EHR

The real impact of the EHR resource shortage

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(AP) New York.  It is Reservoir Dogs 2.0 only this time the terrorists appear to be a clean-shaven group of EPCI subject matter experts. Reuters is reporting that early this morning the group of EPIC consultants, each one armed to the teeth with iPads and wireless mice and Blackberrys was last seen forcing a rag-tag group of hospitalists and CIOs into a windowless, upper floor room of the convention center.  It is rumored that a senior analyst from McKesson was also a member of the terrorist group, albeit in a non-billable role.

CMS has long been suggesting that with the huge shortage of skilled EHR specialists that sooner or later those with the knowledge would rise up and hold the providers hostage.

A spokesperson for the terrorists with a background in CPOE released a list of their demands.  They demand to have their rates tripled, to have an organic smoothie machine placed in the hospital cafeteria, and the right to remain employed even though the EHR will drop productivity by thirty percent.

One terrorist who demanded anonymity stated “I do not know why everyone looks so surprised that their EHR software does not work.  Nobody asked if it would work, they just wanted us to install it.”

EHR: What are your Bona Fides?

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The photo comes from my Robert Redford look alike period.

Do you ever awaken wishing you were all you used to think you were before you figured out you weren’t?  Me either.  I’m someone who has these kind of days when it’s best to keep me away from shiny objects.

During college, I spent several summers volunteering for a group called Young Life at their camps throughout the US.  Silver Cliff was one of their camps in the mountains of Colorado.  Each week we’d take in a few hundred high school kids from throughout the US, and give them the opportunity to do things and challenge themselves in new ways; everything from riding horses to rappelling.

The prior summer I was the head wrangler at one of their camps—I had never ridden a horse prior to being placed in charge of the riding program.  This summer is was the person running the rappelling program.  Needless to say, I had never done that before either.

We received a day’s worth of instruction before we were turned loose on the kids.  One of the first things we had to learn was that the ropes and harness, if properly secured to the carabineers and figure eight, would actually keep you from falling to your death.  The first test was jumping from a platform way up in a tree while on belay.  After a few moments of white-knuckle panic, I stepped over the edge and was belayed safely to the ground.

From there, we scouted a place for the rappel, and found two suitable cliffs, each with about a hundred foot vertical drop.  Watching my first rappel must have reminded others of what it would have been like watching a chimp learn how to use tools for the first time.  After several tentative descents, I was able to make it safely to the bottom in a single jump.

Each day we’d run a few dozen kids through the course, ninety-nine percent of whom had never rappelled, or ever wanted to rappel.  To convince them that it was safe and that they could complete it, I would instruct them in the technique as I hung backwards over the chalk face of the limestone cliff.

Each day we’d have one or two kids who wanted nothing to do with my little course.  Occasionally, while on belay, one of them would freeze half way down the cliff, and I’d have to belay down and rescue them.

Once or twice I’d have an attractive female counselor on belay, her knowing that I was the only thing keeping her from being a Rorschach stain on the rocks below.  Scared, and looking for a boost of confidence, “She’d ask, how long have you been doing this?” I’d look at my watch and ask her how many days ago was Sunday.  I viewed it as an opportunity to have a little fun with her—sort of like turning to your friend in the checkout line in 7-eleven and saying loud enough for others to hear, “I thought we agreed we weren’t going to use our guns.” I also hoped maybe even having to go on a heroic rescue.

How long have you been doing this?  That’s seems like a fair question to ask of anyone in a clinical situation.  It’s more easily answered when you are in someone’s office and are facing multiple framed and matted attestations of their skills.  Seen any good EHR or HIT certificates on the walls of the people entrusted with the execution of the EHR endowment?  Me either.  I have a cardiologist and he has all sorts of paper hanging from his wall.  Helps to convince me he knows his stuff.  Now, if I were to pretend to be a cardiologist—I’ve been thinking of going to night school—I’d expect people would expect to see my bona fides.

Shouldn’t the same logic apply to spending millions of EHR dollars?  Imagine this discussion.

“What do you do?”

“I’m buying something for the hospital I’ve never bought.”

“Why?”

“The feds say we’ve got to have it.”

“Oh.  What’s it do?”

“Nobody really knows.”

“How long have you been doing this?”

“How many days ago was Sunday?”

“What’s it cost?”

“Somewhere between this much,” he stretches out his arms, “And this much,” stretching them further.

“Do the doctors want this?”

“Some do.  A lot don’t.”

“How will you know when you’re done if you got it right?”

“Beats me.”

“Sounds like fun,” she said, trying to fetter a laugh.

Sounds like fun to me too.

EHR: the Prefect Problem

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A perfect problem, in its existing state, is unsolvable.  The way most of us handle it is to click our heels together three times and hope it goes away.  We tend to work on imperfect problems, those that can be solved.

