Healthcare IT Strategy

The question was raised on the blog Software Advice.

I think the very question reinforces the magnitude of the issue. Providers have budgets for products whose cost they do not understand. They have implementation teams who have never implemented one. They are aiming at targets for certification and meaningful use, which from my perspective could just as well be written on an Etch-A-Sketch. Hundreds of committees work towards standards, a requirement forced upon them by hundreds of vendor applications and hundreds of Rhios.

The output of the recent HIT policy meeting shows just how befuddled the process is.

This is a mandated national roll out of EHR without half the required sources and almost none of the required leadership. Who is the decider?

The current failure rate for EHRs is understated due to the large number of small systems. The failure rate for those over $10 million will exceed the rate for large IT systems which is close to 80%.

A hospital CEO with who I met last month told me his peers are uniquely ill equipped to make these decisions. Decisions are based on what their friends did, what they read in a journal. They plan implementations based on meeting gossamer standards and tests. They do not base them on requirements.

Watch the dates move backwards. I think in 6-8 years the rolled out EHR will more closely resemble a single, national, browser-based open EHR.

This problem is not unsolvable, however it remains unsolved.

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Several have written suggesting I toss my hat into the ring to serve as the EHR Strategy wonk or czar.  I was in the process of thinking it through when I was awakened from my fuegue state by a loud noise–my ego crashing to the floor.

Some have suggested that a camel is a horse designed by a committee.  Their point in saying that has something to do with how committees function less well than individuals–the problem with “group thinking.”  Personally, I think the camel design seems rather functional.

Some have asked, what is it about the EHR universe that has you dehorting the EHR process as though you are some sort of savant–nobody really asked that, but I wanted a segue and that’s all I came up with.

It’s the committees.  I feel a little like Quasimodo repining about the bells.  Raise your hand if you are on an EHR committee.  See?  Now, if you think that not only has the committee not accomplished much, but believe that it may never accomplish much, lower your hand.  Now look around.  Not many hands still up.

Please take a look at this for a moment.  Don’t try to understand it–it will only make your teeth hurt.

2011 requirements

• For hospitals, 10% of all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) directly entered by an authorizing physician must be made through a computerized physician order entry process. Individual physicians still must use CPOE for all orders, even if electronic interfaces with receiving entities are not available. The initial draft did not specify the required percentage for hospitals and did not address the electronic interface issue.
• Physicians must be able to check insurance eligibility electronically from public and private payers, when possible, and submit claims electronically. This was not in the initial draft.
• Patients must receive timely electronic access to their health information, including lab results, medication and problem lists, and allergies. The initial draft did not include the word “timely.”
• Physicians must implement one clinical decision rule relevant to specialty or high clinical priority. This was not in the initial draft.
• Physicians must record patient smoking status and advance directives. This was not in the initial draft.
• Physicians must report ambulatory quality measures to CMS. This was not in the initial draft.
• Physicians must maintain an up-to-date list of current and active diagnoses based on ICD-9 or SNOMED. The initial draft did not specify use of the two classification sets.

2013 requirements

• Specialists must report to relevant external disease or device registries that are approved by CMS. This was not in the initial draft.
• Hospitals must conduct closed-loop medication management, including computer-assisted administration. This was not in the initial draft.
• All patients must have access to a personal health record populated in real time with health data. This was moved up from 2015 in the initial draft.

Additional provisions

• Patients’ access to EHRs may be provided via a number of secure electronic methods, such as personal health records, patient portals, CDs or USB drives.
• CMS will determine how submitting electronic data to immunization registries applies to Medicare and Medicaid meaningful-use requirements.
• CMS may withhold federal stimulus payments from any entity that has a confirmed privacy or security violation of the Health Insurance Portability and Accountability Act, but it may reinstate payments once the breach has been resolved.

Source: Health IT Policy Committee

See?  Take a few minutes and work this into your EHR task time-line for processes, work flows, change management, training.  Need more time?  I’d need more time than I have, and when I finished I guarantee I couldn’t explain it to anyone.  This is what happens when people get into a room, have a charter, and try to do something helpful.  I am sure they are all nice people.  But be honest, does this make your day, or does it make you want to punish your neighbor’s cat–you may have to buy them a cat if they don’t already have one.

What to do?  Here’s my take on it.  Plan.  Evaluate the plan.  Test the plan.  Know before you start that the plan can handle anything any committee tosses your way.  Let people who know how to run large projects into the room.  Seek their counsel, depend on them for their leadership.  If the plan is solid, the result has a better chnace of surviving the next committee meeting.

Are you suggesting that coconuts migrate? (Not at all, but a swallow could grip it by its husk.)

