consulting

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?

Should you consider disregarding Meaningful Use?

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Here’s a reply I wrote to a FierceHealthIT on some of Dr. B’s comments on Meaningful Use.

I know of a hospital who has already implemented a top tier EHR costing millions.  This organization ‘gets it’.  They are currently building a work-plan to see what additional work they must do to meet Meaningful use in time to qualify for 100% of the ARRA money.  First blush—it will take tremendous amount of work for them to do it, but they will get there—if they choose to do so.  They have a choice and the fact that they know that is their trump card.

If a hospital hasn’t even begun the EHR process, as more than 80% have not, coupled with the more than fifty percent failure rates, I’d estimate their chances their chances of making the deadline at less than 1/3.

So, what to do?  Stop and think.  Ask the right questions.  You have a choice of two strategies.  Let ARRA money drive your decision, possibly implement it wrong, and probably miss the deadline.  Then what do you have?  Not much.  Strategy number two; define your requirements, figure out what business problems you need the EHR to help solve, and buy the best one for you.  Confused?  Map out two work-plans for yourself.  One work-plan that shows what you would have to do and what you would have to spend to meet the ARRA requirements.  Draft a second work-plan that shows what you would have to do to implement what you really want.  Compare the two plans and determine your deltas, your gaps.

Are you going to chase this for ARRA money?  Because someone in Washington thinks you should do this?

Answer this question first.  Is every hospital the same?  Are you as good as the best, better than the worst?  The EHR vendors think the answer is yes.  Keep you processes the same, skip change management, and the implementation will be a breeze.  We make every hospital look and operate the same.  When did the EHR vendors become the best practice savants?   The government thinks the answer is yes—that is why they are holding everyone to the same Meaningful Use standard.

One standard does not fit all hospitals—nor should it.  Set your own standards and decide for yourself if you fit your version of Meaningful Use.  ARRA money will end—then what?  You’re stuck with your EHR.  Get one you need.

Pass the salt

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Okay campers, we’re going to jump right in to this one. There was a point not too long ago when the US was involved in the SALT talks, the Strategic Arms Limitation Treaty. For those too young to remember, the US and the Soviets—that’s what we used to call the Russians. Actually, they were called Russians before they got married and changed their name to Soviets which is neither here nor there.

This came about because the two countries were MAD at each other. Not in the usual sense, but in the sense of mutually assured destruction—of the world—several times over. Anyway, it finally occurred to both sides that perhaps we only needed enough weapons to blow up the world a few times instead of hundreds of times. What was the result? We’re still here. We’re here because the people who built the weapons agreed to greatly reduce their number of weapons. They learned how to function differently. Instead of saying we can’t do that, they took the approach of saying, “If we wanted to do that, how would we do it?” Getting rid of nuclear weapons—no small feat.

Segue. I realize this is a bit of a stretch just to make a point, but since we’ve come this far we might as well make it. What would you do if you came to work one day and received an email which read that your organization had decided against ever implementing an EHR?

To me that is a perfectly reasonable idea. Of course, I’m someone who wonders how the color purple feels. But why not stop all of this foolishness around EHR?  Agree, or is killing EHR a foolish idea?

I think it’s much less foolish than implementing an EHR and having no reasonable expectation that it will work.  The odds are that your EHR has a better chance of failing than it has of succeeding.

I have no problem with EHR.  I do, however, have a problem with businesses constantly making the same mistakes, making EHR a multi-million dollar repository for their mistakes, and then complain about the fact that the EHR isn’t doing a good job.

What do you think?

How measuring Brittan can improve your EHR success

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So, last night I am watching NOVA.  The episode discussed fractal geometry and aired the same time as the Viking Bears game.  Admittedly, not a typical Y chromosome choice, but interesting none-the-less.

A fractal is a fragmented geometric shape that can be split into parts, each of which is a reduced-size copy of the whole.  Simple enough.  Common examples of fractals include the branching of trees, lightning, the branching of blood vessels, and snowflakes.  In the seventies the mathematician Benoît Mandelbrot discovered that fractals could be described mathematically.

It turns out that a shoreline is another example of a fractal.  For example, let’s say you wanted to determine the length of the coast of Brittan by measuring it instead of just using Google.  The coastline paradox says the measured length of the coastline depends on the scale of measurement.  The smaller the scale of measurement, the longer the measurement becomes.  Thus, you would get a longer measurement if you measured the coastline with a ruler than with a yardstick.  This paradox can be extrapolated to show that the measured length increases without limit as the unit of measures tends towards zero.  In the first picture, using a 200 km ruler, the coastline measures 2,400 km.

