Healthcare IT Strategy

January 12, 2012

Will National EHR Work?

Filed under: EHR,healthcare 2.0,Hospital,NHIN,planning,Rants & Musings,Who's Running the Show? — Paul Roemer @ 9:36 am

I’ve never been mistaken as one who is subtle.  Gray is not in my patois.  I am guilty of seeing things as right and left and right and wrong.  Sometimes I stand alone, sometimes with others, but rarely am I undecided, indecisive, or caught straddling the fence.  When I think about the expression, ‘lead, follow, or get out of the way,’ I see three choices, two of which aren’t worth getting me out of bed.

I do it not of arrogance but to stimulate me, to make a point, to force a dialog, or to cause action.  Some prefer dialectic reasoning to try to resolve contradictions, that’s a subtlety I don’t have.  Like the time I left the vacuum in the middle of the living room for two weeks hoping my roommates would get the hint.  That was subtle and a failure.  I hired a housekeeper and billed them for it.

Take healthcare information technology, HIT.  One way or another I have become the polemic poster child of dissent, HIT’s eristical heretic.  I’ve been consulting for quite a while—twenty-five plus years worth of while.  Sometimes I see something that is so different from everything else I’ve seen that it causes me to pause and have a think.  Most times, the ball rattles around in my head like it’s auditioning for River Dance, and when it settles down, the concept which had led to my confusion begins to make sense to me.

This is not most times.  No matter how hard I try, I am not able to convince myself that the national EHR rollout strategy has even the slightest chance of working as designed.  Don’t tell me you haven’t had the same concern—many of you have shared similar thoughts with me.  The question is, what are we going to do about it?

Here’s my take on the matter, no subtlety whatsoever.  Are you familiar with the children’s game Mousetrap?  It’s an overly designed machined designed to perform a simple task.

Were it simply a question of how to view the current national EHR roll out strategy I would label it a Rube Goldberg strategy.  Rube’s the fellow noted for devising complex machines to perform simple tasks.  No matter how I diagram it, the present EHR approach comes out looking like multiple implementations of the same Rube Goldberg strategy.  It is over designed, overly complex.  For it to work the design requires that the national EHR system must complete as many steps as possible, through untold possible permutations, without a single failure.

Have you ever been a part of a successful launch of a national IT system that:

  • required a hundred thousand or so implementations of a parochial system
  • has been designed by 400 vendors
  • has 400 applications based on their own standards
  • has to transport different versions of health records in and out of hundreds of different regional health information networks
  • has to be interoperable
  • may result in someone’s death if it fails

Me either.

Worse yet, for there to be much of a return on investment from the reform effort, the national EHR roll out must work.  If the planning behind the national ERH strategy is indicative of the planning that has gone into reform, we should all have a long think.

I hate when people throw stones without proposing any ideas.  I offer the following—untested and unproven.  Ideas.  Ideas which either are or aren’t worthy of a further look.  I think they may be; you may prove me wrong.

For EHR to interoperate nationally, some things have to be decided.  Somebody has to be the decider.  This feel good, let the market sort this out approach is not working.  As you read these ideas, please focus on the whether the concept could be made to work, and whether doing so would increase the likelihood of a successful national EHR roll out.

  • Government redirects REC funds plus whatever else is needed to quickly mandate, force, cajole, a national set of EHR standards
    • EHR vendors who account for 90%–pick a number of you don’t like mine—use federal funds to adapt their software to the new standard
    • What happens to the other vendors—I have no idea.  Might they go out of business?  Yup.
    • EHR vendors modify their installed base to the standard
  • Some organization or multiple organizations—how many is a tactic so let’s not get caught up in who, how many, or what platform (let’s focus on whether the idea can be tweaked to make sense)—will create, staff, train its employees to roll out an EHR shrink-wrapped SaaS solution for thousands and thousands of small and solo practice
    • What package—needs to be determined
    • What cost—needs to be determined
    • How will specialists and outliers be handled—let’s figure it out
  • Study existing national networks—do not limit to the US—which permit the secure transfer of records up and down a network.  This could include businesses like airline reservations, telecommunications, OnStar, ATM/finance, Amazon, Gmail—feel free to add to the list.  It does no good to reply with why any given network won’t work.  Anyone can come up with reasons why this won’t work or why it will be difficult or costly to build or deploy.  I want to hear from people who are willing to think about how to do it.  The objective of the exercise is to see if something can be cobbled together from an existing network.  Can a national EHR system steal a group of ideas that will allow the secure transport of health records and thereby eliminate all the non-value-added middle steps (HIEs and RHIOs)?  Can a national EHR system piggyback carriage over an existing network?

