Month: September 2009

Certification; Is it worth worrying about?

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question4Below is an exchange I had on a LinkedIn discussion group regarding certification in response to a comment made by someone speaking to its intended benefit.  As I have not sought his permission to quote him here, I will just provide a link to his comment.  My thoughts are the following.

My understanding is that some vendors are certified and some aren’t. As a provider let’s say I’ve issued an RFP and I select vendor A over vendor B for the sole purpose of the fact that vendor A’s product is certified.

Now, assume I am I large provider, and that this implementation will cost at or above $100 million. Clearly, I am not going to do an ‘out-of-the-box’ installation. Hence, whatever I go live with will differ in many respects with what was certified. That being the case, what I have may now look far different from what the certifiers had in mind.

Regardless of the intent of certification, it also creates very effective artificial barriers to entry for the smaller vendors.

You write that the “hope is…” If I am a hospital CMIO or COO I can’t base my decisions on something as arbitrary as that. Reform, Certification, Meaningful Use, Standards, and interoperability may as well be written on an Etch-A-Sketch as each of these are subject to change.

You also write that the purpose is to “assure” product A will inter-operate with product B using industry standards. As though standards are not final, how can assurance be offered? If for A to get to B the record has to pass through one or more as yet to be defined RHIOs haw can assurance be assured.

I think that although the intent of certification may have some merit, when the national roll-out of EHR scales up, we will see that the time and money invested in certification could have been better spent elsewhere.

Here’s the link, http://www.linkedin.com/groupAnswers?viewQuestionAndAnswers=&gid=130128&discussionID=7499646&commentID=6845299#commentID_6845299

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How do I know if we’re in trouble?

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FunnyCheckDoes anyone remember how many of each type of animal God told Moses to put on the ark? Are you sure? For those who missed it, Noah built the Ark, Charlton Heston built the stone tablets.

One word can make the difference between right and wrong, especially if the question is big enough. Who is asking the questions that are shaping your firm’s EHR strategy? Are they asking the right ones?  What are the right questions?  If your the person responsible for the money that will be spent on EHR, any of these deserve an answer;

  • If the ARRA money went away tomorrow, would we still be doing EHR?
  • May I see a copy of our EHR plan?
  • Who vetted the plan?
  • If so, would we still be doing it the same way?
  • Would we still have selected this vendor?
  • Did we issue an RFP?
  • How did we choose who received the RFP?
  • What criteria did we use to select the vendor?
  • Who in our shop had any experience writing an RFP of this nature?
  • Who has ever evaluated an RFP like this?
  • What commitments do we have from the vendor about meaningful use?
  • What commitments do we have from the vendor if meaningful use changes?

These are very basic questions, but I bet if you ask them of your team, you will not be pleased with several of the answers.  If they can answer all of them to your satisfaction, they may proceed to step two.  If not, send them back for another try.draft_lens5971462module46826602photo_1247932409Creative_Loafing_-_Hanging_out_-_GBowen

EHR: the cost savings can be tremendous

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shrekthefifth

I was at the beach with my family for the week.  There’s something magical about hanging out at the shore with three children ten and under.  There was so much sand in the house that we could have made a laudable entry in any sand castle contest.

For some reason, there is an unspoken understanding that Dad will unload the car, wash of the toys and hand the beach towels while everyone else showers.  By the time I reached the shower the hot water was long gone and enough grains of sand were embedded in the bar of soap that it felt like I was washing with pumice.  I toweled off from my shower with the only remaining dry towel, a pint-sized piece of linen bearing the likeness of Shrek–standing in your-all-in-all face-to-face with the green faced ogre sort of makes one a little less pompous.

My Shrek fan club was watching SpongeBob for the umpteenth time. I pretended to be interested and made the mistake of asking a question about the show. “I don’t get it,” I offered. “It seems like every show is about the same thing, it has something to do with SpongeBob making Krabby Patties for the Krusty Krab.” To which my youngest replied, “They keep making them until they get it right.”

No excuses. Do it until you get it right.  A single line job description for EHR?  I hope not.  There’s not enough money to do it until you get it right.  There is however, plenty of money to do it right the first time.  I call that the DIRT-FIT principle.  That’s where the saving are.

I’d better go; my kids are eating all of my Twizzlers.

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Should EHR vendors certify their system for Meaningful Use?

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question3Sort’a implies it’s time to put up or shut up. Tell your vendor to tie that to the contract.

However, then the onus falls back on the provider. If the software is only 80% of the work, the provider better have one PMO killer team standing by who knows change management, work flow improvement, training, user acceptance. Oh, I let’s not forget that both parties are aiming for a moving target.

The good news. I think Meaningful Use will die off as a requirement before we get to 2012.

