I often write not because I have something that needs to be said, but to try to explain something to myself.  If I get to a point where I think I understand an issue, I’ll make it public to see if the comments reflect my understanding, or to see if I need to have another go at my own thought process.  Which leads me to this—

Let’s back up the horses for a minute and return from whence we came.  EHR.  The idea was simple.  Two groups; patients and doctors.  Create a way to transport securely the medical records of any patient (P) to any doctor (D).

For the time being, let’s keep this at the level that can be understood by a third grader.  What two things do I need to satisfy this P:D relationship?  Data standards and a method of transport.

Do we have them?  We do not.  That being the case, what fury hath the ONC wrought?  (1 Roemer 9:17)  If you don’t have what you need, and you don’t have either the authority or a plan to get what you need, you must facilitate (fund) the creation of workarounds to fill the void.

At some point, the conversation must have quickly shifted from, “We need standards and transport”, to, “Since we don’t have standards and a means of transport, we must come up with other ways to try to make this work.”  Now, I don’t believe this is literally what happened, but I think one could see how it might have evolved.

Other ways.  What other ways?  The ONC loves me; it loves me not.  HITECH.  ARRA.  SO, they get to work and the plan they develop is “Take the monkey off our back and put it on the backs of the providers”.  Pay doctors to implement EHR.  Smote them if they don’t.  Stick and garrote management.  Write checks.  Big checks.  Lots of big checks.  Instead of coming up with a single transport plan and one set of standards, provide guidelines.  Make pronouncements.  Fund RHIOs and make them responsible for creating hundreds of unique transport plans and ask the RHIOs what progress they are making towards a single set of standards.  Get the monkey off your back.

Create artificial goalposts that get the HIT world all a-twitter every time the ONC makes a proclamation.  What goalposts?  Meaningful Use and Certification.  Just so there is no misinterpretation of what I think the issue is permit me to spell it out—Meaningful Use and Certification exist because there are no standards and there is no means of data transport.  Conversely, had the ONC developed standards and transport, there would be no discussion of Meaningful Use and no Certification.  Standards would have forced vendors to self-certify.

The other activity could be viewed as a feint.  Not one developed out of malice, rather one that came about from the void that resulted from the lack of a viable plan.  Meaningful Use and Certification are expensive workarounds for a failed or nonexistent national EHR rollout plan.  As are RHIOs and RECs.

The HIT world grinds to a halt at the very mention of any announcement from the ONC.  Their missives are available in PDF or stone tablets.  Imagine someone robs a bank, and as they exit the bank, they jaywalk on their way to their getaway car.  The police missed the robbery, and focus all their efforts on the secondary issue, the jaywalking.

The chain of events has caused the focus to move away from the primary issues of no standards and no plan, and towards a plethora of secondary issues, issues for which hundreds of people are responsible and no single person has authority.

The model is in such disarray that by the end of 2013 any ONC pronouncements on Meaningful Use and Certification won’t be able to buy time on MTV.

If any of this is close to being correct, what are the implications for a hospital looking to select and implement an EHR?  Simple; pind the EHR that is best for your hospital–not the one most likely to earn ARRA money.  Not the one which will pass today’s Meaningful Use test.  Define your requirements.  What requirements?  The ones you believe will most closely align with how the healthcare industry will look in 2015 and beyond.  Meaningful Use will change.  Reform will change.  Funds will change.  Reform will change again.  Will your EHR be able to change?

The EHRs were written before most people even heard of accountable care organizations (ACOs).  What do you think the chances are of an EHR supporting ACOs without someone having to take it apart with a hammer and chisel?

The ONC’s Meaningful Use proclamation is 556 pages.  If you occupy the C-suite of your hospital, I hope you don’t let those pages define your selection of an EHR.  Some would argue that with so many pages that there must be a pony in there somewhere.  From what I read, I’m in no hurry to rush out and buy a saddle.