Ann Fishman and Richard Yonis of EHRtv at the MGMA annual show in New Orleans speaking with Robert Tennant, Senior Policy Advisor to MGMA
Ann Fishman, Esq.: Ann Fishman and Richard Yonis of EHRtv. We are at the MGMA annual show in New Orleans and we are with Robert Tennant, Senior Policy Advisor to MGMA. Robert, thank you very much for joining us.
Robert Tennant: My pleasure to be here.
Ann Fishman, Esq.: There are a lot of issues right at this moment related to Meaningful Use because the final rules were adopted in July. Would you speak about the proposals, the final rules and what it all means for widespread adoption?
Robert Tennant: Absolutely. Like so many provider groups, MGMA was very active in the HIT field for many years arguing to the government that in order to make widespread use of EHRs possible, we'd need some stimulus money. And so when we saw the passage of the American Recovery and Reinvestment Act assigned actually in Denver, Colorado, our home city, we saw a historic level of incentives. We'd never seen anything like it in the history of medicine. So we now have the opportunity to see up to $44,000 per eligible provider but the money doesn't come without its catches. And even though the original law only set out a very broad set of requirements, we knew that the newly invigorated Office of National Coordinator would develop very comprehensive rules. Right from the beginning MGMA was involved in trying to educate the policy makers as to the practical implications of an overly ambitious regulation. What we saw with the proposed rule, which came out at the very tail end of 2009, was a very, very difficult rule. I think if they had not modified it for the final version of the rule, I don't think we would have seen much adoption at all. But I think because of folks like MGMA and others, we wrote our longest comment letter in our history to ONC and CMS arguing for significant modifications to the rule. So when it came out in July, we were very pleasantly surprised to see increased flexibility, decreased levels of thresholds for each of the Meaningful Use criteria and also I think a realization that this is going to be challenging for physician practices and I think ONC and CMS have done a pretty good job of listening to the concerns of MGMA and others.
Ann Fishman, Esq.: As a practical matter, what are the challenges for the end user community?
Robert Tennant: Well, there are numerous challenges. In fact, we've done some research over the last few years that indicate that the primary challenge continues to be money. It is extremely expensive to transition a practice to electronic. What we've seen is the average is somewhere between 30 and $40,000 per clinician and so we're again pleased to see that the incentors are there but keep in mind the incentors are not upfront monies. These are rebates in a sense. So the practice has to purchase the EHR, implement it, train the staff, prove that they're Meaningful Users and then they start to get access to this cash over five years under the Medicare plan. So cash is still going to be a huge barrier but there's other barriers as well. Implementation challenges such as re-engineering the workflow. We've seen that to be enormously difficult for practices. Everything within the practice will change from patient intake to orders being given by the clinicians, to prescribing of medicine. Everything changes and therefore everything, all clinicians and administrative staff have to be re-trained and it's a big, big challenge for the groups. And as well, it's a cultural change. You've got physicians who are used to dealing with pay per records; they've been in some cases practicing medicine 20, 30 years. Now they're going to be forced to redesign the way that they think and the way that they interact with patients. And a lot of the challenges are also in the infrastructure, you know, what system should they buy, what type of interface with the patient do they employ? Do they use tablets, laptops, smartphones, desktops. There're so many options now. And they're very concerned about picking the wrong options whether it's the EHR software itself, whether it's the interface with the patient, whether it's an ASP versus server model. So there's a lot of challenges just with the selection process itself.
Ann Fishman, Esq.: To the extent that Meaningful Use requires that the physician use a certified product, speak about the certification process at large and what you think is going to be happening in the marketplace.
Robert Tennant: Well, when certification began, under the Certification Commission for Health Information Technology in 2006 we were, of course, strong supporters of it. think what we found is that it adds a level of supports and I think practices feel a little bit better about selecting a product that is certified. It's again, a huge financial gamble in some cases and I think it gives them a level of confidence that they hadn't seen before. So we were of course very supportive of the CCHIT process. Now with the ONC coming out with the certification rule what they've done is, instead of grandfathering in CCHIT and that process, they've opened it up. So now we have not only CCHIT in this game, we also have two other groups, the Drummond Group out of Texas, and Infoggard out of California. What they've done is they've set a standard so each of these three groups, and there may be more down the road, but each of these authorized testing and certification bodies now test against the Meaningful Use criteria which has its positives, meaning that the group should be confident if they have a certified product they will be able to meet the Meaningful Use requirements and thus be eligible for the incentive. So that's the positive. The negative is this very basic certification may not give them the same level of confidence that they would in a more robust type of certification. And I know that CCHIT has a higher level certification that they're offering vendors as well and so I'm confident that I think a lot of perspective purchasers will be looking to, not only get that basic level of certification, but something that goes beyond. For example, CCHIT is now moved into testing usability of systems. Just because two software programs can do the same task, one might take 1,000 key strokes and one might take 10. So usability is going to be a critical factor for a practice administrator and their clinicians are able to use that system effectively and productivity maintains.