The tag line. If you buy something that can’t pass Meaningful Use, there’s nobody to blame but the face in the mirror.

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A thought about EHR companies

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Just a brief note to provide a link to my comments on the blog EHR Blog about EHR Vendors.

http://www.ehrscope.com/blog/electronic-medical-records-companies/comment-page-1/#comment-792

saint

What does it take to be the best hospital?

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Below is a reply I wrote to a question raised on Hospital Impact, “What does it take to be the best hospital on the planet?”

http://bit.ly/v4pr6

I’d like to hear what you think it would take.

Great question and one that needs to be asked with much regularity.  I target my comments at the healthcare business as opposed to the business of healthcare—the clinical part.

May I begin with a statement that may have many readers reaching for their delete keys?  As one who has consulted to many industries, to me the healthcare business appears to be stuck in a 0.2 business model and is being forced to rapidly reinvent itself in a 2.0 model—my use of the term 2.0 does not imply the Internet.

My comments are based on observations, conversation, and inference.  My executives have told me privately that world-class physicians do not necessarily become world-class business executives.  Many lack the depth of experience that is needed to know what aspects of the healthcare business is broken, duplicative, wasteful, or in need of repair.  While discussing EHR, I was told recently by a former CEO of a large hospital that his peers were making multi-multi-million dollar decisions without any sense of the data needed to support those decisions, basing them on what a friend had decided, what they read in an in-flight magazine, or a conversation they had at a convention.

There seems to be significant faith placed in the notion of, “That’s the way we’ve always done it.”  That expression surfaces often when one raises the issue of why a hospital has multiple IT departments, multiple HR groups, payroll, registration, and so forth.  Why do something once if you can do it less well five times.

There seems to be enough waste that for some hospitals looking at moving forward with EHR, my first piece of advice is instead of aiming for best practices, let’s aim for a single practice.  Evaluate how to implement a shared service or managed services approach to business functions that are not part of your core business model.

I close with the notion of what other businesses call customer relationship management (CRM).  For a hospital, patient relationship management (PRM) is one of the unspoken wins waiting for someone to lead the charge.  Add a social media effort to it, and all of a sudden it’s like the hospital gave itself a facelift, at least from the perspective of the patients.

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Controlling the patient dialog

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pigsRemember when there were 200 firms in the Fortune 100?

How long ago was that? I think it was around the same time when people still thought you shouldn’t wear white after Labor Day. Time to drop-kick those white pumps to the back of the closet. What made me think of that bit of nonsense was a meeting I had recently with one of the sharpest people I’ve had the pleasure to meet professionally, and a classmate of mine from grad school. She happens to be the founder and president of one of the country’s go-to firms for dealing with business ethics. Having served as a board member for several publicly-traded firms, as well as chairing their audit committees, when the Andersen and Enron scandals hit she went looking for professionals who could help her help her firms. When she couldn’t find the help, she created it.

That conversation got me thinking and made me wonder why there were no longer 200 firms in the Fortune 100. Was it; is it, a matter of business ethics? How often do unethical practices come up when firms interact with their customers? A couple of takeaways from the meeting—for board members to be able to meet their obligation, they ought to do more than reply on the meeting book pulled together by the firm they serve. Simply relying on the book presumes ethical behavior, a presumption not always supported by fact—how much should one believe if the information is being provided by someone who purchased a $900 shower curtain?

What can they do? Due diligence is being reinvented, and the Social Network is leading the charge. One example is to go to Yahoo Chat to see what’s really being said about your organization. Other things I’ve done to obtain facts and opinions, things which particularly gauge how customers and employees feel about the firm include Google Reader, Facebook, Twitter, and YouTube, to name just a few. You don’t need patient focus groups to learn what’s being said, or to learn how good a job your hospital is doing. The patients already have a laser focus. In many instances the group lacking the focus is the healthcare provider.

Firms should focus on maintaining a strong Reputation Bank, one strong enough to be able to handle withdrawals, because you never know when there might be a run on the bank. Might be a good time to look at your own bank deposit slips.  Deposits can be made easily through the social media network.  You can’t stop patients from talking about you but you can shape what they say.

saint

A doctor writes about his EMR experience

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162_6The following is a response I received to a discussion I raised on a LinkedIn group.  It’s written by Dr. Richard Lamson and is used with his permission.  I liked that it didn’t follow some of the EMR/EHR cheerleading that seems to dominate much of what’s written.

I wish I could say it was a learning “curve”, it’s just a “slope” with no asymptote in sight for many EMR products.

