Many hospitals seeking to obtain federal stimulus funding under the ARRA-HITECH legislation passed by Congress in February will be faced with a major dilemma.
On the one hand, the federal government has provided funding that truly is stimulating hospitals (as well as physicians and physician groups) to implement clinical information systems. Chief among these are CPOE, physician and nurse documentation, medication reconciliation, clinical decision support, performance measurement, and health information exchange. On the other hand, because the number of hospital organizations that have implemented any of these technologies remains a small minority, the number of individuals with expertise, particularly in the rubber-meets-the-road area of actual implementation, is very small.
The question is, could this potential demand for IT professionals with experience create a stampede of need? As organizations that have not already implemented CPOE and other core technologies move to do so in the coming months, what will happen? Are CIOs in danger of having some of their best and brightest IT professionals “poached” by consulting firms and vendors?
John Glaser, Ph.D., senior vice president and CIO of Partners HealthCare in Boston, predicts an industry-wide shortage of truly qualified implementers and has a warning for healthcare organizations that are ahead of the curve: “The organizations that have implemented CPOE or outpatient EHR could indeed be very vulnerable to poaching.” History, says Glaser, may repeat. “I remember at the turn of the millennium where, if you were a Web developer, you were the cat's pajamas.” The same was true, he says, when those who had experience with PeopleSoft were in demand.
And although Glaser says he personally isn't worried about losing many Partners IT professionals, others are.
“The potential for poaching is very much a concern here,” says Paul Conocenti, senior vice president, vice dean and CIO of 1,000-bed New York University Langone Medical Center in Manhattan. Like Glaser, Conocenti and other CIOs whose organizations have long been live with CPOE have a great deal of advice with regard to human resources issues (see sidebar, p. 40).
Conocenti says he has made certain his organization's pay scales are geographically appropriate. In addition, as NYU moves beyond CPOE implementation (the initial version of which was created nearly 30 years ago), Conocenti has worked to insure his staff is involved and enthused.
The numbers game
A look at the numbers, widely debated as they might be, offers a bit of perspective. Using its EMR Adoption Model, Chicago's HIMSS Analytics recently estimated the percentage of hospitals that have reached stage four of its seven-stage schematic (which means CPOE and clinical protocols) at only 3.6 percent nationwide. HIMSS says those that have reached stage six (and have implemented both closed-loop medication administration and physician documentation) are even fewer, at 1.0 percent. More generously, in April, Orem, Utah-based KLAS Enterprises estimated that 12.5 percent of U.S. hospitals had implemented CPOE at that point. It also found that 265,000 physicians in private practice had done so.
Even if, extrapolating from KLAS' estimate, one doubles the figure to include hospitals that are currently moving towards full CPOE implementation, one would come up with an estimate of only one-quarter of hospitals nationwide that have had any meaningful experience at all with CPOE. But if one-half of acute-care hospitals end up applying for stimulus funding (and no one knows at this point how many will do so), the industry will face massive shortages of skilled IT professionals, particularly at the technical implementation level. And that scenario is further complicated by the fact that organizations which fail to meet the series of meaningful requirements will face penalties under Medicare after 2015.
Nonetheless, many vendors and consulting firm executives believe they have the situation well in hand. For example, Andy Vassallo, senior vice president in the Provider Consulting division at Dallas-based ACS, says, “We're anticipating a rise in demand, and we're working to meet it. We've got practices focusing on all the large vendors: McKesson, Epic, Cerner, Eclipsys.” Unlike boutique firms that specialize in one of the big vendors and may not be able to meet the demands of other projects, Vassallo says ACS has experience across the board. Its areas of competency, he says, include teaching customers about project management, Six Sigma, and internal methodology training, in addition to specific CPOE training.
So how are the ACS folks bulking up for CPOE specifically? “We're focusing on our retention of clinicians, mostly of nurses,” Vassallo says. “We're also beefing up our recruiting and sourcing capabilities,” which includes looking to hire both consultants at other firms and people working at hospitals.
Vendor executives are also confident they'll have the bench strength to handle surging demand. “We're presently about 60 to 70 percent staffed for the demand, as far as we can tell,” says Mauraan Schultz, director of CPT upgrades at Alpharetta, Ga.-based McKesson Corporation. “We've been pulling the reins in and making sure we're careful about what we're committing to, so as not cause all sorts of downstream problems.”
