About a decade ago, first the tech folks and then the world in general began to murmur.  The murmur turned to a buzz and then the buzz became a blaze.

Everyone was talking about ‘It.’

Not IT as in ‘information technology,’ but ‘it’ as in ‘it.’  The new big thing.

‘As big as the PC,’ said Steve Jobs of Apple, a guy who knows a thing or two about ‘big its.’

‘Maybe bigger than the Internet,’ fawned investor John Doer, who backed Netscape and Amazon and has made a very large fortune from ‘big its.’

No one knew what the big it was, but everyone was talking about it just the same. 

Then we found out the it had a name.

Ginger.

With that the excitement went even higher.  Ginger seemed so mysterious.

Alas, we later learned that the code name ‘Ginger’ was not a tribute to the stranded red head on Gilligan’s Island, but rather Fred Astaire’s dance partner, Ginger Rogers.  That was OK.  She was a bit mysterious as well.

All throughout 2001, articles and news stories came out about Ginger and how ‘it’ would change the world.  ‘Cities will be built around this,’ predicted Jeff Bezos of Amazon.

Finally, in early December, 2001, we learned what Ginger, this new thing its inventor predicted would change the world, actually was.

A scooter.

I’m not kidding.  A motorized scooter had generated all of this hype. 

Ginger, we know now, was the two-wheeled, gyroscope oriented vehicle that is now occasionally seen being ridden by airport cops. 

She was the Segway. 

A friend of mine and his son recently rode Segways around the Garden of the Gods park in Colorado Springs.  He said it was a total blast.

Cute, fun, a blast – yes.

Change the world – not so much.

‘It won't beam you to Mars or turn lead into gold.  So sue me.’ shrugged Dean Kamen, the inventor, in response to the outcry of disappointment.

Granted, we’re not yet nine years removed from the HITECH EHR stimulus program as we are now with the mysterious Ginger, but we are getting far enough into the whole concept that some early opinions are forming.

Some are sounding a bit like, ‘Really?  That just looks like a cool scooter to me.’  Some are starting to wonder if all this money is really going to change healthcare as the hype has promised.

Maybe those are just the cranky cynics.

And maybe David Blumenthal, the wizard behind the curtain for the government on this whole EHR affair, will want to keep Kamen’s quote handy.

The hospital and large practice world appears to be getting a lot more traction than the independent practice segment.  However, those groups were ahead anyway and gaining momentum, so it is hard to tell how much impact the federal billions are having on moving the needle toward an IT-enabled industry. 

And in all fairness, anyone who has ever done anything with the independent practice segment knows these folks are generally not setting land speed records when it comes to the pace of change.  Small practice physicians are laggards when it comes to technology.  But that is supposedly why HITECH was passed. 

Maybe it is just too early to be drawing even preliminary conclusions.  Then again, it is only about four months until the attestation window opens for physicians to begin to claim those Stage One, Year One payments.

So, accepting in advance that I will be labeled the mutant offspring of the Grinch, trying to steal the HITECH spirit right here before the holidays, here are a few things that might cause someone to say, ‘Really?  It’s just looks like a scooter.’

News from the canaries in the cave, the EHR sales reps who get commission checks when physicians sign up, is not encouraging.  At a recent gathering with a bunch of them from most of the major vendors, the group was a lot more down in the mouth than you would guess given their clients are going to get reimbursed for buying their product.

Clearly, there is a lot of heat and light in this space.  Only those practices living under a rock are not talking to vendors about their EHR.  But activity is not progress.  One source claimed these folks are doing 20 demos for every sale.  I don’t have the hard data, but here’s guessing that is not materially better than the pre-HITECH days.  I’d even wager that it is worse.

What the HITECH incentives have done is bring too many customers into the sales process that are just not ready to buy.  They are, at a DNA level, late adopters of technology.  But the promise of free money causes a lot of weird behavior, so here they are, kicking tires and asking for demos, creating lots of activity.  Yet, the independent physician EHR space is still pretty immature.  Late adopters need a lot of assurance and comfort before buying.  What they want is just not here yet, and future subsidy checks don’t magically make those needs go away.

Thus the canaries are busy, busy, busy, but not busy running to the bank to deposit their checks.  Not a good sign.

It also turns out that price-sensitive buyers, which is much of the independent physician segment, are still price-sensitive in spite of the HITECH subsidy.  Maybe it is hard wired; maybe it is because they have to put the money up first and the incentive payments come later; maybe it is a suspicion that in the upcoming debt and deficit battles that will dominate the new Congress this money will get pulled back.  Maybe it is a little cynicism that comes from not having a Medicare pay raise in, oh, a dozen years or more.  Whatever the reason, these physicians still care about price.

