Is Physician EHR Adoption Getting Past the Penguin Problem?

Remember the penguin problem described by economists?

No one moves unless everyone moves, so no one moves. 

Overcoming the penguin problem has a lot to do with creating expectations. A recent writing by Dr. James O’Connor in Physician Practice expresses a voice from the physician community that I’ve never heard before.  His essay is entitled “Meaningful Use — Doctors Have No Choice”.

Is HITECH Working? #7: Where’s Plan B? Congress and ONC need to address major flaws in HITECH.

by Vince Kuraitis JD, MBA and David C. Kibbe MD, MBA

Pop quiz: Among early-stage companies that are successful, what percentage are successful with the initial business model with which they started (Plan A) vs. a secondary business model (Plan B)?

Harvard Business School Professor Clay Christensen studied this issue.  He found that among successful companies, only 7% succeeded with their initial business model, while 93% evolved into a different business model.

So let’s take this finding and reexamine our human nature. In light of these statistics, what makes more sense:

  • Defending Plan A to your dying breath?
  • Assuming Plan A is probably flawed, and anticipating the need for Plan B without getting defensive?

We question many of the assumptions underlying HITECH Plan A. We also want to talk about the need and content for Plan B in a constructive way.

In this essay we’ll discuss:

1) The Need for HITECH Plan B

2) Questioning Assumptions — Issues to Reconsider in Plan B

a) Rewarding Incremental Progress
b) Addressing Root Causes for Non-adoption of EHR Technology
c) Questioning Health Information Exchanges (HIEs) as Building Blocks for the Nationwide Health Information Network (NHIN)
d) Catalyzing Movement Toward Modular EHR Technology
e) Focusing Incentives on High Leverage Physicians
f) Recalibrating Expectations for EHR Technology Adoption
g) Getting Bang-for-the-Buck in Achieving Meaningful Use Objectives
h) Comprehensively Revamping Privacy/Security Laws vs. Tweaking HIPAA
i) Maximizing Sync Between HITECH and PPACA
j) Leveraging Potential for Patient-Driven Disruptive Innovation
k) Promoting EHR Adoption Beyond Hospitals and Physicians, e.g., long-term care, home health, behavioral health, etc.
l) Dumping Certification

3) Summing Up

Is HITECH Working? #3: ONC got it right on the 3 major policy interpretations: Meaningful Use, Certification, Standards

We concluded our last post in this series with a blunt prediction that “key physicians will sit on the sidelines” and that clinician non-adoption of EHR technology is a potential “deal-breaker for the success of HITECH”.

While this might sound like a criticism of the way HITECH has been implemented, it’s not intended that way — it’s a commentary on 1) the complexity and scope of change that will be required to make HITECH successful, and 2) the level of protective entrenchment existing American health care today.

Rather, we believe that the Office of the National Coordinator (ONC) for Health IT – Dr. David Blumenthal and his staff — have done a superb job in interpreting and defining key aspects of HITECH legislation. We’re big fans.

For those of you who have been following our writings over the past 18 months, think of this post as a summary and status report on the extensive incumbent (cat) vs. innovator (dog) dialogue:

  1. A Recap  — The Stagnant Electronic Medical Record (EMR) Market Before 2009
  2. ONC Gets It Right In Three Major Interpretations and Definitions of HITECH

a) Meaningful Use (MU) Emphasizes “Meaningful”, Not “Use”

b) Vendors Get a Level Playing Field With Certification

c) Lightweight, Open Standards Promote EHR Interoperability and Modularity

Is HITECH Working? #2: Key physicians will sit on the sidelines (at least for now).








(click on any of the above graphics to be linked to the orginal source)

by Vince Kuraitis JD, MBA and David C. Kibbe MD, MBA

In the previous post in this series on “Is HITECH Working?”, we straightforwardly noted that hospitals are playing in the HITECH game. The issue of whether physicians will play is MUCH thornier.

