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Runnin' With the Big Dogs

May 18, 2009
by Mark Hagland
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On Saturday, the Washington Post published an extremely interesting “inside-baseball” look at the efforts of HIMSS and other healthcare IT organizations to influence health care policy legislation in Washington ( I was surprised by how well the article contexted our industry, for a mainstream media report, which quoted such healthcare IT leaders as Blackford Middleton, M.D., and HIMSS president H. Stephen Lieber.

The salient point, however, is that this Post article accurately delved into behind-the-scenes developments in healthcare IT legislative activity. I was wondering how long it would take the mainstream media to get interested in healthcare’s “inside baseball,” particularly of the IT variety. The fact is that, as the ARRA-HITECH stimulus funding moves towards disbursement, and as comprehensive healthcare reform and reimbursement legislation begins to move towards debate and possible passage, we in healthcare, including in healthcare IT, have to expect greater scrutiny of our industry, our leaders, and maybe even some of our less attractive industry “secrets,” just as has taken place with regard to countless other industries (i.e., the auto industry, the oil industry, the airline industry, and so on). Because when major money is involved, there’s no way to keep secrets hidden any longer. In other words, expect these kinds of “delving” to continue in the future, and indeed, to proliferate, as the mainstream media, policymakers, and consumers begin to take a far more detailed interest in what we do in healthcare and how we do it. And some of the stories won’t be pretty. But, as in other industries, they may just lead to needed internal reforms, or spur self-improvement long called for from within the industry.

So if we thought that everything we do was under scrutiny before, just wait—this Post article was only the beginning. Let’s just hope that future articles are as fair and balanced in their reporting; and that we in healthcare and healthcare IT are ready to stand in the limelight of prime time.



The Washington Post's article by Robert O'Harrow clearly hit a nerve when he exposed the origins of the EHR funding portion of the Economic Stimulus Bill—they received so many responses that they stopped accepting comments.

Industry insiders have long-recognized the inherent conflicts of interest summarized in the article, but have been reluctant to make them public.

It is important to understand that the situation is being perpetuated—the people now charged with developing the specific regulations regarding how the money is to be dispersed and the standards which will determine to whom it will be given are the very same stakeholders who were behind the legislation. One has only to listen to the recent "meaningful use" hearing in Washington and look at the appointments to the HIT Policy and Standards Committees for evidence.

First, to clarify the premise—it is not the entire industry that lobbied. It is the traditional EMR vendors who are positioning themselves to receive the benefits. Only the big, CCHIT companies have been invited to the table to be part of the conversation in any significant way other than through very limited opportunities for public comment. No vendors of alternative technologies, i.e., non-CCHIT-certified products, have been given any formal role, regardless of their successful adoption rates and greater physician satisfaction.

It is no wonder that CCHIT is the presumed set of standards which will be used to qualify EMR software for Stimulus Plan payments. The legislation was rushed through with such a short time-table for implementation that it is hard to dispute the conclusion that there is no time to develop new standards. The HIT Policy and Standards Committees are predisposed to CCHIT—the vendor community representatives on each committee are from large, CCHIT companies, and at least one committee member is a CCHIT commissioner. It does not seem to be of concern that these EMRs are the very ones that have experienced miserable adoption track records, (see Landmark EMR Studies), particularly among specialists, nor that evidence does not exist to show that CCHIT certification has improved this adoption record.

In an effort to push the implementation along, the interests of high-performance, private practice physicians are not represented in the process. There are no full-time, private-practicing physicians on the Standards Committee, who can appreciate first-hand the impact the wrong EMR can have on a provider. The seven physician members spend most, if not all, of their time in informatics-focused positions at their respective institutions. Furthermore, the needs of non-primary care physicians are being ignored. By virtue of its composition, the Committee will focus on primary care—of the physicians on the Committee, five are internal medicine-certified, one is a pathologist, and the vendor representative trained as a neurologist. For primary care physicians, CCHIT-type software may be more usable than it is for specialists.

In the era of transparency, it is important that all of these issues be understood and then addressed—before the enormous sums of money are dispersed with limited potential to achieve the desired outcomes.

Evan, I agree with you that all the issues involved in this do indeed need to be understood and addressed. And it is quite interesting to learn that there are no full-time practicing physicians on the standards committee at CCHIT. I certainly hope that imbalance can be rectified going forward. Thank you for your well-reasoned and detailed comment.

Very good points, Mark. I skimmed through the article at first, then decided it warranted another look. You are spot-on that healthcare IT is no longer going to be able to fly under the radar. I also hope the industry is ready because I believe the Post article is the first of much more exposure this topic will see.
I've noticed that friends and family who didn't know much about my industry in the past are now asking me more questions. It's health IT's time to shine, ready or not!

p.s. Love the use of "inside baseball!"

Kate and Joe,
Thank you both for your extremely thoughtful comments!
Kate, I love your phrase "fly under the radar"that is exactly what I was grasping towardsthe idea that healthcare/healthcare IT will no longer be able to escape intense scrutiny of the type all the other major U.S. industries regularly receive in the media. And you're very right that family members, friends, and acquaintances will be asking all of us more questions going forwardsurely a sign of accelerating interest in our field! And Joe, you're absolutely right that so often, mainstream media reporting on health care has gotten the context wrong, and sometimes even the facts. What is fascinating to me is the strong potential that newspapers, magazines and broadcast networks are going to more consistently put "first-string" reporters and journalists on the case, since the money and the ramp-up to legislative activity are putting healthcare and healthcare IT into a much brighter spotlight these days. The upside of that is that I'll predict a greater portion of the writing will be more accurate and better-contexted the downside is that it will become more relentless and probing.
And Joe, thanks also for the good example of the article on PCPs' incomes. So often, stories based on health care statistics are woefully poorly contexted. But, as we three all agree, the potential for a whole lot more page-one stories in the Post, the New York Times (one of the papers that has always covered health care in depth), and other media outlets, can only increase going forward. One hopeful way of looking at this is that those of us involved in writing for, blogging for, and participating in, industry publications like Healthcare Informatics have a very special role to play, as we are creating and reacting to the "inside baseball" stories that mainstream journalists will read as background for their articles and broadcast segments aimed at the lay audience. I've seen this happen time after time, and it's always a very interesting phenomenon. Sometimes, the mainstream journalists really do learn things from our reporting that help them craft better stories and segments (though sometimes, not as we all know, a little knowledge can be a dangerous thing!).
Finally, Kate, yes, I thought you might enjoy the "inside-baseball" phraseit's a sports-oriented metaphor that does seem to carry over well into other areas. :-)

I concur with your analysis and appreciate the link.

One of my big sources for insights is the last few pages of the WSJ A-section. Between the letters to the editor and the commentaries, I often get a perspective that I hadn't fully appreciated.

That said, there are often comments that are wrong. Wrong is a strong word but the right one. There is often inadequate context, such as the source of the "fact", including the ability to understand the context and date. This morning, for example, there was a citing regarding primary care providers income. Since I am trained as an internist, and read the internists' newspapers and magazines, I know this data reasonably well. If you dont use medians, stratify for geography, years in practice, and define the sample, etc, the information is no better than alphabet soup.

Similarly, there are often studies cited that look at the high end or low end of adoption and generalize. This always fails to be explicit about the size of investment and years to get the specified result. Critical aspects.

So, I concur with your praise of the Washington Post piece, as well as your caution about the mis-information campaigns ahead of us.