reform

The change keeps changing

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Hello to those whom I’ve yet to meet.  This is rather long, so you may wish to grab a sandwich.

I write to share a few thoughts.  I reside in the small place where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s where those who place principle over fees dare to tread.

Where to begin? How to build your provider executive team? (Those who wish to throw cabbages should move closer to their laptops so as not to be denied a decent launching point.)

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time your project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing a healthcare organization, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon, external influences—the implications of reform and Stages 2 and 3 of Meaningful Use, and a national roll out of EHR with no viable plan to get there.  Staffing only to execute today’s perceived demands will get people shot and will fail to meet the needs of hospital. To succeed we need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare implications of reform and IT.  They’ve also indicated—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform.  I somewhat disagree with that perspective.

Here’s a simplified version of the targets I think most of today’s hospital CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them.  Here’s what I think. You don’t have to accept this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since this is my piece, I used it.

Before we go there, may I share my reasoning? From a business perspective, many would say the business of healthcare must move from a 0.2 to a 2.0 business model. (This is not the same as the healthcare business—the clinical side.)  The carrot?  The ARRA incentives—an amount that for many providers will prove to be more of a rounding error than a substantive rebate.

Large healthcare providers are being asked to hit complex, undefined, and moving targets, and they are planning on adapting to reform and reforming their own business model while they implement systems which will change how everyone works.  Hospitals are making eight and nine figure purchase decisions based in part on solving business problems they have not articulated. If success is measured as being on-time, in-budget, and fully functional and accepted, for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

Their overriding business driver seems to be that the government told them to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on an EHR system than they would to build a new hospital wing.  Many don’t know what the EHR should cost, yet they have a budget. Many don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff to help ensure my success—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot.  I’d staff with a heavy emphasis on the following subject matter experts:

• PMO
• Planning & Innovation
• Flexibility
• Change Management
• PR & Marketing

Contrary to popular belief, not all of these high-level people need to have great understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years for now the government would like us to believe there will be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of RHIOs, and mapped to a N-HIN.  Under the proposed model, standardization will not occur if only for the fact that there is no monetary value to those vendors whose standards are not standard.

Interoperability, cost, and the lack of standardization will force a different solution—one which is portable.  I think the solution will have to be something along the lines of a single, national, open, browser-based EHR.  It will be driven by consumers.  Consumers will purchase the next generation of super-smart portable devices that offer a combination of iPad/iPhone functionality.

The Personal Health (PRH) will have evolved to become the EMR.  How is this possible?  What do smart devices do?  They do one thing, billions of times each day, and they do it perfectly—they send and receive ones and zeros.  That is what today’s EMR are—ones and zeroes.  Those next-gen devices will be EMR-capable.  Why?  Because there are more than a hundred million customers who will keep buying these devices.

The so-called N-HIN will be the new Super Internet—not some cobbled together network of RHIOs.

Firms like Apple, Google, and Microsoft will drive this change.  We already buy everything they offer, in fact, we line up at midnight to do so.  By then, those firms will care less about selling the devices than they will about transporting the ones and zeroes that comprise the data.  Their current PHRs are their way of introducing themselves to consumers as players in healthcare.

The point I am trying to drive home is that from being able to adapt to change and reform, lean towards staffing the unknown.  Staff with leaders, innovators, and people who can turn on a dime. Build your organization like turning on a dime is your number one requirement. Don’t waste time and money worrying about Certification or Meaningful Use. If anyone asks you why, you can blame me.

If you want a real reason, I have two. First, they won’t mean a thing five years from now. Second, if I am the person writing an incentive check, I want to know one and only one thing—will your system connect with the other system for which I am also writing a check?  That is the government’s home run.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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When reform collides with EHR…

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If I remember my physics correctly, there’s no discernable difference between screaming in a vacuum and not screaming in a vacuum, unless of course someone turns it on while you’re in it, and then by default, you’re screaming. That seemed to make sense to me during my run, but seeing it on the screen isn’t doing much for me. Ever since I tore my Achilles I can’t run as far, and I’ve gained a few pounds. I feel like I’m in my first trimester-running for two of us, sort of a Shamu in Nikes.

