Along with the push to ramp up the use of health information technology in hospitals and doctors' offices comes the need for a highly skilled labor force to get the job done
Editor's note: This is an expanded version of the 2010 Workforce Report published in the May 24 issue of Modern Healthcare.
The American Recovery and Reinvestment Act of 2009, commonly known as the stimulus law, has a host of tight deadlines for its myriad health information technology subsidy and IT network development initiatives.
Nearly all of them are timed to help fulfill the ambitious goal set by former President George W. Bush in 2004 and adopted by President Barack Obama last year to make electronic health records available to most Americans by 2014.
Not surprisingly, a federally funded health IT workforce training effort is both part of the overall program and caught up in its mad rush.
“We are moving fast,” says Patricia Dombrowski, director of the Life Science Informatics Center at Bellevue (Wash.) College, which is leading a consortium of community colleges that applied for and won $3.4 million in workforce training grants funded by the stimulus law—covering career paths from information management to IT hardware installation.View charts on IT workforce
Preparations at the college are moving so fast, “We were talking about using roller skates this morning, but we raised our hands,” Dombrowski says. “We knew the time line, so I really feel confident moving forward.”
Last month, HHS' Office of the National Coordinator for Health Information Technology awarded $112 million of stimulus funds to dozens of universities and community colleges such as Bellevue for various IT workforce training and advanced-education programs ranging from six-month certificates through post-graduate degrees.
The faculties and administrators at those schools will be preparing feverishly for the fall semester and the first influx of what they hope will be thousands of new health IT students and job seekers.
Boosting employment nationwide was a major goal of the stimulus law, and there is little doubt, according to the government and industry leaders, that tens of thousands of new jobs will be needed if the federal effort to push provider adoption of EHRs is to be successful.
Under the stimulus law, both physicians and hospitals seeking subsidy payments for their IT purchases must use certified EHRs in a meaningful manner. Last December, the ONC and CMS issued rules for certification and meaningful use. In response to thousands of subsequent public comments, both rules are likely to be modified sometime this spring.
The National Center for Health Statistics, part of the Centers for Disease Control and Prevention, estimates there are 308,900 office-based physicians who are not federal employees, who are not working for a hospital's ambulatory-care program, and who are not radiologists, anesthesiologists or pathologists.
Almost half of these doctors are either in solo practice or work in partnership with just one other physician. According to the latest NCHS data available—the 2009 estimates from its National Ambulatory Medical Care Survey—only 21% of these office-based physicians have a “basic” EHR.
By NCHS definition, a basic system has rudimentary capabilities, including the ability to create patient problem lists and clinical notes and do electronic prescribing. Although it's not part of the definition, a basic system most likely lacks sufficient functionality to be certified under ONC rules and thus be considered to be an EHR system worthy of reimbursement under the multibillion-dollar stimulus technology subsidy program that is dominating the health IT landscape.
Just 6% of all office-based physicians use what the NCHS defines as a “fully functional” EHR. Such a system might have enough bells and whistles—such as automatic warnings of drug interactions and out-of-range test levels—that a physician using one might reasonably expect to qualify for federal EHR subsidy payments under the stimulus law, based on current drafts of ONC and CMS rules.
But even these advanced EHR systems are likely to require vendor upgrades to meet proposed ONC certification criteria, while many clinicians will still be expected to change their workflows and reporting requirements to fully qualify for EHR subsidy payments under proposed CMS meaningful-use standards.
On average, hospitals are a bit higher up the IT adoption curve than physician offices, but most hospitals are still a long way from where they'll need to be to achieve meaningful use under the proposed CMS criteria.
Computerized physician order entry is an advanced EHR function in hospitals. According to the CMS proposed rule, to qualify for federal EHR subsidy payments under the Medicare portion of the stimulus law, hospitals must run 10% of their orders through a CPOE system for a 90-day period sometime during the first year of the program, which starts this fall.
Jason Hess, general manager of clinical research at KLAS Enterprises, Orem, Utah, a health IT market research firm, says its latest survey data, validated between October 2009 and February 2010, show only about 16% of hospitals have CPOE systems up and running.
“And if you look at those that are doing 50% of their orders or more through CPOE, it's 11.3%,” Hess says.
Given the low levels of adoption and use, Hess asks whether it's even “realistic” for the CMS to require that all hospitals have CPOE installed in the first year and “get 10% of orders through CPOE.”
