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Is CMS Listening to Doctors’ Thoughts on MACRA?

Posted on June 10, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I have to admit that I have a lot of respect for Andy Slavitt. He’s doing a really hard job as Acting Administrator of CMS and he’s been very vocal and open about his view of what they’re doing and their efforts to listen to those of us in healthcare. I’ve really appreciated his willingness to engage the community on challenging topics. Did you ever see this from previous CMS administrators?

This tweet illustrates Andy’s efforts to really listen to doctors when it comes to MACRA:

This illustrates why I previously wrote that Andy Slavitt was very much in touch with the pulse of what doctors are feeling and experiencing. Although, with that comment I also said that I hoped that the policies and programs they implemented would match that understanding.

I realize that this concept is much easier said than done. Andy Slavitt and his team at CMS are sometimes not able to make changes to things like MACRA even if they know it’s the right thing to do. They aren’t the ones responsible for making the legislation. Their jobs are to implement the legislation. It’s a tough balance which always leaves people wanting.

The only thing awkward about Andy Slavitt’s tweet above is that he says CMS has “trained nearly 60,000.” It’s quite interesting that he views these MACRA sessions as trainings. I thought they were more listening sessions than training sessions, but I guess I was wrong. Certainly you have to train a doctor on the MACRA legislation if you want to get the right feedback from them. So, I guess training and listening aren’t mutually exclusive, but it’s not surprising that many doctors don’t want to be “trained” on MACRA. For some doctors, anything less than a full repeal of MACRA will be less than satisfying and that’s not going to happen.

While you can complain about the way Andy might phrase things in a tweet, I don’t think that’s very productive. Although, I don’t think listening to (or should I say training) 60,000 physicians’ thoughts about MACRA is very useful either if we don’t see that feedback incorporated into the final MACRA rule. This tweet gives me some hope that the feedback has been heard and we’ll see some important changes to MACRA:

When the MACRA final rule comes out, I hope that along with the changes that were made we also get a look into the changes that people requested that CMS was unable to make because of the way the legislation was written. I’m not sure if CMS is allowed to be that transparent, but if we’re going to help push for better legislation it would be great to know which feedback was thwarted by legislation so that doctors can push for better legislation.

Halamka Ponders The Need to Leave Medicine If We Continue Our Current Trajectory

Posted on May 5, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The famous Dr. John Halamka, Hospital CIO, Doctor, Former member of the HIT Policy committee, blogger at Life as a Healthcare CIO, recently read the 962 page MACRA NPRM and he wrote up a detailed look at the IT elements of MACRA. The post is worth a read if you’re interested in MACRA. Especially if you don’t want to spend the 20 hours reading it that he spent.

MACRA aside, he ends his post with this bombshell of a comment:

As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.

A doctor in the comments shared a similar view to Dr. Halamka:

Wow, I feel exactly the same as you do. As a front line ortho provider in a small group. I think now I get the message. CMS and ONC wants us out of private practice, either retire, or join as a salaried doc or hospital employee. That is the only justification for this 1000 page nightmare.

We’ve written a lot about physician burnout and many doctors distaste of all this government regulation, but having someone like John Halamka comment like this is quite telling. What’s scary for me is that I don’t see much light at the end of the MACRA tunnel from a physician perspective. Do you?

New Payment Model Pushes HIT Vendors To Collaborate

Posted on April 20, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

CMS has launched a new program designed to shift more risk to and offer more rewards to primary care practices which explicitly requires HIT vendors to be involved at advanced stages. While the federal government has obvious done a great deal to promote the use of HIT in medical practices, this is the first I’ve seen where HHS has demanded vendors get involved directly, and I find it intriguing. But let me explain.

The new Comprehensive Primary Care Plus payment scheme – which builds upon an existing model – is designed to keep pushing risk onto primary care practices. CMS expects to get up to 5,000 practices on board over the next five years, spanning more than 20,000 clinicians serving 25 million Medicare beneficiaries.