Enough about me.  Here’s the deal. There seems to be a slight shifting of the winds in terms of those who now believe reform will work.  The winds are blowing more towards the skeptics.  Who among us can articulate what is included in the reform effort in a single PowerPoint slide?  (Can you picture Ross Perot with his slides and wooden pointer?)  If we can’t explain the reform effort to ourselves, how then can we explain the business problem we’re trying to solve with EHR?  Until you’re comfortable articulating the benefits to your organization—not the ones spelled out on a dot-gov web site, you’re better off holding on to your checkbook.

The current EHR/healthcare reform effort violates Keynes’ third law of shopaholics anonymous–just because something you can’t afford and don’t need goes on sale doesn’t mean you have to buy it. (Unless of course it impresses your friends.)  In addition to the trillion dollar stimulus, maybe the government was awarded discount coupons–20% off on EHR if redeemed before the payors own the providers.

Does reform need to be reformed?

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The following is the comment I posted to,

Kent Bottles: Is It Really Impossible to Control the Cost of Health Care in the U.S.?

Kent, your narrative should be mandatory reading for all those in Washington whose vision of reform stands in stark contrast to the piece. Then, before they are allowed to propose or vote on their vision, they should be forced to explain why their vision doesn’t address these issues.

In my non-luminary opinion, here’s where I think the reformists have failed. The notion of spending funds that don’t exist, to fix things that may not be broken, without fixing those that are could only come from Washington.

Permit me to over simplify things to make a point. When I look at healthcare, I see a three legged stool; pharma, the payors, and the providers—the three P’s. Not exactly in a pod, each working to their own benefits and operating under different business models—models which are in conflict. For example, many hospitals operate as not for profits, which conflicts with the for profit sectors.

I believe the present reform effort will increase the conflict. Why? Because the legislation is siloed—it looks a lot like the word ‘soiled’ which might also be part of the problem. The legislation does not seem designed to address healthcare as in integrated industry. The way reform is positioned, each nudge that is put to one leg of the stool will cause a reaction, an unfavorable one, to the other legs. It is a little like doing an experiment, changing multiple variables at once, and hoping for the best.

Two sides of the stool, the payors and pharma, have behemoths running the show. Among the behemoths, the business models in pharma are quite similar and the same holds for the payors.
I think it is important to distinguish between the business of healthcare (the dollars and cents) and the healthcare business (the clinical side). The provider segment is highly fragmented. There is no behemoth provider cartel. The business of healthcare, is the side most in need of reform. Each of the thousands of providers operates under their own business model. None of these businesses was designed to be interoperable—I do not use this term in the same sense being used by the ONC and CMS.

The business of healthcare, with all of its inefficiencies, is designed to operate within its four walls and across a limited geographical radius. The long term goal of healthcare reform, I believe, is to make the provider side appear as one giant services provider. Just because consolidation sort of worked for steel, the airlines, and the automotive industry does not mean it will work for delivering healthcare.

My final comment has to do with the payor side of healthcare, and I’ll start by acknowledging that this one is more than a little provocative, one for which I have not thought through a workable solution—I’ll leave that to those of you who aren’t grasping for metaphorical tomatoes to throw. I could be convinced to skip the rest of my comments if for a moment I thought that the business model of the payors was—let’s cover everyone who needs care for a fair cost. Ignore for the moment that my statement is naive.

We know that on a small scale it is possible for people to self-insure, to meet their needs without having to rely on payors. I’ll frame my final comment with a question—where is the value-add to healthcare from the payors?

Here is my issue with the current model. You want to go to the movie, you hand me ten dollars for an eight dollar ticket, and I pay the movie theater on your behalf and pocket the two dollars. In this instance I am merely the middle man, I manage the transaction. The theater gets no marginal benefit, and you get no marginal benefit.

Not complex enough? Let’s say someday millions of people want to go to the movies and a ticket will cost them eight dollars. Anticipating that, everyone pays me a dollar a day so that when the time comes they can go. On that day, I pay for movie tickets for those who want to go, pocket the difference, and I keep the money for those who don’t go.

