EHR

Healthleaders Media: E-Health Systems: For Love or Money?

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The following are the comments I posted to Gienna’s article, http://ow.ly/3FWTP

Nicely written Gienna.  My concerns from the get go regarding Meaningful Use (MU) and Certification are:

  • Is Meaningful Use meaningful
  • If so, to whom

 

My answer to both questions is it is meaningful, on paper, to the ONC and CMS.  It is meaningful with the respect that it does one thing.

 

  • Meaningful Use changes the course of a healthcare provider’s business strategy from whatever internal course it was pursuing to one having a national focus.

If you do not believe me, look at your resource plan for meeting MU.  Some hospitals are having to redirect more than fifty percent of their IT resources away from whatever they were doing for the hospital to meet the MU requirements.

The article reports several sets of numbers which I think are at best misleading.  I think those hospitals who meet MU will do so much later than are being reported.  Few will make it in time to capture the full EHR “rebate”.  As such, the pool of available money to go back to hospitals is overstated, as are the number of hospitals who will receive it.

There is a broad chasm between those who expect to receive money and the amount they expect to receive, and how much will paid be paid to how many.

Now, with respect to whether any of this is meaningful; how many hospitals would have been willing to sacrifice their business strategy and spend millions of dollars to try to meet such a gossamer directive if this was tied to any other directive originating out of Washington?

Let us take something so outlandish as to be silly just to try to illustrate the point; paining your hospital pink.  If Washington offered similar sums of money and if one had to spend similar resources to earn it, would a hospital’s executive team approve the expenditure?  What is the business reason that makes MU so different?

The other issue I have with their optimistic MU adoption forecasts is the following.  Meeting MU is binary.  That is, there are no points for getting close.  A hospital which meets ninety-five percent of the criteria receives the same rebate as a hospital which meets none of the criteria.  Zero.  Using their own figures, if hospitals meet it by 2016, all they will have done is spent millions to receive zero payout.

As you calculate the ROI for EHR/MU be sure to include the following:

  • Will your EHR implementation be successful?  The latest figures I have seen suggest that your odds of having a successful implementation of EHR are less than one in two.
  • If you are “successful” will you meet it in time to potentially qualify for the full amount—if not, decrease what you expect to receive.
  • Will you complete the requirements to your satisfaction—if not, multiply your expected payout by a number less than one?
  • Will you pass the MU audit?  Some will not.  That is why there is an audit.  If you do not pass, you can reapply at a later date, but you will no longer be entitled to the full amount.  Again, multiply your expected payout by a number less than one.

And, here’s the kicker.  Here is the calculation most hospitals have overlooked.  How much has your productivity dropped since you implemented EHR?  A heads up for hospitals who have not completed their implementation—a large number of hospitals have spent in excess of a hundred million dollars only to see their productivity still twenty percent below what it was without EHR.

What does such a productivity loss do to your ROI calculation?  There is no language from ONC and CMS stating that such a productivity loss is meaningful.

 

EHR: where’s my hammer?

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Those of you who’ve visited previously may have caught on to the fact that my wife likes to keep me away from bright shiny objects such as tools.  Let me tell you about my first house, a two-story stucco building in Denver, built in 1902.  My favorite part of the home was the brick wall.  That it had a brick wall was not apparent when I purchased the home.

I came home from work to find that my dog had eaten through the lath and plaster in the living room and there was the brick.  I had to decide what to do.  I knew nothing about lathing—I know that’s not really a word—or plastering.  What to do.  My only tool was a hammer, so I began to hammer.  For those who haven’t done this, hundred-year-old plaster being pounded with a hammer makes a lot of dust.  This process proved to be very slow.

What did I do?  I bought a bigger hammer—such a guy approach to a problem, isn’t it?  It took three hammers to get down to just bare brick.  What would you have done?  When your only tool is a hammer every problem looks like a nail–or a wall.

As you go through the EHR planning process in your war room—you do have a war room, don’t you?  (Try Sam’s Club, after all, they sell EHRs.)  Get out the really big piece of paper, the one with your EHR design—you do have a really big piece of paper, don’t you?  (Back to Sam’s.)

