Healthcare IT: How good is your strategy?

July 1, 2010

What if GM were involved in EHR?

Filed under: EHR,NHIN,Rants & Musings,Strategy,business model — Paul Roemer @ 8:59 am
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Goodness knows, the whole car thing did not work our too well for them

Do you ever think about the origination of some of your ideas?  For me, the good and the bad just seem to materialize.  Like the time a friend and I were hiking a peak in the Sangre de Cristo range in Colorado.  It had taken the better part of six hours of circuitous climbing to reach the summit.  It was late in the fall, and the temperatures were around freezing.  Roiling storm clouds were racing towards us from the west.

If we returned by the same route we knew we’d be caught up in a storm that we were neither prepared nor dressed to handle.  I spotted our car about six thousand feet below us.  If we headed straight to it, I thought we could cut our descent time by about an hour.  To do this though required that we make our own trail via a hunt and peck route of whatever the terrain permitted.  We dropped the first fifteen hundred feet in a matter of twenty minutes using a glissade.  This technique allows you to moonwalk and slide down a scree field, using your ice ax as a break.

After an hour we reached a point about two thousand feet above our car.  It was sleeting, and the wind was whipping around the face of the mountain.  There in the middle of nowhere stood a sign from the sheriff that read, “Devil’s Gulch, turn back.”  Our choice was to reclimb the mountain or to ignore the sign and press on.  I hate do-overs.  How tough can this be, I goaded him?  Be smart, kick it into high gear, and we’ll be done.

We pressed forward.  Fifteen minutes later, we reached a four hundred foot limestone cliff.  Between us and the next semi-reasonable terrain was a rather deadly looking wall of rock and scrub pine.  My pack made me feel like it was forcing me forward, so I removed it and tossed it over, thinking I’d retrieve it later.  Watching my pack bound from rock to rock for what seemed like more than a minute did nothing for putting me at ease.

We spent more time discussing each step than we spent taking it.  Those four hundred feet took us two hours.  Not my best idea, but it didn’t kill us.

So, during my run today, I had another idea.  This one is about OnStar, the GM tracking system.  I typed in to Google, “How does OnStar Work?”  Lots of hits.  The more I read, the more I began to feel like if one ignored the technology and focused on the concept a real argument could be made for pairing the idea, and a few others, and seeing what type of EHR network might be possible using a similar set of tools.

The OnStar concept is termed telematics, a combination of telecommunications and informatics.  Telematics is the integration of computing, wireless communications, and GPS.  It provides information to a mobile service like a phone, PDA, or laptop.  It is used for sending, receiving, and storing information over very large networks.  So, why is nobody having the conversation that says what if we image a similar network with added security that works from a healthcare provider’s office rather than a car.

OnStar doesn’t need Rhios.  OnStar has a single set of standards.  Now, instead of arguing why something like this can’t work in healthcare, isn’t there argument is seeing if it can?

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

June 12, 2010

The Swarm theory of failure

Filed under: EHR,HIE,NHIN,RECs,Rants & Musings,Rhio — Paul Roemer @ 12:04 pm
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According to National Geographic, a single ant or bee isn’t smart, but their colonies are. The study of swarm intelligence is providing insights that can help humans manage complex systems. The ability of animal groups—such as this flock of starlings—to shift shape as one, even when they have no leader, reflects the genius of collective behavior—something scientists are now tapping to solve human problems.  Two monumental achievements happened this week; someone from MIT developed a mathematical model that mimics the seemingly random behavior of a flight of starlings, and I reached the halfway point in counting backwards from infinity–the number–infinity/2.

Swarm theory. The wisdom of crowds. Contrast that with the ignorance of many to listen to those crowds. In the eighties it took Coca-Cola many months before they heard what the crowd was saying about New Coke. Where does healthcare EHR fit with all of this? I’ll argue that the authors of the public option felt that wisdom.  If you remember the movie Network, towards the end of the movie the anchorman–in this case it was a man, not an anchor person–besides, in the eighties, nobody felt the need it add he/she or it as some morphed politically correct collection of pronouns.  Whoops, I digress.  Where were we?  Oh yes, the anchor-person.  He/she or it went to the window and exhorted everyone to yell, “I’m mad as hell, and I’m not going to take it anymore.”  Pretty soon, his entire audience had followed his lead.