Richard Yonis: So in terms of the dollars that physicians could potentially receive, is there any concern that the ONC could change the rules of engagement so to speak; that this year a vendor meets the requirement and perhaps next year, if the rules change, they don't? How would that be addressed?
Robert Tennant: They've indicated that there's going to be three stages of the program. Each stage will be progressively more difficult for both the software vendors and for the end user. We've made the argument to ONC that they have to be very careful with developing more stringent criteria for stage two. What we need to see is some experienced clinicians using EHRs, using the stage one criteria before they start developing stage 2. But the problem is, software vendors, and I talked to a lot of them, they are going to push for a minimum of 18 months so a longer window from when ONC releases the new criteria to when it's required understand stage two. So we may have a bit of an issue because in order to meet that 18 month window they basically have to come out with stage two criteria within the next six or eight months. That will not give them sufficient experience with stage one. So our feeling is they may have to delay moving to stage two until they have sufficient evidence and case studies to know whether or not they can push the vendors and the clinicians harder in stage two.
Richard Yonis: And so do you think that those changes are being driven by technology that says this is what we want a physician to do or is it physicians that are looking for an easier way for them to document their day to day life because there's a clear difference between the physician driving the technology and the technology driving the physician.
Robert Tennant: Well, that's a great question. I think there's sort of a third element here and that is you've got a certain group of clinicians and policy makers that are trying to push the industry perhaps a little faster than it can handle both on the vendor side and on the provider side. And I think what we've seen with the policy committees coming out of ONC is that they're all extremely well qualified, extremely well experienced clinicians coming from large integrated health systems for the most part and they see this as an opportunity to really push the industry. I think what I'm concerned about is that in pushing the industry a little bit too hard, they may leave a lot of clinicians behind. So those that are paper based that have the least financial resources may be the ones left behind in this sort of push for Meaningful Use.
Ann Fishman, Esq.: The patients clearly are stakeholders and yet there's really no strong unified voice promoting their interest. Is it the responsibility of groups like yours or of the government or of the technology companies? Who should be making sure that their interest in terms of privacy data security, which are enshrined in law but who's to make sure that this is actually part of the overall result that we get?
Robert Tennant: That's a good question. There are a number of consumer advocates and privacy advocates involved in the process of developing the Meaningful Use criteria. They're involved in these ONC policy committees, they're active in the community, they're writing letters in response to rules, so there is a pretty vigorous group that is promoting the concerns of consumers but we also have to remember that we're all consumers ourselves. And I think our position is that if we can produce the type of technology that is useful for clinicians and it can be wide spread throughout the industry, that's only going to help the patients as well but at the same time, we have to be cognizant, as providers to make sure that the privacy and security of the data is maintained because I think we could see a loss of confidence with patients if there are breaches of data security and I think we've seen that in other industries. Certainly in healthcare there's always the stories coming out in the newspapers about laptops being stolen and data being spread out on the Internet and things like that. We've got to be very vigilant to ensure that we keep control of that data and it's not accessed by any unauthorized individuals.
Ann Fishman, Esq.: Do you think that the personal health record market goes to some extent toward ameliorating some of the problems of control and privacy?
Robert Tennant: The personal health record is an interesting case. Of course it's very consumer centric and I think what we've seen is independent silos. For example, Google Health and HealthVault and all these products that allow the consumer to enter in personal health data or download it and keep it and then they can either present it to clinicians or they can help to maintain their own health status. The key will be the integration between the personal health record and the electronic health record. I think we're not quite there yet on both sides. For example, providers simply aren't prepared for masses of patients to come in and put down their password to their Internet site or to come in with a flash drive and say, oh, here’s my record. We have to still be concerned about standards, we have to still be concerned about privacy but I think what the PHR is doing is driving healthcare to be more consumer friendly and I think the two groups of individuals that benefit the most are of course folks with chronic illnesses, diabetes for example, that have a need to continually monitor their health status but also for our seniors and their care givers to be able to compile a record, to be able to bring to a clinician for example the record that shows what medications they're on, what allergies they have because what happens a lot of times is physicians, specialists were almost in silo so they don't know what the clinician next door is doing, they don't know what the primary care physician has prescribed and in a lot of cases the seniors and sometimes the caregivers can't provide the type of information that the clinician needs in order to make the best possible clinical decision. So I'm excited about PHR's. I think we still have to educate providers to understand how they best can use the data presented to them by the patients but also how they can provide the patients data so they then can load up their PHR's with the information they need for their next care transition.
Ann Fishman, Esq.: We are at MGMA in New Orleans. Robert Tennant, thank you. That was a very informative interview.
Robert Tennant: My pleasure.
Ann Fishman, Esq.: Thank you very much.
Richard Yonis: Thank you very much.