Does it come in blue?

The store for audiophile wannabe’s. Denver, Colorado. The first store I hit after blowing an entire paycheck at REI when I moved to Colorado.

The first thing I noticed was the lack of clutter, the lack of inventory. There were no amplifiers, because amplifiers were down market. There were a dozen or so each of the pre-amps, tuners, turntables, reel to reel tape decks, and these things called CD players. They also had dozens of speakers. At the back of the store was an enclosed 10 x 10 foot sound proof room with a leather chair positioned dead center.

When the ponytailed salesperson asked about my budget, like a rube I told him I didn’t have one. He beamed and took that to mean it was unlimited. It really meant I hadn’t thought of one. He asked me what I liked to listen to.

“Pink Floyd, Dark Side of the Moon.”

Within a few seconds I was seated in Captain Kirk’s chair, and Pink Floyd’s Brain Damage filled the room in pure digital quadraphonic sound. I was in love.

I lived a block and a half away. Since the equipment wouldn’t fit in my Triumph, I made several trips carrying home my new toys—gold plated monster cable, solid maple speakers that rested on nails so as to minimize distortion, a pre-amp, tuner, receiver, turntable, and stylus.

It wasn’t that I deliberately bought stuff I didn’t need. I walked in uneducated. I had never bought what I was looking at. I didn’t know how much to spend, nor what it would do for me. Looking back at that purchase decision, I bought specs I didn’t need. I didn’t realize it was possible to build audio technology that would meet performance specs beyond what I person could hear, heck beyond what anything could hear. Not understanding that possibility, I bought specs I couldn’t hear. I spent hundreds of dollars on features from which I would never receive value. You too?

It happens all the time. Stereos. Cars. Computers. Applications. Technology. Having bought it doesn’t mean it was needed, or that it was the right thing to do, or that it has an ROI, or that it meets the mission.

The cool thing is that even though I could not hear half the features of my new stereo, it looked really, really impressive.

CHIME versus RHIME (Roemer’s Health Information Management Executives)

So, what’s up with CHIME?  The attendees are all tucked away in an underground bunker in the convention center, the entrance of which is guarded by members of AARP.  Rows of cellophane sandwiches are lined up behind the concertina wire.  The group remind me of Yale’s Skull and Bones society, or at very least some renegade chapter of the masons.

If you walk up to Checkpoint Charlie, you must shield your eyes from the search lights.  German Shepherds pull at their leashes lest you get too close.

You need to be a CIO, I am told.  I am not one of the chosen.  I try every trick–they all fail.  I meet one man who is a member of the elite group.  He used to be a CIO, but is no more.  Yet still he is a member.  I asked him how he managed this feat of deception.  He tells me he is a FIO–freelance information officer.  Suddenly, my mind is all-a-twitter.

Change the letters, and I am in.  I try to bluff my way past the guards with the FIO idea.  I don’t really want to be in the meetings; but the free food has my attention.  Mrs. AARP stops me cold.

Then it comes to me.  The answer lies in changing the letter, but not the CIO letters, the CHIME letters.

I have decided to form RHIME.  Roemer’s Health Information Management Executives.  Avoid the rush, join today–and bring sandwiches.

Healthcare IT: Shave the Cat

As I was going up the stair, I met a man who wasn’t there.

He wasn’t there again today…I think, I think, he’d gone away.

This particular fellow happened to be a CIO.  Now, before you throw tomatoes at your monitor, he was atypical; I hope.

We were talking about the various healthcare initiatives that have his attention as the CIO of a hospital.


Meaningful Use—we will pass it in April

Planning for HIPAA 5010 and ICD-10—starting in July

He did not even blink.  It was almost like he was bemused by the triviality of what he faced.  Listening to him, it sounded like he was reading from a scrap of paper he had pulled from hi pants pocket:

  1. Pick up one gallon of milk
  2. Finish EHR
  3. Drop off dry cleaning
  4. Collect ARRA money
  5. Shave the cat
  6. Convert ten thousand systems to 5010
  7. Walk on water

If there is a difference between being confident and being grounded in reality, he may be the poster child.

CIO shift, happens–or shift happens

Another comment of mine to Barbara Quack’s post;

I think you hit the nail on the head.  I think a lot of this can be attributed to the fact that stuff rolls down hill and that shift happens.

In healthcare, as in every significant industry, part of the problem seems to come from the fact that CIOs are often considered to be part of the C-suite in name only.  There are several notable exceptions to this observation, CIOs who drive business strategy instead of merely implementing the business strategy that was developed in the “real” C-suite.  Many C-suiters perceive the real role of the CIO is to apply technology to accomplish what they (the C-suite) want done.

Many executives, CFOs, CMOs, COOs, and CEOs regard the position of CIO such that the “C” (chief) and “O” (officer) are honorariums; officers in name only, officers with commensurately sized offices located on the third floor or in an offsite location.  Responsibility often without authority.

