William Hersh, MD, Professor and Chair, OHSU
Blog: Informatics Professor
Twitter: @williamhersh
A new analysis of the healthcare information technology (IT) workforce indicates that as hospitals and health systems continue to adopt electronic health records (EHRs) and other forms of IT, as many as 19,852 to 153,114 more full-time equivalent (FTE) personnel may be required [1]. The new study has been published by myself and colleagues Keith Boone and Annette Totten in the new journal, JAMIA Open. It updates an original analysis [2] from before the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which has led to substantial growth in the adoption of EHRs [3, 4] and this the expansion of the healthcare IT workforce.
The data used in the analysis actually focus only on hospitals and health systems, so informatics/IT workforce growth will also likely occur in other health-related areas. The results remind us that there remain and will likely be growing opportunities for those who train and work in biomedical and health informatics.
The new paper represents an update of a research interest of mine that emerged over a decade ago. As my activities in informatics education were growing at that time, I became interested in the characteristics of the healthcare IT workforce and its professional development. This led me to search for studies of that workforce, which essentially came up empty. There was a single resource I was able to find that provided some data about healthcare IT staffing, the HIMSS Analytics Database, but no one had ever done any analysis of it. The HIMSS Analytics Database mostly focuses on the IT systems that hospitals and health systems implement but also contains some data on IT staffing FTE. The result of the analysis was a paper that garnered a great detail of attention when it was published in 2008 [2], including an invitation to present the results in Washington, DC to the Capitol Hill Steering Committee on Telehealth and Healthcare Informatics.
Based on 2007 data, our initial paper looked at FTE staffing, especially as it related to level of adoption, based on the well-known HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM), a 0-7 scale that measures milestones of EHR adoption. This was, of course, before the HITECH Act, when a much smaller number of hospitals and health systems had adopted EHRs. Also around that time, there had been the publication of the first systematic review of evidence supporting benefit of healthcare IT, showing the value came mainly from use of clinical decision support (CDS) and computerized provider order entry (CPOE) [5]. As such, we looked at the level of healthcare IT staffing by EMRAM stage, with a particular focus on what increase might be required to achieve the level of IT use associated with those evidence-based benefits. We assessed the ratio of IT FTE staff to hospital bed ratio by EMRAM stage.
Because the self-reported data of the database was incomplete for FTE staffing, we had to extrapolate from the data present to the entire country (recognizing a potential bias from those who responded vs. those who did not). We also noted some other limitations of the data, which was that the data represented only hospitals and health systems, and not the entire healthcare system, nor the use of IT outside of the healthcare system. Our analysis found that the national health IT workforce size in 2007 was estimated to be 108,390. But the real sound bite from the study was that if EHR adoption were to increase to the level supported by the evidence, namely EMRAM Stage 4 (use of CDS and CPOE), and FTE/Bed ratios remained the same for those hospitals, the size of the workforce would need to grow to 149,174. In other words, there was a need to increase the size of the healthcare IT workforce by 40,784 people.
Within a year of the study’s publication, the US economy was entering the Great Recession, and the new Obama Administration had taken office. The recession led to Congress passing the HITECH Act (as part of the American Recovery and Reinvestment Act), which allocated about $30 billion in economic stimulus funding to EHR adoption. Recognizing that a larger and better-trained workforce would be necessary to facilitate this EHR adoption, the HITECH Act included $118 million for workforce development. The rationale for this included the data from our study showing the need for expanding the workforce, especially as the meaningful use of EHRs required of HITECH would necessitate the use of CDS and CPOE.
Since that time, EHR adoption has grown substantially, to 96% of hospitals [3] and 87% of office-based physicians and other clinicians [4]. A few years ago, I started to wonder how the widespread adoption impacted the workforce, especially at the higher stages of EMRAM, which very few hospitals had achieved in 2007. By 2014, one-quarter of US hospitals had reached Stages 6 and 7.