In my small mind, that’s how I view the payor leg of the stool. I think the payors relish reform. I think the more they complain about how badly this will hurt them the more they may like it. It reminds me of the Uncle Remus story in which Brer Rabbitt pleading with Brer Bear and Brer Fox not to throw him into the briar patch.

What industry wouldn’t be salivating if they could find an additional thirty or forty million customers overnight? What if you could charge them a monthly fee and make the co-pay so high that you might not have to cover major medical claims? Does this sound absurd or does it sound a little like the mortgage banking industry? Fess for no service. I am not saying that this will happen in every case, but I do not think one can argue that this will never happen.

Circling back to how to reform reform. From my vantage point, the most advantageous reform idea would be to force multiples of payors to compete in every state. Competition could do wonders for cost control.

A final thought. Earlier this year a House committee passed legislation on “can’t fail” businesses. The Financial Services Committee voted on an amendment that would let regulators dismantle a firm, limit mergers and acquisitions, and force an end to activities deemed systemically risky. The financial industry opposed the measure, as part of legislation to overhaul Wall Street rules. This could be another opportunity for the camel—Washington—to get its nose further under the healthcare tent. There is nothing that limits the legislation to financial services. Call me a cock-eyed pessimist, but what is there to prevent Congress from deciding that the payors need to be dismantled, thereby ushering in a federal payor model? That would give them two legs of the stool. What if…?

How difficult are EHR, Reform, & Interoperability

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My daughter asked me to kill the bug in her room—Super Dad to the rescue.  That got me wondering.  Do most men think we excel at most things?  As I pondered weak and weary, I started to formulate this list.  I ask the men as they read through the list to score themselves on a ranking of one to five, with five being the highest, how they view their abilities in each area.  Ladies, feel free to play along on behalf of someone you know.

  1. Sunday Sports
  2. Getting a taxi
  3. Navigating
  4. Mowing the lawn
  5. Killing spiders
  6. Drawing a straight line by hand
  7. Multitasking
  8. Parallel parking
  9. Anything to do with fire
  10. Opening jars
  11. Sharpening a pencil with a knife
  12. Tipping
  13. Driving
  14. Cooking on the grill

Maybe this comes from that hunter-gatherer thing.  Total your score silently in your head—you can do this because you also happen to think you excel in math.  My guess is that 98% of us scored somewhere between 56 and 70, the majority leaning towards the higher end of the range.  Granted, these are simply opinions, nothing any of us has to prove.

However, when pushed most of us will back down on one or two things if we had to prove our prowess.  Take juggling for example.  Even an egoist will be reticent to rate himself an excellent juggler.

Here we go.  Why then when we (ladies, this also includes you) are faced with something challenging at work we do our best to convince ourselves and others that the task can be no more difficult than opening a jar, asking directions, or asking for help?  We prefer to fly solo, believing we will somehow figure it out on the way.

I cannot recall the last time I heard someone facing a big ugly IT project state anything like:

  • You’ve got the wrong person
  • I have no idea how to do this
  • There is no way this is going to work

EHR, reform, Meaningful Use, interoperability.  These are big ugly projects.  Some are projects for which only a scarce few have real subject matter expertise—a handful of which truly ‘get it’, and others for which no one is credentialed.  Yet when we hear the proclamations about how standards are coming, how the N-HIN will work, and how reform will impact healthcare over the next five years, they seem to be stated with such assurance so as to infer that these industry-altering programs are no more difficult than parallel parking.

Remember the game Trivial Pursuit?  There was an inverse relationship between how certain I was of an answer and the certainty with which I asserted it.  If I said the answer quickly and with enough confidence I could occasionally convince the other players not to even check the answer on the back of the card.  For example, if the question is “name the bird who lays its eggs in the nest of another bird,’ and you belt out, ‘racket-tailed coquette,’ you just may pull it off.

It’s just an observation on my part, but why is it that when the nice people in charge tell us that they know what they are doing to me it sounds like they are yelling, racket-tailed coquette.’