Like Medicare payment reforms focused on hospitals, CPC+ is designed to shift risk to PCPs in stages. Track 1 of the program is designed to help the practices shift into care management mode, offering an average care management fee of $15 per beneficiary per month on top of fee-for-service payments. Track 2, meanwhile, requires practices to bear some risk, offering them a special hybrid payment which mixes fee-for-service and a percentage of expected Evaluation & Management reimbursement up front. Both tracks offer a performance-based incentive, but risk-bearing practices get more.

So why I am I bothering telling you this? I mention this payment model because of an interesting requirement CMS has laid upon Track 2, the risk-bearing track. On this track, practices have to get their HIT vendor(s) to write a letter outlining the vendors’ willingness to support them with advanced health IT capabilities.

This is a new tack for CMS, as far as I know. True, writing a letter on behalf of customers is certainly less challenging for vendors than getting a certification for their technology, so it’s not going to create shockwaves. Still, it does suggest that CMS is thinking in new ways, and that’s always worth noticing.

True, it doesn’t appear that vendors will be required to swear mighty oaths promising that they’ll support any specific features or objectives. As with the recently-announced Interoperability Pledge, it seems like more form than substance.

Nonetheless, my take is that HIT vendors should take this requirement seriously. First of all, it shines a spotlight on the extent to which the vendors are offering real, practical support for clinicians, and while CMS may not be measuring this just yet, they may do so in the future.

What’s more, when vendors put such a letter together in collaboration with practices, it brings both sides to the table. It gives vendors and PCPs at least a marginally stronger incentive to discuss what they need to accomplish. Ideally – as CMS doubtless hopes – it could lay a foundation for better alignment between clinicians and HIT leaders.

Again, I’m not suggesting this is a massive news item, but it’s certainly food for thought. Asking HIT vendors to stick their necks out in this way (at least symbolically) could ultimately be a catalyst for change.

Meaningful Use Holdover Could Be Good News For Healthcare

Posted on January 25, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

I know all of us are a flutter about the pending regulatory changes which will phase out Meaningful Use as we know it. And yes, without a doubt, the changes underway will have an impact that extends well beyond the HIT world. But while big shifts are underway in federal incentives programs, it’s worth noting that it could be a while before these changes actually fall into place.

As readers may know, the healthcare industry will be transitioning to working under value-based payment under the Medicare Access and CHIP Reauthorization Act, which passed last year. But as ONC’s Karen DeSalvo noted last week, the transition could take a while In fact, proposed draft regulations for MACRA rollout will be released this spring for public comment. When you toss in the time needed for those comments to be submitted, and for the feds to digest those comments and respond, my guess is that MACRA regs won’t go live until late this year at the earliest.

The truth is, this is probably a very good thing. While I don’t have to tell you folks that everyone and their cousin has a Meaningful Use gripe, the truth is that the industry has largely adapted to the MU mindset. Maybe Meaningful Use Stage 3 wouldn’t have provided a lot of jollies, but on the whole, arguably, most providers have come to terms with the level of process documentation required — and have bought their big-bucks EMRs, committing once and for all to the use of digital health records.

Value-based payment, on the other hand, is another thing entirely. From what I’ve read and researched to date, few health organizations have really sunk their teeth into VBP, though many are dabbling. When MACRA regs finally combine the Physician Quality Reporting System, the Value-based Payment Modifier and the Medicare EHR incentive program into a single entity, providers will face some serious new challenges.

Sure, on the surface the idea of providers being paid for the quality and efficiency they deliver sounds good. Rather than using a strict set of performance measures as proxies for quality, the new MACRA-based programs will focus on a mix of quality, resource use and clinical practice use measures, along with measuring meaningful use of certified EHR technology. Under these terms, health systems could conceivably enjoy both greater freedom and better payoffs.

However, given health systems’ experiences to date, particularly with ACOs, I’m skeptical that they’ll be able to pick up the ball and run with the new incentives off the bat. For example, health systems have been abandoning CMS’s value-based Pioneer ACO model at a brisk clip, after finding it financially unworkable. One recent case comes from Dartmouth-Hitchcock Medical Center, which dropped out of the program in October of last year after losing more than $3 million over the previous two years.

I’m not suggesting that health systems can afford to ignore VBP models, or that sticking to MU incentives as previously structured would make sense. But if the process of implementing MACRA gives the industry a chance to do more preparing for value-based payment, it’s probably a good thing.

