Expert: Providers must make IT investments on their own, have new implementation strategies

Here is the link to an article in HealthcareITNews that quotes a few of the things we have been discussing on this site.

http://www.healthcareitnews.com/news/expert-providers-must-make-it-investments-their-own-have-new-implementation-strategies

The EHR Certification Myth

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial–like Kojak without the warmth.

Why is this a part of the overall plan?  Is this planned failure?  Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test.  The certification test, by definition, is necessary.  The Full test is both necessary and sufficient.  It is possible to pass certification without passing the Full test.  Therefore, the Full test is a stricter test.  Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test?  Same as always.  Fully functional, on time, within budget, and user accepted.  Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact:  One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion:  The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations.  Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification.  (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact:  Most large, complex, expensive IT projects fail—they just do.  This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed.  Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion:  Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak?  You bet.  Insurmountable?  Doesn’t have to be.

What can you do to improve your chances of success?  Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points.  EHR Fail Safe Points?  The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test.  The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD.  They need not have a slew of EHR implementation merit badges.  The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built.  They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR.  Those skills are needed—in spades—and you need to budget for them.  The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre.  They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

What do you think?

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
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

The EHR Certification Myth

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

Why is this a part of the overall plan?  Is this planned failure?  Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test.  The certification test, by definition, is necessary.  The Full test is both necessary and sufficient.  It is possible to pass certification without passing the Full test.  Therefore, the Full test is a stricter test.  Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test?  Same as always.  Fully functional, on time, within budget, and user accepted.  Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact:  One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion:  The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations.  Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification.  (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact:  Most large, complex, expensive IT projects fail—they just do.  This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed.  Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion:  Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak?  You bet.  Insurmountable?  Doesn’t have to be.

What can you do to improve your chances of success?  Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points.  EHR Fail Safe Points?  The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test.  The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD.  They need not have a slew of EHR implementation merit badges.  The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built.  They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR.  Those skills are needed—in spades—and you need to budget for them.  The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre.  They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

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
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

July is “take your EHR strategy to lunch month”

Several have written suggesting I toss my hat into the ring to serve as the EHR Strategy wonk or czar.  I was in the process of thinking it through when I was awakened from my fuegue state by a loud noise–my ego crashing to the floor.

Some have suggested that a camel is a horse designed by a committee.  Their point in saying that has something to do with how committees function less well than individuals–the problem with “group thinking.”  Personally, I think the camel design seems rather functional.

Some have asked, what is it about the EHR universe that has you dehorting the EHR process as though you are some sort of savant–nobody really asked that, but I wanted a segue and that’s all I came up with.

It’s the committees.  I feel a little like Quasimodo repining about the bells.  Raise your hand if you are on an EHR committee.  See?  Now, if you think that not only has the committee not accomplished much, but believe that it may never accomplish much, lower your hand.  Now look around.  Not many hands still up.

Please take a look at this for a moment.  Don’t try to understand it–it will only make your teeth hurt.

2011 requirements

  • For hospitals, 10% of all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) directly entered by an authorizing physician must be made through a computerized physician order entry process. Individual physicians still must use CPOE for all orders, even if electronic interfaces with receiving entities are not available. The initial draft did not specify the required percentage for hospitals and did not address the electronic interface issue.
  • Physicians must be able to check insurance eligibility electronically from public and private payers, when possible, and submit claims electronically. This was not in the initial draft.
  • Patients must receive timely electronic access to their health information, including lab results, medication and problem lists, and allergies. The initial draft did not include the word “timely.”
  • Physicians must implement one clinical decision rule relevant to specialty or high clinical priority. This was not in the initial draft.
  • Physicians must record patient smoking status and advance directives. This was not in the initial draft.
  • Physicians must report ambulatory quality measures to CMS. This was not in the initial draft.
  • Physicians must maintain an up-to-date list of current and active diagnoses based on ICD-9 or SNOMED. The initial draft did not specify use of the two classification sets.

2013 requirements

  • Specialists must report to relevant external disease or device registries that are approved by CMS. This was not in the initial draft.
  • Hospitals must conduct closed-loop medication management, including computer-assisted administration. This was not in the initial draft.
  • All patients must have access to a personal health record populated in real time with health data. This was moved up from 2015 in the initial draft.

Additional provisions

  • Patients’ access to EHRs may be provided via a number of secure electronic methods, such as personal health records, patient portals, CDs or USB drives.
  • CMS will determine how submitting electronic data to immunization registries applies to Medicare and Medicaid meaningful-use requirements.
  • CMS may withhold federal stimulus payments from any entity that has a confirmed privacy or security violation of the Health Insurance Portability and Accountability Act, but it may reinstate payments once the breach has been resolved.

