Rural providers cope with HIT staffing deficits

If compliance with ONC regulations is challenging for healthcare providers in urban areas, with high concentrations of IT professionals, it is especially challenging for rural providers where IT resources in the form of human capital are scarce.  The federal government's 2009 healthcare stimulus package, HITECH, provided funding for a national network of regional extension centers (RECs) designed to assist rural healthcare systems.  While the program is considered very effective, its funding will dry up in 2014.  Rural providers have devised a creative array of strategies to overcome their HIT staffing obstacles.

Via Modern Healthcare:

It took St. Claire Regional Medical Center, in the small town of Morehead in northeastern Kentucky, 2½ months to fill an open position on its computer help desk.

“We just don't see that many people who are even close to being qualified willing to work for the amount of money we're able to pay,” said Randy McCleese, vice president of information services and chief information officer of the 159-bed hospital. “That's part of what we have to deal with in the rural environment.”

The need for qualified information technology professionals to work in hospital and clinic settings has increased enormously in recent years, given the expanded use of technology such as electronic health records. But more than two-thirds of the CIOs surveyed in 2012 by the College of Healthcare Information Management Executives reported shortages on their IT staff. That's an especially big problem for providers in small towns and rural areas, who can't necessarily afford to pay nationally competitive salaries and who can't offer big-city attractions to lure candidates.

These IT staffing shortages create daily inefficiencies for small hospitals such as St. Claire Regional. New computers sit idle because there's no one there to set them up. Software fixes don't always get taken care of in a timely manner. “We really get into a backlog of the things that need to be done,” McCleese said.

To address these challenges in filling their IT staffing needs, small-town and rural providers are adopting a variety of strategies. Some are training current employees, such as nurses, in IT skills, some are partnering with other hospitals to share IT staff, and some are outsourcing IT work to consultants. Many worry that the end of federal funding for IT regional extension centers will cut off a valuable source of technology assistance.

While small-town and rural providers also have trouble filling clinical positions, McCleese, CHIME's board chairman, estimates that a typical nurse opening at St. Claire Regional might generate 10 to 15 applicants, compared with the three he received for the recent help-desk position. “Comparatively speaking, we get a much smaller number for the IT positions,” he said.

McCleese faces competition for IT workers from providers based an hour away in the bigger cities of Lexington, Ky., and Huntington, W.Va. He estimates that his hospital pays salaries that are 25% to 30% lower than in those bigger towns.

National data confirm that disparity. The median annual salary for a medical records and health IT technician averaged across non-metro areas is $31,390, compared with $33,566 for metro areas, according to U.S. Bureau of Labor Statistics data.

Across the country, the need for HIT professionals has boomed. The BLS estimated that an additional 41,100 health information technicians will be needed between 2012 and 2022. The bureau also projected that employment for medical-records and health-information technicians will increase 22% by 2022, much higher than the expected 11% increase in overall employment.

The starting gun for the HIT employment boom—and the associated squeeze in smaller towns and rural areas—was the American Recovery and Reinvestment Act of 2009, which pushed many providers to adopt EHR systems by 2014 through $25 billion in payment incentives and grants for training programs.

“The demand (for HIT professionals) just exploded when the electronic record stuff took hold,” said Mark Sonneborn, vice president of information services at the Minnesota Hospital Association. From February 2009 to February 2012, the number of online job postings in the field almost tripled from 4,850 to 14,512, according to a data brief from HHS' Office of the National Coordinator for Health Information Technology. The ONC does not break out urban and rural job listings.

Brock Slabach, senior vice president for member services at the National Rural Health Association, said the looming end of the EHR incentive payments could hurt HIT efforts at rural hospitals and clinics. “The question will be, can these facilities, with these declining reimbursements, and the incentives ending with the American Recovery and Reinvestment Act, continue to operate these information systems efficiently and effectively?” he asked.

In addition to the stimulus program, the Patient Protection and Affordable Care Act drove the need for IT development and staffing through its focus on population-health initiatives, quality-of-care measures, and preventable readmissions. Another factor is the looming implementation of the ICD-10 coding system.

Implementing EHRs is the heavier lift for Milly Prachar's hospital, however. “It's so far-reaching and really touches all users within the organization,” said Prachar, director of health-information management at Roseau LifeCare Medical Center, a 25-bed critical-access hospital in Roseau, Minn., a town of 2,600 near the Canadian border.

Tight deadlines and finances are one side of the problem, and finding qualified IT workers is the other. Prachar's hospital opted to train one of its nurses in clinical IT rather than recruit an IT specialist. That's a strategy a number of other rural-health facilities are using for their IT needs. “Because of our location—we're pretty remote—we didn't think it would be likely that there would be someone with the knowledge of the organization as well as EHR knowledge that could step into that role,” she said.

But that does not solve the problem of how to deal with the increasing number and scope of IT projects on top of the hospital's usual workload. The result for small town and rural providers is a backlog of work and delays in implementing meaningful use of EHR systems and cost-saving quality measures. It also holds them back from participating in alternative payment and delivery models such as accountable care organizations and bundled payment, which require sophisticated data systems.

“They're not keeping up with health reform,” said Joe Wivoda, a health IT consultant based in Hibbing, Minn. “There's no way in the world that you can do health reform without robust health IT capabilities.”

Chantal Worzala, director of policy at the American Hospital Association, said there are two issues for rural providers in hiring IT talent. One is whether the hospital can afford to pay enough to be competitive with urban hospitals, vendors and consulting firms, and the answer is often no. The second issue is convincing IT professionals to live and work in a small town or rural community.

A key for rural providers in recruiting students for HIT jobs is identifying candidates who want to live in a rural community or small town, said Sunny Ainley, associate dean of continuing education and workforce development at the Center for Applied Learning at Normandale Community College in Bloomington, Minn. “You have to enjoy the rural amenities of living in Minnesota,” she said.

Effectively using social media is one way to reach candidates. “People have a very high trust for social media, so we always recommend to our clients to make sure they have a Facebook page and they're very active,” said Ralph Henderson, president of healthcare staffing at AMN Healthcare. “That takes away some of the issues that, 'I don't know that health care system' or 'I don't know that city very well.'”

