May 24, 2010
The American Recovery and Reinvestment Act of 2009, commonly known as the stimulus law, has a host of tight deadlines for its myriad health information technology subsidy and IT network development initiatives.
Nearly all of them are timed to help fulfill the ambitious goal set by former President George W. Bush in 2004 and adopted by President Barack Obama last year to make electronic health records available to most Americans by 2014.
Not surprisingly, a federally funded health IT workforce training effort is both part of the overall program and caught up in its mad rush.
“We are moving fast,” said Patricia Dombrowski, director of the Life Science Informatics Center at Bellevue (Wash.) College, which is leading a consortium of community colleges that applied for and won $3.4 million in workforce training grants funded by the stimulus law—covering career paths from information management to IT hardware installation.
Preparations at the college are moving so fast, “We were talking about using roller skates this morning, but we raised our hands,” Dombrowski said. “We knew the time line, so I really feel confident moving forward.”
Last month, HHS' Office of the National Coordinator for Health Information Technology awarded $112 million of stimulus funds to dozens of universities and community colleges such as Bellevue for various IT workforce training and advanced-education programs ranging from six-month certificates through post-graduate degrees.
The faculties and administrators at those schools will be preparing feverishly for the fall semester and the first influx of what they hope will be thousands of new health IT students and job seekers.
Feeling the need
Boosting employment nationwide was a major goal of the stimulus law, and there is little doubt, according to the government and industry leaders, that tens of thousands of new jobs will be needed if the federal effort to push provider adoption of EHRs is to be successful.
Under the stimulus law, both physicians and hospitals seeking subsidy payments for their IT purchases must use certified EHRs in a meaningful manner. Last December, the ONC and CMS issued rules for certification and meaningful use. In response to thousands of subsequent public comments, both rules are likely to be modified sometime this spring.
The National Center for Health Statistics, part of the Centers for Disease Control and Prevention, estimates there are 308,900 office-based physicians who are not federal employees, who are not working for a hospital's ambulatory-care program, and who are not radiologists, anesthesiologists or pathologists.
Almost half of these doctors are either in solo practice or work in partnership with just one other physician. According to the latest NCHS data available—the 2009 estimates from its National Ambulatory Medical Care Survey—only 21% of these office-based physicians have a “basic” EHR.
By NCHS definition, a basic system has rudimentary capabilities, including the ability to create patient problem lists and clinical notes and do electronic prescribing. Although it's not part of the definition, a basic system most likely lacks sufficient functionality to be certified under ONC rules and thus be considered to be an EHR system worthy of reimbursement under the multibillion-dollar stimulus technology subsidy program that is dominating the health IT landscape.
Just 6% of all office-based physicians use what the NCHS defines as a “fully functional” EHR. Such a system might have enough bells and whistles—such as automatic warnings of drug interactions and out-of-range test levels—that a physician using one might reasonably expect to qualify for federal EHR subsidy payments under the stimulus law, based on current drafts of ONC and CMS rules.
But even these advanced EHR systems are likely to require vendor upgrades to meet proposed ONC certification criteria, while many clinicians will still be expected to change their workflows and reporting requirements to fully qualify for EHR subsidy payments under proposed CMS meaningful-use standards.
On average, hospitals are a bit higher up the IT adoption curve than physician offices, but most hospitals are still a long way from where they'll need to be to achieve meaningful use under the proposed CMS criteria.
Computerized physician order entry is an advanced EHR function in hospitals. According to the CMS proposed rule, to qualify for federal EHR subsidy payments under the Medicare portion of the stimulus law, hospitals must run 10% of their orders through a CPOE system for a 90-day period sometime during the first year of the program, which starts this fall.
Jason Hess, general manager of clinical research at KLAS Enterprises, Orem, Utah, a health IT market research firm, said its latest survey data, validated between October 2009 and February 2010, show only about 16% of hospitals have CPOE systems up and running.
“And if you look at those that are doing 50% of their orders or more through CPOE, it's 11.3%,” Hess said.
Given the low levels of adoption and use, Hess asked whether it is even “realistic” for the CMS to require that all hospitals have CPOE installed in the first year and “get 10% of orders through CPOE.”
Talk of a looming labor shortage problem is on a lot of IT buyers' lips, Hess said. Some of the vendors are trying to address the problem by offering remote hosting services for their products, he said, but it remains to be seen whether the software-as-a-service delivery model will catch on fast enough and be used widely enough to make a dent in the workforce shortfall.
Small, rural and community hospitals will feel the stress most severely.
“It's kind of the Wild West for these folks who say we've got to do all the things the big hospitals do,” Hess said.
For starters, thousands of workers will be needed to simply install these EHR systems, configure them to local needs and train clinicians and other healthcare workers in their use. Thousands more will be needed to keep them running and to squeeze the data from them to improve patient safety and quality of care and warrant the multibillion-dollar public investment in them.
Leaders of organizations representing the nation's office-based physicians and hospitals are concerned their members might not be able do all that will be needed to qualify for EHR subsidies under current ONC and CMS rules, given the gap between their current IT adoption status and the high bar set for them in the December drafts.
On May 3, the American Medical Association, American Hospital Association and Federation of American Hospitals as well as a host of medical specialty societies sent a joint letter to HHS Secretary Kathleen Sebelius, calling for the government to dial back its proposed meaningful-use criteria as well as give them more time to meet its performance targets.
For both physicians and hospitals, time is money. The first “payment year” begins Oct. 1 under the Medicare portion of the EHR subsidy program, through which the bulk of the estimated $14 billion to $27 billion in federal IT reimbursements under the stimulus law is expected to flow.
The healthcare industry has not been caught unawares of an IT labor force shortage, even though the advent of such massive amounts of federal EHR subsidy payments have added a heightened sense of urgency.
Back in 2005, the American Health Information Management Association and American Medical Informatics Association formed a joint committee to try and gin up support for education and training in heath informatics and health information management.
They produced a report, Building the Work Force for Health Information Transformation in 2006. In a case of “be careful what you wish for,” one of that group's specific recommendations was to seek federal legislation and support for healthcare IT adoption and funding for IT education and training.
The stimulus law, with its buckets of money for EHR subsidies and education was all that, but with tight timelines as a kicker.
What eventually flowed from the AHIMA/AMIA joint effort was a report released in 2008 laying down what the two groups concluded are the core competencies of professionals working with EHRs.
In addition, AMIA is leading an effort to create a board certification program for physicians in medical informatics with the first credentials being awarded in 2013.
AHIMA, meanwhile, supported the design and rollout of the Virtual Lab for EHRs that provides Web-based coursework to more than 125 associate, baccalaureate and post-graduate health information management, or HIM, degree programs.
The latest figures from the Bureau of Labor Statistics pegged the medical records and health IT workforce in 2008 at about 173,000. About two in five HIM/HIT workers were employed by hospitals, with the rest scattered across physician offices, nursing homes, home health services and other outpatient centers.
Despite the current U.S. unemployment rate hovering just under 10%, the highest figures since 1983, job prospects for health IT workers “should be very good, particularly for technicians with strong computer skills” who will be “in particularly high demand,” according to a BLS report. The healthcare industry, it projected, will need another 35,000 of these positions by 2018, a 20% increase.