Source: Health IT Policy Committee

See?  Take a few minutes and work this into your EHR task time-line for processes, work flows, change management, training.  Need more time?  I’d need more time than I have, and when I finished I guarantee I couldn’t explain it to anyone.  This is what happens when people get into a room, have a charter, and try to do something helpful.  I am sure they are all nice people.  But be honest, does this make your day, or does it make you want to punish your neighbor’s cat–you may have to buy them a cat if they don’t already have one.

What to do?  Here’s my take on it.  Plan.  Evaluate the plan.  Test the plan.  Know before you start that the plan can handle anything any committee tosses your way.  Let people who know how to run large projects into the room.  Seek their counsel, depend on them for their leadership.  If the plan is solid, the result has a better chnace of surviving the next committee meeting

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
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

What benefit is there to meeting Meaningful Use?

Commercials bug me.  Big surprise.

You have probably seen the commercial for the Sleep Number Bed.  A bare mattress, a glass of wine on the mattress, a bowling ball is dropped on the mattress.  The glass of wine does not spill.  That makes some people rush out and buy the mattress.  Why?  For the security in knowing that just in case they leave a glass of wine on their mattress and then happen to drop a bowling ball on it, the wine will not spill.

That dog don’t hunt unless you happen to be opening a bowling alley/Motel 6.  The company is trying to entice you on the merits of doing something by asking you to make the leap of faith by equating the bowling ball falling on the bed to having your spouse get in or out of the bed without disturbing your sleep.

A feint.  A maneuver designed to distract or mislead you from the real purpose.  Meaningful Use.  Certification.  A feint.  Designed to distract or mislead you from the reason you need an EHR.  The terms of Meaningful Use, that is, what is meaningful to your organization should be set by your organization, not some national standard applicable to every hospital in the country.  Hospitals are not ubiquitous—the Meaningful Use standards are.  How can a single set of standards be in line with what you require?

What’s the feint?  Certification, cash incentives, Regional Extension Centers.  A full court press trying to get hospitals to do what the feds want it to do in order to meet their goal of a nationwide interconnected healthcare system.

What proof, other than a check, has anyone offered that you benefit from meeting Meaningful Use?

Should you try to meet Meaningful Use?  I think not.  There is no ROI, and the full set of standards have yet to be published.  What should you do?  Have a glass of wine, or better yet—go bowling.  Don’t forget to buy one of those snazzy bowling shirts.

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
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

EHR Groundswell

EHR, there’s a new groundswell against meaningful use. How do I know? I’m starting it now.

After lunch, if I’m in the right mood, I may start one against certification.

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
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

What may be driving the Meaningful Use announcement

I often write not because I have something that needs to be said, but to try to explain something to myself.  If I get to a point where I think I understand an issue, I’ll make it public to see if the comments reflect my understanding, or to see if I need to have another go at my own thought process.  Which leads me to this—

Let’s back up the horses for a minute and return from whence we came.  EHR.  The idea was simple.  Two groups; patients and doctors.  Create a way to transport securely the medical records of any patient (P) to any doctor (D).

For the time being, let’s keep this at the level that can be understood by a third grader.  What two things do I need to satisfy this P:D relationship?  Data standards and a method of transport.

Do we have them?  We do not.  That being the case, what fury hath the ONC wrought?  (1 Roemer 9:17)  if you don’t have what you need, and you don’t have either the authority or a plan to get what you need, you must facilitate (fund) the creation of workarounds to fill the void.

At some point, the conversation must have quickly shifted from, “We need standards and transport”, to, “Since we don’t have standards and a means of transport, we must come up with other ways to try to make this work.”  Now, I don’t believe this is literally what happened, but I think one could see how it might have evolved.

Other ways.  What other ways?  The ONC loves me; it loves me not.  HITECH.  ARRA.  Take the monkey off our back and put it on the backs of the providers.  Pay doctors to implement EHR.  Smote them if they don’t.  Write checks.  Big checks.  Lots of big checks.  Instead of coming up with a single transport plan and one set of standards, provide guidelines.  Make pronouncements.  Fund RHIOs and make them responsible for creating hundreds of unique transport plans and ask the RHIOs what progress they are making towards a single set of standards.  Get the monkey off your back.

Create artificial goalposts that get the HIT world all a twitter every time the ONC makes a proclamation.  What goalposts?  Meaningful Use and Certification.  Just so there is no misinterpretation of what I think the issue is permit me to spell it out—Meaningful Use and Certification exist because there are no standards and there is no means of transport.  Conversely, had the ONC developed standards and transport, there would be no discussion of Meaningful Use and no Certification.  Standards would have forced vendors to self-certify.

The other activity could be viewed as a feint.  Not one developed out of malice, rather one that came about from the void that resulted from the lack of a viable plan.  Meaningful Use and Certification are expensive workarounds for a failed or nonexistent national EHR rollout plan.  As are RHIOs and RECs, the six million dollars, and the forty billion dollars.

