EHR

How the Grinch stole healthcare

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Not much has changed in the last year…or has it.

Every Congressman Down in Congress-ville
Liked Health reform a lot…But the Payors,
Who lived just North of Congress-ville,
Did NOT!

The Payors hated Health Reform! The Congressional reform season!
And as everyone’s heard there is more than one reason.
Was it the fear of losing their monopoly right?
Worried, perhaps, that Congress might indict.
But I think that the most likely reason of all
May have been that the uninsured took them all to the wall.

Staring down from their man-caves with indemnifying frowns
At the warm lighted windows below in the town.
For they knew every Congressman down in Congress-ville beneath,
Canted an ear to hear Congress gnashing their teeth.

“If this reform passes, they’ll kill our careers!”
“Healthcare reform! It’s practically here!”
Then they growled, the ideologues’ fingers nervously drumming,
“We MUST find a way to keep Reform from coming!”

For, tomorrow, they knew…

…Stumbling home from the tavern at a quarter past two What each Congressman, intern, and page just might just do And then all the milieu. Oh the milieu, the milieu
Which the Payors hated more than their mom’s Mulligan stew.

Then all the Congressmen, the left and the right, would sit down and meet.
And they’d meet! And they’d meet!
And they’d MEET! MEET! MEET! MEET!
Implement full provision; cover pre-existing…how sweet
That was something the Payors couldn’t stand in the least!

And THEN they’d do something Payors liked least of all!
Every Congressman down in Congress-ville, the tall and the small,
Would stand close together, their Healthcare bells ringing.
With Blackberrys-in-hand, the Congress would start pinging!

They’d ping! And they’d ping!
AND they’d PING! PING! PING! PING!
And the more the Obligators thought of the Congressman-Health-Ping
The more they each thought, “I must stop reform-ing!
“Why for all of these years we’ve put up with it now!
We MUST stop health Reform from coming!
…But HOW?”

Then they got an idea!
An awful idea!
THE Indemnifiers
GOT A WONDERFULLY, AWFUL IDEA!

“I know what to do!” The CEO Payor laughed in his throat.
And he made a quick Congressional hat and a coat.
And he chuckled, and clucked, “What a great Payor raucous!
“With this coat and this hat, I’ll look just like Saint Bacchus!”

“All I need is a pass…”
The Payor looked around.
Since Congressional passes are scarce, there was none to be found.
Did that stop the old Payor…?
No! The Payor simply said,
“If I can’t find a pass, I’ll make one instead!”
So he called his aide Max. Then he took some red paper
And he dummied up the pass and he started this caper.

THEN
He loaded some bags
And some old empty sacks
On a Benz 550
And he rode with old Max.

Then the Payor called, “Dude!”
And the Benz started down
To the offices where the Congressmen
Lay a-snooze in their town.

All their windows were dark. Quiet snow filled the air.
All the Congressmen were dreaming sweet dreams of healthcare
When the Payor came to the first office in the square.
“This is stop number one,” The old Warrantist – a winner
And he slipped passed the guard, like sneaking to a State Dinner.

Then he slid down the hallway, Harry Reid was in sight.
Reid was chumming Pelosi, he planned quite a night.
He got nervous only once, for a moment or two.
Then he realized that the leadership hadn’t a clue
Then he found the Congressional stimuli all hung in a row.
“These Stimuli,” he grinned, “are the first things to go!”

The Payor slithered and slunk, with a smile somewhat mordant,
Around the old Cloakroom, looking quite discordant!
There were copies of the bill stuffed in jackets and on chairs, Why, he even found a copy tucked under the stairs
And he stuffed them in bags. Then the Payor, very neatly,
Started humming the jingle from Blue Cross; rather Cheeky!

Then he slunk to the Senate Chamber, the one facing East
He took the Senators’-copies!—didn’t mind in the least!
He cleaned out that Chamber and almost slipped on the floor.
Saw an Internet router, and thought of Al Gore

Then he stuffed all the copies in the trunk of his Benz.
And he thought to himself, “Why don’t I have friends?” “There’s always Tiger,” he said with no jest But TW’s being chased by reporters, those pests.

