Month: January 2010

What are the risks of HIT and EHR?

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It is refreshing to know that the voices I am hearing need not be my own.  When I try to summarize the issues for my own edification, I always circle back to the same few issues.

• No single person is both responsible and in authority regarding HIT and EHR. Provider-world pauses with each new pronouncement from Washington as though the missing EHR Dead Sea Scrolls had just been discovered in the reflecting pool.
• Those who implemented EHR did so without any idea that rules would be imposed after the fact.
• EHR is expected to serve two business models:

o Washington’s N x M patient/doctor connectivity effort
o A provider’s unique business objectives, none of which have anything to do with a patient in Atlanta being able to connect to a doctor in Anchorage.
• What model would providers be following if there were no Meaningful Use
• If the current EHR national rollout model was any good, providers would be racing to the front of the line to implement EHR instead of having to be offered rebates.
• The national rollout plan lacks viability for several reasons:

o No standards
o HIEs are each being developed in their own vacuum
o A horde of vendors whose mission does not tie to the national rollout or the providers’ business model and who have no incentive to adopt standards
o The requirements and dates for Meaningful Use will probably change once providers have tailored their systems to meet Stage 1
o The requirements for Stages 2 & 3, which may cost providers six zeroes preceded by some number greater than five, don’t exist.
o An ROI can’t be calculated on meeting Meaningful Use
o Both the likelihood and the impact of healthcare reform on HIT and EHR, just got vaguer by some order of magnitude.

I firmly believe the right EHR and CPOE will be great for hospitals. Providers will be better served by finding answers to the question, “What’s in it for me,” rather than, “What do they want me to do?” Unless of course, providers want them running their business.

What are the success factors for EHR?

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I just arrived in-country—I was in Wisconsin for two weeks.  I’ve been to forty-seven states, and Wisconsin has to be one of the friendliest.

Anyway, let us begin.  Not long after graduating with an MBA from Vanderbilt, I returned to Vandy to interview job candidates.  With me, was my adult supervisor, the VP of human resources—a stunning older woman; about thirty-five.  At dinner, she invited me to select the wine.  Not wanting to appear the fool, and trying to control my fawning, I pretended to study carefully the wine list.  Not having a clue, I based my selection entirely on price.  I had little or no knowledge of the subject; nonetheless, I placed the order with all the cock-sureness of a third-grader reciting the alphabet.

A few moments later Wine-man returned with a bottle, angled it towards me, and stood as rigid as a lawn statue.  After a few seconds my adult paused and motioned my attention towards Wine-man.  I remained nonplussed.  “You are supposed to tell him that the bottle he is holding is the one you ordered.”

“He knows it is what I ordered, that is why he brought it.”  I thought they were toying with me.

A few seconds later there was a slight popping sound and then Wine-man placed the cork before me on my napkin in a manner similar to how Faberge must have delivered his fabled egg to Tsar Alexander III for his wife Empress Fedorovna.  They were both staring at me, not the Tsar and the Empress—Wine-man and my adult.  “You are supposed to smell the cork.”  And so I did.

“Now what?”

“If it smells bad, it means the wine may be bad.”

To which I replied, “This is the Opryland Hotel—have you seen the wine prices?  They don’t sell bad wine.”  She nudged me with her elbow.  I could tell I was wowing her.  I smelled the cork.  “It smells like a cork,” I whispered to Wine-man.  He smiled and poured a half inch of wine in my glass.  I thought he was still pulling my lariat.

I looked bemusedly at the mostly empty glass, held it out to him, and asked him if I could have some more—I was thirsty.  Rather than embarrass me further, with a slight nod of her head my adult instructed the Wine-man that my sommelier class was over—any further proof of my inadequacies would be of limited marginal value.  Any chance that we would have gone dancing later that evening was about as flat as the wine.  I should have ordered a beer.  I was good at beer.

For those who are still reading, if you are wondering if I am actually going to make a point, here it comes.  I’m not fond of segues, so don’t blink.

Sometimes, a little guidance is helpful—even if it has to come in the form of being led around like camel with a ring through its nose.  One of my on-line friends, a nurse who teaches nursing—seems like a good fit–asked me what are the success factors for EHR.

Often, what is important in a leader is having the knowledge and temerity to ask the right question.  In healthcare it appears that the number of executives with answers may exceed the number asking questions.  Value is often measured by scarcity.   Good questions, especially around EHR and Meaningful Use, seem to be in short supply.