Can We Now Officially Say that ICD-10 Is Going to Happen?

Posted on July 15, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

With the announcement that came a little over a week ago about CMS and AMA working together on ICD-10, does that mean that we can officially say that ICD-10 is going to happen? The ICD-10 Watch blog has a good summary of what CMS committed to do in the announcement:

  • CMS is creating an ICD-10 Ombudsman to deal with healthcare providers’ ICD-10 problems. More on how this will work later.
  • Without using the words “safe harbor” or “grace period,” CMS promises that Medicare will not deny any medical claims “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”
  • Quality reporting programs such as Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) will suspend penalties that may result because of lack of specificity.
  • There will be advance payments available if the Medicare system has problems.

The second and fourth items have gotten all the buzz. Most have interpreted that the second one means that CMS won’t deny ICD-10 claims that weren’t done correctly. That’s an overstatement, but it does decrease the number of denied claims that will occur with the switch to ICD-10. The fourth item listed above was a major concern that I raised, but it applied to all payers and not just CMS. So, it’s nice that CMS has addressed the cash flow challenges that slow claims processing of ICD-10 claims will cause, but that still leaves all the other payers.

With the “peace treaty” signed between AMA and CMS, can we finally say that ICD-10 will not be delayed again? One person suggested to me that it just leaves the AHA as a possible opponent that could stop it. However, I also heard it suggested that they weren’t looking for a delay.

While usually avoiding trying to predict the unpredictable Washington, I’m going to say that we can safely assume that ICD-10 will not be delayed again. We might see an overture or two still that tries to delay it, but if I were putting my money down in Vegas I’d put it all on No ICD-10 Delay in 2015. Are you putting your organization’s “bet” in the same place?

Annual Evaluation of Health IT: Are We Stuck in a Holding Pattern? (Part 1 of 3)

Posted on April 13, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

I don’t think anyone has complained of excessive long-term thinking among health care providers. But an urgent lack of planning has worsened in the past few months as key drivers of the health IT field search for new directions. Given today’s issues with Meaningful Use Stage 3, the FHIR data exchange standard, Accountable Care Organizations, medical device regulation, and health IT staffing, I expect the next several months to be a time of waiting.

This article will look over what has happened during the past year and try to summarize large-scale trends. I used to report annually from the HIMSS conference, the largest health IT gathering in the US, but stopped going because my articles were always cynical, cantankerous, and depressed. So I figure I just write up a cynical, cantankerous, and depressed summary of what’s happening in health IT from home.

Meaningful Use Stage 3: Shoot the Moon?

There are clear indications that the Meaningful Use program has gone off the tracks. I don’t consort with those who disparaged Meaningful Use from the start and claimed that it held back progress in the IT field. What little progress has occurred can be credited to Meaningful Use, because frankly, the health care industry was totally mired before. Choose your favorite metaphor: deer in the headlights (of oncoming disruptive competitors), ostrich in the sand, even possum in the road.

And no one can challenge that Stage 1 met its (very limited) goals. Centers for Medicare & Medicaid Services (CMS) just reported that the vast majority of hospitals have attested to Stage 1 (with rural and children’s hospitals lagging significantly). In fact, while defining Stage 3, CMS could remove some of its requirements because they have “topped out,” meaning that almost everybody already does them.

All the sharper is the contrast between Stage 1 and Stage 2, which was supposed to be incremental but apparently broke the camel’s back for many EHR vendors as well as providers, a lot of whom have thrown in the towel.

Interoperability was certainly a big stumbling block. Two different EHRs can claim to support a standard (such as the C-CDA) while not actually being able to exchange data in a useful manner, for reasons ranging from outright errors to differing interpretations of a fuzzy standard.

But the most whining from providers in Stage 2 arose over a requirement that patients view, transmit, or download (VDT) data from a patient portal. Even though providers needed only 5% of their patients to take a look at the site, they complained bitterly that they were being judged for something that relied on somebody else’s behavior (their patients).