Talk of a looming labor shortage problem is on a lot of IT buyers' lips, Hess says. Some of the vendors are trying to address the problem by offering remote hosting services for their products, he says, but it remains to be seen whether the software-as-a-service delivery model will catch on fast enough and be used widely enough to make a dent in the workforce shortfall.
Small, rural and community hospitals will feel the stress most severely.
“It's kind of the Wild West for these folks who say we've got to do all the things the big hospitals do,” Hess says.
For starters, thousands of workers will be needed to simply install these EHR systems, configure them to local needs and train clinicians and other healthcare workers in their use. Thousands more will be needed to keep them running and to squeeze the data from them to improve patient safety and quality of care and warrant the multibillion-dollar public investment in them.
Leaders of organizations representing the nation's office-based physicians and hospitals are concerned their members might not be able do all that will be needed to qualify for EHR subsidies under current ONC and CMS rules, given the gap between their current IT adoption status and the high bar set for them in the December drafts.
On May 3, the American Medical Association, American Hospital Association and Federation of American Hospitals as well as a host of medical specialty societies sent a joint letter to HHS Secretary Kathleen Sebelius, calling for the government to dial back its proposed meaningful-use criteria as well as give them more time to meet its performance targets.
For both physicians and hospitals, time is money. The first “payment year” begins Oct. 1 under the Medicare portion of the EHR subsidy program, through which the bulk of the estimated $14 billion to $27 billion in federal IT reimbursements under the stimulus law is expected to flow.
The healthcare industry has not been caught unawares of an IT labor force shortage, even though the advent of such massive amounts of federal EHR subsidy payments have added a heightened sense of urgency.
Back in 2005, the American Health Information Management Association and American Medical Informatics Association formed a joint committee to try and gin up support for education and training in heath informatics and health information management.
They produced a report, Building the Work Force for Health Information Transformation in 2006. In a case of “be careful what you wish for,” one of that group's specific recommendations was to seek federal legislation and support for healthcare IT adoption and funding for IT education and training.
The stimulus law, with its buckets of money for EHR subsidies and education was all that, but with tight timelines as a kicker.
What eventually flowed from the AHIMA/AMIA joint effort was a report released in 2008 laying down what the two groups concluded are the core competencies of professionals working with EHRs.
In addition, AMIA is leading an effort to create a board certification program for physicians in medical informatics with the first credentials being awarded in 2013.
AHIMA, meanwhile, supported the design and rollout of the Virtual Lab for EHRs that provides Web-based coursework to more than 125 associate, baccalaureate and post-graduate health information management, or HIM, degree programs.
The latest figures from the Bureau of Labor Statistics pegged the medical records and health IT workforce in 2008 at about 173,000. About two in five HIM/HIT workers were employed by hospitals, with the rest scattered across physician offices, nursing homes, home health services and other outpatient centers.
Despite the current U.S. unemployment rate hovering just under 10%, the highest figures since 1983, job prospects for health IT workers “should be very good, particularly for technicians with strong computer skills” who will be “in particularly high demand,” according to a BLS report. The healthcare industry, it projected, will need another 35,000 of these positions by 2018, a 20% increase.
Claire Dixon-Lee is executive director of the Commission on Accreditation for Health Informatics and Information Management Education; the CAHIIM is a division of AHIMA that accredits 281 health information management certificate and baccalaureate degree programs at schools across the country. In the past, HIM workers dealt with managing paper records, but their jobs have changed with the times.
Dixon-Lee says that today many AHIMA members are doing the work of IT specialists at their hospitals and physician offices while others can be retrained for these new positions. CAHIIM-accredited programs graduate between 3,000 and 3,500 students a year, of which 600 receive bachelor's degrees and the rest associate's degrees, she says.
“Our data show a 95% placement rate, but we aren't producing them fast enough,” says Dixon-Lee, who cited a 2009 private workforce study commissioned by AHIMA last year projecting the need for anywhere between 12,000 and 50,000 new health information professionals over the next eight years.
Many Modern Healthcare readers who participated in our most recent annual IT survey reported having a tough time recruiting and retaining IT staff. A majority of survey respondents (58%) indicated they'll need to hire more IT staff in the next 12 months. Meanwhile, 49% of responding executives said they have a hard time hiring or retaining IT workers, most commonly, because of a scarcity of trained personnel, but also because of low wages for IT workers in healthcare compared with other industries.