We have reached the point of lead, follow, or get out of the way, and two of these are no good.

January 6, 2012

The Physics of EHR

Filed under: EHR,healthcare 2.0,Hospital,informatics,innovation,Rants & Musings,Who's Running the Show? — Paul Roemer @ 9:20 am

To read and complete this post you may use the following tools; graph paper, compass, protractor, slide ruler, a number two pencil, and a bag of Gummy Bears—from which to snack.  The following problem was on the final exam in my eleventh grade physics class.  Let us give this a shot and then see if we can tie it into anything relevant.

A Rhesus monkey is in the branch of a tree thirty-seven feet above the ground.  The monkey weights eight pounds.  You are hunting in Africa, and are three hundred and twenty yards from the monkey.  You have a bolt-action, reverse-bore (spins the shell counter-clockwise as it leaves the gun barrel) Huntington rifle capable of delivering a projectile at 644 feet per second.  The bullet weighs 45 grams.  The humidity is seventy percent, and the temperature in Scotland is twelve degrees Celsius.

At the exact moment the monkey hears the rifle fire it will jump off the branch and begin to fall.  Using this information, exactly where do you have to aim to make sure you hit the monkey?

I used every piece of information available to try to solve this.  I made graphs and ran calculations until there was no more data left to crunch, computing angles and developing new formulas.  I calculated the curvature of the earth, and the effect Pluto’s gravitational pull had on the bullet.

The one thing that never occurred to me was that since the monkey was falling to the ground, so was the bullet—gravity.  The bullet and the monkey both fall at the same rate because gravity acts on both the same way.  So, where to aim to hit the monkey?  Aim at the monkey.

All of the other information was irrelevant, extraneous.  The funny thing about extraneous information is that it causes us to look at it, to focus on it.  We think it must be important, and so we divert attention and resources to it, even when the right answer is staring us in the eye.

Attempting to implement EHR is a lot like hunting monkeys.  We know what we need to do and yet we are distracted by all of this extraneous information that will hamper our chances of being successful with the EHR.  Two of the most obvious distractions are Meaningful Use and Certification.  The overarching goal of EHR is EHR; one that does what you need it to do.  If the EHR does not do that, everything else has no meaning.

December 12, 2011

EHR Incentive Payments: The line forms at the rear

Filed under: EHR,healthcare 2.0,incentive payments,meaningful use,Rants & Musings,Who's Running the Show? — Paul Roemer @ 5:08 pm

Three AM.  A night not fit for man nor beast.  Billowing fog roiled out of the steam grates all but obscuring vast sections of the town.

I arrived early to secure my place in line—my first tail-gate party since leaving college.  The trunk of my car was loaded with my gear as I eased to the curb along Independence Avenue.  Orange traffic cones and blockades were scattered along the street in anticipation of the crowds.  The traffic officer checked my permit and directed me to my parking spot.

“We are anticipating a huge crowd,” he said.  “It looks like you are the first to arrive.”

“You look like you have done this before,” I remarked.

“Pretty much every day.  Ain’t a day goes by when the feds aren’t giving away truck loads of money for one thing or another.”

I unloaded my car—lawn chair, iPad, boom box, sleeping bag, and enough Starbucks to ensure I would need to use the Port-a-Potty well before the doors opened at eight AM.

I had expected the line to be wrapped around the block several times.  “Where are the others I asked?”

