The "all or nothing" approach to defining and achieving meaningful use is too ambitious and will only widen the "digital divide," according to the College of Healthcare Information Management Executives (CHIME), which held its annual meeting in Atlanta, GA, on Sunday.

Other "critical concerns" that CHIME expressed in comments on the Centers for Medicare and Medicaid Services' (CMS) EHR Incentive Program include the fact that it doesn't take into account providers' need for flexibility and does not reward incremental progress. CHIME wants CMS to give providers until 2017 to achieve EHR implementation. Their proposed incremental approach would deem a provider a meaningful user if it can achieve 25% of objectives by 2011, 50% by 2013, 75% by 2015, and "substantially all" by 2017.

According to the comments, it also wants CMS to delay quality reporting to 2012, writing that although automated quality reporting is critically important to the meaningful use of EHRs, no system in use today can automatically report the full set of proposed measures.

"Without an approach that rewards progress or provides sufficient time, organizations with limited resources will likely have little chance of qualifying for payments, thus widening the 'digital divide' in the country," the organization stated in its comments.

CHIME also comments on specific objectives and HIT functionality measures included in the proposed regulations. The organization seeks the elimination of administrative measures, such as EHRs producing metrics on automated claims submissions and insurance eligibility, and makes recommendations about CPOE, medication reconciliation, data submission to public health agencies, and HIT functionality data submissions.

"We wanted to make our position known on the proposed regulations," said Pamela McNutt, senior vice president and CIO of Methodist Health System in Dallas, who chairs the group's policy committee.

Responses to the CMS proposal are due March 15.

In preparation for my new beat as technology editor for HealthLeaders Media, I've been reading back issues of HealthLeaders magazine.

One story in particular caught my eye: a 2007 cover story called EMR Pushback with the catchy subhead "Will physicians ever give up their paper?" A good question at the time—and still relevant today. In the article, we listed the top five reasons physicians groups were resisting EMRs, according to the Medical Group Management Association:

• Lack of support from members
• Lack of capital resources
• Concern about the ability of physicians to input data
• Concern about the loss of productivity during transition
• Inability to easily input historic data

Sound familiar? There have certainly been many developments in EHR implementation—not the least of which is the American Recovery and Reinvestment Act of 2009 (ARRA). So where do we stand on EHR resistance in 2010?

Money is always an issue
Despite ARRA's HITECH provision, which offers more than $30 billion in incentives, the basic questions about how EMRs will impact practices remain largely unanswered, says Sam Harrison, MD, who retired from a four-physician urology practice in Bryan, TX, two years ago.

"We as physicians remain concerned about expensive purchase costs, lack of support, loss of productivity during both implementation and beyond, and the time and resource costs of retrieving, scanning, and populating an EMR system with the existing legacy paper charts," he says. "Mix in a healthy dose of the [inevitable costs of] future system obsolescence, including software updates, hardware replacements, and maintenance, and what you have is a quick recipe for physician headache and heartburn."

"The money is always, always an issue," says Greg Spencer, MD, chief medical officer of Crystal Run Healthcare, a group practice in New York with about 200 physicians. Paper costs money, too, he says, but that feels more like a "normal" expense.

In the 2010 HealthLeaders Media Industry Survey, about 20% of CEOs said technology is one of the top three drivers of cost—it ranked seventh overall, way down from 2009, when it ranked third.

Of the 80% of CIOs who said clinical IT spending will increase in the next five years, a little more than half said that increase is due to HITECH. Fifty-six percent say spending on clinical IT will increase because of HITECH.

Hospital and health system CIOs say they're prepared to achieve meaningful use: 76% said they are on target to have systems in place in 2011/2012 and capture full reimbursement.

Results of the survey suggest that physician-owned organizations may be faring better than their counterparts that are owned by hospitals or health systems.

Physician-owned practices were more likely to say they'd be ready to receive stimulus funding in 2011. Nearly half of physician-owned practices (48%) expect to receive meaningful use funds for an EHR system in 2011, compared to only about 35% of practices owned by hospitals and health systems.

Overall, 41% of all practices said they'll take advantage of ARRA funds to install or upgrade an EHR. Nearly 35% said it's too early to tell. And a little more than 6% said, "No, it's still too expensive."

The transition issue will never go away
Other concerns that haven't gone away: loss of productivity during transition periods and reliable, easy data input. The interface between humans and computers has improved, but it's not perfect, says Spencer.

