EHR

Blazing Saddles: the original HIE-NHIN model

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Several have inquired as to why I came down so hard in yesterday’s post regarding the CMS-ONC’s approach to link our physicians and hospitals through the development of HIEs and the N-HIN.  I think, as do others, the goal is worthwhile but, is the current strategy going to work?

I think the current plan is fatally flawed, and is racing ahead like a herd of turtles.  Just because everyone is working hard, and has good intentions, does not necessarily mean the outcome will deliver what is needed.  It seems over engineered to the point that it is like trying to put ten pounds of turnips into a five-pound bag.

Unfortunately, until the leadership of the CMS and the ONC come to that realization the CMS, the ONC, and healthcare providers will continue to spend hundreds of millions of dollars to support an infrastructure that:

  • Unnecessarily complex
  • Is not necessary nor sufficient
  • Cannot be built
  • Will not work

Call me Deep Throat.  The perspective that the HIE-NHIN plan will not work is only spoken of in the bowels of the Watergate Hotel’s parking garage in hushed voices late at night.  Many of you have shared with me that you are of the same opinion but, like vampires you shudder that your voice on this matter would see the light of day.  It would be less antagonistic to open a kosher deli in Tehran than to say the CMS-ONC needs to be rethunk but, sometimes a little antagonism is what is needed.

Do you recall the scene in Blazing Saddles when Harvey Korman’s horde of bad guys is racing through the desert on horseback to get to the town of Rock Ridge only to be halted in the middle of a wide open prairie by a lone toll gate?  Instead of being able to go directly to where they wanted to go they are forced to go through the toll gate, and their progress is stopped entirely because nobody has any spare change.

What makes it nonsensical, and quite funny, is their failure to realize that all they had to do was o ride around the toll gate.  Maybe it is just the way my mind works, but trying to get electronic health records to a national network via several hundred disparate HIEs reminds me of the toll gate.  Why not just go around it?

 

EHR, HIEs & N-HIN; a prophecy of doom

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Whether it’s vendors, RHIOs, HIEs, or the N-HIN, where is a plan that will work?  Is not this what it’s all about?  Perhaps it is time that the rest of the national HIT leaders at CMS and the ONC who devised this plan, and who have lead physicians and hospitals down this ill-fated path promising them riches at the end of the journey should acknowledge their mistake and look for other ways to pass their time; pursue something more achievable, like gardening.

If the plan of of nationalizing healthcare by using HIEs, RHIOs, Meaningful Use, and the N-HIN had any real chance of working, don’t you think we would see a lot more organizations lining up to collect their EHR rebate?

In 1-2 years Meaningful Use will have been replaced by something else or done away with entirely.  In 3-5 years the HIE-NHIN plan will have changed dramatically.  That does not help people who are spending money today chasing ghosts.

As a side note, many hospitals will miss the ICD-10 conversion date.  Not for lack of interest, but because so much of their attention is focused on chasing the banshee known as EHR.

HIEs remind me of hand-to-hand fire bucket brigades.  It’s time we agree to use a truck.

EHR–it’s like herding cats

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Herd of cats? Of course I’ve heard of cats.

I spent a summer in Weaverville, North Carolina, just outside of Asheville. (I couldn’t find it on the map either.) That summer, I was the head wrangler at Windy Gap, a summer camp for high school kids. I’m not sure I’d ever seen a horse, much less ridden one, so I guess that’s why they put me in charge. I thought that maybe if I dressed the part that would help. I bought a hat and borrowed a pair of cowboy boots from a friend; the boots were a half size too small, and I spent the better part of the first night stuffing sticks of butter down them trying to get them off my swollen feet.

The ranch’s full-time hand taught us how saddle the horses and little bit about how to ride. In the mornings we had to herd the horses from the fields, bring them into the corral, and saddle them. The other wranglers would ride out to the field to bring in the horses, while I being the least experience of the wranglers would race after them in my running shoes trying to coax them back to the barn. We would take the children for a breakfast ride halfway up a mountain path where we would let them rest and cook them a breakfast of sausage and scrambled eggs. One morning there were a group of 15 high school girls sitting on the fence of the corral. I walked up behind them carrying two saddle bags filled with the breakfast fare. I slung the saddlebags over the top rail of the fence, and hoping to make a good impression I placed one hand on the rail and vaulted myself over. I landed flat on my back smack dab in the middle of the pile of what horses produce when they’re done eating—so much for the good impression.  That earned me the nick-name, “Poop Wrangler.”

