What Keeps Me Up At Night – 2013 Edition

Now that Labor Day has come and gone,  I’ve thought about the months ahead and the major challenges I’ll face.

1.  Mergers and Acquisitions

Healthcare in the US is not a system of care, it’s a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.  As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create “systemness” through mergers, acquisitions, and affiliations. The workflow to support systemness may require different IT approaches than we’ve used in the past. We’ve been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  “magic button” viewing and state HIE summary exchange. Interfacing is great for many purposes.  Integration is better for others, such as enterprise appointment scheduling and care management. Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed. Yet, I’m concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation.    Will all aspects of the new HIPAA Omnibus rule be enforced including the “self pay” provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will Meaningful Use Stage 2 proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari’s departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I’ve read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me. I am hopeful that ONC re-examines the certification process and does two things – removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.

4.  Maintaining agility in a resource constrained world

At the same time we have ICD10 (a multi-million dollar burden), Meaningful Use Stage 2 (a multi-million dollar burden), the Affordable Care Act (a multi-million dollar burden), the HIPAA Omnibus Rule (a multi-million dollar burden), and increasing compliance oversight (a multi-million dollar burden), reimbursement is declining, sequestration is squeezing budgets, and fee for service medicine is transitioning to risk based contracts.    The ability of provider organizations to maintain operations while implementing all the new regulatory requirements in parallel is straining healthcare operations to their limits.   Safety, quality, and efficiency innovations are no longer possible because regulatory requirements  have consumed all available resources.

5.  Leading in real time

My organizations maintain hundreds of applications and thousands of devices with 99.9% reliability.    Rather than praise us for our diligence, the average user in 2013 wants to now why we are not meeting their needs .1% of the time.  When I do not respond to a request in 5 minutes or less, I’m asked if something is wrong.   Leadership in the era of Twitter is expected to be all seeing, all knowing, and omnipresent.   Strategic thinking, planning, and consensus building is challenging in a real time world that expects instant gratification.

I do not mean to sound pessimistic in any way.   All of these challenges can be conquered.   For nearly 20 years, I’ve led an IT organization that has continuously delivered miracles with 1.9% of the operating budget.   I am ready for the challenges ahead but wonder if mergers/acquisitions, regulatory uncertainty, MU2 certification challenges, resource constraints, and real time demands will create a set of constraints that are impossible to optimize.    Given that my role is to understand all the constraints and find a path forward, it’s the Kobayashi Maru scenario that keeps me awake at night.

As Captain Kirk figured out, if the rules of the game make it impossible to win, the only answer is to change the game. I remain the eternal optimist and am convinced that if we all work as hard as we can, the rules of the game will be changed so that we can succeed.

John Halamka, MD, is the CIO at Beth Israel Deconess Medical Center and the author of the popular Life as a Healthcare CIO blog, where he writes about technology, the business of healthcare and the issues he faces as the leader of the IT department of a major hospital system. He is a frequent contributor to THCB.

11 replies »

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  2. With all due respect, the ICD-10 should have been implemented in the clinical setting at the same time it was introduced to track mortality. (I reserve judgement on the surgical portion of the manual – it is specific to the US.)
    I do not believe that the general public is aware that the AMA and every major medical specialty organization fought to block this desperately needed change for years. How much money was spent on that? (Rhetorical)
    The World Health Organization (WHO) – yes, we are a member – realized that the ICD-9 was outdated. Medical research, discovery, and treatment has paced so there were no more rooms left for new codes.
    Why are these codes important? Not just for reimbursement. But for assessing the impact of various treatments and events on the health and well-being of the patients.
    If I need a CT scan, I’m asked “What time do you want your appointment?” and they will find an open scanner in this town. I would rather wait a few days and have less scanners (I simplify to make a point) and have the money in the healthcare system for the benefit of the patient and improving outcomes.
    Yes, I am a researcher, a statistician, an epidemiologist…but I worked in a clinical setting for years. Raised in a medical family and married to… and I don’t trust the healthcare system in this country. I know the ICD-10, policy and lack of preparedness – because NO ONE understood what it was about. But that is my soapbox and a response to you is not the proper forum.
    The timing of the programs not too great? I agree. But call your AMA or medical specialty board and complain to them. They are the ones that stalled the implementation of a critical tool for research (and treatments) – and the “powers that be” acquiesced.
    Care to guess how many certified “project managers” that have been hired/contracted for this endeavor even know what a code for billing is? Oops – I’m jumping off now –
    One last thing – and this I learned as a pre-teen working for my father. He didn’t care if someone went through a training program and had a “certificate”. He wanted to know that he could train them to work at the level he demanded. He trained me and I put myself through college as a temp with that training.
    Yet now we rely on a piece of paper – rather than taking the time to assess skills and the persons’ ability to apply/learn in another area. Shame on this industry. Shame on this country!
    I hired people with no experience but brains and good judgement – yes there are ways to measure those – knowing I could train them to do the other jobs.
    So why do we have MBA’s with NO experience or EDUCATION in the basics of billing AND they can’t think to go sign up for a class on hospital finance management…. and they call the system “lack of transparency in billing.”
    Who hired these people? It isn’t just the patients who don’t take their pills.
    Our entire system is sick.
    Hire half a dozen INTJ’s and it’ll be fixed in a couple of years – if everyone minds their own business.

