EHR

Something to consider…

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Did you know that having an EHR is not required?

Since it’s not, wouldn’t it make sense to approach EHR like you would any other business problem?

Project Management lessons from Alice and Wonderland

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During my career I’ve been involved with hundreds of project teams, some quite gifted, others whose collective intellect was rivaled only by simple garden tools.  I’ve been asked often if I can define what distinguishes the two types of teams.  For me it always comes down to leadership.  It doesn’t matter how hard the people work, it matters how well they are lead.  Does the leader know what to do tomorrow?

That got me to thinking.  Are there some leadership secrets, some project management gems that may have been overlooked?  Rather than offering traditional mish-mash consulting jargon, I thought it would be helpful to find a common ground by which we can form a basis for this discussion.  Hence the following narrative: Everything I learned about project management I learned from Alice in Wonderland.

So, you have spent tens of millions on an electronic health records system.  Some did so without even defining their requirements.  The project is chugging along, new regulations and penalties are appearing through the diaphanous mist like the Cheshire Cat’s toothy grin.

“Well! I’ve often seen a cat without a grin,” thought Alice.  “But a grin without a cat! It’s the most curious thing I ever saw in my life!”


How fast must you run so as not to lose ground?  How many milestones do you have to meet, how many due dates do you have to check?  What can be learned from the Red Queen in Alice in Wonderland?  She told Alice, “It takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast.”




For the EHR project to progress it requires extraordinary effort.  This begs a question of the project leader, where does the project need to go?  In a conversation with the Cheshire Cat Alice asks,

“Would you tell me, please which way I ought to go from here?” “That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where,” she said.
“Then, it doesn’t matter which way you go.” “So long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

If you only walk long enough.  What is enough for a three year project?  When are you done?  When the money runs out; when there are no more tasks in the work plan.  It seems many EHR projects are much bigger than allowed for by the plan.  They get big, impossibly big.  A lot of that size comes from underestimating the effort to support workflow improvement, change management, and user acceptance.

“Sorry, you’re much too big.  Simply impassible,” said the Doorknob to Alice.   “You mean impossible?” “No, impassible.  Nothing’s impossible.”

We don’t have the benefit of getting advice from talking doorknobs which is why we get so stymied when confronted with having to do the impossible. What is impassible or impossible for your project?  It might be deciding or knowing when to stop.

Alice laughed. “There’s no use trying,” she said: “one can’t believe impossible things.”
“I daresay you haven’t had much practice,” said the Queen. “When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”

Believing it does not make it so.  Never has, never will.  Belief does not beget success.  Planning does.  Defining your requirements may.  There is no shortage of ex-CIOs who believed their EHR vendor.

Then there’s the skill of managing your EHR vendor.  Perhaps Eaglet said it best, “Speak English! I don’t know the meaning of half those long words, and I don’t believe you do either!”

There will always be those select members of every project team who are so dense that light bends around them; those who have not learned that it is better to keep their mouth shut and appear unintelligent than to open it and remove any doubt; those who have the right to remain silent, who just don’t have the ability.

“You couldn’t deny that, even if you tried with both hands.”

“I don’t deny things with my hands,” Alice objected.

“Nobody said you did,” said the Red Queen. “I said you couldn’t if you tried.”

Do you find yourself sitting through a status meeting unable to tell if the project is moving backwards or forwards, unable to tell what is hiding around the bend?  You think so hard your head feels like your ears are trying to switch places with your eyes.  When all else fails, try this bit if advice.

“Fan her head!” the Red Queen anxiously interrupted. “She’ll be feverish after so much thinking.”  A little thinking won’t hurt, who knows; in small doses it might even be beneficial.

Now, let’s assume you’ve got yourself all worked up.  You and your team are pouring over your work plan, trying to decide what’s left to accomplish, or what can’t be accomplished.  How do you know what’s what and which is which?

“Begin at the beginning,” the King said, very gravely.  “And go on till you come to the end: then stop.”

I’ll take the King’s advice and do the same.

EHR: Why the rush?

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The following is a comment I wrote to the healthcareitnews.com post, “BLUMENTHAL: EHRS WILL BECOME ‘AN ABSOLUTE REQUISITE’ FOR DOCS”.

“The time has come,” the Walrus said, “To talk of many things: Of shoes and ships and sealing-wax, of cabbages and kings– …

The time has also come to ask the question, “Why the rush?”  Is the pronouncement that within the next ten years we will see widespread adoption of EHR in conflict with the timing of the Meaningful Use incentives?  It seems that way to me.

Whereas we may see an “upward slope in the adoption curve” within the next year or two as hospitals begin the process of selecting and implementing an EHR, we will not see so much as a hiccup in the slope of the Meaningful Use curve.

Why?  I think there are several explanations.