He also advises conducting on-campus recruiting at colleges and universities to get to know people early in their careers and establish relationships with them. In addition, he recommends having a strong training program. “The healthcare systems that do a good job of hiring new grads and then setting up training programs for them are the ones that tend to win those competitive wars for talent,” Henderson said. These programs breed loyalty to the hospital as well as the local community.

Hire and train
Another approach is to hire and train, bringing on new employees knowing they'll need skills development to do the job effectively. A related strategy is to develop existing employees' IT skill sets through onsite or off-site training, as Roseau LifeCare Medical Center did with the nurse on its staff.

Other small providers are exploring partnerships with larger hospitals, although Slabach worries this could hurt rural providers in the long run. “If the urban partner doesn't have a real keen sensitivity to rural healthcare, preserving access and maintaining traditional patterns of care, you could see patients being transferred to larger facilities,” he said.

A way around this is the IT cooperative approach, which a few small providers have pursued. The not-for-profit Illinois Critical Access Hospital Network offers IT services to its 53 member hospitals on a fee-for-service basis. “(It's at) far less cost to us than if we A, had hired that individual ourselves or B, if we were working through a third-party consulting firm,” said Harry Wolin, CEO of the 20-bed Mason District Hospital in Havana, Ill.

Even so, consulting firms are finding plenty of work with the boom in IT needs. “Small organizations have limited resources (and) limited availability to reach out to talent because everybody wants to work for a larger organization and make more money,” said Carol LeMaster, senior director of career services and professional development at the Healthcare Information and Management Systems Society. “Typically, it's just easier for them to just hire a consulting organization.”

Educators also are working to connect graduates of their HIT training programs to open positions. Normandale Community College was one of about 81 community colleges that received stimulus funding through the ONC for a program aimed at training HIT professionals to help implement EHRs as demand for these positions soared.

But a key source of support for the smallest rural providers as they strive for meaningful use is about to dry up. The HITECH provision of the 2009 stimulus law funded a nationwide network of 62 regional extension centers, run by the ONC to help rural providers implement EHRs. As of January, 3,427 of the 6,700 providers at critical-access and rural hospitals that worked with the RECs had achieved some level of meaningful use.

The RECs will run out of stimulus funding this year. “That is going to be, in certain parts of the country, really, really hard,” said Mat Kendall, who left his position running the REC program at HHS in March. Seventy-one percent of healthcare leaders surveyed by Modern Healthcare between November and January said they think federal funding for these centers should continue.

Kendall worries that the digital divide between urban and rural providers will widen during implementation of Stage 2 meaningful use of EHRs. The ONC is working with providers and vendors to help them with this process, he said. But “there's nothing we can do about the inability to find (IT professionals).”

By Catherine Hollander

“Rural hospitals get creative in staffing for IT needs,” Modern Healthcare (May 17, 2014)

Tagging technique keeps more sensitive portions of an EHR more private

State and federal privacy laws rigorously restrict sharing of mental health and other highly sensitive patient records.  A technique called “data tagging” may be key in facilitating health care providers’ compliance with these requirements.

Via Modern Healthcare:

Using off-the-shelf content standards and messaging protocols, the Veterans Affairs Department and the Substance Abuse and Mental Health Services Administration of HHS have successfully demonstrated how to electronically tag mental health and other highly sensitive clinical records to help providers comply with stringent state and federal privacy laws limiting the sharing of those records without patient consent.

Development of the electronic patient-consent management system came in response to the VA's and SAMHSA's own needs to protect the privacy of patients under two federal medical record privacy laws that are more robust than the privacy rule under the Health Insurance Portability and Accountability Act.

The demo was part of a Data Segmentation for Privacy Initiative by the Office of the National Coordinator for Health Information Technology at HHS. It also answers a 2010 call by the President's Council of Advisors on Science and Technology to use metadata tagging to enhance privacy while making medical data more readily available for research. A metadata tag provides information about the underlying data.

Tagging a patient's record at the “granular” or data-element level enables patients to give consent to the exchange of some parts of their medical record—such as a diagnosis code for diabetes and a drug prescription for its treatment—but not other parts, such as the diagnosis of a sexually transmitted disease or a mental health counseling session.

“The bottom line is we're trying to provide patients some ability to control what information is shared and make it easy on them,” said Mike Davis, VA project lead and Veterans Health Administration security architect.

Federal law applying specifically to the VA requires that, under typical circumstances, the VA must obtain a veteran's consent before his or her medical records can be shared outside the organization. The VA also abides by another federal law that bars federally funded alcohol and drug treatment providers from sharing information about such treatment without patient consent. The latter law creates a consent requirement that sticks to and flows with the data, so that each subsequent provider to receive it also must obtain patient consent to disclose it elsewhere.

Privacy laws in several states also contain these sticky provisions, said Joy Pritts, chief privacy officer at ONC, who attended the demo in Baltimore this month during a conference sponsored by Health Level 7. The healthcare standards development organization has produced a classification and coding system to identify and constrain particularly sensitive information; the system was used by the VA and SAMHSA in the demo, as were the ONC's Direct messaging protocols.

In the demonstration, a care summary was exchanged between providers for a patient enrolled in an alcohol and drug abuse treatment program. The VA/SAMHSA system tagged discrete elements of the record “do not re-disclose.”

One missing piece in the automated privacy protection scheme, however, is how to deal with dictated notes containing sensitive patient data. A text document could be constrained by tagging the entire document, Davis said, but that would need to be done by hand, whereas tagging of discrete data can be done by the system, which can sit as a layer between one provider's EHR and another's.

Patients can specify their wishes with computerized consent directives created online at home or on a provider's computer system, he said.

Davis said there is no timeline for rolling out these functions across the VA, but the VA has several pilot sites running where the system is in daily use recording a veteran's simple “yes/no” electronic consent directives for exchange of their records with outside providers.

Pritts said ONC has two additional pilots planned, one with the VA and one with private-sector providers.

