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Low-Fat Stimulus

March 27, 2009
by aguerra
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2 percent? It sounds more like a type of milk than a description of how many hospitals in the Unites States have a “comprehensive” electronic environment. But there it is, right in a report from such reputable institutions as the Harvard School of Public Health, Massachusetts General Hospital and the George Washington University.

2 percent … actually 1.5 to be exact.

I don’t know about you, but it makes me a little depressed, like we’ve been talking to each other all this time, cheering each other’s successes while most of the healthcare community glances over from time to time saying something like, “Yeah. CPOE, sure, right.”

The 1.5 percent figure also puts the government’s attempt to spur wider HIT adoption into a new light. You see, the timelines on HITECH are so tight that had those figures been 40 percent instead of 1.5 percent, we still would be in rough shape. But since we’re at 1.5 percent, and with incentives set to kick in for “meaningful use” around October 2010, what’s about to happen isn’t a flowering of HIT across the country, but a “Gold Star” payment sent out to the 1.5 percent (probably including you) that have already created the environment which HITECH is trying to incentivize. Is that what the government intended?

I recently spoke to one very advanced CIO who said the payments will allow her to ‘do more,’ go the extra mile in terms of community integration, and essentially put the icing on the HIT cake. I suspect, however, that she, and other CIOs in her position, would have done those things anyway, without taxpayer dollars.

The Gold Star payments won’t do much to help the poorer segment of that 98.5 percent remainder implement healthcare IT. Those institutions probably don’t have the funding to implement these systems without up-front assistance (HITECH money comes after, not only implementation, but meaningful use), not to mention the fact that they also probably lack the IT staffing, physician influence and project management capabilities needed to pull off a full-boat core clinical transformation.

The HITECH program is like promising shelter to a homeless person after he gets a job.

And, not to drop a news flash on Washington, but this isn’t the greatest climate for scaring up capital dollars. Bond issues aren’t exactly being snapped up, more unemployed workers means more insurance-less folks in the ER (we know who picks up that tab) and, oh yes, taking away the tax-deducible status of charitable donations probably won’t do much to spur philanthropic activity.

Consider this: not only does the new regulatory climate not help the less fortunate hospitals with funding and resources up front, but, starting in 2014/2015, they begin to see their CMS reimbursements decline as a penalty. Thus, rather than all boats rising, we could be looking at a situation in which the rich get richer and the poor get poorer.

The silent majority, which lives in the middle of those extremes, will experience HIT’s version of the 1850’s California Gold Rush, as hospitals that don’t want to miss out on the largess which starts flowing in late 2010/early 2011 staff-up, vendor-up, consultant-up and lawyer-up. The problem with such a rush, much like a hedge fund indiscreetly buying a massive block of stock, is that it moves the market. Prices for the aforementioned goods and services will certainly go up, as everyone tries to qualify for every dime that’s coming to them – we never know, of course, when the next Gold Rush will happen.

Ironically, what I think we can infer from the study is that the problem for all but the poorest hospitals is not the money. The money, as I have written before, is a great excuse not to implement HIT when you know you don’t have the slightest chance of pulling it off, when you know your three tech geeks spend half the day on Star Trek fan sites and the head of cardiology can’t clear his own cache (or return your call, apparently). Look at these figures from the study, then read the statement:

“The most commonly cited barriers to adoption among hospitals without EHR were:

· inadequate capital for purchase (73%)

· concerns about maintenance costs (44%)

· resistance from physicians (36%)

· unclear return on investment (32%)

· lack of staff with adequate IT expertise (30%)

Hospitals with EHR cited physician resistance as a major barrier, but were less likely to cite the other four as major barriers.”

I absolutely believe that the main reasons for low adoption rates are the two I’ve bolded above. Review the last quote again in light of the above statistics. What it tells me is that those who have actually implemented an EMR (meaning the funding has been secured somehow) know that the most difficult part of the process is dealing with the doctors – so the current plan of reimbursement on the back end not only doesn’t address the lack of capital, but does nothing to assist these facilities in learning how to get doctors on board.





"Adopt a unit", "Executive Walk Rounds", and similar commitments are invaluable.  Johns Hopkins has been a leader in the IHI for this practice and related ones.

The vast majority of physicians these days readily use computer applications that work, when they've been properly rolled out in their organizations.

In my experience, the "resistance from physicians" (RFPs) is all-too-often legitimate resistance (objections.)

As you know, I am member of and participate in the AMDIS (Association of Medical Directors of Information Systems) organization and its events.  From that and their discussions of best practices in implementation, I know that, across many vendors, there's little or no attention to the aggregate impact EHR's have on productivity, as a total solution to paperless. That's a significant contributor to the 2% adoption problem. You (Vince, Frank Pogio, and others, in another post) point out that a large volume of build work is simply required to make these systems adequately usable.

There are often design issues or trade-offs.  Good systems can be implemented poorly and basic systems can be used very effectively.

All-too-often, when I investigate RFPs first hand, or talk to CMIO who have done the same, RFP is actually something different from bad attitude. It's things like inadequate attention to having enough devices available, response time, rare-but-painful crashes, or lost work. Things that would make anyone, not just physicians resistant.

It's workflows that make translating a simple request into 5 clicks each, 10 second required waiting between those clicks, and for a workflows that needs to be repeated 20 or more times a day.

Physician's 'resist' new EHRs after they haven't been able to do some intended action. (They're users, like the rest of us, so training and intuitive design only go so far.)

Doctors love "simple tools that work." Making those tools 'simple' can be anything but.

I would refer readers interested in this topic to my Homework First article, as well as my Butler Model post for some practical recommendations, as well as a novel design model.  Never take RFPs at face value.

Thanks Joe. You make an excellent point, which is that physicians can't just be made the scapegoats on this, it's not that simple. Your "Homework First" article is an excellent start for people wanting to understand just how complicated rolling out a core clinical system is.

I remember at the last CHIME conference I was speaking to a CIO who said he was having major trouble rolling out EMR/CPOE. I asked him if he got physician buy-in on the particular system before he signed the contract. No, he said ... talk about the importance of homework first!