Sometimes I get reactions from my clients which suggest that my ideas have people questioning if I just fell out of the stupid tree and hit every branch on the way down, especially when what we’re discussing seems to move from the theoretical and towards the heretical. However, there was a presentation I made to one of my clients where I had the entire room believing that i might as well have been suggesting that coconuts migrate.

Allow me to set the stage. I presented to the CIO of one of the largest providers in Europe a vision for what their IT strategy should be. This was an 0.2 firm requiring a 2.0 solution.  As you can guess, it was fairly easy to suggest that better alternatives were available to them, but if you’re a member of the Flat Earth Socitey you’re not going to believe anything until someone is able to literally change your perspective.

During my presentation I wrote on the white board that I would help them choose between three alternatives. At this point, a British colleague and good friend, came to the front of the room—uninvited, removed the marker from my hand, erased the word ‘between’, and penned the word ‘amongst’. “We choose between two things, and amongst three or more,” he said with a grin and then returned to his seat. I suggested that since English was not the native language of our client that his point was probably lost on them, to which he stated that his point was directed at me whose native language was supposed to be English. God save the queen. He also tried to make the point on more than one occasion that the American War of Aggression with England did not end in 1783 with a victory for America, but with a British retreat.

Anyway, we were choosing between three alternatives, at least I was. After about ten minutes of explaining what could be achieved and how it might be structured, I was interrupted again, this time by the CIO. He too took my marker, concluding that I was a coconut. It took me about thirty minutes to convince him that everything I’d presented was not only achievable, but already operational in a number of their competitors.

So, as we head down the EHR path with our Project Management Executive, the person who will be spearheading the internal effort to affect change, we must find a way to make sure the executive is properly equipped. For starters, the executive needs to have, and to be able to communicate a vision, a vision for the change, for how it will impact the organization, and an ability to communicate it.

Those of you who’ve visited previously may have caught on to the fact that my wife likes to keep me away from bright shiny objects such as tools.  Let me tell you about my first house, a two-story stucco building in Denver, built in 1902.  My favorite part of the home was the brick wall.  That is had a brick wall was not apparent when I purchased it.

I came home from work to find that my dog had eaten through the lath and plaster in the living room and there was the brick.  I had to decide what to do.  I knew nothing about lathing—I know that’s not really a word—or plastering.  What to do.  My only tool was a hammer, so I began to hammer.  For those who haven’t done this, hundred year old plaster being pounded with a hammer makes a lot of dust.  This process proved to be very slow.

What did I do?  I bought a bigger hammer—such a guy approach to a problem, isn’t it?  It took three hammers to get down to just bare brick.  What would you have done?  When your only tool is a hammer every problem looks like a nail.

As you go through the EHR planning process in your war room—you do have a war room, don’t you?  (Try Sam’s Club, after all, they sell EHRs.)  Get out the really big piece of paper, the one with your EHR design—you do have a really big piece of paper, don’t you?  (Back to Sam’s.)

Next to the box on the paper labeled “Shiny New EHR” should be lots of empty space so you can draw in all of the other systems with which your EHR will have to interface.  One of the readers of this blog wrote recently that his EHR had more than 400 interfaces.

EHR, if done correctly, will do much for patients, doctors, and administrators.  It’s not a panacea.  It won’t reach its potential unless you also integrate it with those systems that unlock its potential.  Improving your efficiency and effectiveness takes more than merely an EHR system.

When your only tool is a hammer, you’d better hope every problem is a nail.  What other tools are you using?  Please share your ideas about what works well.

It’s hot and muggy; a hazy pall seems to levitate before me.  We call it Pennsylvania in summer.  Chest pain yesterday, nitro in gym bag.  Intervals today.  I hate running intervals as much now as I did in high school, but they’re better for the heart than just running distance.  Twenty-four 110’s.  Did I mention it was hot?

I am on the high school track.  The football team is/are—where are all the English majors when you need them—going through their drills.  Running and thinking.  That’s a good combination for me.  After two laps I’m glistening, after three I’m soaked through.  That’s when it hits me.

Practice.  Offensive and defensive drills.  Blocking and tackling.  Run the option.  Block the punt.  Come back tomorrow and do it again.  Do it until you get it right.  Do it until you can get it right in the game.  Pretty neat idea all this practicing.

Some adults get to practice.  I refer to what I do as my consulting practice—my father still has no idea what idea what I do for a living but I’m okay with that.  He was a spy and he still won’t tell me what he did.  Lawyers and doctors practice—I hope it means something other than they are still trying to get it right.

Know where this is headed?  See, that wasn’t too difficult—remember, the desk is hard, the task is difficult. (My one takeaway from eighth grade English.)  Who doesn’t get to practice, doesn’t even have a coach?  Bingo, the EHR Project Management Executive.  It would be better if they did.  Imagine this conversation:

“Sorry Charlie, hit the showers.”

