Michael McCoy, M.D. is best known as` the Chief Health Information Officer in the Office of the National Coordinator for Health IT, a role in which he served from January 2015 through January 2016. Meanwhile, Dr. McCoy, who spent 25 years in obstetrics and gynecology practice, has played a number of roles in the healthcare IT world, including as a senior executive at the former Eclipsys Corporation, CMIO at DigiChart, and CMIO, between 2010 and 2013, at the Catholic Health East health system, now a part of the Trinity Health system.
Dr. McCoy currently runs his own consulting firm, Physician Technology Services, and is board co-chair of IHE International (Integrating the Healthcare Enterprise), a not-for-profit initiative by healthcare professionals and industry to improve data- and information-sharing processes in healthcare, via the coordinated use of established standards, including DICOM and HL7.
Dr. McCoy, who is based in Lawrenceville, Georgia, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland, following the conclusion of the annual HIMSS Conference, which took place last week at the Sands Convention Center in Las Vegas. Below are excerpts from that interview.
We were both at HIMSS18, and were able to converse at the CMIO Roundtable. Looking back at HIMSS18, as well as considering all the recent conversations you’ve been having with fellow healthcare IT leaders, how does this moment in healthcare and healthcare IT look to you, broadly speaking?
On the political side, the policymakers [in the current administration] are trying to wind back some of the policies and regulations that have been put in place [including via the MIPS/MACRA law—the Merit-based Payment System, and the Medicare Access and CHIP Reauthorization Act of 2015]. The challenge will be in actually making that happen. Many of those things are baked into law, and you can’t just easily wave your hands and make the law go away. Given that there has been widespread support for many of the elements that have gone into recent lawmaking… it’s difficult to imagine that all of the desired actions would take place.
At the HIMSS Conference, the federal healthcare officials who spoke, talked fairly extensively about deregulation, either explicitly or implicitly. Do you have any thoughts on that?
Yes; some of those comments were specifically related to payment reform—MIPS/MACRA—and also to the issue of physician burden. Considering that many of the requirements embedded in MIPS/MACRA were written into law [as passed by Congress], it would take another law to undo them, unless you go the route of not ticketing people for slightly speeding—that concept—that idea that you can perhaps allow for [the regulatory path to softening certain requirements]. If the goal is to make sure the public gets something for the dollars spent on health IT, both in terms of hospitals and physicians—and healthcare IT spending—it’s difficult to do some hand-waving stuff and make that [the regulatory requirements embedded in laws like MACRA] go away. So there’s a gap between intentions and the ability to actually make those intentions happen. So that’s one of the concerns. There are similar concerns around balance for things like TEFCA [the federal Trusted Exchange Framework].
You’ve seen the comments from various trade groups and professional associations. I think the concept is good; the problem is in the execution, and how much can get done without pointed regulation. So it’s that balance.
I noted in my HIMSS18 reporting that that CMS Administrator Seema Verma, in her speech last Tuesday, called for empowering patients by giving them control over their data. Still, this administration remains at least nominally committed to repealing the Affordable Care Act, which would cause some loss of health insurance coverage. Can sufficient patient empowerment occur in the absence of health insurance coverage, or might that be an uphill proposition?
With regard to that, I’ll just say that there’s a major disconnect between words and actions there; I’ll just leave it like that.
Meanwhile, what about federal healthcare officials’ potential interventionism around EHR and other healthcare IT vendors? Administrator Verma and HHS Secretary Alex Azar both said last week that they want the free market to lead in helping move us forward on interoperability and patient empowerment. To what extent, though, might a more interventionist stance be necessary on their part?
This is my personal viewpoint, of course; as you may know, I am the co-chair of board of IHE International, the standards development organization, endorsed by the European Commission for a number of interoperability elements. There comes a time when you have to be more forceful. As a matter of policy, the U.S. government does not endorse specific standards. But the development of standards can advance things. Thus far, we have some alignment of incentives in the healthcare IT space, but not complete alignment; there’s still not a good reason yet for patients to move freely between and among different hospitals, for example.
And that alignment will require much more of a policy-driven, rather than a free-market-driven, exercise. So I would agree that it’s unlikely to happen, absent explicit policy moves. I was at a meeting in Washington, D.C., where interoperability through procurement contracting was discussed, and David Shulkin was talking about how the VA [Veterans Administration health system] might leverage its power with Cerner and others. So there’s some opportunity to begin helping physicians to have an interoperable solution, as part of the participation requirement. That in turn would mean they would have to go to their local HER vendor and make sure that’s going to happen. …
So we will need some level of interventionism from the federal agencies, to compel interoperability forward, then, correct?
I would agree with that. Relying on the good intentions of hospitals and doctors to move data forward, is somewhat utopian. Without penalties—such as those coming out of ACO contracts—that’s the reality that will make things happen. And that’s not yet there.
You agree that federal agencies will have to tell vendors what to do around interoperability?