Well, no, I guess that’s not right. Your cardiologist will eventually get to 30/30 or so instead of 10/50, so there is an asymptote, it’s just not what it was with paper charts. Say what you will about paper charts (they’re unreliable, slow, get lost easily — all true), they’ve been refined by several generations of physicians, using technology that was well understood 200+ years ago. The data density of pen/ink on paper is very high, (think genograms, drawings of the location of lesions, etc.), the input bandwidth very high, and it is something with which we have been familiar since preschool scribbling with crayons (of course, some physicians’ charts would be improved by scribbling lessons!).

The EMR user interfaces out there are at most 10-12 years old, The input bandwidth is not very high — at most it is dictation speed but with a higher error rate. Because of copy/paste technology, a lot of “information” in charts is copied and pasted from previous notes and does not necessarily reflect what the physican did on this visit. Also, it might not be true this time. Does every doctor look at every diabetic’s feet at every visit? I try to, but when I’m 45 minutes behind sometimes I defer it to the next visit, especially when they can’t put their own shoes back on after I take them off. I try to edit out the foot exam

Don’t get me started on the warnings that EMRs give you every time you open a new patient, write a prescription, etc. You get warning fatigue and tend to blow past them without reading them after a while, since 99+% of them are not germane (oh, this patient’s taking aspirin, maybe they’ve had a heart attack in the last 10 minutes, better not write them for a migraine medication…). These warnings are basically lawsuits waiting to happen. I can hear the attorney now: “But, Doctor, your EMR warned you that this was a bad medication to use in this case, why did you write it anyway?” “Well, you see, it had given me that warning buried in among 20 other warnings, and it was probably the only warning all day that was useful, how can I read 400 warnings a day to see which one is useful?” Cha-ching!

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Universal Patient Record-can that save EHR?

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fermat800Today is the anniversary of the solving of Fermat’s last theorem.  As a long recovering mathematician, these types of thing interest me so I sought a copy of the proof and began reading.  The mathematics for librarians description of the proof is something like this:

  • The Pythagorean theorem states that for a right triangle the sum of the squares of the sides equals the square of the hypotenuse.
  • Fermat stated that the theorem only holds for a coefficient of 2, squaring, and that no other coefficient will work
  • This went unproven until recently

One might have thought that the solution could be solved by brute force using a computer.  How many numbers are there to be dealt with? If you approach the problem this way you’ve got to do it for infinitely many numbers. So, after you’ve done it for one, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a thousand numbers, how many, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a million, well, there’s still infinitely many left. In fact, you haven’t done very many, have you?  In fact, using this approach, you’ll never finish.  This got me thinking about our EHR system.

I think something has been lost in the confusion about a national EHR system.  After all, that’s the target right, a national system?  We only unleash the power of EHR if we are able to make it work out outside of the provider’s four walls.  Is it possible that perhaps the logic of how we have been viewing developing a solution for the problem is wrong?  I think it is.  Since the outset, the problem has been defined as how do we develop a system that will enable us to get everyone’s health records (let’s call an individual record A) to some arbitrary set of healthcare providers, call them P.  There are some 350 million A’s and for simplicity let’s agree that there are 100,000 P’s.  So now, the system to which everyone is working is the system that will enable all of the A’s to get to any combination of P’s.

See?  Now what happens if we place a few hundred Rhios and health information exchanges (HIEs) in between the A’s and the P’s?  Let’s label them G’s for gatekeepers.  So, in the current framework all the A’s (everybody’s health records) have to pass through all the G’s, make it up to the national network, then back through all the G’s and then sorted through all the P’s to the correct P.

How can we know this design will work for every possibility?  The only way is to test every combination of A’s, G’s and P’s.  It’s a difficult problem.  It becomes more difficult when we acknowledge that there are hundreds of EHR vendors supplying software to all of those P’s.  Many of those P’s will have modified the software, meaning that there are probably thousands of variations of EHR systems.  Oh, and did I mention that all of this is being done without any single set of standards?  That means my stuff will look different from your stuff, and the G’s will have to move different stuff, and from an “IT” perspective the EHRs at the end of the food chain will have to interpret different stuff and then update your stuff with their stuff.  That’s a lot of stuff.

So, if that is where things are, what can be done about it?  My take on a solution is that the problem with this model lies with the word in italics, ‘everyone’.  Every possible patient with every possible need getting to every possible provider.  How to solve this or at least simplify the magnitude of the problem?  One possible solution is to build out the EHR system and the network such that one patient’s record can go to one provider and have that record updated.  Would it not make more sense to build it for a single patient, create a universal patient record (UPR) that can handle all instances?  Do it right once.  Prove that it works and then replicate it instead of building millions of different ones and hoping they work?

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The relationship between 2 words: reform and EHR

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Part of the reform discussion should include reform that requires and/or will only come about through EHR.

The other part of the discussion should be about reforming EHR.  Neither will work without the other

saint