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Cash for Computers

John Commins and Jim Molpus, for HealthLeaders Magazine, May 11, 2009
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With an 11-figure incentive to invest in information technology and electronic medical records, healthcare executives need to determine if this offer from Uncle Sam is the kind of help that they are prepared to accept.

Be honest. The first two thoughts in any healthcare leader's mind upon seeing the billions being injected into healthcare information technology in the American Recovery and Reinvestment Act of 2009 were "How much?" and "Where do I get the check?" Now those leaders are into the tough questions about how to use that money in a way that maybe, just maybe, does some good for healthcare.

The enthusiasm for the multibillion-dollar pot is tempered by concern that in the rush to use federal stimulus money to grease a faltering economy, the president may have inadvertently created a new set of confusing and ill-defined regulatory demands coupled with unrealistic deadlines for implementation. With billions of federal reimbursement dollars aimed at dragging doctors and hospitals into the Information Age, hospital leaders must now determine if this is a unique opportunity to leap healthcare forward out of the clipboard age, or a typical big-government boondoggle.

"I look back on my childhood and the Apollo moon mission was the big event that changed the world," says Mark Leavitt, MD, chair of the Certification Commission for Healthcare Information Technology, the independent agency charged by the government with approving health IT systems. "This is a similar program, led by the president, in a time of crisis. This is the biggest thing that has ever happened in health IT and it has permanently changed the field. Health IT being at the spearhead of health reform is mind boggling."

So is the scale of the government spending.

"If you fly over New Orleans these days you will see vast parking lots full of FEMA trailers that aren't being used because they are the wrong trailers," says Bill Roper, MD, CEO of the University of North Carolina Health Care System, and a former administrator of both the Health Care Financing Administration and the Centers for Disease Control and Prevention.

"I am fearful that we may be on the verge of doing that again."

Roper is a longtime proponent of health IT, but he's concerned that effective policy will be lost as hospitals and physicians rush to beat the 2011 deadline for maximum reimbursement set by the stimulus package and cobble together health IT systems.

"Unless we are careful, we may end up spending this money and not accomplishing nearly what ought to be accomplished," says Roper. "This notion seems to be driven by a too-simplistic idea that all we need to do is go out and buy a bunch of computers and wires and plug them all together and, bingo, great things will happen. We all know it's more complicated than that."

U.S. Rep. Jim Cooper, D-TN, shares that sentiment and can't shake the suspicion that "a vendor play" is behind the stimulus money.

"To me this is all backward, with money from the government driving change. Most successful changes are bottom up, not top down," says Cooper. "The political marketplace in Washington lags behind the real marketplace. The future does not have lobbyists because it does not have to."

A scant track record
And healthcare execs cannot easily turn to their colleagues for advice, because so few are up to speed on electronic medical records. A Harvard University/Robert Wood Johnson Foundation survey published in March in the New England Journal of Medicine found that of more than 3,000 hospitals surveyed, only 7.5% use basic digital patient records, and just 1.5% use comprehensive electronic records in every unit.

"The numbers are disappointing and certainly lower than we thought when we went into this study," according to Ashish Jha, MD, MPH, the lead author of the survey, and an associate professor of health policy and management at Harvard. "It just suggests that these systems are expensive and difficult to put in on some level and a vast majority of hospitals haven't felt like it's been worth doing yet."

If so many healthcare leaders don't yet see the value, are they out of touch, or could they be on to something about the current state of the EHR technology?

Scot Silverstein, MD, who teaches Healthcare Informatics and IT at Drexel University's College of Information Science and Technology, is a firm believer in the potential of EHR, but he says a workable national health IT system using today's technology is "absolutely impossible" by 2014, the deadline for any reimbursement, let alone the 2011 deadline for maximum benefit, no matter how much money is involved.

"This forced timeline is a very bad thing. I'm concerned it is going to take an experimental technology and turn it into a train wreck," Silverstein says. "We need a more gradual process where we can learn from mistakes on a small scale to avoid reproducing them on a large scale. But with a 2014 deadline there is no way to do it." Silverstein says healthcare providers and the public are told that health IT is a done deal, using proven, safe, and effective technology, as if "you just plug it in and you've made major improvements and cost savings."

"Where this magic bullet theory came from I believe is largely from the vendors' side, but also from the scholarly community, who were caught up in dot-com-like irrational exuberance in this technology. We now have the president of the United States making definitive statement that health IT will improve the quality of care and reduce costs."

So now, Silverstein says, healthcare providers are caught between their mission to provide quality care and the financial pressure to install an unproven technology that may threaten the mission.

"Health IT, when it's done correctly, can improve healthcare and reduce costs. But health IT when it is not done well has the exact reverse potential," Silverstein says. "It can impair healthcare, decrease quality, and create other adverse effects for patients. That is the missing element in this discussion."

A need to act
Others aren't so pessimistic. Jha says hospitals will have five years to establish EHR before federal penalties kick in. And because it involves the federal government, Jha says it's more than likely that those deadlines will get pushed back even further.

Jha says critics are "missing the point."

"I'm not suggesting EHR is going to be a panacea, but the one thing that is absolutely true is there is nothing else out there now that has any more political appeal," Jha says. "Everybody agrees, whether you are a conservative, moderate, or liberal, that we have to do something about healthcare. So the one place where we can all come to agreement is we have to do something about electronic records."

And the time to do something is now, according to Paul H. Keckley, PhD, executive director of the Deloitte Center for Health Solutions.

"You have to act now because it takes too long to implement," he says. "If you wait two years it actually means you are waiting four years to have the benefit of impact on improved care transparency and taking variation out of the system."

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