I am Stupified

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Got the T-shirt.

Did you know AIG got $79 billion?  There’s also our friends at Goldman.  This got me thinking—some would argue that it in itself is noteworthy.  There’s a reason nobody shed tears for these guys, and that is the average person has no connection to them other than what they hear on the evening news.  We never got a car loan or a mortgage from them, so when they were dangling over the precipice we wouldn’t have lost any sleep had they been allowed to fail.  Unfortunately, the reports of their death were greatly exaggerated.

American poet John Godfrey Saxe based the poem The Blind Men and the Elephant on a fable told in India many years ago.  The poem is about blind men trying to describe the elephant solely on what they are able to feel.  As they are all feeling a different part, they each think the elephant is something different from what it is and from what the other believes.

It feels like the reform effort involves an equally obtuse process—dozens of people in separate rooms, each with their own pad of paper and box of Crayolas. When they finished creating their vision of reform, the person with the biggest office stapled all the pages together with the big red stapler like the one they used in the movie Office Space.

Here’s how this all ties together—don’t blink or you may miss it.  People weren’t vocal about AIG and Goldman because we weren’t connected, because it wasn’t personal.  The opposite is true about healthcare reform.  We are connected.  It is personal.  This is what Washington doesn’t get.  If they don’t demonstrate that they get it, it will fail.

Nancy Pelosi has been the poster child for the reform effort.  Her unfavorable ratings are at two to one.  Sixty percent of Americans, also known as voters, are against the reform.  I’d wager that nearly one hundred percent of those people have insurance, and rightly or wrongly, they believe that reform will take that from them.  There is a small but important distinction here.  They are not against reform per se; they are against the reform as is being discussed.  Moreover, the snowball rolling down hill that Washington–and most of the east coast–can’t stop is that nobody can accurately describe what it is they’re against.

How can the average person know if reform will work?  If reform can’t be explained clearly on a single page, Washington will lose the voter–they have.  The opponents of reform had their message down to a page; the one bullet point is “change the bill.”

My 1st post on HealthsystemCIO.com

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The following is my first guest post on Anthony Guerra’s new site, HealthsystemCIO.com.

If you haven’t begun the process of selecting and implementing an EHR, Meaningful Use may not be something with which to concern yourself. The reason, you probably will not be done in time to collect the incentive money. How can I state that with such assurance? One of my clients has already implemented EHR and CPOE—already done the heavy lifting—and they will have to divert most of their resources just to meet the Stage 1 requirements.

If you haven’t begun, there may be no rush to acquire a vendor, although the vendors will not tell you that. Rushing may lead to a bad selection. Don’t cost yourself tens of millions get to have a chance at a few. By the way, did any of the vendors with whom you are speaking mention that they have no clue if their system will meet any of the Stage 2 and 3 requirements? Right now, it’s like the vendors are selling cars without knowing whether it will need to run on gas or Hydrogen.

I think the Meaningful Use dates will be pushed back. Why? Because few if any of the providers will be in a position to apply for the incentive money. Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.

Now for those whose EHR implementation is well underway or up and running — should you try for the incentive money? That’s a valid question. Just because someone is offering you a check doesn’t mean you have to take the money. Here are some questions you ought to be able to answer prior to deciding if Meaningful Use is meaningful to you.

  • Meeting MU requires a shift in your direction; you take on the MU tasks and sacrifice some of what you were going to do
  • What are those tasks, what resources will they consume
  • What year is the best year for you to meet MU; 2011-2015?
  • Did you know you can still maximize incentive dollars if you pass MU in 2013?
    • That gives you very little time to react to Stage 2 & 3 requirements

Meaningful Use is a binary contest — you make it or you don’t. The decision to meet Meaningful Use does not have to be binary. There is no way to collect for meeting 90 percent of the requirements. How might you financially calculate the probability of obtaining the incentives? Let’s begin with Stage 1—the easy one.