“I think this can work for what's called structure data—medications in the medication list, allergies in the allergies list, diagnostic codes in the problem list, lab test results, vital signs—that type of information,” said Daniel Gottlieb, a partner in the Chicago office of McDermott Will & Emery who heads the firm's health information technology and data protection practice.

With the EHR systems used by providers today, “typically the technology doesn't have the capability” to segregate those drugs on a medication list for a common ailment from those drugs to treat another, more sensitive one, such as a psychiatric condition, Gottlieb said.

“That leaves you with two options in the real world,” he said. “One is not to make that medication list available” outside the organization. “Or, you can take the position that providing high-quality care” is the greater good, “and just decide that you're going to accept that legal risk.”

Gottlieb said many providers lean toward the latter, for instance if a patient is taking medication for a psychiatric disorder but also for a chronic condition such as diabetes. “There could be the potential for the adverse reaction between the psychiatric drug and some other drug,” prescribed either in the same hospital or by another provider. “I think most people think avoiding that reaction takes precedent over the privacy concern.”

By Joseph Conn

Working with the rules: Data tagging allows selective sharing with EHRs,” Modern Healthcare  (September 22, 2012)

HHS advisory panel recommends delaying Stage 2 Meaningful Use until 2014

The HIT Policy Committee, which advises the Office of the National Coordinator for Health IT in the Department of Health and Human Services, voted 12-5 to approve a significant delay in requiring providers to meet Stage 2 Meaningful Use until 2014.  If finalized by CMS, such delay would be a welcome relief to those providers who qualified for Stage 1 Meaningful Use in 2011 (and therefore would have only a few months to commence Stage 2 Meaningful Use under the current rule).

Via Government Health IT:

The delay is among the stage 2 recommendations that the Health IT Policy Committee approved at its meeting June 8 by an overwhelming vote of 12 to 5.

The original 2013 timeframe does not give vendors enough time to design, develop, and test new functionality and providers to deploy it and report measures for one year, said Dr. Paul Tang, vice chair of the Health IT Policy Committee and chair of its meaningful use work group.

“The only group that would be affected is the early entrants who qualify for stage 1 in 2011 who get put into a bit of predicament in an unintended way,” he said. Tang is also chief medical information officer at the Palo Alto Medical Foundation.

As a result, stage 1 demonstration and attestation would continue through 2013; stage 2 would start in 2014 and stage 3 in 2015. With the revised timing, providers will still receive the same payments as originally planned. Instead of 2013, however, early entrants will have to wait to attest and receive payments for stage 2 in 2014.

You can find and download the Meaningful Use workgroup's recommendations by clicking here.

Our column in Government Health IT on RECs and HIT contracts

Government Health IT published a column by Steve Fox and yours truly on the critical role Regional Extension Centers (RECs) can and should play in distributing best practices regarding contracting for health IT systems, including EHRs.  Via Government Health IT:

RECs have the potential to serve as a valuable resource, especially for remote and underserved paper-based primary practices. However, RECs could be doing a disservice to physicians by failing to advise or provide them with essential EMR contract negotiation skills.

With HITECH Act incentives expiring in just a few years, healthcare providers will likely get only one chance to qualify for the full amount of the incentive payments. Thus, successful implementation and operation of an EMR system by the selected health IT vendor becomes critical to each healthcare organization trying to achieve “meaningful use” and take advantage of the incentive program.

In this environment, strong and effective contracts between healthcare providers and health IT vendors is especially significant, because such agreements can provide adequate protections, safeguards and other rights for the provider-customer, in the event a vendor defaults or otherwise fails to perform to the provider’s satisfaction.

You can read the full column by clicking here.


WSJ: Major consolidation among HIT vendors likely

The HITECH Act added over $27 billion to an industry whose publicly trading companies' market cap is below that, around $25 billion.  Such dramatic expansion of the industry will likely lead to significant consolidation among HIT vendors. We have already seen a merger between Eclypsis and Allscripts this summer (which became final last month); and now Cerner, another leading HIT vendor, entered into a partnership with MedAssets, Inc., a company that has specialized Internet-based financial improvement systems.  Via the Journal:

As that funding makes its way to health-care IT companies, it's likely to necessitate a lot more consolidation in an industry that's currently very fragmented. For instance, hospitals are not only looking to reduce the
number of different IT systems they use in-house, they also want more seamless ways of connecting to doctors' offices and insurers.

"We're at the beginning of the single fastest transformation of any industry in U.S. history," said Glen Tullman, chief executive of the health-care IT company Allscripts Healthcare Solutions Inc. (MDRX). <...> Tullman said he expects a lot more deals to come in the industry. He said that some of that consolidation will likely take place among the companies that provide IT systems to hospitals, a list that
includes Allscripts, privately held Epic Systems Corp., General Electric Co. (GE), Cerner, Germany-based Siemens AG (SI), McKesson Corp. (MCK) and privately held Medical Information Technology Inc., commonly known as Meditech. Tullman declined to comment on what companies he expects to make deals.

You can read more at the Wall Street Journal web site here

"Health-Care IT Sector Shaking Up As Medical World Goes Digital," Wall Street Journal (October 15, 2010).


Advisory panel submits recommendations to HIT Policy Committee regarding health data exchanges

On August 19, 2010, the "tiger team" advisory panel submitted a letter to the HIT Policy Committee, established pursuant to the HITECH Act, proposing new safeguards for personally identifiable information on health information exchanges.  Via Bloomberg Business Week:

The recommendations were developed in response to a specific set of privacy-related questions raised by the Office of the National Coordinator for Health Information Technology. They touch upon and clarify topics such as patient consent and the use of third-party service providers in the exchange of personally identifiable health information.

<...> One of the bigger recommendations relates to patient consent. The direct exchange of electronic patient data between health providers for treatment purposes does not require any additional patient consent, the panel noted. The same rules that apply to paper or faxed exchanges of health information should apply in the electronic realm as well.

HIT Policy Committee will have to review and approve the proposed safeguards.  You can read more about the proposed standards after the jump, and can read the letter in full by clicking here.


