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'Geek Squads,' Federal Money, Will Spur Health IT, New Czar Says

By John Reichard, CQ HealthBeat Editor

March 20, 2009 -- Harvard Medical School professor David Blumenthal, named Friday by the Obama administration to head federal efforts to spur the adoption of health information technology, says that federal funding, hand-holding "geek squads" to help doctors and hospitals learn how to adopt and use the technology, and performance-based payment systems are key to overcoming formidable national obstacles to adoption of health IT.

Blumenthal said in an e-mail message Friday that he will "keep his powder dry" about his plans for his first weeks in office until after he starts in mid-April as National Coordinator for Health Information Technology. But in an article written in January for the Commonwealth Fund, Blumenthal detailed his thinking about the challenges the federal government faces in spurring the nation's laggardly adoption of electronic health records (EHRs) and computerized "decision support" software that prompts doctors to make the best medical choices.

Blumenthal's analysis preceded the economic stimulus law (PL 111-5), which provides billions in new spending on health IT, and so did not directly address its provisions. But Blumenthal noted the great fear even among health IT supporters that spending billions may not lower costs or improve public satisfaction with health care. "The great dangers are that providers will acquire EHRs, but those EHRs will not have the computerized decision support that makes them effective," he wrote. "Or they may have the necessary capabilities, but providers won't know how, or be motivated, to use them."

"To avoid this, at least three things must happen," Blumenthal said. "First, the vendors of records must produce user-friendly systems that have the ability to improve provider performance; federal certification would help in this regard. Second, tech-averse providers will need a lot of hand holding" through "geek squads" formed locally by creating HIT-support organizations using federal grants or loans. "Third, and perhaps most important, the health care system will have to reward—or force—providers to improve their performance, so that they will be motivated to buy capable systems, get the help they need, and use the systems to full capacity."

The economic stimulus law provides for net additional federal spending of $19 billion for health information technology, including $2 billion in discretionary funds and $17 billion for investments and incentives offered through the Medicare and Medicaid programs to help increase the use of the technology in hospitals, doctors' office and other medical facilities. The law requires the government to lead the development of standards by 2010 that would allow health information to be exchanged nationwide. The money will initially boost Medicare payments for providers using IT, but by the fifth year, payments to providers will be cut if they don't use the technology.

While the money addresses some of the financial challenges, Blumenthal noted in his January article that the payoff from health IT comes from "computerized decision support, which, in its simplest form, reminds clinicians to get needed tests or provide certain treatments . . . But decision support can do even more. It can let a doctor know which diabetics need to increase their insulin or to adjust drug dosages in special situations," Blumenthal said. "Unfortunately, many existing commercial software systems lack such capabilities."

But only about 17 percent of U.S. doctors and 8 percent to 10 percent of U.S. hospitals have at least a basic electronic health record, Blumenthal said. In most European countries, 80 percent to 100 percent of primary care doctors have electronic health records, he added. While some experts argue that its better to take a "bottom up" approach that improves software in the United States before spending billions to encourage providers to adopt imperfect systems, "a counterargument is that doing this amounts to letting the perfect be the enemy of the good," Blumenthal noted.

"Countries around the world are adopting existing systems to good effect, and here in the United States a number of health care organizations, such as Kaiser Permanente, Geisinger Health System, and the Marshfield Clinic have done the same thing. Existing EHRs could be better, but while we wait for a bottom up approach to work (if it does), we will sacrifice important opportunities to save money and improve quality of care."

Blumenthal brings policy expertise to the challenges he faces more than nitty gritty systems expertise. Writing for the technology news Web site ZDNet, business journalist Dana Blankenhorn said of the Blumenthal announcement, "what we have is someone who knows what needs to be done rather than someone who knows how to do it."

David Brailer, who held the health IT coordinator's position during the Bush administration, agreed that Blumenthal "is not a geek—thank God."

"I don't think this is a job for a geek," said Brailer, who said he is "delighted" with the Blumenthal appointment because he is "remarkably prepared" for policy challenges like assuring medical privacy and figuring out how Medicare payments should be changed to spur IT adoption. Blumenthal also has organizational savvy, Brailer said. "He understands how you get things done and build organizations."

One of the biggest will be figuring out what constitutes "meaningful use" of health IT, the standard for receiving added Medicare money, Brailer said. The term has to be defined and a way to measure it has to be developed through extended rulemaking likely to generate 7,000 to 12,000 comments, Brailer predicted. All of that has to be done in time for fiscal 2011, which begins 18 months from now.

"It's an unprecedented policy shift in how doctors are paid," according to Brailer. He said the actual money going out the door is $34 billion, not $17 billion, which he calls a net figure. The $34 billion will generate $17 billion in savings, resulting in the $17 billion net figure, Brailer said.

How much money will be enough is unclear. A recent analysis by the consulting firm Avalere Health suggested that some doctors might be better off financially not investing in health IT, despite the noncompliance penalty.

Among the longer-term challenges Blumenthal faces is the cost of creating a national network for the exchange of health data. Blumenthal and other analysts estimated in an Augut 2, 2005, article in the Annals of Internal Medicine that a national network would require $156 billion in capital over five years and $48 billion in annual operating costs.

But for now Blumenthal is likely to enjoy strong industry and Capitol Hill backing as he takes on IT challenges. Senate Health, Education, Labor, and Pensions Committee Chairman Edward M. Kennedy, D-Mass., said in a statement Friday that "President Obama has made an inspired choice in selecting David Blumenthal to lead the Administration's effort to bring health care into the digital age. David is the right person to oversee this major initiative to reduce costs, avoid errors, improve care, and save lives." Blumenthal, a medical doctor, was a member of Kennedy's health staff from 1977 to 1980. In addition to his Harvard professorship, he also is currently director of the Institute for Health Policy at Massachusetts General Hospital in Boston.

The American Health Information Management Association said "there is not a more appropriate selection" than Blumenthal.

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