Right, that will give them the ‘air cover’ they need to make changes. Because the vendors won’t do things unless their customers demand it. And the customers won’t demand it until it’s mandated. As a forcing function, regulation can help. I can agree with you partly on the CAFÉ standards—GM wouldn’t have done it. But that was also an example of the federal government pacing some of the wrong things. Regulators aren’t the true engineers in car companies and who can figure out what you can get. To get 40 MPH, we’d have to be driving tiny cars with different engines than consumers want. And also, rather than looking at fuel economy per vehicle, how about fuel economy per passenger? If you’re looking at a seven-seating automobile that mostly carries one person, are you really gaining there? So over-regulation can be just as burdensome as under-regulation. So it comes back to the lack of alignment of incentives on the part of hospitals and physicians. I mean, vendors aren’t deliberately withholding capabilities; they would do it if the customers demanded it.
Moving forward on health IT, what have your conversations been like recently with CIOs, CMIOs, and other healthcare IT leaders?
It’s much more now about optimizing the deployment of systems already in place—whether it’s replacing systems or enhancing them. It depends on the size of the organization. Personally, one of my friends who’s a rheumatologist is looking at replacing her EHR, and she’s very challenged by the expense and the difficult of moving from Vendor X to Vendor Y; it’s a nightmare. And for big patient care organizations, it’s a tweaking kind of thing? Do you re-implement, as opposed to tweaking it? There are all kinds of approaches that have to be considered. Many organizations were penny-wise and pound-foolish, and were just looking at getting the MU dollars.
Given everything going on right now, what should CIOs and CMIOs be focusing on right now?
I would say the first focus should be on cybersecurity, because if your situation [the overall IT infrastructure of your organization] ends up bricked up, nothing else matters. So that should be at the top of the list. And that’s a challenging front, because there are so many ways that one can be taken down, unfortunately; but insiders still doing the wrong thing—insider exposure is still the biggest. And there are organizations that are getting daily now; it’s just a fact of life. So if you don’t manage that properly, with the appropriate business continuity, etc., you’re screwed. So that would be number one.
I think looking at productivity, and how you get clinicians to the right level of resumption of activity, is the next thing. Whether that means reimagining the workflows you have, or if the vendors can provide better updates or UIs to allow that, that would be next. And the third priority would be making sure you’ve got a better understanding of where ewe think we’re going, from a payment perspective. I’m not sure whether anyone can fully predict that—whether ACA is killed or not, or reimagined, or whatever. Healthcare spending can’t continue forward as it has; and Congress has indicated they want a cap on HC spending, and to get more value for what’s spent. And whether that involves a free-market solution, or Medicare for all, or whatever it is, is still to be determined. And people are still getting paid under the old system. There’s a challenge for hospitals to stay alive, during this gradual transition from volume to value.
It's what so many have described as the one-foot-on-the-boat, one-foot-on-the-dock problem, correct?
Yes, with the one foot on a banana peel on the dock! And any readmission within 30 days is a problem. And there are challenges because of the mix of incentives facing providers during this long transition to a value-based system. One of the most entertaining moments for me at the HIMSS Conference was in the CMIO Roundtable, where there was some of the usual EHR-bashing coming from some people, but the gentleman from KLAS indicated that not everybody hates EHRs. The reality is that EHRs aren’t the problem; they’re part of what people can vent at.
The level of abilities needed by CIOs and CMIOs—to be true system leaders—is really amazing now. Many industry observers have talked about the need for “CIOs 2.0,” “CMIOs 2.0,” etc.—healthcare IT leaders who are at entirely new levels of professional development—to help lead their organizations right now.
You’ve hit the nail on the head there; CIOs and CMIOs have been promoted up through the trenches. And the c-suite in general does not realize the true leadership requirements they’re facing, for individuals with those titles. And we generally talk about CMIOs and CNIOs, rather than CHIOs. But when you look at the functions and roles of the CMIOs and CNIOs—focused on their specific disciplines—well, the reality is that we need to work as a team, strategically as well as operationally. Some of the organizations that are just getting going, may need someone in the trenches.
But more advanced organizations need more advanced leaders, focused on moving into population health and analytics, and that’s strategic, that’s not just slapping your colleagues on the back, saying, you’re doing a great job of CPOE, or using your screens. It’s things like transforming care delivery and improving outcomes, and that’s a strategic challenge. And frankly, a lot of the clinical leadership isn’t standing up to the executive leadership and saying, this is an important set of challenges we need. It’s interesting, we have the new clinical engagement officer and patient experience officer and this and that, but they haven’t quite figured out yet what it is that people are really doing. And we talk about mobile technology; well, how much of what we do isn’t mobile anymore these days?
So the reality is that when we talk about mobile health, telehealth, all those things, it’s all just health, really. So that’s part of the long-term strategy; as we learn and adapt to new ways of doing things, I think we are going to have to own up to the fact that computers are everywhere, and the Internet of things and the Internet of threats, they’re all changing everything.
After the experience of the HIMSS Conference this year, would you say overall that you’re more optimistic about healthcare IT leaders moving forward to do what needs to be done? Less optimistic? About the same as before?
From an industry perspective, about the same. It takes time for things to advance; I think things will happen. My concerns are more on the policy side and how that impacts everything else. I think it will take a few years to sort out what will happen in the policy area, and how that will affect everything. From the perspective of a large patient care organization, how do you plan for the future when you don’t know exactly what it will be? That is an important question that will be difficult for many to answer right now.