As the headlines above succinctly convey — we conclude that for now there is too much fear, uncertainty, and doubt (FUD) to expect significantly increased EHR technology adoption by most physicians from the HITECH incentives and penalties.

Here are topics we’ll cover today:

  • Fear, Uncertainty, Doubt
  • Little Risk by Waiting a Year or Two
  • A More Granular View — Segmenting Physicians
  • Is There Another Side to the Story?
  • How Important is Physician Adoption to the Success of HITECH?

Is HITECH Working? #1: Hospitals are grumbling but are playing in the game; success is not guaranteed.


by Vince Kuraitis JD, MBA and David C. Kibbe MD, MBA 

The rationale for hospitals having to play in the HITECH game is straightforward: the financial carrots through 2015 are helpful, and the financial sticks after 2015 will be very painful.

We’ll discuss:

  • Financial Impacts on Hospitals
  • Survey Data Showing Hospitals Will Play
  • Why Success is Not Guaranteed

Financial Impacts on Hospitals

Even prior to HITECH, most hospital executives already had passed the threshold decision and concluded that they need to implement EHR technology. Thus, the issue for most hospitals isn’t “whether” to implement EHR technology, but “when”, “at what cost”, and “how”.

Is HITECH Working? 7 Observations Mom Could Understand

“Make everything as simple as possible, but not simpler.” Albert Einstein

by Vince Kuraitis JD, MBA and David C. Kibbe MD, MBA

If you’re like many folks we talk with, you understand the importance of the HITECH Act legislation — yet feel overwhelmed by the complexity and details.

This series of blog posts is for you. We address the question “Is HITECH working?” with seven straightforward observations. We’ve worked hard to boil down the complexity and make it understandable to the casual industry observer.

Is HITECH Working? Summarizing the Seven Observations

Our 7 Observations are:

A Compendium of Perspectives on the HITECH Certification NPRM

Just the Facts 

Certification Programs NPRM (Notice of Proposed Rulemaking)

Health IT, U. S. Department of Health and Human Services; March 2, 2010

Certification NPRM




Bookmarked version of Certification NPRM (much easier to navigate)

U. S. Department of Health and Human Services; March 2, 2010

Via OCCAM Practice Management blog, March 3, 2010


Commentary and Analysis


Proposed EHR Certification Rule Changes Game

HDM Breaking News; March 2, 2010

“The rule mentions the Certification Commission for Health Information Technology, but does not grant it any grandfather status…. So, while CCHIT appears to be able to continue its operations under the proposed temporary certification program, its future isn’t clear in the proposed permanent program.”


Certification NPRM: A Statement from Alisa Ray, Executive Director, Certification Commission for Health Information Technology (CCHIT)

EHR Decisions; March 3, 2010

“…we feel confident about our prospects of becoming accredited…. We feel confident about the future, and we look forward to the opportunity to continue playing a role in accelerating the adoption of health IT.


 Why Rush Vendor Certification of EHR Technologies?

The Health Care Blog; March 08, 2010

“David Blumenthal and his staff have unveiled two separate plans to test and certify EHR technology products and services. We don’t think this is a good idea…this recently-announced two-stage EHR technology certification plan bears all the marks of a hastily drawn up blueprint that, if rushed into production, could easily collapse of its own bureaucratic weight.”


HIT Leaders React to Proposed EHR Testing and Compliance Rule

HealthLeaders Media; March 4, 2010

  • “They got it exactly right.” Simeon Schwartz, MD, president and CEO of WestMed Medical Group.
  • “It’s going to be interesting to see how much the vendors got out ahead of this and how much they’ve hedged their bets” Eric Saff, CIO of John Muir Health
  • “…no matter where you are in the chain of this market, you can in fact certify those modules as opposed to waiting until you meet complete meaningful use to be certified. So I think that’s great. I think that’s really considerate of the ONC.” Luigi Leblanc of Solink

A Compendium of Resources on the Federal HIT Meaningful Use NPRM and Standards IFR

