Marc Probst, Member, HIT Policy Committee, CIO, Intermountain Healthcare, Transcript/Podcast Chapter 1

These days, Marc Probst spends a good deal of his time helping to create a framework for the development and adoption of Meaningful Use as a member of the Health IT Policy Committee. But his first priority is his role as VP & CIO at Intermountain Healthcare, a nonprofit health system based in Salt Lake City that includes 23 hospitals, a large physician group, and health insurance plans. In this interview, Probst talks about how he balances his CIO duties with his committee obligations, his concerns that Meaningful Use is surging ahead too quickly, and the challenges brought on by the start of attestation.

Chapter 1

• Attestation begins, but will it tell us much?
• “If we don’t pay attention to what happens in Stage 1, we could completely debilitate this process in Stage 2”
• “Meaningful Use was written very much for the vended applications”
• Defining success for the Meaningful Use program
• Implications of the Stage 2 “timing glitch”
• Thoughts on the Meaningful Use governance process
• Wish listers vs implementers
• Tony Trenkle signals enough is enough
• Is it all worth $36 billion?

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Bold Statements

“As difficult as Stage 1 has been, if we don’t pay attention to what happened in Stage 1, we could completely debilitate this meaningful use process in Stage 2 by just piling on in areas where organizations can’t really meet the needs.”

“It’s going to be difficult to measure some of the quality measures, but I think over time CMS will be able to do that, and they’re probably looking at… what’s happening with these quality measures, and is the use of electronic medical records really improving or helping in those quality measures.”

“There’s also the factor of some of us have full time jobs that are within the industry. I’m the CIO at Intermountain Health Care. That’s my primary job.”

“I think we are gathering a lot of good information on the work groups. I also believe the process is exposing the benefits of electronic medical records, and that’s obvious. Just look at how busy the vendors and the consultants are because of that.”

Guerra: Good morning, Marc. Thank your for being with me today to talk a little about your work on the Policy Committee in the different work groups and your thoughts on meaningful use and all that good stuff.

Probst: Thanks for having me, Anthony. I look forward to the conversation.

Guerra: All right. Well, I guess a good place to start would be attestation opening. I personally have not seen this as an event to go crazy about. I mean, it’s paper work filing. I think we can assume we’re going to see some pretty advanced organizations coming through, especially if they’re doing it this early. Anyway, give us your thoughts around attestation opening—what that means, and if there’s anything that we’re going to be able to take away from any early data—how “meaningful” would the data be?

Probst: That’s a great question. In the last Policy Committee, I asked the question of Paul Tang and George Hripcsak, who were presenting on meaningful use. I said, you know, not only do we need a learning healthcare system, but we need a learning meaningful use process. I’m not sure how well that sunk in but I would agree with what you’re saying. Up until maybe two or three months ago, everyone was so focused and busy; I’m not sure we were learning much from the past. Nor was there all that much data actually to be gathered. But I did feel a shift maybe two or three months ago where I don’t know if it hit us flat in the head—if that’s the way we figured it out or if it was just a natural process—but we’re taking data, understanding what AHA is gathering, understanding what CHIME is bringing to the table, and maybe listening to some of the defending groups that are coming forward and saying, ‘You know, this is a very complex process.’ And as difficult as Stage 1 has been, if we don’t pay attention to what happened in Stage 1, we could completely debilitate this meaningful use process in Stage 2 by just piling on in areas where organizations can’t really meet the needs. So in terms of attestation itself, I would agree with you. I mean, actually, we are going to see some organizations struggle. I personally—and this is some of my bias as CIO at Intermountain Healthcare—believe that meaningful use was written very much for the vended applications that exist today. And so, if you’ve been involved in some of those top name vended applications, you’re going to be able to test pretty easy, and thus, the organizations will see a test; organizations that have taken a different route like Intermountain Healthcare, maybe like Mayo Clinic. I don’t know where they’re at, but my guess is they’re similar to where we are because we haven’t chosen that vended route and the requirements for meaningful use are so aligned with what the vended products offer. We’re going to take a little longer to a test, so I don’t expect a huge volume. There will be volume, and as you suggested, it’ll be the organizations that have been using these products for a while.

Guerra: You mentioned the fact that if you don’t go to vended route, that means the whole certification burden is on you. It may even be on you if you’ve gone the vended and you have reached out for a lot of different applications and you need to do the sort of the self-certification that some of the certification bodies offer out there, which I’ve read. John Halamka put up a post about doing the self-certification; it sounded incredibly complex, but if you’re largely homegrown, then the whole certification burden is on you. That’s part of why it’s a little more difficult if you haven’t gone the vended route.

Probst: It certainly plays into it, and certification is pretty complex. It’s a huge testing effort and planning effort, and understanding the requirements is critical. So, it is one of the reasons. Again, at Intermountain, our systems weren’t really designed for physician interaction; they were designed for data and actually more nurse documentation and encoding. So, we fundamentally have been working over the past five years to shift that, but our plans weren’t to do it quite as quickly as we need to do it now. So, we have CPOE in several areas, but we need to expand that. We need to get the percentages up. We’re actually completely rewriting our CPOE application, and it takes a while to develop the test and then deploy and get certified. So, there are all of these steps in there. That would be the major functional piece that we need to get in place. But yeah, certification is pretty detailed, and the requirements are very complex.

