Q&A With Stephen Lieber
Healthcare Technology: How does HIMSS currently drive its goal of providing connected, interoperable healthcare?
Stephen Lieber: I think there are at least a couple of very visible external additions to where we were at this time last year, as well as a significant number of internal initiatives that contribute toward that goal. The two external, very public initiatives that we’re a part of are our work with the Certification Commission for Health Information Technology (CCHIT) and our work with the Healthcare Information Standards Panel. In both cases HIMSS was a founder and organizer of the entity, which is an example of the leadership role the organization has taken in two areas that are absolutely critical to interoperability: You must have a common set of standards, and you must have testing to see whether or not products actually conform to those standards. In both cases, we and several other different organizations set out to create those entities, and we continue to serve in both governance and operations of both entities. Those are the hallmarks I point to – the leadership role HIMSS has taken in driving those two components of the interoperability issue.
When I look at our annual business plan, which includes some 150 different initiatives, dozens are focused on this issue. In fact one of our internal goal areas is called “interoperability.” It is one of the organization’s six strategic goals.We are working on things that range from privacy and security guidelines for regional health information organizations, as these start to form, and we’ve provided them with tools and resources to deal with these issues. Another example is that we’re working with other organizations around the interoperability of the business applications, eligibility and reimbursement transactions. Those need to be interoperable, too, as all of that information needs to be shared. Often we are so focused on clinical applications – and rightfully so since that’s the most important part of healthcare – but there’s a business side that has to be addressed as well. So we’re working with a variety of organizations on the operating rules associated with business applications. Both on an international and domestic basis, we’re working with organizations across a multitude of scenarios and disciplines to ensure there are sets of interoperability standards so that we can get to the point where data can be shared seamlessly.
The tie between interoperability and quality is an initiative of ours, the idea being to ensure that whatever the most widely recognized standards of quality measurement are, that there is a degree of interoperability of exchanging data that most directly affects those quality measures. These are just a handful of examples that we feel illustrate what we’re doing in the area of interoperability. Our rules are 1) we’re looking to influence the outcome and direction of the national debate on a policy basis that involves our work in Washington as well as with other organizations, and then 2) develop resources on a very practical, applied basis to take what they are doing in a healthcare setting and realize the objectives of quality and efficiency that are the broader objective of goals of a system with a greater degree of interoperability.
HCT: Where does HIMSS stand on the HIT legislation?
SL: We are very supportive, as we have been since the beginning, of both of the pieces of legislation – H.R. 4157 and S. 1418 – and we are now engaging with the conference committee trying to reconcile the differences between the two pieces of legislation. Two things that are most important in this legislation are the codifying of the Office of the National Coordinator and the establishment of the American Health Information Community. That’s important so that this effort to establish a national agenda on HIT isn’t something that comes and goes with the whims of the administration. By including this in legislation we are formalizing it, ensuring that there is an ongoing effort to develop a national agenda, to maintain a national focus on HIT. Government needs to recognize and then to provide some level for support for its role in healthcare IT adoption. There needs to be a grant system of some kind, as in S. 1418, which has $650 million in grant funding. There needs to be some sort of expression of support from the federal government. There is still a digital divide between healthcare providers; a one- or two-person doctor’s office has far different resources in support of technology adoption than a 500- to 600-bed academic medical center. Government has the role, which it has demonstrated in other sectors, of ensuring that if the private sector can’t deliver something that it recognizes to be in the public good, then it will deliver. Some degree of federal funding is important, and it’s something we’re going to push for.
The establishment of quality measures is also a provision in S. 1418. It’s significant because we want to drive people toward a common view of the most important quality measures that have the greatest impact on the outcomes of care. If we focus on the things that are important, utilize the technology tools that make us most effective – or allow us to avoid the greatest number of medical errors – then we’ll have a better healthcare system. There should be a government statement saying to the industry, “Okay, you guys that are in the know, especially you clinicians, you decide what’s most important in terms of quality measures so that we can drive our system toward them.” I think that’s a critical component we need to look at. Then, of course, there is the issue of safe harbors and the sharing of technology between business entities. This is the Stark provision, which is designed to prevent collusion and kickbacks and antitrust issues. There need to be some safe harbors that allow healthcare organizations or systems that have those resources to engage with those providers in their communities that do not have the same level of resources – and find a way they can provide assistance without being in violation of federal regulations.
