Why Healthcare IT Can’t Be Built In A Day

One of my main complaints with the Meaningful Use program has always been its seeming disdain for the immutable laws of technology adoption. In a free market, products and services must mature to the point they are compelling to prospective buyers. At the same time, sellers tinker to find the price point the market will bear. When those levers sync, we have a sale. But that’s just the first step. Depending on the complexity of the product, significant time may be required to move from mere possession to meaningful use.

In HITECH’s Meaningful Use program, the government is essentially trying to do everything – improve the products (usability), define standards to facilitate information exchange, spur system purchases, require deep and significant usage of those systems, ensure users understand a very complex and continually morphing incentive program (while also preparing to collect and report metrics for that program) – all at once. Of course, all this must be done while continuing to do one’s day job.

The frantic nature of the pace that’s been required means much that is being done will need to be undone, redone and, certainly, upgraded. Fans of the program say this is the way it had to be. But why couldn’t the first two years have been spent establishing data standards and enhancing usability, then requiring those for EMR certification. The second phase could have been, “Operation Adoption” during which ONC and CMS incented hospitals and EPs (the vast majority of which are still on paper) to simply make a purchase, providing them education on how to choose wisely. At that point, we’d have good standards, good systems and much deeper adoption than we have today. Then, and only then, would we work to deepen the usage of those systems – at least they would have known where the “On” buttons were!

CMS and ONC could have taken advantage of those early years to learn a lot more about clinical IT implementation and change management themselves because – while many involved with the program are “in healthcare” – those not intimately involved with such work little realize the downstream pain caused by nonchalantly adding this or that new measure.

I recently listened to a book about the beginning of World War I (highly recommended) called “The Guns of August” by Barbara Tuchman. In it, she recounts an instance of a French commander wondering why one of his subordinate generals couldn’t just “turn his army around” if the enemy happened to be coming from the opposite direction. Such change is not easy for those leading armies, or healthcare IT shops.

I believe there are many in ONC and CMS who wonder why healthcare providers can’t just “turn around” in response to a new MU requirement or FAQ.  While they have come a long way in understanding the effects of their edicts (for example, the push to delay Stage 2 for those who attest to Stage 1 in 2011), they still fall short of fully understanding the complexity of system change.

What they fail to understand – and this is why I think those recommending and ultimately making policy should be required to attend a CHIME-like CIO Boot Camp – is that asking for a new piece of data here or there requires new fields  and, thus, new code. That means an upgrade, which means time, money, and resources. But that’s just step 1. All CIOs know that what makes core systems truly effective are the interfaces that connect them to ancillary systems – the information exchange and data flow the government so desperately desires. But changes to code in one application that sits in an interface-laden Web of dozens means many of those delicately crafted data bridges have been broken. To simply get back to square 1, they must all be rebuilt, then meticulously tested. One piece of data incorrectly transported from Application A to Application B can literally mean the difference between life and death.

Despite the effort to delay Stage 1, the Meaningful Use program is still ludicrously complex to understand and incredibly difficult to comply with. When the spinmeisters begin applying a varnish of success on this program, look not at the pure number of those who have qualified, but at that number in relation to the total universe of eligible providers and hospitals. I guarantee those figures will be frightfully low, and the only ones finishing the race will be those who were almost done when it started.

PS: Want a second opinion? Check out this post by HIT Policy Committee Member, Co-Chair of its Certification and Adoption Workgroup, and Intermountain Healthcare CIO Marc Probst: “Is the Meaningful Use Race Fair?“