Month: September 2009

EHR: What questions remain unanswered?

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red stapler

“We need to talk about your TSP reports.”  Office Space—Possibly the best movie ever made. Ever worked for a boss like Lumbergh? Here’s a smart bit of dialog for your Friday.

Peter Gibbons: I work in a small cubicle. I uh, I don’t like my job, and, uh, I don’t think I’m gonna go anymore.

Joanna: You’re just not gonna go?

Peter Gibbons: Yeah.

Joanna: Won’t you get fired?

Peter Gibbons: I don’t know, but I really don’t like it, and, uh, I’m not gonna go.

Joanna: So you’re gonna quit?

Peter Gibbons: Nuh-uh. Not really. Uh… I’m just gonna stop going.

Joanna: When did you decide all that?

Peter Gibbons: About an hour ago.

Joanna: Oh, really? About an hour ago… so you’re gonna get another job?

Peter Gibbons: I don’t think I’d like another job.

Joanna: Well, what are you going to do about money and bills and…

Peter Gibbons: You know, I’ve never really liked paying bills. I don’t think I’m gonna do that, either.

One more tidbit:

Peter Gibbons: Well, I generally come in at least fifteen minutes late, ah, I use the side door – that way

Lumbergh can’t see me, heh heh – and, uh, after that I just sorta space out for about an hour.

Bob Porter: Da-uh? Space out?

Peter Gibbons: Yeah, I just stare at my desk; but it looks like I’m working. I do that for probably another hour after lunch, too. I’d say in a given week I probably only do about fifteen minutes of real, actual, work.

I like to think of Peter as my alter-ego.

When I’m playing me in a parallel universe, I’m reading about a surfer dude cum freelance physicist, Garrett Lisi. Even the title of his theory, “An exceptionally simple theory of everything,” seems oxymoronic. He surfs Hawaii and does physics things—physicates—in Tahoe. (I just invented that word; it’s the verb form of doing physics, physicates.)

Ignoring that I can’t surf, and know very little physics, I like to think that Garrett and I have a lot in common. I already know Peter Gibbons and I do. So, where does this take us?

It may be apparent that I look at EHR from a different perspective than many of others involved in this debate; I’m the guy who doesn’t mind yelling ‘fire’ in a crowded theater. The guy who will never be invited to speak at the HIT convention unless they need a heretic to burn for the evening entertainment. I can live with that.

Like Garrett, I too see an exceptionally simple theory in everything, especially when it comes to improving business. It’s not rocket surgery, but then, it was never meant to be. You’ve seen the people running it, they are definitely not rocket surgeons—before someone writes, I know it should be scientists.

Sometimes I like to look at the problem from a different dementia—Word didn’t have a problem with that usage. I look at EHR and ask myself three questions:

1. Why do people really believe the existing national roll out plan will work?

2. How did the plan ever get so complex?

3. How much money will be wasted before people look for a realistic solution?

What do you think?

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Revising patient interactions via social media and CRM

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SmidgeFor those who don’t have time for 140 characters, or who don’t have much to say, I’ve created an alternative, smidge.com. The Urban Dictionary defines a smidge as a small amount of something, short for smidegeon.

This will revolutionize the interaction between patient/customers and the healthcare provider. We all know how annoying customers can be. Why should providers continue to enable bad behavior? They call, fax, email, and tweet. Enough already.

It’s time providers show a little backbone, show the customers who’s in charge.

Here’s how smidge.com works. Each time a customer interacts with you, give the patient their smidegeon account. Explain to them that this is their private way to communicate with you. It’s instantaneous, totally secure, and it operates 7 x 24 x 365. No more navigating IVRs, no more being placed on hold, no longer will they be transferred to another agent, never again will they be monitored for quality control purposes. Let the customers know that anytime they want to smidge, the world is theirs.

Explain to them that you are doing away with archaic forms of interacting; closing your call centers, throwing away your fax machines, and deleting your presence on the web. What are the advantages to your firm? They’re almost too many to document. Think of the capital savings. No more IT expenditures to support those millions of whining customers. No more CSRs complaining about not being allowed to browse the web, or about not getting their mid-morning break.

And now for the best part. In order to minimize bandwidth and storage costs, each smidegeon only allows the user to use each letter of the alphabet one time, meaning the largest smidge can’t exceed 26 characters. The longest message one could get is, “The quick brown fox jumps over the lazy dog”.  That being the case, there will no longer be any justification for the customer complaining that your company didn’t resolve their problem.The roles will be reversed. The upper hand will now go to the company.

