The billions of dollars that have been set aside for health IT in the American Recovery and Reinvestment Act of 2009 (ARRA) should certainly boost the adoption of electronic health records, but a big question remains: Where will the health IT expertise and educators needed to integrate those systems come from?

Despite years of trying, EHR penetration nationally remains low. A recent survey of thousands of U.S. hospitals published by the New England Journal of Medicine concluded that fewer than 8 percent of non-Veterans Affairs hospitals have EHRs in even one clinical department; only 1.5 percent have them in all departments.

Hospitals and large practices typically use their own IT staff to help them with the intricacies of EHR implementation. That's not true of small, individual physician practices, for whom adoption rates of the kind of comprehensive EHRs promoted by the federal government have been miniscule.

The upfront cost of EHR systems is often the major reason cited for this. Others, such as help with installation and concerns over ongoing support, are not far behind. EHR vendors can provide some support, but critics contend that is nowhere near enough to satisfy demand.

"The dilemma now is that software and hardware vendors provide a basic level of services and training," said Micki Tripathi, president and chief executive of the Massachusetts eHealth Collaborative (MAEHC). "But they don't typically provide enough for an effective implementation."

Studies suggest that anywhere from 30 percent to 66 percent of retail EHR implementations fail, he said. So simply giving physicians thousands of dollars in stimulus money to buy EHRs doesn't seem very productive.

Wrap-around services

So providers will need help in IT networking and security, and in setting up privacy protections, said Holt Anderson, executive director of the North Carolina Healthcare Information and Communications Alliance (NCHICA). They will also need assistance with knowing what kind of EHR systems qualify for incentives under ARRA.

"I don't think a lot of physicians want to be propeller heads and geeks," he said. "So they will need support they can trust."

One answer is to provide a "wrap around" service that will help them choose and install EHRs, adapt workflow where necessary, help train doctors and nurses to use EHRs effectively, and deliver ongoing support, Tripathi said.

It's a method the Massachusetts collaborative has used to bring hundreds of physicians onto EHRs throughout the state, using practice consultants as "navigators" to provide overall project management and help with workflow redesign, as well to provide assessment and support post-implementation.

The Massachusetts solution, expanded in scale, could dramatically boost the number of trained health IT professionals needed to provide this kind of support. But just how many of these professionals would be needed to suit demand remains unclear.

A 2008 Oregon Health & Science University (OHSU) study, which were released prior to the Obama plan, concluded that another 40,000 additional health IT professionals would be needed to meet the IT workforce demands of the projected hospital adoption of EHRs, nearly 40 percent more than the 108,000 that were then employed in U.S. hospitals.

There are 12,000 practicing physicians in Indiana, said Marc Overhage, President and Chief Executive of the Indiana Health Information Exchange. A minimum of 250 health IT professionals will be needed to support them with EHR implementations in Indiana alone.

"That points to the country needing a boatload of people to help with this," he said. "Perhaps as many as 140,000, nationwide." Other estimates call for a health IT workforce of as many as 200,000.

Rural demand

Many health providers in rural and underserved urban areas are unable to plan for health IT deployment in the near term because of a lack of organization and the availability of trained health IT technicians, said Neal Neuberger, Executive Director of the Institute for e-Health Policy.

"Their needs are tremendous," he said. "When you go to rural and inner-city groups, you realize what they don't know is astounding."

They need help with planning, assembling implementation strategies and vendor selection. Vendors also want this, Neuberger said, because they realize they don't know how to aggregate demand from these kinds of users.

The question is where all of these extra health IT professionals will come from, given that the ARRA legislation envisions a five- to seven-year period for the EHR adoption plan. Typical college-level training courses take up to two years to turn out a qualified health IT worker.

There are things that can be done, said Linda Kloss, Executive Vice President and Chief Executive of the American Health Information Management Association (AHIMA). Certification can be extended to those with basic IT credentials, and there's room to expand the current network of training programs at universities and colleges.

One concern, however, is the development of faculty at these institutions.

"We need help to train the trainers," she said. "There are some 300 [health IT] programs at U.S. universities now, and they just don't have the faculty to take on more students."

Before there can be a ramp-up in the number of health IT professionals, faculty numbers will need a boost, she said.

IT industry response

But not everyone thinks there will be a problem. David Lansky, President and Chief Executive of the Pacific Business Group on Health (PBGH), a coalition of 50 large healthcare purchasers, said his members have not yet considered what the needs will be for extending these kinds of services to physicians who adopt EHRs.

"We get the sense from vendors that they have developed a great deal of knowledge and expertise in this area, and have a great deal of capacity for offering support to their customers," he said. "We feel the market will figure out how to do this effectively, when it's needed."

In fact, IT industry groups are starting to investigate ways of extending their members' interests to the healthcare arena. A lot of the skills necessary for implementing an EHR are on a par with mainstream IT skills, said Trista Roehl, Public Policy Manager for the Computing Technology Industry Association (CompTIA). So EHR implementation would be good fit for IT value added resellers (VAR), she said.

VARs work with IT vendors to help install IT systems, and also provide ongoing support to help maintain those systems.

"I think we'll see a lot of VARs looking at [EHRs] as an opportunity," said Michael Wendy, CompTIA's Director of Public Affairs. "The best ones will see it as a differentiator for them to better deliver services."

However, it seems apparent that technical and business support will be needed, whether it is supplied by VARs or other sources, to provide assistance to at least smaller practices and rural health institutions. Even with the increase in trained health IT professionals, there's no guarantee their expertise will find its way to those EHR users.

Extension service

ARRA sets out one way to do that, through the creation of regional HIT extension centers. With 50 percent funding from the federal government, these so-far-undefined centers will assist in the incorporation of health IT in various regions around the country, help coordinate the participation of industry, universities and state agencies and disseminate best practices.

It is still unclear just how these centers will be organized. The Department of Health and