flying cadeuciiThe American Recovery and Reinvestment Act of 2009 (ARRA), sometimes called the Stimulus Actwas an $831 billion economic stimulus package enacted by the 111th Congress in February 2009 and signed into law on February 17, 2009 by the President.

It included $22 billion as incentives to encourage adoption of certified electronic medical records in hospitals and medical practices. The rationale behind the policy directive was clear: system-wide implementation of electronic medical records enables improvement in diagnostics and treatment coordination, fewer errors, and better coordination of patient care by teams of providers.

Almost immediately, the medical community cried foul.

Their primary beef: the cost to implement these new systems would not be recovered by the incentives.

Similarly, physicians pushed back on the conversion of the U.S. coding system from ICD-9 to ICD-10. They did not question the need for the upgrade: the increase from 19,000 to 68,000 codes is necessary to more accurately capture all relevant clinical aspects of a patient’s condition and align our data gathering with 20 other developed systems of the world where ICD-10 is already used.

That health insurers, medical groups, hospitals and others must use the same coding system that reflects advances in how we diagnose and treat seems a no brainer. But some physicians pushed back due to costs and disruption in their practices.

Last week, physicians won a battle: the Centers for Medicaid and Medicare Services (CMS) announced it was delaying the deadline for implementation of ICD-10 for a year, to October 1, 2015.


The American Medical Association commended CMS; the American Hospital Association, BlueCross BlueShield Association, Advanced Medical Technology Association were caught by surprise and disappointed since the delay will cost up to $6 billion (American Health Information Management Association estimate) and the majority were well on their way to making the transition by October 1, 2014.

But many physicians were lagging in its implementation while also playing catch-up with meaningful use, so CMS conceded to their request.

No stakeholder in the U.S. system likes mandates. Doctors don’t like rules made by others outside of their profession, especially expensive IT requirements that aren’t offset by higher revenues or more favorable reimbursement.

Hospitals face eroding operating margins from aggressive insurers and declining reimbursement from Medicare and Medicaid: the cost for implementing meaningful use and ICD-10 means other investments must wait.

And for insurers, expanded coding using a new system means higher administrative costs at a time when premiu increases are more tightly regulated and their margins cut by the new excise tax and cost of compliance with the Affordable Care Act. The fact remains that the federal policy in the U.S. health system is to connect the system using modern clinical and administrative information systems.

That government cost-cutting in the past five years has not raided the $22 billion meaningful use fund for other purposes speaks volumes.

It is worth it? Here’s my take:

HIT is a necessary investment; it is a means to the end of better care. The rationale for HIT is not improved efficiency or higher revenues. It is better care. Improved accuracy in diagnosis, increased efficacy and effectiveness in treatment coordination, fewer errors, improved safety and enhanced patient adherence.

It is necessary overhead—the cost of being in business.

The biggest HIT challenge is not the systems we buy, but the way we manage our people and processes. Spending up to $20 million to implement the ICD-10 transition and $80,000 per clinician for a certified electronic health record is a waste if unaccompanied by changes in the way care is organized, accountability assigned, performance monitored, and payments disbursed.

The major barriers most organizations face are people issues: the cost of a poor hire, failure to extrapolate data from HIT into process improvements and strategy, and or delusional thinking that HIT is a nightmare that might go away. Paralysis in organizations facing HIT decisions is not an app that needs fixing or a security breach; it’s about failure to effectively integrate technologies into strategy that defines the organization’s path to sustainability and growth.

There’s no going back. The Gen X and Millennial generations are tech-savvy. They demand access to their own medical record, seamless navigation of their treatment options and the associated costs, specifics about the performance of their providers—safety, outcomes, user experiences, easy access to coverage and denial deliberations by their health plan, and inclusion of alternative providers and retail health options rarely presented by their plan or provider.

And they see HIT as the means to those ends. And at a macro level, the health system’s role in a global marketplace for its goods and services requires it use 21st century information technologies.

I am not a tech head. I cringe when dealing with online, laptop and mobile device issues, and lean on my tech-savvy son Josh when I hit technology walls. But I know this: these technologies are permanently changing how our society operates with some good and some disappointing consequences.

Physicians have a legitimate concern: HIT is costly. And the majority of physicians are genuine in their passion to serve their patients interests first and above all. Their disconnect is this: to serve their patients best, information technologies that enhance the accuracy, quality and efficiency of the services provided is what patients want.