Bloomberg Business Week described some of the proposed safeguards:

However, any data exchange that involves a third-party does require specific and "meaningful" patient consent, the letter noted. Any such consent also needs to be transparently and easily revocable by the patient at any time, the panel said.

The letter also recommended further exploration of technologies that allow individuals to exercise more granular control over the data for instance permitting the exchange of certain kinds of health data, but not all.

Third-party service organizations should also not be allowed to collect, use or share personal health data for any purposes other what's specified in their service agreements, the panel recommended.

Third parties should also be required to retain personal health data only for as long as it is reasonably needed and should then be required to destroy the data, the panel said.

All third parties having access to patient health information also need to comply with the privacy and security requirements of HIPAA.

"Panel drafts privacy recommendations for health data exchanges," Bloomberg Business Week (August 19, 2010).

Major breach at a New York hospital affects over 130,000 patients

Lincoln Medical and Mental Health Center (LMMHC) in New York suffered a major breach affecting 130,495 of its patients, according to a notice provided to HHS.  The breach occurred when the hospital's contractor, Siemens Medical Solutions USA, shipped seven password-protected, but not encrypted, CDs containing patient information via FedEx; and these CDs were subsequently lost in transit.  Via Bloomberg Business Week:

The CDs were sent by the hospital's billing processor, Siemens Medical Solutions USA, around March 16, but never arrived at their intended destination. They included sensitive health and personal information including Social Security numbers, addresses, dates of birth, health plan numbers, driver's license numbers and even descriptions of medical procedures, the hospital said on a note posted to its Web site.

<...> Siemens is no longer FedExing CDs to Lincoln, the hospital said. It is not aware of any of the data being improperly accessed.

LMMHC's breach should serve as a reminder for all healthcare providers currently negotiating health IT contracts to include proper protections in the event its vendor causes a breach or loss of protected data.  This is particularly crucial in the post-HITECH Act era.  

We always include specific compliance with privacy laws warranties, indemnification clauses and limitation of liability carve-outs for vendor's own negligent acts or omissions which result in a data breach or loss.  LMMHC's example clearly illustrates that providers must insist on such protections -- often, over strenuous objections from vendors -- because, otherwise, providers may be exposed to a wide range of expenses and damages from third-party claims, fines, investigations and breach notification associated with a data breach or loss resulting from vendor's actions.

For more information, please listen to or view the slides from our Webinar on negotiating "must-have" provisions in HIT contracts.

"New York hospital loses data on 130,000 via FedEx," Bloomberg Business Week (June 29, 2010).

Slides from webinar on negotiating "must-have" provisions in HIT contracts

Last Thursday, March 18, 2010, from 1:00PM to 2:00PM (EDT), Post & Schell hosted the second webinar in a series examining the effects of meaningful use and other HITECH Act regulations on the healthcare industry. 

The webinar focused on identifying and negotiating the essential elements of HIT agreements, particularly in light of the HITECH Act and related HHS regulations regarding "meaningful use" of "certified EHR technology." Post & Schell's Steve Fox and Vadim Schick, along with Jim Oakes, Principal at Health Care Information Consultants, discussed:

  • Warranty, limitation of liability and privacy and security provisions in HIT contracts
  • Structuring payments to correspond with certain achievement milestones
  • Acceptance testing procedures
  • Provisions specific to vendor-financing transactions
  • ASP / SaaS models of software licensing

If you missed the presentation, you can listen to the podcast here. You can also view the slides from our presentation here.

This webinar was the second in a series devoted to structuring vendor-provider agreements in the post-HITECH Act world. If you missed our first webinar, A Lawyer's Take on "Meaningful Use," you can still view the slides from that presentation


Grassley follows up with letter to 31 hospitals regarding HIT vendor practices

Following up on his letter to health IT companies last fall, Senator Chuck Grassley (R-IA) sent a letter to 31 hospitals in the United States to inquire about each hospital's experience with purchasing and implementing health information technology.  According to Healthcare IT News:

Grassley cites reports he’s heard about “difficulties and challenges associated with HIT implementation,” including “administrative complications,” “formatting and usability issues,” “computer errors stemming from the programs themselves,” and problems with “interoperability between programs.”

More specifically, he raises concerns that “when [providers] report such problems to their facilities and/or the product vendors, their concerns are sometimes ignored or dismissed.” Often, he writes, “this is attributed to alleged ‘gag orders’ or non-disclosure clauses in the HIT contract that prohibit health care providers and their facilities from sharing information outside of their facilities regarding product defects and other HIT product-related concerns."

You can find more about Sen. Grassley's letter to hospitals in his office's press release, which includes the full text of the letter.

"Grassley inquires about hospitals’ IT experiences," Healthcare IT News (January 21, 2010).

Study: US lags behind other nations in HIT use

A study conducted by the Commonwealth Fund, published in this month's issue of Health Affairs, found that physicians in the United States significantly lag behind their colleagues in Western Europe, Australia and New Zealand in several categories, including rates of adoptions of electronic medical records.  This study of more than 10,000 primary care physicians in 11 countries found that only 46% of U.S. doctors use electronic medical records, compared with almost universal EMR use among doctors in Australia (95%), Italy (94%), the Netherlands (99%), New Zealand (97%), Norway (97%), Sweden (94%), and the United Kingdom (96%).  Among other HIT-related findings, the study concluded that:

<...> among the seven countries with near-universal EMRs, the majority of physicians reported electronic access to lab results, yet fewer than half of Dutch, Norwegian, and U.K. doctors can order tests electronically. Across countries, most doctors with EMRs reported electronic clinical notes, routine electronic prescribing, and computerized alerts about potential problems with drug doses or interactions (except in Norway). Answers varied for other functions.

Decision support appears generally less well developed. Computerized reminders for treatment guidelines, tracking laboratory tests, and prompts to provide patients with test results were the least frequently reported, including in countries with multifunctional capacity. Notably, the seven countries with near-universal EMRs have succeeded in spreading multifunctional capacity to smaller as well as larger practices. Their national policies and standards have supported spread of multifunctional capacity. In contrast, U.S. multifunctional capacity remains concentrated in larger practices. Half of U.S. practices with high-function capacity were associated with integrated care systems such as Kaiser.

