Far From Shovel-Ready

November 9, 2009
9 Comments

Legislation that took weeks to write will wreak havoc for years.

Though some Cliniticos (clinicians turned politicos) increasingly refer to HITECH as a “brilliant” piece of legislation, it’s clear the impending market damage is only now coming into focus.

My unpalatable HITECH morsel of the moment centers, generally, around the lack of healthcare IT workforce necessary to make the legislation’s goals a reality and, more specifically, the bizarre market dynamics that will be precipitated by the half-baked Regional Extension Center (REC) farce.

Let’s do what Congress and the lobbyists didn’t — think this through logically. HITECH calls for the industry to work towards a goal at the same time it is defining that goal (meaningful use). I have been told, “That’s the way life works,” by some, but I just can’t figure out what that means. Any project manager worth his salt will tell you it’s critical to have a vision of the end point when designing a strategy. I’ve spoken to a number of people who say that, rather than spurring the market, HITECH has put much activity on hold. People, it seems, do want the clarity some say they shouldn’t require.

At least HITECH took care of the financing issue around EMRs, though it offered no money upfront to support purchases. Many say this is the most “brilliant” part of the legislation, not merely paying for a system, but rather its meaningful use. OK, maybe brilliant is a bridge too far (we didn’t split the atom here), but that’s a sensible plan to make sure tax monies are well spent.

But maybe it didn’t solve the funding issue after all, as cash-strapped providers that scrape together the purchase price often have nothing left for critical consulting help needed to select the right system, negotiate a contract and redesign workflow.

While the government could have solved that by providing some upfront funding for providers to hire existing consultancies, it chose instead to mandate the creation of 70 RECs. These organizations will receive taxpayer funding, averaging $8.5 million, but can charge providers whatever they want. Thus, there’s no guarantee they’ll be a more cost-effective solution to what’s currently offered on the market. These organizations only have to come up with a 10 percent match on operating costs and can pump whatever “profits” they make back into the organization (see salaries, T&Es, etc.).

As if the proposal wasn’t bad enough, the mandate for these organizations borders on the ridiculous. RECs are supposed to help approximately 1,000 primary care providers become meaningful users of certified EHR technology within 24 months of receiving their first financial infusion. Running the numbers shows that each center would have to make a meaningful user out of more than 40 practices per month, many of which are not even on an EHR today. With the scope of their mandate including system evaluation, selection and on-the ground technical assistance, it’s unclear how success is possible.

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Excellent commentary! You illustrate a number of the weak points in the legislation. I'd say you have mapped out a number of the hot spots.

You say DEbacle, I say DebAcle, lets call the whole thing off!

Ooops, it doesn't look like we can do that.

So how far will we get? I don't think it will be as bad as you say for overall industry progress, but I know bunches of IT people who'd join in the fun for a fantasy salary and give it a good try.
They are smart people and they might just improve on an old rusty process even if they have to spoon feed 2k bps modem bits into the payer's receptacles.

Face it. Current industry tech (especially govt) is so utterly in the 70s and 80s that anything (even throwing gobs of inefficient money) has to be better than letting the industry evolve on it's own.

Sure there might be some sore problems, but better that than letting healthcare and insurance transactions keep to the pitiful morass of idiocy we have now.

How about you do another post and focus it on the father of a child who can't get the doctor and the lab results into the same room for a personal visit? How about doctors who don't like getting electronic records because they are afraid of liabilities for missing something important? Let's not talk about an electronic virtual meeting over smart phones that's just too much to ask for.

I'm personally ashamed of the way doctors exchange money, treatment, get records, send records, send bills, and get paid.

We need all of this to work tons better to truly improve hundreds of millions of lives.

Now, pick yourself up off the field, rub some gravel on where it hurts, and get back in there and play ball!

thanks for ALL your comments and kind words. I'd like to take up the thread of Bill Hersh, who wrote:

"so many academic institutions are throwing together programs to jump on this bandwagon. While we need more programs, I am not convinced that just throwing together an amalgamation of healthcare, IT, and HIM courses, without a coherent view of what competencies these individuals need, is the answer."

I absolutely agree with you Bill. I think there will be a number of shoddy HIT program thrown together that produce students who are not able to perform the duties their diplomas would indicate. Just like anything else, students need to do their homework on a program before forking over money, and employers need to understand that all HIT diplomas are not created equal.