The VDT measure is indeed a responsibility that depends on the behavior of outsiders (as are the interoperability requirements). But health providers seem slow to grasp the whole idea of “pay-for-value,” which means they won’t be rewarded in the future for doing stuff–they’ll be rewarded for results. Not that patients will get healthier just by viewing or transmitting data. But we need something measurable to mark progress, and since everybody issues paeons to patient engagement, the VDT measure is a natural one.

Calls have come from around the industry to water down or otherwise “simplify” Meaningful Use for Stage 3. A common request is to eliminate clinical quality measures (such as how many patients smoke) and focus on interoperability, which I oppose.

To muddy the Meaningful Use landscape further, Congress has started weighing in with complaints that the Office of the National Coordinator (ONC) hasn’t done enough to achieve its goals. One proposed bill overrides ONC and CMS to mandate changes in health care policy. There are rumors that Congress (who of course created the Meaningful Use provision in the first place) will take it back and do some serious micromanagement, perhaps as part of a bill on a totally different topic, the “doc fix” that is supposed to regularize Medicare payments.

In the midst of this turmoil, the ONC and CMS recently released Stage 3 recommendations, and it looks like they haven’t pulled their punches on a single thing. Interoperability is central, but the clinical quality measures still appear in full force. The requirement that patients engage with the technology has been softened, but still requires patients to take some action such as using a portal or uploading their own data.

Perhaps the boldest stake that CMS put in the ground was to force all providers onto a single schedule in Stage 3, a tremendous departure from the gentle steps offered by the first two stages. This has touched off a provider frenzy. They’ve been lobbying for years to slow Meaningful Use down, and notoriously ran to Congress to delay adoption of ICD-10 disease coding. But putting everyone on the same track makes eminent sense, particularly at this stage. If you’re really serious about data exchange and coordinated care, everybody has to equally capable. Otherwise we’re back to finger-pointing and claims that technology lapses have prevented compliance.

So what are ONC and CMS up to? Are they shooting the moon–hoping to make the big leap to their maximal goals in one bold play? Are they floating an audacious wish list that they know will be cut back in the course of negotiation? Are they even taunting resistant industries to go to Congress, knowing that Congress recently has been making even more radical noise than the Administration about the drawbacks of health IT? Something along these lines seems to be in the works.

To return to the theme of this article, I’m afraid that health care providers, insurers, EHR vendors, and all their business associates will freeze up while waiting for Congress and the various branches of Health and Human Services to determine which behaviors to prescribe and which to punish. So that’s my take on meaningful use–more on other developments in health IT in the next installments.

Meaningful Use Stage 3 to Come Out Before HIMSS15?

Posted on March 11, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Madelyn Kearns from Medical Practice Insider is reporting that we might see meaningful use stage 3 regulations before HIMSS. Here’s the exact quote from Robert Anthony, deputy director of CMS’ quality measurement and health assessment group:

“We will have two regulations that will come out in time to discuss meaningful use”

It’s hard to imagine that one of these 2 regulations will not be meaningful use stage 3. No doubt CMS and ONC will want to get some feedback from the HIMSS community on meaningful use stage 3. What better place than at the conference?

Madelyn aptly points out that Robert Anthony already has one session scheduled at HIMSS to discuss the meaningful use stage 3 requirements. I have a feeling that is going to be one of the really well attended sessions. Especially if the MU stage 3 rule does come out before HIMSS.

I realize that CMS is bound by laws on when they can announce the various rules and regulations, but I hope they’ve planned out the timeline better than they’ve done in the past. My colleague Neil Versel at Meaningful Health IT News has regularly pointed out how the rules always seem to go public on a Friday. He’s hypothesized that it was the case that they were trying to hide something. I think that’s true for many Washington news stories, but I think it was coincidence in meaningful use’s case.

Even worse than a Friday is the Friday before HIMSS. Talk about ruining the weekend before HIMSS. Although, if I remember right one time they announced the rule in the middle of HIMSS. I remember meeting with a number of EHR vendor’s government relations people who were grumbling about the late night reading of the meaningful use rule that they’d be consuming all night in the middle of the craziness of HIMSS.

Hopefully CMS has learned from past experience and has planned properly to be able to announce the meaningful use stage 3 rule well before HIMSS. Doing so will give people time to look over the rule so they can have a meaningful discussion of the rule at HIMSS as opposed to some frenetic review of what’s been proposed.

