If the mark of a good leader is the ability to evolve, as many believe it is, then Chuck Christian may be one of the greatest. Throughout his career, he’s been a staunch advocate for state’s rights, and a firm believer that healthcare is provided locally, and therefore should be governed locally. But as someone who has been heavily involved in advancing data sharing (both as Director of Executive Engagement with the Indiana Health Information Exchange, as well as an active member of CHIME and HIMSS), he has seen the challenges created by the lack of an overarching consent model. And so, Chapter 2
Recently, we spoke with Christian about why he believes the patient-centered data home model could be a difference maker, the need for better education and more transparency when it comes to data access, and what he hopes to see from ONC’s proposed rule. He also provides his thoughts on CommonWell and Carequality, the obstacles still facing smaller facilities when it comes to federal regulations, and what he believes is the key to effective advocacy.
- Physician frustrations with the “spinning beach ball”
- TEFCA – “It was much more descriptive and complex than everybody thought.”
- Interoperability and the new “bucket of worms”
- Changing the policy discussion
- “Don’t just go in complaining – come in with good information.”
- IHIE & the “rising tide”
- His challenge to HHS
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They’ll say, ‘I sit here and watch the beach ball spin for five minutes, then it comes back and says no data has been found.’ Well, does that mean there’s nothing there, or that they couldn’t match data with that patient? After a number of times, they’ll stop looking.
ONC received a lot of comments about TEFCA — that it was much more descriptive and complex than everybody thought. And so it makes me wonder if the next iteration is going to be kinder and gentler.
If you look at some of the questions asked in the proposed rulemaking, you get the feeling they’re going to expand this into post-acute care and behavioral health as well, and that’s going to open up another bucket of worms.
They’ve done a really good job of engaging the industry and listening to a variety of stakeholders — not necessarily just the EHR vendors and the large health systems, but the community hospitals. I wish they did it a little bit more, particularly critical access hospitals, but they’re reaching out to them.
We need to find those common areas that we can share. It’s like the saying, ‘the rising tide raises all boats.’ But we also need to understand that what works well in one place may not work well in another.
Christian: I’ve listened to a lot of physicians — particularly in the emergency room — who are connected to CommonWell and some of the other networks. What happens is, they go in and click the button to see if there’s data, and they just sit there. One of them said, ‘I sit here and watch the beach ball spin for five minutes, then it comes back and says no data has been found.’ Well, does that mean there’s nothing there at all, or that they couldn’t match data with that patient? After a number of times, they’ll stop looking, because they can either ask a question or have somebody to get the data to them, and it’s quicker than sitting and watching a beach ball spin.
Gamble: Right. You mentioned TEFCA before; we’re all waiting with bated breath for ONC’s proposed rule on data blocking. I realize this could be a whole other conversation — a very long conversation. But what are your thoughts on that?
Christian: I think ONC was hoping to get the rule out before their annual meeting [in November of 2018] so they could talk about it. Of course, they were asked about it a hundred times, and they did exactly what they were supposed to do. They said, ‘We’re in rulemaking. We can’t talk about it. We can’t even hint at it.’
What we have heard, through a variety of channels, is that it’s 700-plus pages. I saw that Genevieve Morris [former ONC Principal Deputy Coordinator for Health IT] tweeted a remark about how ONC should stand for ‘Office of No Christmas,’ because they drop these things right at the holidays. The year Meaningful Use came out, I spent New Year’s Eve with my family, but while they were celebrating, I was reading the first iteration of the Meaningful Use guidelines. I’m sure I’ll spend part of the holiday again reading over a variety of things. We know that the rules on what is not considered information blocking are due to be released soon. We know, based on what Don Rucker [National Coordinator for Health IT] said in his commentary, that the second iteration of TEFCA is coming out soon. At the recent meeting, Senator Lamar Alexander said ONC had received a lot of comments about TEFCA — that it was much more descriptive and complex than everybody thought. That’s what they heard. And so it makes me wonder if the next iteration is going to be kinder and gentler. I don’t know yet, but we’ll have to wait and see. There’s still going to be a million questions.
The last thing HHS has hinted at through [CMS Administrator] Seema Verma’s office involves the Inpatient Prospective Payment System (IPPS), the Outpatient Prospective Payment System (OPPS), and the physician fee schedule rules that came out in August, and whether CMS should make interoperability a condition of participation in the Medicare and Medicaid rules. And if you’re going to participate in the programs, do you have to do certain things and say you’re not an information blocker — those types of things.
