What if GM were involved in EHR?

Goodness knows, the whole car thing did not work our too well for them

Do you ever think about the origination of some of your ideas? For me, the good and the bad just seem to materialize. Like the time a friend and I were hiking a peak in the Sangre de Cristo range in Colorado. It had taken the better part of six hours of circuitous climbing to reach the summit. It was late in the fall, and the temperatures were around freezing. Roiling storm clouds were racing towards us from the west.

If we returned by the same route we knew we’d be caught up in a storm that we were neither prepared nor dressed to handle. I spotted our car about six thousand feet below us. If we headed straight to it, I thought we could cut our descent time by about an hour. To do this though required that we make our own trail via a hunt and peck route of whatever the terrain permitted. We dropped the first fifteen hundred feet in a matter of twenty minutes using a glissade. This technique allows you to moonwalk and slide down a scree field, using your ice ax as a break.

After an hour we reached a point about two thousand feet above our car. It was sleeting, and the wind was whipping around the face of the mountain. There in the middle of nowhere stood a sign from the sheriff that read, “Devil’s Gulch, turn back.” Our choice was to reclimb the mountain or to ignore the sign and press on. I hate do-overs. How tough can this be, I goaded him? Be smart, kick it into high gear, and we’ll be done.

We pressed forward. Fifteen minutes later, we reached a four hundred foot limestone cliff. Between us and the next semi-reasonable terrain was a rather deadly looking wall of rock and scrub pine. My pack made me feel like it was forcing me forward, so I removed it and tossed it over, thinking I’d retrieve it later. Watching my pack bound from rock to rock for what seemed like more than a minute did nothing for putting me at ease.

We spent more time discussing each step than we spent taking it. Those four hundred feet took us two hours. Not my best idea, but it didn’t kill us.

So, during my run today, I had another idea. This one is about OnStar, the GM tracking system. I typed in to Google, “How does OnStar Work?” Lots of hits. The more I read, the more I began to feel like if one ignored the technology and focused on the concept a real argument could be made for pairing the idea, and a few others, and seeing what type of EHR network might be possible using a similar set of tools.

The OnStar concept is termed telematics, a combination of telecommunications and informatics. Telematics is the integration of computing, wireless communications, and GPS. It provides information to a mobile service like a phone, PDA, or laptop. It is used for sending, receiving, and storing information over very large networks. So, why is nobody having the conversation that says what if we image a similar network with added security that works from a healthcare provider’s office rather than a car.

OnStar doesn’t need Rhios. OnStar has a single set of standards. Now, instead of arguing why something like this can’t work in healthcare, isn’t there argument is seeing if it can?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

The EHR Certification Myth

Posted by Paul Roemer

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

Why is this a part of the overall plan? Is this planned failure? Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test. The certification test, by definition, is necessary. The Full test is both necessary and sufficient. It is possible to pass certification without passing the Full test. Therefore, the Full test is a stricter test. Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test? Same as always. Fully functional, on time, within budget, and user accepted. Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact: One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion: The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations. Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification. (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact: Most large, complex, expensive IT projects fail—they just do. This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed. Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion: Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak? You bet. Insurmountable? Doesn’t have to be.

What can you do to improve your chances of success? Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points. EHR Fail Safe Points? The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test. The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD. They need not have a slew of EHR implementation merit badges. The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built. They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR. Those skills are needed—in spades—and you need to budget for them. The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre. They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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EHR: What bugs you about it?

Posted by Paul Roemer

This is the time of year in the east when cinerescent caterpillar nests hang thickly from the trees, peppered tufts of cotton candy. During these long, flavorless August days, the sky is a similar achromatic color. My nine-year-old is concerned because I told her we are having caterpillar soup for dinner tonight—watch out for the crunchy bits. Once again, it seems I’ve gotten off message.

I wonder how much of the difficulty surrounding EHR has to do with getting off message, much like we seem to have done with the reform discussion. What difficulties? Got time? You can name more of them than can I.

What is off message? It’s that the day-to-day tactics of implementing EHR office by office, and hospital by hospital have overshadowed the strategy, have displaced the business driver behind the mandate. The focus became internal, not national. Bits and bytes have overshadowed charts.

I doubt few, if any, can articulate a believable explanation of how a few years from now your medical records will accurately and expeditiously be delivered from where you live to the lone clinic on Main Street, Small Town, USA, to the nurse practitioner who at midnight is giving you an EKG.

It’s that fact, that we are not able to define how we get from A to B, let alone do so with multitudes of A’s and B’s, that to me suggests we are building something of which we have little comfort will do what we set out for it do.