  • Calculate the maximum incentive you could receive
  • Multiply that figure by the degree of certainty you have that your plan will be completed on time — a number less than 1
  • Then multiply it by the probability you think exists for passing the audit, another number less than 1
  • Calculate your cost to complete Stage 1, then figure out your ROI — not much is it?I’ve seen one provider whose ROI is negative.
  • This makes evaluating Stage 2 & 3 calculations seem rather superficial. Want my advice for calculating an ROI out of requirements that don’t exist? I’d use a placeholder of six zeros preceded by a number greater than five for each Stage.

So take time to evaluate your options. The only people who will look foolish are those who don’t know what questions to ask.

How will reform impact Payors?

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I have developed quite a fondness for children’s books, particularly those with a well disguised allegory.  Long favorites of mine include the short stories, Uncle Remus, written by Joel Chandler Harris.  Br’er Rabbit (“Brother Rabbit”) is the main character in each of the stories, a likable troublemaker and prone to tricks.

His opposition is usually Br’er Fox Br’er Bear. In one tale, Br’er Fox and Br’er Bear hope to capture Br’er Rabbit.  Fox constructs a lump of tar and puts clothing on it. When Br’er Rabbit comes along he addresses the “tar baby” amiably, but receives no response.  Br’er Rabbit becomes offended by what he perceives as Tar Baby’s lack of manners, punches it, and becomes stuck. Now that Br’er Rabbit is stuck, Fox and Bear ponder how to dispose of Br’er Rabbit.

With each idea suggested for his demise, Rabbit has no complaints, however the helpless, but cunning, Br’er Rabbit always pleads, “Do with me what you will, but please don’t throw me in to that briar patch.”  Finally catching on to how “frightened” Br’er Rabbit is if the briar patch, Fox, believing he has the upper hand, throws Rabbit into the briars.  As rabbits are at home in thickets, the resourceful Br’er Rabbit convinces his enemies to do what he wanted them to do all along.

Sound familiar?  It should.  Br’er President and Br’er Congress.  The contest is how do they capture Br’er Payor and get Payor to play nicely.

“Let’s put caps on Br’er Payor’s rates,” suggested Br’er Congress.

“Do with me what you will,” pleads Br’er Payor.  “Cap my rates, but please don’t make us cover the uninsured.”

“Why not make Payor cover pre-existing conditions?”  Asked Br’er President.

“Do that,” chided Br’er Payor.  “We’ll even cover hangnails.  But please don’t make us cover the uninsured.”

“You know Br’er President,” said Br’er Congress, “Br’er Payor seems awfully afraid that we will make them cover all of the uninsured.   Let’s do that, let’s hit Payor where it will hurt the most.”

And so they did—made Br’er Payor cover the uninsured—threw them right into the briar patch.  Right where Br’er Payor wanted to be all along.  Thirty-one million new customers—how awful.  Smack dab in the middle of a recession, payor is handed a windfall of new customers.  Premiums.  Times twelve—twelve months.  Let’s estimate a hundred dollars a month.  That’s about thirty-seven billion in new revenues.  Billion with a B.  How is that for cutting healthcare costs.

Now suppose, just suppose that Br’er Payor has little motivation to be a good corporate citizen.  I know I am asking you to take a leap of faith.  Silly me, but I have this question that is gnawing at my craw.  What if Br’er Payor collected all these premiums and set the deductible so high that none of their new customers was ever able to file a claim?  The feds tossed the payors right into the briar patch, didn’t they?

Thank you for reading and commenting

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Curious to hear your thoughts as to what impact the election of Senator-Elect Brown will have on the current healthcare legislation?

What’s the deal with reform?

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In the sixties, the initial funding for Medicare or Medicaid was sixty-five million dollars.  For purposes of this discussion, it does not matter which one.  It’s now more than a trillion.  Most floods start as a trickle.  Stay with me and see if this makes sense.

One cold night, as an Arab (this is not profiling, I pasted it from the web) sat in his tent, a camel gently thrust his nose under the flap and looked in. “Master,” he said, “let me put my nose in your tent. It’s cold and stormy out here.” “By all means,” said the Arab, “and welcome” as he turned over and went to sleep.