“I am not sure.  Dr. B. told us to expect to be overwhelmed,” responded the officer as he blew on this hands, and did the “my feet are freezing dance” on the pavement.

Sitting there for two hours I was undisturbed until two vans pulled alongside.  A warmly-dressed woman wearing a Mayo North Face jacket set up camp next to me.  “You look cold,” she said.  “In Minnesota, weather like this reminds us of spring.”

Disembarking from a big pretty white van with red stripes, curtains in the windows that looked like a big Tylenol was a man wearing shorts, flip-flops, with his hair tied back in a pony tail.  All he carried was a skate board.  “Rex Kramer,” he said as he extended his tanned hand to shake mine.  “You can call me ‘Dude’.  I’m from Kaiser.”  (As though the skate board and shorts were not a dead giveaway.)

“Where are the others?” I inquired.

Dude Kaiser and Spring Mayo looked at me like I had just told them I had implemented EHR on my MP3 player.  “Nobody else is coming,” quipped Spring.

“Surely, you jest.”

“I jest you not…and please don’t call me Shirley.”

I was worried for a moment whether she would ask me if I liked movies about gladiators.  Instead I asked, “Nervous?”

“Yes.”

“First time?”

“No.  I’ve been nervous before.”  She slapped me back to reality and causing me to drop my poor imitation of Ted Striker.

Dude gave me his take on the EHR rebate situation.  “Nobody else is coming because nobody else can collect.”  I looked into his blue eyes with a stare of my own that suggested I was the deer that had just been run over by the pair of headlights to which everyone always references.

“When you factor in all of the critical success factors about EHR, certification, the RECs, HIEs, CPOE, and the N-HIN, a lack of standards, and interoperability, one thing is always overlooked.  And that one thing takes precedence over all the others.  KM.”

“And just what is KM?”

“Kaiser Money—any number that is followed by nine zeros.  It took us a long time to decide between spending that kind of cha-ching.  I tried to get them to buy a country from South America, but got no takers.”

“How much will you get for your investment?” I inquired.

I could see him doing the calculations in his head as he applied another coat of Hawaiian Tropic to his skin hoping the glow of the moon might enhance his tan. “Well, it’s difficult to say with any degree of certainty.  But when all is said and done, I estimate we’ll see somewhere between one-ten point four and one-ten point five.”

“Million?”

“No silly, dollars. By the way, you ever been to a Turkish prison?”

December 11, 2011

How the Grinch stole healthcare

Filed under: EHR,healthcare 2.0,Hospital,incentive payments,Interoperability,meaningful use,Rants & Musings,reform,Who's Running the Show? — Paul Roemer @ 2:54 pm

Not much has changed since I wrote this two years ago…or has it?

Every Congressman Down in Congress-ville
Liked Health reform a lot…But the Payors,
Who lived just North of Congress-ville,
Did NOT!

The Payors hated Health Reform! The Congressional reform season!
And as everyone’s heard there is more than one reason.
Was it the fear of losing their monopoly right?
Worried, perhaps, that Congress might indict.
But I think that the most likely reason of all
May have been that the uninsured took them all to the wall.

Staring down from their man-caves with indemnifying frowns
At the warm lighted windows below in the town.
For they knew every Congressman down in Congress-ville beneath,
Canted an ear to hear Congress gnashing their teeth.

“If this reform passes, they’ll kill our careers!”
“Healthcare reform! It’s practically here!”
Then they growled, the ideologues’ fingers nervously drumming,
“We MUST find a way to keep Reform from coming!”

For, tomorrow, they knew…

…Stumbling home from the tavern at a quarter past two What each Congressman, intern, and page just might just do And then all the milieu. Oh the milieu, the milieu
Which the Payors hated more than their mom’s Mulligan stew.

Then all the Congressmen, the left and the right, would sit down and meet.
And they’d meet! And they’d meet!
And they’d MEET! MEET! MEET! MEET!
Implement full provision; cover pre-existing…how sweet
That was something the Payors couldn’t stand in the least!

