Wednesday, May 26, 2010

EHR Adoption – Fix the Project Plan

HITECH was signed into law in February 2009 and the Meaningful Use clock starts in October 2011. We’re about half way through the process. How are we doing so far? Will we be ready in time? Everybody seems busy, none more so than ONC, and about $1.5 Billion has been awarded to States, Universities and Health Care organizations.

There are roughly five categories of grants: Interoperability, Adoption Assistance, Workforce Development, Pilots and HIT Research, all of them starting to take shape roughly at the same time. In parallel, ONC is working on the NHIN and NHIN-Direct interoperability frameworks, the EHR certification process is in final stages of definition, CMS is almost ready to finalize Meaningful Use criteria and NIST has finished a first draft of test procedures for whoever will be certifying EHRs during Stage 1 of Meaningful Use.

Arguably all the above are necessary endeavors towards the final goal of an EHR for every American by 2014. The only missing artifact is a Project Plan. A good old fashioned Project Plan with time-lines, milestones and above all dependencies of tasks on completion of other tasks. For example, EHR adoption assistance provided by Regional Extension Centers (REC) is dependent of the availability of a trained workforce, which in turn is dependent on the existence of training programs, which is dependent on the creation of a suitable curriculum. Not to mention that EHR vendors will also need to tap into properly trained cadres of implementers and trainers if they are to satisfy the astronomic increase in demand of their products.

While every single REC out there is issuing RFIs and RFPs for their short list of supported EHR products, the main requirement that an EHR be certified is dependent on a final definition of the certification process and on the accreditation of certification bodies, whose activities are dependent on a final version of NIST’s testing procedures, which is dependent on the definitive ruling on Stage 1 Meaningful Use criteria.

Anyone dealing with Project Management in daily life knows all too well what happens when you ignore dependencies. You miss your deadline. By a mile. And you go over budget. By a lot. And many times, the entire Project will be canceled as a result.

We, as a nation, cannot afford to cancel the HITECH Project. In a recent article, David Kibbe and Vince Kuraitis called for a Plan B. I’m an optimist. I still think that Plan A can be salvaged. However, it is imperative right now to reassess our time-lines and our milestones in view of the real status of each task, and its dependencies on all other tasks currently, and erroneously, proceeding in parallel.


  1. I think you've hit on the real problem everyone's brought up: the timeline. Without final rules on anything (let alone certification), we can't move forward.

    I was taught once that there's a triangle with any project, whose three points are called speed, cost, and quality. All three can not be reached simultaneously.

    So, when we finally have products being certified, a provider will have to make the choice: Do I purchase something that is quick to implement and good for my practice, but costs an arm and a leg? Do I purchase a product that is a best fit for my workflow and cost-effective, but takes forever to get going? Or (and here's the one to be scarred of), do I make a decision based on speed and cost, and so miss quality completely?

  2. I think Michelle, we are over constraining the entire process of national EHR adoption, not just the decisions of a particular doc.
    The deadline is set and the money has been allocated. The only variable that can be relaxed is the quality of this entire computerization effort. I'm sure nobody is going to make a deliberate decision to sacrifice quality, but nothing else seems movable, and something has to give way....

  3. Something to add to this: we must not define "quality" such that we end up always making (to use a cliche) the best the enemy of the good. Because "the best" has never been produced -- it is like old St. Anselm's ontological proof of the existence of God: "God is the greatest being imaginable..." We must not compare a real EHR to an sketchily-imagined EHR God. A mere EHR angel or even a fallen man would be a meaningful improvement. We must get over thinking "quality" in terms of Star Trek fiction. Maybe in two centuries...