One of my college professors—way back when we still had inkwells on our desks—told me that if you cannot solve the problem the way it is stated, it is to your advantage to restate the problem.  I tried this on a final exam; the problem as it was stated was to contrast two philosophers, one of whom, having not read the book, I had no idea who he was. I restated the problem to contrast two philosophers I knew.  He wrote back on my exam saying I had made a nice effort at using the technique but that the philosopher I chose was the wrong one.

What is the difference between the two problem types?  The first step is the ability to understand what makes the perfect problem uniquely unfixable.  Perhaps a few examples would help.

  • The CEO imposed a deadline for the implementation of EHR.
  • CMS Meaningful Use rules do not fit with our operational strategy.
  • If we do not implement EHR by this date, we do not get the money.
  • We must meet Meaningful Use
  • We do not have enough resources from the EHR users to understand their processes.
  • We cannot continue to support these low-margin services
  • We do not have enough time to define our requirements
  • We cannot afford to spend the time required to assess our processes before we bring in the EHR vendor.

What can be done?  The easy answer is to plan for failure and do your best to minimize it.

What is another way to describe the above examples?  They are constraints.  They can all be rewritten using the word “can’t”.  Rewritten, we might say, “We had a chance to succeed, but because of X, Y, and Z we can’t.”  If that assessment is correct, you will fail, or at least under-deliver at a level that will be remembered for years to come.  That’s a legacy none of us wants.

There are a few solutions to this scenario.  You can eliminate the seemingly intractable constraints; the organization can determine to re-implement EHR and hope for different results; or they can simply find someone else to solve the perfect problem.

Experience teaches good leaders really want reasoned advice.  They want the members of the C-suite to tell them what must be done to be successful.  Good leaders do not accept “can’t”—not on the receiving end, not on the delivering end.

Some will argue, “This is the way our organization works.”  Even if that is true one must consider what is needed to make an exception to the constraint.  Would you accept this logic from a subordinate?  Of course not.  You’d demand a viable solution.  If you are being constrained in your efforts to solve a perfect problem, perhaps it is time to restate the constraints.

Maybe the solution to the perfect problem is to restate it in a manner that makes it imperfect—solvable.

 

Jihad Joe: EHR Vendors, What’s not to like?

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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.

Which EHR should you buy? Read & Learn

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Last week I attended the If It Walks, You Can Hunt It convention.  Hunters—no gatherers allowed—convened from across the globe.  People whose firms make things for hunters to use to kill things were scattered across five hundred thousand square feet of convention floor, offering everything from how to properly kit yourself in trendy camo prior to eviscerating the last Dodo bird using only a rudimentary can opener, to hunting deadly hamsters with Stinger missiles.

I was interested in learning about hunting deer, not because I like to hunt deer, but because I like to eat it, and until they start selling deer at my local convenience store, my options are limited.  Apparently there are numerous weapons one can use to hunt deer.  There is the eco-friendly method whereby the eco-mentalist warrior lies naked under a pile of compost and recycled Priuses—not sure if the plural should be Prii, and tries to lay waste to the poor beast by making it listen to an entire Celine Dion CD.  However, this degree of cruelty is banned in fifty-one states.

Of course, there are the more traditional methods using bullets and arrows, although not in combination as this would be redundant.

I did notice a large crowd of mono-eyebrowed men listening to a pitch in one corner of the hall.  I made my way in that direction and listened to a very enthusiastic salesman talking about how to hunt deer with a fly swatter.  “You will find,” he continued “more people will choose to hunt deer with a fly swatter than with any other device.  It is less cumbersome, it is inexpensive, and you do not have to feed it.”

I thought about his agreement as I watched hundreds of men line up to buy fly swatters.  “Has anyone ever killed a deer with a fly swatter?”  I asked.

“Of course not,” the salesman replied in hushed undertones.  “Just because more people buy it does not mean it does what they want it to do.

Segue.  EHR Vendors.  “We have more EHR customers than anyone else.”

“How is your productivity?”  Asked the cynic.

Do not listen to the man selling fly swatters.  It really does not matter which of the top five EHR products you buy.  What matters is how well you install it.

Bzzzzzz….This fly has been bugging me all day.

Shift Happens: A little IT knowledge can kill you

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It almost killed me.  Curious?  I lived in Colorado for a dozen years, and spent almost every other weekend in the mountains, fly-fishing, skiing, climbing, and painting—any excuse would do.  Colorado has 54 peaks above fourteen thousand feet.  In my twelve years I climbed most of them.  Some solo; some with friends.

I owned almost everything North Face made, including a down sleeping bag with thermal protection which would have made me sweat on the moon and a one-burner propane stove which cranked out enough BTUs to smelt aluminum.  Two of my friends and I felt we needed a bigger challenge than what Colorado’s peaks offered.

The dot in the photo is me.