And THEN they’d do something Payors liked least of all!
Every Congressman down in Congress-ville, the tall and the small,
Would stand close together, their Healthcare bells ringing.
With Blackberrys-in-hand, the Congress would start pinging!

They’d ping! And they’d ping!
AND they’d PING! PING! PING! PING!
And the more the Obligators thought of the Congressman-Health-Ping
The more they each thought, “I must stop reform-ing!
“Why for all of these years we’ve put up with it now!
We MUST stop health Reform from coming!
…But HOW?”

Then they got an idea!
An awful idea!
THE Indemnifiers
GOT A WONDERFULLY, AWFUL IDEA!

“I know what to do!” The CEO Payor laughed in his throat.
And he made a quick Congressional hat and a coat.
And he chuckled, and clucked, “What a great Payor raucous!
“With this coat and this hat, I’ll look just like Saint Bacchus!”

“All I need is a pass…”
The Payor looked around.
Since Congressional passes are scarce, there was none to be found.
Did that stop the old Payor…?
No! The Payor simply said,
“If I can’t find a pass, I’ll make one instead!”
So he called his aide Max. Then he took some red paper
And he dummied up the pass and he started this caper.

THEN
He loaded some bags
And some old empty sacks
On a Benz 550
And he rode with old Max.

Then the Payor called, “Dude!”
And the Benz started down
To the offices where the Congressmen
Lay a-snooze in their town.

All their windows were dark. Quiet snow filled the air.
All the Congressmen were dreaming sweet dreams of healthcare
When the Payor came to the first office in the square.
“This is stop number one,” The old Warrantist – a winner
And he slipped passed the guard, like sneaking to a State Dinner.

Then he slid down the hallway, Harry Reid was in sight.
Reid was chumming Pelosi, he planned quite a night.
He got nervous only once, for a moment or two.
Then he realized that the leadership hadn’t a clue
Then he found the Congressional stimuli all hung in a row.
“These Stimuli,” he grinned, “are the first things to go!”

The Payor slithered and slunk, with a smile somewhat mordant,
Around the old Cloakroom, looking quite discordant!
There were copies of the bill stuffed in jackets and on chairs, Why, he even found a copy tucked under the stairs
And he stuffed them in bags. Then the Payor, very neatly,
Started humming the jingle from Blue Cross; rather Cheeky!

Then he slunk to the Senate Chamber, the one facing East
He took the Senators’-copies!—didn’t mind in the least!
He cleaned out that Chamber and almost slipped on the floor.
Saw an Internet router, and thought of Al Gore

Then he stuffed all the copies in the trunk of his Benz.
And he thought to himself, “Why don’t I have friends?” “There’s always Tiger,” he said with no jest But TW’s being chased by reporters, those pests.

The Payor spotted the Grinch having trouble with his sacks
And he lent him a hand—he offered him Max Max was quite pleased, for he knew this December,
That the Grinch would become the Payor’s newest board member.

The Grinch was all smiles–he’d made quite a killing
Offering to help pillage if the Payor was willing.
He stared at the Payor and asked, “New glasses?”
The Payor simply smiled, saying “These people are such (You did that to yourself, not me.)

And, you know, that old Payor was so smart and conniving
When he next saw Pelosi he found himself smiling!
“Why, my dear little Nanc’,” the Bacchus look-alike stiffened,
“Botox in this light makes you look like a Griffin.”
“I’m taking these bills home,” he said pointing to the copy.
“There’s a comma on one page that looks way too sloppy.”

And his fib fooled the Griffin. Then he patted her head
And he gave her a wink, and he sent her to bed
And as Speaker Pelosi shuffled off to her army,
The Payor said to himself, “What a waste of Armani!”

The last thing the Payor needed to do,
Was to mess with these records systems, all four thousand and two.
So he drove to HHS, the DOD and the VA,
And stuffed mint jelly in their servers so their networks would not play

And the one EHR, that still worked in the DC
Was the one bought from CostCo and tucked under the tree.

Then he did some more damage
To HIEs, and the N-HIN,
Making the idea of a healthcare network
Just a has-been!

