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The (Certified) Vendor Recovery & Reinvestment Act

May 21, 2009
by aguerra
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HITECH has never made sense to me, not from the moment I understood there would be no upfront money to help providers afford the systems being foisted upon them, especially not from the moment I saw the ridiculous deadlines involved. Later, as people came to understand that only CCHIT-certified systems might qualify for incentives payments, the act became even more disconcerting.

As I worked through questions, the answers left me perplexed.

Q: “You mean providers, many already on the financial razor’s edge, get no money up front to buy these systems?”

A: “Not really.”

Q: “You mean they only have until the end of 2010 to prove meaningful use of systems they may not even own today?”

A: “Yes.”

Q: “You mean they won’t even know for sure what constitutes meaningful use until the end of 2009?”

A: “Yes.”

Q: “You mean that studies are showing HIT adoption is incredibly low in all but a sliver of the nation’s hospitals and physician practice?”

A: “Yes.”

Q: “You mean it looks like only CCHIT-certified systems will qualify for incentive money?”

A: “Yes”

Q: “But what about hospitals and physicians that have invested in something not certified? What about vendors not getting clients onto a certified version of their software by the deadline?”

A: “I guess they’re SOL.”

Q: “What about the almost undisputed fact that these systems slow doctors down, show them so many alerts they ignore them all, and generally irritate them with their user un-friendliness?”

A: “Not sure.”

Q: “Well, who wrote this awful legislation?”

Apparently HIMSS did. And now it all makes sense.

This legislation has never been about the safe and appropriate use of healthcare IT to assist in, and improve, the delivery of care. That’s because, if such was the intention, there is no chance in the world the legislation would have been written as it is.

I have absolutely no doubt that if you asked the top 100 healthcare IT implementation professionals to write a national plan, not one of them would have come up with anything slightly resembling HITECH. As the pages of HITECH evolve into practice, what’s been done so far verges on the comical. I’ve listened to the first meetings of the Policy and Standards Committees and to the NCVHS sessions where policy wonks waxed on about the potential of healthcare IT, and I couldn’t tell you who is doing what, when and how. I can’t tell you how Kathleen Sibelius, David Brailer, John Glaser, the Policy Committee, the Standards Committee, NIST, NCVHS, HITSP, CCHIT and whoever else will actually come up with any plan that doesn’t leave a large majority of small hospitals and practices scrambling to find money and resources that don’t exist. To be honest, I don’t know how that many individuals and organizations come up with any coherent plan at all.

While project-management professionals would never have come up with HITECH, big vendors certainly would have.

Q: “But if the big vendors wrote the legislation, wouldn’t they have asked for the money up front so they could get paid?”

A: “Maybe. But which version of legislation do you think would be an easier sell on Capitol Hill. And who really cares where providers find the money? They beauty is … they’ll have to!”

HITECH is inevitably going to turn all the major vendors into something Epic has worked over 20 years to become: order takers. Gone are the days of hospitals issuing RFPs, then putting vendors through their paces to earn the business. AH (After HITECH), hospitals will be lucky to get their phone calls returned, as vendors will have more business than they can handle. BH, there were plenty of implementation failures already, many due to the vendors, many also due to the hospitals that failed to commit sufficient resources or lay the groundwork. Epic, you see, is one company that understood it’s better to walk away from a deal that lacked sufficient commitment from the other side than preside over a failed implementation and the attendant bad press which would follow.

AH, vendors will be stretched even thinner as they try and lap up all the business puddles across the country. But an implementation that is poorly staffed on the vendor side, combined with clients that are only doing the implementation because they are required by law will see failure rates skyrocket. The vendors may have gotten what they wanted, but may not want (or be able to handle) what they get.

Q: “But what about all the practices and organizations that have implemented HIT successfully?”

A: “Organizations that have successfully implemented HIT, obviously, had leaders that drove the change, found the resources, and did it on their own timeline. With HITECH, none of those things will be put into place, yet we expect the same outcomes.”




Thanks for both your thoughtful comments.

First, I want to make clear that I am not vilifying vendors. I am merely pointing out (as the Washington Post made clear) that vendors drove this legislation, and I think the legislation clearly reflects that. Vendors are in business to make money. I love the free market, and I love competition, so there's no problem there. But our legislators should have done a better job of bringing in healthcare IT professionals who could give them an understanding of both where hospitals and practices are on the front line today and how fast it is possible (and what is required) to move them to any future state.

Similarly, when I write that physicians have a disdain for products and processes that slow them down and negatively affect their quality of life/revenue, I am not vilifying them, merely pointing out that, just like anyone else, they don't like it.

