Month: September 2009

EHR: Impact on DR Patient Relationship

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feastI’m a fan of foreign films, but since I don’t speak the language for me to really enjoy the movie, the visual story must be really compelling.  I also love to cook, not from recipes, but creatively, making it up as I go along.  Fortunately for purposes of this blog, there is a film which does both—Babette’s Feast.

The Danish film is set in France in the early eighteen hundreds.  The story centers around a group of pious sisters who receive a visitor who offers to spend her lottery winnings by preparing a feast for them.  The visitor, Babette, happens to be a very skilled chef.  There are those who may think the movie’s plot has more to do with the interplay among the participants.  However, as I am not a professional movie critic, we can skip the interplay and fast forward to the parts I find most relevant, the feast.

(This paragraph comes from Wikipedia.)  The sisters agree to accept Babette’s meal, and her offer to pay for the creation of a “real French dinner”. She leaves the island for a few days in order to return to Paris, as she must personally arrange for supplies to be sent to Jutland. The ingredients are plentiful, sumptuous and exotic, and their arrival causes much discussion amongst the clan. As the various never-before-seen ingredients arrive, and preparations commence, the sisters begin to worry that the meal will be, at best, a great sin of sensual luxury, and at worst some form of devilry or witchcraft. In a hasty conference, the sisters and the congregation agree to eat the meal, but to forego any pleasure in it, and to make no mention of the food during the entire dinner.  The last and most relevant part of the film is the preparation and the serving of an extraordinary banquet of royal dimensions, lavishly deployed in the unpainted austerity of the sisters’ rustic home.

The denouement—I thought it appropriate to use a French word—is whether or not the piety of the guests will prevent them from participating in the feast. It wouldn’t have made for much of a movie if the guests never came and the food sat there getting cold, but what if?  What if there was all of this preparation and no guests?  What if she prepared the feast, and in her haste forgot all about the guests?  Indeed.

Has anyone felt that something is missing in the discussion on EHR?  There’s plenty of talk of Washington and payors.  ARRA and money.  Stimulus and penalties.  Where are the guests?  Are we all responsible for not inviting the EHR dialog to include the patients?  I know it’s there, tucked away somewhere.

We’ve discussed on several occasions the notion that EHR should not be about the EHR.  It should be about the users and the patients.  Nevertheless, how is it being viewed by those groups?  Is it seen as a success?

Let’s make it a little more personal—my recent trip to my cardiologist at a superb teaching hospital in Philadelphia, Pennsylvania.  I usually get about an hour with the doctor—face time—clinical, examination.  Important time to a heart patient, eye contact that communicates you are doing all the right things, your test scores are all off the charts in the right direction, and you are healthier today than most people twenty years younger than you who haven’t had a heart attack.

That’s the real reason I go for the annual checkup, not to find out what I should be doing—I know I’m doing those things, not to find out if I am sick because I know I’m not.  I am there to reap the comfort that comes from having this specific person tell me things that help me believe that if I continue to play an active part in my recovery I will be there to raise my children.

During my last visit, we had about ten to fifteen minutes of eye contact, and the rest of the hour was spent with me watching him enter data into the EHR system.  It wouldn’t have been his choice, and it wasn’t mine.  Other than the first ten minutes, my entire checkup could have been done on WebEx.

I wonder if they offer an EHR?

 Paul Roemer Business Card

Inside & Outside

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When speaking about EHR system there are huge differences from an implementation and usage standpoint depending on if one is discussing record inside the healthcare provider or the movement or transport of the information from point A to point B.

Since most EHR statements have to do with one or the other, not both, for purposes of clarity, is there merit to labeling statements about EHR that mostly relate to the healthcare provider as IntraEHR, and those dealing the the transport of the record as InterEHR?

The_Saint_Pin

Certification & Meaningulful Use

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Doctor cartoon bad funny silly goodHere’s a comment I made to John’s Blog, http://www.emrandhipaa.com/emr-and-hipaa/2009/09/12/preliminary-arra-certified-and-cchit-certified/.  Any time I need details,this blog is my first stop.

