Q&A: ONC's Jon White, MD
Jon White, MD, acting deputy national coordinator for health IT, has been coming to the HIMSS Annual Conference & Exhibition since 2004. Back then, the Office of the National Coordinator didn't yet exist – it was still a few months away from being founded. President George W. Bush (who will deliver his HIMSS15 keynote address on Wednesday from 4:30-5:30 p.m. in the Skyline Ballroom) had only just made his momentous mention of EHRs in the State of the Union address.
White says he's impressed and gratified by the growth and maturation he's seen in health IT since then.
"What you've really seen is an influx of a lot of larger information technology companies," he says. "They were interested before, but they're really interested now."
Key to that, of course, is the more than $28 billion dollars in incentives made possibly by the HITECH Act and the meaningful use program. On Tuesday morning, White spoke to Healthcare IT News about the recent evolution of both meaningful use and ONC.
Q: Five years ago, meaningful use money was like an injection of rocket fuel for this industry. In the past year or two, however, it seems like the program may be seen as something of a drag by some providers.
A: It's become more part of daily practice, for sure. I started working on health IT with the federal government in 2004. The IOM had just recommended that we start using electronic health records to drive improvement in practice. I was running a research program at that time at AHRQ and it was really about the potential and the excitement ad the promise.
I would say that the past five years have definitely been rubber hitting road. And any time that happens you hear a lot of great stories, and also a lot of challenges that have gone with it. I think that's what we've heard over the past five years.
Q: Were you surprised at all by some of the difficulties with Stage 2?
A: Not necessarily surprised. Stage 2 is ambitious. It hopes to drive a lot of improvements in processes and outcomes. The flip side is that's a pretty heavy lift. It it were easy to make a lot of these changes it would have happened a long time ago. Everyone's been working very hard at it, and even though you hear about a lot of the challenges, I really am impressed by the way the whole health system is digging into it and trying to make it happen.
Q: What do you say to those who say, "We don't need meaningful use anymore. Let the market take over"?
A: I would ask them rhetorically: Is the point to have a box on a desk? Or is the point to have people live longer, suffer less and have better value for their dollars? The obvious answer is the latter. Meaningful use has definitely done its job as far as driving adoption. I think that has been a great success. I think that now the secret sauce is providers grappling with these tools and understanding them at a fundamental level.
My background is as a family doctor. When you do primary care you coordinate across a lot of different folks and coordinate across a lot of different problems. By and large, my stock in trade is information. You come in, I ask what brought you into the office, I ask more pointed questions, I examine you, record data, send you out for labs, get more data. It all goes into the wetware, and I turn that into care and hopefully good outcomes for the patients.
Q: Does it concern you at all that family docs and EPs are having some of the hardest challenges with meaningful use?
A: I always worry about family doctors wherever I go, just being part of the clan. Family doctors have hard jobs. They really do. So it's not unexpected that they'd have some of these challenges. They're engaged, and you certainly hear some strong feedback on some things. But the flip side of that is there seems to be a strong commitment to the use of these tools. I've not heard a (physician) professional society yet say we should go back to paper. It's a hard fight, but I think it's the right fight.
Q: Talk about Stage 3. CMS has talked about simplifying things, reducing the reporting and measuring and focusing on eight core measures. Does it strike the right balance?
A: I would love to give you all sorts of comments. It's a proposed rule. But even more so it's not my rule, its CMS'. But what I'll say is I think it's a very interesting and exciting rule. And we look forward to comments. A lot of people have been very engaged, and we're starting to hear comments back now.
Q: Meaningful use is a CMS rule and certification is an ONC rule. Ho much do you compare notes as you're developing them?
A: Through all the different stages the rules get developed in tandem. Obviously the timing gets a little off sometimes, but yes, they initially get developed at their respective agencies but then go thorough a clearance process within the department, and then the broader administration. By the time you get to the published NPRM, you've had a lot of weigh-in from across the administration: These rules affect not just the private sector, but impact the government too, so it's obviously important to get their feedback. And then on to the public stage, which is where we are now.
Q: Talk a bit a about the new 2015 Edition certification criteria. We ran a Stage 3 analysis whose authors said that, while "the the CMS rule is laid out logically and pretty easy to follow," they wished they "could say the same about the ONC Certification Rule." There are more than 400 pages of regulations. Talk about the balance you have to strike between certified products and allowing the vendors the latitude to innovate.
A: It's a great question. And it is a balance. Without trying to comment specifically on what's in the NPRM, because of course it's in a public comment period, I would say that any time you're working on one of these rules, you're trying to balance the public good versus the burden that it causes. And that's reflected in the actual structure: there's the rules, and then there's the analysis of what happens when you put the rules in place. The public feedback is tremendously valuable.
There are a lot of different demands. Not just in healthcare, but on ONC and the federal government. I know that a 400-page rule sounds like a lot. But on the other hand I can promise you that my pathology textbook was a lot bigger than that.
Again, there's a lot of things that are in there for which public feedback would be really valuable. There's a lot of very smart people out there and we look forward to their feedback to make it the best rule it can be.
Q: Just as meaningful use has evolved in recent years, so has ONC. You guys have had some pretty big turnover this past year and a half, and a lot of people were questioning just what the agency's role will be going forward. How do you envision it?
A: Well, of course, Karen is the national coordinator, and she ultimately sets the vision, and my job as acting deputy is to be good support for her. I'm a career fed, and one of the ways I'm able to complement Karen is I have a lot of longstanding working relationships with other staff, and a lot of the federal programs and operating divisions. I also have worked with a lot of the ONC staff for a long time.
But ONC has gone through a pretty big transition, we've gone through the past five years where ARRA and HITECH set up a lot of different programs, and the funding for those is winding down, but I think what you're seeing is the work is not done. It's pretty clear that in addition to the things that we see – for example, Congress asking about information blocking – there are a lot of ongoing phases in adoption and use.
I don't see the information systems staying static, there are a lot of very smart people, and they're going to innovate. I think we're here to see that the public is best served by those systems, and by the healthcare system more generally.
Q: Do you worry that as the money runs out, and we move away from the carrot phase and into the stick phase, your job will get harder?
A: I think it's just a different phase. Again, what this gets back to is working with those in this country who provide care, and those in this country who receive care, to understand that to get the best care you really need great information systems, great tools and practices. That need is not going away. And although there are challenges associated with it, I think most folks do understand that promise.