Clearly, there are hundreds if not thousands of very talented and dedicated professionals focused on finding a solution. However, it seems their efforts remain handcuffed by hundreds of competing products, no well-defined overriding set of requirements that would enable anyone to say with certainty, “Yes, that is it. That captures what we need to do. When we have done that, we are done.”

Until that time, I think we all need to be concerned about the crunchy bits.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

July is “take your EHR strategy to lunch month”

Posted by Paul Roemer

Several have written suggesting I toss my hat into the ring to serve as the EHR Strategy wonk or czar. I was in the process of thinking it through when I was awakened from my fuegue state by a loud noise–my ego crashing to the floor.

Some have suggested that a camel is a horse designed by a committee. Their point in saying that has something to do with how committees function less well than individuals–the problem with “group thinking.” Personally, I think the camel design seems rather functional.

Some have asked, what is it about the EHR universe that has you dehorting the EHR process as though you are some sort of savant–nobody really asked that, but I wanted a segue and that’s all I came up with.

It’s the committees. I feel a little like Quasimodo repining about the bells. Raise your hand if you are on an EHR committee. See? Now, if you think that not only has the committee not accomplished much, but believe that it may never accomplish much, lower your hand. Now look around. Not many hands still up.

Please take a look at this for a moment. Don’t try to understand it–it will only make your teeth hurt.

2011 requirements

For hospitals, 10% of all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) directly entered by an authorizing physician must be made through a computerized physician order entry process. Individual physicians still must use CPOE for all orders, even if electronic interfaces with receiving entities are not available. The initial draft did not specify the required percentage for hospitals and did not address the electronic interface issue.
Physicians must be able to check insurance eligibility electronically from public and private payers, when possible, and submit claims electronically. This was not in the initial draft.
Patients must receive timely electronic access to their health information, including lab results, medication and problem lists, and allergies. The initial draft did not include the word “timely.”
Physicians must implement one clinical decision rule relevant to specialty or high clinical priority. This was not in the initial draft.
Physicians must record patient smoking status and advance directives. This was not in the initial draft.
Physicians must report ambulatory quality measures to CMS. This was not in the initial draft.
Physicians must maintain an up-to-date list of current and active diagnoses based on ICD-9 or SNOMED. The initial draft did not specify use of the two classification sets.

2013 requirements

Specialists must report to relevant external disease or device registries that are approved by CMS. This was not in the initial draft.
Hospitals must conduct closed-loop medication management, including computer-assisted administration. This was not in the initial draft.
All patients must have access to a personal health record populated in real time with health data. This was moved up from 2015 in the initial draft.

Additional provisions

Patients’ access to EHRs may be provided via a number of secure electronic methods, such as personal health records, patient portals, CDs or USB drives.
CMS will determine how submitting electronic data to immunization registries applies to Medicare and Medicaid meaningful-use requirements.
CMS may withhold federal stimulus payments from any entity that has a confirmed privacy or security violation of the Health Insurance Portability and Accountability Act, but it may reinstate payments once the breach has been resolved.

Source: Health IT Policy Committee

See? Take a few minutes and work this into your EHR task time-line for processes, work flows, change management, training. Need more time? I’d need more time than I have, and when I finished I guarantee I couldn’t explain it to anyone. This is what happens when people get into a room, have a charter, and try to do something helpful. I am sure they are all nice people. But be honest, does this make your day, or does it make you want to punish your neighbor’s cat–you may have to buy them a cat if they don’t already have one.

What to do? Here’s my take on it. Plan. Evaluate the plan. Test the plan. Know before you start that the plan can handle anything any committee tosses your way. Let people who know how to run large projects into the room. Seek their counsel, depend on them for their leadership. If the plan is solid, the result has a better chnace of surviving the next committee meeting

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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What did you budget for EHR?

Posted by Paul Roemer

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? This is not like going to the supermarket for a gallon of Soy Milk–not that anyone would want to do that.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Is the C-suite fiddling while EHR burns?

Posted by Paul Roemer

There is an adage in the military—different spanks for different ranks. If speaks to a double standard, the less egregious their punishment for similar offenses, similar misjudgments.

We see that every day in business, and we see it a lot in healthcare, especially in hospitals. Physicians are held accountable for medical errors. Hospitals pay millions for malpractice insurance knowing that mistakes will be made and people will be held accountable for their mistakes.

But what about on the business side? Who is held accountable for business mistakes? An acquisition that failed to deliver. An expensive new service offering that bled the company dry. A decline in the number of patients. The failure of a major IT initiative to deliver results.

