Q&A: Blumenthal Talks EHRs, Healthcare Reform

During his two-year stint as National Coordinator of Health IT, Dr. David Blumenthal oversaw the development and implementation of the American Recovery and Reinvestment Act's $27 billion HITECH Act stimulus programs to encourage the adoption and "meaningful use" of electronic health records by hundreds of thousands U.S. hospitals and clinicians. Blumenthal--a former primary care physician at Massachusetts General Hospital--left his Office of National Coordinator job in April to return to his tenured post at Harvard. InformationWeek Healthcare senior writer Marianne Kolbasuk McGee caught up with Blumenthal at the recent Partners Healthcare's Connected Health Symposium in Boston.

InformationWeek: What do you think of the progress so far with the Meaningful Use programs?

Blumenthal: There are 114,000 registrants, which is 20% of the eligible population, and we're only halfway through stage one and Meaningful Use incentives last through 2015. So I think everyone wants to know if we are ready to declare victory, and the answer is that I'm encouraged by the progress, but I think it's too soon to make conclusions. It's encouraging that a fifth of the eligible population of providers have registered, and it's encouraging to see that upward of 6,000 have gotten paid, even though only 20 states have gotten their Medicaid incentive programs up and running. So, the whole Medicaid population is still not yet able to participate because the states just aren't giving away the money. I think also pretty soon we'll have ready additional data on EHR adoption, and I expect it will be very positive. Meaningful Use is one standard, but getting people to electronic health records so that they can build into Meaningful Use is another important thing.

InformationWeek: What will happen if healthcare reform is repealed after the next presidential elections--what would be the impact on the reforms closely linked to health IT, such as accountable care organizations?

Blumenthal: The question that will come up is how assertive will the next administration be in using all the authorities available to facilitate healthcare reform. Everything that they need is on the books--the question is will they use it and also will it stay on the books.

I think probably the authority that's most vulnerable is the center for Medicare and Medicaid innovation because there is $10 billion assigned to it. So, it's a relatively flexible and therefore pretty easy tool for the government to use in showing leadership. And I don't know whether the next administration will believe the federal government should be leading with innovation in health reform or health delivery systems. What happens with ACOs I think will again depend on the philosophy and inclination of the next administration. None of these things get implemented by themselves. They need a lot of nurturing. They need a group of people who are committed to a significant government leadership role. So the question is: What will the attitude be in the next administration, and I don't know.

I think some of the system reform elements of the [health reform] legislation have bipartisan support. Yet, individually they are not going to change the landscape. I think they need to be knit together in fairly concerted, coordinated, well-planned efforts to change the way complicated patients are treated. So I am concerned that implementing each individual provision of the law without an overarching vision and goal will not get us to where we need to go. And that's true of IT as well. The successful implementation of the IT project depends on the government and health system using IT with the purpose of health improvement.

InformationWeek: Besides the adoption of EHRs, what other technology do you think will have the biggest impact in terms of improving quality of patient care, reducing costs?

Blumenthal: Clinical decision support is really pivotal. I think that's a very important capability--and then the ability to exchange information. Those are part of the agenda and they need to be built into the capability of EHRs. But they won't be unless there are incentives to do so. Meaningful Use will emphasize those, I'm pretty confident. But there will be push back from the provider community if the technology is not ready, is expensive, or changes their workflow.

InformationWeek: Once the Meaningful Use programs end, do you think use of health IT will stall?

Blumenthal: The programs don't end. They change from incentives to penalties, till 2018--so that's another seven years. And I think we're already close to turning a corner. Now I think psychologically people have shifted their view of electronic records in medicine. Meaningful Use kind of held up a mirror to the industry, where the industry said, 'you know, really how can we ignore the information technology revolution.'

InformationWeek: What do you think the big hold ups are on the consumer side in expecting this capability?

Blumenthal: Well, it would be really nice if consumers got behind this, but I think it will take a little while. I think consumers also need to go through a mind shift as well about who manages their health, and maybe come to see that they can be more knowledgeable without threatening their physicians or taking away their physicians' roles. Most people are reluctant to push their physicians or challenge them. And they know their physicians are busy and if they value their relationship with their physician they don't want to do anything to upset that. InformationWeek: There's been a lot said about health information exchanges, and some doctors being resistant to the idea of sharing their patients' data with other doctors. But what do you think the feeling is among doctors about sharing their patient information more readily with the patients themselves?

Blumenthal: I think physicians have a lot of concerns about it, and I don't think most want to go to the trouble of doing this unless someone would make it possible to build in protections to prevent patients from getting information that could be very damaging if it's not explained, some things that are very important but need to be put into context. So, most information sharing systems that now exist do not share pathology results, for instance, because you don't want to learn you have cancer from a report. Most systems say they'll share information with patients within 48 hours, except for some information that will be shared after a week, which gives the physician a chance to catch up.

