Keckley says it's important to remember that EHR is advancing in tandem with episode-based bundled payments and the move toward comparative effectiveness. "You can't manage the decisions about that 80-year-old fragile patient who needs a new hip in a bundled payment system unless you have an IT platform. It's not simply the docs' judgment anymore. I can't imagine a CEO who isn't going to be aggressive about evaluating and implementing."
Don't trust, but verify
If Keckley is right about CEOs being aggressive on the HIT front, they may need to extend that aggressiveness to their dealings with HIT vendors.
Ronald Reagan used to say "trust but verify" in his missile-reduction negotiations with the Soviet Union. When it comes to the promises of EHR vendors, however, perhaps healthcare executives should adopt an expedited process that skips "trust" and moves directly to "verify."
"The vendors are salespeople. They are for-profit and they are going to do a song and dance to sell the product," Silverstein says. "Your CEO, COO, CIO all need to do extra-special due diligence. Comb the market," he says. "Do site visits and talk to people who've used the particular vendor's technology and make sure the people they are talking to are not receiving funds or favors or in some way have a conflict of interest with the vendor."
Keckley says due diligence is a cheap way to learn the difference between substance and vaporware. "Listening to demos and having people come in and describe it or doing an online tutorial isn't enough," he says.
This is particularly critical in areas like clinical decision support. "It doesn't mean you simply link over to the national guideline clearinghouse as a link on the side of the page," Keckley says. "That means that data is coming into the system. It's prompting, alerting, and reminding based on science. A lot of these companies shortcut that. They don't want to invest in the fixed costs of building clinical decision support. That is a huge difference between some of the players."
Keckley recommends using physicians, nurses, and other clinicians who will actually use the EHR to create a wide range of patient diagnostic scenarios to see how the system responds. "That will separate a lot of these platforms," he says.
Keckley says "docs have to be at the table" when hospitals and physician groups are deciding what EHR system the need. "IT does not really negate physician judgment. That is a myth," he says. "If the doctors and IT systems people aren't on the same page, it is a train wreck."
An abundance of amateurs
EHRs at this scale are still a relatively new technology and extremely complex, so Keckley says CEOs shouldn't assume that their CIOs and technical support people know what they're doing. "You might find that they're in over their heads. It's one thing to implement a financial system to get your bills out. It is quite another to deal with clinical information technology," he says. "They are going to have all kinds of challenges with doctors, and that is probably the biggest challenge. Because this does impose a certain regimen on doctors that they are prone not to appreciate."
Silverstein says the move toward EHRs in most healthcare organizations is highly politicized. Often, he says, hospitals will rely on the judgment of enthusiastic amateurs. "They'll have some techie doctor who has decided he is going to be a computer maven," Silverstein says. "He doesn't have any professional computing skills, but this is the guy who the hospital's executives are counting on. Hospital executives will depend on amateurs in health IT, which include doctors who know a little bit about computers and computer people who know nothing about medicine. Get credible advice from those with formal credentialing and experience at the intersection of medicine and computing."
Some serious decisions
Even with all the trepidation, Jha says healthcare providers need to make the leap, and the sooner the better. "This is really inevitable. I don't think it's going to be tolerable in the year 2020 to still be a hospital that is primarily still paper based," he says. "You are going to have to do this. Do you do it now or wait six months or a year? That is where you get into the specific issues. But every hospital is going to have to make serious moves toward this."
Serious moves, indeed. Senior healthcare executives must make what will likely be the most important capital investment decision of their career. They aren't just choosing an EHR system; they're writing their own legacy.
Keckley remains confident that EHRs will succeed. "I don't see a meltdown. You are going to see a lot of false starts. You are going to have folks who grab the money and find out they bought vaporware and they have to go back and buy some more and there is no stimulus money. It's going to be messy, but what in healthcare isn't?"
Given the complexity of health IT and the crush by providers to install systems by 2011 to secure maximum reimbursement, there are concerns that there aren't enough people with the necessary computer and healthcare expertise to fashion, install, and operate effective health IT systems.