Meaningful Use and Certification Improvements

Today, HHS circulated the following important announcement:

"CMS to Propose New Timeline for Meaningful Use Implementation and ONC to Propose New Regulatory Approach to Certification

I wanted to make sure you were aware that the Centers for Medicare & Medicaid Services (CMS) today proposed a new timeline for the implementation of meaningful use for the Medicare and Medicaid EHR Incentive Programs and the Office of the National Coordinator for Health Information Technology (ONC) proposed a more regular approach to update ONC’s certification regulations.

Under the revised timeline, Stage 2 will be extended through 2016 and Stage 3 will begin in 2017 for those providers that have completed at least two years in Stage 2. The goal of this change is two-fold: first, to allow CMS and ONC to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2; and second, to utilize data from Stage 2 participation to inform policy decisions for Stage 3.

The new regulatory approach to certification that ONC is proposing would allow for certification criteria to be updated more frequently under the ONC HIT Certification Program. This approach is designed to provide public input on policy proposals, enable our certification processes to more quickly adapt to include newer industry standards that can lead to greater interoperability, and add more predictability for EHR technology developers. We also anticipate that this new approach would spread out over a longer time period the certification requirements to which EHR technology developers have previously had to react.

More information is available at www.healthIT.gov/buzz-blog"

There has been some misinterpretation of this text, so it's important to clarify what it means.

This is NOT a delay of Meaningful Use in 2014 (Stage 1 or Stage 2).   All 2014 certification and attestation deadlines are still in force.  

This announcement adds another year to Stage 2, delaying Stage 3 to 2017 and making Meaningful Use Stage 2 a three year cycle. 

The federal government does things methodically.  Though it may seem that this decision is lower priority than addressing 2014 issues, it needed to happen now.  Since Marilyn Tavenner messaged at HIMSS that there would be "no rule making in 2013," the timeline established in previous regulations had Stage 3 beginning in 2016, which would have ONC and CMS releasing proposed regulations now.

The fact that today's announcement did not address 2014 issues does not imply that no one is listening to those concerns.  Some may complain that they were expecting lunch and dinner but only got lunch.  It's fair to say that lunch comes before dinner.

The second part of the announcement about certification is a good thing for developers of EHR technology.

ONC is starting a new iterative process of certification that will allow ONC to "telegraph the pass" as Acting National Coordinator Jacob Reider said today - giving developers advance warning of functionality that will be expected in subsequent iterations of the certification program, enabling feedback on such intentions very early, and facilitating adoption of new standards/new versions of standards.  Developers will be able to evolve their products as standards evolve, rather than maintaining alignment with old standards that are part of stale certification criteria.  

In summary, today's announcement is a first step in the fine-tuning of the national healthcare IT timeline.  Stage 2 is now a three year cycle beginning in 2014, Stage 3 begins in 2017, and the certification program moves from a waterfall approach to an agile approach.   In the table below, the three's in the 2016 column become two's, without any changes to 2014.

This is important progress and should be welcomed as a sign that HHS is listening.   There is still work to do and I look forward to continued refinements over time.

Building Unity Farm - Preparing for Winter

Snow will begin falling in New England over the next few weeks.    Most nights have subfreezing low temperatures and it's challenging to maintain water sources for the animals and plants on the farm.

How do we do it?  Heated buckets, heated troughs, heated poultry waterers, heating panels, and yard hydrants.

Here's how it all works:

Ducks - ducks are very resilient to cold and enjoy living outside, only retreating to the duck house in the most severe weather.    Within their pen, the ducks have a heated 50 gallon stock tank/water trough and a heated poultry waterer.   Both activate at 35F.  In the duck house, the ducks have a safe Infratherm heating panel which raises  the temperature of the space by 10F and is activated by a 35F on/45F off Thermocube.  Never use a heat lamp to heat a coop.  Every winter, stories abound about unnecessary coop fires.

Chickens - the chickens are also resilient to cold but prefer to roost inside the coop on very cold or windy days.   They have a poultry water heater (activated at 35F), a heated 5 gallon bucket "nipple waterer" which includes 4 small drinking spigots, and 4 infratherm heating panels that raise the temperature of the coop 10 degrees F.

Alpaca/Llama/Dogs - they have 5 gallon heated buckets (activated at 35F)

Hoop House and Barn water - we use yard hydrants which are supplied from pipes buried 4 feet deep below the frost line.  This enables us to fill buckets and water plants even in the coldest part of winter.

We have 350 bales of hay in the loft, 4 tons of alfalfa in the barn, 300 pounds of poultry grain in waterproof cans and 300 pounds of ice melter (animal safe magnesium chloride).

Let it snow!

Commanding Versus Leading

When I first became a CIO, my role involved writing applications and managing architecture at a detailed level.   Over the past 17 years, my role has become much more strategic, ensuring the right investments in the right overall architecture are made with appropriate resources to support them.    I've had to master the political, communication, and interpersonal skills of leading rather than the technical skills of being a strong individual IT contributor.   Although the way, I've learned the difference between Commanding and Leading.

In an academic health center, formal authority is rarely exercised.   The ability to get things done (or not done) depends upon reputation, trust, and personal influence.    The greatest leadership I challenge I face in 2013-2014 is that the plate is overfilled with ICD10, MU2, HIPAA Omnibus Rule, and the Affordable Care Act.   The majority of my leadership efforts involve getting the entire organization to focus on the regulatory must dos, while deferring nice to haves.   I do this because it is the right thing to do for the institution, but equally important is to triage work away from my staff, which are at the breaking point because of too many demands.

Budgets over the next year at most hospitals are not likely to enable the hiring of new resources beyond those needed for ICD10, HIPAA related security updates, and ACA related analytics.   My leadership task is to limit work to the right work, attempting to buffer my staff from the mayhem of competition for scarce IT resources.

With all the tensions and anxieties involved in running governance committees, planning efforts, and communication outreach, what drives me to do it?

I recall reading a quote from General Shinseki about his views on leadership from his retirement message in 2003:

"You must love those you lead before you can be an effective leader. You can certainly command without that sense of commitment, but you cannot lead without it."

I have maintained my role at BIDMC for 17 years because of loyalty, admiration, and affection for my staff.   I've encountered many leaders who do not understand loyalty and are driven by fame, fortune, or the next new thing.    I'm hopeful that my devotion to staff helps with creating a positive culture, reduces turnover, and builds informal authority - a sense that we're all in this together, fighting important battles every day.

Top down command and control works in some organizations and some industries.   Some employees in organizations which thrive on command and control have told me that they work with constant fear of failure/criticism.   My hope is that leadership built on the the strength of employee relationships creates a joy of success motivation without fear.   Whenever bad things happen, and they do, we should ask how our work processes enabled the mistake, celebrating the learning and not blaming the individual.

When I was young, I thought that management meant authority, power, and self-reliance.   Over time, I've learned that management is about relationships, collaboration, and creating a community of people who support each other.   Leading a team of people you admire is much more satisfying than commanding and that's why I'm still a CIO.