"Voice recognition software is much further along, but it's not at the point of human dictation," says Spencer, who uses the latest version of Nuance's speech recognition software, Dragon. It's "remarkable," he says, even "awesome," but "it still makes silly errors" and you still have to make corrections.

The transition issue will remain a big pain point—regardless of how technology evolves. "There is a learning curve, no matter what, no matter how good the system," he says.

Meanwhile, only 12% of CEOs said in the 2010 survey that technology and system equipment were among their top three priorities for the next three years—technology ranked eighth overall. Among physician practice leaders, technology ranked sixth in terms of priorities over the next three years.

The steady move toward adoption
Harrison, who is now co-owner of an investment company and who advocates for state and national healthcare initiatives, says the answer to two simple questions could prompt widespread adoption: "How will an EMR impact our bottom line? And will it allow us to see more patients and thereby allow us to pay for the system?"

But Spencer notes that physicians who've been practicing for 20 or 30 years won't see a big productivity boost because they are already close to maximum efficiency. And they're already seeing patients for the shortest amount of time possible before patients start looking elsewhere for care.

Although adoption in mid- to large-size organizations is moving steadily forward, small and rural hospitals, obviously, still struggle with the financial piece. HITECH and its promise of stimulus dollars has helped overcome some of those concerns. But Patrick O'Hare, senior VP and CIO at Spectrum Health in Grand Rapids, MI, still hears people calling HITECH an unfunded mandate.

"There is still that concern out there that some health systems cannot afford and are not prepared to embrace meaningful use," he says.

One sign that smaller healthcare organizations will soon adopt EMRs? The vendors are starting to target smaller and smaller organizations, he says.

"HITECH is providing the incentive for participation. Funding is still an issue, but now under HITECH you have five years of a carrot and then that carrot becomes a stick," Jack Kowitt, chief information officer for Parkland Health and Hospital System in Dallas, TX, said in the 2010 CIO survey report.

Despite all of the "buyers beware" concerns, the pressure to purchase a system remains immense, agrees Harrison. "The government threatens future punitive fee schedule payment cuts and tells us the 'clock is already ticking.'"

The future impact
In the survey, most CEOs said the HITECH Act would have either a very positive (13%) or slightly positive effect on future business. But only 17% rate their organization's information technology as "very strong," up slightly from last year's 13%.

Among CIOs, nearly 47% said HITECH will have a slightly positive impact on business. Another 24% said the impact would be very positive.

Most healthcare technology leaders (64%) say the HITECH act will have "some modest success." About 10% said it will have the intended effect to improve quality and reduce costs; 21% said it will not improve quality or cost, and about 4% went so far as to say it will be counterproductive.

"Things have kind of come along," Spencer says. "Overall it feels like there's a lot more momentum now as far as the user interface and the sense of what is important information and how information is dealt with."

There also seems to be more agreement about what information clinicians need to take care of the patient. "That's encouraging," he says. But again, it's not perfect—and it's not where reluctant adopters want it to be, for sure. "Those people are going to hold on for . . . " he says, trailing off before finishing his thought: "I don't know how long."

HIPAA got a big boost from the 2009 HITECH act, which extended privacy rules to business partners, threatened steeper penalties for violations, and promised periodic audits. But even with the beefed-up rules, these days HIPAA just doesn't seem to be that big a priority—to anyone.

One reason HIPAA elicits the big ho-hum is that, despite the fact that Health Information Technology for Economic and Clinical Health (HITECH) Act purports to be very serious about privacy violations, there hasn't been a lot of governmental follow-through. It's like dad telling the kids he's going to count to three and then saying, "One . . . two . . . two and half . . . two and three quarters . . ."

The Office of Civil Rights hasn't decided when it will conduct the periodic audits, for example, or even how it will pay for them. Sue McAndrew, the deputy director for Health Information Privacy for the OCR, said at the 18th Annual National HIPAA Summit last week that OCR is working with a HIPAA privacy and security expert to help the organization "map out essentially the range of options that we have and what would be the most effective." There are, she said, "1,000 ways to do this."

(How long do you suppose the government will take to settle on one of those 1,000 ways?)

Another factor: HHS' "harm threshold" standard in its interim final rule on breach notification, which says that the unauthorized use or disclosure of personal health information is a breach only if the use or disclosure poses some harm to the individual. So covered entities and their associates will now perform a risk assessment to determine what kind of harm the breach caused. Some Congressmen are "deeply concerned" about the harm provision because it gives covered entities and business associates a "breadth of discretion" as they investigate. Providers, meanwhile, love it. No big surprise there.

