Billboards and banners inside the grand hall of McCormick Place set the tone for the vendor floor at the annual meeting of the Healthcare Information and Management Systems Society, version 2009 in Chicago: "The time is now," one read. Another said: "Is your strategy shovel ready?" Urgency was the undertone, from poster to corporate brochure.
And, in the polished, produced introduction to the HIMSS conference, a strong pronouncement reminiscent of the Reagan-Gorbachev Berlin Wall speech appeared on the screens insisting to thousands of attendees: "Tear down these proprietary walls."
That was the HIMSS leadership alluding to the fact that we need open standards, interoperability and connections for health information exchange, which have been provided $19 billion in funding courtesy of President Obama and the U.S. Congress. That's what's included in Title IV of the Health Information Technology for Economic and Clinical Health (HITECH) Act.
ARRA Is the New "Ohmm" for Health IT Folk
Thus, the mantra this year at HIMSS was a low, sustained chant of "ARRA," focusing the vendor collective on health IT money earmarked in the American Recovery and Reinvestment Act -- President Obama's stimulus package. "Our work has changed in 19 billion ways," said a CIO from a venerable big hospital.
Or, as one PR observer representing a large services provider said while surveying the conference vendor floor, "Everyone on the exhibition floor is tilting at the piñata of HITECH funding."
Hospital CIOs and others firmly focused on their day-to-day operations while at HIMSS didn't find any concise vendor-provider roadmap of how to proceed from April 2009 to Jan. 1, 2011. I saw a few such Trip-Tik-type timelines, but none was able to forecast key elements about qualifying for incentives such as what quality measures might need to be reported, how to prove interoperability, what products are certifiable, and simply how to submit applications for incentives.
What This Is Really About
The $19 billion is not about electronic health record technology in and of itself. It's about patients, health providers, their communities and connectedness. The latter is the raison d'etre of HITECH, not converting patient data from a paper file into a digital format. It's about the connectedness and exchange of that data around the community for patient, provider and community benefit.
Ultimately, these connections will enable the health information exchange that will finally empower the U.S. to get its national arm around costs, quality and payment for outcomes.
Two early examples of best practices in health IT connectedness are the PaperFree Tampa Bay effort and the Vermont regional health information exchange (officially known as Vermont Information Technology Leaders).
Both projects have done the heavy lifting of bringing together the broad range of stakeholders in their community/state for a collective benefit. An important lesson these projects learned was that bringing together clinicians, hospitals and other stakeholders in the community was a far harder task than selecting technology. Both projects developed innovative partnerships, financial alignment and IT architectures.
Based on these best practices, we can identify some of the key requirements for the connected era of health IT. They include:
- New kinds of partnerships between providers and technology developers;
- Shorter cycle times;
- The software-as-service model and other lower cost solutions that make it easier for clinicians to adopt health IT, especially in the current economic climate; and
- Innovative financing arrangements, particularly for small- to mid-size institutions.
Economy Is the Context
Unemployment, the uninsured and underinsured, record levels of uncompensated care, the liquidity crisis, falling reserves and dwindling endowments -- that's what hospitals in the community are up against as they face the prospect of applying for HITECH incentives.
In the first quarter of 2009, the three major credit rating agencies -- Fitch, Moody's and S&P -- all gave the hospital sector thumbs-down financial outlooks. Fitch expects operating profits are likely to be depressed well into 2010 -- just as big checks for health IT purchases will be written.
So, while incentives under HITECH will be two to three years out in the future, providers must take real-time financial risks when signing on to a product and vendor. In the current environment and looking toward 2010, it is very difficult for many hospitals to find cash. Even with incentives, what are the upfront costs for providers? Providers are asking themselves this question at a time when, fiscally, they're skating on the thinnest of margins -- if indeed there is any margin at all.
Even with incentives offered in legislation by Rep. Pete Stark (D-Calif.), many CIOs believe that the liquidity crisis will still be "out there" for some time.
As one hospital CIO told me, "Relaxing Stark isn't enough for a lot of doctors with busy workloads." That means real demand for revenue-cycle management, which is a major opportunity for health IT vendors to address in partnership with providers over the next 12 to 36 months.
Less Urgency, More Listening Required
There are two key phrases to keep in mind through the rest of 2009 when it comes to HITECH funding: "meaningful use" and "at the discretion of the secretary."
For the former phrase, there remain questions concerning what constitutes meaningful use and "connectedness" under the incentive program. This should be clarified over the coming months as HHS and the Office of the National Coordinator for Health IT develop definitions and reporting requirements and parameters.
Regarding the second phrase, the legislation gives the yet-to-be-confirmed HHS secretary broad discretion. Thus, the appointment of the next secretary (who may or may not be Kathleen Sebelius at the time of this writing) is critical in light of the HITECH Act. The lack of a confirmed secretary of HHS only adds to the angst among those health providers who have to take on the financial risk of investment in health IT during this economic downturn.
The prescription for the rest of the year is to listen to HHS and ONC, to learn from the best practices of peers, as well as lessons from other industries that have brought community stakeholders together in information exchange projects, and to assess the organization's ability to access capital for health IT investment vis-à-vis other projects in the pipeline.
Some 58% of health providers told HIMSS in its annual survey of health care CIOs that they will wait to invest in EHRs under the HITECH incentive program until the funding guidelines are clarified. They're getting the timing right. On the other hand, 20% of providers said they'll start investing "now." These are the big risk-takers in this scenario. My advice to them: wait for a roadmap and a new secretary of HHS.