As you say, Joe, I am interested in better healthcare, I am very pro IT, but only when it is done right. As well as anyone, you've pointed out how seriously organizations must take these implementations, and how much effort is required, if they are to be carried out successfully. I do not think HITECH puts us in the best position to yield those positive outcomes.

PS (from HISTalk today):

Cerner says ARRA could boost its revenue up to $600 million a year, a 33% increase.

You have certainly made some strong and thought provoking statements. I have to admit that since our organization has been very perspicacious in implementing an electronic health record, I have had a perhaps skewed view of this issue.
That being said, I am still more optimistic than you seem to be, but cautiously so. There are some very good and smart people working within this process (alongside the political hacks -) and I remain hopeful...

Yes Joe that is a bridge too far :)

I have to agree with Dr. Bormel's assertion that infrastructure is the key for any meaningful exchange or sharing of information.

Could we ever really consider a single health IT platform? The high cost alone would prevent this from happening, let alone the M&A and competitive pressures against it. To this end, an infrastructure much like what is built to support community exchanges is also required for hospitals to connect and share with ambulatory facilities.

This foundation will require patient identification from a patient registry, an integration engine or service oriented architecture to enable the actual communication between systems and a portal or EMR that can view the relevant information about the patient while still supporting privacy and security.

Many organizations are close to sharing information and with some investment in some infrastructure technology, could enable meaningful use and information sharing to begin to qualify for the incentives from ARRA.

P. Schlyer
Initiate Systems

I appreciate you extending the 'non-vilification' clause to physicians, as well as vendors. We should add in Certification as something to not vilify. The extent and roll-out is reasonable to question. While I have the stage, I'd like to add "evaluation" as a christmas present as well, at least on the road map to FY2015!

On the positive side, I think we can hopefully agree that the ARRA legislation was wisely crafted to incent providers directly, and, try to help them with the details. (We can also agree that, from a timing perspective, you're right, that's not going well.)

Apparently, it's too much to ask you to "thank the vendors" for driving societal resources toward EMRs?  :)  [How do I put a smiley face in one of these comments?]

Thanks for writing this. You've highlighted the concerns that I'm hearing at lunch and dinner tables across the country.

I share Brian's spirit of optimism, and I appreciate that you are also a very positive, progress-oriented guy. I think we can all agree that ARRA-HITECH has shed a lot of light on a promising vision. I think the best, reductive words for that vision should be "Perfect Care."

If forced to elaborate or defend that, I'd use IOM's language, i.e. Safe, Timely, Transparent, Efficient, Effective, Equitable, and Patient-Centered Care. There's no question that technology enablement is necessary to get there; no question that it's complicated; and no question that healthcare has historically under-invested in this technology.

For completeness, it's important to state at the outset, as everyone reading this knows, lack of technology investment is less than 20% of the problem. Probably about five percent. The other 95%, in order of priority are People/Behavior/Incentives, followed by process redesign, and skill development.

Perfect Care, combined with payment/coverage reform could meet our societal goals of improving basic coverage and bring government healthcare spending down.

I do need to address the vilification of vendors issue. For one thing, that's where I work. But more importantly, vendors are responding to the same larger system forces that impact companies are in other industries.

Over the last thirty years, the US has systematically moved healthcare to operate more and more in a market-driven manner, despite the facts that there are important difference. (See J.D. Kleinke's first chapter of Bleeding Edge for a succinct, humorous elaboration of those facts.  In short, market forces aren't at work, and the health care system isn't a system.)

You brought up Sam's humorous portrayal of the usability challenge. Vendor systems as a whole are not significantly better or worse than non-vendor created/maintained HIS systems (See Ash/Burns conference materials on CDDS in HIS- vendor and non-vendor systems are indistinguishable, for good and bad.)

As I shared in my NCVHS testmony, almost exactly 10 years ago by the way (, the way forward is simple. And it is infrastructure, before magical leaps to nirvana.

Being able to share, pardon my language but 'semantically interoperable,' basic information, i.e. problems, allergies, medications, and vitals, electronically and reliably, needs to be the first step. If that was the only focus for 2011, certification would be simpler and more effective, and our 20-40 billion dollars would be put to good use.

Although a gross simplification, it's a matter of simple observation that we aren't recording and exchanging that basic information today.

If the vendors did, as you suggest, create a bit of a burning platform, perhaps they did the industry a service. Arsonists or reforming leaders? I wish it was that simple; perhaps it was a bit of both!