The Payor spotted the Grinch having trouble with his sacks
And he lent him a hand—he offered him Max Max was quite pleased, for he knew this December,
That the Grinch would become the Payor’s newest board member.

The Grinch was all smiles–he’d made quite a killing
Offering to help pillage if the Payor was willing.
He stared at the Payor and asked, “New glasses?”
The Payor simply smiled, saying “These people are such (You did that to yourself, not me.)

And, you know, that old Payor was so smart and conniving
When he next saw Pelosi he found himself smiling!
“Why, my dear little Nanc’,” the Bacchus look-alike stiffened,
“Botox in this light makes you look like a Griffin.”
“I’m taking these bills home,” he said pointing to the copy.
“There’s a comma on one page that looks way too sloppy.”

And his fib fooled the Griffin. Then he patted her head
And he gave her a wink, and he sent her to bed
And as Speaker Pelosi shuffled off to her army,
The Payor said to himself, “What a waste of Armani!”

The last thing the Payor needed to do,
Was to mess with these records systems, all four thousand and two.
So he drove to HHS, the DOD and the VA,
And stuffed mint jelly in their servers so their networks would not play

And the one EHR, that still worked in the DC
Was the one bought from CostCo and tucked under the tree.

Then he did some more damage
To HIEs, and the N-HIN,
Making the idea of a healthcare network
Just a has-been!

It was quarter past dawn…
None in Congress were his friends
All the Congressmen, still a-snooze
When he packed up his Benz,
Packed it up with their copies of reform in those bags! Stacked to the leather ceiling,
Manila envelopes with name tags!

Three miles away were the banks of the river,
He was poised with the bags all set to deliver!
“Pooh-pooh to the Congressmen!” he was Payor-ish-ly humming.
“They’re finding out now that no Reform is coming!
“They’re just waking up! I know just what they’ll do!
“Their mouths will hang open a minute or two
“The all the Congressman down in Congress-ville will all cry BOO-HOO!”

“That’s a noise,” grinned the Payor,
“That I simply must hear!”
So he paused and the Payor put a hand to his ear.
And he did hear a sound rising over the snow.
It started in low. Then it started to grow…

But the sound wasn’t sad!
Why, this sound sounded merry!
It couldn’t be so!
But it WAS merry! VERY!

He stared down at Congress-ville!
The Payor popped his eyes!
Then he shook!
What he saw was a shocking surprise!

Every Congressman down in Congress-ville, the tall and the small,
Was singing! Without any health reform at all!
The Congress didn’t care, a few were disgraces,
All they wanted, it seemed, was TV with their faces

And the Payor, with his Payor-feet knee deep in the muck,
Stood puzzling and puzzling: “Man, there goes my bucks.
It could be about healthcare! It could be global warming!
“It could be Al Qaeda, Afghanistan and desert storming”
And he puzzled three hours, `till his puzzler was sore.
Then the Payor thought of something he hadn’t before!
“Maybe Congress,” he thought, “simply needs a free ride.
“Maybe Congress,” he thought…just needs to look like they tried.

And what happened then…?
Well…in Congress-ville they say
That the Payor’s small wallet
Grew three sizes that day!
And the minute his wallet didn’t feel quite so tight,
He zoomed in his Benz passing through a red light
And he brought back the copies of the bill for reform!
And he……HE HIMSELF…!
The Payor calmed the whole storm!

 

HIT/EHR: A little adult supervision

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Among other things, EHR requires adult supervision–kind of like parenting.

My morning was moving along swimmingly.  The kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—those of you more politically astute would call them evergreens—to make them look snow-covered.  (I just em-dashed an em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  It may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things it can be are things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR, a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctor’s.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.

‘Twas the night before reform when all in the House…

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I wrote this piece last year on the eve of the healthcare reform legislation.  It seems that the only thing tha has changed over those twelve months are the twelve months.