I brushed myself off and saddled my horse. The moment I gripped the reins the horse reared, made a dash for the fence and jumped it in one motion. I could tell the high school girls were impressed as I flew by them. Both of my arms were wrapped around the horse’s neck, and I had my hands locked in a death grip. I yelled, “whoa” and stop”, only to learn that the horse didn’t speak English. We raced the 200 yards to the dining hall, stopped on a dime, and raced back to the corral, as the girls continued to cheer. One final leap, and I was back where I started; on the ground, in the corral, looking up at the girls. I took a bow and quickly remounted my steed. The full-time ranch hand came over and instructed me rather loudly, “You can’t let the horse do that. You have to show the horse that you’re in charge.” After that piece of wisdom he grabbed my horse by its bit, pulled its head down, and bit a hole in my horse’s ear. I’m not sure what kind of in an impression it made on my horse. I guarantee you it made an impression on me.

Horses aren’t very intelligent, but they know when you don’t know what you’re doing, when you’re bluffing—dressing like a cowboy didn’t even fool the girls, much less my horse—I guess he hadn’t seen many westerns. Here we go—you had to know where this was headed.

Selecting and implementing an EHR will be the most complex project your hospital will undertake.  If you do it wrong, you may not look any better than I did laying on my back in the corral.  You won’t have girls laughing at you, but you also may be looking for another line of work.

You don’t want to read this, but if your projected spend exceeds ten million dollars, your chances of success, even if you do everything right, is less than fifty percent.  I define success as on time, on budget, functioning at the desired level, and accepted by the users.  That’s reasonable, correct?  We don’t need to talk percentages if you don’t do everything right.

These figures come from the Bull Report—that’s really the name, honest.

The main IT project failure criteria identified by the IT and project managers were:

missed deadlines (75%)
exceeded budget (55%)
poor communications (40%)
inability to meet project requirements (37%).

The main success criteria identified were :

meeting milestones (51%)
maintaining the required quality levels (32%)
meeting the budget (31%)

How is yours matching against these?  Given a choice, sometimes I’d rather be the horse.

 

Why people buy an EHR

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Do you ever wonder why people buy drills?  Because they need a drill?  No.

They buy drills because they don’t sell holes.

Why buy an EHR system? Because you need an EHR?

I hope you have a better reason than that.  If you’re interested, I sell holes.

Nietzsche on HIT Strategy

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The problem with being a consultant is not everyone wants their responses packaged in the same manner I tend to deliver them.  I communicate best visually, pictorially.

Asked what I want for dinner, I respond with a 3-D bar graph.  Forty-five percent of me wants pasta, thirty percent wants roast beef—a year over year increase of seven percent, but not a statistically significant sample size—and one hundred and twelve percent of me wants whatever she is willing to cook—which means I do not have to cook.

There are two kinds of consultants and, I am the other kind.  ‘Nuff said.  On a side note, as I keep telling the police, I am not the person responsible for holding giraffe fights in the linen section of Neiman Marcus.  Nor am I the guy with the collection of taxidermist-stuffed German World War II soldiers in my basement.

When one reviews the value of a healthcare IT strategy—if your organization does not have one click (http://www.disney.com) and you will be taken to a site to make more valuable use of your time—in order for it to be worth more than graffiti on an overpass (plebian) the plan must have a plan.  It also helps if the strategy at least pretends to be strategic.

The stigmata of most strategic plans is they are neither strategic nor plans.

If there is one thing a strategy should be able to address it is to be able to answer why, to be able to answer what benefit the execution of said strategy will deliver.

More than fifty percent of hospitals will not have a written IT strategic plan.

More than half that do have strategic plans will not pass the value test.

Let us suppose for a moment a hospital has what they believe to be a real HIT strategic plan.  Does that document contain answers to the following questions?

  • Implement XYZ EHR.  Why?  Why XYZ?  What benefits will the hospital receive?  Few if any will formalize benefits ahead of time because they can be held accountable when those benefits are not delivered.  Is it safer to simply check the box for having “completed” the implementation?
  • Meet Meaningful Use.  Ditto.
  • Accountable Care Organization.  Ditto.
  • ICD-10.  Ditto.
  • Family Experience Management.  Ditto.

Maybe Nietzsche knew more about IT strategy than he has been credited.  “All things are subject to interpretation.  Whichever interpretation prevails at a given time is a function of power, not truth.”

 

EHR Failure Factors–step away from the computer

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There are days when it doesn’t pay to be a  serial malingerer, and when it does, the work is only part time, but I hear the benefits may be improving as I think I heard somebody mention healthcare is being reformed.

I don’t know if you are aware of it, but there are actually people who have taken an Alfred E. Newman, “What, me worry” attitude towards EHR.  For the youngsters in the crowd, Alfred was the poster child for Mad Magazine, not Mad Med.