In this photo, using a 50 km ruler, the coastline measures 3,200 km.

I’m not sure why this idea needed to be discovered, it seems a little obvious—more information yields more informed results.

A few years ago I was hired by a firm to report to their board on their vendor selection process.  The firm was about to issue a two-page RFP to two vendors.  I convinced the firm to redo the process.  They ultimately issued an RFP of more than a thousand requirements and selected a vendor who was not on their original list.

Again it seems obvious, but being obvious doesn’t always result in smart behavior.  If you’re getting ready to spend seven to nine figures on and EHR, wouldn’t you like some degree of confidence that you selected the best one for your hospital?

EHR Thought Leadership Summit Slides

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This presentation was delivered 12.10.09 in NJ.

http://www.slideshare.net/paulroemer/em-rgemcy-medicine-event-121009-joint-ppt-final

EHR: work plans are necessary but not sufficient

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I wonder about things, little things, things I see on Nova or on Bizarre Foods.  Take water, more specifically, ice.  It floats.  The only solid that floats in its liquid state.  Most solids sink, not ice.  For those of you thinking boats float, they’re not considered to be solids—does that make them liquids?

It turns out that as water goes from four degrees centigrade, its densest point, and towards freezing, it becomes less dense and floats.  It’s volume increases by 9%, and part of that 9% is trapped air.  That air, even though you can’t see it, exists between the two H’s and the O.  which takes us to the following.

Have you spent much time studying work plans?  While there are more interesting ways to spend your time, there are times meant for writing them, and times meant for studying them.

Having a work plan can be a little like having a bike; nice, practical for some things, impractical for others.  Like with most things, there are work plans and there are work plans.  Some may not be worth the paper on which they are written.

Just like not everyone can write a book worth reading, not everyone can write a work plan worth implementing.  Lines on paper don’t necessarily yield a project of much value.  Remember how with the ice there are things between the H’s and O’s?  Well, with a lot of healthcare IT and EHR work plans, there are things between the tasks on the work plan, or at least there should be.  Can’t see them either.  Those things?  The missing tasks, the tasks that should have been in the plan, the tasks that would have given the plan a fighting chance to succeed.

Some gaps are good, like with ice.  Others can leave you hanging.

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EHR meeting etiquette and survival guide

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How many times have you been involved in one of those EHR committee meetings whose purported purpose was to elicit ideas?  I find it to be a helpful barometer to scout the room and see if the person who offered an idea at last month’s meeting was invited to this month’s meeting.   To survive across months of meetings requires a lemmingesque ability to walk in silence to the edge of the cliff.

Don’t be fooled into offering an idea simply because the leader is doing that tricky thing about using silence to see who will get so uncomfortable that they just need to hear a voice–their own.  Mistakenly, you believe that someone is actually interested in what you have to say, and you toss your idea into the black hole that used to be your career. Your idea is met with silence, the kind of silence you hear on a warm summer night. You swear you can discern the chirping of individual crickets outside.

Those voices you’ll been talking about in counseling are trying to warn you.  But to no avail, out it comes; “How come we’re not doing those work flow things they talked about?”  “Why did Our Lady of Perpetual EHR Hospital use and RFP to select their EHR vendor?”  “Why is radiology bulding their own EHR?”  “How come nobody is worried about whether this system will allow the referral docs to connect?”

You notice that your brother-in-law, the CMIO, has moved his chair away from yours.  Your best friend’s eyes are locked on his Blackberry.  It’s only then you learn that you and your colleagues aren’t petting the same dog. I think EHR implementations are a lot like that. There’s a lot of talk about doing something new, but more often than not it’s just talk.

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The real role of the C-suite in selecting an EHR vendor

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Cool Hand Luke.  Great guy film, not on Oprah’s chick flick list.  “What we have here is a failure to communicate.” That’s the line spoken by the captain of the prison pronouncing his summary judgment of the problem between he and Luke—Paul Newman: the line refers to Luke failing to understand the one-way nature of the communication between the chain gang prison captain and Luke. The line is an opening for a second speech directed to the other prisoners who are watching the abuse. The captain goes on to say “Some men you just can’t reach.”

