Ashby Wolfe, MD, MPP, MPH
Chief Medical Officer, CMS Region 9
San Francisco, CA
Here at CMS, we’ve been working for several months on some of the new programs and initiatives created by the Medicare Access and CHIP Reauthorization Act signed of 2015. Additionally, we are now seven years in to the concerted launch of a truly national health information technology platform. A lot if important steps have been made in this effort, but we’re still at a stage where technology often hurts, rather than helps, physicians provide better patient care. CMS is committed to taking a user-centered approach to designing policy.
Understanding what we want from technology means first understanding how we provide and receive care today in America, where the patient is more diverse, more mobile and more demanding than ever before. The consumers CMS serves are a good representation of all of our care needs – 140 million Americans, most on fixed or low incomes – in every type of care situation: the Medicare patient leaving the hospital with five prescriptions to fill and 2 appointments to book; the Marketplace customer who will have coverage for the first time and finally be able to have his wife’s chronic fatigue looked at; the daughter who has made the difficult decision to move her father in a nursing home and wants to know staffing ratios and quality ratings; the family with a child with disabilities on Medicaid that requires 24-hour care and is watching every dollar and interviewing every home care worker.
The way people get care today – on the go, on their own terms, often not anchored in the system – means their information needs are ever more vital and yet so basic. People ask: “Am I recognized when I show up? Are my needs, preferences, and history available?” Today’s technology at its best is ideally suited to meet these needs: the cloud, social media, one-click purchases, information at our fingertips, everything wired, convenient devices, expert systems, intelligent agents. We know what we need to do and the technology is available.
To address these issues, our agency is charged with implementing the new bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) – legislation intended to bring value-based care to the everyday physician practice. We have created a new playbook at CMS by making our most concerted effort ever at listening to front-line physician and patient input upfront. After first collecting feedback from across the health care sector, we launched our work with a four-day session with physicians and technology companies and sought more comment through a public Request for Information. But the bulk of our work has been directly with front-line physicians. In coordination with our Central Office in Baltimore, we have completed eight focus groups with front-line physicians in four separate markets and have many more coming. I’ve been on the road meeting with a number of physicians to learn more specifically how they interact with technology and what their day-to-day challenges are. My colleagues and I have received powerful feedback, including comments that current EHR platforms and systems put too much of a burden on physicians and their teams, taking time away from caring for patients. Many physicians report challenges with needing information from a different EHR that doesn’t communicate well with their practice EHR, so there remains a heavy reliance on faxing or “snail mail” to coordinate care and follow-up. One person pointed out that it takes eight clicks on a computer to order aspirin for a patient. Many physicians see fewer patients each day because they are spending more time doing data entry into their EHR. At times, there is too much information but it is still very difficult to find on a busy EHR screen.
Three themes have emerged that are shaping CMS’ agenda moving forward:
- Physicians are hampered and frustrated by the lack of interoperability. Simple issues such as needing to simply track a patient referral, or review a hospital discharge summary to ensure proper follow-up, can be terribly difficult and onerous in a busy practice.
- Regulations in their current form slow down physician practice, create documentation burdens and often distract from patient care.
- Physicians find their EHR technology hard to use and cumbersome. It slows them down, and doesn’t speed their path to answers.
CMS will be addressing these themes in very specific ways, as we work to implement the new MACRA legislation. We have issued our first proposed regulation on MACRA with the Quality Payment Program proposed rule, published in April 2016. Information related to the content of the proposed rule, and how the Quality Payment Program will work, is available at http://go.cms.gov/QualityPaymentProgram. Below, I share the concepts of our approach and how our agency views the work moving forward.
The first area we are addressing is the documentation overhead associated with the Meaningful Use program. The following represents the vision for the approach to this work. We have been working to try to close the gulf between our public policy work and what is happening in the reality of patient care. From a number of focus groups and listening sessions, we are hearing the message loud and clear: “stop measuring clicks, focus instead on allowing technology to become a tool and focus on the results technology can create. Give us more flexibility to suit our practice needs and ultimately more control.” Where possible, we favor letting outcomes rather than activities drive the agenda. We can take advantage of how the landscape has changed over the last five years with the proliferation of programs that depend on care coordination and population health.
Interoperability is the second area of our focus. It is an essential ingredient not only for better patient care, but as President Obama mentioned in early March, it is also a key part of the precision medicine initiative that will unlock an entirely new future of better health. We are making a concrete effort to commit to this work; on February 29 HHS Secretary Burwell announced that companies representing 90 percent of EHRs are committing to three vital steps to work towards true interoperability to prevent data blocking or firewalls from getting in the way of coordinating patient care. Our agency has also recently announced funding to connect many of the remaining parts of the system that are not part of the EHR incentive program but serve our neediest Medicaid patients every day – long-term care, behavioral health and substance abuse providers. Ultimately clear communication pathways between electronic systems will give physicians and patients what they want from their technology, so called bottom-up interoperability. Our agency will help facilitate two goals that practicing physicians have identified: closing the referral loop and patient engagement.
That leads to the third area CMS is focused on: to give the physician better tools that help him or her with patient care. It’s not only Meaningful Use (MU) regulations that concern physicians, they want better technology. It is time to finally create the improved workflows and the apps that physicians are looking for. Shifting from MU-oriented design to developing certified technology that is user-centered is a big opportunity. Flexible EHR incentives should give tech companies new products to develop. As part of this effort, our sister agency, the Office of the National Coordinator, is launching an App Discovery Site as an EHR-neutral place for new apps that can securely move data in and out of an EHR.
CMS is working to ensure that our policies communicate what is important – improved patient care, better spending, and healthier people. A challenging goal, but one made easier by talking about it publicly and listening to physician and clinician input. The implementation of the MACRA legislation is an ongoing process and our agency is committed to closing the gap between on-the-ground care delivery and policies that promote the tools for better care. Connecting to what happens in daily patient care is vital to our policy-making as we seek a better, smarter healthier system and better patient outcomes. To that end, please do not hesitate to contact me with questions or concerns at firstname.lastname@example.org. In addition, you can keep track of new developments and sign up for our listserv at the Quality Payment Program website: http://go.cms.gov/QualityPaymentProgram.
Ashby Wolfe, MD, MPP, MPH
Chief Medical Officer, Region IX
Centers for Medicare and Medicaid Services
90 Seventh Street, Suite 5-300
San Francisco, CA 94103