business model

Is the C-suite fiddling while EHR burns?

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There is an adage in the military—different spanks for different ranks.  If speaks to a double standard, the less egregious their punishment for similar offenses, similar misjudgments.

We see that every day in business, and we see it a lot in healthcare, especially in hospitals.  Physicians are held accountable for medical errors.  Hospitals pay millions for malpractice insurance knowing that mistakes will be made and people will be held accountable for their mistakes.

But what about on the business side?  Who is held accountable for business mistakes?  An acquisition that failed to deliver.  An expensive new service offering that bled the company dry.  A decline in the number of patients. The failure of a major IT initiative to deliver results.

Take EHR.  Some of you are saying, “Yes, please take it.”

  • Around sixty percent of the large EHR projects have failed in one respect or another
  • Most will not receive ARRA incentives
  • A large number of hospitals are on their second implementation of EHR
  • Some have productivity losses of thirty percent

Who is going to be fired for the two hundred dollar misstep?  The board?  Never.  The CEO—no.  The COO or CFO?  Unlikely.  The CIO?  That is the safe bet.

Did the CIO authorize the expenditure?  Nope.  Did the CIO get all the dollars needed to be successful, all the user support?  Unlikely.

In most cases the CIO has all of the responsibility and only some of the authority.  There are a handful of people in each organization tasked with the oversight of the large project.  They are the ones who should be asking the right questions, the ones who should be demanding answers.

A failed project, a failed strategy should not come as a surprise.  The only people who will be wearing EHR 2.0 T-shirts are those who authorized EHR 1.0.  How come these individuals are not accountable?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Are hospitals making the the same mistake as BP?

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“The time has come,” the Walrus said, “To talk of many things: Of shoes and ships and sealing-wax, of cabbages and kings—…

A lot of the strategic issues in healthcare are not easily explained.  One issue can be explained to a fifth-grader.  So, get your crayons out and follow along.

Fifty-some days and counting.  Say it with me—BP.  In many respects healthcare’s approach to social media is analogous to BP’s—the major difference is that neither the payors, pharma, nor the providers has yet to wipe out an entire geography—but the week is not over yet.

BP is offering an MBA in how not to use social media.  Nobody is queuing up on Amazon to buy the book, “BP’s ten pointers on crisis management.”

The funny thing about disasters is being able to schedule them in Outlook.  There are no pop-ups fifteen minutes before the big bang reminding you to get ready—“pipeline blows up in 15 minutes.”

We both know, sooner or later you will have one.  While yours may not crater the shrimping industry, it may be enough to do some serious damage to your business.  Most hospitals have a risk management group.  BP has one.  The mission statement of risk management is to assess and mitigate risks.

BP’s group probably had a plan in place to address a number of risks—risks like OPEC, an expansive war in the middle east, a tanker collision.  Apparently, they overlooked the risk of having a blowout a mile under the ocean.  Who’da thunk it?

If you Google “oil spill” there are fifty million hits.  Add “BP” to the search and the results narrow to a mere forty million.  That toothpaste is never going back in the tube.  People who can’t find the Gulf of Mexico on a map know that BP ruined it.  Thirty years from now people will still know the name of the firm that poisoned the Gulf, destroyed businesses, ruined vacations, made people sick, and cratered home sales along hundreds of miles of shoreline.

No matter what type of disaster BP could have faced, they demonstrated they were not prepared.  Even if it is proven that the disaster was not BP’s fault, it is too late to change their ownership of it.  Nobody is ever going to delete those forty million Google pieces linking BP to failure.  If BP hired a thousand workers whose only job was to try to counter each piece of negative media it would take them decades.

What is the one word to describe BP’s social media strategy?  LATE.

There is no useful social media strategy worth anything that begins after a disaster, none worth anything that begins after a misstep, after a faux pas.  Dictionary.com defines a faux pas as a social error—a boo-boo.

Unlike Meaningful Use, a good social media strategy can have an almost infinite ROI.  A good social media strategy, in addition to adding revenues and capturing patients, can help assuage the bleeding.  A good social media strategy played out in advance creates allies.

Let us look at this from the perspective of large healthcare providers.  What types of unfavorable events could negatively affect a hospital?

  • A medical disaster
  • Fraud
  • Medical errors
  • Reform
  • Scandal
  • Medical malpractice
  • Natural disasters
  • A data breech

While all negative events are not the same, many aspects of a good social media strategy apply regardless of the type of problem.