  3. One participant’s “waste” is another’s “revenue stream.” Therein lies the problem, and has for quite some time. Given the disproportionate juice of those on the the receiving end of the largesse, significant cost-reduction will continue to be extremely difficult.

  4. The problem with mergers and acquisitions is that they reduce competition in the marketplace and will ultimately raise the cost of healthcare.

  5. Our President’s goal for healthcare reform is to “bend the cost curve,” an uninspiring and near meaningless goal. The US healthcare industry will exceed $3 trillion (20% of GDP) this year. Numerous studies have acknowledged that less than half of that amount is actual healthcare. In fact, most studies agree there is at least $1 trillion in waste, inefficiency and fraud – why isn’t that the target? Nothing in the ACA does anything to eliminate that waste and inefficiency. Nothing.

    By allowing the “industry” the opportunity to write this Law, the participants simply enriched and protected themselves. The result will be higher costs and additional taxes – not affordable healthcare.

  6. John, you just want everything!
    What is an emr that works efficiently and indelibly?
    At what price is a reasonable price for an end?
    Does the patient bear any responsibility in maintaining, as well as supporting the costs of their medical records?
    Too much in medicine and running a business and trying to survive for our patients keep me up at night.

  7. If I were a hospital CIO here’s what would keep me up at night — it’s a long list

    1. Scenario one – let’s call it the Fukushima Daichi scenario – Something or someone: a power outage, a storm, a deadly software glitch, an unhinged IT employee – succeeds in completely shutting down my system for a week or longer. Doctors are no longer able to access patient information. Tests are lost. Crucial patient notes are no longer accessible. Personnel who have grown dependent on technology are no longer able to keep up. Chaos ensues. The hospital is forced to shut down or evacuate patients to neighboring facilities resulting in a massive blow to our credibility.

    2. Scenario two – An idiot – could be anyone, – there are plenty of potential suspects wandering around my hospital to pick from – does something stupid leading to a data breech. We won’t worry about what it is. Maybe they leave a USB lying on table at Starbucks. Maybe they “accidentally” “forget” about a laptop and it ends up in the wrong hands. Despite the fact that nobody actually accessed the data, nobody suffered any harm and the odds that anything will happen in the future are conservatively one in a gazillion, the incident is depicted as the crime of the century. A federal investigation is ordered. We face probing Geraldo Rivera type questions from the media (“So doctor, you were too busy playing golf to monitor this sensitive data. What kind of human being are you? For god’s sake, I don’t even play golf. I don’t have time.

    Faced with this onslaught, my CEO – understandably anxious to find somebody else to pin the blame on other than him- has me fired. A replacement is brought in, promising to create a new culture of responsibility and efficiency.

    3. Scenario three – Somebody smart invents a really good electronic medical record that does what it is supposed to do, inexpensively and efficiently. (I haven’t seen this yet, but have reason to suspect it may exist in the not very distant future.) I am, for want of a better term, “pantsed.” I am stuck paying the really big bill for my outmoded technology for years while my competitors who left themselves more room to manoever are able to move to the new really good electonic medical record. Miffed by the screw up (what did i do?) My hospital’s board votes to fire our CEO. I – and most of my friends – are shown the door with him.

    4. Scenario four – An unknown but previously suspected software bug causes an algorithm to go haywire. As a result something really, really bad happens that probably means the end of my career and a huge legal liability for the hospital. A dosing is miscalculated. A diagnosis is overwritten. The wrong order is issued. Five patients die over the course of a month before the issue is discovered. Federal investigators are called in. Patient families file lawsuits. I call this the “I flee the country and go live in Canada” scenario …

  8. “As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create “systemness” through mergers, acquisitions, and affiliations.”

    That’ll get rid of that pesky “competition” aspect of the exchanges. Watch for insurance venders to do the same.

    ” The workflow to support systemness may require different IT approaches than we’ve used in the past.”

    Tell me what that means to the patient in terms of cost reductions – not profit preservation, but cost reductions?

    IT won’t solve this, although you won’t hear that from IT vender$.

  9. Re John’s point 4), seems like a lot of costs and staffing for what societal ROI? In John’s case, e.g. Massachusetts, they’ve already done their coverage expansion. Look no further than the continued regulatory pressure on hospitals for an explanation of their declining cash flow. Where are the savings and care improvements we’ve been waiting for?