How? Let’s look at an example. The patient wants to smidge the following change of address information, “We are moving on October 13 to 1175 Harmony Hill Road, Spokane, Washington. Please forward our bill.” Since smidges don’t allow numbers, we’ve already simplified the message, and the ease of entry. Now, if we translate the message into a correctly formatted smidegeon, we get the following message, “We ar moving ctb Hny l d Spk f u b d.” Now, how can you be expected to understand that kind of nonsense? If you can’t understand it, how can your patients possibly blame you?

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EHR: How to recover from poor planning

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feathersSuccess and failure are often separated by the slimmest of margins. Sometimes you have to be prepared to think on your feet to out think unfavorable circumstances. Sometimes success hinges on how you present your idea. It is possible to force the circumstances via rapid evolution to pass from problem, to possible solution, to believable, to heroic? I believe so.

Permit me to illustrate with frozen chicken. Several hours before dinner I threw the frozen chicken breasts into the sink, choosing to thaw them with water instead of the microwave. Some twenty minutes later while checking emails I wondered what we were having for dinner. Not to be outdone by own inadequacies, I remembered we were having chicken. I remembered that we were having chicken because I remembered turning on the hot water. The only thing I couldn’t remember was turning off the hot water.

I raced to the kitchen. My memory was correct. Grabbing every towel I could find, I soaked up the puddles from the hardwood flooring, thinking while mopping about how I might answer to my wife if she happened to return to a kitchen that looked like the Land of Lakes. My first reaction, admittedly poor, was to tell her that I thought the countertop wasn’t level and that the only way to know for sure was to see which direction the water ran. Telling her the truth never entered my mind.

Once the major puddles had been removed, I worked on version two of the story, quickly arriving at a version of the truth that was more palatable—tell her I decided to wash all the towels. Why not get bonus points instead of getting in trouble? Version three looked even better. Since I was wiping the floor with the towels, instead of telling her I washed the towels, why not double the bonus points? I decided to wash the floor, and wash the towels. Husband of the year can’t be far off.

A few hours have passed. The floor is dry—and clean, the towels are neatly folded and back in the linen closet, and the chicken is on the grill. All the bases covered. A difficult and embarrassing situation turned into a positive by quick thinking.

A few of you have asked, let’s say we buy into what you are saying, how do you propose we turn around our EHR approach? All kidding aside, it comes down to presentation. Clearly you can’t walk into a room with a bunch of slides showing that your EHR investment was wasted. The first step involves defining the quantitative returns that can be achieved by changing the focus of EHR away from ARRA money and Washington the the business problems EHR will address.

So, how did the dinner turn out? I was feeling confident that I had sidestepped to worst of it. Overconfident, as it turned out. My son hollered from the basement, “Dad, why is all this water down here?”

saint

Can you blame providers if they fail Meaningful Use?

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3Here’s what I wrote in reply to a post on Healthcare Informatics, http://bit.ly/LX8Jb

I don’t wake up each day planning to be at odds with ninety-eight percent—I’m probably being overly generous assuming two percent of the people are as jaded as me—of the HIT community, maybe I just come by it naturally.

The first time I heard of RECs (regional extension centers) the first thing that came to mind was playgrounds, something akin to what the Police Athletic League might find useful.  Five hundred and ninety-eight million dollars.  They tried 597 and determined it wouldn’t be enough and figured 599 would be too much, but 598 million was just right.  Then Goldilocks made her way over to the porridge—sorry for turning left at the fairy tale ramp.

A large part of the success or failure of reform hinges on the success or failure of EHR.  Accordingly, the government made the egregious decision to manage the process of building and rolling out a national EHR down at the molecular level.  They have involved themselves at the front-end, at the vendor level, and at the back-end.  The more anxious they become, the more money they waste, adding another guise to get the healthcare providers to take their eyes off the ball.  Five hundred ninety-eight million “we’re just here to help you” dollars.

This money could be spent to pay the top EHR vendors to create one set of standards and modify their systems to fit those standards.

Meaningful Use.  Don’t get me started.  How can I fault thee; let me count the ways.  Those tested early for Meaningful Use will be examined less rigorously than those tested later.  This is like the IRS saying that if you file your taxes in February, don’t worry about those silly little math errors.  Healthcare will be the only industry whose software quality assurance check occurs after they pass the fail-safe point, the point of no return.

With good leadership providers should know EHR will pass meaningful use before implementing the system. If they fail to pass Meaningful Use, shame on them.

saint

Could Mashups solve the EHR integration problems?

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Silly walks

Silly walks

That number represents the number of different ways to arrange the seventy-five numbers on a BINGO card—five columns of a specific group of fifteen numbers.

I may have mentioned that part of what drives me to write is the need to help me frame ideas for myself.  It serves as a checkpoint before I unlock the gate and let them loose on you.  This idea required a good deal of thought, just to get me comfortable that the premise even made sense.

