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The Calm Before the Storm

May 8, 2009
by aguerra
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It’s been an eerily quiet week on the healthcare IT front. While we usually publish four news items a day, a few days found us with nothing significant to write up. I honestly can’t remember such a lack of noteworthy happenings since the week of Christmas/New Year's, more than four months ago.

I think we’re waiting for the other shoe to drop.


That shoe, of course, is the first iteration of “meaningful use,” which should come out of David Blumenthal, M.D.’s (and John Glaser’s, for a time) Office of the National Coordinator for Health Information Technology. An office, we all know, under HHS and its newly sworn-in chief Kathleen Sibelius. Blumenthal and Glaser have no shortage of input to consider when writing up the requirements, though it might have been gracious to issue those statements as comments after the definition had been put forth, as is the normal protocol.

Meaningful Use Definitions (with release date)

CHIME (May 1)

Markle Foundation (April 30)

AHIMA (April 29)

NCVHS Holds Hearing to Define Meaningful Use (April 28 & 29)

HIMSS (Acute, Ambulatory) April 27

But, of course, patience has no place when interests jockey for power and influence. Thus, HIMSS jumped the starting gun first, upstaging even Blumenthal’s NCVHS hearing by injecting its input the night before that meeting convened. That organization’s focus was, of course, on ensuring CCHIT-certified products took their rightful place. HIMSS is a vendor-supported organization, and the fact that it looks to further the interests of its largest members is nothing to howl about.

CCHIT, of course, continues to advocate for the fact that certification is absolutely necessary. Even if you aren’t swayed when conspiracy theorists declaim a nefarious HIMSS/CCHIT connection, it is difficult to argue against the fact that CCHIT’s input on the value of certification is of dubious value. I am not familiar with many organizations that espouse their own demise. Today, the organization is on the verge of either becoming uber-powerful or marginalized. It will either hold something akin to a medieval imprimatur or watered-down stamp of approval.

But voices are rising against CCHIT assuming a kingly role. I’ve heard many, many comments that CCHIT should not be the sole all-powerful body which impacts healthcare IT vendors, or be such an expensive body (in terms of certification fees) at that. Many see such control as inevitably stifling innovation and being too mined with potential for influence peddling. CCHIT, to be fair, is saying the right things about being flexible enough to accommodate new, untested products and having an avenue for open-source technologies to qualify for its blessing.

But the fact that one organization — saying or not saying, doing or not doing the right things — will be able to make or break a private business is disturbing to me.


The fact that a private practice or hospital cannot evaluate the market without an uninvited chaperone is a problem, especially in the inpatient market where CIOs bristle at such oversight.

But, you say, of course freedom still reigns. Physicians and CIOs can buy whatever they want. Yes, that would only be the case if CCHIT’s stamp of approval isn’t required to show meaningful use, thus eligibility for HITECH monies. Market forces rule everything, so it’s a simple fact that if CCHIT certification is a requirement to qualify for government cash, those without it will wither and die. Those vendors that fail to meet CCHIT approval (and spend the money to do so) won’t make the hospital’s or physician’s long list, let along short list.

But how can we guarantee interoperability if all vendors aren’t on the same “technical specification” page, you ask? The government can, and will, require that certain “activities” be carried out to demonstrate meaningful use, such as exchange of information between entities. Why not allow those in the field to determine if a product will help them achieve those standards. (If someone wants to write interface, why not let them?)

At this point, there is simply too tenuous a link between EMRs and improved care — let alone improved financial outcomes for physicians and hospitals — for government to force these technologies into private organizations. Everyone wants better coordinated care and the better outcomes that we know will follow. Simple fixes have already been identified like Peter Provonost’s checklists, and making sure clinicians constantly gown, glove and wash their hands.

The big, massive, giant elephant in the room, however, is the disconnect between the healthcare system we want and the current reimbursement model we have.


Essentially we are putting technology and reimbursement at odds, rather than ensuring they harmonize. EMRs undoubtedly, at least initially, have a negative effect on physician revenue (both in terms of upfront costs for software and implementation, and an attendant slowdown in patient throughput).

Perhaps a better sequence would be to figure out the goals, alter reimbursement to incentivize for them, disseminate best practices in workflow redesign, mentor physicians and hospital administrators on the finer points of change management, and then figure out where and how IT can be introduced into the new paradigm. That introduction of IT, to be clear, should only be done when automation adds more than it subtracts from the interaction being addressed.

I fear, more and more, we’re putting the cart before the horse, that we haven’t done what Joe Bormel, M.D., called ‘Homework First.’ Frank Poggio recently wrote an article that stipulated organizations would do better to watch and wait, perhaps even forgo the incentives, rather than do something that does not make long-term sense for their organization and doesn’t have a good chance of success. Such advice sounds more sagacious every day as we wait for the other shoe to drop. The expressions I keep coming back to are telling: ‘Set the bar low,’ and, ‘First, do no harm.’


Related Posts:

Adrift in PolicyLand

HITECH Deadlines Slipping Away?

HITECH Goal Number 1: Do No Harm

Death of the Solo Practice

Best HITECH Strategy? Rush In or Watch & Wait

Guerra on HITECH: Take a Listen (Podcast)

Low-Fat Stimulus



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