Guerra: Right. One of the other things I want to touch on is the idea of defining success. Whatever data we see, and even in terms of the entire program, I don’t know of a yardstick that’s been put out there by HHS or CMS or ONC that will give us something to measure any data against a goal. Do you know of anything out there, any benchmark indicating that a program has been successful?

Probst: The only benchmark I know that’s out there relative to the success of the program is the actual deployment and use of these EHRs. We can measure that. It’s going to be difficult to measure some of the quality measures, but I think over time CMS will be able to do that, and they’re probably looking at that as some of the benchmarks; what’s happening with these quality measures and is the use of electronic medical records really improving or helping in those quality measures. But as far as having 90 percent of all hospitals on an EHR, I haven’t seen that set as a goal. That’s a very good questions.

Guerra: When we look at the numbers that come in now, one of the things that may skew things is that it’s been put out by different organizations that you’re better off to wait until 2012 to attest, because if you do it in 2011, your reporting period for Stage 2 will have to start only a few months after you get the Stage 2 requirements. So some are advising that you really don’t lose anything by waiting to attest until 2012—you may, in fact, gain information and time. We really don’t know how many organizations have seen that and are going to take that advice. So that may be skewing the numbers. We may see low numbers, but it may not be because organizations are not ready yet, but just because they’re taking advantage of the switch to hold off. Does that make sense?

Probst: Yes. I was speaking in the last Policy Committee and they were talking about this, and I don’t know if it’s a legislative fix or if it’s simply something that can be done with ONC but I think that is an error in how the program was developed. I don’t know if they can fix it or not, but I’m sure it’s skewing some people.

Guerra: What are your thoughts on the process in terms of the number of people on the Policy Committee, the way it’s broken down with work groups, and the way it seems to be that there is no limit to how many work groups someone can volunteer for? So, if you have the time, you can volunteer for five, six, or seven work groups, and I documented that in a column I wrote. But the overall process in terms of a governance issue—do you feel it’s working well, or do you see it as a little unwieldy and maybe that’s why we’re not getting this thing buttoned up or clarified as quickly as some might like.

Probst: That’s a very good question and I’m offering my personal opinions because that’s all I have. If I look at it a little differently, there certainly could be tighter governance processes relative to how the work groups are formed and the work that those groups are doing. There are a few factors that I think impact it, and one is pace. Things were happening so quickly. It was, ‘If anyone will work on these groups, please get together. We know it’s going to be a lot of effort.’ And so, the work groups are basically formed around people that could dedicate their time to actually do the work that was required. There was a fair amount of thought in the initial co-chairs of the work groups, and when Paul Egerman and I were put into certification and adaption, I think they had thought through the process of what Paul’s background was and what Marc’s background was, and certainly on meaningful use when Paul Tang was leading the meaningful use work group. I think some of it was his political background, because he’s very tied in. But also, he’s a physician with a very good informatics background. So I would say it’s not haphazard, but it isn’t tremendously tight. Now, my personal insight is that if this is incredibly time consuming, what’s happening on the Policy Committee? These work groups spend a lot of time working through issues, looking at comments—generally, there are several hundred comments. ONC is good about consolidating the data but you still have to get together, discuss that data and come up with a recommendation that just isn’t completely inane, or hopefully is positive, to move this process forward. And you have to do that outside of political beliefs. I’m pretty open. I’m very conservative, and I wouldn’t consider that panel a very conservative work group. But you work within the needs of health care and what this particular goal of EHR deployment is all about. You hit on it with your article, which is very good.

There’s also the factor of some of us have full time jobs that are within the industry. I’m the CIO at Intermountain Health Care. That’s my primary job. Secondary is going to be working on this work group, and then the various other things that I’m involved in. There are other people that are more tied into Washington and even their roles are specific to a ‘You got get involved in something like this work group.’ And you can dedicate your time to do that. We’ll leave you a good staff to support you in doing that role. And I think you see that, and I’m not going to mention names, but there are people that are more ‘professional’ in working in work groups or in committees like the Policy Committee. They can dedicate more time, and therefore, you see them in a lot more of the work groups, and they represent interests that want them in all of those work groups.

There’s a whole series of events that drive how the work groups form and even what the outcome of the work group is, because some people are just able to dedicate more time. But Latanya Sweeney—if you know her, she is wonderful, but she’s incredibly absorbed in the work that she has to do up in Boston. So we may not get as much of her time, and I think her influence would be great. But it’s simply a fact that she has a full-time job and it’s difficult to dedicate as much time to the Policy Committee as even she’d like to, I’m sure. And I go through that myself.

Guerra: You’re one of a few people on the committee involved with the formation of this process that actually has to do what the committee produces. Do you know what I mean? So, you’re sitting there and people are saying, ‘Let’s do this. Let’s do that. Let’s require this. Let’s require that.’ And then they go home and they don’t have to worry about it. But you’re actually going to have to do this stuff. So it’s an incredibly different dynamic for the people that are on the provider and vendor side and the people that are on the pure advocacy side.

