As the comment period has closed on both the Meaningful Use NPRM and Certification Standards IFR, the industry takes a collective deep breath in anticipation of the final rules. CIOs like Buddy Hickman (also an executive vice president) have thought hard about the proposals and given their feedback through industry organizations like CHIME and HIMSS. One concern of Hickman’s is the “denominator problem” — accounting for every single order processed in a hospital as the universe against which to overlay the electronic ones. To learn more about this issue and others, healthsystemCIO.com Anthony Guerra recently caught up with the New York-based CIO.
BOLD STATEMENTS
… the kind of money that’s flowing back in no way whatsoever pays for the electronic health record effort.
I saw a base assumption that the average hospital EHR will cost $5 million and that number was used then to form a basis computation for much of this stuff … the reality is probably a multiple of five, maybe seven times that number for a hospital of average size.
… I feel it very appropriate that I step out of the pilot’s seat and sit down in the co-pilot seat and allow a clinician to sit in the pilot seat to guide us from a physician leadership standpoint to where we need to be.
GUERRA: Earlier in our interview, you used the word “energized” when describing the effect HITECH has had on providers — that seems a very positive characterization. Does that accurately reflect how you feel?
HICKMAN: Well, let’s see, how would I describe it today? I think energized goes with stimulus. It’s good to see that we finally have this discussion occurring as a national agenda. As I said to another vendor or CEO just yesterday though, we’re doing a whole lot of talking about it and we still haven’t done anything. I was even pondering as I drove into work this morning about the amount of energy that I see the industry spending right now. I thought it’s actually a remarkable thing because we’ve got hosts of folks who work in the provider sector and in the vendor sectors fully engaged and offering their viewpoint about the way they want to see this work out. Oftentimes I’ll use the words ‘energy and emotion’ because I think it’s a very positive thing that people aren’t sitting back waiting on this to happen.
GUERRA: Well, $19 billion will buy you some energy, right?
HICKMAN: I think it has something to do with $19 billion, but I think it also has something to do with the fact that a lot of people care about the destiny of where this stuff is headed and want to see the right thing done. In the end, you break down the money and start splitting it up across the entities, it’s a nice way to do a little bit of cost replenishment or cost avoidance, but the kind of money that’s flowing back in no way whatsoever pays for the electronic health record effort.
GUERRA: The other day, someone said that providers are just getting to visit with the money anyway before it gets paid out to vendors and consultants.
HICKMAN: Well, on the practice EHR side of things, the money is a little bit more attractive than on the hospital side. You know, $40,000 per eligible provider as a one-time installment goes a long way to help cover the cost if you’re doing something of reasonable scale. So it does help offset the capital side.
On the hospital side, with the implementation of electronic health records and all the other elements that we’re talking about, the sort of money that’s flowing from a Medicare payment standpoint is “Sand off a beach.” It was the either the HHS or CMS documents, or one of the two documents that came out on Dec. 30, where I saw a base assumption that the average hospital EHR will cost $5 million, and that number was used then to form a basis computation for much of this stuff. Well, what’s the average hospital size today? 150-200 beds? What would it really take for them to put an electronic health record in place and then do all of the other things — from a connected strategy standpoint, patients’ access to the data, et cetera — depending on how sophisticated the toolset is they want to use, the reality is probably a multiple of five, maybe seven times that number for a hospital of average size.
So that’s why I say it’s sand off a beach. It’s a little bit of money. It helps. But on the other hand, we all know that we have a disincentive coming at us later if we don’t do it, and I’ll stop and say it again, I think most of us were already on the path and wanted to see these things happen, so we’re moving forward because they’re mission critical and the right things to do.
GUERRA: You touched on some of this, but what are your thoughts on all the spending and intellectual capital required around a core EHR to make it successful?
HICKMAN: Around, underneath, through — all the above. Those things that we can name as infrastructural have application not only to the electronic health record initiative but other things we’re doing as well. So if we’re trying to secure our wireless environment via various technologies, they will be deployed in a way that will support not only the electronic health record and health record-related systems but all sorts of other clinically rendering systems, all the various business supporting systems and, in our case, the academic and research supporting systems as well.
So those sorts of investments get spread across a lot of things, not just the electronic health record. There are some others though that are more directly related. For example, what we will have to do to provision our organization to interconnect with and to other providers — and perhaps other payers — is an investment directly associated with the exchange of clinical information, not necessarily for all the other purposes I named a moment ago. And so yes, there’s a big investment. We can’t debate that, and so the effort goes beyond the direct EHR, and it is substantial.
GUERRA: Running a hospital is no longer a Mom and Pop operation, if it ever was.
HICKMAN: I referenced this in the beginnings of our conversation. We now have had requirements delivered to us, whereas we were behaving a lot more independently on these sorts of initiatives. Well, there is a method to that madness, because the intention is that patient health data will be exchanged over the continuum of care and over our lives, and there is a cost to causing that kind of reform in our industry. Many people associate this to what we saw in the banking industry a few decades back and the revolutionary change that occurred. Something that I also saw happen in the banking industry is the number of dollars invested in information technology and information technology jobs increased and stayed at a higher level — in the sense of percentage of operating expense or percentage of capital budgets — going forward because the industry became much more automated.
So I think the same can happen in healthcare. I recall reading this past week one of our congressmen or senators was saying that an object at rest tends to stay at rest, and he was saying that in reference to the healthcare industry and our need for reform. I found myself thinking, ‘You know, that’s Newton’s first law.’ Well, the second law is an object in motion tends to stay in motion, and I think that there is a momentum going on right now that similarly, once started, is not something likely to stop.
I do believe we’re going to see a change in complexion of how healthcare organizations are run, because there will be more automation available, the workforce is going to be trained to utilize that, the expectations for even better automation, better workflow tools and such that exist today will continue, and we’ll find new ways to innovate and use technology. This is the beginning of something different for our industry because it’s really been an information business for a long time. Doctors make decisions based on information, so do nurses, other clinicians and interventions are very dependent these days on information, not just in the sense of decision-making but the technologies utilized. I think we’ll just continue to see the investment follow that trail.
GUERRA: How important are you finding it to have staff with clinical backgrounds, and do you have a CMIO or need one?
HICKMAN: There is absolutely no shortage of work to be done, and the work that we’re talking about now has a very complex, diverse spread across competencies. The classic CIO came from a combination of computing, process engineering and business background, and now what we see are CIOs who also have a clinical blend of competency, hopefully as an addition to the stack I just named. But we’re also finding that take shape in the form of CMIOs. We also find chief technology officers where the individuals have deeper competencies in the technology aspects of how to architect and build a technology organization. I believe it takes all those to deliver the mission.
In my circumstance, I know I’ve got a number of things that I feel fully reliant upon physician leadership to help me accomplish. I find often I might be an initiating sponsor of change, but once we get the ball rolling, I feel it very appropriate that I step out of the pilot’s seat and sit down in the co-pilot seat and allow a clinician to sit in the pilot seat to guide us from a physician leadership standpoint to where we need to be. Sometimes I even move back to the navigator’s seat and plot coordinates and call things out from an engineering standpoint while others are directing the flight. I think we’ve got to have comfort in moving around in the cockpit based on what’s happening and where we are at a particular point in time. And yet I also believe it’s critically important that we find the blend of competencies necessary to deliver the mission. So how do I feel about clinical competency in the CIO role? I think whether it’s the CIO or CMIO roles, we have to have clinical leaders helping to guide what we’re doing right now.
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