One CIO's Random Thoughts on Healthcare (Part 1 of 3) | [node:field-byline] | Healthcare Blogs Skip to content Skip to navigation

One CIO's Random Thoughts on Healthcare (Part 1 of 3)

October 2, 2009
by Neal Ganguly
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It’s the week after National HIT Week in Washington DC, and I’ve been trying to process and reconcile a lot of what I heard there and what I’ve been reading with the daily challenges of running a hospital IT shop.

The key themes from Washington were effective use of Stimulus dollars; reform of the healthcare system; and the meaningful use of technology to accomplish that reform. This brought a number of thoughts to my mind. I started to think about the drivers around ARRA and how the industry was reacting to it. I thought about the current delivery system and some of the things that were ‘broken’ from a CIO’s standpoint (at least my standpoint). Finally, I spent a lot of time trying to formulate a plan to deal with all of the above. I’ll split my thoughts into three documents to make it more readable (hopefully).

In this document let’s focus on the drivers.

Some of this is a rehash of prior discussions on stimulus, but the events in DC last week put them back in my head. My, perhaps simplistic, view of the world breaks the drivers down by constituency as follows:

  • Physicians: Primary Driver = Stimulus dollars; Secondary Driver = Easier access to data; Tertiary Driver = Better outcomes / continuity of care
  • Hospitals: Primary Driver = Stimulus dollars; Secondary Drivers = Strengthen physician relationships / Fear of reduced reimbursement; Tertiary Drivers = Better outcomes / continuity of care
  • Government: Primary Driver = Reduce costs by eliminating waste and redundancy; Secondary Driver = Better outcomes / continuity of care; Tertiary Driver = Better data to analyze and drive ongoing health reform.

Yes, you can debate these.

Yes, I put the money issues ahead of the outcomes.

Disagree if you like, but secretly you probably agree.

I know I left out long term care, home care, and other healthcare settings, but I need to start with a manageable model.

So, how are the above constituencies reacting to ARRA?

  • Government: The government put incentive money on the table for EMR software and tied it to ‘meaningful use’ of technology. They set dates around which to comply with meaningful use in order to collect the money. They realized that there were resource gaps and created the concept of extension centers to help promote the spread of HIT. They realized that sharing information would require a network and they made funds available for Health Information Exchanges (HIEs). This all sounds great in concept – but the issue is in the reality of timing.
  • Hospitals / Physicians: It can take 3-6 months to evaluate and select a system and then it takes 18-24 months to install a hospital clinical system. It takes 2-5 months to properly install a physician EMR. It can take 6-12 months or more to work out the kinks and become productive on such systems.

The talent pool to accomplish this work is spread thin. Hence the extension center concept. However, it can take 3-6 months to establish centers operationally (find space, recruit staff, establish curriculums, etc), and then 3-6 months to recruit and train people to a reasonable standard to make them minimally effective. So optimistically, it would be 6-12 months from inception before the first trained individuals emerge from those centers – and really, 12-24 months before they have some of the real life experience needed to be effective.

Once the hospitals and physicians install these EMRs, they need to be able to exchange data with others to be meaningful users. This leads us to the HIE focus. Over $500 million has been set aside in stimulus money to help promote this exchange on a state by state basis, with little prescription or direction for how each state should accomplish the exchange of health information. Averaging out to a little over $10 million per state, it is clearly not enough money to fully fund the multiple state HIE initiatives in my state (NJ), and leaves the question of what is truly needed to fund and maintain a nationwide HIE infrastructure unanswered.

Framing all of the above for the providers is the fact that incentive payments can begin in 2011. How many will be able to become meaningful users by then, or by 2013 when the definition is tightened further? The bottom line seems to be that incentive payments set out by ARRA will go to those providers who made the investments in advance of the availability of extension center resources, and a robust HIE infrastructure. It may be a relatively small pool of providers that qualifies for the maximum incentives. The rest will be working to avoid the penalties – which may be more significant to hospitals than to physicians.

Ultimately, the unanswered question in my mind is around timing. Could, or should, the timing of incentives been structured in such a way as to allow providers to benefit from the existence of extension centers and a more robust HIE environment?



Robert, I agree that healthcare leaders, and public policy leaders, need to drive the adoption of CPOE and EMRs as infrastructure. I worry that leaving the formation of HIEs to 'the marketplace' may not work, and will waste time and money. The dollars being devoted to HIEs and regional extension centers are good starting points, but the provider incentives are timed in such a way as to preclude providers from benefiting from the emergence of HIEs & RECs.

In my most optimistic moments I envision physicians embracing the EMR. Besides overcoming behavioral aspects of resistance the daunting hurdle will be in convincing docs that the effort of using the EMR will translate into better more efficient care. I am not sure that I can make that promise with today's state of available commercial products. Sure, there are notable exceptions and even success stories, but the reality is that we rarely process data into actionable decision support.
As in the present healthcare debate we have lost the vision of the real goal of an EMR which to me is improved outcomes. Good outcomes relate to cost savings. It seems that the legislators and patients are focused on the "quantity" of care and not the "quality." It is no wonder that developers too are missing the target. I am not confident that physicians will be lured in by cash incentives alone.

Thanks for the comment Jim. I am fearful that the those who are lured in by financial incentives may actually suffer through lower billings due to reduced productivity, if they don't embrace the needed culture change.

I think as time passes and more statistics show the value proposition of CPOE in terms of outcomes and efficiency and satisfaction for all stakeholders the adoption numbers will steadily rise. The push back and challenges from clinicians will also fade with time. I meet dozens of physicians who have been in practice over 30 years and they understand the transition from paper to plastic so to speak. Unfortunately, the vociferous doubters and naysayers get too much press.

Seriously, as leaders and experts we have press change management and the transition to complete adoption. Hand in hand with that vendors and developers will continue to improve the products on offer. Its not the future. We are behind the times.