There are two major components of a good healthcare social media strategy:

  1. It should be pro-active.  Your social media strategy should be building goodwill each day.  Google the name of your hospital and see how many hits you get.  Next, see how many thousands of those hits are attributable to people outside your organization—too many to count.  You are already late.  People are already posting videos and writing about you.
  2. It should be reactive.  Make sure your “What are we going to do now?” account has a positive balance.  At the very least make sure you can push a button and unleash a plague of social media “I feel your pain” initiatives.

I’d wager a hospital could develop an outstanding social media strategy for less than one-tenth of what it pays in legal fees.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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A Perfect Metaphor

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Few things are perfect, and when you find something that is, it is worth examining.  One thing that is perfect is baseball, at least some aspects of it.

Think with me for a minute. 1845.  How much has changed since then?  Just about everything.  Do you know what has not changed—the distance between the bases—90 feet?  This distance may seem insignificant or inconsequential.

In the last 165 years the distance between the bases remained unchanged.  Equipment changed, improved.  The players got bigger, faster, and stronger.  It never dropped to eighty-nine feet; it never jumped to ninety-one feet.

To those who follow baseball, have you noticed how close many of the plays are at first base, or the closeness of the steals of second base?  Can you imagine what would happen to the game of baseball if the distance was shortened to eighty-nine feet?  Almost everyone stealing second base would be safe.  If the distance was ninety-one feet they would all be out.

Somehow, 165 years ago those people got it right, got it absolutely right.  Something as simple as a measurement along a dirt path has stood the test of time.  There are not even any discussions about trying to improve it.

Remember the Titanic?  If one measured all the time spent in its design, and all of the time it sailed before it sank, if you were a betting person you would have bet on the boat.  Reasonable people would have bet on the boat.  You would have been a fool to have bet it would have sunk.

You know what; the Titanic’s sinking was not a fluke. The laws of physics and ship design did not suddenly cease to work.  Do not blame the iceberg.  The Titanic was designed to sink—otherwise it would not have sunk.

What is often misjudged in business is the ill-informed notion that just because something has not collapsed it is not broken.  Hospitals are starting to collapse.  The business model of most of them almost ensures that left unchanged, many, many more will collapse.  They have been designed to collapse.  Just because they have yet to collapse does not mean they won’t, all it means is that they have not—yet.

Few things are perfect.  What discussions there are about the business model are not about improving the model, they are about cutting costs.  What do you have when there are no more costs to cut?  You have a less costly dysfunctional model.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Planning an EHR?

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You’ve probably figured out that I am never going to be asked to substitute host any of the home improvement shows.  I wasn’t blessed with a mechanical mind, and I have the attention span bordering on the half-life of a gnat.

I’ve noticed that projects involving me and the house have a way of taking on a life of their own.  It’s not the big projects that get me in over my head—that’s why God invented phones, so we can outsource—it’s the little ones, those fifteen minute jobs meant to be accomplished during half-time, between pizza slices.

Case in point—trim touch ups.  Can, brush, paint can opener tool (screwdriver).  Head to the basement where all the leftover paint is stored.  You know exactly where I mean, yours is probably in the same place.  Directions:  grab the can with the dry white paint stuck to the side, open it, give a quick stir with the screwdriver, apply paint, and affix the lid using the other end of the screwdriver.  Back in the chair before the microwave beeps.

That’s how it should have worked.  It doesn’t, does it?  For some reason, you get extra motivated, figure you’ll go for the bonus points, and take a quick spin around the house, dabbing the trim paint on any damaged surface—window and doorframes, baseboards, stair spindles, and other white “things”.  Those of us who are innovators even go so far as to paint over finger prints, crayon marks, and things which otherwise simply needed a wipe down with 409.

This is when it happens, just as you reach for that slice of pizza.  “What are all of those white spots all over the house?”  She asks—you determine who your she is, or, I can let you borrow mine.  You explain that it looks like that simply because the paint is still wet—good response.  To which she tells you the paint is dry—a better response.

“Why is the other paint shiny, and the spots are flat?”