Officials at the ONC think the demand for workers skilled in healthcare IT will be even greater than the BLS suggests, but perhaps near the upper end of the numbers Dixon-Lee cited.
“In the aggregate, we have estimated to get to meaningful use by almost all care venues in the country we're going to need something like 50,000 more trained healthcare workers in these roles than the educational system as it currently exists can produce,” says Charles Friedman, chief scientific officer for the ONC and its point man on ONC-funded educational and workforce development programs. The goal is to have 10,500 new healthcare IT workers trained each year over five years.
“We believe most of the people who can benefit from this program will come into it already possessing part of what they will need to know,” Friedman says. “They will be either IT people who will need to know more about health, or health people who will need to know more about IT. I can't say what the balance between those two is.”
Friedman says the ONC picked the six “career paths” that the community colleges will train students to take. Those jobs are: clinician/practitioner consultants; implementation managers; implementation support specialists; practice workflow and information management redesign specialists; technical/software support staffers; and trainers.
“We looked at the field as it was evolving, not as it is today, but as we expect it to evolve,” Friedman says. ONC staffers looked at all the activities under the stimulus law and the low EHR adoption rate “and said, OK, what's going to be necessary to get these practices from paper to electronic, and what roles are needed,” and what is needed to do it properly?
Under the ONC-supported, six-month certificate programs, U.S. community colleges are expected to train 10,500 students a year over five years. For those programs, there will be no certification organization required to look over the shoulder of the 70 community colleges expected to churn out those graduates.
“It's a bit early to be contemplating that,” Friedman says.
Instead, Friedman says, the ONC has awarded a $6 million grant to Northern Virginia Community College, Annandale, to create and administer a competency examination for graduates of the community college training programs. AHIMA is “very much involved” in the grant, Friedman says.
The individual competency testing program was chosen as an alternative to certification, Friedman says, “to make it very clear this grant award is to assess objectively a certain set of competencies in each examinee who sits for the exam.
“This could evolve in the future into some kind of certification program,” he says.
Community college graduates of the six-month certificate programs won't be required to sit for the competency exam, “but we hope they will,” Friedman says. Part of the money for the competency testing grant is to underwrite the cost of 20,000 students to sit for the exam for free, he says. “We're considering this as a pump-priming mechanism to ensure enough sit for the exam to demonstrate its value.”
For the new student certificate holders, “We think it will improve their job prospects. Think of how colleges use the SAT exam to complement a student's grades to enhance admission. I think in the same way, this exam will be a comparable assessment of a certain set of competencies,” Friedman says
“For a prospective employer, it will be information above and beyond” the educational program, Friedman says. Data on pass-fail rates from the competency exams could be aggregated and reported back to the community colleges to help them assess their programs, he adds.
Bill Hersh is a physician and chairman of the medical informatics and clinical epidemiology department at Oregon Health & Science University and a man on the hustle.
The university was a triple winner in the federal workforce grant competition, receiving a total of $5.8 million in funding for three programs—nearly $3.1 million for advanced training to medical professionals in healthcare informatics; more than $1.8 million to develop curricula to be used by community colleges to train healthcare IT workers; and $900,000 to serve as the National Training and Dissemination Center for the curriculum-development program.
Oregon Health & Science has an established, nationally recognized medical informatics program. At any given time, Hersh says, the university may have as many as 200 people enrolled in its post-graduate, 24-credit-hour certificate program and its 52-credit-hour, master's degree in biomedical informatics program.
About two-thirds of the current enrollment in those programs consists of clinical professionals—with half of that group being physicians—and the remaining third being computer people, Hersh says.
The federal, advanced-education grants will be for scholarships to those programs, Hersh says, with the caveat being that enrollees in the federally funded graduate certificate programs must complete their work in 12 months, whereas in the past, a typical enrollee, who works and goes to school at the same time, often takes longer to complete the same course.
“If they do our graduate certificate program, they have to do it all in a year,” Hersh says, but the trade-off for the rush is, “in essence, people can get a free education.” Tuition for the certificate program is about $12,000. “We have 45 slots per year,” Hersh says. “The people who don't get funded can still do the program.” It just won't be subsidized, he adds.
Aid recipients under this one-year, advanced educational grant program also must choose from six career paths: clinician/public health leader; HIM and exchange specialist; health information privacy and security specialist; research and development scientist; programmers and software engineers; and health IT subspecialist.
