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

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.

(Part I)

PODCAST

[audio: One-on-One-W-John-Glaser-Chapter-2.mp3]

BOLD STATEMENTS

So one of the reasons you’d come out high is because you can subtract and remove, because you’ve heard from the people who’ve looked at it, who have said, “You’ve got to delay or remove this.” It’s a whole lot harder to come in and introduce stuff that nobody has ever seen before …

What will matter is these rules that come out, and whether the industry says, “I can do that, even if I can’t make it in 2011.” I don’t think Partners will be able to make it in 2011 …

… (Committee members) don’t always see the world the same way, they have different things they emphasize, they have different goals for their constituencies, etc.

GUERRA: As far as you know, is there unlimited flexibility in how much an NPRM can be changed before it becomes a final regulation?

GLASER: It depends where you sit on a definition. I don’t think there’s unlimited flexibility. There are some constraints that confront the federal government. I don’t think it would be possible — though I guess all things are possible — for them to come out with a final reg that’s radically different from what was seen in January, because it’s very important to the government that there be a comment period that’s open for some discussion and debate. If something radically different came out — without the benefit of at least some reasonable level of public discussion — it would not have had that. And so they must, in a way, center around the proposed rule which has been viewed and commented on by the public.

This generally means that it’s hard to add stuff to a rule that has not gone through public scrutiny of some form. It’s easier to subtract or delay. So one of the reasons you’d come out high is because you can subtract and remove, because you’ve heard from the people who’ve looked at it, who have said, “You’ve got to delay or remove this.” It’s a whole lot harder to come in and introduce stuff that nobody has ever seen before, because then the public cries foul.

So how much flexibility is there? There are limits within the legislation. The legislation does give out some dates and I think Congress, the people who wrote the legislation, certainly has particular things in mind. I think the president has certain things in mind, etc. So it won’t come all the way down to, “Just fire up the computer and you’re good,” but there’s an opportunity to be in the middle. Now the middle ground’s quite wide in its range, and what I don’t know is where it’s being settled.

So will it change? Probably. Will it go all the way down to where 100% of providers can clear the bar in 2011, 2012?  Probably not, because Congress would say, “Boy, that just doesn’t look like what we had in mind. When we appropriated all this money, we wanted to see more progress,” and you might get the same out of the president. So whatever changes are likely to be made will probably be more around stuff being either softened, removed or pushed into 2013, but what that mix will look like, I don’t actually know. We’ll have to see how the internal conversations resolve themselves when it comes out, and I think their expectation is that it will come out relatively soon.

GUERRA: Does it matter if HITECH is about financial stimulus versus healthcare reform?

GLASER: Well, a lot of the intention of the American Recovery and Reinvestment Act was to get money out into the economy quickly. I mean things like building bridges, putting people to work, etc, but not all of it was. Some of it was around investments in the American economy, some of it which will play out in the short term, some of it which will play out in the long term, and I think you can argue pretty soundly that investments in interoperable electronic health records and the meaningful use area are good investments in the health of this country. They will help keep insurance premiums lower and healthcare costs moderated.

So not everything in that legislation was purely jobs creation or public works funding, etc., some were longer term investments. And frankly, we ought to remember that the bill was put together in a very short period of time, roughly December through January, at a time when the economy was in all kinds of crises, and so not everything was subjected to a litmus test of whether it really was job creation, although you’d be hard pressed to argue that this was an investment that should not have been made. This makes healthcare better for all of us.

At the end of the day, you, I and others could probably debate that into the wee hours of the morning, and it doesn’t really matter. What will matter is these rules that come out, and whether the industry says, “I can do that, even if I can’t make it in 2011.” I don’t think Partners will be able to make it in 2011, I think it’s a good path, it’s a great path. In 2013, we will go off and get that stuff.

GUERRA: I’d like to talk a little bit about the process of implementing the HITECH Act, creating the Policy and Standards Committees, their roles, etc. Can you take me through some of that?

GLASER: The Policy Committee composition was largely driven by the General Accounting Office (GAO) and David (Blumenthal) had authority to put together the Standards Committee — although his recommendations had to be approved by the Department of Health and Human Services and the White House had to feel comfortable with them. So I think there were a lot of ideas and some great names put forward, and in one case the GAO came up with a list which was then complemented by what David was able to do, both on the Policy Committee and the Standards Committee. And I think whenever you put those committees together, you’re looking for, as well as you can get it, a spectrum of people from the very diverse stakeholders that are in healthcare.

So you’re looking for people who are from small physician practices, people from large health systems, you’re looking for people who represent purchasers of care — whether insurance companies or employers — you’re looking for people from the patient advocacy community, you’re looking for people from the vendor side of the equation who can contribute, you’re looking for people whose organizations serve inner cities and poor populations versus people who perhaps serve more well off communities. We were looking for a diversity of perspectives in those committees because, at the end of the day, whatever one comes out with has got to do as well as it possibly can of trying to get a middle ground that at least all the various stakeholders which exist in healthcare can say, “I can live with that.”

Sometimes that’s a complicated discussion because, obviously, as you and I know, they don’t always see the world the same way, they have different things they emphasize, they have different goals for their constituencies, etc. So I think, under any circumstances, one is going to get a diverse composition on those committees, and you have to because that’s the only way to really make sure you heard all the opinions and arrived at an outcome that is as well balanced as it can possibly be.

I think the people on those committees are terrific people and together they are an all-star lineup of the healthcare field, and they do a good job of representing diversity. In the various workgroups, they were able to add more folks. We wanted to have “this type of person or that type of person” in some of the workgroups, and so they were able to bring them in across all of the workgroups.