So, starting today, I begin my search for starlings.  A group whose collective wisdom may be able to help shape the healthcare EHR debate.  The requirements for membership is a willingness to leave the path shaped by so few and trodden by so many, to come to a fork in the road and take it. Fly in a new flock.  A flock that says before we get five years down the road and discover that we have created such an unbelievable mess that not only can we not use it, but that we have to write-off the entire effort and redo it, let us at least evaluate whether a strategic change is warranted.  The mess does not lie at the provider level.  It lies in the belief that hundreds of sets of different standards can be married to hundreds of different applications, and then to hundreds of different Rhios.

Where are the starlings headed?  Great question, as it is not sufficient simply to say, “you’re going the wrong way”.  I will write about some of my ideas on that later today.  Please share yours.

Now, when somebody asks you why you strayed from the pack, it would be good to offer a reasoned response.  It’s important to be able to stay on message.  Reform couldn’t do that and look where it is. Here’s a bullet points you can write on a little card, print, laminate, and keep in your wallet if you are challenged.

  • Different standards
  • Different vendors
  • Different Rhios
  • No EHR Czar

Different Standards + Different Vendors + Different Rhios + No Decider = Failure

You know this, I know this.

To know whether your ready to fly in a new direction, ask yourself this question.  Do you believe that under the present framework you will be able to walk into any ER in the country and know with certainty that they can quickly and accurately retrieve all the medical information they need about you?  If you do, keep drinking the Kool Aid.  If you are a starling, come fly with us and get the word out.  Now return your seat backs and tray tables to their upright and most uncomfortable positions.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

April 13, 2010

The RHIO Answer

Filed under: EHR,Rants & Musings,Rhio,Strategy,planning — Paul Roemer @ 11:32 am
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It may be helpful as you read this to use your highlighter on the screen to accentuate the important parts or some white-out for the parts you don’t favor.

Do you ever kick an idea around, speaking about it, writing about it, until at some point you finally capture it in a way that makes sense to you?  That’s how I reason things through.  I write like I’m talking aloud and sometimes it lands in my lap.

That just happened to me as I was trying to get my arms around what it is about the concept of the RHIOs that has been bothering me.  Bear with me.  I was on LinkedIn emailing someone using the ‘send a message’ feature.  I was returning an email which she was returning which I had initiated.  The process works like this.  I get an email from LinkedIn telling me I have a message.  I go to LinkedInm read the message and send a reply via LinkedIn.  She receives an email indicating she has a message, goes to LinkedIn, and so forth and so on.

Do you see it?  In this scenario, what is the added value provided by LinkedIn?  Nothing.  It’s all hat and no cowboy.  LinkedIn serves simply as a pass through, contributing nothing.  I wrote in my message to her, “Send me your email address, I feel like I’m in my own RHIO.”

When is a RHIO not aRHIO?  When there’s no need for it.  Is there any functionality intended for the hundreds of RHIOs which couldn’t be dealt with at the N-HIN?  What do you think?

April 2, 2010

My remarks to Brian Ahier’s insightful interview of Dr. Blumenthal

Filed under: EHR,NHIN,RECs,Rants & Musings,Strategy,Who's Running the Show?,meaningful use,planning,standards — Paul Roemer @ 12:38 pm
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I encourage those who have not read Brian’s interview of Dr. Blumenthal on HealthSystemCIO.com to make time to read it.  http://healthsystemcio.com/2010/03/27/chatting-with-the-national-coordinator-for-health-it/#comments

Brian also has a link to the audio.

Brian asked me to comment, and I was pleased to do so.  Here is what I wrote.

I enjoyed reading your interview with Dr. Blumenthal. Clearly he and the members of his team are working very hard on a number of difficult and rather diverse issues.

I have been wondering, how does one tell the story of EHR to someone who has no understanding of EHR? Not the story about the EHR system in a physician’s office, or the ungainly one in a hospital. The story to which I refer is the story of the national rollout of EHR and the drive for interoperability.