In addition to Oregon Health & Science, eight other universities will share in a total of $32 million in stimulus law funding for university-based, advanced IT education programs. They are: Columbia University; the University of Colorado Denver College of Nursing; Duke University; George Washington University; Indiana University; Johns Hopkins University; the University of Minnesota; and Texas State University, San Marcos.
Along with its graduate-level programs, Oregon Health & Science, as part of its triple-win, will join Columbia, Duke and Johns Hopkins as well as the University of Alabama at Birmingham in sharing ONC grants totaling $10 million to develop curricula to support the six-month, community college IT certificate programs.
The new curricula will cover 20 different content categories, including history of health IT, installation and maintenance of health IT systems, project management, and the use of IT in quality improvement.
“The people who got funded were all experts in informatics who have been doing this kind of instruction,” Hersh says, although none before have developed curricula for community colleges.
To make up for lack of community college experience, each of the contracting universities was obliged to enlist “a suitable number of community college partners,” Hersh says. “In my center, there are four community colleges partners. There are faculty that will work with us as subject-matter experts that will come up with curricula suitable for the community college setting.”
Work on curriculum development by the five universities and their community college partners began almost immediately after the grants were awarded in early April, Hersh says.
The schools have less than four months to complete their curriculum development work before Oregon Health & Science welcomes 400 community college educators to Portland in August for a crash course in the new IT training program outlines.
“It will be a pretty intensive week late that month,” Hersh says. After that, the newly trained faculty will return home and get ready for a hoped-for influx of new IT students. By the end of September, the entire first wave of new IT students is expected to be enrolled.
The participating 70 community colleges will form five consortia, each geographically dispersed, although not every state will have a participating community college. The five consortia will each be led by one community college—Bellevue (Wash.) College; Los Rios Community College, Sacramento, Calif.; Cuyahoga Community College, Cleveland; Pitt Community College, Greenville, N.C., and Tidewater Community College, Norfolk, Va. Grants awarded to these schools could total $70 million over the next two years—$36 million this year and up to $34 million the next.
Bellevue College's Dombrowski is director of the life science informatics center at the school, where administrators years ago foresaw the looming demand for health IT workers and began developing training programs to meet the industry's needs.
For example, the college has graduated about 17 health IT workers a year over the past six years from its own 12-month, 30-credit-hour health IT training program, Dombrowski says.
In 2008, as doldrums beset the Puget Sound IT job market, the college responded by creating a six-month program aimed at providing experienced IT workers from other industries with a background in healthcare IT. The 18-credit-hour program for these IT veterans opened this January with students to spare.
“We could have probably seated 50 or more, but we limited it to 25,” Dombrowski says.
In addition, Bellevue just finished curriculum development and will begin offering this summer a three-month program for incumbent physician-office practice managers on IT project management and EHR support, she says. “Now we're ready to scale up” for the HHS-funded training program, Dombrowski says.
Community colleges are not obligated to use the curricula developed by Oregon Health & Science and the other four universities, but all must focus their training programs on the six federally designated career paths. Although no single school is required to offer courses on all six job targets, each consortium must see that all six are covered within their group.
“I doubt we'll do all six,” Dombrowski says. “We have to see a little more about the curriculum before we make a decision about that.”
Bellevue could get by with just some tweaks to its existing courses and curricula to adapt them to the federal program, Dombrowski says.
“We think we're spot on and at the very worst, very close, but we have not seen the standard, and we've made some suggestions about the ONC accepting the existing curriculum, but that remains to be seen,” she says. If required, “We stand ready to implement the national curricula.”
Bellevue will receive $1 million from the ONC grant to oversee its consortium, which includes seven other community colleges. Each community college, including Bellevue, will receive the same $625,000 in federal grant money to run its training programs and other services. Bellevue's additional $375,000 will go to administer the consortium.
In addition to teachers and course materials, Bellevue will provide its students with retention programs, such as student tutoring and counseling, and employment services, Dombrowski says. The amount of money the ONC is providing, “seems adequate to the task,” she adds. “Community colleges are always looking at ways to enhance existing programs and add new programs and have a sustained output from it.”
Will there be enough time to develop and disseminate the curricula, train educators and be ready for the first day of school come September?
Dombrowski thinks so.
“It's wonderful in these tough times for people to be able to draw a direct line from training to be put to work,” she says. “The beauty of this is it's so directly related to people who need work.”