ARRA: A New Era for Health IT, and for CCHIT – Part 1

Mark LeavittWhen President Obama signed the American Recovery and Reinvestment Act (ARRA) into law, health IT
was catapulted into a new era.  I believe this is — and forever will be — the biggest milestone in the history of health IT.  I’d like to share my perspectives on it, but it will take several blog posts to cover such a big topic.  Today, I’ll start with a high level view of the significance of this event, and talk about some of the confusion that has resulted from the injection of so much new money – and with it, some new politics – into the world of health IT.  Then I’ll follow up with posts that delve into the details of how I believe CCHIT will need to evolve in this new environment. 

I’m personally struck by the parallels to a historical event still vivid in my memory: Project Apollo, President Kennedy’s incredible national goal of achieving manned spaceflight to the moon.

Apollo cost $22B (in 1969 dollars, now worth five times that) and took 8 years to achieve the first moonwalk.  NASA, a new government agency, spearheaded the effort, but the technology was developed by private sector contractors.

The health IT provisions of ARRA invest at least $35B to incentivize full EHR deployment, allowing 5-7 years to reach that goal – remarkably similar to Project Apollo.  The Office of the National Coordinator (ONC) has been codified and funded to lead the effort, and just as in the case of Apollo, I expect much of the work will need to be accomplished by contractors in the private sector — CCHIT included, of course, provided we quickly “grow up” to meet the enlarged responsibilities. 

But here’s the key difference: for Apollo, the critical challenge was in the development of new technologies.  The only people who had to “adopt” the new technologies were the astronauts.  In contrast, although ARRA requires some degree of advancement in technologies, its real challenge lies in changing the behaviors of hundreds of thousands of individuals, and thousands of organizations, across the health care industry.  Audible “gulp” here.

This takes something money can’t buy:  inspiring, consistent, trustworthy leadership.  We need that leadership right now, but we are in the midst of a major political transition.  We have a bold new President and landmark legislation, but very limited information on how it will be implemented.  Whenever there is incomplete information, rumors and speculation circulate to fill the void.  But I’m confident the noise will dissipate as fresh, accurate information begins to flow.  And my goal in the blog entries that follow will be to provide what factual information is available, and to offer my own opinions that are clearly identified as such. 

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10 replies »

  1. hello. i am a 50 year old single woman with one child. living in a small town with not much work so i live on a tight budget and what are we auppose to do for health care. i can,t afford any coverage and the coverages that are out there for 250 bucks a month do not even cover all that is needed for a 50 year old person. also many will not even take you with pre existing conditions and i have asthma so i just get lost in the shuffle i guess. and its awful scarey at this age with no coverage. seems like there would be a way to help us out in our age bracket so we could afford reasonable good coverage.

  2. First, a disclaimer. I consult with and serve as CMO for Cielo MedSolutions, LLC, who has commercialized software we developed inside the University of Michigan. As an academic family physician researcher I’ve worked with and studied HIT since residency 20 years back. My comments speak mainly to the challenges of HIT implementation in primary care.
    I think some caution should be advised when considering behavior change in order to deploy HIT. To an extent I agree, some aspects of primary care workflow are long overdue for examination and redesign. If the Patient Centered Medical Home movement lives up to it’s promise, moving from an acute care workflow to a continuity care over time workflow will happen. If however, behavior change involves redesign of workflow to fit HIT that has not been designed more for the hospital and integrated health system, that’s where I say “just a moment.”
    I think there remain large technology development challenges in this area. We need to understand better how technology can solve the information challenges in primary care. Yesterday I spent a good 5 minutes of a 15 minute visit searching for an imaged document that was where it was supposed to be, but it wasn’t linked in a way that made it readily accessible when and where I needed it.
    It’s not just money that has kept primary care on the sidelines. People hear rumors of 86 clicks to document a visit for sinusitis, there is literature that documents practices losing real money because of disruption of workflow, and for many the dream of information on labs, etc flowing into the record remains a dream. Those are just a few of the valid concerns I hear my colleagues voicing.
    I too look forward to the day when I have an elegantly designed HIT tool that truly assists me in providing the highest quality continuous, comprehensive care possible. If the ARRA can move the field forward in that direction, I can’t wait. Let’s just make sure we do the science and development needed to fit the technology to the space, and then let’s optimize the workflow to take advantage.