 

‘Twas the night before reform when all in the House

Were Tweeting and blogging and squawking like grouse

Their bill filled with zeroes and commas and flair

In hopes that the Senate would soon be there

The voters were restless, and in need of good care,

And they whined and they pleaded and they yelled ‘don’t you dare’

“Don’t sidestep this issue, don’t do it for votes”

“Don’t kowtow to payors or we’ll be at your throats.”

With Pelosi and her Botox, and while Reid took his nap

Didn’t care if the people put up with their (you rhyme it, I’m pretending to be neutral)

The docs sat on the sidelines, bemoaning their fate,

While payors dressed like succubi caroled “ain’t this great?”

On the lawn of the White House there arose such disdain

As the public fought reform from ‘Frisco to Maine.

MSNBC, neigh now Comcast, buttressed their base,

And Fox, aka Rupert, said it was all a disgrace.

The words on the pages of the newly printed bill,

Hid nuance, erudition, obfuscation, and swill,

Do not read the details, adjectives and signs,

Do not worry how it impacts your bottom lines.

We are here to pretend we did that of import,

To Hell with Medicare, Medicaid, and the sort

It’s voters we want, It’s our doxology, our mantra,

And this year silly people, this year WE are Santa

On Boxer, on Biden, on Fienstein they came,

And we chortled, berated, and chided by name.

“What about seniors, and sick people” we cried?

“What about uninsured, don’t you care if they die?”

“This is about people you meet on the street.

People who must choose between their meds and to eat

It’s about Lipitor, Xanax, Prozac and Viagra,

It’s about doing what’s right; do what’s right or we’ll bag ‘ya”

And then in a twinkling I heard in my head,

The gnawing and chiding of Congress, who said,

We cavorted and sucked up, the best we knew how,

We spent bucks, made big payoffs, and said change healthcare now.

Festooned all in new regs from NHS to VA

There were those who suggested, this is not going to play,

HITECH and ARRA are not making it fun,

RHIOs and RECs will soon come undone,

We’re paying the hospitals to do EHR

We know it seems silly, like we lowered the bar

If that doesn’t work we will tax them instead,

Make them spend gobs of money, make their budgets bleed red.

Spend it, refund it, and print new money now,

Buying Canada would be cheaper and easier but wow

They want to sign something, sign it soon, sign it fast,

But don’t assume that they’ve read it from first page to last,

We could’a been more like France, like the Swiss or the British

Make us more European, make our rich people skittish,

The tall socialist exclaimed as the dems shifted right,

Will Obamacare fail, have I lost all my might?

Meaningful Use: Where’s the Pony?

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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.  SO, they get to work and the plan they develop is “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.  Stick and garrote management.  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 data 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 HIT world grinds to a halt at the very mention of any 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.

The model is in such disarray that by the end of 2013 any ONC 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?  Simple; pind 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 EHRs were written before most people even heard of accountable care organizations (ACOs).  What do you think the chances are of an EHR supporting ACOs without someone having to take it apart with a hammer and chisel?

The ONC’s Meaningful Use proclamation is 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.

EHR… “You are not twenty anymore”

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There is a first time for everything.  Yesterday was the first time it occurred to me that there is a difference between being twenty and not being twenty.  A few days ago one of the women at the gym was bemoaning the fact that being forty wasn’t at all like being thirty–puhleeaasse.

My wife would have me point out her admonition of “You are not twenty anymore.”  Women do not understand that to men this phrase goes into our little brains and comes out reshuffled as the phrase “Just you wait and see.”

There are those who would have you believe that there is no single muscle that is connected to every other muscle, a muscle which if pulled will make every other muscle hurt.  I beg to differ.  I think I found it—I call it a my groinal—it’s connected to my adverse and inverse bent-egotudinals, the small transflexors located behind the mind’s eye.  I found the muscle while running back a kickoff during a Thanksgiving morning game of flag football.

Call it an homage to the Kennedys.  Sort of made me fee like one of them—I think it was Ethyl.  Old guys versus new guys—I know it’s a poor word choice but you know what I mean which after all is why we’re both here.  Did I mention that everything aches, so much so that I tried dipping myself in Tylenol?