Here’s what got me thinking about it.  It seems there are three major groupings of things that need to work together precisely in order for EHR to work.  Each time one fails, the network fails.  What are those groupings?

  1. Data
  2. Systems
  3. Transport

The data are Personal Health Records (PHRs), Electronic Medical Records (EMRs), and standards.  There are perhaps hundreds of variations among the elements of that group.  Secondly, there are the systems, the Electronic Health Record (EHR) systems.  Again, hundreds of different systems can house the data.  How many possible combinations are there at this point in the process?  The correct answer is that there are too many.  Finally, there is the issue of transport, getting the data from one system to another system.  Under the present model (the one to which everyone seems to be building) let’s include the Health Information Exchanges (HIEs), the Regional Health Information Organizations (Rhios), and the National Health Information Network (NHIN).

The problem with each of these grouping (data, systems, transport) is that their individual elements are not grouped.  That lack of grouping means that the total number of paths that can be ridden to get a health record from provider A to provider B is much larger than that of the BINGO illustration.

Therefore, for inter-EHR (the transport part of EHR) to have any hope of functioning the groupings need to be fully grouped in such a manner so as to remove the hypergeometric distribution among the elements.

This is the point where some of you may tell me that I am not spending enough time on this planet.  If the prior discussion is at all correct we need to solve the grouping problem.  Here’s where I leave my pay-grade and need your help to see if this dog can hunt.  I was able to clarify the idea for myself by thinking about potatoes–please don’t stop reading, this is not an attempt on my part to be funny.  What happens if you take two potatoes and mash them together?  The two become one, and any individual distinctions are lost.

Is it possible to create mashups of each of these groups such that instead of having billions of billions of permutations, we have just a few?  A mash-up is a Web page or application that integrates complementary elements from two or more sources.  That one sentence used up the entirety of what I know about the topic.  I don’t know enough about it to know if the technology will work with EHR, however that is not my point.  What I am pushing for is that we look at the concept of using mashups.  If the concept is sound, then let’s figure out the technology that would be needed to drive it.  I think a solution along these lines is what is needed to have a working national EHR system.

What do you think?

saint

WSJ compares House and Senate bills

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This help clarify the situation.

http://ow.ly/pQhI

Certification may be of zero value to the healthcare provider

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HIT do-overs

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I read a very interesting and well-written post on the Healthcare Blog by MARGALIT GUR-ARIE.

http://www.thehealthcareblog.com/the_health_care_blog/2009/09/what-if-i-had-to-do-hit-all-over-again-.html

It reminds me of the conversation in the movie City Slickers when Billy Crystal tells his friend his life is a do-over. From where I sit, I think a do-over is exactly what’s needed on two fronts. On the provider side, EHR decisions need to be based on what business problems are being addressed and on an ROI, not on what DC may or may not do. On the interoperability or transport side of the record I do not believe much of what is being worked on today will exist in 3-5 years (which further compounds the difficulty of what the providers are doing.) I think Meaningful Use and Certification will cease to exist, and that the structure of hundreds of Rhios and HIEs will cease to exist because they will have failed to work.

saint

Don’t let DC drive your selection process

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The decision to do EMR/EHR should be made independently of Washington. There either is or isn’t a valid business reason for going forward.  ARRA funds and penalties are not valid business reasons unless perhaps you operate a very small practice.

I believe there are valid reasons. I also believe that without knowing which of those reasons suite your organization there is a strong possibility of selecting the wrong system.

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EHR Leadership–Who’s in charge?

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Nicely written.  I look at the need from the perspective of the path not traveled.  For most, the task of selecting the correct EHR and managing the effort would be like me buying a spaceship–never been there, never done that.
Providers are well-staffed on the clinical side, and on the IT side.  The problem is that none of them has the high cost, high risk, high visibility PMO (project management officer) skills that are required to buy something that can cost more than a new hospital wing.
So what do they do? They pull someone out of IT or clinical and hand her the keys.  Most large IT projects will fail.  MOre EHR projects will fail.

 

anonymous-leadership-5000373Here’s a nicely written piece by Elyse of AntiClue.  http://www.anticlue.net/archives/000970.htm 

I look at the need from the perspective of the path not traveled. For most, the task of selecting the correct EHR and managing the effort would be like me buying a spaceship–never been there, never done that.

Providers are well-staffed on the clinical side, and on the IT side. The problem is that none of them has the high cost, high risk, high visibility PMO (project management officer) skills that are required to buy something that can cost more than a new hospital wing.

So what do they do? They pull someone out of IT or clinical and hand her the keys. Most large IT projects will fail. MOre EHR projects will fail.

That’s my opinion, but nobody has talked me out of it.

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