  3. Yes, Apollo was a joint effort between government and private industry, with private-sector contractors developing the technology. But in the end, the government owned, operated and maintained the hardware/technology that was produced by private industry, all in pursuit of a public mission that was government directed.
    And that’s what’s missing here. The government is “incentivizing” ehr with public monies, but the product will be owned by private entities all acting independently, without an overarching goal directed by the public. The money is from the public till, but it is hard to see what health technology infrastructure the public will inherit from this program.
    Instead, we will get lots of privately held data-silos that do not speak to each other. In the national push for ehr, what incentive is there for standards or portability? Health provider networks view ehr as a “competitive differentiator” that will bind patients (customers) to a particular health network. Vendors as well seek to lock in market share, and lock out competitors. Today in the NYT, it was reported that Wal-Mart is getting into the ehr market, seeing ehr as an enticement to physicians to join their employed physician model – and once they get these physicians to join, the ehr will bind them to Wal-Mart. None of these entities have any incentive towards portability and interoperability – quite the contrary in fact.
    But the real winner in this patchwork of data-silos that will result from unsupervised public funding of private ehr initiatives will be the insurance industry. With complex billing-backends being built into this disjointed patchwork of proprietary ehr’s at enormous cost, we are all being further locked into our wasteful and inefficient multi-payer system of private insurers. Indeed, through such stalking-horse groups as Newt Gingrich’s “Center for Health Transformation”, the insurance industry is inciting a manic gold-rush for proprietary ehr’s – a hidden strategy to further solidify the sclerotic status-quo where private insurers continue to reap enormous profits. With each new implementation of a multi-billion dollar proprietary ehr at another large hospital network, the hurdles to enacting some kind of national single payer system become that much more difficult to overcome.
    If the government is going to employ public tax dollars for ehr, then the government needs to direct this effort, needs to ensure that this effort is aimed towards the public good, and that the public owns part of what is produced from this venture. Like the Apollo program.

  4. I agree with healthcare GURU,
    I was at Duke University when CPOE (computer physician order entry) “rolled out”. It was a mess. We all were excited about the technology, but were disappointed with the results to say the least. In theory it was a novel concept, but again theory and practicum don’t always mesh (espescially in healthcare). As with other healthcare programs it fell short time and again. I think some programs like EMAR, Meditech, HSM, CMS and adhoc definitely have positively impacted us in some ways but have hindered us in just as many. The main problem is that healthcare does not fit into the same mold that most businesses do. There are so many variables that need to be considered before we can actually bring this “theory” into a functional utility tool that will save time and money.

  5. To bring the analogy back down to earth, I fly a 737 EMR in my office, a 747 in hospital A, a 767 in hospital B and a 717 in the surgery center. Eventually I’ll have to fly a 777 when I can no longer practice solo and join a group. Since no two systems are remotely alike, how can I offer better care?

  6. I have experience with some of the existing products. When I heard first time complain about doctors intransience to CPOE, i started asking question.
    You would realize is that in the form, it is waste of time. It takes a phsician less than 30 second in most cased to write presecription…and I can tell you that it will take alot more with current for of CPOE in addition to it being cumbersome.
    That is not to say it can not be made to compete with the current paper-pen system. While CPOE may be good concept, but its adoptation is mostly about its inability to provide a competitive edge.

  7. “This as a goal is akin (using your NASA analogy) to having a goal of deploying a bunch of rockets for astronauts to fly.”
    My take on this as well. I’ve always said NASA budgets exist to provide interesting jobs for smart people. I’ve yet to see tangible benefits for the taxpayers funding it. I can see some benefit for health IT (imaging) but don’t see it as our savior for cost control or better outcomes. Healthcare is a people business, IT makes it a machine business.

  8. Mark,
    First, I am a huge proponent of improving patient safety and quality of care through the implementation of computerized clinical decision support and other HealthCare IT tools.
    But I think that people have valid concerns about a couple issues as it relates to the spending on HealthIT throug this ARRA.
    First, there is a concern about the goal. That is, “to incentivize full EHR deployment”. This as a goal is akin (using your NASA analogy) to having a goal of deploying a bunch of rockets for astronauts to fly. This should not be the goal. The goal should be to achieve improved patient outcomes. The EHR is just a vehicle that should be developed that will be used to achieve the mission.
    Second, there is a concern that the current EHRs available are less than satisfactory. Therefore, having a goal of incentivizing deployment of these EHRs may be undesirable, and in fact may lead to less than optimal outcomes. In NASA terms, its like deploying a bunch of space vehicles made for the Mercury and Gemini programs and asking the astronauts to fly them to the moon (for those folks who aren’t NASA enthusiasts, these were the stepping stones to the Apollo program that got out astronauts to the moon).
    I am very thankful to see that significant funding is being directed for HealthIT. I hope that it will be more akin to the efforts put into a little entity previously known as the Advanced Research and Project Agency (ARPA). ARPA had a small office called the Information Processing Techniques Office (IPTO) headed by JCR Licklider, who wrote internal white papers on the “Galactic Network”. The IPTO was responsible for funding the research projects that eventually led to the Internet. Now just for a moment, lets imagine if we are at that moment in time, right now, for HIT.

  9. Thanks-Excellent.
    I believe the key to much of this is bringing in sociologists who study health organizational(user)cultures BEFORE any HIT is implemented.
    But techies and greedy vendors are eager to dismiss such “soft science”
    Prof.Ross Koppel from University of Pennsylvania is such a sociologist who publishes on HIT.
    Read his publications (JAMA etc) before you leap to fast and to far.
    Dr. Rick Lippin

  10. I must admit I am certainly not an IT professional, but I have used many of the healthcare computer charting programs like CPOE, Meditech, EMAR, HSM, just to name a few. I would say that I do agree with Mark that the real concern/problem will be educating healthcare workers. As with any new “revelations” in improving healthcare and its delivery, there is always going to be the “human” element as well as legal ramifications for such. Sure the “astronauts” of the program will be on the top of their game but at the end of the day it will always be the end user putting in the information leaving plenty of room for error. These are “lone” programs that I am referring to. The effects of this “electronic” transformation will certainly give a much larger yield.

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