You pause.  I pause, like when I’m trying to come up with a good bluff in Trivial Pursuit.  She knows the look.  She sees my bluff and raises the ante.  Thirty minutes later the game I’m watching is a distant memory.  I’ve returned from the paint store.  I am moving furniture, placing drop cloths, raising ladders, filling paint trays, all under the supervision of my personal chimera.  My fifteen-minute exercise has resulted in a multi-weekend amercement.

This is what usually happens when the plan isn’t tested or isn’t validated.  My plan was to be done by the end of halftime.  Poor planning often results in a lot of rework.  There’s a saying something along the lines of it takes twice as long to do something over as it does to do it right the first time—the DIRT-FIT rule.  And costs twice as much.  Can you really afford either of those outcomes?  Can you really afford to scrimp on the planning part of EHR?  The exercise of obtaining EHR champions and believers is difficult.  If you don’t come out of the gate correctly, it will be impossible.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Strategy Millstones, should that read Milestones?

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If you like adventure, here’s a site to check, http://www.jfk50mile.org/.  This is an annual event whose origin came about during the cold war.  Fortunately for both of us, the entry date has already passed.  The thought behind the JFK fifty-mile hike/run was that because of the possibility of a nuclear attack, each American should be in good enough shape to cover fifty miles in a day.

I participated in the event twice—I wrote participated because to state that I ran the entire way would be misleading— and I can state with certainty that almost no Americans are close to being able to complete this.  The event is run in the fall starting in Boonsboro, Maryland.  It takes place along the Appalachian Trail and the C&O Canal and various other cold, rain soaked, and ice and leaf covered treacherous terrains.

We ran it in our late teens or early twenties, the time in your life when you are indestructible and too dumb to know any better.  One of my most vivid memories of the event was that on the dozen or so miles along the mountain trail, leaves covered the ground.  By default that meant they also covered the rocks along the trail, thus hiding them.  That we were running at elevation—isn’t everyone since you can’t not run at at least some elevation, (that may be the worst sentence every written) but you know what I mean—meant the prior night’s rain resulted in the leaf covered rocks being sheathed in black ice.  That provided a nice diversion, making us look like cows on roller skates—roller blades had yet to catch on outside of California.

There were several places along the trail where the trail seemed to fork—I’m not going to say and I took it—and it wasn’t clearly marked.  Runners could easily take the wrong fork (or should that be Tine?).  I think it would have been helpful had the race organizers installed signs like, “If you are here, you are lost.”  Hold on to that thought, as we may need it later.

Some number of hours after we began we reached the C&O Canal, twenty-six miles of flat terrain along the foot path.  It’s difficult to know how well I was doing in the fifty-mile race, in part because I had never run this distance and because there we no obvious mile markers, at least so I thought.  Then we noticed that about every five and a half to six minutes we would pass a numbered white marbled marker that was embedded along the towpath.  Mile stones.  At the pace we were running, we anticipated we would finish high in the rankings.  As fast as we were running, we were constantly being passed, something that made no sense.  That meant that a number of people were running five minute miles, which we knew they couldn’t do after running through the mountains, or…Or what?

The only thing we knew with any certainty at the end of the day was that the markers with which we used to determine our pace and measure how far we’d run were not mile markers.  We never figured out why they were there or how far apart they were, but we greatly underestimated their distance and hence our progress.

It doesn’t really matter whether you call them mile stones or milestones.  What matters is whether they serve a valid purpose.  If they don’t, milestones become millstones.  Milestones are only useful if they are valid, and if they are met.  Otherwise, they are should’ a, could’ a, would’ as—failure markers, cairns of missed goals and deliverables.

How are your milestones?  Are they valid?  What makes them valid?  Are they yours, or the vendors?  All things to think about as you move forward.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Patient Relationship Management–lessons from Thumper

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Today it feels like I got a little too befuddled, steered into the skid, and took a left into the dementia cul-de-sac.  I like to dig a little esoteric hole right up front to test myself—hopefully I won’t overshoot.

One billion, two hundred and twenty million. That’s the number of hits on Google for ‘hotel’. A fairly competitive business one could easily surmise. A business in which one would benefit by trying to attract and retain customers, especially loyal customers. Their tagline is, ‘It happens at the Hilton’. You know what they say, ‘It happens’–it certainly does, ‘It’ happened to me. I’m standing at the Hilton Honors desk, checking in to the hotel. I’m in Memphis. Tennessee is one of the friendliest places I’ve ever been. The people are genuine. We go through the niceties of how my flight was, and what I’m doing in Memphis. Yada, yada. I then provide the clerk with my Hilton Honors number.

