No Free Rides

June 24, 2011
President Obama recently blasted taxpayer-subsidized Wall Street bonuses as “the height of irresponsibility.” He also expressed displeasure with
President Obama recently blasted taxpayer-subsidized Wall Street bonuses as “the height of irresponsibility.” He also expressed displeasure with Citigroup's TARP-powered intention to buy a $50 million jet and spend $400 million for naming rights to the new version of Shea Stadium.

In reaction to these excesses, Obama and other prominent members of Congress are advocating limits on executive pay at both institutions that have received TARP monies and - in what may ultimately be a case of overreaching - institutions that have not.

In the auto industry, life-extending (not saving) taxpayer monies have come with talk of tighter emission standards and quotas to produce a certain number of eco-friendly vehicles, regardless of whether there is a market for them.

Assistance, it's clear, is rarely given without expectation of return.

Over in the world of healthcare IT, billions could soon be sloshing around. While not in the form of a bailout, this money would be part of a “stimulus package” of taxpayer cash, meaning - as with the financial services and automotive industries - there will be expectation of return.

While savvy CIOs have come to define return, or success, as the deep and widespread use of a clinical IT system (think level of functionality utilized, combined with percentage of clinician population onboard), how will the government define it? What will the government expect to get, or see, for the millions it spends?

Will government be happy that “you bought it”? Will it only be satisfied if a system is “turned on and rolled out”? Or will officials insist on the aforementioned definition of success? To date, the only government-produced guideline is that the technology be used “in a meaningful way.”

Understanding expectations is important because, as we know, cost overruns in large-scale IT implementations can make even GAO-number-crunchers take notice. Will an administration official or member of Congress declare a CIO derelict if success isn't realized to his satisfaction? Will the flow of money be stopped if the price tag goes too high? How long before C-suite hospital executives - especially at non-profits - get their pay “reviewed”?

I assure you, price tags on stimulus-funded implementations will occasionally be too high and some projects will simply fail, just as it happens today with no federal money at stake. If rolling out applications like EHRs and CPOE were merely a matter of spending, healthcare IT insiders would rejoice at the proposed influx of cash, but they are not.

Recent comments about the stimulus include words and phrases such as: apprehension, disconcerting, worry, fear, waste and haste. It is with good reason that people are expressing reservation. The difficulty of effecting implementation - especially at hospitals staffed by non-employed community doctors - is three-fold, encompassing workflow-change management, clinician buy-in, and inter-system data transfer; none of which are solved by simply funding an initial system buy.

Currently, poverty is the last refuge of not the scoundrel, but the CIO who knows the environment at their hospital makes a large-scale clinical IT project impossible. Such an environment may feature intransigent docs, a tech-unsavvy C-suite and an understaffed IT department. Removing the lack-of-cash factor without altering the rest of the equation could result in wasted money, a disrupted revenue cycle and, at worst, compromised patient safety.

There are many more factors that determine success in an implementation than having the money. Inevitably, some brave CIOs will resist the cash until other critical pieces have been put in place; anything to the contrary would be the height of irresponsibility.

Anthony Guerra, Editor-in-Chief
Healthcare Informatics 2009 March;26(3):8

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