CIOs, Others React To Meaningful Use Final Rule. InformationWeek Healthcare–my comments http://ow.ly/2bS4D
July 15, 2010
July 3, 2010
The EHR Certification Myth
EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial–like Kojak without the warmth.
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?
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
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June 30, 2010
The EHR Certification Myth
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.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
June 27, 2010
July is “take your EHR strategy to lunch month”
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
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
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June 20, 2010
What benefit is there to meeting Meaningful Use?
Commercials bug me. Big surprise.
You have probably seen the commercial for the Sleep Number Bed. A bare mattress, a glass of wine on the mattress, a bowling ball is dropped on the mattress. The glass of wine does not spill. That makes some people rush out and buy the mattress. Why? For the security in knowing that just in case they leave a glass of wine on their mattress and then happen to drop a bowling ball on it, the wine will not spill.
That dog don’t hunt unless you happen to be opening a bowling alley/Motel 6. The company is trying to entice you on the merits of doing something by asking you to make the leap of faith by equating the bowling ball falling on the bed to having your spouse get in or out of the bed without disturbing your sleep.
A feint. A maneuver designed to distract or mislead you from the real purpose. Meaningful Use. Certification. A feint. Designed to distract or mislead you from the reason you need an EHR. The terms of Meaningful Use, that is, what is meaningful to your organization should be set by your organization, not some national standard applicable to every hospital in the country. Hospitals are not ubiquitous—the Meaningful Use standards are. How can a single set of standards be in line with what you require?
What’s the feint? Certification, cash incentives, Regional Extension Centers. A full court press trying to get hospitals to do what the feds want it to do in order to meet their goal of a nationwide interconnected healthcare system.
What proof, other than a check, has anyone offered that you benefit from meeting Meaningful Use?
Should you try to meet Meaningful Use? I think not. There is no ROI, and the full set of standards have yet to be published. What should you do? Have a glass of wine, or better yet—go bowling. Don’t forget to buy one of those snazzy bowling shirts.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
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June 19, 2010
EHR Groundswell
EHR, there’s a new groundswell against meaningful use. How do I know? I’m starting it now.
After lunch, if I’m in the right mood, I may start one against certification.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
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June 2, 2010
How to calculate Meaningful Use’s ROI
Just to make sure we are all turned to the same page in our Cliff Notes on Meaningful Use, today’s conversation is, “There is no “R” in ROI.”
Are you familiar with the Abilene paradox? It is a paradox in which a group of people collectively decide on a course of action that is counter to the preferences of any of the individuals in the group. It involves a common breakdown of group communication in which each member mistakenly believes that their own preferences are counter to the group’s and, therefore, does not raise objections.
I think it occurs more often than we think. Try to recall the last meeting you attended in which you really disagreed with something that was said. Chances are you knew some of the others in the meeting well enough to know they also disagreed. The reason you know they also disagreed is because you had discussed the topic. However, none of you raised your disagreement during the meeting. Why? Because you did not want to rock the boat.
It is similar to a pseudoconsensus. Pluralistic ignorance. These create a bystander effect—people are more likely to speak out about an issue when they are alone with someone than when others are present.
After further consideration I think we must consider the very real possibility that there is no ROI for Meaningful Use. I write this in all sincerity. Healthcare executives march in lock-step or group think to achieve the myth of finding an ROI for Meaningful Use. The ROI is healthcare’s quest for the Holy Grail, albeit without the Monty Python sound track. They cannot proceed without one, so they set the target, figure out what data will demonstrate that they have hit it, and disregard the reams of data that does not support the ROI.
What if the government came out with a standard stating all hospitals ought to buy, install, and use a fifty million dollar transplant device that also flosses the patient’s teeth? This initiative is “optional”, but the government will pay the hospital a two hundred thousand dollar rebate. There are several types of transplant flossers—the ones that deliver that fresh mint taste cost extra.
If we were having a business discussion about the ROI for the transplant device, healthcare executives would be foaming at the mouth about how impossible it would be to calculate an ROI, and rightly so. They would argue all hospitals are different, they have different cost structures, the devices are all different.
The standards for Meaningful Use are arbitrary. The standards were developed by people who do not need to meet an ROI. There was no mandate in the development of those standards to create standards which when met would yield an ROI. Any attempt to force an ROI will naturally differ in a number of ways:
- by provider—size, structure, offering, geography
- by their interpretation of Meaningful Use
- by which EHR they implemented
- when they began the implementation
- how well they implemented the EHR
Somebody somewhere may hit a positive ROI on Meaningful Use, just like somebody playing darts may hit a bull’s eye. Any positive ROI will be accomplished more out of chance, and from having fit the data to a predetermined ROI rather than measuring the ROI against its true impact.