Unfortunately, there will be such a rush to hire that merely being able to articulate a few keywords during an interview could suffice. Buyer beware on all counts.

Anthony,

I agree with your analysis of the problem. We have paid too little attention to the issue of who will lead the implementation and optimization of these systems.

The good news, however, is that there are opportunities for individuals to gain those knowledge and skills. Academic programs in clinical informatics give people the key understanding at the intersection of healthcare, IT, and business/management. Many of them are tailored for short-term training that is convenient and on-line, such as the Graduate Certificate program at Oregon Health & Science University:
http://www.ohsu.edu/ohsuedu/academic/som/dmice/

One concern I have is that so many academic institutions are throwing together programs to jump on this bandwagon. While we need more programs, I am not convinced that just throwing together an amalgamation of healthcare, IT, and HIM courses, without a coherent view of what competencies these individuals need, is the answer.

I also have concerns about the level of training required. While our community colleges have historically stepped up to the plate in our communities to impart needed skills, many of the competencies might be more appropriately taught at the graduate level to people already having strong backgrounds and some experience. Teaching at the graduate level now also will enable these people to expand their credentials further down the road (e.g., through master's degrees).

I have a blog myself devoted to these issues and have address these issues, e.g.:
http://informaticsprofessor.blogspot.com/2009/10/what-level-of-training-...

I look forward to further dialogue about this.

(Sorry to reply in multiple places, but you posted in multiple places!)

William Hersh, MD
Professor and Chair
Department of Medical Informatics & Clinical Epidemiology
Oregon Health & Science University
www.billhersh.info

Frank/Pam, Thanks for clarifying things. I've been such a fool! :) I need to get on the HITECH bandwagon. Wait, there's no room.

Great post Anthony and once again - spot on. There are NO short term solutions to the HCIT talent shortage and serious compromises on skill set and a (much) longer learning curve will have to be made. I still remember being hired for my first full-time HCIT job. I was like a deer in headlights on the first day. The CEO had me spend 4 weeks in a CBO listening to support calls, entering data, processing patient statements and HCFA 1500's while attending meetings that could have easily been in German or French and it would not have mattered. However, at the end of 90 - 120 days I was starting to "get it". I think some sort of OTJ training plan has a lot of merit once one has some basic training. He used to tell me "jump in - the water is fine". He was right.

When someone figures out the right HCIT training model - they will do very well. And, someone will figure this training issue out. I hope it's soon! Gwen and I will be waiting...

Great analysis, Anthony. Indeed, the workforce is not ready for a mass EHR implementation - especially in smaller practices that lack in-house tech resources, robust computer and wireless networks and savvy project managers.

In my opinion, the larger question is whether or not existing EHR products, with their well-documented spotty track records of success, are "shovel-ready" and usable on a mass scale by busy ambulatory physicians.

-Evan Steele, CEO SRSsoft

Reality, reality, reality....Anthony you've hit it right on the head. The staggering need for qualified resources is a concern for many CIOs we work with. Part of the challenge, however, is that their budgets are scrutinized and FTE addition discouraged. Most are lucky to get extra funding for the resources recommended by their vendor - which typically leaves out process redesign, informatics, education, back-fill, quality metric development, etc and many other activites that will have to occur to meet the MU requirements.

Great Article Anthony,

Is there any chance that you have reached out to your representative and/or senators? I believe that your concerns are valid and serious, but as long as we bandy them back and forth between us, they have little effect on the actual policy debate. I would think that your position as editor-in-chief of Healthcare Informatics might even give you the opportunity to interview some of the politicians and cliniticos and to ask these questions directly. Take a page from the Tim Russert playbook, give them the rope and then make them sweat over hanging themselves or addressing the real issue.

My experience with the cliniticos is that for all of their brilliance, they are eye-deep in saccharin, having no real power and serving at the pleasure of the politicians, all they seem to do is back-slap, congratulate and praise whatever comes off the floor or out of committee. This is politics at its worst, a classic group-think scenario with all of the attendant dangers.

Anthony, I challenge you to be the contrarian, the lone voice in the wilderness! I hope that your words of warning, unlike Cassandra's, will be heeded.

Oh Anthony!
You need to be more positive...the glass is half full, stop being so damn realistic. Here try this.

IT IS SHOVEL READY. ARRA is a big, very BIG pile of 'crap' waiting for some big vendor steam shovels to cart it all to the bank.
See...now you got lemonade!