“I’m afraid you don’t exist, Mr. Roemer.”

I have the right to remain silent; I just don’t have the ability. I can feel it coming. I’m about to have a Roemer-minute. You know the feeling, when the words are going to jump pass the lips before you have the chance to go into lock down mode. I’m a bit of a stickler for English, so I press him to do better with his statement. “Here I am”—I am Sam, Sam I am, I wanted to add, but I didn’t know how up to speed his was with his Green Eggs and Ham reading. “How can I not exist?”

“In the system. You’ve expired—I checked my pulse to make sure I hadn’t—you’ve been deleted.”

“My reservation?”

“No, you. You are no longer an Honors Club member.”

Now I had it. I hadn’t expired, they expired me. Somebody had to think up that little gem of an idea, and somebody else had to approve it. They could have just pretended I was still in their little club and not said anything and everything would have been fine. Bambi 101. Thumper’s mother; ‘If you can’t say something nice, don’t say anything at all.” A clear violation of the rule. As competitive as the hospitality industry seems to be, how smart does one need to be to know that it is not a good idea to expire customers?

I was in the middle of my run today, four miles away from the parking lot.  Next to the dirt trail was a bright orange Igloo water cooler with a hand-written note stating it was provided by a local running store.

What have you done for your patients recently?  What makes you stand out?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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How to calculate Meaningful Use’s ROI

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Just to make sure we are all turned to the same page in our Cliff Notes on Meaningful Use, today’s conversation is, “There is no “R” in ROI.”

Are you familiar with the Abilene paradox?  It is a paradox in which a group of people collectively decide on a course of action that is counter to the preferences of any of the individuals in the group.  It involves a common breakdown of group communication in which each member mistakenly believes that their own preferences are counter to the group’s and, therefore, does not raise objections.

I think it occurs more often than we think.  Try to recall the last meeting you attended in which you really disagreed with something that was said.  Chances are you knew some of the others in the meeting well enough to know they also disagreed.  The reason you know they also disagreed is because you had discussed the topic.  However, none of you raised your disagreement during the meeting.  Why?  Because you did not want to rock the boat.

It is similar to a pseudoconsensus.  Pluralistic ignorance.  These create a bystander effect—people are more likely to speak out about an issue when they are alone with someone than when others are present.

After further consideration I think we must consider the very real possibility that there is no ROI for Meaningful Use.  I write this in all sincerity.  Healthcare executives march in lock-step or group think to achieve the myth of finding an ROI for Meaningful Use.  The ROI is healthcare’s quest for the Holy Grail, albeit without the Monty Python sound track.  They cannot proceed without one, so they set the target, figure out what data will demonstrate that they have hit it, and disregard the reams of data that does not support the ROI.

What if the government came out with a standard stating all hospitals ought to buy, install, and use a fifty million dollar transplant device that also flosses the patient’s teeth?  This initiative is “optional”, but the government will pay the hospital a two hundred thousand dollar rebate.  There are several types of transplant flossers—the ones that deliver that fresh mint taste cost extra.

If we were having a business discussion about the ROI for the transplant device, healthcare executives would be foaming at the mouth about how impossible it would be to calculate an ROI, and rightly so.  They would argue all hospitals are different, they have different cost structures, the devices are all different.

The standards for Meaningful Use are arbitrary.  The standards were developed by people who do not need to meet an ROI.  There was no mandate in the development of those standards to create standards which when met would yield an ROI.  Any attempt to force an ROI will naturally differ in a number of ways:

  • by provider—size, structure, offering, geography
  • by their interpretation of Meaningful Use
  • by which EHR they implemented
  • when they began the implementation
  • how well they implemented the EHR

Somebody somewhere may hit a positive ROI on Meaningful Use, just like somebody playing darts may hit a bull’s eye.  Any positive ROI will be accomplished more out of chance, and from having fit the data to a predetermined ROI rather than measuring the ROI against its true impact.