However, the study also found a high rate of increase of EMR use among U.S. doctors, rising from 28% to 46% from 2006 to 2009.  At the same time, only 26% of U.S. physicians were reported to have "advance electronic information capacity" (i.e., reporting use of more 9 - out of 14 - clinical IT functions such as e-prescribing and ordering tests, Rx alerts, clinical notes, and others).

The situation seems even more dire in Canada, where only 37% of physicians use EMRs, and only 14% have "advance electronic information capacity."

On the access, cost and quality of care issues, the Commonwealth Fund study found that:

More than half (58%) of U.S. physicians—by far the most of any country surveyed—said their patients often have difficulty paying for medications and care. Half of U.S. doctors spend substantial time dealing with the restrictions insurance companies place on patients’ care.

Only 29 percent of U.S. physicians said their practice had arrangements for getting patients after-hours care—so they could avoid visiting a hospital emergency room. Nearly all Dutch, New Zealand, and U.K. doctors said their practices had arrangements for after-hours care.

Twenty-eight percent of U.S. physicians reported their patients often face long waits to see a specialist, one of the lowest rates in the survey. Three-quarters of Canadian and Italian physicians reported long waits.

While all the countries surveyed use financial incentives to improve the quality of care, primary care physicians in the U.S. are among the least likely to be offered such rewards; only one-third reported receiving financial incentives. Rates were also low in Sweden (10%) and Norway (35%), compared with large majorities of doctors in the U.K. (89%), the Netherlands (81%), New Zealand (80%), Italy (70%), and Australia (65%).

Patients with chronic illness require substantial time with physicians, education about their illness, and coaching about treatment, diet, and medication regimens. Care teams composed of clinicians and nurses have been shown to be effective in providing care to people with chronic conditions and in improving outcomes. The use of such teams is widespread in Sweden (98%), the U.K. (98%), the Netherlands (91%), Australia (88%), New Zealand (88%), Germany (73%), and Norway (73%). It is less prevalent in the U.S. (59%) and Canada (52%), with France (11%) standing out on the low end.

You can find the Commonwealth Fund study here, and please be sure to take a look at the accompanying graphs here.

"A Survey Of Primary Care Physicians In Eleven Countries, 2009: Perspectives On Care, Costs, And Experiences," Health Affairs (November 5, 2009).

Sen. Grassley voices concerns about HIT vendor practices

According to the Wall Street Journal's Health Blog:

In letters sent earlier this month to 10 companies, [Senator Chuck] Grassley says that he’s “received complaints” about systems that allow doctors to enter medical orders by computer. (Here’s a copy of the letter.) This is a big deal these days because the stimulus bill provides billions of dollars in federal incentives to encourage doctors and hospitals to start using these sorts of systems.

Grassley asks the companies to send him copies of “complaints and/or concerns” that health-care providers have expressed about the systems. He wants to know whether the companies typically include legal provisions in their contracts that “shift responsibility for errors in the … systems to physicians, nurses, pharmacists, and other health care providers.”

And he cites reports that contracts sometimes “include ‘gag orders,’ which prohibit health care providers from disclosing system flaws and software defects.” He asks the companies how many settlement agreements they’ve executed in the last 18 months.

So far, representatives of Cerner, McKesson and Allscripts indicated that they plan to cooperate with Sen. Grassley's request. 

You can find more information on Grassley's letters via the Washington Post, here.

You can see a copy of Grassley's letter to 3M here.

"Chuck Grassley Has a Few Questions for the Health IT Industry," Health Blog (October 26, 2009).

"Electronic medical records not seen as a cure-all," Washington Post (October 25, 2009).


Health IT Market Heats Up

The last few weeks saw a tremendous amount of activity in the health IT market.  Dell and Xerox were among the companies trying to capitalize on opportunities created by the ARRA incentives and certain market trends, including high demand for HIT products due to the ongoing digitization of the industry and, more generally, the expanding healthcare needs of an aging population in the United States.

Dell is quickly establishing itself as a major player in health IT.  In April 2009, Dell aligned itself with Wal-Mart and eClinical Works to supply hardware for Wal-Mart's new EHR system.  Last month, Dell rolled out its own EHR system aimed at physicians affiliated with hospital practices, with Tufts Medical Center and Memorial Hermann Health Care System among the early adopters. 

Even more significantly, on September 21, 2009, Dell announced its plans to acquire the health IT vendor Perot Systems Corp. for $3.9 billion.  Perot is a major player in the healthcare industry:  about half of Perot's $2.8 billion in annual revenue comes from the healthcare market; and as much as half of the hospitals that outsource their IT are Perot clients.   Perot runs over 3,000 healthcare applications for its clients, though the company does not have a preferred provider arrangement with a specific application vendor.

A mere week following Dell's announcement, Xerox's CEO Ursula M. Burns revealed her company's "game-changer" plan to buy Affiliated Computer Services (ACS) for $6.4 billion.  According to IT World:

ACS may be in a good position to get even more business in the next few years as the federal government starts spending billions of dollars to help health care providers create electronic medical records systems. ACS said that health care projects account for about $1 billion of its $6.5 billion in revenue for the year ended June 30.

While Dell and Xerox acquisitions grabbed most of the spotlight this week, other Wall Street giants, like Wal-Mart Stores, Inc., Intel and Google, havemade significant inroads into the health  IT market.  Healthcare consultants Frost & Sullivan, as cited in Healthcare IT News, see an expanding market which will benefit new players.

Companies with a fresh, outside perspective will be invaluable to improving healthcare delivery and producing the next generation of medical technology <...> The enormous demand for new technology and solutions to address both the clinical needs of patients and the systemic problems of healthcare delivery will create opportunities for companies with the foresight to identify and capitalize on opportunities.

However, Frost & Sullivan also cautions companies against jumping into this industry without considering potential downsides, including the incredibly complex regulatory framework governing U.S. healthcare.

Joseph Conn, "Dell's HIT Power Play," Modern Healthcare (September 28, 2009).

