What keeps this hospital CIO up at night

Now that Labor Day has come and gone,  I’ve thought about the months ahead and the major challenges I’ll face.

1. Mergers and acquisitions. Health care in the US is not a system of care, it’s a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.  As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create “systemness” through mergers, acquisitions, and affiliations. The workflow to support systemness may require different IT approaches than we’ve used in the past. We’ve been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  ”magic button” viewing and state HIE summary exchange. Interfacing is great for many purposes.  Integration is better for others, such as enterprise appointment scheduling and care management. Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty. Will ICD-10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed. Yet, I’m concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD-10 implementation.    Will all aspects of the new HIPAA omnibus rule be enforced including the “self pay” provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will meaningful use stage 2 (MU2) proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari’s departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful use stage 2 challenges. Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a health care institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I’ve read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me. I am hopeful that ONC re-examines the certification process and does two things — removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.

4.  Maintaining agility in a resource constrained world. At the same time we have ICD-10 (a multi-million dollar burden), meaningful use stage 2 (a multi-million dollar burden), the Affordable Care Act (a multi-million dollar burden), the HIPAA omnibus rule (a multi-million dollar burden), and increasing compliance oversight (a multi-million dollar burden), reimbursement is declining, sequestration is squeezing budgets, and fee for service medicine is transitioning to risk based contracts.    The ability of provider organizations to maintain operations while implementing all the new regulatory requirements in parallel is straining health care operations to their limits.   Safety, quality, and efficiency innovations are no longer possible because regulatory requirements  have consumed all available resources.

5.  Leading in real time. My organizations maintain hundreds of applications and thousands of devices with 99.9% reliability.    Rather than praise us for our diligence, the average user in 2013 wants to now why we are not meeting their needs .1% of the time.  When I do not respond to a request in 5 minutes or less, I’m asked if something is wrong.   Leadership in the era of Twitter is expected to be all seeing, all knowing, and omnipresent.   Strategic thinking, planning, and consensus building is challenging in a real time world that expects instant gratification.

I do not mean to sound pessimistic in any way.   All of these challenges can be conquered.   For nearly 20 years, I’ve led an IT organization that has continuously delivered miracles with 1.9% of the operating budget.   I am ready for the challenges ahead but wonder if mergers/acquisitions, regulatory uncertainty, MU2 certification challenges, resource constraints, and real time demands will create a set of constraints that are impossible to optimize.    Given that my role is to understand all the constraints and find a path forward, it’s the Kobayashi Maru scenario that keeps me awake at night.

As Captain Kirk figured out, if the rules of the game make it impossible to win, the only answer is to change the game. I remain the eternal optimist and am convinced that if we all work as hard as we can, the rules of the game will be changed so that we can succeed.

John Halamka is chief information officer, Beth Israel Deaconess Medical Center and blogs at Life as a Healthcare CIO.

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  • buzzkillerjsmith

    What the heck is this guy saying? What language is he speaking? Is there anyone out there who speaks businessjive?

    Perhaps his post has something to do with “transformation.” I do not subscribe to JAMA but get it every week. Every once in a while they send a letter saying it will be cut off if I don’t send money, but, sadly, they never keep their promise.

    So, in keeping with the transformation theme, I like this little gem from the 9-11 JAMA issue, p. 1031: ” The trials by (two groups) provide a great opportunity to ask the question of how to best use the limited but expensive primary care physician workforce in the most effective manner in the evolving health care delivery system.”

    I don’t know about you, but being used is exactly what I was looking for lo those many years ago in training. Are you listening, med students?

    • southerndoc1

      JAMA considers the “primary care physician workforce” to be expensive, but Dr. Halamka tells us that “one of my colleagues at a health care institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems. I have 25 developers and a part time analyst available for the task.”

      We’re deep, deep, deep down the rabbit hole.

      • buzzkillerjsmith

        And Dr. H. and similar are playing the role of the Hatter.

        • guest

          Poor man. It is just one of the many occupational hazards of hat making.

  • John

    I like the way that patients truly are at the center of your concerns.

    Oh, wait. You didn’t mention patients once.

    Never mind.

  • azmd

    Well, this nicely answered my questions about where all of our healthcare dollars are going, since they don’t appear to be getting used to provide decent medical care to our patients.

  • bdkern

    Wow, it seems those commenting here have very little knowledge about what hospitals deal with from an administrative standpoint. The guy you’re criticizing has not only an MD, but a lot of business credentials plus real experience. You may not be interested in what healthcare IT people do, but it would do you well to learn because those facilities are now required by law to do the things he’s talking about and if they don’t they don’t get paid, or worse, they get fined and put out of business. That’s where Obamacare is taking us.

    Here’s his bio: http://investing.businessweek.com/research/stocks/private/person.asp?personId=4839534&privcapId=4165815&previousCapId=22127&previousTitle=North%20Bridge%20Venture%20Partners

  • Kaya5255

    Sounds like job justification to me, at the expense of the heathcare consumer. But then again, what else is new?? Consumers are always the last on the priority list in healthcare.

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