“Why Coach?”

“Your change management isn’t working for you today.  You’re leaving processes untouched.”

“It was the docs’ fault.  They just toy with me.  Treat me like a wonk and tell IT jokes behind my back.”

“Your game plan is coming apart.”

“But I didn’t get to practice, we didn’t even get to warm up.  I’ll do better next time.”

“Which next time is that Charlie?  With whose money?  These are The Bigs, Charlie.  Only grownups play here.  I’m afraid I’m going to have to send you back down to Single A.”

“Private practice.?”

“Sorry Charlie”—sounds like the tuna commercial.

You’ve got one shot at this, no warmups, no practicesm there are no do-overs, and you are gambling millions.  DIRT-FIT  Do It Right The FIrst Time

Okay, so today was going to be one of those days when I wasn’t going to allow myself to be stupified–at least no more than was really required.

Then it sneaks up smack dab in the middle of a call, and from what I’ve been able to determine, people find it annoying if you burst out laughing on the call.  (They are not annoyed at all if you simply write about them provided they don’t read it.)

What got me going is this statement, “We’ve budgeted $X for EHR.”

Really?  You did this all by yourself?

The facts as I understood them are as follows:

• Never bought an EHR
• Don’t know how big they are, if they are blue or green, come gift-wrapped, or if you need two people to carry it
• No input from vendors about EHR
• no discussions with others abot what an EHR system costs

So, with absolutely no information how does one determine how much they need to spend?  This is not like going to the supermarket for a gallon of Soy Milk–not that anyone would want to do that.

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

Why is this a part of the overall plan?  Is this planned failure?  Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test.  The certification test, by definition, is necessary.  The Full test is both necessary and sufficient.  It is possible to pass certification without passing the Full test.  Therefore, the Full test is a stricter test.  Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test?  Same as always.  Fully functional, on time, within budget, and user accepted.  Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact:  One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion:  The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations.  Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification.  (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact:  Most large, complex, expensive IT projects fail—they just do.  This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed.  Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion:  Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak?  You bet.  Insurmountable?  Doesn’t have to be.

What can you do to improve your chances of success?  Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points.  EHR Fail Safe Points?  The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test.  The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD.  They need not have a slew of EHR implementation merit badges.  The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built.  They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR.  Those skills are needed—in spades—and you need to budget for them.  The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre.  They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

What do you think?

There were four of us, each wearing dark suits and sunglasses, uniformly walking down the street, pausing at a cross-walk labeled “consultants only”—I think it’s a trick because a lot of drivers seem to speed up when they see us. We looked like a bad outtake from the movie Reservoir Dogs. We look like that a lot.

Why do you consult, some ask? It beats sitting home listening to Michael Bolton or practicing my moves for, So You Think You Can Dance, I tell them.

Listening to the BBC World News on NPR whilst driving, there’s one thing I always come away with—they’re always so…so British. No matter the subject—war or recession—I feel like I should be having a proper pot of tea and little cucumber sandwiches with the crusts removed; no small feat while navigating the road.

Today’s conversation included a little homily about the Gordian knot with which the company Timberland is wrestling, questioning whether as a company Timberland should do well, or do good. (Alexander the Great attempted to untie such a knot, and discovered it had no end (sort of like a Möbius strip, a one-sided piece of paper–pictured above. (For the truly obtuse, among which I count myself, the piece of paper can be given a half twist in two directions; clockwise and counter-clockwise, thereby giving it handedness, making it chiral—when the narrative gets goofy enough, sooner or later the Word dictionary surrenders as it did with chiral.))) I’m done speaking in parentheses.

Should they do well or good? Knowing what little command some people have of the English language, those listeners must have wondered, why ask a redundant question. Why indeed? That’s why I love the English, no matter the circumstances they, they refuse to stoop to speaking American.

Back to Gordo and his knot. That was the point of the knot. One could not have both—sorry for the homonym. Alexander knew that since the knot had no end, the only way to untie it was to cut it. The Gordian knot is often used as a metaphor for an intractable problem, and the solution is called the “Alexandrian solution”.

To the question; Well or good. Good or evil. Are the two choices mutually exclusive? For an EHR? They need not be. The question raised by the BBC was revenue-focused (doing well) versus community or green-focused (doing good). My question to the reader is what happens if we view EHR with this issue as an implication, a la p→q.Let’s review a truth table:

From a healthcare provider’s perspective the answers can be surprising; EHR can be well and good, or not well and not good.  The Alexandrian solution for EHR is a Alexandrian PMO.

Have you people call my people–we’ll do lunch.

Most of the real work that needs to be done in EHR workflow improvement happens in the blank white space between the boxes on the org chart.  That’s where you’ll find a lot of the BRPs–Barely Repeatable Processes.