Next to the box on the paper labeled “Shiny New EHR” should be lots of empty space so you can draw in all of the other systems with which your EHR will have to interface.  One of the readers of this blog wrote recently that his EHR had more than 400 interfaces.

EHR, if done correctly, will do much for patients, doctors, and administrators.  It’s not a panacea.  It won’t reach its potential unless you also integrate it with those systems that unlock its potential.  Improving your efficiency and effectiveness takes more than merely an EHR system.

When your only tool is a hammer, you’d better hope every problem is a nail.  What other tools are you using?  Please share your ideas about what works well.

EHR: The Migratory Patterns of Coconuts

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Are you suggesting coconuts migrate? (Not at all, but a swallow could grip it by its husk.)

Sometimes I get reactions from my clients which suggest that my ideas have people questioning if I just fell out of the stupid tree and hit every branch on the way down, especially when what we’re discussing seems to move from the theoretical and towards the heretical. However, there was a presentation I made to one of my clients where I had the entire room believing that i might as well have been suggesting that coconuts migrate.

Allow me to set the stage. I presented to the CIO of one of the largest providers in Europe a vision for what their IT strategy should be. This was an 0.2 firm requiring a 2.0 solution.  As you can guess, it was fairly easy to suggest that better alternatives were available to them, but if you’re a member of the Flat Earth Socitey you’re not going to believe anything until someone is able to literally change your perspective.

During my presentation I wrote on the white board that I would help them choose between three alternatives. At this point, a British colleague and good friend, came to the front of the room—uninvited, removed the marker from my hand, erased the word ‘between’, and penned the word ‘amongst’. “We choose between two things, and amongst three or more,” he said with a grin and then returned to his seat. I suggested that since English was not the native language of our client that his point was probably lost on them, to which he stated that his point was directed at me whose native language was supposed to be English. God save the queen. He also tried to make the point on more than one occasion that the American War of Aggression with England did not end in 1783 with a victory for America, but with a British retreat.

Anyway, we were choosing between three alternatives, at least I was. After about ten minutes of explaining what could be achieved and how it might be structured, I was interrupted again, this time by the CIO. He too took my marker, concluding that I was a coconut. It took me about thirty minutes to convince him that everything I’d presented was not only achievable, but already operational in a number of their competitors.

So, as we head down the EHR path with our Project Management Executive, the person who will be spearheading the internal effort to affect change, we must find a way to make sure the executive is properly equipped. For starters, the executive needs to have, and to be able to communicate a vision, a vision for the change, for how it will impact the organization, and an ability to communicate it.

 

EHR productivity losses are rampant

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I remain stupified with how Meaningful Use continues to play itself out among hospitals.

What has me all a-twitter today is that there are no productivity thresholds tied to qualifying for incentive payments.  Many hospitals, even after two years of running EHR, report productivity losses of twenty percent or more.

Yet these hospitals can qualify for meeting Meaningful Use.  That sounds too much like ‘we do not know where we are going, but we are making really good time’.

Is there a pony hidden in there somewhere?  Where else can you spend a few hundred million dollars implementing a system, have your productivity fall off the charts, and be awarded a seal of approval and cash for how well the implementation went?

How far must one’s productivity drop before someone speaks up and says what the emperor does not want to hear?  Namely, you were probably better off before you implemented EHR.

 

EHR; stop, look, and listen

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You have 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, last weekend’s playoff games—trim paint touch ups.  Paint 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, wipe the screwdriver on your shirt, apply paint, and affix the lid using the other end of the screwdriver.  Back in the chair before the microwave beeps letting you know the pizza is hot.

That’s how it should have worked.  It doesn’t, does it?  For some reason, you get extra motivated, figure you’ll go for spousal bonus points, and so you 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 the paint looks like that simply because the paint is still wet—good response.  To which she tells you the paint is dry—a better response and one for which you have no rebuttal.

“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.

Back to my project.  Would you believe me if I said I deliberately messed up?  Maybe I did, maybe I didn’t, but the one think I know with certainty is that I now have half-times all to myself.