It was quarter past dawn…
None in Congress were his friends
All the Congressmen, still a-snooze
When he packed up his Benz,
Packed it up with their copies of reform in those bags! Stacked to the leather ceiling,
Manila envelopes with name tags!

Three miles away were the banks of the river,
He was poised with the bags all set to deliver!
“Pooh-pooh to the Congressmen!” he was Payor-ish-ly humming.
“They’re finding out now that no Reform is coming!
“They’re just waking up! I know just what they’ll do!
“Their mouths will hang open a minute or two
“The all the Congressman down in Congress-ville will all cry BOO-HOO!”

“That’s a noise,” grinned the Payor,
“That I simply must hear!”
So he paused and the Payor put a hand to his ear.
And he did hear a sound rising over the snow.
It started in low. Then it started to grow…

But the sound wasn’t sad!
Why, this sound sounded merry!
It couldn’t be so!
But it WAS merry! VERY!

He stared down at Congress-ville!
The Payor popped his eyes!
Then he shook!
What he saw was a shocking surprise!

Every Congressman down in Congress-ville, the tall and the small,
Was singing! Without any health reform at all!
The Congress didn’t care, a few were disgraces,
All they wanted, it seemed, was TV with their faces

And the Payor, with his Payor-feet knee deep in the muck,
Stood puzzling and puzzling: “Man, there goes my bucks.
It could be about healthcare! It could be global warming!
“It could be Al Qaeda, Afghanistan and desert storming”
And he puzzled three hours, `till his puzzler was sore.
Then the Payor thought of something he hadn’t before!
“Maybe Congress,” he thought, “simply needs a free ride.
“Maybe Congress,” he thought…just needs to look like they tried.

And what happened then…?
Well…in Congress-ville they say
That the Payor’s small wallet
Grew three sizes that day!
And the minute his wallet didn’t feel quite so tight,
He zoomed in his Benz passing through a red light
And he brought back the copies of the bill for reform!
And he……HE HIMSELF…!
The Payor calmed the whole storm!

New thoughts on EHR and ARRA money

Filed under: EHR,healthcare 2.0,Hospital,innovation,meaningful use,Rants & Musings,Who's Running the Show? — Paul Roemer @ 2:31 pm

So, there I was, laying out my plans for 2012.  I had started training to become the first person to cross the English Channel on horseback, but I was having difficulty finding a company to sponsor me.  Given my reputation as a water-walker, several firms indicated they would sponsor me to walk it, but I have never been one to do things the easy way.

Scratch the horse idea.

Then it hit me.  I’ve decided to retrace the footsteps of the Norwegian explorer Thor Heyerdahl in his quest to travel from Peru to Pacific Polynesia on a raft made from natural materials.  His book Kon-Tiki narrates his 101 day journey.

But since balsa wood is scarce, I will need some other readily available material I can lash together to build my vessel.  (Have you figured out where this is headed?)

With so many broken EHRs littering the dustbins, I figured why not?  I bought them for pennies on the million and had them shipped to the seaport of Callao.  I hired a few systems integrators to integrate the various platforms; McKesson and EPIC formed the major components of the hull, and several copies of AllScripts served as decking.

Launch is set for April 1 of this year.  My backup plan in case this fails is to use all of the unclaimed ARRA money, convert it into single dollar bills, and lay it on the water in front of me, bill by bill, for 4,000 miles.  I know this is a bit extravagant, but I hate to see all that money go to waste.

November 23, 2011

EHR’s marmalade-and-toast hypothesis

Filed under: EHR,healthcare 2.0,Hospital,innovation,productivity,Rants & Musings,Who's Running the Show? — Paul Roemer @ 10:14 am

Les choses son contre nous—things are against us.  EHR is the marmalade-and-toast hypothesis, that the marmalade-side will land on the carpet when the toast falls from the breakfast plate, played out in bits and bytes.  Resistentialism is the belief that inanimate objects have a natural antipathy towards human beings.  If one were to view the marmalade-toast through the glasses of resistentialism one would conclude that the likelihood of the toast laying marmalade-side down increases with the cost of the carpet. So it is with the EHR.  Your expensive EHR is laying marmalade-side down on a very expensive carpet.