One of the comments I made was, ‘Please don’t do that, because it’s already difficult enough for smaller facilities and post-acute care and behavioral health facilities, who have been on the outside looking in on this whole automation piece, and have had to automate just to keep up.’ The fact is, if you look at some of the questions asked in the proposed rulemaking, you get the feeling they’re going to expand this into post-acute care and behavioral health as well, and that’s going to open up another bucket of worms that people are going to have to deal with.
The way this comes across, some will say it’s an unfunded mandate, because they’re making rules that will require, in some cases, a significant investment that they have no way of recovering. And those facilities are running on razor-thin margins as it is, so we really need to be cognizant of what we’re doing.
One of the things HITECH did is it provided a level of funding. Did it cover all the costs? No. Was all the money used for the intended purposes? I don’t know. It depends on what you read and what study you look at, but there was a level of investment. At the other end, you had to have these things in place to avoid a down payment, which is a term I love. Rather than calling it a penalty, they called it down payment, meaning they’re going to take money away from you, regardless of what you call it.
And so everybody is waiting, as you said, with bated breath trying to figure out, ‘When is this going to drop? Are all three going to drop within rapid succession? What’s the timing?’ Because with a couple of them, here will be comment periods. And we’ve already got a couple of other things out there, including an RFI about changing the HIPAA rules, so we’ll see how the incoming Congress deals with some of these privacy issues.
Gamble: So certainly a lot coming down the pike. It should be a really interesting year.
Christian: Absolutely — ‘interesting’ is a good term. I think it’s going to make more my hair turn white and/or fall out, but I think it’ll be okay. But really, I give kudos to everybody in D.C., and that hasn’t necessarily always been the case. I’m not poking at any administration, because I think, over time, we’ve been able to build relationships with both ONC and CMS and with some of the Hill staff about having these conversations.
The way it used to be, we’d go there to have a meeting or discussion, and we came across as whining. So we realized, we can’t just go in complaining. We need to come with good information, and it needs to be based upon facts. If there is a reasonable alternative, you need to be able to articulate that and offer good debate around why this alternative may be better than what was presented. They’re actually really good about listening.
Now, there are reasons sometimes why they can’t always include all of it or parts of it, and they’re willing to have that dialogue and say, ‘No, we can’t do that. Here’s why, but maybe we can do this. Let’s talk about it.’ And so, I really appreciate their willingness to enter into that conversation.
Over the years, I think they’ve done a really good job of engaging the industry and listening to a variety of stakeholders — not necessarily just the EHR vendors and not necessarily just the large health systems, but they’re listening to the community hospitals. I wish they did it a little bit more, particularly the critical access hospitals, but they’re reaching out to them, in addition to everything else.
Gamble: Right. I think it’s important to make sure you’re not just coming in and saying, ‘here’s what’s wrong,’ because the policy people are working really hard too. It’s not easy for anyone. So it’s important for both sides to acknowledge that.
Christian: Absolutely. The thing about it is, are we always going to agree on everything? No, but we need to seek those places where we can find something that would be beneficial to everybody, and I know that’s a challenge.
Indiana HIE has been around for a long time; [CEO] John Kansky calls us ‘the tallest kindergartner,’ because we’re not mature yet, but we’re a little taller than everybody else because we’ve been doing it a long time. We’ve plowed some of the fields where others are planting, and so we need to find those common areas that we can share. It’s like the saying, ‘the rising tide raises all boats.’ But we also need to understand that what works well in one place may not work well in another.
What the federal government is trying to do is find solutions that everybody can take benefit from, rather than making winners and losers. Sometimes we do that. I don’t think there’s any intent, but it happens, and I’m one of the people standing out and waving the flag. For example, on more than one occasion, I’ve told Don Rucker, ‘You’re expecting the EHR vendors to solve this issue of interoperability. You need to take your blinders off and look around at others that are doing great work — and have been doing this work long before the EHR vendors even cared about it — and see if we can’t bring these together and figure out how to make them work.’ I think they’ve listened to the challenge, but we’re not there yet. So I’m going keep issuing the challenge until they tell me to shut up or they take away my internet access.
Gamble: We can’t let that happen!
Gamble: Well, I want to thank you. We always appreciate you giving such good insights. I look forward to reading your blog, and I hope we can continue to have these discussions. I enjoy them, and I know our audience appreciates your perspective on everything that’s happening.
Christian: I have an opinion, and I’m not afraid to share it. I’m always glad to offer whatever assistance and help in any way I can.
Gamble: Thanks so much, and we’ll talk again soon.