For me, the question of how to tell the story in a way to make it understandable raises a number of other questions. Is there a story, or is it a collection of short stories written by different people, guided by different principles and goals? Is there a plot? Does the story come together in a natural manner?

Sticking with the story theme for a moment—who are the main characters, do they relate to one another? Does it come to a meaningful conclusion, in fact, does it conclude?

Look at the various antagonists—EMR, EHR, PRH, Meaningful Use, Certification, HIEs, RECs, the N-HIN, interoperability, the ONC, CMS, ARRA, standards, vendors, and PR. I am sure I missed several.

Imagine if Random House allocated millions of dollars to publish and market a book which had yet to be put to paper. No plot, no outline. What if they hired a dozen writers, each with their own areas of expertise—and lack of expertise—and crossed their fingers.

Would they be more successful if they offered penalties and incentives to the writers—a garrote and stick approach? What if they changed the rules after the writers started? What if they left undefined numerous areas of rules, rules which will impact the story, and told the writers to keep pushing ahead?

I do not see how the national EHR rollout story comes together. Now or some distant tomorrow—at least not under this approach. Is the approach viable? Having a few disparate successes does not make me a believer. Call me a cock-eyed nihilist.
Once every so often, an announcement is made that another single hospital reached Stage 7. One among thousands. Why do I view this from the vantage point of a glass half-empty? For me, the existing approach is one of guidance and facilitation. There are no long lines of providers trying to beat the others to the front of the EHR line. There have been several hundred million dollar do-overs.

If we circle back to the providers for a second, three of the largest causes of failure include the arbitrary setting of go-live dates without knowing what needs to be done or can be done in that time frame; second, letting IT and the vendor drive and manage the project; third, not getting users to define what they need and then having IT replicate those needs. IT does not need an EHR.

As I look at the government’s national rollout of EHR I see the same three problems. Who are the government’s users? Doctors, clinicians, and hospitals. There are fixed dates, many having undefined requirements. These are causing some providers to dash for the cash. Who is driving the rollout—the government’s users, or the government. They way the rollout is structured, the users have all of the responsibility and little of the authority. This is a government led IT project. Where are their users? They are running their practices and hospitals. They have one ear open towards, reform, another to the garrote and stick project rollout approach, another to EHR, and yet another to their business model. They have run out of ears.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

My profiles: WordPressLinkedInTwitterMeetupBlog RSS

March 26, 2010

What is the future of the EHR/N-HIN landscape?

Filed under: EHR,NHIN,Rants & Musings,Strategy,healthcare 2.0,informatics — Paul Roemer @ 5:09 pm
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One may argue it is possible to build the real Brooklyn Bridge with nothing but toothpicks, and a lake filled with Elmer’s Glue.  Difficult yes; prudent, no.   Urban legend is when the United States first started sending astronauts into space, they quickly discovered that ballpoint pens would not work in zero gravity.  To combat the problem, NASA scientists spent a decade and $12 million to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300C.

The Russians used a pencil.

The ability to do something is not justification for doing it.  Nor is that fact that someone has put it forth as an idea.  The willingness to do something merely because everyone is doing it or because someone instructed it be done probably has nothing to do with a business strategy, or if it does, it shouldn’t.

In the next five to seven years the business of healthcare at the provider level will have the opportunity to change markedly—the unanswered question is, will it have the ability?  To answer that at the provider level—primarily hospitals and clinics—I believe one must distinguish between the business of healthcare (how the business is run) and the healthcare business (how the care is delivered).

In many respects, the business of healthcare and the strategy surrounding it is pinned to a 0.2 business model.  Certainly there are exceptions to any aphorism, but taken as a whole, there is plenty of room for improvement.  As one hospital CEO told me, “What we really lack is adult supervision.”

So, how exactly does the toothpick bridge apply to healthcare?   Here’s my take on the situation.