The HIT world grinds to a halt at the very mention of an announcement from the ONC.  Their missives are available in PDF or stone tablets.  Imagine someone robs a bank, and as they exit the bank, they jaywalk on their way to their getaway car.  The police missed the robbery, and focus all their efforts on the secondary issue, the jaywalking.

The chain of events has caused the focus to move away from the primary issues of no standards and no plan, and towards a plethora of secondary issues, issues for which hundreds of people are responsible and no single person has authority.

I think that by the end of 2013 pronouncements on Meaningful Use and Certification won’t be able to buy time on MTV.

If any of this is close to being correct, what are the implications for a hospital looking to select and implement an EHR?  Find the EHR that is best for your hospital.  Not the one most likely to earn ARRA money.  Not the one which will pass today’s Meaningful Use test.  Define your requirements.  What requirements?  The ones you believe will most closely align with how the healthcare industry will look in 2015 and beyond.  Meaningful Use will change.  Reform will change.  Funds will change.  Reform will change again.  Will your EHR be able to change?

The ONC’s recent Meaningful Use proclamation required 556 pages.  If you occupy the C-suite of your hospital, I hope you don’t let those pages define your selection of an EHR.  Some would argue that with so many pages that there must be a pony in there somewhere.  From what I read, I’m in no hurry to rush out and buy a saddle.

What is wrong with the ONC’s 2010 budget?

Some comments I wrote to ahier.blogspot.com’s posting of the ONC’s 2010 budget.

Their mission, “ONC leads, coordinates, and stimulates public and private sector activities that promote the development, adoption, and use of health information technologies to achieve a healthier Nation” although offering nice sentiments, for $61 million, ought there not be a way to measure whether or not they achieved the mission? How does one know if they led, coordinated, and stimulated, and if so to what degree?

Who certifies their work? Who determines if their work resulted in Meaningful Use? Before anyone gets excited by what they plan to do in 2010, let’s look at what they did in 2009.

1. What did the ONC accomplish, complete, put to bed?

2. What did they complete that facilitated the HIT work required of the providers?

There are no standards. There is no believable plan to obtain standards anytime soon. There is no viable national roll-out plan for EHR.

Instead of HIT/ARRA handouts, and HIE’s designed by hundreds of independent groups, and RECs designed by inexperienced appointed committees, why not use the $61 million to state that by such-and-such a date there will be a written and executable plan stating when we will have standards and a workable and believable roll-out plan?

They continue to promise funds to support an ill-conceived plan trying to get everyone on board, an approach that yields to the notion that “There must be a pony in there somewhere.” Ladies and gentlemen–there is no pony.

If a Certified system is so special, offer a certification warranty

I think that certifying the EHR product prior to installing it is worthless. Certification to me means that the product is capable of performing some function.   If certification is of any value, the fact that it’s certified means it should still be certifiable after it’s installed.

We all know that that is not the case. If the feds think it’s so important to certify the EHR products, let’s certify them after installation.   The large vendors are the ones pushing certification.  They do it for one reason, to limit competition.  If the vendors think certification somehow implies that their product is somehow better because it has been certified, let them offer a cost free warranty and re-certify it after installation.

It’s an easy test.  Let’s see how many of them respond to this plan.

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Certification; Is it worth worrying about?

question4Below is an exchange I had on a LinkedIn discussion group regarding certification in response to a comment made by someone speaking to its intended benefit.  As I have not sought his permission to quote him here, I will just provide a link to his comment.  My thoughts are the following.

My understanding is that some vendors are certified and some aren’t. As a provider let’s say I’ve issued an RFP and I select vendor A over vendor B for the sole purpose of the fact that vendor A’s product is certified.

Now, assume I am I large provider, and that this implementation will cost at or above $100 million. Clearly, I am not going to do an ‘out-of-the-box’ installation. Hence, whatever I go live with will differ in many respects with what was certified. That being the case, what I have may now look far different from what the certifiers had in mind.

Regardless of the intent of certification, it also creates very effective artificial barriers to entry for the smaller vendors.

You write that the “hope is…” If I am a hospital CMIO or COO I can’t base my decisions on something as arbitrary as that. Reform, Certification, Meaningful Use, Standards, and interoperability may as well be written on an Etch-A-Sketch as each of these are subject to change.

You also write that the purpose is to “assure” product A will inter-operate with product B using industry standards. As though standards are not final, how can assurance be offered? If for A to get to B the record has to pass through one or more as yet to be defined RHIOs haw can assurance be assured.

I think that although the intent of certification may have some merit, when the national roll-out of EHR scales up, we will see that the time and money invested in certification could have been better spent elsewhere.

Here’s the link, http://www.linkedin.com/groupAnswers?viewQuestionAndAnswers=&gid=130128&discussionID=7499646&commentID=6845299#commentID_6845299

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