My 2 takeaways are the phrase to “justify meaningful use”, and the question about whether anyone should worry about any of this. Meaning no slight to those working on this, I think that with each new bit of information on Cert & Meaningful Use, the less likely it is that either will be relevant.

A word to healthcare providers who are implementing EHR. Do not use these benchmarks as your guidelines. Do not use ARRA as a business reason to implement an EHR. If you make an EHR decision as though Washington played no role in the decision, and make your selection of an EHR based on your actual business requirements, Certification and Meaningful Use will not matter. I believe we will learn that the only test that will matter is interoperability. The sooner we learn that under the present framework interoperability can’t happen, the sooner we will get to a solution that will work.

Here’s my take away.  Meaningful Use has no meaningful use.

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Your EHR –Do you neeed to change the threat level?

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escapekeyboard“Step away from the wall,” Veronica yelled through her ear microphone, loud enough so everyone could hear her.

I knew if I released my grip, the chances of me remaining upright weren’t very good.  Permit me to roll back the clock thirty minutes.  Friday morning in Philadelphia.  It’s raining.  In Texas they call this much rain a frog-floater.  Two and a half hour delays at the airport.  A cold biting rain, the kind that sees you in Gortex and simply laughs at you for being too silly to be indoors.

I cancelled my run and decided to sit in on one of the classes at the gym, take a break, rest up for a long run tomorrow.  The only class scheduled was kickboxing, and it’s being led by the mother of my seven year-olds best friend—not exactly my biggest physical threat. She wore her hair like Veronica in the Archie comic books, and because I couldn’t remember her real name, for purposes of this narration, that’s how we will address her.  I don’t even know what kickboxing is, but I know it doesn’t get any easier than that.  I’d finished my lifting, finally got to thirty pull-ups today—yes, in a row, and I was pumped.

I walked into the mirrored room.  The floors were recently shellacked—I love the smell of shellac in the morning.  Spandex clad women decked out in puce—isn’t that a great word—purple, lime green, and hot pink were everywhere.  The music—some sort of electronic something or other—started to blare and bodies started to move.  Knowing that I wouldn’t be sucking wind, I thought about asking Veronica to put on some music with words so we could sing along.  She gave me one of those looks that said, “In five minutes you will be so mine.”

The class is scheduled to last sixty minutes.  We began by jumping rope and I almost broke both of my legs—I am the poster boy for the theory that white men can’t jump.  I grabbed a pair of dumbbells to do with the exercises, just to make sure I got a bit of a workout.  Twelve minute into the class and I looked like the rain had followed me inside.  At minute thirteen, I dropped the dumbbells.  By minute sixteen, I no longer had any feeling in my shoulders.  I thought I saw a few of the participants checking me out, one advantage of being the only Y chromosome in the class—the one closest to me came over to ask if I was okay.

A twenty-second break for a sip of water—I had already downed my liter.  The colors of the spandex outfits had started to blur into what looked like a Peter Max painting that had been left out during a downpour.  Minute twenty-two, thighs are burning.  Twenty-four, I am found clinging to the wall.  I would not have made the twenty-fifth minute.  I reached for my cell phone and pretended that I had a voice message.  Two minutes later, I crawled out of the room.

I had under estimated the threat level, under planned, and under delivered, surpassing even my own inadequacies.

My fall from grace was short lived.  A fall from grace once you get beyond seven figures of cost implementing your EHR won’t be so short lived.  Those names will echo down the commercially carpeted hallways for a long time.

What’s being under planned?  The plan for one thing.  Once you’re into eight figures, I hope you have a written and signed-off plan.  That sign-off may be your life jacket, unless they decide to parole only those above you.  Once you get into even the potential of a nine-figure spend, I’d plan on a planning process of three to six months.

Anything less may find you clinging to a wall.

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A solution to the problem of EHR standards

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I borrowed the following paragraph from the August 31 post of the Healthcare Blog.

