Month: January 2010

My comments to Dr. Blumenthal’s Blog

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It says they are awaiting moderation–they could be waiting a long time.  Here they are.

I think hospitals need to give a lot of thought to whether it’s in their best interest to even try to meet MU.  Those who haven’t begin EHR and CPOE will be hard pressed to benefit.  There is more unknown than known about the impact of changing an entire business strategy in light of reform, the magnitude of Stage 2 and 3 requirements, no standards, 400 vendors–all lacking 2011 certification, hundreds of different HIE’s, and an N-HIN strategy that may not be viable.

Washington is building a healthcare model whose long term goal is to be able to connect each patient to any doctor.  Hospitals have a far different business model.  The sad thing is that none of the hospitals who have undertaken EHR had any idea that costly rules would be applied after the fact, they have no means to know what the next set of changes will be, or if the dates of meeting MU will be pushed back.  If the dates don’t move MU will be like hosting a lottery for which only a handful of people bought tickets.


As for ambulatory doctors, my recommendation is to wait until a firm shrink wraps EHR (software, implementation, training, change management, and work flow improvement.)  There’s no rush here either.


Should you consider skipping Meaningful Use?

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I am going through an analysis for my client, a hospital chain who has already installed EHR and CPOE to see if they should change their strategic direction to get the ARRA money, or continue along their original course.

It does not have to be an either or decision.  Their options are not do go for MU, to go for all of the money, to go for it at some combination of their hospitals, or to go for it later.  With so many unknowns, it may be best to slow down and evaluate the options. 2011 is around the corner, however you have five years, until 2015 until the penalties begin.

What’s your take?

Thank you for reading and commenting

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Curious to hear your thoughts as to what impact the election of Senator-Elect Brown will have on the current healthcare legislation?

The doctors’ thoughts on social media are probably correct « Healthcare IT: How good is your strategy?

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The doctors’ thoughts on social media are probably correct

Posted by Paul Roemer on January 18, 2010

Some more thoughts on the post on KevinMD’s site stemming from Dr. Gwenn’s blog.

Justifiable on-line road rage.  I run a consulting firm.  You know what?  I hate it—running the firm, that is.  The consulting is great fun.  I am guessing that being a physician is a lot like that.  Very few of you became doctors to run a business, let alone one that is front and center on the evening news, Twitter, and every other blog on the planet.  Add to that a government who is changing the business model without any thought to how it impacts your business.  They want a nationalized healthcare system whereby each patient can be accessed by any doctor—that has nothing to do with your effort to treat actual people.

Interesting discussion, and the comments are spot on, especially the, “Where’s the beef” comments.  It is silly to expect that overlaying a few technologies makes things better.  This reminds me a little of Dorothy running around in ruby slippers, and the magic answer was clicking her heels three times.  Unless K-mart had a big sale on ruby slippers, there is no quick win technology for doctors lining the shelves of Office Max.

To rub salt in the wound, the government is forcing more technology on physicians, namely EHR.  If the technology was as great as the prognosticators write, doctors would be scrambling to be first in line.  Has that happened?  Of course not.  Instead, the government is taking a Tony Soprano approach, offering rebates for doctors who take a course they don’t want to take, alternatively, burying bodies off the New Jersey Turnpike.

So, some tactical thoughts starting with EHR.  Don’t do anything yet.  You have at least a year.  Yeah, you won’t get the ARRA money—that’s according to what’s written.  Guess what?  Nobody else will get it either.  The ONC will have to change either the timing of Meaningful Use, or the rules, or both.  I think they will push it back.  Twelve to eighteen months from now, someone will offer a robust, shrink-wrapped solution that makes sense.  If you’re interested, here’s a link to an audio interview I did for doctors about an EHR strategy—it’s just ideas, I’m not pushing anything.  Go to EMRFIX.com and search for the link.