The new study reports some interesting findings. First, the FTE/Bed ratios in 2014 for different levels of EMRAM are remarkably similar to those in 2007 (with the exception of Stage 7, which no hospitals had reached in 2007). However, because of the advancing of hospitals to higher EMRAM stages beyond Stage 4, the total workforce ended up being larger than we had estimated to be needed from the 2007 data. Probably most important, as more hospitals continue to reach Stages 6 and 7, the workforce will continue to grow. Our new study estimates that if all hospitals were to achieve Stage 6, an additional 19,852 healthcare IT FTE would be needed. Our analysis also shows an almost explosive growth of 153,114 more FTE if all hospitals moved to Stage 7, although we have less confidence in that result due to the relatively small numbers of hospitals that have achieved this stage at the present time., and it is also unclear whether the leaders reaching Stage 7 early are representative of the rest of hospitals and health systems generally.
Nonetheless, the US healthcare industry is moving toward increased EHR adoption. At the time of the data snapshot we used in the analysis in 2014, there were 3.7% and 22.2% of hospitals at Stages 6 and 7 respectively. The latest EMRAM data from the end of 2017 show those to have increased to 6.4% and 33.8% respectively. In other words, the healthcare industry is moving toward higher levels of adoption that, if our findings hold, will lead to increased healthcare IT hiring.
The new paper also reiterates the caveats of the HIMSS Analytics data. It is a valuable database, but not really designed to measure the workforce or its characteristics in great detail. Another limitation is that only about a third of organizations respond to the staffing FTE questions. In addition, while the hospital setting comprises a large proportion of those who work in the healthcare industry, there are other places where IT and informatics personnel work, including for vendors, research institutions, government, and other health-related entities. As healthcare changes, these latter settings may account for an even larger fraction of the healthcare IT workforce.
Because of these limitations of the data and the changing healthcare environment, the paper calls for additional research and other actions. We note that better data, both more complete and with more detail, is critical to learn more about the workforce. We also lament the decision of the US Bureau of Labor Statistics (BLS) to not add a Standard Occupational Classification (SOC) code for health informatics, which would have added informatics to US labor statistics. Fortunately the American Medical Informatics Association (AMIA) is undertaking a practice analysis of informatics work, so additional information about the workforce will be coming by the end of this year.
It should be noted that some may view the employment growth in healthcare IT as a negative, especially due to its added cost. However, the overall size of this workforce needs to be put in perspective, as it represents just a small fraction of the estimated 12 million Americans who work in the healthcare industry. As the need for data and information to improve operations and innovations in health-related industries grows, a large and well-trained workforce will continue to be critical to contribute toward the triple aim of improved health, improved care, and reduced cost [6]. In addition, and many career opportunities will continue to be available to those who want to join the informatics workforce.
References
- Hersh, WR, Boone, KW, et al. (2018). Characteristics of the healthcare information technology workforce in the HITECH era: underestimated in size, still growing, and adapting to advanced uses. JAMIA Open. Epub ahead of print. (The data used in the analysis is also available for access.)
- Hersh, WR and Wright, A (2008). What workforce is needed to implement the health information technology agenda? An analysis from the HIMSS Analytics™ Database. AMIA Annual Symposium Proceedings, Washington, DC. American Medical Informatics Association. 303-307.
- Henry, J, Pylypchuk, Y, et al. (2016). Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2015. Washington, DC, Department of Health and Human Services.
- Office of the National Coordinator for Health Information Technology. ‘Office-based Physician Electronic Health Record Adoption,’ Health IT Quick-Stat #50.
- Chaudhry, B, Wang, J, et al. (2006). Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine. 144: 742-752.
Berwick, DM, Nolan, TW, et al. (2008). The triple aim: care, health, and cost. Health Affairs. 27: 759-769.
This article post first appeared on The Informatics Professor. Dr. Hersh is a frequent contributing expert to HITECH Answers.