Take EHR. Some of you are saying, “Yes, please take it.”

Around sixty percent of the large EHR projects have failed in one respect or another
Most will not receive ARRA incentives
A large number of hospitals are on their second implementation of EHR
Some have productivity losses of thirty percent

Who is going to be fired for the two hundred dollar misstep? The board? Never. The CEO—no. The COO or CFO? Unlikely. The CIO? That is the safe bet.

Did the CIO authorize the expenditure? Nope. Did the CIO get all the dollars needed to be successful, all the user support? Unlikely.

In most cases the CIO has all of the responsibility and only some of the authority. There are a handful of people in each organization tasked with the oversight of the large project. They are the ones who should be asking the right questions, the ones who should be demanding answers.

A failed project, a failed strategy should not come as a surprise. The only people who will be wearing EHR 2.0 T-shirts are those who authorized EHR 1.0. How come these individuals are not accountable?

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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EHR Czar posting

Posted by Paul Roemer

One summer in college, I worked for the state roads commission in Maryland. If you like being outdoors, getting a lot of exercise, driving around in the back of dump trucks drinking beer it was the perfect job.

The average day went like this. Each morning we’d report to the facility at seven, and sit around for an hour as the supervisors received their assignments for the day. It would take another hour to gather the tools needed to complete whatever project we were given. On the road by nine, the two full-time employees inside the truck, my friend and I laying in the back on burlap bags..

By ten, we had unloaded the tools, and scoped the work. Most days we’d forget one or two tools needed to complete the work, radio back to the facility to have someone deliver it to us, and practice sitting on our shovels until we were fully outfitted. It didn’t make sense to start the work knowing lunch was only thirty minutes out, so on most days we would simply wait until after lunch. By one o’clock, our bellies full, we began our assignment—fix a guardrail, shovel some gravel, install a road sign, scoop a dead deer of the road.

The foreman, Butch, knew the location of every liquor store in the county. Happy hour in the dump truck usually began at three—one case of beer for the two men in the front, one case of beer for my friend and me in the back. We’d lay there with our shirts off as the supervisor chauffeured us around the county trying to kill time until we could return to the service bay.

I wonder if they need any help this summer.

One of the things I remember about that summer was a job posting in the service shed. The posting was for a supervisor/foreman. The single qualification was the requirement of having completed education through grade five—the “Are you smarter than a fifth grader” test.

I have no segue. I am wondering if there is a posting in the ONC service shed for an EHR Czar. If there were, what would be the requirements?

WANTED: EHR Czar—Fourth graders need not apply.

Count me in.

What benefit is there to meeting Meaningful Use?

Posted by Paul Roemer

Commercials bug me. Big surprise.

You have probably seen the commercial for the Sleep Number Bed. A bare mattress, a glass of wine on the mattress, a bowling ball is dropped on the mattress. The glass of wine does not spill. That makes some people rush out and buy the mattress. Why? For the security in knowing that just in case they leave a glass of wine on their mattress and then happen to drop a bowling ball on it, the wine will not spill.

That dog don’t hunt unless you happen to be opening a bowling alley/Motel 6. The company is trying to entice you on the merits of doing something by asking you to make the leap of faith by equating the bowling ball falling on the bed to having your spouse get in or out of the bed without disturbing your sleep.

A feint. A maneuver designed to distract or mislead you from the real purpose. Meaningful Use. Certification. A feint. Designed to distract or mislead you from the reason you need an EHR. The terms of Meaningful Use, that is, what is meaningful to your organization should be set by your organization, not some national standard applicable to every hospital in the country. Hospitals are not ubiquitous—the Meaningful Use standards are. How can a single set of standards be in line with what you require?

What’s the feint? Certification, cash incentives, Regional Extension Centers. A full court press trying to get hospitals to do what the feds want it to do in order to meet their goal of a nationwide interconnected healthcare system.

What proof, other than a check, has anyone offered that you benefit from meeting Meaningful Use?

Should you try to meet Meaningful Use? I think not. There is no ROI, and the full set of standards have yet to be published. What should you do? Have a glass of wine, or better yet—go bowling. Don’t forget to buy one of those snazzy bowling shirts.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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EHR Groundswell

Posted by Paul Roemer

EHR, there’s a new groundswell against meaningful use. How do I know? I’m starting it now.

After lunch, if I’m in the right mood, I may start one against certification.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The Swarm theory of failure

Posted by Paul Roemer

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 you are 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.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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EHR: What bugs you about it?