EHR has created an air of technostalgia with users yearning for the bygone days when the technology involved a number two pencil and a pad of paper.  Now that you are using your EHR system, do you ever wonder how different the experience of using it would have been if someone had asked for your input about what the EHR should do?  Would merely asking have solved the EHR myopia that was brought about by those who implemented it, implemented it without involving a single systems designer?

That this problem even exists is demonstrated by the fact that to use the EHR required hours of training.  Users sat there like sock puppets listening to the buzzword-bingo put forth by the trainers.  This should have been the clue that none of what they were about to learn was intuitive or self-evident.  The reason they offer EHR training is to explain “This is how you get the system to do what you need it to do,” because without viewing it that way it will not do anything.

The EHR has turned a lot of normally complacent physicians and nurses into stress puppies.  To understand how far amiss the functioning of the EHR is from what the users had hoped it would be all one has to do is observe it being used.  How many doctors and nurses have apologized to a patient during an exam because of something related to the EHR?  “Sorry this is taking so long…If you will just bear with me while I figure out how to do this…When the nurse returns I will get her to show me how to schedule your next appointment.”

If ever there was a time to have employed defensive pessimism, the implementation of EHR was such a time.  Users went into the project skeptimistic, certain it would go badly.  As niche worriers doctors and nurses imagined all the ways that the EHR would under deliver and would make their jobs more difficult, and they watched their stress portfolios rise.  The forgotten task was that nobody mapped out ways to avert the damage.

That this jump-the-shark problem can and should be corrected by something not much larger than a two-pizza team—a team small enough that it can be fed by two pizzas—seems to have escaped the reason of many.

Many are guilty of treating the productivity drop brought on by EHR as a problem with no solution.  If a problem has no solution it is not a problem, it is a fact.  And if it is a fact it is not to be solved, but coped with over time.  There is way too much coping going on.

The EHR productivity drop can be undone.  It will not be undone by redoing the training.  It will be undone by assessing the human factors and user experiences of those using the EHR, by researching how they users want to use it, and by reconfiguring the user interface.

This is not cheap, but it is much less expensive than the cost of loss productivity.

 

September 20, 2011

Step away from the computer

Filed under: EHR,EMR,healthcare 2.0,Hospital,planning,PMO,Rants & Musings,Who's Running the Show? — Paul Roemer @ 5:06 pm

Our middle school child is in the middle of a family consumer science project (home economics) to organize one room in our home.  He has redefined the project so that he reorganizes during commercials, and he is seven hours into a project involving our walk-in closet.

While watching the news it occurred to me that something is missing from my life, I do not belong to a gang, not even a little one.  So, I have decided to start one, a white collar gang of consultants.  A rough and tumbled, manicured group of professionals.

Instead of gang emblem, I am thinking each member of the gang will have their own embossed business card.  We will come up with creative gang nicknames.  For myself I am vacillating between ‘Dr. Knowledge’ and ‘The Voice of Reason.’  Instead of Harleys, we will roll through town to our national rallies on monogrammed Segways, and instead of leathers we will dress in Armani.

Mothers will hide their children from us as we power noiselessly down Main Street at four miles an hour, and their CPA husbands will turn green with envy.  We might not win many fights, but we will have the satisfaction of knowing we are smarter than those who beat us to a bloody pulp.

Sounds too good to be true, doesn’t it?

There are days when it doesn’t pay to be a  serial malingerer, and when it does, the work is only part time, but I hear the benefits may be improving as I think I heard somebody mention healthcare is being reformed.

I don’t know if you are aware of it, but there are actually people who have taken an Alfred E. Newman, “What, me worry” attitude towards EHR.  For the youngsters in the crowd, Alfred was the poster child for Mad Magazine, not Mad Men.