And the notion that physicians would require payment to use a tool that enables them to do their job better is disconcerting to many. Clearly, the market—patients, employers, and health insurers—expect compliance and associate improved care with these information technologies.

Health information technologies are integral to the future of the U.S. health system. They’re expensive, especially if mismanaged or ineffectively integrated with strategies and operating changes. Physicians and all stakeholders know it, but it’s sometimes hard to accept.

Paul Keckley, PhD  (@paulkeckley) is an independent health care industry analyst, policy expert and entrepreneur. Keckley most recently served as Executive Director of the Deloitte Center for Health Solutions and currently serves on the boards of the Ohio State University Medical Center, Healthcare Financial Management Leadership Council, and Lipscomb University College of Pharmacy. He is member of the Health Executive Network and advisor to the Bipartisan Policy Center in Washington DC.  Keckley writes a weekly health reform newsletter, The Keckley Report, where an earlier version of this post appeared.

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13 Responses for “Health Information Technology: Sorry, There’s No Turning Back!”

  1. Art Centeno says:

    Mr Keckley is like every other well intended bureaucrat. The theory is sound but implementation a nightmare. The HIT that physicians push back against is one that is not ready for prime time. It is like requiring Hollywood to make holographic movies with current technology. I use the HIT everyday unlike the men in their Ivory Towers. I am here to tell you that hospital’s HIT systems do not communicate with physician’s office HIT systems that do not communicate with laboratory HIT systems or Radiology Clinic HIT systems. It is unfair to judge physicians for pushing back against a rudimentary HIT. Give us something that is seamless, efficient, and cost effective and we will embrace that HIT. What we have now is not efficient, user friendly, or cost effective. For the United States to make significant changes in Health Care delivery, Pharma has to be regulated, hospitals have to offer a menu priced competition model that can be accessed ….as do M.D.s. HIT is not the panacea.

    • @BobbyGvegas says:

      I missed the part where he called Health IT a “panacea.”

      “Spending up to $20 million to implement the ICD-10 transition and $80,000 per clinician for a certified electronic health record is a waste if unaccompanied by changes in the way care is organized, accountability assigned, performance monitored, and payments disbursed.”

      Did you actually read the post?

  2. Granpappy Yokum says:

    “And the notion that physicians would require payment to use a tool that enables them to do their job better is disconcerting to many.”

    And the notion that independent health care analysts think that the craptastic EHRs we’re being paid to use enables us to do our job better is disconcerting to many physicians.

  3. john irvine says:

    No. But I did.

    There are two memes worth calling out here:

    “The biggest HIT challenge is not the systems we buy, but the way we manage our people and processes. Spending up to $20 million to implement the ICD-10 transition and $80,000 per clinician for a certified electronic health record is a waste if unaccompanied by changes in the way care is organized, accountability assigned, performance monitored, and payments disbursed.”

    “The notion that physicians would require payment to use a tool that enables them to do their job better is disconcerting to many. Clearly, the market—patients, employers, and health insurers—expect compliance and associate improved care with these information technologies…”

    • @BobbyGvegas says:

      I have a new post up on my THCB-banned REC Blog:

      “”Electronic medical charts have become ground zero for deteriorating patient care”

      :)

      • john irvine says:

        Apparently Google thinks you’re a bot of some kind. I wonder why.

        But seriously, Val submitted to us. We’ll be running on THCB soon.

        - John

        • @BobbyGvegas says:

          It only happens on THCB. Laying it off on Google begs a question. Google “REC blog” (with or w/out quotes). I’m the first search result. It’s just a normal blog. One that gets relatively good traffic for its niche.

