TEXT/PODCAST: One-on-One w/Former ONC Senior Adviser John Glaser, Part I

Over the past year, John Glaser, Ph.D., has been eating and breathing Meaningful Use and Certification even more than his HITECH-focused CIO colleagues. That’s because while Glaser has kept up his role as VP & CIO at Partners HealthCare on a part-time basis, he’s also been winging down to D.C. every week to fulfill his duties as Senior Adviser to ONC and its chief, National Coordinator David Blumenthal, M.D. In this — his first extensive interview since the culmination of that role in March — Glaser talks frankly with healthsystemCIO.com editor Anthony Guerra about working in the federal government, the proposed regulations, and what the future may hold for both the industry and himself.

PODCAST

[audio: One-on-One-W-John-Glaser-Chapter-1.mp3]

BOLD STATEMENTS

It is very difficult to get it right coming out of the gate, and it’s so important that there’s all kinds of feedback, pro, con, in between, all the way along the way.

… part of it is — and you see this in the proposed rule on the part of CMS — they don’t actually expect that every provider will get there by 2011. So in a way, Meaningful Use is a statement of where we’d like to go, realizing that not everybody will be there in 2011, more will be there in 2012, etc.

If you said, “To what degree do you think it’s too high to be accomplished between now and 2011?” I think I’ll probably agree that it is too high.

GUERRA: We’ve spoken a number of times before, but not in a while because you were busy with some important work down in D.C., which I think a few people in the industry might have heard about. Do you think everyone’s heard of Meaningful Use (laughing)?

GLASER: I’m sure that they have, Anthony, by this time (laughing).

GUERRA: It’s been about a year, right? You started around spring last year, so we’re coming up on a year. Are you officially finished?

GLASER: I was working part time with ONC starting in early May of last year and finished my tenure there at the end of March of this year.

GUERRA: So you’re full time back at Partners now?

GLASER: Yes.

GUERRA: Your title was special adviser, and I would imagine going into it you weren’t even quite sure what exactly that would entail. Tell me what it did entail.

GLASER: My official title was senior adviser, not that that matters much, but when I arrived, shortly after David Blumenthal arrived, the HITECH legislation had passed and, as the industry knows, there were some very short-term deadlines that were in the legislation. So they were saying that the proposed rule surrounding Meaningful Use, the proposal for standards and certification, all of that had to be out by the end of the calendar year and into the hands of the industry for discussion and comment, et cetera.

In addition to that, there was money given to the office of National Coordinator, about $2 billion, to be devoted to a variety of elements that were viewed as being important for accelerating the Meaningful Use of electronic health record systems. This had to do with the regional extension centers and state health information exchanges. So all of that work was on the table in early May, late April, and it was just an amazing amount to do. And while there was a very talented and capable ONC staff, it was just overwhelming the amount of work that they had to do.

So what I was involved with — particularly through the summer and into the early fall — was helping David and the ONC folks work with the HIT Policy and Standards Committees, which had also been established by the legislation. First of all, to form and then begin to do the initial set of work that was being asked of them — whether it had to do with some recommendations regarding Meaningful Use or some examinations of the certification process that was in place, looking at some work that ought to be done and had been done on health information exchanges and also on the Standards Committee. There were obviously legislative requirements that certain standards be identified, so I helped them sort through what some of the options were and what some of the recommendations were.

There was a very concerted focus throughout the summer with those two committees to get some initial recommendations and some good recommendations by mid August, so that those could then be fed into the federal process of writing rules and writing regulations. The core of the work was, again, working with federal folks, but also the volunteers who did great work on the various committees, to get that done.

Through the fall, the work became more internal to the federal government in starting to put together the rules and regulations and listening to thoughts and ideas from other federal agencies such as the NIH or the CDC or the Department of Veterans Administration or the Department of Defense, and it’s also about that time that the grants where beginning to be formed. And so, for example, if you want to set up a regional extension center program, what do you do, how do you think about it, the SHARP grants, if there are areas of research that should be focused on, what are those areas, and so there was a bit of a shift in the fall into finalization of the rule writing but also the formation of the grant programs.

