Last night as I’m sitting on a hard bleacher watching my seven-year-olds baseball practice I noticed the mom sitting next to me looking a little forlorn. Being naturally inquisitive, I asked if everything was okay.

“I lost his glove,” she replied.

Noticing a glove on her son’s hand, she saw my look of confusion. “Not his. My husband’s. I had it with me last Thursday, and I left it here.”

“I don’t suppose this was a new glove. Judging by the look on your face I’d say this was his favorite glove; thirty years old, supple, broken in, fold flat as a sheet of paper.”

“Twenty-five years,” she corrected as she lowered her eyes.

“It’s rained the last three days,” I told her, which caused her to grimace even more. Having nothing better to do, I flayed her emotions. “I bet that glove meant the world to him. He probably planned on giving it to your son in a few years. The glove probably reminds him of some of the big events in his life, every scar, each stain on the leather, points to something important. You know, if it was outside for a few days, the field mice will have chewed on the leather.”

She brushed away a tear, and headed to the lost and found.

“Any luck?” She shook her head in despair. “In some countries, if a wife does something life that, the husband can sever the relationship, literally,” I said as I made a slashing motion with my hand. She made the briefest of smiles. At least she knew I was pulling her lariat. Reeling her in, I continued.

“You’re not thinking of spending the night at home, are you? If you are, you should at least call someone and let them know of your plans. He’ll heal over time,” I told her. “But he won’t forget it. Twenty years from now the two of you will be watching something on TV, and something will remind him of the glove YOU lost.”

Fast forward to tonight. My daughter and I are getting out of the car so I can coach her and her softball team in the playoff game.

“Is your glove in the trunk?” I asked. This is after I spent several minutes grilling her at home about whether she had everything she needed for her game.

“I hope so,” she said shamelessly as I popped the trunk for her. “You hope so?” I repeated with an edge in my voice.

“It’s not here Daddy.”

I left her with her friends and drove home to look for it. Ten minutes. Nothing. For some reason, I looked in the trunk. There it was. Death by 1,000 cuts.

“I hope so.” What kind of a response is that?  Does it all come down to baseball gloves?  As a member of your executive team, you should be able to raise these types of questions of your EHR project manager.

Will this EHR application work with our ambulatory care providers?  I hope so.

Can you confirm for me that the EHR provider you chose will be in business in five years?  I hope so.

Is somebody handling the change management issues for EHR? I hope so.

Do you think we will pass the certification requirements for interoperability?  I hope so.

Will we both still be working here next year?  I hope so.

I almost fell out of my chair when I had this conversation last night with a reasoned and responsible IT executive at one of the best known hospitals in the US.  I’m paraphrasing only because my on-the-fly stenography skills are non-existent.

ME:                        “What is the hospital’s plan for linking outside specialists and physicians to your EHR?”

HOSPITAL:           “The term “plan” may be overly optimistic.”

ME:                        “How so?”  I asked with a bit of intrigue.

HOSPITAL:           “A lot of the doctors like to program as a hobby.”

ME:                        “You’re kidding, right?”

HOSPITAL:           “No.  We have a number of people building their own EHR.”

ME:                        “So, in effect you guys have lots of CIOs.  That should be fun watching you make that work.”

Clearly that’s not the real implication, but it does go a long way to the need for an EHR Czar, even within the confines of a single provider.

…are like the Mars and Venus of healthcare IT–Ambulatory is from Mars, Clinical is from Venus, at least that’s what it sounds like some days.

What’s your take on this?

For starters, I am curious as to what costs, if any, were sunk costs?  Are they suggesting that even the variable costs were too high?

What does this say about the EHR ROI for ambulatory care?  I think it could be saying three things.

1.  Perhaps it shows that there is some lower threshold in terms of the number of physicians in a practice needed to show a positive ROI
2.  Perhaps in these economic conditions it makes more sense to use a managed services approach for ambulatory EHR
3.  Perhaps this is a strong argument for purchasing a wrap-around EHR service

What do you think?

“Physician groups in Phoenix are canceling their EMR contracts as a result of training, functionality or affordability issues. This is especially prevalent among smaller physician groups, the report says.

The report said “deinstallation” due to financial issues is not unique to  physician groups or to Arizona. For example, in areas like Miami, where the economic downturn is threatening the profitability of hospitals, adoption of EMRs has been slow because of a lack of funding for such capital projects.”

http://www.healthcareitnews.com/news/study-deinstallation-emrs-phoenix-could-be-trend

Is it fair to characterize stimulus funds as an after the fact (post implementation) performance based rebate?  How do you think the feds will evaluate performance as relates to earn-out:
1.  Will it be based at all on how well it meets your internal needs, or
2.  Will it be entirely based on whether your EHR is able to fully connect with the NHIN?

