What We Should Do

1. Replace the meaningful use program with alternative payment models and merit-based incentive payments as part of MACRA.

Stage 2 and Stage 3 will not improve outcomes. If alternative payment models offer compelling reimbursement for health and wellness, then clinicians and hospitals will adopt products and change behavior to achieve that goal.

2. Replace certification with enabling infrastructure. 

To accelerate interoperability we need a national provider directory, a master patient index/relationship locator service, a consent service, a certificate management service, and test beds for developers to exercise these services. Today in Massachusetts we exchange over 3,000,000 patient records per month among 500 organizations because we created such enabling infrastructure backed by data governance (common policies and agreements). Certification will not accelerate interoperability.

3. Consider evolving the role of ONC to become a focused policy shop (supported by advisory committees) with a narrowed scope such as identifying ways to reduce errors, improve safety, enhance quality, accelerate interoperability and meet the needs of diverse populations. 

It could also provide transparency and true coordination for actions of government, communicating the IT efforts of agencies including DOD/VA. ONC has become distracted by grant making, political agendas (see "information blocking" above), and expansive certification ambition. It's time to narrow the scope and enhance the effectiveness of this important agency.

4. Stop considering health IT developers and providers as the enemy.

Some believe health IT developers are responsible for creating information silos or resisting interoperability. Some believe clinicians are lazy or greedy, requiring  government mandates to become patient-centric. I'm sure there are exceptions, but in general, both are myths. I've said that there are a few effective ways to influence clinician behavior: align incentives, give them a better work/life balance and help them avoid public humiliation (malpractice assertions, poor quality scores, negative Yelp reviews). A partnership of government, payers, providers, patients, and health IT developers working together to achieve common goals is possible if there are mutually aligned incentives, such as the ideas embodied in value-based purchasing/MACRA.

5. Focus our efforts on a few things that really matter. 

The Federal Interoperability Roadmap has 117 goals. The certification program has so many objectives that it takes a few hours just to read them all.

How about a laser-like focus on interoperability that includes just 3 objectives?

• ability to use FHIR to read a provider directory (could be hosted by government such as CMS as part of the national provider identifier or the private sector such as Surescripts, DirectTrust, or an HIE) and send a Direct message to that provider.
• ability to use FHIR/OAuth to read a relationship locator service (could be hosted by government or the private sector such as Surescripts, Commonwell, Sequoia, or HIE) and perform a query/response of the MU Common Data Set using a FHIR API.
• ability for a patient to download the MU Common Data Set using an app (that is curated/reviewed to ensure security and data integrity) using FHIR/OAuth or appropriate variants of OAuth such as HEART. Several folks have contacted me to discuss the real purpose behind the consumer API requirement in the ONC and CMS rules. Some suggest it was motivated by special interests who want to monetize patient submitted data. Some suggest that it is an enabler for future provider to provider transactions. Some say it is the best government lever to motivate the industry to move from messaging to APIs. I'm not sure which interpretation is correct, but it is certainly true that providing data to the patient should be one of the focuses of interoperability.

Since MACRA will base payment on wellness which requires care coordination, providers will demand appropriate interoperability features when buying an EHR product.  Additionally, an independent third party such as KLAS could publish unbiased statistics about the actual experience of interoperability by speaking with hundreds of clinicians and staff. Recently all the major health IT developers agreed to have their interoperability measured by KLAS via customer interviews using this questionnaire. 

I'm really trying to be helpful here and incorporate the overwhelming feedback I've heard from stakeholders. More Meaningful Use and Certification criteria are not the answer. Paying for outcomes that encourage government, payers, providers, patients and health IT developers to work together, instead of being adversaries, is the path forward.