And the other part of this is that those meetings are public, so additional perspectives can get included through testimony that is brought in the form of panels or comments that are submitted afterwards. There are plenty of opportunities to put those in front of the group and put them out in a way that the whole world’s watching. You know, they’ve been very, very good about having these meetings all be open, and so I think you’ve got to have balance no matter how you do it. You may miss a person or perhaps a constituency, but there are ways to address that through testimony, the openness of the meetings, and the public comment periods that exist at the end of all these, all of that in addition to the comments that can be developed during the course of the rule-writing process.

GUERRA: The workgroups, Committees, and even ONC seem to all be crafting advice for CMS and HHS — can you clarify who is making recommendations versus who is actually making the concrete decisions?

GLASER: The committees — called FACAs (Federal Advisory Committees) — are established through a bunch of rules that surround how you put them together and manage them, but their job is to provide advice to the federal government. So once, let’s say, Paul Tang takes a vote and everybody approves, that’s written up and formally transmitted as advice to HHS. And now if it’s Meaningful Use advice, it goes on its way to CMS. If it’s in relation to the Standards and Certification process, it goes on to ONC. Sometimes the advice is not immediately directed to a regulation or rule that’s in place. It’s just that we’ve debated this topic — for example the National Health Information Network — and, “We think this is what you guys ought to be doing,” and that advice may factor into grant programs.

So it arrives as advice, and neither David Blumenthal nor whoever’s going to be running CMS is required to take that advice. Just like any advice that you would get, you can take it 100%, you can take it 0% or somewhere in between. On the other hand, what you’re not really in a very good position to do is to ignore it because sooner or later rules show up and either the industry or congress is saying, “Wait a minute, what happened to all this advice you were given,” and it’s advice given by some terrific people in very open sessions, so if you ignore it, then you’ve got a problem on your hand because you took the best in the industry and you’re ignoring what they’re telling you. So there is a lot of pressure, frankly, to take the advice very seriously and incorporate as much of it as you possibly can into the eventual rules.

Now you’ll never see, I think, all advice show up as a mirror image in the rule, but I think if you looked at, for example, the CMS proposed rule for Meaningful Use, boy, do you see the fingerprints of the Policy Committee all over that thing, and if you would take the standards and certification criteria, IFR, boy, you see the Standards Committee all over that thing. So I think, at the end of the day, while they write the rule, the rule is for us, not for them, and they know we have to live with the rule out here. They do to a degree, but not to the same degree. So they are really careful and thoughtful about making sure that whatever gets introduced improves the industry or improves whatever you’re trying to improve, knowing the quality of people and the quality of the discussion that this advice constitutes is probably as good as you’re going to ever get on this particular topic.

GUERRA: Maybe it’s because of his great DJ voice (laughing), but Tony Trenkle from CMS seems to be quite a powerful man in that room, and CMS is quite a powerful organization, obviously a lot bigger than ONC and a lot more influential. How would you describe his role and the role of CMS in this process?

GLASER: Well, I met lots of really terrific people and Tony Trenkle is one of them. I think the world of Tony and Tony has been, for us at ONC, the primary person one interacts with at CMS which is, as you point out, a very large complex federal agency. So it was Tony who obviously sat on the Policy Committee, had a lot of internal discussions about Meaningful Use and a variety of other things. When one had to put CMS and ONC people at the table — you worked through Tony to get that to happen.

So he’s very important guy, very smart thoughtful guy who understands CMS as a complex agency, but also understood a lot about ONC and what was coming through the various committee works here. So he was a very important collaborator and a terrific contributor to the discussions. So was he important? Big time. But beyond whatever title he has in there, it is an importance that comes from having the respect and the working relationships with ONC, but also with those committees, that made for effective discussions.

GUERRA: How deeply was HHS involved? Did David interact with Sebelius much?

GLASER: She and David would meet fairly regularly, I don’t remember exactly the frequency, and he would give her updates on how this was all progressing, both the rule writing process but also the development of the grant programs. To the degree that there where issues she needed to be aware of, he would put those things on the table and get her guidance.

There were also discussions with some principals in the White House about the same thing and, obviously, there’s ongoing review with the Office of Management and Budget. So as the process unfolded, both the rule writing process and the grants process, there were a number of people that it was David’s job to keep looped in, and those were people at the high echelon of HHS, the high echelon of the White House and in other federal groups, such as the OMB, etc. So Sebelius was fairly close to this. Obviously, she’s got a zillion things to pay attention to, but this was clearly one of them.

GUERRA: Were you sitting in all the meetings? You seemed to largely sit back and listen. Was that intentional?

GLASER: Well, early in the process, through the summer, I wound up in front of the Policy Committee a couple of times to guide a conversation, some of the early Meaningful Use panel presentations. I was providing staff support until the full time federal staff who would take this on going forward were brought on board. Farzad Mostashari was brought on board at the end of the summer and, at that point since he’s the fulltime permanent federal employee, this was moved to him as it should be.

And I think the other thing is when one is in D.C. working for the government, one has to be very, very careful about commenting on rules, because what you don’t want to do is inappropriately either disclose stuff that still needs to be kicked around or undermine the Policy or Standard’s Committee processes. So there are appropriate ways to engage and inform the public and we have to rely on those, but also as those people came on board and were in a position to carry forward the committee work, they stepped in. As you know, I’m transient, I was there temporarily to make sure that the work was moved from my plate onto theirs as they came up to speed.

Part III