  1. It may be possible to build and roll out a national network of EMRs through EHRs connected by HIEs to an N-HIN—I don’t think will happen in the next five to seven years, especially if to be effective the network requires a minimal participation of somewhere between 70 to 80 percent of healthcare providers.
  2. Even if I am wrong, why would anyone build a national EHR network out of toothpicks?  Could they possibly have devised a more complex and costly approach?
  3. The government arrived late for the party, has only limited authority, and chose to provide cash incentives instead of direction or leadership.  They passed the responsibility of the success of the national EHR roll out to hundreds of thousands of healthcare providers.
  4. The providers are burdened by having no experience in the sector, hundreds of EHR systems from which to select, no standards, hundreds of HIEs, no viable plan, no one with singular authority, a timeline that cannot be meet, and an unwritten set of Meaningful Use requirements.

The plan sounds like something designed by Rube Goldberg.  Could it be done this way?  I do not think we will ever know.  Not necessarily because it will fail, but because I think the plan will be supplanted by a more realistic one from the private sector.

The government’s plan relies on a top-down approach—albeit with a missing top; from the government, to the providers, to the patients.

The private sector plan will come from firms like Apple, Google, and Microsoft.  It will work because it will be built from the bottom up; from the patients, to the providers, and back.  Personal Health Records (PHRs) will become EMRs.  This approach will allow them to flip their PHR users to EMR users, and will be adopted quickly by millions of customers (patients).  Their approach will have a small handful of decision makers calling the shots instead of hundreds.

This model’s other component will be driven from another direction, by large hospitals and clinics that connect to small hospitals, small practices, and ambulatory physicians via a SAAS model.  Something like this is underway today at the Cleveland Clinic using their offering, DrConnect.

I believe the approach will be refined even further as the distinction between PHRs and EMRs erodes.  Instead of requiring remote care providers to have their own mini-EHR integrated with their practice management system, they will be able to use the EHR of a large hospital.  I anticipate that they will be able to log on to the system to access their patients’ EMRs as though they were actually resident in the large hospital.  This will all but eliminate the role of Health Information Exchanges (HIEs).  It will also extend the reach of those large hospitals, and aid in the retention and recruiting of physicians.

Why is this important?  Because the federal plan, which won’t be viable for several years, is designed to use software solutions which address a current business issue.  By the time their networked solution is fully functional it will be well on its way to obsolescence.  The government is forcing the expenditure of more than a hundred billion dollars on a static offering to address a non-static issue.  Their approach will not be able to keep pace with the changes demanded by market forces.  It reminds me off building a plan to go to the moon based on where the moon was instead of where it will be.  
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saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

February 13, 2010

How difficult are EHR, Reform, & Interoperability

Filed under: EHR,Interoperability,NHIN,Rants & Musings,meaningful use,reform — Paul Roemer @ 8:23 pm
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My daughter asked me to kill the bug in her room—Super Dad to the rescue.  That got me wondering.  Do most men think we excel at most things?  As I pondered weak and weary, I started to formulate this list.  I ask the men as they read through the list to score themselves on a ranking of one to five, with five being the highest, how they view their abilities in each area.  Ladies, feel free to play along on behalf of someone you know.

  1. Sunday Sports
  2. Getting a taxi
  3. Navigating
  4. Mowing the lawn
  5. Killing spiders
  6. Drawing a straight line by hand
  7. Multitasking
  8. Parallel parking
  9. Anything to do with fire
  10. Opening jars
  11. Sharpening a pencil with a knife
  12. Tipping
  13. Driving
  14. Cooking on the grill

Maybe this comes from that hunter-gatherer thing.  Total your score silently in your head—you can do this because you also happen to think you excel in math.  My guess is that 98% of us scored somewhere between 56 and 70, the majority leaning towards the higher end of the range.  Granted, these are simply opinions, nothing any of us has to prove.

However, when pushed most of us will back down on one or two things if we had to prove our prowess.  Take juggling for example.  Even an egoist will be reticent to rate himself an excellent juggler.

Here we go.  Why then when we (ladies, this also includes you) are faced with something challenging at work we do our best to convince ourselves and others that the task can be no more difficult than opening a jar, asking directions, or asking for help?  We prefer to fly solo, believing we will somehow figure it out on the way.