Implementing an EHR can be very good for a hospital. However, it should be a business decision for the hospital based on the same set of business rules the hospital would use to justify any other large expenditure. If the hospital achieves an ROI it will not be because of having followed an arbitrary set of standards. Any ROI for an EHR will come from having done it correctly. Hitting the figure any other way means two things; it was a coincidence, or you are in for trouble down the road.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
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June 1, 2010
If you come to a fork in the restaurant…
In Greek mythology, there was a not so nice man, Procrustes. He had an iron bed in which he invited wayfaring strangers to spend the night. Some of the strangers were too long for the bed and others were too short.
Apparently Procrustes liked things orderly and could be a tad anal when learning his guests did not fit. He would set on them with his smith’s hammer, to stretch the shorter ones to fit. If the guest proved too tall, Procrustes would amputate the excess length. Truth be told, nobody ever fit the bed exactly because Procrustes had two beds.
In contemporary terms, a Procrustean Bed is an arbitrary standard to which compliance is forced. A Procrustean Solution involves fitting a business problem to a preconceived set of strictures.
Raise your hand if you have already figured out where this is headed. Preconceived. Arbitrary. Compliance. Strictures.
Do you spell Meaningful Use with an upper case Procrustean or one in lower case? I prefer the upper case. The business problem being fitted is the implementation of EHR. The preconceived sets of strictures are the Meaningful Use standards.
This in turn leaves the healthcare provider in what is best described as a Morton’s Fork scenario. Shall I explain? A Morton’s Fork is a choice between two equally unattractive alternatives—a dilemma. The concept originated in 1487 under the rule of Henry the VII as a result of tax policy to ensure everyone paid taxes. The argument was because the rich had enough money to buy things they must have enough money to pay taxes, and the poor who had bought nothing had saved their money, and thus had money with which to pay taxes. The two prongs of the fork—back then forks only had two prongs. Q. E. D.
The healthcare provider must choose between—as one may not choose among—two alternatives. Attempt to meet Meaningful Use—a Procrustean Solution—turn their business model inside out to meet the government’s Gossamer standards.
Attempting to meet the standards does not ensure they will in fact meet the standards. Should they only meet ninety-nine percent of the standards, they lose. The Pareto principle does not apply. There is no 80:20 rule. They will not receive any incentive money as Meaningful Use is an all or nothing game.
The second alternative is to not meet Meaningful Use. This choice may be voluntary, or involuntary—trying to meet Meaningful Use and failing. Alternative Two—it is said—will result in reimbursement penalties from Medicaid and Medicare.
I do not think those penalties will be implemented, or at least they will not be implemented in the documented timeframe.
I also do not think there is a Morton’s Fork, because I think Meaningful Use will disappear because it is so arbitrary and capricious—and because the number of large providers who will meet it could all drive to lunch at Morton’s in a Yugo, at which time they could dine with a fork from Morton’s.
We have now come full circle. My work here is through.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
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May 28, 2010
My latest post to healthsystemCIO.com
I think there is plenty of merit to quit chasing Meaningful Use and get on with your business.
http://healthsystemcio.com/2010/05/28/ten-catechisms-of-meaningful-use/
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
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Contact me: paulroemer paulroemer paulroemer
Is there a business argument for Meaningful Use?
I remember the first time I entered their home I was taken aback by the clutter. Spent and wet leaves and small branches were strewn across the floors and furniture. Black Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.
There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”
“We try hard to keep the place neat,” she replied.
“Where does it all come from?” I asked.
“The windows.”
I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.
“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.
And, the constant bother of emptying the buckets, and the sweeping of the leaves.”
“Why don’t you shut your windows? It seems like that would solve a lot of your problems.”
She looked like I had just tossed her cat in a blender.
When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives. Sort of like all the scurrying around Meaningful Use. The normal has been subsumed by the abnormal, and in doing so has created an entire entity which is slowing devouring the resources of the organization.
Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid on a daily basis. When I talk with hospital executives they are marching headstrong into the Meaningful Use abyss.
It makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.
If I ask about it they always have an answer. It all boils down to something like, “We simply can’t turn down the money.” They say that with a straight face as though they are waiting to see if I will drink the Kool Aid. It’s gotten to the point where no matter how goofy things get, as long as they are consistently goofy, there not goofy at all.
This is the mindset that enables leaders to be fooled by their own activity. Busy replaces thinking.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
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