But the main reason no one seems to get too worked up about HIPAA anymore is that healthcare organizations know what they have to do to prevent breaches. And they know that some breaches—such as an employee who, acting on his or her own, dishes out juicy tidbits about celebrity patients to the tabloids—are nearly impossible to prevent. The truth of the matter is that HIPAA is no longer the big scary mystery it was in 2003.

That's not to say, however, that healthcare organizations are actually doing what they should to comply with the rules. There are still laptops with unencrypted data floating around out there, just waiting to be lost or stolen. In January 2010, there were 35 reports of breaches affecting more than 500 individuals, resulting in 712,000 notices, according to McAndrew. Most of the reports were about personal health information contained in lost or stolen unencrypted media or portable devices.

McAndrews also noted that business associates can be held directly liable for a breach of unsecure protected health information and responsible for those hefty new fines. On the other hand, she went on to say OCR would consider decreasing or even waiving some of the penalties depending on the financial state of a violating hospital. The "settlement door is always open," she added. (Two and sixteen-eighteenths . . . two and seventeen-eighteenths . . .)

While you're waiting for mom and dad to finally get to three, be sure to check out the more detailed reports from last week's HIPAA summit in Washington, DC, by HealthLeaders Media's Dom Nicastro, including an article that outlines five ways healthcare organizations could be doing a better job at HIPAA compliance:

• Five Stumbling Blocks Hinder HIPAA Compliance.
• HIPAA Harm Threshold Works, Say Providers.
• OCR Leader: No HIPAA Enforcement Schedule Yet.

When healthcare marketers talk about measuring the success of their campaigns, they tend to lump all measurement under the heading ROI. I do it, too, by the way. We count the number of hits on a Web site, the number of physicians who stop us in the hall to say they liked your most recent campaign, the number of people who attended the opening of a new hospital. And that's fine, but it's not ROI.

"'Hard' ROI simply means that results are measured by the actual collected revenues after taking into account the actual cost of the effort," writes healthcare marketing consultant David Marlowe in the introduction to his book, A Marketer's Guide to Measuring ROI, published by HealthLeaders Media. "ROI means there is a financial return. If no revenue was generated as a result of the marketing effort, there is no ROI."

It's true that there are many challenges to measuring hard ROI in the healthcare setting and that, for many campaigns, the only way to show that your marketing had impact are the softer measurements, such as an increase in patient satisfaction scores. But, Marlowe says, "That doesn't relieve provider-based marketers from the responsibility of establishing other quantifiable methods."

Healthcare marketers seem to be getting better at setting objectives and demonstrating results, Bob Konold, senior vice president and group creative director at SPM Marketing & Communications in La Grange, IL, told me for an article in this month's HealthLeaders magazine.

But in healthcare, at least, "better" doesn't always mean "great." Susan Dubuque, president and cofounder of Neathawk Dubuque & Packett in Richmond, VA, agrees with Konold that healthcare marketing professionals are getting better at documenting outcomes of their efforts, with a caveat: "True measures of ROI in the accounting sense of the word are, however, still not common in healthcare."

Patrick Buckley, president and CEO of PB Healthcare Business Solutions LLC in Milwaukee and author of the HealthLeaders Media book, The Complete Guide to Healthcare Marketing, puts it even more plainly: Counting Web hits and impressions isn't evidence of a successful campaign, he says.

Indeed, in the 2009 HealthLeaders Media Industry Survey, only 7% of marketing leaders said they place an emphasis on financial ROI only. The vast majority of marketers—just more than 85%—say they use a mix of soft and hard measurement.

That number isn't likely to shift dramatically anytime soon. So while financial ROI is still the gold standard, the fact that healthcare marketers seem to be getting better at showing the impact of their efforts in a variety of ways is still good news.

Just don't call it ROI.

For more insight into the current state of healthcare marketing—including how hospitals have changed their tactics during the recession and emerging trends in healthcare marketing—check out Taking the Measure of Healthcare Marketing.

You can download a PDF of the first chapter of Marlowe's book, which offers examples of what constitutes financial ROI as well as a tutorial on how to calculate financial ROI. The first chapter of Buckley's book is also available for free download—it includes a section that details some of the challenges that healthcare marketers face, including a discussion about the fact that the value of healthcare marketing is often intangible.