I cannot recall the last time I heard someone facing a big ugly IT project state anything like:

  • You’ve got the wrong person
  • I have no idea how to do this
  • There is no way this is going to work

EHR, reform, Meaningful Use, interoperability.  These are big ugly projects.  Some are projects for which only a scarce few have real subject matter expertise—a handful of which truly ‘get it’, and others for which no one is credentialed.  Yet when we hear the proclamations about how standards are coming, how the N-HIN will work, and how reform will impact healthcare over the next five years, they seem to be stated with such assurance so as to infer that these industry-altering programs are no more difficult than parallel parking.

Remember the game Trivial Pursuit?  There was an inverse relationship between how certain I was of an answer and the certainty with which I asserted it.  If I said the answer quickly and with enough confidence I could occasionally convince the other players not to even check the answer on the back of the card.  For example, if the question is “name the bird who lays its eggs in the nest of another bird,’ and you belt out, ‘racket-tailed coquette,’ you just may pull it off.

It’s just an observation on my part, but why is it that when the nice people in charge tell us that they know what they are doing to me it sounds like they are yelling, racket-tailed coquette.’

January 7, 2010

Is the N-HIN helathcare’s black hole?

Filed under: Interoperability,NHIN,Rants & Musings,Strategy — Paul Roemer @ 12:48 pm
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Last year scientists turned on the largest machine ever made, the Hadron Collider. It’s a proton accelerator. This all takes place in a donut-shaped underground tube that is 17 miles in circumference.

Fears about the collider centered on two things; black holes and the danger posed by weird hypothetical particles, strangelets, that critics said could transform the Earth almost instantly into a dead, dense lump. Physicists calculated that the chances of this catastrophe were negligible, based on astronomical evidence and assumptions about the physics of the strangelets. One report put the odds of a strangelet disaster at less than one in 50 million, less than a chance of winning some lottery jackpots—what they failed to acknowledge is that someone always wins the lottery, so negligible risk exists only in the mind of the beholder.

If I understand the physics correctly from my Physics for Librarians mail-order course—and that’s always a big if—once these protons accelerate to something close to the speed of light, when they collide, the force of the collision causes the resultant mass to have a density so massive that it creates a gravitational field from which nothing can escape. The two protons become a mini black hole. And so forth and so on. Pascal’s triangle on steroids. Two to the nth power (2ⁿ) forever. Every proton, neutron, electron, car, house, and so on.

The collider could do exactly what it was designed to do. Self fulfilling self destruction. Technology run amuck. Let’s personalize it. Instead of a collider, let’s build a national healthcare information network (N-HIN) capable of handling more than 1,000,000 transports a day. What are the rules of engagement?  Turn on the lights and let’s see how it functions.

Let’s say we need to get anybody’s record to anybody’s doctor.  That’s overly simplistic, but if we can’t make sense out of it at this level, the N-HIN is doomed.  The number of possible permutations, although not infinite, is bigger than big.  Can you see what can happen? Strangelets.  The giant sucking sound comes from ARRA and stimulus money as it is pulled in to the black hole.

So what is the present thought leadership proposing to fight the strangelets? Healthcare information exchanges (HIEs)—mini N-HINs.  Regional Exchange Centers (RECs).  A few million, a few billion.  Not only does their plan have them repeating the same flawed approach, they are relying on embedding the same bad idea, and doing it using hundreds of different blueprints.

Einstein defined insanity as doing the same thing over and over and expecting different results.

Stop the craziness. I want to get off.

It’s the end of the world as we know it…and I feel fine. R.E.M.

December 28, 2009

What is wrong with the ONC’s 2010 budget?

Filed under: Certification,Interoperability,NHIN,meaningful use — Paul Roemer @ 8:27 pm
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Some comments I wrote to ahier.blogspot.com’s posting of the ONC’s 2010 budget.

Their mission, “ONC leads, coordinates, and stimulates public and private sector activities that promote the development, adoption, and use of health information technologies to achieve a healthier Nation” although offering nice sentiments, for $61 million, ought there not be a way to measure whether or not they achieved the mission? How does one know if they led, coordinated, and stimulated, and if so to what degree?