InformationWeek: In your work as national coordinator, what was most challenging and what are you most proud of?

Blumenthal: I think I was proud that we got the Meaningful Use program launched. It's not perfect and people will continue to find problems with it and make suggestions for improvements. But it was good enough to get us started. In some ways, the tight time was somewhat helpful because we had so much to do, and you know it all couldn't be perfect. I was pleased that we got a lot of other programs up and running, and we'll see how well they do.

I was pleased that we set up Office of National Coordinator in a way that seems to support these programs, and earn the respect of people in the Dept. of Health and Human Services and made it credible to the outside world. The challenges--I never felt like I came across a challenge that was so severe that it was capable of undermining the entire program, but there were many challenges. Finally getting agreement on the Meaningful Use regulations inside the administration was a challenge. There was a lot of education to do, a lot of discussion, and a lot of compromise. Another challenge was managing the critique of it.

I would say communicating to the professions and to the institutions was another important challenge. I knew intellectually how important communication was but I came to understand it in a very visceral way. I don't think people think of the technology project as being reliant on a communication program, but believe me it was and is. In that context, I had to make sure we were above criticism in terms of the objectivity, in respect to the industry and different professional groups, so managing the press was an important challenge, too.

InformationWeek: Did you meet with President Obama about the programs?

Blumenthal: No, I met with all the people around him.

InformationWeek: What was it like to be part of that time in the administration?

Blumenthal: I enjoyed it enormously. A lot of the energy was focused on health reform, which we were busy implementing with our programs, and other people were working on and managing health reform in the administration and in the Capitol. It was very exciting to be part of that environment and watch it evolve. At the same time I had relatively protected space with a set of responsibilities that was already established and approved so I felt that I had a very privileged, protected area of responsibility and a lot of opportunity to lead and to bring the administration along. It was a very fortuitous set of circumstances. InformationWeek: What do you miss most and least about the ONC job?

Blumenthal: I don't miss commuting to Washington [from Boston] every week. I don't miss the ethics scrutiny and constant accounting for time and expenses. What I do miss is the sense of being involved with something important where the stakes are high and the impact is great. And the constant flow of information into your environment from the outside. Washington gives you a special perch where you can observe the country and all its diversity. The amount of learning you do just by virtue of people wanting to tell you about themselves and their problems is enormous. It's almost impossible to duplicate anywhere else.

InformationWeek: How do the politics of Washington and the work you were involved with compare to medicine and academia?

Blumenthal: I've always thought that Washington politics are a whole lot easier to navigate. It's not as personal. Everyone understands you're going to make decisions that other people don't like and it's a matter of learning to live with it, and having to manage it and reach compromises that work, and if you can't, you can't, if you do, you do.

In the bipartisan environment of Congress there's less of that civility than there was in my world, which was a relatively professional environment. Republicans were not always supportive, but they were mostly supportive. I certainly didn't take attacks personally. And the interest groups that criticized us clearly weren't making personal attacks, they were representing their constituents.

In academia, people tend to take disagreement extremely personally. There aren't processes and institutions for managing conflict. Sometimes it gets personal in Washington, but in the process of managing substantive issues in Washington, I've found there's greater room for disagreement. In Washington, there's an acknowledged need to agree and disagree. People agree on some issues, and disagree on others without sabotaging the process.

InformationWeek: You were a primary care doctor before taking the job as national coordinator in 2009. Have you gone back to practicing medicine?

Blumenthal: No, I haven't gone back to practicing medicine. I miss it but I don't feel it's responsible for me to start again till I'm quite sure what I want to do. I had a practice before taking the position in Washington. I took my job in Washington on April 20, [2009] and had my last patient session on April 17.

InformationWeek: How did your patients react to you taking the National Coordinator position in Washington?

Blumenthal: Some people thought it was great, and some thought I'd be destroyed by the whole process. I don't think a lot of people understood it. Generally, patients are very supportive of their physicians.

InformationWeek: Were your patients surprised at all with you taking that job--did they see you as the tech-savvy doctor?

Blumenthal: First of all, I wasn't all that tech savvy. But I did have a computer, so I don't think they knew how tech savvy I might be. I think in general, they were sorry--I hope--to see me leave. But physicians move and take new jobs. I think they took it in stride. They all ended up with new physicians. Some ended up not finding a physician they like at Mass General, and moved on to other institutions.

InformationWeek: Now that you're out of ONC, you've been doing a lot of traveling for public speaking. What else are you up to? Are you also teaching at Harvard?

Blumenthal: I'm doing a lot of writing, and teaching as a guest lecturer in lots of courses. I've been at Harvard Medical School, MIT, and I'll be teaching at the [Harvard] Kennedy School of Government and the School Public Health. Harvard has lots of opportunities.