"Dell to Buy Perot Systems for About $3.9 Billion," The New York Times (September 21, 2009).

"Major corporations looking for stake in healthcare, medical technology market," Healthcare IT News (October 1, 2009).

"Doc, you're getting a Dell (EMR)," Healthcare IT News (September 10, 2009).

"Xerox Buys Affiliated, Fueling Shift to Services," The New York Times (September 28, 2009).

"With ACS, Xerox will gain a firm growing quickly offshore," IT World (September 28, 2009).


HIT Standards Committee endorses privacy and security standards

On September 15, 2009, the HIT Standards Committee endorsed a set of privacy and security standards for electronic health record systems. 
These standards will be recommended to Dr. David Blumenthal, the National Coordinator for Health Information Technology, as a basis for establishing the privacy and security criteria for, inter alia, "certified EHR technology" as defined under the HITECH Act.  Eligible healthcare providers must meet the criteria for "meaningful use" of "certified EHR technology" in order to qualify for significant incentives available under the HITECH Act.

The committee’s Privacy and Security Workgroup included access control, authentication, authorization and transmission of health data among the requirements that electronic health record systems must include by 2011 in order to meet the definition of "certified EHR technology."   Specifically for 2011, the Standards Committee approved the Workgroup's recommendation to require certified products to provide the capabilities necessary to support the HIPAA and ARRA security and privacy requirements and best practices for “meaningful use.”  The endorsed privacy and security standards will become more rigorous in 2013 and 2015.

You can find the spreadsheet of endorsed privacy and security standards here.

You can also view the presentation from the Workgroup here.

"Federal panel okays EHR security, privacy standards," Government Health IT (September 15, 2009).



Government Health IT: CCHIT to serve temporarily as sole EHR certifier

Via Government Health IT:

The federal Health IT Policy Committee today endorsed recommendations that would leave the Certification Commission for Health IT in the short term as the sole organization authorized to certify health IT systems that qualified for funding under the economic stimulus plan. More certifying organizations would be added later.

Certification of electronic health record systems that met federal criteria for “meaningful use” of health IT could start as early as October, members of the Department of Health and Human Services’ Health IT Policy Committee said at the August 14th meeting.

Under the plan, CCHIT would provide a preliminary stamp of approval that health IT systems were HHS-qualified or certified until a final meaningful use regulation is published at the end of the year, said Marc Probst, chief information office of Intermountain Healthcare and co-chairman of the Committee’s certification work group.

Preliminary certification is meant to give providers and vendors enough certainty to proceed with planning, designing and purchasing systems in 2010. The HHS certification-qualification would mean that a provider purchasing the systems would be eligible for Medicare and Medicaid incentive payments under the stimulus law beginning in 2011.

"CCHIT will be sole health IT certifier, for now," Government Health IT (August 14, 2009).

Maryland awards $10M for CRISP, a health IT exchange

The State of Maryland awarded $10 million to support the Chesapeake Regional Information System for our Patients (CRISP), a newly created health information technology exchange organization.  Some of  the biggest players in Maryland's health care industry, including Johns Hopkins, MedStar and the University of Maryland Medical System are going to participate in CRISP. 

According to the Baltimore Business Journal:

Funding will come from the hospitals that will receive a slight increase in the prices they can charge patients and federal stimulus money.

The news comes as health care officials and lawmakers champion electronic medical records as a way of reducing health care costs. They argue that electronic medical records will reduce costs by hopefully eliminating unnecessary tests and reducing errors by allowing doctors to quickly access patients’ medical records.

State health insurers plan to provide incentives to hospitals, which include a lump sum payment or increased reimbursement, to adopt electronic health records.

"Maryland awards $10M for health IT exchange," Baltimore Business Journal (August 5, 2009).


HIT Policy Committee Reveals "Meaningful Use" Proposal

Via Healthcare-Informatics:

By 2011, at least 10 percent of all orders processed in a hospital must be entered through CPOE to qualify that institution for CMS incentives under the HITECH Act, according to a proposed matrix of meaningful use released today by ONC’s HIT Policy Committee.

Other 2011 hospital requirement are:

  • implementation of drug-drug, drug-allergy, and drug-formulary checks
  • maintenance of up-to-date problem lists of current and active diagnoses based on ICD-9 or SNOMED
  • incorporation of lab-test results into EHR as structured data
  • reporting of hospital quality measures to CMS
  • implementation of one clinical decision rule related to a high-priority hospital condition
  • providing of patients with an e-copy of their health information
  • capability to exchange key clinical information (eg. discharge summary, procedures, problem lists, medication lists, allergies, test results) among providers of care

In another major development, the committee recommended that incentives be paid according to an ‘adoption year’ timeframe rather than a calendar year timeframe. “Under this scenario, qualifying for the first-year incentive payment would be assessed using the 2011 Measures. The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the ‘adoption-year’ approach,” the committee stated.

Here is the link to the matrix.

Stay tuned for more on meaningful use definition.

Study: HIT adoption in the U.S. can save $332 BN in 10 years

According to a study by UnitedHealth Group, America's largest health insurer by market value, widespread adoption and use of HIT may save the healthcare industry and the U.S. government up to $332 billion over 10 years.  According to Reuters, modernization of current practices is the report's main tool for achieving significant savings:

The report identifies ways that technology can be applied to save money by modernizing the administrative and transactional aspects of health care.

For example, use of automated cards swiped at the doctor's office or hospital to validate patient benefits could generate $18 billion in savings alone, according to the paper.

According to the Los Angeles Business Journal, the UnitedHealth report describes additional savings by eliminating paper records:

Much of the $332 billion in savings would come from getting rid of paper records of all types at providers. For example, UnitedHealth estimates more than $108 billion would be saved in printing, postage and administrative costs by shifting payments and remittances to an electronic format.

National information systems also could save money. UnitedHealth estimates more than $47 billion could be saved if their [sic] was a national system to monitor and flag questionable health claims.


