What keeps me up at night: Fall 2013

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

Healthcare 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 ICD10 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 ICD10 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 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 healthcare 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 ICD10 (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 healthcare 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.