* = highly recommended


Descriptive Summaries and Documents


 *Dissecting the Meaningful Use Proposed Rule PowerPoint

eHealth Initiative Policy Webinar; January 8, 2010


*What You Need to Know About the Meaningful Use Proposed Rule, Standards and Implementation Specification, and Interim Final Rule Certification Criteria PowerPoint

HIMSS Webinar; January 6, 2010


*Meaningful Use, Certification Criteria and Standards, and HHS Certification Process

HIMSS, frequently updated material, some members-only


Source Documents (Bookmarked)

Notice of Proposed Rulemaking (NPRM), Medicare and Medicaid Programs; Electronic Health Record Incentive Program; December 30, 2009

Warning: 536 pages of barely intelligible gobbledygook; stay away from this unless you are a lawyer, accountant, actuary, consultant, geek or wanna-be thereof 

Interim Federal Rule (IFR), HIT: Initial Set of Standards, Implementation Specifications, and Certification Criteria For EHR Technology; December 30, 2009


NPRM and IFR Tables in Spreadsheet Format

Healthcare Standards; January 9, 2009


Centers for Medicare & Medicaid Services (CMS) Website, Fact Sheets, Links


Updates on Meaningful Use, Certified EHR Technology and the Stimulus Bill

Software Advice; January 10, 2010




*Urgently Needed: Useful Meaning of Meaningful Use

The Health Care Blog; January 9, 2009


*Now Reading: Proposed CMS Rule for EHR Incentives (from a patient access perspective)

Ted Eytan MD; January 10, 2010


HITECH Health IT Legislation: Opportunities for the DMAA Community

Dr. Don Storey and I spoke at the at The Forum 09 conference in San Diego earlier this week. The DMAA publication “The Continuum” had an excellent writeup of our enthusiastically received presentation. 

Here’s a copy of our PowerPoint slides…

View more presentations from vincek.

and here’s DMAA’s writeup:

Helping physicians and hospitals meet the “meaningful use” criteria for federal support for health information technology under recently passed legislation represents a keen opportunity for the population health management industry, presenters at this session said yesterday.

Vince Kuraitis, JD, MBA, of Better Health Technologies, LLC, and Don Storey, MD, of RMD Networks, presented a look at the evolution of HIT and the electronic medical records systems from a strongly proprietary model with little interoperability to new model of integrated, modular applications from various vendors sharing common languages and platforms.

The Third Rail in HITECH Implementation: “Please Don’t Make Us All Speak Latin”

By Vince Kuraitis and Steven Waldren MD, MS.  Dr Waldren is Director of the Center for Health Information Technology at the American Academy of Family Practice (AAFP).

Two issues have rightfully surfaced front and center in the public’s understanding of HITECH Act implementation:

  • ” definition of “Meaningful Use” of EHRs, and
  • ” definition of “certification” process for EHRs

…and we applaud the progress of the workgroups and the HIT Policy Committee in addressing these issues constructively.

However…a THIRD issue lurks – “Data harmonization at the expense of data liquidity“, or put another way – “misplaced pursuit of one (and only one) language at the expense of practical communication.”

On August 20, the HIT Standards Committee approved recommendations to bring forward to the HIT Policy Committee meeting later this September. 

In this post, we will:

  1. Summarize aspects of the HIT Standards Committee’s recommendations that are problematic
  2. Develop an analogy to illustrate how the recommendations will limit innovation and increase barriers to communication.  Our analogy:

The Standards Committee recommendations are like mandating that everyone in the U.S. be required to speak Latin by 2013.


Dr. Blumenthal has wisely anticipated that there could be a situation where in his role as national coordinator that he should not follow a Committee’s advice:

“This committee does provide advice to the national coordinator, but it does not make policy,” Blumenthal said, with a noticeable emphasis on “not.” [iHealth Beat; August 18, 2009]

Dr. Blumenthal, this is exactly the situation you have anticipated.