Other practical thoughts.  There are a few hundred thousand doctors, none of whose Hippocratic Oath said anything about healthcare 2.0, or offered any training on how to get there, or whether you should even try to get there.  Most of my physician friends set up their business model on a whim and a prayer, like all entrepreneurs do—like I did.  There are probably as many business models for doctors as there are doctors.  The good news is that some have done better figuring out the business side of healthcare than others.  It’s not an ego thing.  It’s not about being intellectually gifted and not being smart enough to figure out something as simple as running a business.  Why?  Smart has nothing to do with it.  There are things to be learned from the efforts of others, and there are ways that some of the technologies can help.

Those things?  Blocking and tackling.  Business processes.  Social media.  Eliminate the rework.  Eliminate whatever tasks that don’t add value to your business.  Are there activities you can outsource?  Payroll?  Can you have someone design a website that will answer questions for your patients so they don’t have to call you?  Can you collaborate with other doctors?

Just some ideas.  You are justified in your angst.

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The doctors’ thoughts on social media are probably correct

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Some more thoughts on the post on KevinMD’s site stemming from Dr. Gwenn’s blog.

Justifiable on-line road rage.  I run a consulting firm.  You know what?  I hate it—running the firm, that is.  The consulting is great fun.  I am guessing that being a physician is a lot like that.  Very few of you became doctors to run a business, let alone one that is front and center on the evening news, Twitter, and every other blog on the planet.  Add to that a government who is changing the business model without any thought to how it impacts your business.  They want a nationalized healthcare system whereby each patient can be accessed by any doctor—that has nothing to do with your effort to treat actual people.

Interesting discussion, and the comments are spot on, especially the, “Where’s the beef” comments.  It is silly to expect that overlaying a few technologies makes things better.  This reminds me a little of Dorothy running around in ruby slippers, and the magic answer was clicking her heels three times.  Unless K-mart had a big sale on ruby slippers, there is no quick win technology for doctors lining the shelves of Office Max.

To rub salt in the wound, the government is forcing more technology on physicians, namely EHR.  If the technology was as great as the prognosticators write, doctors would be scrambling to be first in line.  Has that happened?  Of course not.  Instead, the government is taking a Tony Soprano approach, offering rebates for doctors who take a course they don’t want to take, alternatively, burying bodies off the New Jersey Turnpike.

So, some tactical thoughts starting with EHR.  Don’t do anything yet.  You have at least a year.  Yeah, you won’t get the ARRA money—that’s according to what’s written.  Guess what?  Nobody else will get it either.  The ONC will have to change either the timing of Meaningful Use, or the rules, or both.  I think they will push it back.  Twelve to eighteen months from now, someone will offer a robust, shrink-wrapped solution that makes sense.  If you’re interested, here’s a link to an audio interview I did for doctors about an EHR strategy—it’s just ideas, I’m not pushing anything.  Go to EMRFIX.com and search for the link.

Other practical thoughts.  There are a few hundred thousand doctors, none of whose Hippocratic Oath said anything about healthcare 2.0, or offered any training on how to get there, or whether you should even try to get there.  Most of my physician friends set up their business model on a whim and a prayer, like all entrepreneurs do—like I did.  There are probably as many business models for doctors as there are doctors.  The good news is that some have done better figuring out the business side of healthcare than others.  It’s not an ego thing.  It’s not about being intellectually gifted and not being smart enough to figure out something as simple as running a business.  Why?  Smart has nothing to do with it.  There are things to be learned from the efforts of others, and there are ways that some of the technologies can help.

Those things?  Blocking and tackling.  Business processes.  Social media.  Eliminate the rework.  Eliminate whatever tasks that don’t add value to your business.  Are there activities you can outsource?  Payroll?  Can you have someone design a website that will answer questions for your patients so they don’t have to call you?  Can you collaborate with other doctors?

Just some ideas.  You are justified in your angst.

Why doctors fail to embrace healthcare 2.0

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This is a reply I wrote to Kevin MD’s blog to a post written by Gwenn Schurgin O’Keeffe, MD, FAAP.