A failure to communicate. Indeed. It’s not always obvious where to place the blame. For example. I had pulled together a pile of my clothes to donate to Goodwill; suits, blazers, pants—the usual mélange. Next to them, several feet away, on top of the ironing board, were two of my new suits, a taupe, double-breasted Jones of New York, and an Ungaro Uomo Parisian pinstripe—they were destined for the cleaners. Stop me if you’ve heard this one before. Seeing the pile on the floor, my wife offered to drop my donated items at the Goodwill.

It wasn’t until later that same day that I thanked her for dropping my suits at the dry cleaner, at which point the quisling replied with a look that told me she did not know that of which I spoke. A failure to communicate. All of my suits, those destined for Goodwill, and the two destined for the drycleaner had done an Elvis and left the building.  Poof, nada, nothing.  Disappeared into the fashion catwalk abyss.  Never mind that I was planning to wear the pinstripe to a rather important meeting.  Wave goodbye to the suits.

Two intelligent people separated by a common language.  Dictionary dot calm defines that as marriage.  Mars and Venus.  In our case it was Goodwill versus Chin’s drycleaner—that’s not racist, just the name of the business.

Two intelligent people separated by a common language.  Like healthcare providers and vendors. Like the IT and the hospital’s C-suite. If A implies B, and B implies C, then maybe B is just intended to be a clever roadblock. Maybe the C-suite invented B so they didn’t have to deal with A—vendors. It sure seems like it sometimes. If the C-suite was really interested in selecting the best EHR, they should start by listening and learning to the clinicians and those in IT.

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Pigeon Project Management Office (PMO)

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I just finished stacking two cords of wood, much like a squirrel getting ready for a long cold winter. My feet were doing the “Boy is it cold dance” in an effort to keep the blood circulating.  As I was picking up the scraps, my eldest picked up a piece and placed it in his backpack. When I asked him what he would do with it he told me he was going to carve it after school. His statement brought back boyhood memories of hours of whittling, an activity done if for no other reason than to get from one minute to the next. Grab a stick and whittle it away until there was nothing left.  What next? Grab another. The weight of the pocketknife felt equally good in my hand as it did in my pocket.
When is the last time the thought of whittling crossed your mind? Probably been a long time. It’s an activity meant for idle minds and hands, or minds that should be idle. There are times I find myself questioning what value so and so brings to the party. Do you do that?  “Why is she in this meeting?”  You know who I mean.  You’re sitting there trying to get your work done and all of a sudden, some Mensa wannabe with more idle time on their hands than a Lipitor salesman at a BBQ cook-off, makes an aerial assault on your cubicle like a pigeon on a Rodin bronze.  Drops in and changes the rules of the universe, at least your universe.

This happens more often than is documented on large healthcare IT projects.  People set new courses and define programs rules that may have nothing whatsoever to do with the project’s charter or scope.  You do have a written charter and scope in the project office, don’t you?  If not, it’s easy to see how new directions and rules can be given a certain specious authority.

What’s the best way to handle this situation? Often these management Mensas are nervous about a lack of visible results and they need to report on something.  They may feel the need to be doing something, something resembling leading.  They don’t mean to interfere, and they believe that their little forays into the world of super PMO (Program Management Officer) will actually add value. You tell me, are they adding value, or are they preventing the team from sticking to the scope? There’s that irritating scope word again.  The next time you see one wandering aimlessly through the rows of cubicles, hand that person a pocketknife and a nice piece of balsa wood.  Although their efforts won’t add any value to what you’re trying to accomplish, at least it will get them out of the way for a little while.

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Why is change management so important?

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If  EHR is about anything it’s about change.  So much of what exists today has to do with creating and moving documents.  Did you know?

  • Of all documents handled each day in the average office,
    90% are merely shuffled
  • Currently, 90% of corporate memory exists on paper
  • There are over four trillion documents in the U.S. alone,
    growing at a rate of 22% per year
  • Professionals spend 5-15% of their time reading information,
    but they spend up to 50% looking for it
  • Corporate paper-based documents are growing at the rate of
    200% per year
  • 19 copies are made from each paper document
  • 22% of all documents are lost
  • 7.5% of paper documents are lost completely
  • 3% of the remainder get misfiled
  • $20.00 is spent on labor to file a document
  • $120.00 is spent on labor searching for the misfiled paper documents
  • $250.00 is spent on labor to search for lost files

From Price Waterhouse

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