August 20th, HHS Secretary Kathleen Sebelius and ONC head David Blumenthal announced $598 million in grants to set up about 70 “regional extension centers” (RECs) that will help physicians select and implement EHR technologies. Another $564 million will be dedicated to developing a nationwide system of health information networks.

It goes on to state that the RECs are based on the federal agricultural extension offices of the early 1900’s.

Do you ever get the sense that some days the topics just walk up and slap you in the face?  I may have deciphered the difference between the federal sector and the private sector—for those of you who were thinking I was going to write competency, it crossed my mind, just couldn’t decide to which group.  I think it’s speed and planning.  The private sector travels at the speed of the Dow and plans at speeds approaching the half-life of a fruit fly.  The federal sector travels at the speed of a ten-year-old eating broccoli and plan around the life span of a black hole.

They plan, and then plan and then write the backup plan, and then back that up.  It’s like the healthcare version of the movie Fail Safe.  Only this time it’s not done ‘in case’ the plan fails, it’s done for ‘when’ the plan fails.  Here’s my take on all of this as relates to EHR.

  • Certification—a backup in case EHR doesn’t looks like it will work
  • Meaningful Use—backup in case certification looks like it won’t work
  • Speaking in parentheses—as I’m wont to do—at this point, neither matter, because under the current schema, interoperability won’t work.
  • Did I mention we still don’t have a set of standards?
  • Next comes RECs
  • And, another half billion for nationwide system of health information networks—HIEs?
  • Does the last point mean we are done with the notion of RHIOs and HIEs, or are HINs their backups?

What to do?  Set up another backup plan—REC centers.  The first time I read about this I thought REC centers were something like the Police Athletic League—if EHR failed, let’s play basketball.

Since you asked, here’s what I think we should do with this billion.  Give it to the EHR vendors—I can’t even believe I wrote that.  This is the same group of businesses who haven’t learned how to share their toys and play nicely in the sand box.  Ready?

  1. Some small number of EHR vendors (let’s label them Group A) does account or will account for a percentage of the installed base in the upper nineties.  The also-rans are Group B.
  2. It can be argued that not having a single set of standards is the reason we must have all of the intermediary non value-add strictures which make interoperability insurmountable.
  3. It can further be argued that not having a single set of standards causes the need for certification and Meaningful Use which would otherwise have no meaningful use.
  4. Give Group A the following mandate:
    1. Agree upon a set of standards to which you will modify your systems
    2. Modify your systems to those standards
    3. Provide that version to your installed base
    4. Agree that all future install will be of the standards-meeting application
  5. Group B may continue to market provided they meet the standards.

This could work.  It would fix a lot of the current problems and make a lot of the upstream ones disappear.  What do you think?

Gumby1

A eulogy for universal healthcare

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rip1It’s funny how things work when the cameras are on and all are dressed to the nines.  It appeared as though Hillary and Nancy called each other confirming red was the color of the evening–a quick rock, paper, scissors, and Hillary won the right to wear a pants suit.  Congressman Rangel nattily attired with threads he was able to afford by forgetting to pay taxes on income earned from properties he forgot he owned.  (In sotto voice—I digressed again, didn’t I?)

Amid the applause and bravado, nobody, I mean nobody so much as blinked when the president dropped the number of people covered under the public option from forty-six million to a paltry thirty million.

  • Who are those sixteen million?
  • Did the cost of the plan drop by a similar amount?

Universal coverage was pulled from the table as though it had never been on the table.

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What can be learned from a predecessor

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advice1With all the efforts underway with EHR, it’s only natural that some efforts will have problems, and those leading the efforts may be replaced.

If you’re the new EHR lead, how do you know what to do tomorrow?  You walk in to your new office; a withered Ficus tree is leaning awkwardly against the far wall, vestiges of a spider’s web dangle from a dead leaf.

You place your yellowed coffee mug on the worn desk, change out of your sneakers, and after rubbing your feet, slip on a pair of black Bruno Magli pumps.  The feel of the supple leather relaxes you.