  • Not enough providers are far enough along to even attempt to pass a Meaningful Use audit.
    • Will they complete the requirements
    • If yes, will they pass the audit
    • Of those who have attempted to do the heavy lifting of EHR and CPOE, they do not know the Stage 2 & 3 requirements.  Those requirements may be enough to ensure nobody passes the audit.
    • To those providers just underway, whose board insists that they complete the installation in time to qualify for the incentives—good luck.  Many will make poor selection decisions which they will support with even worse implementations.
    • To those who have yet to start, there is no chance they will meet the target dates.

So what’s next?  What would you do if you were having a party and learned nobody could come that night?  You’d change the date.  Washington will do the same.

What does that mean if you are a provider?  I think it means you have enough time to do it right, even when the conventional wisdom is pushing you to hurry.

Jihad Joe EHR selection

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When competing hypotheses are equal in other respects, the principle recommends selection of the hypothesis that introduces the fewest assumptions and postulates the fewest entities while still sufficiently answering the question. It is in this sense that Occam’s razor is usually understood.  There is no corollary that works with EHR vendors.

What if we look at HIT vendor selection logically?  Have you ever noticed at the grocery store how often you find yourself in the longest checkout line, or when you’re on the highway how often you find yourself in the slowest lane?  Why is that?  Because those are the lines and lanes with the most people, which is why they move the slowest.

If you are asked in which line is Mr. Jones, you would not be able to know for certain, but you would know that the most probable option is the one with the most people in it.  You are not being delusional when you think you are in the slowest lane, you probably are, you and all the people in front of you.  The explanation uses simple logic.  It’s called the anthropic principle– observations of our physical universe must be compatible with the life observed in it.

It can be argued that the business driver which shapes the software selection process of some is the aesthetics of efficiency, a Jihad Joe approach to expediency.  Buy the same system the hospital down the street bought, the one recommended by your golfing buddy, or the one that had the largest booth at the convention.  Or, one can apply the anthropic principle, rely on the reliability of large numbers and simply follow the market leader.

Might work, might not.  My money is on might not.  There’s still plenty of time to do it right.  If that fails, there will always be time to do it wrong later.  Of course, you can always play vendor darts.  If you do, you should sharpen them so they’ll stick better.

What should you think about HIEs

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Part of the problem I have with HIEs is similar to the old Wendy’s commercial, “Where’s the beef.” Only in this case the question becomes, “Where’s the value add?”

There are hundreds of them, HIEs that is. Each one developed autonomously. Some are built within a hospital which has more than one EHR. Others are being built to serve among a hospital group, and others are geographical. Which of the HIEs is being built by a team of people who have ever built one? To my knowledge, none.

Hundreds of HIEs being built independently from one another by people who’ve never before built an HIE. Hundreds being built to transport the electronic medical records of providers using a few hundred different EHRs, each EHR operating with different standards, none of which benefits from interacting with another.

What is the purpose of the HIE? It reminds me of this children’s’ icebreaker game where the children sit in a circle. The first child starts by whispering a phrase into the ear of the person sitting next to her. She can only say the phrase once. The child she whispers it to must then whisper it to the child next to her. This continues until it goes all the way around the circle. Usually, by the time the phrase gets back around to the original person, it is completely different.

Like shuffling an EMR from one place to the next through a series of intermediaries. What does it look like when it comes out the back end?

After all, what is the purpose of the HIE? It should act like a handoff, like a mini N-HIN. It does not modify the data, at least not intentionally. If there is a more complex way to get a person’s health record from point A to point B, I have not seen it. HIEs are healthcare’s Rube Goldberg mechanism.

I think that when all is said and done, HIEs will have faded away. Until then providers should keep their focus on developing an EHR which actually serves their business model.

How hospitals should deploy EHR to attract Docs

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This is a response I wrote to Brian Ahier’s post on HealthsystemCIO.com

Here’s an idea I raised a few months ago which discusses how to use EHR to your advantage in retaining ambulatory physicians. What prompted the idea was knowing of a hospital which spent nine figures on their EHR, only to find out that its functionality essentially ended inside its four walls. At the time nobody wrote that it wouldn’t pass muster. This idea may die before anyone finishes reading the comment; if not perhaps it merits at least a look-see.

From the perspective of the business model of the hospital, what do we know?

• Hospitals work at attracting and retaining good physicians
• In many markets, ambulatory physicians may choose to send their patients to any one of a number of hospitals
• The competition to attract patients and physicians is building
• The hospital and physicians both benefit if they are:

o On the same EHR
o On an EHR which interfaces easily

What if we change the question being asked, or at least change what constitutes a desirable answer from the perspective of the hospital? Let us go back to what we know.

