Renata Tebaldi's Dimples of Steel: Just the Gesture Needed at this Inflection Point in MU and Healthcare Reform?

June 24, 2013
Comments made by Marilyn Tavenner, R.N., of CMS, and Farzad Mostashari, M.D., of the ONC on Wednesday at the HIMSS Conference were fascinating on many levels and along many dimensions-and well worth pondering in some depth.
celebrated soprano Renata Tebaldiand her famed "dimples of steel"

I found the presentation by Acting Administrator of the Centers for Medicare & Medicaid Services (CMS) Marilyn Tavenner, R.N., and the press conference remarks by Farzad Mostashari, M.D., National Coordinator for Health IT, on Wednesday morning, March 6, to be fascinating on many levels and along many dimensions—and well worth pondering in some depth.

Both the top federal official at CMS and the leader of the Office of the National Coordinator for Health IT (ONC) spoke in strong, clear, forceful terms about a variety of topics on Wednesday at HIMSS13 in New Orleans, laying out and defending a unified vision of healthcare information technology as a vital facilitator of healthcare reform and accelerated healthcare system change in the United States. Both their prepared remarks and their responses to audience (in the case of Ms. Tavenner) and media (in the case of Dr. Mostashari) questions reflected a newly aggressive stance on the part of both CMS and ONC towards the healthcare industry. The clear message: we realize that some in the industry have been frustrated/unhappy/resentful/whatever, with certain aspects of meaningful use, healthcare reform, ICD-10, and the like; and we understand that what we’re asking the industry to do is big, complex, and challenging. But this stuff has got to get done and get done right, and while we’re going to show more flexibility in certain areas (such as waiting for input about the successes and challenges of meaningful use Stage 2 before moving onto the Stage 3 preliminary rule), we’re not backing down for a moment on the basics; in fact, we’re stepping up the pressure.

I’m somehow reminded of the great Italian soprano Renata Tebaldi, who in the middle years of the last century thrilled audiences at the Metropolitan Opera and La Scala of Milan with her interpretations of such beloved operatic roles as Mimi, Tosca, Aida, Desdemona, and Adriana Lecouvreur. Madame Tebaldi, who was possessed of magnificent charm both onstage and off (not to mention one of the greatest lirico-spinto voices of the 20th century) was aptly described as having “dimples of steel,” as she was as tough as an old-style union boss in negotiating the terms of her contracts with the Met and other houses; but she never stopped smiling while making her demands of Sir Rudolf Bing, the Met’s general manager.

Well, Dr. Mostashari has well-noted dimples, too, and they certainly are not made of latex.

But here’s the thing: when one looks at the bullet points in the self-described “aggressive agenda” announced early on Wednesday morning, just prior to Marilyn Tavenner’s speech to a HIMSS audience, one can hardly call said agenda wildly ambitious or unreasonable, given the cost and quality challenges facing U.S. healthcare right now, viz., setting the “aggressive goals” at the Department of Health and Human Services (HHS), the parent agency of CMS and ONC, of getting 50 percent of U.S. physicians to use electronic health records (EHRs) by the end of this year, and 80 percent of eligible hospitals receiving meaningful use payments within the same timeframe.

To be honest, it would be hard to come up with an argument for why the federal government should not push at least this hard on those two goals. Not only is the United States tremendously behind most western European nations in physician and hospital EHR adoption; but the need to adopt EHRs not only in order to improve care quality and patient safety but also to save terribly needed federal dollars is also wildly apparent (N.B. the current monthly fights to the death in Congress over federal spending, of which Medicare spending comprises an alarmingly growing portion).

In fairness, two points must absolutely be made here. First, there are numerous complexities in meeting the requirements of meaningful use in Stage 2, and as we head towards Stage 3, the ramp only gets steeper (and in fact, considerably more so). Also, the better-satisfied physicians and hospitals working in countries like Finland, Denmark, the Netherlands, France, and Switzerland, are working in healthcare systems that are streamlined, rationalized, purposeful, and orderly, and whose systems make the American non-system look absolutely chaotic (not to mention criminally wasteful of resources) in comparison.

But such acknowledgments only underscore the centrality of healthcare IT as a facilitator of healthcare reform and system change in this country. If it’s not possible to make such core structural changes as shifting all physicians to employee status (and in fact, when one looks at the clinical transformation efforts of the most innovative patient care organizations in America, every single such innovative organization has at least a significant plurality of employed, versus freelance, physicians) in order to align incentives, then we’ve got to do what we can to effectively leverage healthcare IT to improve the performance of both clinicians and organizations. Hence such vital Affordable Care Act programs as the mandated value-based purchasing program and avoidable readmissions reduction program, and the voluntary accountable care organization and bundled payment contracting programs.

And when you think about it, how can anyone justify continuing to pay physicians billions of dollars to care for patients using demonstrably error-enhancing paper-based medical records and clinical documentation systems, or to allow them to care for patients without the use of automated performance improvement dashboards?

That’s why the word outrageous comes to mind when august national newspapers like The New York Times allow editors run amok to commission agenda-driven articles determined to characterize the HITECH [Health Information Technology for Economic and Clinical Health] Act as a big-vendor boondoggle in the face of the healthcare system’s not having completely transformed itself within four years of the passage of that major piece of enabling legislation.

So I think it’s time to put in perspective the “aggressive agenda” announced by HHS on Wednesday, and to see it the way that former President Bill Clinton did when he spoke to HIMSS13 attendees just a few hours later. President Clinton noted that, in the context of the remarkable work that his foundation is doing in bringing health improvements to terribly impoverished countries around the world, the resources that leaders in the U.S. can bring to solving our healthcare value crisis are enormous in comparison.

“There’s a big difference in working on a challenge of quality or inequality on issues like healthcare in the United States, which has been wealthy for a long time, and in countries that are poor,” the former president told a standing-room only audience Wednesday afternoon. “Before the earthquake, 70 percent of the people in Haiti were already living on less than two-and-a-half dollars a day.” And when you look at the systems, institutions, and resources that we can call upon in this country to solve our problems, there really is no excuse for us not working together as a society to make healthcare more affordable and of higher quality and value, he added (my paraphrase).

In the context of things as President Clinton put them, it’s hardly unreasonable for federal officials like Tavenner and Mostashari to make remarks insisting that we move forward, for the sake of our economy and our society, because our nation can no longer afford the old ways of doing things, and time is running out to get the new healthcare underway. And a few sharp words from federal officials, well-timed, perfectly adjudged, and delivered with a smile, seem to me just what’s needed right now, as we reach an inflection point on EHR adoption and on participation in transformative healthcare reform programs. Given what’s at stake, I have to think that in her own way, Renata Tebaldi would absolutely have understood the gesture.

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