The UnitedHealth report proposes twelve major changes to the current system, "including replacing "explanation of benefits" letters with monthly personalized health statements and creating a national clearinghouse to address payment errors and settle payment balances."  Reuters (June 30, 2009).  The UnitedHealth Group's press release states that the report's goals and savings may be achieved through:

  • Tighter mandatory data and transaction standards;
  • Elimination of antiquated manual processes, unnecessary paperwork, and redundant intermediaries;
  • Automated payment accuracy processes across the health care system;
  • A single credentialing and quality measurement process; and,
  • A sophisticated and consistent regulatory regime.

"UnitedHealth sees $332 bln in U.S. health savings", Reuters (June 30, 2009).
"UnitedHealth: e-payments could save billions, help pay for health reform", Los Angeles Business Journal (June 30, 2009).
"UnitedHealth Group Report Shows How Technology Can Streamline Administrative Processes and Create Potential Health System Savings of $332 Billion Over Next Decade", UnitedHealth Group Press Release (June 30, 2009).


Nationwide EHR adoption critical to health care reform

Sen. Edward Kennedy (D-MA) revealed the first draft of the healthcare reform bill, the "Affordable Health Choices Act."  Competing versions of the healthcare reform legislation are expected shortly from senior House Democrats, including Energy and Commerce Committee Chairman Henry Waxman (D-CA), and Sen. Baucus (D-MT), chairman of the Senate Finance Committee.  According to the Los Angeles Times, while the various drafts will differ significantly, congressional Democrats agree on three broad goals for the new healthcare framework:

  • Improving the quality of care for everyone by encouraging doctors, hospitals and others to adopt the best, most effective courses of treatment.
  • Curbing the explosive growth in costs by prodding the medical system to make more cost-effective decisions and to increase efficiency by moving to computerized medical records.
  • Expanding coverage to those who do not have health insurance.

Sen. Kennedy's bill does not provide additional funding for adoption of EHR systems, but, according to Piper Jaffrey senior research analyst Sean Wieland interviewed today by Healthcare IT News, "the use of the data generated from these yet-to-be-installed systems is a central theme throughout [Kennedy's] 615-page bill." 

Wieland continued:

The language in the bill is a dramatic shift towards a pay-for-performance reimbursement model ... Public and private health plans will be required to provide incentives for the provision of high quality healthcare, including the implementation of case/disease management, promotion of the medical home model, prevention of hospital re-admissions, promotion of patient safety and reduced medical errors through the use of best practices and evidence-based medicine and additional incentives for the use of health information technology.

The first public hearing on the draft bill are scheduled for tomorrow, June 11, 2009, with mark-ups beginning on June 16, 2009. 

In general, healthcare reform is going to be the blockbuster debate not only of this year, but perhaps of the entire Obama Presidency.  There is much disagreement about the proposed solutions among Democrats, while Republicans will almost certainly oppose any effort as unnecessarily government intervention.  Washington Post provides an excellent summary of the history of healthcare reform in the last 16 years.  The Post article ends with a quote from - appropriately - Hillary Clinton's pollster Geoff Garin:  

Compared to any other time in the last 30 or 40 years, there's a better chance of success than ever before. But this is going to be like a Indiana Jones movie, where we kind of slip through a lot of narrow escapes.

"A healthcare reform bill will affect nearly everyone", Los Angeles Times (June 10, 2009).
"IT central to health reform draft bill released Tuesday", Healthcare IT News (June 10, 2009).
"On Health Care, Congress Must Navigate Tricky Political Terrain", Washington Post (June 10, 2009).


Maryland's new HIT legislation

On May 19, 2009, Governor O'Malley of Maryland signed into law a bill requiring private insurance companies to offer healthcare providers financial incentives to adopt healthcare information technology (HIT), while establishing penalties for those providers who do not bring an electronic medical records system on line by 2015.  According to the Baltimore Sun,

The stimulus money went to Medicare and Medicaid, which are to give it to doctors who adopt electronic medical records. But because Medicare and Medicaid account for less than half of payments to many providers, state Health Secretary John Colmers said, private insurers are now being enlisted to add incentive, beginning in 2011.

The bill allows insurers to choose among several forms of inducement - increased reimbursements, lump-sum payments or in-kind services - so long as it has a monetary value.

"The goal here in Maryland was to assure that all of the payers pull their oars in the same direction," Colmers said. "There is a great promise in electronic health records, but the greatest promise comes when it's done in a coordinated fashion, across all of the payers.

The new law also requires Maryland to develop "a health information exchange, a computer network that would link all of Maryland's physicians, hospitals, medical laboratories and pharmacies. It could be linked with those of other states to create [a] national network."

"Bill pushes doctors to computerize records", The Baltimore Sun, May 19, 2009.

Maryland General Assembly HB706 "Electronic Health Records - Regulation and Reimbursement"

Deloitte Publishes Healthcare Consumer Survey Findings

Deloitte published the results of its 2009 survey of more than 4,000 healthcare consumers, and the findings included some good news for the healthcare IT industry:

  • 9% of consumers have an electronic personal health record (PHR), but 42% are interested in creating one connected online to their physicians.  This leaves much room for growth for companies like Microsoft and Google which offer a PHR product.
  • 55% want the ability to communicate with their doctor via email to exchange health information and get answers to questions, and 57% would be interested in scheduling appointments, buying prescriptions and completing other transactions online if their information is protected.
  • 4 in 10 favor increasing government funding and incentives to support adoption of electronic medical records by doctors, hospitals and health plans.

However, consumers remain worried about the privacy and security of their personal health information, with 38% of those surveyed being "very concerned" as opposed to 24% of those who are not concerned at all.  Sixty percent support government establishing standards "for how medical for how medical information is collected, stored, exchanged and protected." 

The full survey findings can be downloaded here.

"Deloitte Survey Finds Healthy Consumer Demand For Electronic Health Records, Online Tools and Services",, April 6, 2009.

"2009 Survey of Health Care Consumers: Key Findings, Strategic Implications", Deloitte Center for Health Solutions, released April 2009.