I view healthcare 2.0 with a bit of a twist from the Wikipedia definition, less from the perspective of social media and more from the vantage point of moving the business of healthcare from Version 1.0 to version 2.0.  I should note that I distinguish the business of healthcare (how it is run) from the healthcare business (the clinical side).

Having worked with executives in a number of industries, I think that for healthcare reform to be truly effective, the business of healthcare needs to evolve from an 0.2 model to a 2.0 model.  I think the same issues you raise still come into play; sheer panic, loss of control, loss of connection with patients, and blinders.

Going from an in-house business model to one being transformed by reform and Meaningful Use to a national healthcare model will exacerbate further those issues.  The in-house business of healthcare (how healthcare is run) was never built to handle a business model that will require every patient to be able to be connected to any doctor.  The system advances over the past few years—EHR, CPOE, and ePrescribing were implemented without any idea that the rules would change after the fact.

Will healthcare 2.0 offer huge advantages to how healthcare is run?  Absolutely.  The first question to answer before aiming for 2.0 is whose 2.0 model should you follow; yours or the government’s.  Are they the same?  No, and they are diverging even further as you read this.  The good news is that I think they will converge several years down the road.  What you need to decide is which model do you pursue before that happens.

Who is responsible for your hospital’s HIT strategy, you or the ONC?

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Who is responsible for your hospital’s HIT strategy, you or the ONC?  Here are my thoughts regarding “What’s Next” and the “Gap Analysis”  with regard to the ONC’s interim final rule.  Remember, you don’t have to follow the IFR.

What’s Next:

  • Most if not all of the current HIT was built prior to government constraints
  • The ONC changed the rules after many hospitals already spent millions on EHR and CPOE
  • Nobody knows the staying power of the Meaningful Use rules or the impact of reform
    • Will the implementation be pushed back?  Quite possibly
    • Will the requirements be toughened?  Very likely
    • What if reform reduces revenue and increases demand?
    • What if existing doctor and nurse shortages grow worse?
    • What if some of the most vulnerable and expensive patients continue to have no coverage?
    • What if the ONC changes the rules?
    • What if reform cuts costs by eliminating “disproportionate share” payments?
    • What if there is a reduction in Medicare reimbursements?
    • More is unknown than is known about the impact on hospitals and physicians
    • There are two business models in play;
      • The ONC’s and reform’s nationalization and interoperability of healthcare
      • The mission of your organization
      • Do you build your HIT strategy to align with your hospital’s strategy or with the ONC’s strategy
      • Your pre-Meaningful Use HIT goals likely included:
        • Supporting your strategy
        • Consolidation for shared services
        • Clinical integration
        • Operational excellence
        • Reducing functional duplication between departments
        • Process improvement
        • EHR and CPOE implementation
        • Which of those goals would have to be altered because of Meaningful Use
        • What would your HIT strategy have been if there was no Meaningful Use

What’s the GAP between what you had planned and what your now have to consider?

  • How many millions will it take to meet Meaningful Use
  • What planned HIT projects must be delayed because of timing or resources
  • How do those millions compare to what you will receive from the ARRA funds
  • Even if the funds exceed the cost to get them, how do the changed systems impact your business model
  • You have a number of options to analyze regarding Meaningful Use:
    • Meet Meaningful Use later
      • A wait and see approach buys you time for the uncertainty to settle and for the impact of reform on HIT to become clearer
      • There is no requirement to be first
      • You have five years before Meaningful Use penalties begin
      • If the requirements expand as expected it will likely cost more to modify systems than to wait for a complete set of requirements
  • Do not meet Meaningful Use
  • Meet all of the Meaningful Use opportunities
  • Meet portions of Meaningful Use
  • What projects must be undertaken to achieve each option
  • Will those projects have long-term value for you, or is their only value meeting Meaningful Use
  • What process and change management implications are built into meeting Meaningful Use

How to improve EMR adoption-a guest blog

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The well-written guest blog which follows is by Richard Hom, Public Policy Consultant, Richard Hom Consulting.  http://grandrounds4ods.com.  You can also find him on Twitter at grandrounds4ods.  Thanks Richard for contributing.