Here’s my take on some of the critical success factors:

  • Adult supervision—this is not defined by the age on your driver’s license
  • Invest time to plan your EHR plan; 6-9 months for a fair sized hospital
  • Actual written requirements (an RFP) that comes from your business strategy
  • A written healthcare information technology plan
  • Invest more than half of your time and effort in work flow alignment, change management, and training.
  • Should your plan seek to meet Meaningful Use
    • By when
    • How
    • What drives your strategy—Washington or your business model

Pretty simple things.  The right things usually are—like knowing what to do with the wine cork.

What is the value of perfection?

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Here’s another great post by another great person I met online, Maryanne Colter, of MMColter Ltd.   She’s on Twitter @mmcolter.  What I love about this post is her emphasis on hitting a target worth hitting.  Aim for the moon on quality or defects and you may hit it.  Perfect ought not be a stretch goal, as a target it should be de rigeur.  Thanks Maryanne–the rest is hers.

Treating people like shoes…

On January 19th Senator Grassley issued an open letter to medical software vendors and hospitals, chastising them for slamming in EMR software, giving higher regard to being on time and on budget than making sure the software was performing flawlessly.  After all, we are dealing with people’s lives. I got the impression from the Senator’s letter that the passive “mistakes were made” is not going to be an acceptable answer; 100% accuracy should be the only acceptable answer.

And yet it happens. A few weeks ago I spoke to a charge nurse at an Academic Medical Center  (one that was cited in a 2006 study as being exemplary in high quality care) who told me they had around 100 fixes to their system in the first few weeks after go-live.  He also recounted an incident where they lost an entire day of a patient’s nursing documentation somewhere in the transfer between the PACU and the patient’s room.

Strange as this may sound, the solution may be to treat people like shoes.   I once consulted at a company that’s known for its shoes.  Not a tiny company, but one where probably half the world owns a pair of their shoes.  A team of highly trained employees and consultants streamlined processes and put in the technology that increased the overall efficiency of the supply chain by 34%.

Imagine if we had done a shoddy job with their data and said 98% accuracy was ‘good enough’?   We would have transferred data from design to manufacturing, but maybe the shoelaces were a little short, but that hit the 98% mark and would have been ‘good enough’.  When we started manufacturing the shoes, who would have cared if the sole were a little cockeyed?  It still would have been within our 98% mark.  Two percent of the customer orders for the faulty shoes would have contained 2% wrong products or the wrong sizes. Two percent of all orders would have been shipped to the wrong stores. Invoices that were 98% accurate would have been ‘good enough’.  And all of those mistakes would have been done 34% faster.

How about if we treat the delivery of medicine with the same regard as a carton of shoes? We supplied shoes to a major retailer who demanded 100% accuracy of carton labels.  If any one of the hundreds of characters on the carton label were misplaced, the carton would be automatically rerouted, photographed, and emailed back to the supplier with the message of “get this 100% accurate, or else…”.  Think of all the places in medicine where a “get it 100% accurate, or else” rejection message might save a life.

There is no single analogous situation from business to medicine and there are certainly enormous differences, not the least of which is we are dealing with biological systems and the things that can go wrong increase by a thousand-fold.  But instead of looking at what works and adapting it to healthcare, most of healthcare patently rejects ‘outsiders’ with ‘outside ideas’ and throws the baby out with the bathwater.

Whenever using analogies it is imperative to do a thorough analysis of the differences, but the answer to the question “what is different?” is not “everything”! Data is either accurate or not.  Software testing results are either thorough or not. The only answer to the question, “Did you get enough training to flawlessly perform you job?” should be yes, or else more training is needed. Period. These are not unique notions. The healthcare industry has the worst case of ‘not invented here’ refusal to adapt quality improvement measures from ‘outside sources’ since JIT had to be renamed Lean because the US could not get over its WWII bigotry of anything remotely Japanese.

“Outsiders” are not viewed as people who would take accuracy even more seriously when dealing with human beings. Instead, we are viewed with the assumption that because we have only dealt with shoes and cardboard boxes that our concern for accuracy and quality must somehow be cavalier.

The healthcare industry needs perfectionists and they can come from anywhere.  It needs people who when they hear “perfect is the enemy of the good” answer with “tell that to the patient whose medicine is one decimal point away from killing them.” Sometimes, perfect is the only option.