A little later the Arab awoke to find that the camel had not only put his nose in the tent but his head and neck also. The camel, who had been turning his head from side to side, said, “I will take but little more room if I place my forelegs within the tent. It is difficult standing out here.” “Yes, you may put your forelegs within,” said the Arab, moving a little to make room, for the tent was small.

Finally, the camel said, “May I not stand wholly inside? I keep the tent open by standing as I do.” “Yes, yes,” said the Arab. “Come wholly inside. Perhaps it will be better for both of us.” So the camel crowded in. The Arab with difficulty in the crowded quarters again went to sleep. When he woke up the next time, he was outside in the cold and the camel had the tent to himself.

Here’s my take on where we are.  I know you didn’t ask, I simply sensed you wanted to know.  Reform will pass.  What kind of reform?  Who knows?  Very few of us. Who cares?  A large number of those voting on it, those whose winter condos lay inside the 495 corridor don’t care.

Will healthcare reform legislation be the 3 AM call of our generation?  Many raised this same question in 1993.  Would it be different had the republicans brought healthcare to the table?  We will never know.  It does not matter if the camel’s nose enters from the left side or the right side of the tent.  Others debate which end of the camel is in the tent.  It matters not.  Once the Chicago Cubs went to night games, we were forced to change how we look at the world.

There are many things in healthcare reform.  I think that the most important one is the government.  It’s like a bad stain, once it’s in, it’s difficult to remove.  You may choose to differ, but I think the crux of the discussion is not what the details are in the reform legislation, but that it exists.

I agree fully that reform is needed.  Unfortunately, once we let the government drive, we never again get the keys.  In for a penny, in for a pound—if you convert from the Euro, it still makes sense.

Call me a cock-eyed nihilist

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I offered the following comment to Kent Bottles post,

My New Year’s Resolution: To See the World Clearly (Not as I Fear or Wish It to Be).

http://icsihealthcareblog.wordpress.com/2010/01/04/kent-bottles-my-new-year’s-resolution-to-see-the-world-clearly-not-as-i-fear-or-wish-it-to-be/#comment-131

As this is the first Monday of the New Year, I had not planned on thinking, at least not to the extent necessary to offer comment on your blog.  I distilled it to three points—perhaps not the three about which you wrote, but three that tweaked my interest—happiness, counterfeit, and healthcare clarity.

Suppose one argues that happiness lives in the short-term.  It is something that one spends more time chasing than enjoying, something immeasurable, and once attained has the half-life of a fruit fly.  I do not think it is worthy of the chase if for no other reason that it cannot be caught.  As such, I choose to operate in the realm of contentment.  Unlike happiness, I think one can choose contentment.

There are those who would have us believe that contentment, with regard to healthcare, comes about through clarity, and that clarity comes from contentment—the chicken and the roaders.  Those are the ones who argue that reform, any reform, is good.  Where does the idea of counterfeit come into play?  I think it is the same argument, the one which states that any reform, even something counterfeit, is good.  The healthcare reform disciples argue that reform in itself is good; be it without objective meaning,purpose, or intrinsic value.  Therein lays the clarity, even if the clarity is counterfeit.

Call me a cock-eyed nihilist, the abnegator.  I am not content.  My lack of contentment comes not from what is or isn’t in the reform bill.  It stems from the fact that reform, poorly implemented, yields an industry strapped to change, an industry that may require greater reform just to get back to where it was.

Healthcare IT reform, HIT, will have to play a key role in measuring to what degree reform yields benefit.  Without a feasible plan, HIT’s role will be negative.  There are those who feel such a plan exists.  Many of those are the same people who believe the sun rises and sets with each announcement put forth by the ONC.

I think the plan, one with no standards, one that will not yield a national roll out of EHR, is fatally flawed.  I think that is known, and rather than correcting the flaws, the ONC has taken a “monkey off the back” approach by placing the onus on third parties, and offering costly counterfeit solutions like Meaningful Use, Certification, Health Information Exchanges, and Regional Exchange Centers.  If the plan had merit, providers would be leapfrogging one another to implement EHR, rather than forcing the government to pay them to do it.