I think the issue of Meaningful Use is a clear example of how the practice works.  I worked with a large group of hospitals whose CIO had a detailed IT strategy and plan—projects, ROIs, resources, and capital.  His plan was tied to the business plan which he helped author.

He did EHR and CPOE before EHR was de rigueur.  Then along came Meaningful Use.  Without any understanding of the business issues or consequences associated with meeting Meaningful Use, the C-er’s and the board decided that not meeting Meaningful Use was not up for discussion.  The analysis was thorough, but unimportant.

In a nutshell, the organization which had already implemented EHR and CPOE because of his thought leadership—and long before DC got into the EHR thought leadership business—was instructed to meet Meaningful Use, all else be damned.  The “all else” included whatever it was that eighty percent of his IT staff would have worked on during the next three years.

For the sake of a check, the IT strategy was sacrificed, and the IT strategy’s alignment to the business strategy was sacrificed.  Did they get the check?  Will they pass the Meaningful Use audit?  IT will be blamed if they fail to meet Meaningful Use.  They will be blamed when they fail to deliver all of the other parts of their original plan.  And, they will be blamed if the standards shift in mid-stream.  Why?  Shift happens.  Responsibility often without authority.

“Memo from the CFO: How’s that whole ICD-10 initiative coming?  Holler if I can do anything.”

And guess what’s coming around the corner?  The new hot topic to roll down hill will be the decision that comes out something like this; “Memo from the CEO: The board decided we need to be seen as an Accountable Care Organization by the end of 2012.  Holler if I can do anything.”

Information Technology—IT.  “That must be where we keep all the technology in case we need it.”  Just send out a request and one of those technology guys will put it in for us.

There is only one thing that will stop this train from making the office of the CIO the bucket into which the downhill water is running.  Lead.  Plan.  Instead of planning for what technology and IT resources you need to deliver to meet their orders, draft a healthcare strategy instead of an IT strategy.  Bring forth a business plan addressing business problems that uses technology as a solution to solve the problems.

Define what is needed, on top of what you already need, to meet ICD-10.

Define what is needed, on top of what you already need, to make ACOs viable.

If you wait to respond to their IT orders, it will be too late.

EHR: How important is due diligence?

What was your first car?  Mine was a 60’ something Corvair–$300.  Four doors, black vinyl bench seating that required hours of hand-stitching to hide the slash marks made by the serial killer who was the prior owner, an AM and a radio, push-button transmission located on the dash.  Maroon-ish.  Fifty miles to the quart of oil—I carried a case of oil in the trunk.  One bonus feature was the smoke screen it provided to help me elude potential terrorists.

I am far from mechanically inclined.  In high school I failed the ASVAB, Armed Services Vocational Aptitude Battery—the put the round peg in the round hole test.  Just to understand how un-complex the Corvair was, I, who hardly knows how to work the radio in a new car, rebuilt the Corvair’s alternator—must not have had many working parts.  Due the the excessive amount of rusting I could see the street from the driver’s side foot well.

However, it had one thing going for it; turning the key often made it go—at least for the first three or four months.  Serves me right.  The guy selling the car pitched it as a date-mobile, alluding to the bench front seat.  Not wanting to look stupid, I bought it.  Pretty poor due diligence.  An impulse purchase to meet what I felt was a social imperative—a lean, mean, dating machine.

The last time I made a good impulse purchase was an ice cream sandwich on a hundred degree day.  Most of my other impulse decisions could have used some good data.  The lack of good data falls on one person, me.

How good is the data you have for deciding to implement an EHR?  In selecting an EHR?  Did you perform the necessary due diligence?  How do you know?  Gathering good data is tedious, and it can lack intellectual stimulation.  I think it affects the same side of our brain as when our better half asks us to stop and ask someone for directions; we like being impulsive, and have built a career based on having made decisions on good hunches.

The difference between you buying and EHR and me buying a clunker is that when I learned I’d made a poor decision I was able to buy a different car.  You can’t do that with an EHR that has more zeros in the price tag than the Dallas Cowboys front line.  Plenty of hospitals are on EHR 2.0–they also happen to be on CIO 2.0. while CIO 1.0 is out shopping for a Corvair.

EHR leadership isn’t always a democracy


That’s my new word. I coined it the last time my wife was traveling and I was in charge of breakfast and making sure nobody missed the bus. Cerealizable is what happens when you walk into the kitchen and are confronted with two hungry dogs, three hungry kids, hair that needs brushing, homework assignments that need to be reviewed, and lunches that have to be packed.

Breakfast orders are shouted at me across the room as though I’m their short-order cook; pancakes, French toast, sausage, and who knows what else. What does one do? I was quickly headed down the path of self destruction, too many tasks and not enough taskers. I needed a light at the end of the tunnel and so I created one. I cerealized the problem; simplified it–turned into something I could solve. Go to the pantry, pull out the cardboard cereal boxes, three bowls, three spoons, and the gallon of milk. Check off breakfast.