I have a dear friend who has a brain tumor.  Thankfully it is benign, but eventually he will need radiation or surgery.   When that day comes, one of the most brilliant, wise, and compassionate minds in the world will be one decimal point away from destruction or cure.  He is the only reason I keep pounding my head against the wall of “ideas from outsiders are not good enough here.”

One of my heroes once said about accidents, “I am of the opinion that zero is the right number…You cannot plan to kill three people a year because you killed four people last year and you want to get a little better…So the goal is zero…Zero injuries. Zero reportable incidents.”  That man was Paul O’Neill when he was the CEO of Alcoa.  Heaven forbid we should learn a lesson from people who make pop cans.

How Can Healthcare Technologies Help Revive Healthcare?

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The following well-delivered blog was written by Matthew Browning RN, MSN, APRN is CEO of YourNurseIsOn.com.   I hope you find it as insightful as I did.  Thank you Matthew for contributing.

As Paul has so poignantly illustrated in his recent articles on EHRs, Meaningful Use, CPOE, etc., the reality and the practicality of many of these systems, with their constantly moving goalposts and expectations, does not live up to the dreams and the promises being made. Millions of dollars are being wasted on the pursuit of a nebulous standard that is being corrupted by various factions, some fighting for openness, transparency and patient portability versus those wanting the control, ownership and monitoring of our personal medical records and data. If you are betting millions of dollars on these systems prudence dictates that you must be sure they are market ready and will meet regulatory approval. Besides, their are cutting-edge health 2.0 companies that will give you EHR systems for free.

While this drama has been forefront in the public eye, many new, easy to implement solutions have entered the marketplace to help get the daily business of healthcare done in ways never before possible. There are patient reminder services, staff communications tools, inventory control systems, waste management technologies and social media sites to connect facilities and their communities. Even without the spotlight, without government involvement, without the millions in promised taxpayer dollars and without the traditional healthcare company heavyweights, real change is being effected in healthcare delivery today.

What are some of the expectations we have of these types of real solutions in the healthcare environment? Well, as a nurse, I expect these technologies to make my life ‘easier’ if you will. They should help increase the amount of hours I spend at a patient’s bedside because every study shows that is the number one indicator of patient outcomes. The technology should make me more efficient in delivering the care my patients need: save steps when looking for supplies; decrease repetitive procedures; encourage efficient workflow and decrease the amount of time I must spend on non-nursing duties. Technology should enable collaborative, real-time communications with my employers, colleagues and even patients where we communicate at our best- from work, home, or on mobile devices and computers. Technologies can monitor patient status and notify caregivers when extra attention is needed, or can allow me to change my status from available to occupied or unavailable for care flow management.

As a business owner or investor, these technologies must be present and functioning today, must make the things we currently do every day more efficient and less costly, and should increase our abilities to communicate, manage, market, sell and make a profit or remain sustainable. We would like to increase our customer’s satisfaction with our services, increase their word of mouth and serve their needs while they are here. Since our customers are patients we would like technologies that help us decrease patient recidivism, infections rate, injuries and mortalities while improving patient outcomes. Since our staff is healthcare providers we would like technologies that increase employee moral, retention, satisfaction and productivity while decreasing turnover, absenteeism, vacancy rates, overtime costs and agency usage.

As a patient we expect to have these technologies make us feel well cared for, valued and respected. We do not want to fill out the same form multiple times, we want our complete, accurate, legible medical record available on demand- where ever we may be. We want scheduling software that eliminates waiting room ‘lay overs’ or technology that let’s US bill THEM when we have to wait 😉 We need to be able to research our hospitals and providers effectiveness, complaints, pricing and availability- or we will go to those who allow us to see this info. We want technologies that allow us  to age in place at home, or to help make our nursing homes better staffed and safer.           Technologies can keep us in touch with loved ones and families when separated by distance or circumstance and can connect us with providers from around the world or world renowned experts. It can be deployed cheaply, widely and quickly. It doesn’t have to do everything but it must do something well…and keep learning to do it better. Technology cannot be allowed to become an obstacle to doing business and continuing progress. We must harness its power to effectively achieve our healthcare objectives while faced with a seemingly insurmountable combination of increasing patient population contrasted with our shrinking supply of healthcare professionals. That is both the promise and the reality of technology in healthcare today. Your thoughts and comments are essential to continue the discussion and guide the adoption of technologies today in the healthcare arena. What are YOUR thoughts, wishes, needs and concerns about the state of technology in healthcare today??