There are two types of people who play football, those who like to hit people and those who don’t like being hit.  I am clearly a member of the latter camp.  I used to be able to avoid being hit by being faster than the other guy.  This day I avoided getting hit by running away from the other guy.

The weird part is that my mind still pictures my body doing things just like the college kids on the field, and it feels the same, it just isn’t.  Two kids passed me–they were probably on steroids, and my only reaction was the parent in me wanting to ground the two of them.  Half the guys are moving at half the speed of the other guys.  At the end of each play, we find our side doubled over, our hands on our knees, our eyes scanning the sidelines for oxygen and wondering why the ground appears to be swaying.

As the game progresses, instead of running a deep curl pattern, I find myself saying things like, “I’ll take two steps across the line of scrimmage, hit me if I’m open.”  Thirty minutes later I’m trying to cut a deal with their safety, telling him, “I’m not in this play, I didn’t even go to the huddle.”  After that I’m telling the quarterback, “If you throw it to me, I’m not going to catch it, no matter what.”

All the parts are the same ones I’ve always had, but they aren’t functioning the way they should.  It’s a lot like assembling a gas grill and having a few pieces remaining—I speak from experience.  Unfortunately, implementing complex healthcare information technology systems can often result in things not functioning the way they should, even if you have all the pieces.  It helps to have a plan, have a better one than you thought you needed, have one written by people who plan nasty HIT systems, then have someone manage the plan, someone who can walk into the room and say, “This is what we are going to do on Tuesday, because this is what you should do on Tuesday on big hairy projects.”.

Then, if you pull your groinal muscle implementing EHR, try dipping yourself in Tylenol.

 

EHR–WWOD (What would Oprah do?)

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So, I’m watching the Alabama Auburn game and it suddenly strikes me, there are probably a lot of people trying to understand what it is a consultant does that we can’t do for ourselves.

For those who have a life, those who missed the game, Auburn entered the game undefeated and had a good chance to play for the national title.  Alabama opens the game with several well-scripted opening plays and grabbed an early lead.

Their first ‘n’ offensive plays were brilliant.  They were planned perfectly.

It became apparent they had not planned the however many of the ‘n + 1’ plays.  Their plan failed to go beyond what they’d already accomplished.

How does that apply to what you do, what I do, and why I think I can help you?  It is best described by comparing your brain to a consultant’s brain.  Your work brain functions exactly as it should.  It’s comprised of little boxes of integrated work activities, one for admissions and registration, one for diagnosis, another for care.  There’s probably another box for whatever it is the newsletter stated IT was doing three months ago and how that impacts what you do.  That’s your job.

Your boxes interface in some form or fashion with the boxes of the person next to you in the hospital’s basement cafeteria who is paying for her chicken, broccoli, and rice dish that reminds you of what you ate at crazy Uncle Bob’s wedding reception.  That interface is the glue that makes the hospital work.  It’s also the synapse, the connective tissue—I know it’s a weak metaphor, but it’s a holiday weekend—give me some slack—that tries to keep healthcare functioning in an 0.2 business model.

There are names for the connective tissue, you know it and I know it.  It’s called politics.  It’s derived from antiquated notions like, “this is how we’ve always done it”, “that’s radiology’s problem”, and “nobody asked me”,

At some point over the next week or two the inevitable happens; the need arises for you to add some tidbit of information.  Do you add it to an existing box, put it in an empty box, or ignore it?  This is where you must separate the wheat from the albumen—just checking to see how closely you’re following.

Your personal warehouse of boxes looks like the final scene in Raiders of the Lost Ark—acre after acre of dusty, full boxes, no Dewy-decimal filing system, and no empty box.  There are two rules at the hospital; one, bits of information must go somewhere, and two, nobody can change rule one.

The difference, and it’s a big one, is that consultants have an empty box.  It’s our Al Gore lockbox.  We were born that way.  It’s like having a cleft chin.  We also have no connective tissue to your organization.  No groupthink.  No Stepford Wives. No Invasion of the Body Snatchers to turn us into mindless pods.  Consultants may be the only people who don’t care.  Let me rephrase that.  We don’t care about the politics.  We don’t care that the reason the hospital has four IT departments is because the hospital’s leadership was afraid to tell the siloed docs that they couldn’t buy or build whatever they wanted.

