In the new health IT environment created by the American Recovery and Reinvestment Act, you could conclude that money talks: extra payments approaching $45,000 per physician and several million dollars per hospital for prompt electronic health record adoption and meaningful use, and penalties for foot-dragging beyond 2014 that can knock up to 5% off government reimbursements.
Estimates by the Congressional Budget Office suggest the total incentive payout could reach $34 billion, although with expected savings the net cost is half that. Add to that another $2 billion that the Office of the National Coordinator for Health IT can use on various initiatives in support of the goal of having an EHR for every American by 2014.
But more important than the money itself is the message implicitly conveyed along with it. Will incentives be perceived as an intrusive, carrot-and-stick manipulation of health care providers' business decisions? Or will health care providers interpret ARRA as the correction of a reimbursement anomaly, welcoming the opportunity to modernize their information management and transform the care they deliver?
Some of the early signs have been worrisome. Before ARRA, most surveys concluded that cost was the No. 1 barrier to EHR adoption. But as soon as it appeared that the cost barrier might finally be overcome, individuals with a deeper-seated "anti-EHR" bent emerged. Their numbers are small, but their shocking claims -- that EHRs kill people, that massive privacy violations are taking place, that shady conspiracies are operating -- make stimulating copy for the media. Those experienced with EHRs might laugh these stories off, but risk-averse newcomers to health IT, both health care providers and policymakers, are easily affected by fear mongering.
Trusted Leadership Needed
If there is one factor that might stall out the ARRA initiative, it would be a lack of trust leading to a cynical perception of the financial incentives. Right now, health IT needs trusted, inspirational leadership in both the public and private sectors, and those leaders need to communicate clearly and continuously about their vision, their plans and the facts that support them in order to set the record straight.
The opportunity for success still remains. The bill instructed ONC to set up other helpful programs -- regional health IT extension centers, enlargement of the informatics training pipeline, getting EHRs into medical schools so doctors and nurses won't continue being 'paper-trained,' research on EHRs, and more. The details and execution speed of these elements will matter.
Many health IT experts emphasize that the adoption bottleneck is a change management issue, not a technology deficiency. There are not enough individuals with the rare combination of people and health IT skills needed to manage the difficult changeover. And we need more clinician champions who can motivate their colleagues by example, spreading the news of how they successfully harnessed EHR technology to practice higher quality, safer, lower cost care -- and they get home on time and less frustrated as well.
Time for Creative Solutions
We need creative ways to address these shortages. I can envision a health organization equivalent to the Peace Corps -- attracting bright people who are passionate about improving health care, who enjoy working with people as well as technology and who would respond to a challenge to 'change the (health care) world, one village (office or hospital) at a time.' The work might begin with the mundane plugging in of PCs, but it would not end until the concept of health care was transformed in that facility.
Care would be patient-centered, and the focus would shift to the national health outcome priorities recently articulated by ONC:
- Improving quality, safety and efficiency;
- Engaging patients and families;
- Improving care coordination;
- Improving population and public health; and
- Ensuring adequate privacy and security protection of personal health information.
Practices and hospitals would use their new technology to measure and drive progress toward those goals.
From my perspective as chair of the Certification Commission for Healthcare Information Technology, the change in atmosphere since passage of ARRA has been dramatic and abrupt.
Besides becoming a bit of a lightning rod for the political dramas mentioned above, we at CCHIT have seen an explosion in demand for certification, as well as for information on how health providers will qualify for incentives and how certification will operate under ARRA. We've also seen an explosion of interest in contributing as volunteers, with more than twice the number of applicants to our work groups than last year.
Three Certification Paths Needed
We've concluded that certification -- an explicit requirement for EHRs under the ARRA incentive programs -- must become more robust and more flexible, and that these conflicting demands cannot be satisfied with our existing single certification model.
Accordingly, we have proposed introduction of three distinct paths to certification instead of one:
- A rigorous certification of comprehensive EHRs (EHR-C) will be available to vendors whose products offer a complete solution, and will include usability ratings and verification of successful, meaningful use at multiple customer sites. Health care providers who want maximal assurance before they invest in an EHR may insist on this certification.
- A second program, EHR-M, will be lighter in weight and modular, offering flexibility for vendors that focus on a subset of the EHR use goals. This will provide a wider choice of certified technologies for health providers who prefer to choose products from two or more vendors to gather the capabilities to demonstrate meaningful use.
- Finally, for health care providers who develop their own EHRs or use technology from noncertified sources, we will offer a simplified, low-cost site certification (EHR-S), enough to satisfy the federal government that the tools for demonstrating and reporting meaningful use are in place.
We are also hoping to accelerate development of EHR certifications for specialties and settings that had previously been postponed, because ARRA incentives won't wait. Our aim is to serve a much wider spectrum of health care providers and vendors, ensuring that certification will not become a barrier to adoption or to innovation in the EHR market.
How ARRA will play out is not up to ONC alone, nor will it be determined by the choice of interoperability standards. The choice lies within the larger health IT community because collectively we set the standards that matter.
If our standards demand honesty, respect and trust, then health care providers and policymakers will pick up on this message and we can achieve success in this once-in-a-lifetime opportunity to transform health care.