          • Unfortunately this is another blog written by a non-physician about a physician’s world. It is clear the author has never used HIT in any meaningful manner.
            As a cardiologist having used our system for 6 years and multiple hospital computers for a similar amount of time, I can tell you these systems are nothing more than very expensive filing cabinets. What is missing is artificial intelligence to make the practice of medicine safer, more efficient and cost effective. This can be added to existing systems, when available at significant cost.
            Examples: Systems currently in use cannot provide automatic drug interaction information, provide online automatic “appropriate use criteria” for testing and therapy, differential diagnosis hierarchical information, and the list goes on and on. Information from labs, xray departments and hospitals need to be manually placed into patient charts similar to paper charts.
            There is a general lack of connectivity between hospitals, labs, doctors offices and where it exists, it requires an expensive bridge to connect since all of these entities have different platforms that do not play well together.
            As to who should pay for all this “technology”, I believe the payers should be those who benefit. Physicians do not benefit much at all. Patients, insurers and the government are the beneficiaries up to now and as the major stakeholders, they should pay for the vast majority of it now and forever. Physicians are not operating more efficiently or cost effectively and should definitely not bear the current and future costs. This is especially true with shrinking reimbursements and rising costs.
            So, once again, a non-physician with no skin in the game makes pronouncements about issues he has no hands on or significant knowledge of and cannot possibly have a relevant opinion.
            See: http://healthcare-financing-myths.blogspot.com/2014/03/electronic-medical-records-not-what-its.html

          • @BobbyGvegas says:

            Steve Weinberg says:
            April 23, 2014 at 8:44 pm

            “Unfortunately this is another blog written by a non-physician about a physician’s world.”
            __

            It’s the health care world, Not the “physician’s world.” That antiquated, narcissistic Iron Man conceit is precisely a big part of the problem.

  4. “HIT is costly. And the majority of physicians are genuine in their passion to serve their patients interests first and above all. Their disconnect is this: to serve their patients best, information technologies that enhance the accuracy, quality and efficiency of the services provided is what patients want.”
    There you have it, quality patient care is costly, but that is what physicians are achieving for. So I say, there’s really no turning back now.

  5. SteveofCaley says:

    “They did not question the need for the upgrade: the increase from 19,000 to 68,000 codes is necessary to more accurately capture all relevant clinical aspects of a patient’s condition and align our data gathering with 20 other developed systems of the world where ICD-10 is already used.”

    “That health insurers, medical groups, hospitals and others must use the same coding system that reflects advances in how we diagnose and treat seems a no brainer. But some physicians pushed back due to costs and disruption in their practices.”

    “It’s the health care world, Not the “physician’s world.” That antiquated, narcissistic Iron Man conceit is precisely a big part of the problem.”

    Look, I’m all for the Borg, I really am. I played for them in college. But this is not an argument about technology, nor scolding the Luddites. This is the oxymoron of 19th Century Modernism – a principle of reform and technology that basically hit the cee-ment wall in the 1940′s. We can all jolly well go and Be Assimilated into the grand scheme. The fact that it’s embarrassingly lame and feeble, well – go team go, I guess. But don’t get your hopes up. Nothing wrong with being a loyal Joe and taking the USA to win the next World Cup. But be realistic.

    How, for instance, do you deal with the clear, obvious and indisputable fact that the VETERANS ADMINISTRATION has had the most progressive and functional, beautifully crafted EMR for twenty years; they implemented fully automated physician order entry and automated hospital medicine dispensing in 2000. Why can’t our healthcare systems work as well as the VA? Why don’t our EMR’s work as well as the VA? Is that a sign that “private enterprise” is inherently incapable of keeping up with the Federal system?

    I think it would be “meaningfully useful” to Federally decertify any EMR that cannot perform up to the VA EMR/EHR standards. Now. No more subsidizing wasteful HIT projects. Perform, or shut down.

  6. John Smith says:

    AutoCollectSpectrum automates the traditional collection methods of standard mail delivery and costly representative phone calls, to a more elaborate, seamless, cost effective auto collection process. Log on to http://clinicspectrum.com/AutoCollectSpectrum.html

    • SteveofCaley says:

      And now we can integrate the collections process into the medical record, John Smith reminds us. From ICD-10 to dunning letter without the interference by the fragile mind of humans!
      There’s no going back. Resistance is futile. “(T)he cost to implement these new systems would not be recovered by the incentives.” Like the stereotype self-affirmed by collectivists everywhere, the only obstacle to nirvana is greed and selfishness. Governmental force, properly applied against the enemy within, will bring us greater joy.
      What if we were to save money by eliminating all the health care industry analysts, policy expert and entrepreneurs who live on a smile, a shoestring, and a scolding attitude towards everything? No, that’s bad savings. Good savings is to be done by enforced spending on what does not work. It’s been tried, and tried and tried – good luck on this time.

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