When John Glaser left his position as CIO at Partners HealthCare, he also left a vacancy in the weekly CHIME SmartBrief, where he was the voice of the CIO. It was a void that CHIME’s leaders felt could only be filled by someone who had both years of industry experience and a firm grasp on legislative issues. They chose Bill Spooner, a 25-year veteran who has earned recognition from HIMSS and other organizations for the IT initiatives that have helped transformed San Diego-based Sharp Healthcare into one of the most advanced systems in the country. In this interview, Spooner talks about the work his team is doing at Sharp, how health reform presents both challenges and opportunities for CIOs, and why it is so critical for the provider community to serve as the voice of reason in the Meaningful Use debate.
- Writing commentary on industry trends
- “All of a sudden we’ve been upended by HITECH, health reform …”
- Thoughts on HITECH
- The importance of advocacy
- Why change takes time
- Mostashari takes over for Blumenthal
- Breaking down the government’s MU governance process
- The ACO/MU connection
- Privacy overkill
We’re all doing what I call our day jobs, trying to do a better job providing IT to support patient care and our administrative functions. But then all of a sudden we’ve been upended by HITECH—which is a great opportunity, and by health reform—which is an opportunity and a challenge at the same time. It’s definitely an exciting time, and somehow we have to keep them all in a balance.
Some of us are closer to the front line of patient care than others, and some are more experienced than others in terms of recognizing what effort it will take to change our organizations.
We really have to engage in this… it’s only the provider community itself that can realistically inform the policymaking groups about the impact some of these proposals would have and the challenge that they would have realistically in implementing them.
Just looking at normal development cycle from a vendor perspective and normal organizational strategy, to augment Meaningful Use requirements with things that appear to be great ideas but are not part of an overall program may actually hurt the provider’s ability to achieve Meaningful Use. They may be unrealistic in terms of what vendors can deliver and in terms of software modifications.
Guerra: Good morning, Bill. Thanks for taking us some time to speak with me. I’m looking forward to chatting with you about the state of the industry and the fun policy stuff we’re all going through.
Spooner: Thank you, Anthony. This certainly is an exciting time.
Guerra: That’s for sure. Well, you’re now doing a column—a short piece for CHIME SmartBrief. Is that every week or every two weeks?
Spooner: It’s every week.
Guerra: Okay. First off, are you enjoying that? What is that like having to sift through the materials and articles you find out there, and then selecting something and breaking it down a little bit? Are you enjoying it?
Spooner: It’s a challenge and I’m enjoying it. Just to give you a little bit of background. I think I spoke up once too often. I asked who was going to replace John Glaser when he moved to Siemens, and Rich Correll said, “Keith and I think you should do it”. And that was a real challenge because my first thought was nobody replaces John Glaser; he’s brilliant. And yet at the same time writing comes difficult for me. So I said, ‘I’m going to do it because it’s a challenge.’ So I took it on, and the way it works is each Tuesday morning I’m given links to two articles, and I could go find another article if I want, but basically the idea is that I should comment on either one of those two articles. I have to have it turned around by Wednesday morning and back to the editor for printing and then it’s in the Thursday CHIME SmartBrief. So my Tuesday evenings are sometimes short, sometimes long, but that’s my opportunity comment, and I happen to enjoy it.
Guerra: That’s good. There are some good side effects in that it forces you to have to devote some thought to things that are otherwise might be passing; at least that’s what I’ve found. I have to write something every week with my e-newsletter and there are some nice benefits to what might be the painful process of writing in that it really crystallizes and focuses your thoughts because you have to do it.
Spooner: It helps to crystallize my thoughts, but I also enjoy it as a vehicle for introducing some ideas to others, whether they think I’m right, wrong or indifferent. I’m hoping that a few people read it, and I’m hoping a few people think, ‘perhaps it makes sense, perhaps he’s crazy,’ but they think about it.
We’re in a really interesting time where we’re all doing what I call our day jobs, trying to do a better job providing IT to support patient care and our administrative functions. But then all of a sudden we’ve been upended by HITECH—which is a great opportunity, and by health reform—which is an opportunity and a challenge at the same time. It’s definitely an exciting time, and somehow we have to keep them all in a balance.