Who certifies their work? Who determines if their work resulted in Meaningful Use? Before anyone gets excited by what they plan to do in 2010, let’s look at what they did in 2009.

1. What did the ONC accomplish, complete, put to bed?

2. What did they complete that facilitated the HIT work required of the providers?

There are no standards. There is no believable plan to obtain standards anytime soon. There is no viable national roll-out plan for EHR.

Instead of HIT/ARRA handouts, and HIE’s designed by hundreds of independent groups, and RECs designed by inexperienced appointed committees, why not use the $61 million to state that by such-and-such a date there will be a written and executable plan stating when we will have standards and a workable and believable roll-out plan?

They continue to promise funds to support an ill-conceived plan trying to get everyone on board, an approach that yields to the notion that “There must be a pony in there somewhere.” Ladies and gentlemen–there is no pony.

December 7, 2009

Interoperability-this is the problem

Filed under: EHR,Interoperability,NHIN,Rants & Musings — Paul Roemer @ 8:44 pm
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How does one depict the complexity of the mess being presented as the national roll out plan of electronic health records (EHR) via the national health information network (N-HIN) using Health Information Exchanges (HIEs) designed by Regional Health Information Organizations (RHIOs), with the help of regional extension centers (RECs) without Standards (Standards) and with N too many vendors?

Class?  Ideas?  Class?

If this looks dumb, undo-able, unimplementable, uninteroperable–it’s because it is.  your vision is fine.

Remember the idea behind all this is to get your health record from point A to point B, any point B.  It’s that little word ‘any’ that turns the problem into a bit of a bugger.

Find yourself in the picture below, pic a dot, any dot (Point A).  Now, find your doctor, any doctor (Point B).  Now figure out how to get from A to B–it’s okay to use a pen on your monitor the help plot your course.   That was difficult. Now do it for every patient and every doctor in the country.

Now, do you really think the DC RHIO-NHIN plan will work?  If EHR were a Disney park, who’s playing the Mouse?

November 20, 2009

Why the N-HIN will be owned by public firms

Filed under: NHIN,Strategy,healthcare 2.0,informatics — Paul Roemer @ 2:03 pm
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Here are a few more thoughts just to Emerilize the discussion—to kick it up a notch.  Not only do I think the national EHR market is ripe for the taking by a big three like Microsoft, Google, and Oracle, I’ll go so far to suggest that when the dust settles in 5-7 years, the N-HIN, the National Health Information Network, will be a regulated combination of a handful of those firms.

As for the other firms offering or planning to offer PHRs, permit me to suggest the following scenario.  Let’s say I am in charge of Google’s so far somewhat nonexistent healthcare line of business.  One of my goals would be to have more users of my PHR than any other firm.

Why does this model make sense?  Two ways, both of which come from the cable/telco business model.  Rule number one, content is king.  In cable, it is shows like HBO and Discovery.  In healthcare it is data; patient data, effectiveness data, disease data.

Reason number two, the cable/telco model values the businesses based on the number of assets.  What are the assets?  Subscribers.  You and me.  Each body adds somewhere between five and ten thousand dollars to the valuation model of a Comcast or Verizon.  Downstream, some valuation will be placed on each PHR subscriber.

So, back to the example of me running Google’s healthcare offering—if you don’t like Google as an example, insert your favorite firm.  If I’m Google, am I troubled by the fact that other firms are building their own solutions?  No, and here’s why.  The difficult part of the business model is adding users, adding subscribers.  Why not let a bunch of firms do the business development work for me, do the dirty work to get the users, and then just devour those firms?  Once I own them, I convert them to my platform.  Do I then get some ‘ownership’ or right to use the data?  That would certainly be the business goal.

One million users valued at five thousand dollars adds five billion in valuation.  Ten million adds fifty billion.  Ten billion is about 2.5% of the US market.  Do I stop at the border?  Of course not.

By the way, while all this is going on, Google, MS, or whoever will also be creating standards and be building or buying up EHR firms.

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