Medical providers across the country are grappling with many medical care issues. Of the many, one that has received much attention, thought and talk has been computerized electronic medical records (EMR).  Although not a novel idea, EMR use and adoption have regained center stage as economic stimulus funding from the Federal Government has been dangled as an added incentive.

The monetary incentive, though, has not overcome the resistance and hesitation that providers have toward EMRs.  More urgent problems that preclude EMR adoption dwindling reimbursement, rising malpractice premiums and an array of private and public regulatory issues that smother provider authority.  In this atmosphere of medical practice the promise of the benefits of EMR adoption has not outweighed the attention gained by the aforementioned issues.

If EMR adoption is to spread and embraced by the medical community, more tangible and direct benefits may be needed. For example, with EMR use, physician accountability is enhanced by legible and available documentation of patient care. Tying EMR use to malpractice premiums would be an attractive carrot, just as a non-smoker might benefit with health or automobile insurance.

Likewise, EMR use should benefit a physician’s patients by easing information sharing.  Therefore, an initiative to lessen the burden of eligibility of benefits or referrals to specialists would be welcomed.

Finally, electronic presentation of Explanation of Medical Benefit forms (EOMBs), rejections and electronic resubmission should further invite greater EMR participation. In this one area alone, the blizzard of paper correspondence surrounding reimbursement is a significant problem area that may be lessened with EMRs and practice management software.

In summary, a cash incentive may attract medical providers, but only those providers who already may have successful office workflow processes and may require only a cash incentive. For the remaining, though, relief from the paper flow, claims submission,and  malpractice premiums may be the carrot that will move more providers to EMR adoption.

Should you consider avoiding Meaningful Use?

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Where were we?

There are a few things stuck in my craw—imagine that.  One is Meaningful Use.  The other is also Meaningful Use.  Permit me to address these one at a time.  I’ll start with Meaningful Use.

Are you kidding me?  Who are these people?  To disguise that of whom I write, let’s invent some aliases, Dr. B and Dr. H.  For all the meetings, all the pronouncements, you’d think sooner or later one of them would state, “There is no way any of this makes sense.”

Why do you say that Paul?  May I?   What if you threw a party and nobody came?  What if you held a $40 billion lottery and nobody won?  Here are the rules.  A handful of people less than seven feet tall decide to buy homes in a community.  All the homes have door openings that are seven feet high.  New people move into the community.  One day the homeowner’s association mandates that all homeowners must build homes with door openings that are seven feet high.  Most homeowners ignore the mandate.  The association then decides to offer the homeowners rebates if they comply with the mandate, and penalize them if they don’t.  Most of the homeowners ignore the mandate.

Indifferent to the fact that their mandate isn’t working, the association decides to add new rules, rules that affect the homeowners who already built homes with seven foot tall doors, and those who didn’t.  One of the rules is that the seven foot tall doors must now be eight feet tall; another mandates that all roofs must be in the basement.  Homeowners who comply will win the lottery.  Those who don’t won’t.

How does the lottery pay out?  It doesn’t.  They made it impossible for anyone to get the money.   Suppose you gave a lottery and nobody won?  Suppose you made it so obtuse that nobody cared if they won.

That’s where I think we are with EHR.  The smart healthcare providers are asking themselves the question, “What if we make a business decision not to meet the Meaningful Use requirements?”  “What if we decide what is and isn’t meaningful.”

There are 2 “business models” in play—the national healthcare model, and the model your firm follows—they have different goals.  I asked my client, “When you made your selection of EHR, did you have any hint that the government was going to create rules to manage what it does?”  I assume their answer is a lot like yours—“Not at all.  We were worried about FDA oversight, but nothing like the stimulus.  The PQRI was available as an incentive to use ePrescribing, but really small potatoes.”