Sometimes it comes down to your WWOD (what would Oprah do) moment.  Not ‘what do they want me to do’, not ‘what would they do’, not ‘what is the least disruptive’, not ‘what goes best with what the other hospital did’.

At some point it comes down to, what is the right thing to do; what should we do.

Big, hairy healthcare IT projects come out of the shoot looking like Alabama did against Auburn.  The first however many moves are scripted perfectly.  Heck, you can download them off Google.  Worse yet, you can get your EHR vendor to print them for you.

The wheat from the albumen moment comes when you have to come up with an answer to the questions, “What do we do next,” and “Why doesn’t it work like they said it would?”

That’s why consultants have an open box.  You know what we are doing when our brain takes us to the open box?  Thinking.  No company politics to sidetrack us.  Everybody knows the expected answers, but often the expected answer is not the best answer.  Almost everybody knows what comes after A, B, C, and D.

Sometimes…E is not the right answer or the best answer.

EHR: Show me the money

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Every wonder how it is that all the billions in healthcare IT money came about?  I imagine it went something like this.

DC 1: Email those fellows over at HHS and tell them we should just make the doctors install Electronic Health Records (EHR).

DC 2: While we’re at it, how about we pay them a bonus to do it…

DC 1: …and we penalize them if they don’t.  Give them money with one hand and take it back with the other.

DC 2: How do we get EHRs to communicate?

DC 1: Make the states do figure it out.  They are looking for more money.

DC 2: I’ll email the governors and tell them we’ve got more billions to pass around.  Let them build some sort of Information Exchange.  They can set up committees and staff them with appointees.

DC 1: Then we can glue those together in some kind of national network.  Where are we going to get one of those?  Figure another ten billion for that.

DC 2: I’ll email the DOD, they are supposed to know something about building national networks.

DC 1: Just to get things kick-started, let’s email the troops and tell them we’ll sweeten the state pots a little more.  Get them to build these extension centers on a region by region basis.

All these dollars, so little value.  Most of it focused on trying to figure out how to get millions of somethings from point A to point B.

How did all those millions of emails get securely from point A to point B?  For a lot less than forty billion dollars isn’t it possible to figure out  how to get my health information to whomever needs it?  Email me, maybe we can come up with an idea for a network.

If you’re still puzzled, we can play hangman.  It has eight letters, starts with an ‘I’, and ends with ‘ternet’.

 

HIT/EHR: A little adult supervision

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Among other things, EHR requires adult supervision like parenting.  My morning was moving along swimmingly.  Kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—I guess we could call them evergreens—to make them look snow-covered.  (I just em-dashed and em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  I may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things are other things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctor’s.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.

 

To some patients, EHR is a non-issue

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LAST CHRISTMAS

It is easy to remove one’s self from what is important as we trade metaphorical tomatoes about what is wrong with EHR, what may happen regarding reform, and why the N-HIN is DOA.  Debating healthcare IT on the internet is an esoteric and antiseptic conversation, one with few if any catastrophic implications to anyone other than the person trying to sell a used, hundred million dollar EHR on eBay.

We write about the fact that it is supposed to do something to benefit the patient.  Is there a more sterile word than patient?  Whether we use patient or patients, we keep it faceless, nameless, and ubiquitous.  They do not have to be real for us to accomplish our task; in fact, I think we do our best work as long as we keep them at arm’s length.

We calculate ROIs for EHR around people who exist to us only by their patient IDs.

What if these hominoid avatars turned out to be real people?  What if indeed?

Two weeks ago I learned of a real patient; a friend, thirty-seven, mother of three.  Lots of tests.  They call itmyelodysplastic syndromes, MDS—MDS sounds more polite.  One would think that because it has its own acronym that might infer good news.  It does not.