So both pieces of legislation are very strong and very positive, and they have the potential of driving the country in the right direction on issues of cost and quality. It’s just a matter of how many of the provisions we can get everybody to agree on. As with anything in the political process, there is going to be some trading back and forth, but our objective is to get something out of the Congress this year; it’s going to get tougher and tougher as we get closer to the election. But our view on this is that the American healthcare system is in a no-lose situation if anything comes out of these two pieces of legislation.
HCT: Reimbursement issues have been an ongoing obstacle toward the wider adoption of various healthcare technologies. Are Medicare and Medicaid starting to budge a bit?
SL: Not really, in the places where Medicare and Medicaid could be most effective, which is looking at their reimbursement systems to provide incentives or disincentives for the way care is delivered. Right now, with Medicare, Medicaid and private insurance, there is no incentive to avoid duplication, even if the tests don’t need to be done, even if they were done at a different facility. Lack of access to shared patient data becomes an incentive to repeat tests. Unfortunately, we haven’t gotten to the point – and the lack of interoperability is a main reason why – where payers will say, “That procedure was done recently – and we’re not going to pay for it again.”
The good news from our government agencies is that out of legislation, out of the executive order that President Bush signed in August, it mandates that government agencies buying healthcare IT applications meet the standards coming out of the standards panel, or that they meet the certification criteria coming from the certification commission. That’s the government’s new role now, as a purchaser of HIT applications, to ensure that they use their buying power to influence the market. Prior to that, the government’s role was more as a cheerleader or motivational force as evidenced by the actions taken by the first HIT National Coordinator, Dr. David Brailer. Now we see government moving into an implementation mode. All of these were necessary steps in the evolution, so government is definitely moving in the right direction. The things we need to focus on next are the reimbursement and financing issues, and that’s going to be very difficult because there are all kinds of interests that come into play when you start talking about reimbursement. The pie is not going to be any bigger; nobody’s shoveling any more money into this. There will be winners and losers when the debate moves to reimbursement.
The fortunate thing up to now – and we’d like to perpetuate this for as long as possible – is that the discussions around IT adoption and quality measures and business efficiency have not been about winners and losers. To this point, there have been no losers in this process. That’s made a huge difference in the tone of the debate and the speed at which we’ve been able to accomplish things. Unfortunately, the questions don’t get easier; they get tougher.
HCT: Can you provide an update on HIT?
SL: Sure. I’d like to talk about two significant issues. The first one is quality of care. Later this year we are launching a quality domain within our Integrating the Healthcare Enterprise (IHE) initiative. The intent of the IHE quality domain is to link interoperability to quality measures. So rather than just looking at a scenario involving simply the movement of patient data – which if you go back to the roots of IHE was a common scenario – you have X-rays or lab results that need to go from point A to point B. Now we’re talking about the linkage between interoperability and quality outcomes. So, we are committed to developing a technical framework for companies to use in their products so that quality measures can be easily extracted from the patient record and relatively easily shared among providers or reporting agencies. That’s the level of data exchange that has significant value, both in terms of individual care but also in terms of reporting data, so we can see trends in terms of patient delivery and outcomes.
The second thing we’re working on is the issue of business efficiency, demonstrating interoperability of business transaction applications. The group that is actually developing the tools of interoperability is the Council for Affordable Quality Healthcare (CAQH), and we’re looking at that consortium of payers and providers to demonstrate the standards and the technical framework for business applications. They can bring their work into our interoperability showcase at the HIMSS conference in February which will allow us to demonstrate not only clinical interoperability but business interoperability as well. That’s an important part of our focus.