Just to be contrarian for a moment–as though that’s out of character for me–most providers have no need to fear–does this happen to you?  You are writing aloud, trying to make a point, and the one thing that pops into your mind after, ‘there’s no need to fear’ is “Underdog is here.”

Anyway, since many providers haven’t begun the process, or even begun to understand the process, there is still time for them to lessen the risk of failure from an EHR perspective.  Many don’t want to talk about it, the risk of failure.

Here’s another data set worth a look (The Chaos Report).  They went a little PC on us calling them ‘Impaired” factors.  EHR impairment.  Step away from the computer if you are impaired, and take away your friend’s logon if they are.  These are failure factors.

Project Impaired Factors % of  the Responses
1. Incomplete Requirements 13.1%
2. Lack of User Involvement 12.4%
3. Lack of Resources 10.6%
4. Unrealistic Expectations 9.9%
5. Lack of Executive Support 9.3%
6. Changing Requirements & Specifications 8.7%
7. Lack of Planning 8.1%
8. Didn’t Need It Any Longer 7.5%
9. Lack of IT Management 6.2%
10. Technology Illiteracy 4.3%
11. Other 9.9%

My take on this is with overall “failures” so high, several respondents could have replied to “all of the above.”  Also of note is that these failure reasons differ from the ones listed previously.

Who knows, maybe if we multiply them by minus one we can call them success factors.

 

EHR-Do not use as a flotation device

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EHR potentially will offer a number of benefits.  It won’t offer much at all if you don’t install it correctly.

However, EHR is not a panacea.  Without having a detaile understading of the business problems you are trying to solve, it may not be of much more value than a Xerox machine.

Can you make color copies with your EHR?

 

The Physics of EHR

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To read and complete this post you may use the following tools; graph paper, compass, protractor, slide ruler, a number two pencil, and a bag of Gummy Bears—from which to snack.  The following problem was on the final exam in my eleventh grade physics class.  Let us give this a shot and then see if we can tie it into anything relevant.

A Rhesus monkey is in the branch of a tree thirty-seven feet above the ground.  The monkey weights eight pounds.  You are hunting in Africa, and are three hundred and twenty yards from the monkey.  You have a bolt-action, reverse-bore (spins the shell counter-clockwise as it leaves the gun barrel) Huntington rifle capable of delivering a projectile at 644 feet per second.  The bullet weighs 45 grams.  The humidity is seventy percent, and the temperature in Scotland is twelve degrees Celsius.

At the exact moment the monkey hears the rifle fire it will jump off the branch and begin to fall.  Using this information, exactly where do you have to aim to make sure you hit the monkey?

I used every piece of information available to try to solve this.  I made graphs and ran calculations until there was no more data left to crunch, computing angles and developing new formulas.  I calculated the curvature of the earth, and the effect Pluto’s gravitational pull had on the bullet.

The one thing that never occurred to me was that since the monkey was falling to the ground, so was the bullet—gravity.  The bullet and the monkey both fall at the same rate because gravity acts on both the same way.  So, where to aim to hit the monkey?  Aim at the monkey.

All of the other information was irrelevant, extraneous.  The funny thing about extraneous information is that it causes us to look at it, to focus on it.  We think it must be important, and so we divert attention and resources to it, even when the right answer is staring us in the eye.

Attempting to implement EHR is a lot like hunting monkeys.  We know what we need to do and yet we are distracted by all of this extraneous information that will hamper our chances of being successful with the EHR.  Two of the most obvious distractions are Meaningful Use and Certification.  The overarching goal of EHR is EHR; one that does what you need it to do.  If the EHR does not do that, everything else has no meaning.

 

What do processes have to do with EHR success?

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As a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR? The reason is simple. The taxonomy of most, if not all EHR systems, is that they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

 

EHR: This is not a trick question

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Okay, so today was going to be one of those days when I wasn’t going to allow myself to be stupified–at least no more than was really required.

Then it sneaks up smack dab in the middle of a call, and from what I’ve been able to determine, people find it annoying if you burst out laughing on the call.  (They are not annoyed at all if you simply write about them provided they don’t read it.)

What got me going is this statement, “We’ve budgeted $X for EHR.”

Really?  You did this all by yourself?

The facts as I understood them are as follows:

  • Never bought an EHR
  • Don’t know how big they are, if they are blue or green, come gift-wrapped, or if you need two people to carry it
  • No input from vendors about EHR
  • No discussions with others abot what an EHR system costs

So, with absolutely no information, how does one determine how much they need to spend for an EHR?  This is not like going to the supermarket for a gallon of Soy Milk–not that anyone would want to do that.