In case you’re wondering, Cocoa Puffs still turn the milk brown, just like they did thirty years ago. Lunch orders began to be shouted across the bowls of cereal. Ham and cheese, PB&J, tuna–extra mayo, no celery. Once again small beads of perspiration formed quickly on my brow. For a moment I considered calling the school and telling them that all three were sick. That would solve the lunch problem, but it would also mean that the three of them would be home all day–my own private hostage situation. What to do? My coffee remained out of reach, still untouched. That explained the pending headache. Back to lunch. Cerealize it. “Everyone is buying lunch today,” I announced above the roar.

A half hour later, the din had subsided. I made a fresh cup of coffee and collected my thoughts. What had I learned from the exercise? Three things. One, some situations require leadership. Two, three children and one grownup is not time to establish a democracy. There is no Bill of Rights. To quote Mel Brooks, “It’s good to be the king.” Three, break the problem down into bite-sized pieces, don’t try to swallow the elephant whole.

That same approach works just as well with EHR grownups; clinical grownups and IT grownups. Improving the interaction takes leadership. Large, institution-changing projects involve pulling people out of their normal routines and relationships.  Solving problems will not involve a kumbaya moment–Program management is not a democracy. To succeed, the program champion, having created a vision, will have to break it down into bite-sized pieces.


Patients are issuing RFPs for healthcare services

The following is my latest post for healthsystem

If a patient fell in the woods and nobody heard him, so what?

I’ve spent a lot of time trying to understand what a patient is worth to a hospital over a period of let us say five to ten years. Simply put, what is the ROI of a patient?  Apparently, no one has answered this question. If they have, the answer is well hidden.

Why are hospital marketing departments continuously searching for new patients when they already have access to a ready supply of past and current patients?  It will always be much cheaper to retain those patients, than to try to acquire new ones.

Patients are both customers and consumers. Unless the patient is in the back of an ambulance being driven to the nearest hospital, as I was the night I had my heart attack, the patient can choose which hospital to purchase services from.

Choice. If I wish to “hire” a healthcare procedure, how might I go about doing so?  This concept of a customer hiring a product or service comes from Harvard’s Clayton Crhistensen.  It flies in the face of how businesses, hospitals included, normally view their business.  It employs a pull model, driven by patients (customers), rather than pushing services down to the customers.

The entire healthcare provider model is being turned on its head and the only people who do not acknowledge it are those running the hospitals.

Hospitals replicate each other’s services instead of making themselves unique.  They sacrifice and outsource their highly sought, low margin services to other organizations that are able to quickly raise the profitability of those same services.

Let us examine this notion of hiring a service from a more easily understood example.  If I want to “hire” a large HDMI flat-screen television I issue an RFP (Request for Proposal) to the market.  I do not walk into Best Buy and see what they have to offer and repeat this process across several chain stores.  I go to the web, input my hiring criteria, obtain information, and evaluate my options. Through social networking, I force vendors to submit their RFP responses to me.

For some reason the large provider business model continues to operate under the premise that healthcare can treat people who research options before making a purchase as an anomaly.  They approach patient acquisition as though they still have the keys to the car, having their chief marketing officer authorize the installation of billboards touting their urology expertise, believing incorrectly that this type of direct marketing will offset patients’ ability to choose their own provider.  Look at your numbers.  Does that approach appear to be working?

Of course not.

Patients want to hire healthcare services the same way they want to purchase breakfast cereal. Patients want to own the hiring decision.

When I had my heart attack eight years ago, I wasn’t able to choose among hospitals. I could not tell the ambulance driver, “My insurance does not cover this hospital.” I could not tell him, “I’ve heard good things about the cardiology department at hospital ABC.”

After being treated, I issued an RFP for cardiovascular services.  I did considerable research and decided to hire my cardio services from Penn Medicine.  I now hire all of my cardio services from Penn, and my decision had nothing to do with which organization was covered by my insurer.

The large provider business model is being disrupted. It is being disrupted by prospective patients—consumers of healthcare and customers.  Providers will be faced with patients who hire their services under two new models; “pay as you go” and “pay for performance.”

When you have a few minutes, Google your name-brand hospital. You’ll get thousands of responses. Almost all of them have been initiated by current and prior patients.  Many of the responses will not convey a positive message.

The healthcare market is changing to a patient-driven model. But nothing the C-suite is doing acknowledges that shift. Large providers fail to recognize the fact that patients are doing the hiring, that patients are issuing RFPs. No hospitals take a business approach to maximizing the life time value of a patient. In fact, no hospitals can even tell you the lifetime value of a patient.  Yet the lifetime value of an individual patient is probably seven figures.