The national healthcare model under development will create an infrastructure such that every patient can be connected to each physician via a series of HIEs and the N-HIN.  To get there, they need you—they can’t do it without you.  What do they need from you?  Participation.  Participation by having and EHR, ePrescribing, and CPOE.

Even if it were to work, what’s in it for you?  Very little.  They know that—that’s why there are payments and penalties.  Most hospitals like the idea of implementing EHR.  Given the choice those same hospital executives would choose to listen to an entire Celine Dion CD if it would allow them to skip implementing CPOE.

If there are not many good business reasons to meet Meaningful Use, why should you build an entire strategy around it?  You wouldn’t paint your hospital pink simply because Washington said you should, although given a choice between the two ideas, pink sounds pretty good.  Let’s say you take them up on meeting Meaningful Use.  You build your strategy, drop current initiatives, implement these systems, train your people—then what?  Indeed.  What happens if the government changes its mind?  Moves the dates, changes the requirements?

In order to go for Meaningful Use you must be able to suspend your ability to think rationally.  If you do not think the HIE and N-HIN model will work—I have not met anyone who thinks it will—why even give Meaningful Use another thought.

My client is a group of 14 hospitals—they could get millions of ARRA dollars.  If you don’t have more than one hospital, your ARRA rebate will be much less.  They have already installed EHR and CPOE.  To get the millions they have to spend millions.  What happens if they spend it and the feds change their direction?  What then?  What do they do with the eight or nine figures of systems they build to follow Washington’s lead?  Take them out?  Modify them?  What happens to their business model as a result of all of this “leadership” from the ONC?

What should you do?  That’s up to you.  Here’s an idea or two.  First, ask yourself what your EHR/HIT strategy would be if there was no ARRA money.  (You do have a written HIT strategy, don’t you?)  Second, decide if you think that the current national roll out strategy will work.  Third, figure out what you won’t be able to do if you have to invest even more time and money meeting Meaningful Use.  Next, add up all the money it will cost you to meet their requirements and compare that to what they will pay you.  I bet the costs are more than the rebate.

I think Meaningful Use won’t exist in 3-5 years.  I think the N-HIN won’t be available by then either.

Here’s the real kicker for hospitals that have more than two beds.  If you have not yet selected your EHR vendor you shouldn’t even be thinking about meeting Meaningful Use for the first year because you can’t there in the time available to you.  That take’s the pressure off, doesn’t it.

How good is your vision?

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So, there I was thinking about all the times I didn’t get the invitations to the technical savants meetings.

I remember when Compaq came out with their first portable PC.  It was about the size of a suitcase and twice as heavy.  There was no way I’d ever have a need to lug around a computer.  A few years later my boss showed me his new cell phone—beige and about the size of a shoe box.  I remember asking him why he needed a phone and not being impressed by his answer.  Another piece of technology that would never get off the ground.

A few years later, out popped the internet.  A friend of mine showed it to me.  I asked him what he does with it.  He replied that it was good for sending messages to his brother.  I suggested he use the phone.

I think the fault I had was I looked at those three things from the perspective of the technology. It didn’t occur to me to look at it from the perspective of what business problems could they solve.

Technology, from the standpoint of its functionality, is often vastly under employed.  This happens not because of limitations of the technology, but limitations of vision.  I needed to not ask, what am I able to do with this, rather, what might I be able to do with this.

For example, let’s look at the fascination, or lack of it, around implementing an Electronic Health Records system (EHR).  By the time the dust has settled on your implementation, say three to five years—by the way, that means you missed the deadline to get the ARRA money, what does the industry look like?

Do you buy the EHR that meets what the industry looks like today, or did you give it enough thought so that your EHR functions at the level needed to support your business in 2015?