GUERRA: You just made me think that it’s not necessarily easy to give money away.

GLASER: Well, I think the intention of the money was to really help the industry move as fast as it could, and as effectively as it could, to adopting the technology well, more than just the adoption. I think one of the major milestones or pieces of this legislation was having the industry focus on Meaningful Use and see mere adoption as insufficient. You’ve got to be writing prescriptions, you have to be recording problems, you have to be sending discharge summaries to the care providers who will be engaged in the follow-up of care, so you want to make sure that the money is devoted to advancing that, and that requires you think long and hard about, “Well, how would you spend it?” I mean, because there’s a range of different ways you could think about that, there was very little in the legislation that says you have to spend exactly this amount on that area and this amount on that area, etc.

There is a discussion about what’s the portfolio of issues that you would engage in, whether it’s workforce development or research or state HIEs, things along those lines, and also what’s the relative amount that you might put in each of those. And if you were then to talk about how you would create a large number of regional extension centers, what is it that you’re going to ask them to do, how will you evaluate the proposals and how would you measure their success on a go-forward basis. All this while being mindful of the fact that there have been presidential pledges that every American will have an electronic health record by 2014, and so that becomes part of the yardstick by which one says, “Well, geez, will this help us advanced towards that goal?”

All this while realizing that the movement towards that goal to a large extent depends on the federal government’s incentive moneys and grant programs, but to a large extent also it’s the private sector responding with a lot of innovative ideas. People are saying, “I think I know how I can help the small physician practice become a Meaningful User.” Or in large academic health centers like the one I work for, looking at how it will continue strategies of putting these systems in place. So it’s putting together the programs and making sure that they’re solid, that they advance towards the goal, and trying to structure the federal activities to support that goal, and also ensure they’re supported by private sector activity.

GUERRA: You mentioned working with NIH, CDC, VA, the DoD, and, of course, CMS, NIST, etc. What about D.C. surprised you? Did working at Partners prepare you?

GLASER: Well, it’s certainly different. I mean you’re in a political organization, so it’s an organization that pays attention to elections, it pays attention to the mood of the public, it pays attention to the issues, etc. Partners pays attention to all those factors too, but the fact that it happens to a greater degree in government is not surprising. It is, at the end of the day, a political institution. There’s also a great deal of emphasis in the federal government about make sure you take care of all Americans. So a lot of the regional extension center work is directed to small physician practices that don’t have IT staffs and hence need some help, and the reason you need to do that is because at the end of this stuff, all of this activity, you can’t have large sectors of the American public underserved or not served at all by this technology just because they are taken care of by small hospitals or small physician practices.

So there’s a more significant emphasis on the public good and taking care of the public. And again, Partners does that too but not necessarily to the same degree that the federal government is concerned about that. The federal government is a very large, complex organization. There’s a lot of negotiation that goes on and a lot of trying to meet the other person halfway, or however you might phrase that.

One of the things that I was most pleased by is the people who I worked with were really very good, very smart, worked very hard and cared about getting it right. And I sometimes think that boy, I might have had conceptions of a federal person as being stodgy and not that interested in innovating, but that’s not what I saw down there. I saw some extraordinary people, which was just really cool to see and in almost Boy Scout fashion it made me proud of the fact that that’s good government. I hope my tax dollars are being spent and thought about by people as smart and as capable and as hard working as the folks that I worked with.

GUERRA: I read your piece where you wrote about that and then Russ Branzell wrote a piece on my site where he talked about the same type of thing. John Halamka wrote a piece on his blog praising the ONC staff as well. I personally have been a critic of some of the stuff that’s come out, there are going to be a lot of critics, but it seems like when you get to know these people on a personal level, you’re a fan.

GLASER: I think it’s fair and appropriate that people critique and be critical. As smart as you might think you are down there, and as much terrific advice and thought as you get from the Policy and Standards Committees, and lots of people who come to visit, it’s really hard to think through all this stuff and to have thought about every nook and cranny and aspect of it. The government recognizes that in a way, which is why we have comment periods for people to give feedback. I think that’s how ideas get better.