Probst: No doubt. But I tell you, I felt and I spent about an hour and a half with Farzad Mostashari last week. It was before the Policy Committee meeting, and he listened really well. I felt that David Blumenthal really listened to what I had to say. Everyone else in the committee may feel that as well, but I did feel that he understood the dynamics, that I am the one involved in the playing of these systems. Larry Wolfe, who represents Rick Chapman most of the time on the committee, is very engaged in deploying and developing the things that we do at Kindred Healthcare. And Charles Kennedy has a different perspective, but he does understand how to deploy some of these things; to say, ‘Hey, let’s be careful because we’re piling on to these CIOs and these health care systems.’ Gayle Harrell has been incredibly supportive of providers and health care organizations, and we have a lot of common beliefs on how this should be deployed. So yeah, I think it brings a unique perspective, but I do think that by and large, they’ll listen. Deven McGraw definitely has a role and she’s very bright. I really like Deven, and I feel that she listens and she will temper even some of the things that she believes very strongly on based on the conversations that we have. Well, it’s good to be heard, as long as we say the right things.

Guerra: One thing I thought was very interesting was listening to Tony Trenkle from CMS. Maybe it’s his voice. He’s got a great DJ voice, but he does ring a lot of gravity when he speaks. But he really, over and over again, urged the group not to pile on like there were other mechanisms, other ways to go without getting the things they want done and get from programs. And Christine Bechtel responded basically saying, ‘Well, this is the program that I’m involved in. So, I really can’t trust you that. I’ll take this over and how do you feel as if I’m here and I’m going to try and get my point across and get the things I want across.’ So it was an interesting exchange between her and Tony. What are your overall thoughts on Tony, and any thoughts you had on his comments in the last meeting.

Probst: Oh, I thought his comments were right on, and in the committee meeting I stated that. I really thought he had a clear vision of it, and Tony himself is a class guy, class act. You can paint a lot of pictures of CMS in your mind when you’re a health care provider, but Tony will spend time with us. He’s very accessible. He’s very open and honest, and he just softened that comment. I thought he had a clear head about what we’re trying to accomplish here, and he was looking out for not just CMS but for this program to actually be successful. I like Tony a lot.

Guerra: Meaningful use ultimately rests with CMS, no matter what the Policy Committee recommends, no matter what ONC and Farzad does with it. CMS is the final arbiter of meaningful use, correct?

Probst: That is correct. But there is a tight relationship between ONC and CMS. And again, not having a long history in politics while working in Washington, I think the relationship being formed there is pretty unique.

Guerra: Any other thoughts on the interaction of the different entities? We start from the bottom up. We have the work groups reporting up to the Policy Committee, a little bit of interaction between the Standards Committee and the Policy Committee. I guess all that boils up to the National Coordinator, to Farzad, and then he takes that and gives recommendations to CMS, and all that bubbles up to HHS, and then White House takes a look at it. Is that somewhat correct?

Probst: That’s somewhat correct. I’m not sure how closely the White House looks at it. But clearly, HHS, the secretary, has a huge responsibility in determining some of these decisions that need to be made and has obviously appointed the ONC to help make those decisions. It’s an okay process. We have a lot of work groups. For instance, we have a hearing for the certification adoption work group on usability. I think it’s going to be a very interesting hearing to understand the issues surrounding usability, some of the best practices in usability and then some of the relationship between usability and safety and usability and the disabled. So, it’s going to be an interesting fact-gathering mission. The question is, what will we really do with that? I mean, I can’t see that being a huge impact on meaningful use. It might have, you know, some Stage 3 implications if we learn something that’s really, truly altering. But I think we are gathering a lot of good information on the work groups. I also believe the process is exposing the benefits of electronic medical records, and that’s obvious. Just look at how busy the vendors and the consultants are because of that. And there’s a positive. Now is it worth $36 billion? That we could debate, but it’s certainly increasing interest in the use of these electronic tools.

Guerra: Great point, and it makes me think of how we saw the ONC funding. You know, it was 90 percent from the government for the first two years—the other 10 percent, organizations had to come up with, and they didn’t have the option to extend that. It was supposed to flip after that where the organizations were supposed to come up with 90 percent, but the government extended it to 90 percent funding for two more years. So, that made me think, and I’m totally throwing out arbitrary numbers, that success at $10 million is the same as success at $100 million. Sometimes we pretend that it almost doesn’t even matter with these things, but it does matter.

Probst: Oh, it does matter. And now, politics get into play to some degree as well. And as I told ONC when I went on the committee, I would never have voted for this act or this process of HITECH. But, in the end, I think it’s good to be part of it, because there is so much money and it would be nice to see it at least done to some level of success. But someday, it’ll be interesting to see the ROI on this particular effort.

Guerra: Yeah, and we have to remember it was a little nugget in a giant $900 billion stimulus test, sort of in an apocalyptic kind of mode when everybody thought the economy was about to fall off the cliff. So putting in a little nugget for a healthcare IT, that wasn’t really a tough one. I mean, there were far more ridiculous things in that giant bill. Do you know what I mean?

Probst: I do.

Chapter 2