Either way, I’m very interested to see what meaningful use stage 3 will look like. My prediction is that it won’t be dramatically different from stage 2. It will be more of the same with maybe 1-2 additions. It’s too bad, because I’d still love to see them blow up meaningful use. Every doctor I know would love to see that as well. Instead I think we’ll be saying “more of the same.”

Small Meaningful Use Penalties for Small Practices

Posted on February 17, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Michelle has posted an interesting CMS analysis of the price of EHR penalties for physicians:

CMS reports that the majority of physicians who will be penalized this year for not having met MU requirements will lose less than $1,000 of their Medicare reimbursement; 34% of the penalties will be $250 or less, while 31% will exceed $2,000.

The adjustments will impact approximately 257,000 eligible providers. While no one likes losing money, the CMS penalty “stick” is pretty small compared to the overall cost of implementing an EHR.

Unfortunately her link to the CMS report seemed to be the wrong link. I’d love to dig into the 31% of doctors who will exceed $2000 in penalties. $2000 still isn’t very compelling to most doctors I know, but if it scales from there we could see how many doctors are really going to suffer from the EHR penalties.

What’s also not clear to me is if this includes the PQRS penalties as well. All of the penalties start to add up. I also heard one doctor talk about the feared 22% Medicare cut that’s been delayed for a decade or so (I lose track of the number of years). I’ll be surprised if those cuts aren’t delayed again, but it’s interesting that many doctors fear these cuts even if they’re likely to be delayed. Perception is still very important.

Back to the meaningful use penalties, $1000 penalty is not something most doctors will bat an eye at. Even those who have an EHR are opting out of meaningful use stage 2. The math doesn’t work out for small practices. $1000 of penalties certainly won’t balance the equation either. I expect a very small number of small practices to do meaningful use stage 2. Hospitals on the other hand are a different story.

Athenahealth Goes After Hospitals and Tavenner Steps Down

Posted on January 22, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

There were two big pieces of news this week that I thought I’d discuss. Hopefully you’ll also add your thoughts and insights in the comments.

1. Athenahealth Moves Into Hospital Market With Acquisition Of Atlanta Startup RazorInsights
I thought the announcement of this acquisition was really interesting. Literally the day before this came out, someone asked me what I thought of Athenahealth. After some discussion, they said do you think they’ll take on Epic and Cerner. I quickly responded, “Well, they don’t have an inpatient EHR, so they don’t have a dog in the fight.” Well, now they do have a dog in the fight. Of course, RazorInsights still isn’t a big competitor of Epic and Cerner. However, if I know Jonathan Bush, that’s the ambition. At least that’s what his numerous cloud rants lead you to believe that he thinks he can take down Epic and Cerner with one single word: Cloud. We’ll see what RazorInsights can do under the Athenahealth umbrella.

2. CMS Leader Marilyn Tavenner Steps Down
Neil Versel has a great article covering Tavenner’s departure. His comments are pretty interesting when it comes to her staying low-profile and away from the media during her tenure at CMS. She’s certainly taken a lot of heat from the botched rollout of Healthcare.gov and other programs.

Personally, I’ll most remember her for her promise at HIMSS 2014 that ICD-10 was going to happen and that healthcare organizations better be ready. Of course, we know how that story played out with Congress passing a few lines in the SGR bill to delay ICD-10 another year. Given Tavenner’s promise, I’m quite sure she was blind sided by Congress’ move as well.

I’m not sure her departure is a good or a bad thing for healthcare. I’m sure that the healthcare behemoth will move along like it always has. Best of luck to her wherever she lands. No doubt working in the government in a high profile position is a rather thankless job that usually pays below market wages.

Who do you think will take Tavenner’s position at CMS? Does it matter?

Looking Back at 2014: Thermidor for Health Care Reform?

Posted on December 29, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

As money drains out of health care reform, there are indications that the impetus for change is receding as well. Yet some bright spots in health IT remain, so it’s not yet time to announce a Thermidor–the moment when a revolution is reversed and its leaders put to the guillotine. Let’s look back a bit at what went right and wrong in 2014.
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