Now, you can always take criticism as a personal wound, but you know you can’t do that because it’s very complicated. I mean, you know, Anthony, you and I have been in this industry for awhile, I’ve never seen anything like this, this much change, anything this complicated and this transformative, if one wants to use that word. It is very difficult to get it right coming out of the gate, and it’s so important that there’s all kinds of feedback, pro, con, in between, all the way along the way. I frankly think it’s going to go on for several years because a lot of the stuff we still haven’t implemented.

You know we’ll be seeing it in a year from now and it’ll still be early in the exchanges, it will be early in the certification process, it will be early in seeing how extension centers work and some ideas will be brilliant, some will be less than brilliant and some that we think today are pretty good will turn out to be not so good, some that we think today are kind of questionable might turn out to be really smart. So we’ll have to have a lot of pretty open, frank conversations. Sometimes they are soft, sometimes they’re hard conversations about what’s working and what’s not. So I think it’s always appropriate to be critical or to critique or whatever, because it shapes the conversation and makes the ideas better.

GUERRA: A number of comment letters have said the Meaningful Use bar was set too high, such as those from CHIME and AHA. During an interview, Pam McNutt said you can forget about stages 2 and 3 at Methodist because they’re just not going to make it. So if you got a top CIO like Pam saying that, what chance does the average hospital have? Do you think the bar was set too high, if so, why?

GLASER: I think there’s debate. There’s other organizations that step forward and say keep the bar where it is, don’t lower it. I think a couple of things about it, one approach is looking at each element of Meaningful Use individually, seeing one as a good idea, saying we ought to be doing this, we ought to be doing that, etc., so I actually find few people would disagree with each row in a way of thinking about it as a table. I mean, obviously, there are people who think that in aggregate it’s too much to ask between now and 2011. I mean part of it is — and you see this in the proposed rule on the part of CMS — they don’t actually expect that every provider will get there by 2011. So in a way, Meaningful Use is a statement of where we’d like to go, realizing that not everybody will be there in 2011, more will be there in 2012, etc. I think it’s a statement of what ought to be going on and what Meaningful Use ought to be. It is a terrific statement and very well balanced across patient engagement, privacy, security and care quality, along those lines.

If you said, “To what degree do you think it’s too high to be accomplished between now and 2011?” I think I’ll probably agree that it is too high. It was set as an aspiration of where we ought to go, it is put out as a proposal. I mean, that’s what Notice of Proposed Rulemakings are, they’re saying, “Here’s a proposal, tell us what you think,” realizing that it’s not possible in a proposal to have gotten it all right. But you really do want the feedback to figure out, “Well, where is it too high?” and if you said, “Well, it’s too high and you ought to lower it,” how would you lower it? Will you change 80% to 30%, would you move this row in 2013, would you keep this row in 2011, how would you alter it?

So in a lot of ways, I think it’s a good strategy to come out with something that is aspirational and high, realizing you may settle for something lower than that, but what you really want is to hear — whether it’s the AHA or CHIME or Pam McNutt or anybody who’s out there — is if you were to change it, how would you change it, and give us some thoughts and ideas that will temper it. So it is a straw man in a way and a high bar, which is perhaps how you ought to have a straw man — “I want to shoot here, tell me why I can’t and what you would change to do this?” We may wind up in a place that’s lower, but still if we were actually to achieve that, even in a significant minority of provider organizations in 2011 and 2012, we would have made extraordinary progress.

Anyway, those are my thoughts on it — I think it’s very well done, it is aspirational, it will be, presumably, tempered a bit, and it will be tempered based on a lot of the feedback that has come back, not just purely on the statement that it’s too high, but much more on the specifics of what would you do differently if you believe it’s too high. I think we’ll see a lot of the thumbprints of those kinds of comments and suggestions on the final rule whenever it’s released.

Part II

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