One-on-One With Baylor CIO David Muntz (I)

As chair of the CHIME Advocacy Leadership Team, David Muntz is as plugged into the Meaningful Use saga as any non-government employee can be. And to hear him tell it, the interim final definition of MU needs to be significantly tempered if the majority of healthcare organizations are to have the slightest shot at qualifying for HITECH funds. Recently, healthsystemCIO.com editor Anthony Guerra talked with Muntz about what’s wrong with Meaningful Use, and how the government can make it right.

BOLD STATEMENTS

I think a personal health record stored somewhere on the Internet makes a lot more sense, but that’s not what the regulations call for.

What I would have preferred is that they move away from the all or nothing kind of approach so that you could do a subset of things that they require in order to meet the requirements.

When I do a map that shows what the certification process might require and what the typical government turnaround is, it appears to me you couldn’t even make that if you wanted to.

GUERRA: On a recently held CHIME Webinar, you voiced some concerns about the preliminary Meaningful Use criteria. One of them was around the requirement that patients receive electronic copies of their records. Can you expand on that?

MUNTZ: Some of my concerns are practical and some are around policy. If you come to me and ask me to give you an electronic copy of your record, right now the media that seems to be most available and cheapest would be a CD or DVD. Let’s assume I make a copy of it and give it to you. Now, I haven’t done much better than paper. In fact, it’s worse than paper because you can’t view it without a special device, which we call a computer. If you take it to somebody else and you have had other work done there, then they’re going to give you a second CD, and it may or may not be labeled appropriately. The question is: do I give you a CD that has just this visit or does it have all of your history on it? If you wanted to combine data from visits, how would you do that? If I decide I have a thumb drive that I want to use, that’s a problem too because, by policy, we don’t allow thumb drives on our machines — we’re worried about viruses being transmitted via thumb drive.

You just think about the little practical matters and the access to electronic data doesn’t seem that impressive then. You’ve got to think through what’s the standard format, how do I encrypt it, if I try to encrypt it, then what kind of program do I use to decrypt it. If you’re going to encrypt and decrypt, you probably want a smart thumb drive which is far more expensive and really a challenge to use, then how does a person who’s reading it decrypt it without you being there to see it. In an emergent situation, how does that happen? So just on the surface, it seems tough.

Then the question of confidentiality is probably the same as it is with paper. If I take the chart home with me and somebody finds it and looks at it, it’s easier to take the data that sits in an electronic format and then text it between friends. So now, all of a sudden, medical records start showing up on Facebook, whereas the paper medical record wouldn’t allow that, nor should a secured electronic record.

So there are a lot of challenges in how to make this work in a way that’s elegant and achieves the appropriate objectives. I think a personal health record stored somewhere on the Internet makes a lot more sense, but that’s not what the regulations call for. The regulations talk about that, but you still have to accommodate somebody who requests an electronic copy of their electronic record.

GUERRA: Do you get the feeling that the people writing this legislation were vague so that different ways could be found to the same objective?

MUNTZ: The problem really is that, in some cases, the writing is very broad, as in the case we just mentioned, but in others, it’s so specific that you don’t have any choice about how to do it. And what I would have preferred is that they move away from the all or nothing kind of approach so that you could do a subset of things that they require in order to meet the requirements. For example, I would prefer if you could meet 18 or the 23 objectives and still qualify. So I’m afraid it’s going to punish people who are trying to do the right thing but haven’t gotten there 100 percent.

Let’s take CPOE, if you’re not completely electronic in terms of CPOE, then what you have to do is count the number of orders that are done manually in order to determine what the denominator of CPOE usage is. And that’s almost too proscriptive when you’ve got to prove that your numbers are accurate. So the requirement to do that means you’ve got to change your workflow so that every time somebody writes an order, somebody else has to count it in order to come up with the denominator. So I just don’t think that enough time was given to consider the workflow implications.

GUERRA: Do you think the government will change the definition much, based on the comments that come in? If there is significant change, that doesn’t leave much time until October.  

MUNTZ: When I do a map that shows what the certification process might require and what the typical government turnaround is, it appears to me you couldn’t even make that if you wanted to. Am I hopeful that CMS is going to lighten their required restrictions? Absolutely.

I think the differentiation has to be made between those things that are legislated and those that are not. For example, the timeline versus those things that are going to be part of the proposed regulations which would be how you prove that you’ve reached meaningful use. I think they’re reasonable people trying to do the right thing, and that when thoughtful suggestions are given, they will be carefully considered. I’m very encouraged that the intent will be honored.

GUERRA: I have always felt that the policy side of this was being shaped by “true believers” who have a vision of what they want healthcare to be, but aren’t that plugged into what it takes to change things on the ground. Do you think there is a tension at play here between vision and reality?

MUNTZ: I do. I think that’s why you have the comment period. I think the term stimulus was exactly the right term. They’ve certainly stimulated conversation and an examination of where we are and where we need to go as an institution and as individuals, as individual practitioners. So I think they did exactly the right thing, and I think if they hadn’t put the bar up high and talked about what the ideal was, you couldn’t quite figure out where to come back to reach a more pragmatic solution. So I think it’s the right kind of approach.

GUERRA: You’re assuming that the bar is going to be lowered.

MUNTZ: Yes, considerably. I think it has to be. The truth is that if we could do even a portion of what was being talked about, the advantages to the country would be extraordinary. And so to meet the ideal might get us the most reward but the rewards that would come from an incremental success shouldn’t be underestimated.

We see that as we go through the implementations in our own facility. We don’t know how to put in the perfect system. You’ll fail if you try because the fact is people have to adapt the change. We look at the ideal and then we try to come up with something that’s less ideal. In fact, the way I describe it is we look at the sundae that everybody wants — with every topping on it — and then what we provide is usually vanilla with a lot of sprinkles.

GUERRA: I love it!

MUNTZ: People know what I mean when I say that. So when people start to go a little far afield on their request, I say, “Excuse me, vanilla with sprinkles. We didn’t say we’re going to add chocolate this time, we’ll do chocolate in the future.”

And so we build our approach to be incrementally successful. The trick is that once you can convince somebody that these major changes are going to work, they usually are pretty hurried to adopt even more of the technology. The Apple iPhone is a good example, it didn’t take the perfect selection of apps to make that one of the hottest selling things ever. It took the potential to get you there and, once that happened, the floodgates were opened. I think the same thing is true here.

By the way, I heard a great quote the other day, and I’m not sure to whom the attribution goes — people don’t hate change, they hate transition. And so the question is, how do you shorten the painful transition period and get to the change that’s beneficial.

Part II