Just to be contrarian for a moment–as though that’s out of character for me–most providers have no need to fear–does this happen to you?  You are writing aloud, trying to make a point, and the one thing that pops into your mind after, ‘there’s no need to fear’ is “Underdog is here.”

Anyway, since many providers haven’t begun the process, or even begun to understand the process, there is still time for them to lessen the risk of failure from an EHR perspective.  Many don’t want to talk about it, the risk of failure.

Here’s another data set worth a look (The Chaos Report).  They went a little PC on us calling them ‘Impaired” factors.  EHR impairment.  Step away from the computer if you are impaired, and take away your friend’s logon if they are.  These are failure factors.

Project Impaired Factors % of  the Responses
1. Incomplete Requirements 13.1%
2. Lack of User Involvement 12.4%
3. Lack of Resources 10.6%
4. Unrealistic Expectations 9.9%
5. Lack of Executive Support 9.3%
6. Changing Requirements & Specifications 8.7%
7. Lack of Planning 8.1%
8. Didn’t Need It Any Longer 7.5%
9. Lack of IT Management 6.2%
10. Technology Illiteracy 4.3%
11. Other 9.9%

My take on this is with overall “failures” so high, several respondents could have replied to “all of the above.”  Also of note is that these failure reasons differ from the ones listed previously.

Who knows, maybe if we multiply them by minus one we can call them success factors.

July 26, 2011

Whatever happened to Healthcare Reform?

Filed under: healthcare 2.0,healthcare costs,patients,Public option,Rants & Musings,reform,Universal coverage,Who's Running the Show? — Paul Roemer @ 11:55 am

I wrote a piece last year titled ‘Robbing Peter to Pay Paul’.  Yesterday I read a thoughtful post by Kim Chandler McDonald which offered a very similar albeit somewhat different perspective on the topic of where the focus on healthcare really lies.  Kim wrote on ‘meHealth’, taking the responsibility for eHealth as the only real way to create an ROI in the space http://ow.ly/5NCPN.  For those who enjoy reading something by someone who knows the difference between an adverb and a potted plant and can actually write a proper sentence I encourage you to take a read.

Mine was on heCare and sheCare and it also speaks to the individual but does so without any attempt to disguise my belief that healthcare reform missed the mark http://ow.ly/5NDet.  Kim wrote asking what if anything has changed in the period since I penned my piece.  For those who may have missed it, and to borrow from FDR, my premise was that the only thing to fear about healthcare reform was reform itself.

For all the talking that healthcare reform created, the silence on the topic has risen to a new crescendo.  The only thing that has changed concerning reform is that the silence has grown louder.

Why has reform missed the mark and what can be done about it?  Permit me a moment to illustrate.  I would ask that all the altruists reading this post take one step forward—wait a minute Sparky, where are you going?  The reform package efforted (simple past tense and past participle of effort) to be all things to all people, especially to those who have been disenfranchised under the current system.

While the goal is laudable, it did not pass the test of being both necessary and sufficient.  Its insufficiency is hampered by the fact that when we are ill altruism ends at our individual front doors.  It goes back to the notion of robbing Peter to pay Paul.  Do unto others, but do not undo unto me.

Most observers believe there is some dollar amount that contains the total spend available for healthcare and that to increase services to those less fortunate—the theyCare populous—means paying for it by removing services from those who presently have healthcare, the heCare and sheCare taxpayers.  And, it is those same people, the heCares and sheCares, whose support of reform has fallen silent.

While a rising tide may indeed lift all boats, it also drowns those tethered to the pier.

July 11, 2011

Strategy–The land of small ideas

Filed under: business model,healthcare 2.0,Hospital,planning,Strategy,Who's Running the Show? — Paul Roemer @ 9:26 am

Hangin’ by a thread

“It will feel better when it quits hurtin’.” Well duh.  It will also feel better when we stop self-inflicting the hurt.

To help me understand how things work I need to decompose issues, not into small parts, but into a series of pictures or shapes.  The pictures I come up with represent my particular perspective of how things look.  That can be a far cry from how others view them.  Maybe that stems from when I was a child and enjoying putting puzzles together upside down.