About the author:

Matthew Browning RN, MSN, APRN is CEO of YourNurseIsOn.com a healthcare staff communications company. Mr. Browning is a frequent speaker, contributing author, tireless change agent and fierce advocate for Health 2.0, Patient’s Rights, Healthcare Technology, Aging at Home and Nursing. Matthew lives in New Haven, CT with his wonderful wife, Phoebe, and their energetic son, AJ. He can be contacted by email at Matthew@YourNurseIsOn.com , on Twitter @MatthewBrowning or feel free connect on LinkedIn at http://www.linkedin.com/in/matthewbrowning .

My New PowerPoint deck just posted on SlideShare: Should you meet meaningful use

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http://www.slideshare.net/paulroemer/should-you-meet-meaningful-use

My 1st post on HealthsystemCIO.com

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The following is my first guest post on Anthony Guerra’s new site, HealthsystemCIO.com.

If you haven’t begun the process of selecting and implementing an EHR, Meaningful Use may not be something with which to concern yourself. The reason, you probably will not be done in time to collect the incentive money. How can I state that with such assurance? One of my clients has already implemented EHR and CPOE—already done the heavy lifting—and they will have to divert most of their resources just to meet the Stage 1 requirements.

If you haven’t begun, there may be no rush to acquire a vendor, although the vendors will not tell you that. Rushing may lead to a bad selection. Don’t cost yourself tens of millions get to have a chance at a few. By the way, did any of the vendors with whom you are speaking mention that they have no clue if their system will meet any of the Stage 2 and 3 requirements? Right now, it’s like the vendors are selling cars without knowing whether it will need to run on gas or Hydrogen.

I think the Meaningful Use dates will be pushed back. Why? Because few if any of the providers will be in a position to apply for the incentive money. Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.

Now for those whose EHR implementation is well underway or up and running — should you try for the incentive money? That’s a valid question. Just because someone is offering you a check doesn’t mean you have to take the money. Here are some questions you ought to be able to answer prior to deciding if Meaningful Use is meaningful to you.

  • Meeting MU requires a shift in your direction; you take on the MU tasks and sacrifice some of what you were going to do
  • What are those tasks, what resources will they consume
  • What year is the best year for you to meet MU; 2011-2015?
  • Did you know you can still maximize incentive dollars if you pass MU in 2013?
    • That gives you very little time to react to Stage 2 & 3 requirements

Meaningful Use is a binary contest — you make it or you don’t. The decision to meet Meaningful Use does not have to be binary. There is no way to collect for meeting 90 percent of the requirements. How might you financially calculate the probability of obtaining the incentives? Let’s begin with Stage 1—the easy one.

  • Calculate the maximum incentive you could receive
  • Multiply that figure by the degree of certainty you have that your plan will be completed on time — a number less than 1
  • Then multiply it by the probability you think exists for passing the audit, another number less than 1
  • Calculate your cost to complete Stage 1, then figure out your ROI — not much is it?I’ve seen one provider whose ROI is negative.
  • This makes evaluating Stage 2 & 3 calculations seem rather superficial. Want my advice for calculating an ROI out of requirements that don’t exist? I’d use a placeholder of six zeros preceded by a number greater than five for each Stage.

So take time to evaluate your options. The only people who will look foolish are those who don’t know what questions to ask.

How will reform impact Payors?

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I have developed quite a fondness for children’s books, particularly those with a well disguised allegory.  Long favorites of mine include the short stories, Uncle Remus, written by Joel Chandler Harris.  Br’er Rabbit (“Brother Rabbit”) is the main character in each of the stories, a likable troublemaker and prone to tricks.

His opposition is usually Br’er Fox Br’er Bear. In one tale, Br’er Fox and Br’er Bear hope to capture Br’er Rabbit.  Fox constructs a lump of tar and puts clothing on it. When Br’er Rabbit comes along he addresses the “tar baby” amiably, but receives no response.  Br’er Rabbit becomes offended by what he perceives as Tar Baby’s lack of manners, punches it, and becomes stuck. Now that Br’er Rabbit is stuck, Fox and Bear ponder how to dispose of Br’er Rabbit.