What is happening in response?

Old vendors are stripping functionality and costs out of their product to offer a ‘lite’ version, in part because new vendors have newer architecture and have not yet accumulated years of functionality add-on, allowing them to sell at a lower price.

Implementation services, a key part of the cost of an EHR, are being streamlined, delivered online, put into ‘do-it-yourself’ tools, and sometimes just flat ignored.  One vendor promises you can be ‘Live in Five’ on their EMR.  Minutes, that is.  Five minutes.  If you’ve been anywhere near any technology implementation in any industry at any time, you know that is NOT quite the whole story.  If you understand what the Meaningful Use criteria require in order to receive subsidy payments, that approach to implementation will make you laugh out loud.

Well, the implementation issues are going to be solved by the RECs, right?  This army of new organizations, many not-for-profit, are going to be paid to help small physician practices adopt EHR technology.  A lot of government grease is being applied to establish RECs so this massive level of technology adoption will all go smooth and fast.  But there are some inherent problems.

The mission of the RECs has to be accomplished in a very short window of time.  Software vendors who have been hammering in this market for years will tell you this audience does not buy quickly.

It will also be tough to find and get the right talent on board.  Most RECs will not be able to hire and deploy people in the necessary time frame to actually deliver on their mission.

Speaking of talent, the RECs are competing with the vendors for already scarce experienced HIT resources, something that is not helping the overall problem. 

Furthermore, what the RECs are charged to do by CMS is already being done by the vendors, consultants and solution providers like ALN.  The duplication is not helping, but merely adding to the noise physicians have to sort through as they make these decisions.

The final argument lodged against the RECs is that they limit the market.  With the staffing and time limitations, most are doing a logical thing – they are selecting a short list of preferred EHR vendors.  But in the process, they are artificially and prematurely reducing the options for any practice that elects to use the REC in the process.

RECkless and ‘Train REC’ are my favorite satirical tags penned by some of the REC critics.

We are now hearing more frequently that specialty physicians, most often through their specialty colleges, are pushing back on the Meaningful Use criteria, claiming rightly that the criteria are very primary care focused and do not apply to them.  Some are supposedly receiving waivers, not to simply ignore or replace a criterion that does not apply, but to ‘count it’ as fulfilled if it does not apply to their specialty.

Really?

So if my specialty would not naturally do the work or collect the data related to one of the MU criterion, I get to count it as one that I have actually satisfied?  We’re going to pay physicians to attest to the fact that their electronic system does not collect data that their paper charts did not collect.  How do I get in on that gig?

In case you think I am just being a negative wag who needs to channel his inner Stuart Smalley (If you are too young to get that reference, just know that it somehow leads to the strange juxtaposition of ‘Saturday Night Live’ and ‘US Senate’), know that a CMS deputy administrator recently told a group that they really don’t think HITECH will get a lot of small practices across the EHR line and they are counting on Accountable Care Organizations (read:  Hospitals buying up those practices) to take care of it.

A friend of mine regularly rails, from a tax payer perspective though he is an HIT industry guy, that this whole mess is a shame.  Stage One Meaningful Use requirements were watered down substantially, and continue to be whittled away bit by bit.  Software and implementation are dialed back accordingly.  And now, a physician can get about 70% of their stimulus money from just meeting Stage One objectives.  Why, he asks, wouldn’t a physician simply get to the lower level MU thresholds, pocket 70% of the money, and then stop?  So we pay most of the money and get few of the promised benefits?

Let’s recap.  More physicians are moving to an EHR, but we might not get that many to adopt, and what they do adopt will be called ‘electronic,’ but will likely fall short of the kind of IT-enabled industry transformation that was envisioned.  But, we’re going to spend a boat load of money doing it.

Kind of looks a little like a scooter, doesn’t it?

Does this mean that I am recommending physicians just ignore all of this EHR talk?

Of course not.  Remember, ALN does sell these for a living.  I might be slow, but I am not totally stupid.

But, as we have said to our clients from the beginning and in this space repeatedly, this is a long term business decision, not a short term coupon grab.  There are big, macro market forces that are driving physicians to implement this technology. And done right, there are big, tangible, financial benefits for physicians.

The HITECH money is a consideration that might cause you to go now instead of a year from now, but it probably should not fundamentally change your overall decision making framework. 

Do it when it makes strategic sense.  Do it in a way that lets you change the way you practice so you are stronger to survive the future and deliver better care to your patients.

Then if you get some HITECH money, go buy a Seway. They are pretty fun to ride.