• Non-hospital based doctors will not be part of the calculation to determine if the hospital meets Meaningful Use.
• Each of those doctors benefit from implementing and EHR system, and they will either qualify for stimulus money or be fined.
• Those same doctors and their patients benefit from having a seamless relationship with a hospital.
• None of those doctors has anything close to what can be considered an actual IT department.

o If 400 providers who practice at your hospital have to select an EHR, how many dozens of different EHRs will they select
o Not only do the providers lack the skills to select a good system, they lack the skills to implement it successfully.
o Most IPAs are not even offering a recommendation

What happens if we rephrase the question and ask, “What steps can a hospital take to:”

• Make ambulatory doctors want to send their patients to them
• Make it easy for the patient/physician/hospital relationship to appear seamless
• Possibly be paid for facilitating the EHR for their ambulatory physicians

If it were my hospital, here’s what I would do:

• Pull together a plan to figure out how a hospital could offer an EHR solution for each of the ambulatory doctors. This EHR solution could:

o Be the same EHR or one which can integrate with their EHR
o Be offered as a managed services solution
o Be offered as an outsourced solution

• Figure out what information is needed to determine the viability of offering its ambulatory doctors an EHR solution:

o Staffing
o Marketing
o Incentives
o Cost
o Roll-out
o Training

• Determine if the ambulatory doctors can somehow sign-over their incentive payments to the hospital.

o If yes, the incentive payment from 400 ambulatory doctors could fund about $18 million of the roll-out cost
o If not, there are still a number of great business reasons to think about helping the doctors get on the hospital’s EHR.

What is the long-term ROI, say five years and beyond, of having an ambulatory doctor send its patients to a given hospital? I bet it exceeds the cost of installing an ambulatory EHR.

What are the risks of HIT and EHR?

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It is refreshing to know that the voices I am hearing need not be my own.  When I try to summarize the issues for my own edification, I always circle back to the same few issues.

• No single person is both responsible and in authority regarding HIT and EHR. Provider-world pauses with each new pronouncement from Washington as though the missing EHR Dead Sea Scrolls had just been discovered in the reflecting pool.
• Those who implemented EHR did so without any idea that rules would be imposed after the fact.
• EHR is expected to serve two business models:

o Washington’s N x M patient/doctor connectivity effort
o A provider’s unique business objectives, none of which have anything to do with a patient in Atlanta being able to connect to a doctor in Anchorage.
• What model would providers be following if there were no Meaningful Use
• If the current EHR national rollout model was any good, providers would be racing to the front of the line to implement EHR instead of having to be offered rebates.
• The national rollout plan lacks viability for several reasons:

o No standards
o HIEs are each being developed in their own vacuum
o A horde of vendors whose mission does not tie to the national rollout or the providers’ business model and who have no incentive to adopt standards
o The requirements and dates for Meaningful Use will probably change once providers have tailored their systems to meet Stage 1
o The requirements for Stages 2 & 3, which may cost providers six zeroes preceded by some number greater than five, don’t exist.
o An ROI can’t be calculated on meeting Meaningful Use
o Both the likelihood and the impact of healthcare reform on HIT and EHR, just got vaguer by some order of magnitude.

I firmly believe the right EHR and CPOE will be great for hospitals. Providers will be better served by finding answers to the question, “What’s in it for me,” rather than, “What do they want me to do?” Unless of course, providers want them running their business.

What’s the probability around Meaningful Use?

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Below is a reply I wrote to a post on MU in Healthcare IT News
What’s the probability, that you complete the Stage 1 Meaningful Use requirements?  What’s the probability, after doing your best to meet the Stage 1 requirements that you actually pass the audit?  What’s the probability you’ll have the time needed to implement Stage 2 and 3 before the penalties begin? (That’s sort of like asking if you know the probability of seeing a bluebird on the third Tuesday of June.)
Now, go ahead and calculate an ROI based on everything you don’t know.  Not too easy is it?

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

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The hospital we use just dedicated a new wing.  For months the job site was a maze of people, duct, and tools.  It cost $145 million.  There’s 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.

My comments to Dr. Blumenthal’s Blog

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It says they are awaiting moderation–they could be waiting a long time.  Here they are.

I think hospitals need to give a lot of thought to whether it’s in their best interest to even try to meet MU.  Those who haven’t begin EHR and CPOE will be hard pressed to benefit.  There is more unknown than known about the impact of changing an entire business strategy in light of reform, the magnitude of Stage 2 and 3 requirements, no standards, 400 vendors–all lacking 2011 certification, hundreds of different HIE’s, and an N-HIN strategy that may not be viable.

Washington is building a healthcare model whose long term goal is to be able to connect each patient to any doctor.  Hospitals have a far different business model.  The sad thing is that none of the hospitals who have undertaken EHR had any idea that costly rules would be applied after the fact, they have no means to know what the next set of changes will be, or if the dates of meeting MU will be pushed back.  If the dates don’t move MU will be like hosting a lottery for which only a handful of people bought tickets.


As for ambulatory doctors, my recommendation is to wait until a firm shrink wraps EHR (software, implementation, training, change management, and work flow improvement.)  There’s no rush here either.