With each idea suggested for his demise, Rabbit has no complaints, however the helpless, but cunning, Br’er Rabbit always pleads, “Do with me what you will, but please don’t throw me in to that briar patch.”  Finally catching on to how “frightened” Br’er Rabbit is if the briar patch, Fox, believing he has the upper hand, throws Rabbit into the briars.  As rabbits are at home in thickets, the resourceful Br’er Rabbit convinces his enemies to do what he wanted them to do all along.

Sound familiar?  It should.  Br’er President and Br’er Congress.  The contest is how do they capture Br’er Payor and get Payor to play nicely.

“Let’s put caps on Br’er Payor’s rates,” suggested Br’er Congress.

“Do with me what you will,” pleads Br’er Payor.  “Cap my rates, but please don’t make us cover the uninsured.”

“Why not make Payor cover pre-existing conditions?”  Asked Br’er President.

“Do that,” chided Br’er Payor.  “We’ll even cover hangnails.  But please don’t make us cover the uninsured.”

“You know Br’er President,” said Br’er Congress, “Br’er Payor seems awfully afraid that we will make them cover all of the uninsured.   Let’s do that, let’s hit Payor where it will hurt the most.”

And so they did—made Br’er Payor cover the uninsured—threw them right into the briar patch.  Right where Br’er Payor wanted to be all along.  Thirty-one million new customers—how awful.  Smack dab in the middle of a recession, payor is handed a windfall of new customers.  Premiums.  Times twelve—twelve months.  Let’s estimate a hundred dollars a month.  That’s about thirty-seven billion in new revenues.  Billion with a B.  How is that for cutting healthcare costs.

Now suppose, just suppose that Br’er Payor has little motivation to be a good corporate citizen.  I know I am asking you to take a leap of faith.  Silly me, but I have this question that is gnawing at my craw.  What if Br’er Payor collected all these premiums and set the deductible so high that none of their new customers was ever able to file a claim?  The feds tossed the payors right into the briar patch, didn’t they?

What’s the probability around Meaningful Use?

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Below is a reply I wrote to a post on MU in Healthcare IT News
What’s the probability, that you complete the Stage 1 Meaningful Use requirements?  What’s the probability, after doing your best to meet the Stage 1 requirements that you actually pass the audit?  What’s the probability you’ll have the time needed to implement Stage 2 and 3 before the penalties begin? (That’s sort of like asking if you know the probability of seeing a bluebird on the third Tuesday of June.)
Now, go ahead and calculate an ROI based on everything you don’t know.  Not too easy is it?

May I have receipt for my EHR in case I return it?

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The hospital we use just dedicated a new wing.  For months the job site was a maze of people, duct, and tools.  It cost $145 million.  There’s a plaque displaying the name of the architect, the contractor, the mayor, and the rest of the adults who made it happen.  While it was being built there were numerous permits, certifications, and sign-offs taped to the building.  Their purpose was to ensure the public that the adults were keeping an eye on things.  A phase of work couldn’t be started until the prior phase had all the requisite sign-offs.

Those in authority had to be licensed.  Had to be certified as qualified.

They have another project underway.  One that costs more than the new wing and impacts more people.  This one doesn’t have a blueprint.  There are no building permits.  No certifications.  No licensed professionals.  You can’t even see it.  There are no hard-hatted workers.  No foreman.  You know who’s in charge of the project?  A hospital executive—prior experience—zero.  Has he ever built one before?  No.  Does he know what to do when he encounters risks, pitfalls?  No.  There is one other person running the show—a vendor—that should let everyone get a good night’s sleep.

Would anyone let this same executive be in charge of building a new wing?  Of course not.  Why then do we not employ the same standards for what will turn out to be the most expensive and far reaching non-capital project that the hospital will ever undertake?  If you think you know, please share your answer.

By the way, I asked one of those executives how it was that he happened to be selected to lead the EHR project.  “I forgot to duck,” he quipped.  I guess that’s as good a reason as any.

Dr. Blumberg’s blog post

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Well, not only did they post my commentary, it’s receiving  several “thumbs up”.  Maybe there is something behind what we’ve been discussing.

http://healthit.hhs.gov/blog/onc/index.php/2009/12/30/a-defining-moment-for-meaningful-use/comment-page-1/#comment-458