I reside where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s a small space where only those who place principle over fees dare to tread.

Where to begin? How to build your team? (Those who wish to throw cabbages should move closer to the front of the room so as not to be denied a decent launching point.) There are two executives, I hasten to add, who will defend what I am about to offer, a CIO, and a CMIO, ideas from both of whom you’ve probably read.

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time the project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon. I believe that staffing only to execute today’s perceived demands will get me shot and will fail to meet the needs of hospital. I need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications for healthcare IT.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare issues from an IT perspective. They’ve also indicated that—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform. I disagree with that position.

Here’s a simplified version of the targets I think most of today’s CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them. Here’s what I think. You don’t have to believe this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since I’m writing, I used it.

Before I go there, may I share my reasoning? From a business perspective, many would say the business of healthcare (how it is run) is being moved from 0.2 to 2.0. The carrot? Stimulus funding—an amount—should you earn it, and you will probably want to since your CFO has already built it in to the budget—that will prove to be more of a rounding error than a substantive rebate. Large providers are being asked to hit complex, undefined, and moving targets. They are making eight and nine figure purchase decisions based in part on solving business problems they don’t articulate. If success is measured as on time, in budget, and functional and accepted, I estimate for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

The overriding business driver seems to be that the government has told providers to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on EHR than they would to build a new hospital wing. They don’t know what it should cost, yet they have a budget. They don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot. I’d staff with a heavy emphasis on the following subject matter experts:

• PMO
• Planning & Innovation
• Flexibility
• Change Management
• PR & Marketing
• And..Disaster Recovery

None of these high-level people need to have much if any understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime. That will account for about fifty percent of the success factors.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years from now there will not be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of Rhios, and mapped into a NHIN. Under the current model, standardization will not occur if only for the fact that there is no monetary value to those whose standards are not standard to make them so. This discussion is orders of magnitude more complex than cassettes and 8-tracks.

Interoperability, cost, and the lack of standardization will force a different solution. I think the solution will have to be something along the lines of a single, national, open, browser-based EHR. Can an approach to solving this be pieced together by looking at existing examples like airline reservations, ATM, OnStar, Amazon, FaceBook, and others? I believe so. Are some of my words and examples wrong? Count on it. Please don’t pick a fight over my lack of understanding of the technology.

The point I am trying to drive home is that from a staffing perspective, lean towards staffing the unknown. Staff it with leaders, innovators, and people who can turn on a dime. Build like turning on a dime is the number one requirement. Don’t waste all of your resources on certification or meaningful use. If anyone asks you why, you can blame me. If you want a real reason, I have two. First, they won’t mean a thing three years from now. Second, if I am the person writing a rebate check, I want to know one and only one thing; can your system connect with the other system for which I am also writing a check.

However, when all is said and done, I call upon us to remember the immortal words of Mel Brooks “Could be worse, could be raining.”