Restated, is the stimulus money only there to help stimulate healthcare providers to build their EHR in such a manner that it is part of the national network?

Many organizations have a Program Management Office and a Program Steering Committee to oversee all aspects of the EHR.  Typically these include broad objectives like defining the functional and technical requirements, process redesign, change management, software selection, training, and implementation.  Chances are that neither the PMO or the steering committee has ever selected or implemented and EHR.  As such, it can be difficult to know how well the effort is proceeding.  Simply matching deliverables to milestones may be of little value if the deliverables and milestones are wrong.  The program can quickly take on the look and feel of the scene from the movie City Slickers when the guys on horseback are tyring to determine where they are.  One of the riders replies, “We don’t know where we’re going, but we’re making really good time.”

One way to provide oversight is to constantly ask the PMO “why.”  Why did we miss that date?  Why are we doing it this way?  Tell me again, why did we select that vendor?  Why didn’t we evaluate more options?  As members of the steering committee you are responsible for being able to provide correct answers to those questions, just as the PMO is responsible for being able to provide them to you.  The PMO will either have substantiated answers, or he or she won’t.  If the PMO isn’t forthcoming with those answers, in effect you have your answer to a more important question, “Is the project in trouble?”  If the steering committe is a rubber stamp, everyone loses.  To be of value, the committee should serve as a board of inquiry.  You your instincts to judge how the PMO responds.  Is the PMO forthcoming?  Does the PMO have command of the material?  Can the PMO explain the status in plain English?

So, how can you tell how the EHR effort is progressing?  Perhaps this is one way to tell.

A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick the cat up. The brother hesitated, then said, “I’m so sorry, but while you were away, the cat died.”

The man was very upset and yelled, “You know, you could have broken the news to me better than that. When I called today, you could have said the cat was on the roof and wouldn’t come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said he had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and won’t come down.”

If you ask the PMO how the project is going and he responds by saying, “The vendor’s on the roof and won’t come down,” it may be time to get a new vendor.

I was thinking the other day about my heart attack six years ago.  As I was awaiting my angioplasty it occurred to me that although I had a pretty good idea about what was about to happen, I had absolutely no input or information about who would be performing the procedure.  What I wanted was input and information somewhere between the extremes of ‘none at all’ and how to perform the procedure on myself—Type A personality.

I wouldn’t have felt they way if I was having a plantar wart removed, or repairing a broken bone, but we’re talking about my heart.  From the back of an ambulance nobody asks you who you want for a cardiologist, you go to whoever happens to work at the hospital.  It’s a little like getting a haircut—I go to whichever barber is available.

I don’t care who cuts my hair, what’s left of it, but I do care about who might have to operate on my heart.  Through some connections I have at CHOP I received the names of three cardiologists, I interviewed them, and made my decision.

This got me to thinking about how doctors might view this entire EHR issue.  I asked myself if I was a doctor, what would I want to know?  What is the proper balance of input and information I need to be able to make a reasoned decision on EHR?  It lays somewhere between, “I’ll code my own,” and “Call me when you’re done.”

I don’t want to buy something simply because a sales rep tells me it’s a good idea.  I also don’t want an associates degree in IT.  For me, the ideal solution would be to have someone bring me three or four good choices, provide me a business perspective of the pluses and minuses of each, and information about the cost, the impact to my practice, and the training.  Show me the cost breakdown of having my own versus having it run elsewhere.  Having enough information upon which to make an informed decision, once I’ve made it, I’d like to be able to do my work, and have whomever I’ve selected install it for me.

In effect, I’d like a “wrap around” EHR.  Perhaps it handles the practices in my office, perhaps the ones in my building.  Maybe someone else hosts it; maybe I can get it integrated with my billing.  I’d like it to include my federal reporting requirements.  I’d like it to facilitate peer learning, and have customizable work flows, on-line training via a learning management system (LMS), and help desk and support rolled into the package.  I want whoever is doing this to clean up my records and have them present in the new system.  I also need to know what will be done if my computer gets fried or the building blows up.  Lastly, I want somebody to manage this whole process on my behalf, somebody who can make sure that what I think I bought is what I get.

What do you think?

A large hospital with whom we’ve been meeting has significant work flow duplication across their revenue silos, both clinical and back office.  We are trying to help them understand the evolution of operating under a single set of work flows through shared services, in-sourcing, or outsourcing, and then aim for best practices.  That will provide for significant cost savings and a return on the EHR even if it’s years before the EHR moves beyond their 4 walls.

EHR without an intense review of its work flows and business rules really undermines the ROI.

The work flow effort can be started now, even prior to selecting and EHR.  What is your organization doing in this area?