In the news: "Octomom" privacy breach at Kaiser Permanente; uptick in HIT stocks; and more

  • After what has become a rather typical breach of patient privacy for Southern California, Kaiser Permanente fired fifteen employees (and disciplined eight additional employees) for looking at the medical records of Nadya Suleman, the mother of octuplets commonly referred to as "Octomom".  Previously, similar breaches occurred at UCLA when that medical center's staff leaked celebrities' medical records to the tabloids.  (, via AP, March 30, 2009.)
  • Wall Street Journal reported last week that HIT stocks, especially smaller companies, like eClinicalWorks (which provide the software component of Wal-Mart's new EHR package) will benefit greatly from the billions of dollars in HIT funding included in the stimulus bill.  Also, in another sure sign of a growing industry, Quality Systems, the maker of the NextGen EHR software, is "beefing up its sales force." ("Stimulus Funds for E-Records Augur Big Windfall for Small Health Firms", Wall Street Journal, March 24, 2009.)
  • A new bill is introduced in the Pennsylvania Senate that would ban businesses from collecting personal data from driver's licenses.  This should also serve as a good reminder for businesses not to collect or store more information than absolutely necessary.  (, March 30, 2009.)
  • Perot Systems will launch a new service tomorrow (April 1, 2009) to help hospitals achieve "meaningful use" status under HITECH, geared towards meeting the interoperability and standardization of HIT use.  (Healthcare IT News, March 30, 2009).


Debate on EHR Savings Rages at Harvard

A battle royal rages on among various Harvard physicians about the effects of a widespread adoption of EHR technology.  In a Wall Street Journal op-ed, two Harvard doctors questioned President Obama's claim that nationwide adoption of EHR technology will save the taxpayers as much as $80 billion annually.   Drs. Groopman and Hartzband call on Mr. Obama to "apply real scientific rigor to fix our health-care system rather than rely on elegant exercises in wishful thinking."  

However, three other Harvard physicians, including Geek Doctor John Halamka, published a Letter to the Editor in response to the Groopman/Hartzband Op-Ed, claiming that the latter did not present a full or accurate picture of the positive effects of widespread adoption of EHR technology.  In part, Drs. Halamka, Bates and Middleton claim that:

The electronic health record represents a transformational change in healthcare, and will enable an array of improvements—although it will not necessarily result if implemented badly. The electronic record is to the paper record as the automobile was to the horse and buggy. No one will want to go back.


Separately, Stephen B. Soumerai, a Harvard Medical School professor (with a University of Alberta co-author, Sumit R. Majumdar) published an Op-Ed in the Washington Post supporting the Groopman/Hartzband claim that EHR technology is not going to produce the promised mass savings because major studies

have found that electronic records with computerized decision support did not result in a single improvement in any measure of quality of care for patients with chronic conditions including heart disease and asthma.

Soumerai and Majumdar sadly concluded that "a $50 billion investment in health information technology won't do much for many Americans." 

This did not go unnoticed by Halamka and the EHR enthusiasts, Drs. Bates and Middleton.  Their response in another Letter to the Editor (this time, in the Washington Post), systematically deconstructed Soumerai and Majumdar's conclusions, reinforcing the theme articulated by Halamka, Bates and Middleton in the Wall Street Journal:  bad implementation can lead to bad results; EHRs are the way of the future, and the focus should be on how to improve quality of care, not whether to implement EHR technology.  The Letter to the Editor also cited specific examples of savings produced by successful adoption of EHR technology:

a detailed case study of the cost and quality benefits of EHR at Family Care of Concord, NH found net benefits per clinician per year of $30,324. Another study of hospital-based provider order entry identified net savings of $1.7 million per year from drug dosing guidance, nursing time utilization, and error prevention.

While the fight continues at Harvard, there is some positive news from Wall Street.  The Wall Street Journal reports that the HIT funding included in the stimulus appears to boost stock prices of certain HIT vendors, including Quality Systems Inc. (QSII), Athenahealth Inc. (ATHN) and Allscripts-Misys Healthcare Solutions Inc. (MDRX).  Thus, it appears the stimulus is working for someone.  Let's hope the EHR enthusiasts at Harvard are correct, and that we will all benefit from lower-costs, increased efficiency and higher-quality health care as a result of nationwide EHR adoption.

"Obama's $80 Billion Exaggeration", Wall Street Journal, March 11, 2009.
"Bad Bet on Medical Records", The Washington Post, March 17, 2009.
"Health IT Push Helps Physician Practice Software Stocks", Wall Street Journal, March 23, 2009.

David Blumenthal Named National Coordinator for HIT

Dr. David Blumenthal was named as National Coordinator for Health Information Technology at the Department of Health and Human Services (HHS).  Dr. Blumenthal will "lead the effort for implementation of a nationwide interoperable, privacy-protected health information technology infrastructure" authorized by ARRA and the HITECH Act. 

According to the HHS Press Secretary,

As a practicing physician and a leading scholar on health information technology, Dr. Blumenthal is uniquely qualified to help America’s doctors, nurses, hospitals, and patients reap the benefits of a modernized health system. Dr. Blumenthal shares President Obama’s commitment to investing in a health IT infrastructure that will protect patient privacy, and improve both quality and efficiency in our nation’s health care system.

An adviser to Mr. Obama during his presidential campaign, Dr. Blumenthal is unquestionably qualified for this job.  Among numerous other accomplishments, he was a physician and director of the Institute for Health Policy at Mass General in Boston; Professor of Medicine and Professor of Health Care Policy at Harvard Medical School; and served as director of the Harvard University Interfaculty Program for Health Systems Improvement.

Dr. Blumenthal's appointment has been well-received by commentators.  According to Healthcare IT News, John Halamka, CIO of Beth Israel Deaconess and Harvard Medical School, called it a "great choice" and Joseph C. Kvedar, MD, chief of the Center for Connected Health, stated that "Dr. Blumenthal brings a wealth of relevant experience to the post. The health of our nation will improve due to his involvement."

We extend our congratulations and best wishes to Dr. Blumenthal as he takes on this important role.

David Blumenthal named new National Coordinator for Health IT (Healthcare IT News, March 20, 2009).

HHS Names David Blumenthal As National Coordinator for Health Information Technology (HHS Press release, March 20, 2009).