You spot the three envelopes that are stacked neatly on the credenza.  A hand-written note on Crane stationary reads, “If there is an emergency, open the first envelope”.  You place the three envelops in your YSL attaché case, and go about trying to salvage the implementation. 

Three weeks pass.  Things are not going well.  You are summoned to meet with the hospital’s COO.  After checking your makeup, you retrieve the first envelope and read it.  “Blame me,” it reads.  You were going to do that anyway.

Two more months.  The vendor has become a sepsis in the lifeblood of the organization—pretty good word for a math major.  You are summoned to meet with the CEO.  After checking your makeup, you bang you first on your desk, tipping over your coffee, and spilling it all over your Dolce & Gabbana suit.  You don’t have time to change.  You retrieve the second envelope and read it.  “Blame the budget,” it reads.  You were going to do that anyway.

Six months.  Deadlines missed.  Staff quit.  Vendor staff doubles.  Vendor output cut by half.

You are summoned before the board.  You no long check your makeup—you haven’t worn makeup since the day you publically went mano y mano with the head of the cardiology department inside the surgical theater, demanding to see his updated work flows.  You still haven’t been able to get the blood off of your Hermès scarf that he used as a towel.  You are dressed in a pair of faded jeans and your son’s black AC/DC T-shirt, the one with the skull on the back.  You don’t care.

As you reach in the desk drawer for the third envelope, you realize you haven’t had a manicure in four months.  You feel like a disenfranchised U.S Postal employee.  You have become the poster child for the human genome project run amuck.  Somebody is going to lose their DNA today.

You open the third envelope.  “Prepare three envelopes,” it reads.  You were going to do that anyway.

My Best – Paul

Austin Powers

Healthcare–0.2 to 2.0, mind the GAP

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dog Alex van Klaveren raised a question in his blog, Medicexchange about a point we raised here stating that Healthcare is moving from version 0.2 to 2.0.

My thoughts on this center around differentiating between the business of healthcare and healthcare as a business. That they may not be easily separable makes it difficult. There are many factors which if viewed from the perspective of an MBA student that suggest the as a business (processes, management, use of technology to run the business) it is found lagging when compared to for example to banking and manufacturing. Healthcare is being pushed to catch up quickly, and has little guidance in how to get from A to B, and doesn’t understand how to define the Gap.

We’ve also stated that it’s not about EHR.  So then, what is it about–sorry for the preposition?  It’s about the Gap.  It’s about knowing where you are, defining where you want to be, and being able to articulate a strategy which will get you there.  It’s about change management, and work flow improvement.

My best – Paul

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CMIO Magazine Article

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CMIO invited me to write a regular article for them.  Below is the link to the first.

http://www.cmiomagazine.com/?p=220

Thanks.SaintLogo

Acronym-free EHR–Same Great Taste, Less Confusing

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acronymsI raised the following question on Twitter:  Who blieves the current approach (PR, EMR, EHR, Rhio, to NHIN) will actually work in 3, 4, or 5 years?  Will you state why.  I do no think it will.

I raise it here as well.  Can you make an agrument to help me understand what needs to happen for this to possibly work?

 

  • 400 vendors
  • 300-400 RHIOs–some home made
  • a few hundred standards groups
  • a few hundred thousand instnaces of EHRs
  • 300 million patients

 

The combinatorics alone of getting my PR up the food chain and back down to the right place should be enough to bring it to the idea to its knees.

Remember that ice-breaker kids play at parties where they sit in a circle?  A phrase is whispered in the ear of one child, and each child in turn whispers the phrase to the person next to them.  By the time the phrase returns to the originator, it sounds nothing like to original.

A colleague whose opinion I respect wrote that I’d get better responses if I explain the acronyms, so that why we’re here.

The offending terms are:

PR–Patient Record

EMR–Electronic Medical Record

EHR–Electronic Health Record

RHIO–Regional Health Information Organization

NHIN–National Health Information Network

Does anyone know of a link to a good healthcare IT/EHR acronym glossary?

My work here today is done.

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