Guerra: From reading your stuff out there and from interacting with you in our e-mails back and forth, is it safe to say that you think there could be some improvements in the way this program has been rolled out?
Spooner: I will say that everyone is really well intentioned; there’s just no question about that. There’s been so much work and so much thought behind it, and we all have different opinions about it. I think that the real challenge from my perspective is that it’s taken so much time to gain broad public input, and that it doesn’t leave a lot of time for the vendors and for the providers to really respond to the outcomes of it.
And I think beyond that, it’s natural that we’re going to lobby. We always would like to make it easier to meet our goals. So a lot of the advocacy that were doing, regardless of the organization, is to try to make it easier to earn money. At the same time, some of us are closer to the front line of patient care than others and some are more experienced than others in terms of recognizing what effort it will take to change our organizations. So many people have spoken up about the difficulty in getting physicians to CPOE in their organization, just to use that as a common example. And in some cases, the feds and the committees have responded to that, and in other areas, they haven’t. In some areas, they’ve proposed very smart and realistic ideas, and in some areas, there are ideas that will take a long, long time to implement, and some might even argue whether they will have a beneficial effect once completed.
Guerra: When I listen to the policy meetings and the work group meetings, you can hear a distinction between what I would call the special interest groups that are on the consumer and the patient side; they may not be as familiar with the intricacies of the workings of a hospital and physician practice. And they throw out things they’d like to see done for benefit of the patients. They tend to be more aggressive on that side in terms of what they’d like to see done. On the vendor side and certainly the provider side, you often hear a voice of caution saying, ‘Hey, we need to talk about how much it is going to take to actually accomplish this stuff.’ I wonder if that’s the real tension. And it seems to me that with some of the stuff we see coming out, we’re seeing what I call the ‘wish listers’ maybe winning the day a little bit. And some of the stuff seems to be quite onerous.
Spooner: I suspect that there is some of the ‘wish-list winning the day’ in that many organizations have full-time advocacy staffs that are trying to inject their viewpoints in any form that they can. So they’re going to have an inordinate amount of impact. And I think that the providers—especially those of us in IT who haven’t experienced this before—have recognized that we really have to engage in this, and that it’s only the provider community itself that can realistically inform the policymaking groups about the impact some of these proposals would have and the challenge that they would have realistically in implementing them.
I think from our perspective, we can see a couple of areas that are really obvious. One is that it takes time for a vendor to produce software. And we’ve all gone through experiences where software has taken a lot longer than a vendor predicted it would; it always does. I think it’s just that mode of optimism that comes out initially when a new product is announced. So we all know that it’s going to take longer than expected.
It’s also hard to get change in an organization; to get clinicians and physicians to adopt change, especially if it means that they end up doing more work than they were before. Everyone is really working hard in today’s environment; it’s not like they have extra cycles. And so when I tell the physician that they need help me collect XYZ data elements and they need to record this as part of a patient’s problem list, they’re going to resist. And we have to be as clever and creative as we can be in supporting these physicians and other clinicians in doing this work.
Guerra: Yeah. There may not be that sensitivity, but they’re talking about more; the sensitivity to understanding that, first of all, if you’re affecting certification and the vendors have to change their software and then get certified, then get it out to the customers, and the customers have to get trained on it—it’s a lot to consider. I just upgraded my version of Firefox and they moved the refresh button to somewhere else on the screen, and just by force of habit I’ve gone back to the same old spot 50 times to hit refresh and been slightly annoyed, and I can just imagine what it must be like to roll out a new application in the ED. Change is painful; even small change, and it takes time for people to get trained.
Spooner: And we don’t want the way clinicians deal with that change to impact patient safety or patients care. We don’t want them hitting the wrong button accidentally. It may be you or me in the emergency room at the time that they’re learning this.
Guerra: So tell me your thoughts on David Blumenthal’s tenure and the new selection of Farzad Mostashari. I don’t know if you had much interaction with him, but just your thoughts on Blumenthal’s tenure and Farzad being selected to replace him?
