot afford to fail over the next few years in transforming the healthcare system. We have to work together to make it the best system that we can. And I’d like to make one more plea for providers to tell us what they like and what they don’t like in Stage 2 [MU} and help us craft a final regulation that will strike the right balance between promoting greater use of EHRs while recognizing the challenges that are faced by providers as the implement these EHRs.