The thing I like best about Google is knowing that if an answer exists to a query, I can find it.  I may have to vary the syntax a few times, but sooner or later I will find that for which I am looking.  The converse can be quite disquieting, especially if you happen to enter a phrase like, ‘survival rates for MDS.’  After a few tries I realized that the reason I was not getting any hits to my query had nothing to do with poor syntax.  It had everything to do with a lack of survivors.

Last Christmas—rather strange title for a blog.  In this instance the title has nothing to do with anything religious.  It is simply a line in the sand, a statement with a high degree of probability.  Unfortunately, “Last Christmas” does not have the same meaning as the phrase, ‘this past Christmas.’

She has had thirty-eight Christmases.  Apparently, MDS is able to alter simple mathematical series.  If presented with the numerical series 1, 2, 3…37, 38, 39, and if we were asked to supply the next number, we would all offer the wrong answer—40.  In her case there may be no next number; the series will likely end with 39.  MDS math.

Then there are the three children, each one of them in the same grade as my three children.  They will be learning a different version of MDS math.  All the numerical series in their lives will reset and begin again with the value of one.  First Christmas since mom died.  First birthday since mom died.  Every life event will be dated based on its relationship to an awful life-ending event.

It will be their B.C and A.D.

EHR probably has very little value when you break it down to the level of an individual patient.  Stalin said something like, “one death is a tragedy, and a thousand deaths is a statistic.”  While it is unlikely that he was discussing patient outcomes, the import is the same.

Rule One: There are some awful diseases that will kill people.

Rule Two: Doctors are not allowed to change Rule One.

I guess it goes to show us that as we debated things that we view as being crucial components of whatever lies under the catch-all phrase of healthcare, when it comes down to someone you know who you know is probably not going to get better, they do not seem very important.


Why is implementing EHR like getting kids to eat broccoli?

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Do you ever wonder if perhaps you are the only person who was never photographed with one of the Kennedys?  That got me thinking about our presidents.  NPR interviewed the person who spent eighty hours interviewing Clinton during the eight years during which he was allowed to park freely anywhere in DC.  See how this is already starting to come together?

The interviewer mentioned that Clinton described the Lewinski episode as a distraction.  I also employed several descriptors of that affairs—and yes, the pun is intentional—but I must have overlooked calling it a distraction.  People on both sides of the aisle called the episode a stupid thing.  Perhaps we should define the term ‘stupid thing’—doing long division and forgetting to carry the one is ‘a stupid thing’; mixing a red sock with a load of whites is ‘a stupid thing’.  Sometimes politics can have us all screaming infidelities.

When I share my thoughts about these things, some look at me like they are staring at an unlabeled can of food and trying to guess the contents.  Perhaps objectivity is only for the truly unimaginative.

Here comes the segue.  All of that thinking about presidents got me to thinking about Mr. Obama, reform, and EHR.  A lot of the original economic reform discussion had to do with TARP monies being tossed at the banks.  It was almost like a reverse bank holdup as the feds made the banks take money.

Which now takes us to healthcare reform and EHR.  ARRA money and states like New York providing a stimulus to the stimulus.  What is so distasteful about EHR that it makes governments offer money to get providers to implement it?  How might we illustrate this?

Let’s say I offer my children a choice of two things to eat; broccoli and chocolate cake.  What happens?  My kids make a bee-line for the cake.  The broccoli requires an incentive to get any takers.  My children are prepared to suffer untold penalties instead of eating the broccoli.  There may be some financial incentive which will entice them to eat broccoli, but it will be pricey.  Telling them it’s good for them, or that they have to eat it makes no difference to short people—they need to be bribed.

Telling healthcare providers EHR is good for them, or that they have to do it makes no difference to tall people—they want to be bribed.  What does this signify?  What is it about EHR that requires incentives and some foreign force majeure to get the discussion underway?  It’s not as though the healthcare providers don’t want to do things that will improve their business.  What is it they know that we don’t?  What other than money would make them run towards EHR rather than away from it?

You don’t suppose it has something to do with broccoli, do you?

For those who enjoy Dana Carvey, here’s a link to his song about chopping broccoli.

http://www.youtube.com/watch?v=gO57XRDDodk