Spooner: I think that Doctor Blumenthal did a stellar job, and in a really difficult situation. I’m not sure that he expected as much industry resistance to the meaningful use framework as it was originally constituted. If you go back to about July or August of 2009 when the first framework came out, it seemed like a very logical, orderly thing, and then industry lobbying and the resistance just started from all sides in. I’m not sure the he expected that.
I think that for the amount of resistance that he faced, and especially given that there were really three branches of government dealing with this—CMS and ONC, both within HHS, and the White House staffers, who had their perspectives—it was quite a balancing act for him to achieve, and it was incredible that he got what he did done. So I applaud him.
I met Farzad at a meeting back in the fall, and it was my only direct interaction with him. He’s brilliant—there’s no question about that, and he’s energetic. I would hope that he is able to broaden his industry input as he goes forward so that some of the areas where many of us had felt that some of the proposals have lacked the connection with reality, I hope he’s able to bring something to that. He certainly has had a head start having worked within ONC for a long period of time. He absolutely knows this stuff. I think that he will be a great replacement for Dr. Blumenthal.
Guerra: You mentioned CMS, and I wrote one of my recent columns that you have these advisory buddies like ONC, and they kick up to advice to the national coordinator, and I don’t know the exact technical way it works, but it goes over to CMS’ advice. And in terms of Meaningful Use, CMS is the final arbiter of what’s going to be in there. And CMS is also the entity that has to manage the program from a technical point of view. I heard Tony Trenkle from CMS a number of times in the last policy meeting caution policy members not to try and do everything in Meaningful Use; not to think that Meaningful Use is the only way that health care is going to move forward; not use it as a dumping ground for every wish they may have. I want to hear your thoughts on that advice. It seems interesting to me that we’re hearing that now. It would suggest that CMS is saying that this program is getting a little too heavy and they don’t want to burden it and make it a failure.
Spooner: I would definitely echo that. I would even go beyond that and point out that the requirement within the regulation around accountable care organizations that 50 percent of physicians have to be Meaningful Users is probably overkill as well. I think that to be an accountable care organization, you’re going to have to collect the data. And thus, you’re going to need an electronic health record to put that requirement inside of the ACO regulations, and this may be cumbersome. I think similarly, we keep adding to privacy regulations as we go forward. And privacy is just so controversial and so complicated that it really would be preferable in my view to have a single body try to embrace privacy collectively without multiple organizations having potentially conflicting requirements.
And beyond that, just looking at normal development cycle from a vendor perspective and normal organizational strategy, to augment Meaningful Use requirements with things that appear to be great ideas but are not part of an overall program may actually hurt the provider’s ability to achieve Meaningful Use. They may be unrealistic in terms of what vendors can deliver and in terms of software modifications. And then you have to ask the basic questions about whether these specific things can really be shown to improve quality, improve access to care, and release cost, which is really the bottom line of everything we’re trying to do.
Guerra: Yeah. That sounds like you’re reflecting the comment letter that CHIME send out about the federal strategic framework, and there were a couple areas touched on. One is in health information exchange and the balance between privacy and access. CHIME basically stated, we can’t lock this information down so much that it’s impossible to get to it, practically speaking. If you want to expand on that, the balance between privacy advocates getting what they want and health care practitioners being able to access information in timely manner.
Spooner: Well, I really think that the debate between the popularly called opt-in versus opt-out is a top one. Clearly we want the patient to be informed to make those decisions, but from a practical standpoint, if it becomes so cumbersome for a physician to get permission to look at a record from another provider electronically, he or she is probably less likely to do it. And they may end up repeating some of the diagnostic work because it’s just seems easier than having to go through the entire release of information process for them. And when you even go beyond that—and this is not in a current regulation but in the PCAST report that was released in December, where they were talking about metadata tags and patients actually specifying more granularly the information permissions. It would leave a physician in a position of not knowing whether he or she is looking at a complete record once they have achieved consent to look at the record, and thus, be confidently be able to perform in their care processes, because they’re not sure that they have a complete record of the patient’s care, which would probably take them right back to the earlier point of repeating a lot of testing work.