There is no ‘I’ in team, but there is in failure

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As a guy, I am entitled to be a fan of badly made war movies if for no other reason than they are war movies and come with a built-in plot, which minimizes the need to think too much—which is why some are so fond of Meaningful Use, but lest I get ahead of myself.

One such film, A Bridge Too Far, starred everyone but Mel Brooks.  The movie depicts Operation Market Garden, the allied attempt to break through German lines and seize several bridges over the Lower Rhine in Arnhem in the occupied Netherlands.  The operation fails, with many of the allied soldiers killed or taken prisoner.

At the conclusion of the movie the British generals are assessing their performance in a formal manner only the British can pull off.  Ignoring the failures, the dead, and those captured by the Germans, the last lines are:

Lt. General Frederick “Boy” Browning: I’ve just been on to Monty. He’s very proud and pleased.
Major General Urquhart (played by Sean Connery): Pleased?
Lt. General Frederick “Boy” Browning: Of course. He thinks Market Garden was 90% successful.
Major General Urquhart: But what do you think?
Lt. General Frederick “Boy” Browning: Well, as you know, I always felt we tried to go a bridge too far.

For those who have not seen the movie, the allied failure resulted from having spread their resources too thinly, for trying to accomplish too much with too little with too little time.

A bridge too far.  A euphemism for biting off more than one should, for the idea not being amongst the best laid plans of mice and men, one having the intelligence of a bowl of mice.

EHR.  Meaningful Use. Accountable Care Organizations.  ICD-10.

Which of these is a hospital’s bridge too far?  Or, is it all of them.

 

EHR, the wisdom of crowds

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According to National Geographic, a single ant or bee isn’t smart, but their colonies are. The study of swarm intelligence is providing insights that can help humans manage complex systems. The ability of animal groups—such as this flock of starlings—to shift shape as one, even when they have no leader, reflects the genius of collective behavior—something scientists are now tapping to solve human problems.  Two monumental achievements happened this week; someone from MIT developed a mathematical model that mimics the seemingly random behavior of a flight of starlings, and I reached the halfway point in counting backwards from infinity–the number–infinity/2.

Swarm theory. The wisdom of crowds. Contrast that with the ignorance of many to listen to those crowds. In the eighties it took Coca-Cola many months before they heard what the crowd was saying about New Coke. Where does healthcare EHR fit with all of this? I’ll argue that the authors of the public option felt that wisdom.  If you remember the movie Network, towards the end of the movie the anchorman–in this case it was a man, not an anchor person–besides, in the eighties, nobody felt the need it add he/she or it as some morphed politically correct collection of pronouns.  Whoops, I digress.  Where were we?  Oh yes, the anchor-person.  He/she or it went to the window and exhorted everyone to yell, “I’m mad as hell, and I’m not going to take it anymore.”  Pretty soon, his entire audience had followed his lead.

So, starting today, I begin my search for starlings.  A group whose collective wisdom may be able to help shape the healthcare EHR debate.  The requirements for membership is a willingness to leave the path shaped by so few and trodden by so many, to come to a fork in the road and take it. Fly in a new flock.  A flock that says before we get five years down the road and discover that we have created such an unbelievable mess that not only can we not use it, but that we have to write-off the entire effort and redo it, let us at least evaluate whether a strategic change is warranted.  The mess does not lie at the provider level.  It lies in the belief that hundreds of sets of different standards can be married to hundreds of different applications, and then to hundreds of different Rhios.

Where are the starlings headed?  Great question, as it is not sufficient simply to say, “you’re going the wrong way”.  I will write about some of my ideas on that later today.  Please share yours.

Now, when somebody asks you why you strayed from the pack, it would be good to offer a reasoned response.  It’s important to be able to stay on message.  Reform couldn’t do that and look where it is. Here’s a bullet points you can write on a little card, print, laminate, and keep in your wallet if you are challenged.

  • Different standards
  • Different vendors
  • Different Rhios
  • No EHR Czar

Different Standards + Different Vendors + Different Rhios + No Decider = Failure

You know this, I know this.

