Trustees around the country likely have been jolted by the capital commitment and care recalibration associated with federal incentives for adoption of health information technology in hospitals and physician settings.

Those incentives in the American Recovery and Reinvestment Act calling for meaningful use of electronic health record systems will be attainable only if providers invest in new or significantly upgraded computer systems and ensure they are introduced into care settings in ways that yield the eligible results. It's a complex but essential undertaking with not only near-term incentives at stake, but also extended financial and quality performance implications long after the ARRA is history.

Now envision that considerable IT investment dead in the water or at least struggling to demonstrate its intended benefits. That could happen without enough experienced hands on deck to manage the technological challenge. Health care is heading into a serious IT workforce shortage just as the world of health IT needs to ramp up for its biggest job ever.

The industry has contended with shortages of IT professionals before, notably in the Y2K marathon of the 1990s. But this staff shortage is not just about numbers. It's about a dearth of rare individuals who are equally at home in clinical and technical settings during a period in which all health care entities will need them to meet the same comprehensive objectives by the same unforgiving deadlines.

"We are competing for the same [human] resources with a number of players," says Douglas Abel, vice president and chief information officer of Anne Arundel Health System, a single-hospital system in Annapolis, Md., along a Baltimore-to-Philadelphia corridor of large health systems with high demand for sophisticated health IT staff. "We're all competing for the same level of expertise as well."

In a poll of health care CIOs last fall, more than 70 percent said their organizations had inadequate IT staff to implement the clinical software that's critical to raising the level of their computer systems to meet government expectations. About 10 percent said inadequate staffing definitely would complicate their ability to qualify for incentive payments, and another 50 percent said staffing might affect their chances.

The prime issue is the quality of individuals rather than quantity, as was the case in the 1990s, says Abel. "Y2K was primarily a technical problem. The difference you see now is, while there is a competition for purely technical resources, the real competition is for IT-savvy, clinical resources. It's the people who can create change, and frankly that's what this is about."

Meeting Uncommon Needs

According to David Blumenthal, M.D., national coordinator for health IT, the prevailing data "indicate a shortfall over the next five years of about 50,000 qualified health IT workers required to meet the needs of health professionals and hospitals as they move to adopt EHRs." He made the statement in announcing last October a $118 million infusion of federal money into the training of health IT workers to fill a dozen specific job descriptions tied to EHR adoption.

But to fill the bill right now, "You're talking about very specialized people who understand the business of health care," says Keith Fraidenburg, vice president for education and communications with the College of Health Information Management Executives, the trade group for health care CIOs that conducted the workforce survey.

"Physicians, nurses and other clinical users of electronic health records are some of the smartest people in our workforce," says George Hickman, senior vice president and CIO of Albany (N.Y.) Medical Center. "You have to sit highly competent, people-centric, experienced talent across the table from them to create systems that can be adopted into their work habits."

That calls for an extra set of skills that may be uncommon in an IT professional, even a veteran one, says William Hersh, M.D., chair of the medical informatics and clinical epidemiology department at Oregon Health & Science University in Portland. "You hear that IT people just don't really understand the culture of health care; a lot of them don't have good soft skills—of being able to listen and process and work together in teams and things like that—that you need for these sorts of complicated health IT projects to succeed," he notes.

The IT projects in question don't end with installation of tools to enable meaningful use of EHRs. Each system carries a lifetime load of staff expense to keep it running, upgrade it often and get the most out of it. What's more, all providers must overhaul their medical coding systems to an expansive new disease classification scheme that determines how services are paid for—a concurrent assignment for many of the same types of IT staff.

For boards, their first level of understanding involves "recognizing what these systems really take to undertake and support," Abel says. "All of us get charged up for the project, and there's less emphasis on really what it takes to manage these systems. And frankly the work's just beginning. There's so much more to be done to enhance, to optimize, to leverage the platform that you're putting in place."

Secondly, boards need to "recognize what the competition for these resources is," he adds. "Not only do we need certain levels of staffing, but there's the demand for those staff." That means once you have the top guns on board, you'll most likely have to fight to keep them.

From Recession to 'Gold Rush'

First, the industry has to get a grasp on the issue. For example, the grip of a deep recession may have skewed the CIO survey's results on the scope of the staff shortage, says Fraidenburg. Though seven in 10 said they had inadequate staff, most respondents said less than 5 percent of jobs were open. "We know that hospitals shed jobs like crazy over the last couple of years," he says. "Out of the 85 percent who have openings, half say, 'Yeah, but we don't have that many.' I'm not sure the crush has hit them."

The downturn prompted cutbacks in IT projects, says Hickman. Accordingly, "Most of us significantly slowed, if not stopped, our recruitment machines," he says. So the Health Information Technology for Economic and Clinical Health Act, the incentive plan within the ARRA legislation, had many providers back on their heels when the starting gun went off.