Instead, the business strategy of most hospitals is to replicate the business strategies of their competitors.  Few hospitals appear to operate strategically.  They operate against budgets because that is how their boards measure them. If the hospital next door buys a machine that goes “ping,” hospitals feel the need to purchase the machine that goes “ping,” even though it adds no value to their bottom line.

Whether or not hospitals acknowledge it, patients are now driving the business model. Each patient, or prospective patient, is an asset—not the MRI and not the machine that goes “ping.” Each patient/asset may be worth more than a million dollars.

Hospitals need to get beyond the magnificence of their own credentials. Prospective patients do not care about marketing or billboards. Patients, especially informed patients, are narcissistic; they care about themselves, not how providers market their services.

There is one thing, and only one thing, about patient experience management that the C-suite needs to understand. Patients are learning to hire healthcare from among a range of options. If you want them to hire you, you have got to give them a reason to buy. Being like the hospital next door is not enough.

I am convinced IT can play a substantial role in providing former and prospective patients the information they need to drive the hiring process to their organization.  It is a combination of churn management and patient experience management, and the experience which has to be managed starts before the patient hires its provider.


Informationweek Healthcare Article on Meaningful Use

This link takes you to an interesting and well-written article written by Anthony Guerra.  Even if he didn’t quote me in the piece, it would still be worth reading.

EHR–One time at band camp…

Like many of you, I see two distinct groups who do not play well in the same sandbox—clinical and IT.  Having clinicians go to the HIT summer camp to pick up a few skills is not the same as pulling a few costly and hairy projects from the bowels of project hell any more than it would be to have an IT executive take an EMT course and then assume that person was qualified to perform surgery—this one time at band camp…

Before I get up on my stool and knock myself off, I know CMIOs and CIOs who have made HIT and EHR very successful.  To them I ask, do not rake me across the Twitter coals as I try to make a point.

There’s knowledge, and then there’s qualified.  Doctors do four years of medical school, they intern, and if they specialize, they throw in a few more years before they become the in-charge.  Years of training and practice before the doctor is allowed to run the show.  Why?  Because what they are about to undertake requires practice, tutelage, and expertise.  Most of the actual learning occurs outside the classroom.

There are those who suggest the skills needed to manage successfully something as foreboding as full-blown EHR can be picked up at HIT Camp.  This does a disservice to seasoned IT professionals.

Most large IT projects fail.  Large EHR projects fail at an even higher rate.  Most clinical procedures do not fail, even the risky ones.

What’s the spin line from this discussion?

  • Rule 1—large EHR projects fail at an alarming rate
  • Rule 2—sending a clinician to band camp probably won’t change rule one

Don’t believe me?  Ask friends in other industries how their implementation of an ERP or manufacturing system went.  There are consulting firms who make a bundle doing disaster recovery work on failed IT projects.  They line the halls like turkey vultures waiting for CIO or project manager carrion.

Back to Rule 1 for a moment.  How can I state that with such assurance?  Never before in the history of before—I know that’s not a proper phrase—has any single industry attempted to use IT to:

  • impart such radical charge (patients, doctors, employees)
  • impart it on a national basis
  • hit moving and poorly defined targets—interoperability, meaningful use, certification
  • take guidance from nobody—there is no EHR decider
  • implement a solution from amongst hundreds of vendors
  • implement a solution with no standards
  • move from an industry at 0.2 to 2.0 business practices
  • concurrently reform the entire industry

Just what should a CMIO be able to do?  What are the standards for a CMIO?  To me, they vary widely.  Is a CMIO considered an officer in the same sense as the other “O’s” in the organization, or is it simply a naming convention?  The answer to that question probably depends on the provider.

Here’s how I think it should work—I realize nobody has asked for my opinion, but this way I’ll at least provide good fodder for those who are so bold as to put their disagreement in writing.

I love the concept of the CMIO and think it is essential to move the provider’s organization from the 0.2 model to the 2.0 model.  Same with the CIO.  However, getting them to pool their efforts on something like EHR is likely to fail as soon as one is placed in a position of authority over the other.  It’s sort of like getting the Americans and French to like one another.

I liken the CMIO’s value-add to that of the person providing the color commentary on ESPN—it adds meaning and relevancy.  The CMIO owns and answers a lot of the “what” and the CIO owns and answers a lot of the “How”.

Still unanswered are the “Why” and “When”.  A resource is needed who can state with assurance, “Follow me.  Tomorrow we will do this because this is what needs to be done tomorrow.”  That skill comes from an experienced Project Management Officer, the PMO.  It does not come from someone who “we think can handle the job.”  Nobody will respect a PMO’s  ability if they do not have the requisite expertise.  EHR needs someone who can state from their experience, “One time at band camp…”   If the EHR can’t lead, or the team is not willing to follow the PMO, you can plan on doing the project over.