Implementing an EHR can be very good for a hospital.  However, it should be a business decision for the hospital based on the same set of business rules the hospital would use to justify any other large expenditure.  If the hospital achieves an ROI it will not be because of having followed an arbitrary set of standards.  Any ROI for an EHR will come from having done it correctly.  Hitting the figure any other way means two things; it was a coincidence, or you are in for trouble down the road.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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If you come to a fork in the restaurant…

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In Greek mythology, there was a not so nice man, Procrustes.  He had an iron bed in which he invited wayfaring strangers to spend the night.  Some of the strangers were too long for the bed and others were too short.

Apparently Procrustes liked things orderly and could be a tad anal when learning his guests did not fit.  He would set on them with his smith’s hammer, to stretch the shorter ones to fit.  If the guest proved too tall, Procrustes would amputate the excess length.  Truth be told, nobody ever fit the bed exactly because Procrustes had two beds.

In contemporary terms, a Procrustean Bed is an arbitrary standard to which compliance is forced.  A Procrustean Solution involves fitting a business problem to a preconceived set of strictures.

Raise your hand if you have already figured out where this is headed.  Preconceived.  Arbitrary.  Compliance.  Strictures.

Do you spell Meaningful Use with an upper case Procrustean or one in lower case?  I prefer the upper case.  The business problem being fitted is the implementation of EHR.  The preconceived sets of strictures are the Meaningful Use standards.

This in turn leaves the healthcare provider in what is best described as a Morton’s Fork scenario.  Shall I explain?  A Morton’s Fork is a choice between two equally unattractive alternatives—a dilemma.  The concept originated in 1487 under the rule of Henry the VII as a result of tax policy to ensure everyone paid taxes.  The argument was because the rich had enough money to buy things they must have enough money to pay taxes, and the poor who had bought nothing had saved their money, and thus had money with which to pay taxes.  The two prongs of the fork—back then forks only had two prongs.  Q. E. D.

The healthcare provider must choose between—as one may not choose among—two alternatives.  Attempt to meet Meaningful Use—a Procrustean Solution—turn their business model inside out to meet the government’s Gossamer standards.

Attempting to meet the standards does not ensure they will in fact meet the standards.  Should they only meet ninety-nine percent of the standards, they lose.  The Pareto principle does not apply.  There is no 80:20 rule.  They will not receive any incentive money as Meaningful Use is an all or nothing game.

The second alternative is to not meet Meaningful Use.  This choice may be voluntary, or involuntary—trying to meet Meaningful Use and failing.  Alternative Two—it is said—will result in reimbursement penalties from Medicaid and Medicare.

I do not think those penalties will be implemented, or at least they will not be implemented in the documented timeframe.

I also do not think there is a Morton’s Fork, because I think Meaningful Use will disappear because it is so arbitrary and capricious—and because the number of large providers who will meet it could all drive to lunch at Morton’s in a Yugo, at which time they could dine with a fork from Morton’s.

We have now come full circle.  My work here is through.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Is there a business argument for Meaningful Use?

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I remember the first time I entered their home I was taken aback by the clutter. Spent and wet leaves and small branches were strewn across the floors and furniture. Black Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The windows.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.

And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

“Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives. Sort of like all the scurrying around Meaningful Use.  The normal has been subsumed by the abnormal, and in doing so has created an entire entity which is slowing devouring the resources of the organization.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid on a daily basis. When I talk with hospital executives they are marching headstrong into the Meaningful Use abyss.

It makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about it they always have an answer. It all boils down to something like, “We simply can’t turn down the money.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid.  It’s gotten to the point where no matter how goofy things get, as long as they are consistently goofy, there not goofy at all.

This is the mindset that enables leaders to be fooled by their own activity. Busy replaces thinking.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Are terrorists smarter than us?

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Sri Lanka has been in a twenty-six year civil war with the Tamil Tigers. NPR reported the leader of the Tigers was killed. Within a day, the Tamil Tigers’ web site posted a blurb stating that the leader was not killed—a la Monty Python—“I’m not dead yet.”

I’ll be brief. The bad guys. These bad guys live in the jungles, others live in the Afghan mountains. As far as I’ve been able to ascertain, they don’t use Cisco servers, they don’t have a call center. There’s no marketing department, no financial analysts, no freshly minted MBAs walking the hallways telling them what to do.  They have established virtual nations.

Yet as primitive as these groups are, they know the value of rapidly employing social networking to their advantage. What amazes me is not that they do it, but that most people reading this don’t have a proactive policy and the resources required to effectively manage their social media.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
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