Instead if hitting myself over the head with a hammer, I set aside the easy pieces—those with straight edges and the four corners.

The puzzle was equally complete no matter whether you worked with the picture or just the shapes, but the exercise was quite different.  The advantage in doing it my way is that upon staring at 500 pieces of cardboard backing I had to bring different problem solving skills to the table.  The disadvantage is that once I could picture the solution in my mind, I lost all interest in completing the last few pieces of the puzzle.

I find myself looking at coming up with a reasoned approach for attacking the large provider healthcare business model.  Puzzle pieces are scattered across my desk; some right-side up, others right-side down.

Here’s where the process breaks down or breaks up—I am sure the direction is irrelevant.  How does one change someone that either does not want to change or one who thinks change is not needed?

Just because you think you’re being followed does not mean you are paranoid—it could mean you are the only one with enough focus to know what is happening.  Charging someone eight dollars for a bag of popcorn to keep your business afloat is not insightful, frankly, it is embarrassing.  Charging forty dollars to check a bag on a plane does not earn a CEO the Baldridge Award, it only allows the airline to lose less money, to stave off inevitable bankruptcy a little bit longer.  Eastern, Pan-Am, Braniff, TWA, Republic, Northwest, Piedmont, Midway, Independence.  They proved the same thing.  Continuing to use the same failed strategy delivered the same failed result.  Just because the first five people to jump off the garage roof couldn’t fly doesn’t mean you can’t.  Or does it?  Bigger wasn’t better, was it?

What does it cost to fly from New York to Seattle?  It depends.  What does it cost to have an angioplasty on Philadelphia?  It depends.  Did the airlines adopt their pricing model from hospitals, or was it the other way around?  Does it matter?  Probably not.

The land of small ideas, like Monty Python’s silly walks.  Somebody actually comes up with these ideas.  I doubt it is someone on the board.  People who lead do not one day lose their marbles and decry, “Our model is not working, let’s start charging passengers if they sit during the flight.”

If staying afloat requires a hospital to charge eight dollars a unit for Tylenol, the land of small ideas is winning.

June 27, 2011

Wayne Newton’s 4th law of relative immobility

Filed under: business model,crowdsourcing,healthcare 2.0,Hospital,planning,Rants & Musings,Who's Running the Show? — Paul Roemer @ 8:02 am

Last night I was speaking with a woman at a gathering of graduates from my high school.  She got into the subject of reading glasses and then commented that she first learned she needed regular glasses since the age of four.

As she was not wearing glasses, I asked her if she’d had Lasik.  No, she said, “I always hated how I looked in them, so I quit wearing them in high school.”

“Don’t you miss being able to see things?” I asked.

“Not really.  This is how I’ve seen the world for the past thirty years.  I’ve grown comfortable with how I see the world.”

I think many business leaders have the same perspective.  They get comfortable with how they see their world—comfortable with the issues and how to address them.  Given the choice, people will stay in their comfort zone.

Do you remember your physics?  Relative motion is the branch of physics that studies the motion of the body relative to the motion of another moving body (Newton).  For example, if you are in a train and another traveling at the same speed pulls alongside you, it appears to both set of passengers that neither train is moving.  If your train decelerates it will appear to you the other train has accelerated.

Now, take the perspective of someone standing on the platform viewing the two trains.  To that person, there is no illusion.  The bystander can see exactly what is happening; who is moving forward and who isn’t.

Some business leaders get caught up in what I call Wayne Newton’s 4th law of relative immobility.  When they look out their windows at the executive in the hospital across the street, it appears they are both moving at the same speed and at the same direction.  That is how they have seen the world each day for the last several years.  They look at each other, wave, and then go about their business, knowing their competitor hasn’t passed them or changed course.

But you and I know why it looks that way to them.  The reason they have not been passed is because neither hospital is moving forward.  The reason they do not perceive a change of direction is that they are both moving in the same direction.  In actuality, there is no motion.  Only an outsider can see neither hospital is moving.

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