We decided on a pair of volcanoes in Mexico, Pico de Orizaba and Popocatépetl—both over 18,000’.  We trained hard because we knew that people who didn’t train died.  We trained with ropes, ice axes, carabineers, and crampons.  One day in early May we arrived at the base of Pico de Orizaba.  The man who drove us to the mountain made us sign the log book, that way they’d know who they were burying.  After a six hour ride from a town with less people than you’d find inside a rural K-Mart, we were deposited at a windowless cinder-block hut—four walls, tin roof, dirt floor.  Base camp.

Before the sun rose we were hiking up ankle-deep volcanic ash; gritty, coarse, black sand.  The sand soon turned in to thigh-deep snow.  We took turns breaking trail, stopping only long enough to refill our water bottles by hand-pumping glacier melt from the runoff in the bottom of cobalt blue ice caverns carved from solid glacier.

Ice Cave we used to collect drinking water

Throughout the trek we passed crude wooden crosses stuck into the ash and snow, serving as grim reminders of those who’d gone before us.

We knew the signs of pulmonary edema, but were reluctant to acknowledge them when we first saw it.  It was about one the following morning when we decided to make camp.  My roommate was having trouble concentrating, and his speech was slightly slurred.  When we asked him if he was ill, he responded much like one would expect an alcoholic would respond when asked if he was okay to drive.  “I’m fine.”

We were at 16,000’, the wind chill had the temperature slightly warmer than a Siberian winter, and the snow made for a whiteout.  The slope seemed to be at about forty-five degrees.  The sheet of ice upon which we stood was slicker than a car salesman selling Corvairs out of his basement.  I removed my tent pole from my pack and placed it on the ice—we were going to camp for the night.  We watched in intellectual confusion as the tent pole gained speed quickly and hurtled down the side of the volcano, quickly lost in the darkness.

Realizing my friend wasn’t doing well, and that I was now feeling somewhat punkish, we made the difficult decision to turn back.  The only survival for edema is to lose enough altitude until you reach one where there is enough air pressure to force the oxygen into the blood.  Eighteen hours of climbing.  Pitch black.  We headed down, me carrying my pack and his, he with our friend.

We arrived at the block hut around four that morning.  By then I was no longer making any sense.  My roommate had recovered, but I had become somewhat delirious—at least that’s what they told me later.  Not knowing right from left or wrong, I was determined to keep walking.  The two of them took turns laying on me to prevent me from sneaking out during the night.

A little knowledge almost killed us.  The scary thing is that we knew what we were doing.  We had trained at altitude, had a plan, worked the plan.  The plan shifted.  Sometimes shift happens.

It happens more with IT.  Much more.  Do you know what the chances are of any IT project ‘working’ that costs more than$7-10 million?  (Working is defined as having a positive ROI, a project that was delivered on time, withing the budget, and delivered the expected results.) (IT includes workflows, change management, training, etc.)  Two in ten.  Twenty percent.  That’s below the Mendosa Line—non baseball fans may have to look up that one.  Remember the last industry conference you attended?  Was it about EHR?  Pretty scary knowing most of them were planning for a failure.

Put your best efforts, your brightest people on planning the EHR.  Make them plan it, then make them plan it again, and then make them defend it, every piece of it.  If they don’t convince you they can do it in their sleep, you had better redo it.  Do they know what they’re planning to do?  Do they know why they’re planning to do it that way?  If they haven’t done it before, this may not be the best time for them to practice.  EHR is not a good project for stretching someone’s capabilities.

Planning is difficult to defend twice during the life of a large program.  First, at the beginning of the program when the C-Suite is in a hurry to see people doing things and signing contracts.  The second time planning is difficult to defend is the moment the C-I-Told-You-Sos are calling for your head for having such an inadequate plan.

How would I approach planning an EHR program for a hospital?  If we started in September, my goal would be to;

  • Have a dedicated and qualified PMO in place in four weeks
  • Begin defining workflows and requirements by October (I’m curious.  For those who have done or are doing this piece, how many FTE’s participated?  I ask because i think chances are good that your number is far fewer than I think would be needed.)
  • Issue a requirements document by mid-January.
  • Be able to recommend a vendor by the end of March.

That seems like a lot of time.  There are plenty who will tell you they can do ‘it’ quicker.  Good for them.  The best factor in your favor right now is time.

Reread this in a year and see where you are…

…See, I told you so.  Anyone want to go hiking?

Is the C-suite Fiddling while EHR Burns?

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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 million 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?

July is “take your EHR strategy to lunch month”

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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.

Take a few minutes and work Meaningful Use 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 chance of surviving the next committee meeting

What did you budget for EHR?

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

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

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

Really?  You did this all by yourself?

The facts as I understood them are as follows:

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

The Myth of EHR Certification

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EHR certification inspectors will swarm hospitals like fifty-year-old women to a Celine Dion concert.

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

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.