At the Malvern, Pa.-based Siemens Medical Solutions, Angela Nicholas, M.D., senior director in product management, says the company is actively hiring CPOE experts to fulfill the anticipated demand for stimulus-focused implementation help. Nicholas, a former community hospital CMIO, says the industry will have problems “staying staffed up.” She says as they are lured from one sector of the industry to another, some people will go back and forth between provider and vendor sides. So, in addition to actively hiring (including hiring from hospital organizations). Siemens is trying to simplify that work itself. “We've shortened and adjusted our methodology at Siemens,” she says. “We're in beta with the methodology, but we believe we'll cut the implementation down to somewhere around five months for CPOE, maybe even less.”
Kansas City, Mo.-based Cerner Corporation has adopted a similar approach in which Michael Valentine, executive vice president of Worldwide Client Organization, says he and his colleagues are creating a templated approach to CPOE implementation that should significantly shorten the typical rollout. “We do most of the build and design of our solution in a centralized fashion at our solutions center in Kansas City,” he says, “and we limit the impact on clients by essentially making it a process of three to five trips to Kansas City. We've been trying to accelerate the process for them.”
Inevitably, though, one of the keys to success in this area, including ensuring one has the right people in place, is to get started now, says Erica Drazen, partner in the Waltham, Mass.-based Emerging Practices Group of Falls Church, Va.-based CSC. “Many, many people are waiting for some final word before they get going; though I don't think the word is going to get any more final,” she says. Moving forward is vital, and Drazen says waiting will risk one's ability to engage top-tier consulting firms and vendor implementation specialists. And though it is possible to create “no-poaching” understandings with consulting firms and vendors, the complexity and fluidity of the situation tend to preclude rigid contract language.
Those who've implemented CPOE agree: it's resource-intensive. Tim Zoph, vice president and CIO of Chicago's 873-bed Northwestern Memorial Hospital, which has been enterprise-wide with CPOE since early 2007, says it won't be easy. “When you think that 2 or 3 percent of organizations nationwide have really done this, you realize that it's going to be harder to get to than people imagine. I know, having gone through it, how hard it will be for them.”
Jesse Long, CIO of Alamance Regional Medical Center (Burlington, N.C.), a 238-bed community hospital that rolled out CPOE in 1997, says, “Implementing CPOE requires a huge number of resources, human and otherwise. We did it with a range of disparate systems, which was a huge problem.” Lang urges his colleagues to line up all resources prior to any major IT implementations.
What about those CIOs who are now beginning to move forward on this path? Some have already identified particular strategies they'll use to make sure they've “got people” going forward. Jim Boyer, CIO at the 25-bed Rush Memorial Hospital in Rushville, Ind., says he's “absolutely confident” that his organization will be able to implement CPOE within the required timeframe to obtain stimulus funds. Boyer's hospital is already 98 percent electronic, with physician order sets built. He has identified a few early-adopter physicians and worked out an implementation schedule with his EMR vendor for CPOE rollout.
In addition to working things out in advance with vendors, Boyer says clinician involvement is also critical. “It's strategically key to keep the doctors constantly informed, while not exhausting them by forcing them to attend every meeting, and to get a physician champion who will move the others.” Boyer says implementation at smaller hospitals, such as his own, will be easier and faster.
Meanwhile, George Conklin, senior vice president and CIO of the Dallas-based Christus Health, a 22-hospital Catholic health system, is taking another tack. Conklin's system serves some of the poorest markets in the country, and its hospitals are primarily concentrated in the three states with the highest levels of uninsurance in the country (Texas, Louisiana, and New Mexico). For Christus, hiring significant numbers of consultants is out of the question. “We're doing this almost all internally,” he says, relying on consultants “only for very specific technical tasks like network configuration and wiring and cabling.” Still, Conklin believes his health system will achieve meaningful use on CPOE in all but one of the organization's nine regions. Part of his confidence, Conklin says, comes from having a rock-solid relationship with his EMR vendor.
In the end, many CIOs recognize that the road toward implementation of CPOE and the other key meaningful use-related technologies is a long and complex one. And whether they've already implemented CPOE or not, they say the journey will be an uphill climb. Geting started now, they urge, and keeping human resources considerations top of mind are key.