Hospitals "were moving along some sort of plan to deploy a full suite of electronic health record technology capabilities," Hickman says. "HITECH in many cases caused us to take the plan that we already had on the boards and accelerate it." Hiring people to handle that program load also had to pick up speed. "We went from famine to feast in 2010, and we had to do a number of things to: one, get good recruitment activity moving quickly; and two, assure we were retaining the right people."

An academic medical center in New York, Albany Medical had plenty of staff experienced in the types of systems that all health care organizations suddenly had to implement. "Because we do recruit and engage the best people, and because we train them well and give them opportunities for growth, I think we're regularly the target of recruitment efforts by others," says John Robinson Jr., a member of the board of directors for nearly 25 years.

Teaching hospitals, which are out in front on clinical IT adoption and more likely to be on track to enabling meaningful use, reported worse staffing problems than community hospitals, says CHIME's Fraidenburg. But the numbers belie a potential crisis situation for smaller hospitals, which may not have ramped up their efforts to a point where they're hiring for the higher demands of HITECH.

The IT staff employed by Partners HealthCare, the Boston-based parent of several Harvard teaching hospitals, number 1,500, says Sue Schade, CIO of Partners' Brigham and Women's Hospital. To meet changing needs, "What it comes down to is shifting priorities, and potentially moving existing staff from work they're doing into other work."

At Anne Arundel, by contrast, an original staff of 45 was increased by 30 positions since 2008 to implement a replacement of inpatient and ambulatory clinical information systems, but it still lacks a "bench" of less experienced staff from which to draw if top talent leaves, says Abel. "So when I lose a resource that has a certain level of experience and capability, I almost always have to go rehire at that same level," he says. "That makes us compete even more for the quality of the resources out there."

The hospital system's three years of work implementing an information system from Epic also makes it a target for recruiters at several academic medical centers in the region that are adopting Epic and looking for ready-made talent, says Abel.

The threat to retention will hit home when the "gold rush" begins in earnest, says Rich Correll, CHIME's president. That's when EHR vendors finish retooling for the HITECH requirements and start upgrading their clients, and consulting firms gear up to help. "As the gold rush ensues, everybody's trying to get the gold, whether it's the hospitals trying to get the incentives or the consultants trying to get the business," he says. IT system vendors "are a whole other source of hiring and stealing."

"I can guarantee you when the vendors move into these hospitals and start doing their work," Fraidenburg says, "they're going to be looking for very skilled IT in-house staff who might be able to be plucked out with a nice bag of money."

Protecting the Investment

For teaching hospitals, which tend to be in competitive markets and have a wealth of talent, "These folks would be highly attractive to others who are looking for that kind of skilled position, whether it's a vendor or consultant or even a smaller health system," Fraidenburg says.

At a smaller organization, meanwhile, "If you've only got 26 staff and you lose three, that's a whole lot different than if you've got 126 staff and you lose three," Correll says, adding that they'll be "probably your best ones. So you're looking at your little cadre and thinking, 'Wow, if I get picked off here, my progress toward meaningful use could really be impacted.'"

Trustees, while staying out of the details, have a duty to protect their IT investment in not only hardware and software, but also the efforts of management to find and keep the skilled professionals required to power the program, says Robinson of Albany Medical, who serves on the finance committee where the "massive investment"—half the annual capital budget—in IT is overseen.

"If, for some reason, the institution starts hemorrhaging its talented people, and people are unhappy and leaving, it might be appropriate for the board to inquire at that point to see what's going on and what's being done to fix it," Robinson says. "If the management team has been successful in the past, has recruited and retained good people, needs more resources to comply with a new federal regulation and can make a compelling business case as to why those resources should be provided, then the board should listen and act accordingly in support of the recommendations of management."

Actions can involve improving working conditions and advancement as well as higher pay and bonuses. Hickman says he surveyed the IT staff on what they liked about their jobs—compensation, job security, job content, career growth opportunities and so on—to put tactics for retention in place.

Schade says Partners has a formal retention program called the Career Growth Initiative that includes regular training, flexible schedules and telecommuting.

Anne Arundel Health System does a regular compensation review of the IT market to benchmark salaries generally and then applies a premium "to recognize that marketability, if you will, of the resources that we have," Abel says. He's taken the system's board through the process of justifying the need to expand not just staff numbers, but also their compensation. Then the hospital adds options to telecommute and otherwise improve the job environment. "In our minds, taking care of offering competitive compensation is just the starting point for what we feel we have to do," he notes.

Adds Fraidenburg, "At this point, your best strategy is to circle the wagons and protect the best people you've got, and hope to save as many of them as you can, with the understanding that you might get picked off around the edges. But you've got to keep your best people with the business and the clinical knowledge, because this is no technical Y2K problem—you're not looking for coders."

John Morrissey is a freelance writer in Mount Prospect, Ill.

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