To know whether your ready to fly in a new direction, ask yourself this question.  Do you believe that under the present framework you will be able to walk into any ER in the country and know with certainty that they can quickly and accurately retrieve all the medical information they need about you?  If you do, keep drinking the Kool Aid.  If your a starling, come fly with us and get the word out.  Now return your seat backs and tray tables to their upright and most uncomfortable positions.

 

May I have receipt for my EHR in case I return it?

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A hospital in our area just dedicated a new wing.

For months the job site was a maze of people, duct, and tools.  It cost $145 million.  Affixed to the new wing is a plaque displaying the name of the architect, the contractor, the mayor, and the rest of the adults who made it happen.  While it was being built there were numerous permits, certifications, and sign-offs taped to the building.  Their purpose was to ensure the public that the adults were keeping an eye on things.  A phase of work couldn’t be started until the prior phase had all the requisite sign-offs.

Those in authority had to be licensed.  Had to be certified as qualified.

They have another project underway.  One that costs more than the new wing and impacts more people.  This one doesn’t have a blueprint.  There are no building permits.  No certifications.  No licensed professionals.  You can’t even see it.  There are no hard-hatted workers.  No foreman.  You know who’s in charge of the project?  A hospital executive—prior experience—zero.  Has he ever built one before?  No.  Does he know what to do when he encounters risks, pitfalls?  No.  There is one other person running the show—a vendor—that should let everyone get a good night’s sleep.

Would anyone let this same executive be in charge of building a new wing?  Of course not.  Why then do we not employ the same standards for what will turn out to be the most expensive and far reaching non-capital project that the hospital will ever undertake?  If you think you know, please share your answer.

By the way, I asked one of those executives how it was that he happened to be selected to lead the EHR project.  “I forgot to duck,” he quipped.  I guess that’s as good a reason as any.

 

Meaningful Use is a binary contest—you make it or you don’t

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If you haven’t begun the process of selecting and implementing an EHR, Meaningful Use may not be something with which to concern yourself.  The reason, you will probably not be done in time to collect the incentive money. How can that be stated with such assurance?

If you haven’t begun, there may be no rush to acquire an EHR, although the EHR vendors will not tell you that. Don’t cost yourself tens of millions get to have a chance at a few.

Meaningful Use will be delayed because few if any of the providers will pass the Meaningful Use Audit. Washington created a multi-billion dollar lottery, and they are having trouble finding any providers who are able to purchase tickets.

Now for those whose EHR implementation is well underway or up and running — should you try for the incentive money? That’s a valid question. Just because someone is offering you a check doesn’t mean you have to take the money. Here are some questions you ought to be able to answer prior to deciding if Meaningful Use is meaningful to you.

  • Meeting MU requires a shift in your direction; you take on the MU tasks and sacrifice some of what you were going to do
  • What are those tasks, what resources will they consume
  • What year is the best year for you to meet MU; 2011-2015?
  • Did you know you can still maximize incentive dollars if you pass MU in 2013?
  • However, that gives you almost no time to react to Stage 2 & 3 requirements

Meaningful Use is a binary contest — you make it or you don’t. The decision to meet Meaningful Use does not have to be binary. There is no way to collect for meeting 90 percent of the requirements. How might you financially calculate the probability of obtaining the incentives? Let’s begin with Stage 1—the easy one.

  • Calculate the maximum incentive you could receive
  • Multiply that figure by the degree of certainty you have that your plan will be completed on time — a number less than 1
  • Then multiply it by the probability you think exists for passing the audit, another number less than 1
  • Calculate your cost to complete Stage 1, then figure out your ROI — not much is it?
  • This makes evaluating Stage 2 & 3 calculations seem rather superficial.

Take time to evaluate your options. The only people who will look foolish are those who don’t know what questions to ask.

EHR and HIT positions available

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Thanks to those of you who have been faithful readers for so long.

If you know of any skilled EHR or HIT professionals looking for interesting opportunities with a great firm, please forward them this link.  Openings include;

  • EPIC
  • McKesson
  • NextGen
  • Meditech
  • Management Consulting
  • Allscripts
  • Cerner
  • Eclipsys
  • SeeBeyond
  • Cloverleaf

http://www.santarosaconsulting.com/Consultant/JoinOurTeam.aspx

Thanks for your help.