How to push the EHR into the cloud

For those wondering if the fact that I have not written recently is a result of me having mellowed or having found the world more to my liking, not true.  I have been busy earning minus points as I tried to get it sorted in those wide open spaces of my mind.  It is difficult for me to find much comfort in sleep when I think all the leftist gremlins are in cahoots—I see two masons shaking hands and I think conspiracy.

Now, before this begins to read like I wandered too far from the republican rest home, I note that some of my best friends actually know democrats; so I am not as close-minded, or perhaps clothes-minded, as I would like to be.

Some are slow to adapt ideas to a changing world, aimlessly swatting new ideas away with a no-pest-strip as though they were plague carrying mosquitos.  Their thoughts, frozen in time, move so slowly they have been overtaken by a skateboard—and that skateboard was under someone’s arm.  These are the same individuals whose ability to play outside of the comfort of their own sandbox has not been seen since the internet was powered by steam.  It is a little like being a dinosaur while those around you are still floundering in the primordial bisque, still trying to wrap their synapses around the cold ideas distilled in the anecdote.

That is not to suggest that others do not think.  I am sure they have dozens of thoughts scribbled on the inside of their head, but those thoughts are erased each time they play with their hair—brains not big enough to swing a cat in without giving it a minor concussion.  There are fomenting alchemies of thought nuggets, but never quite enough to turn base metals into gold.  Sometimes, when the lighting is just right, you can see their curve of illogic thought arching overhead like static electricity.

In normal prose, I tend to be few of words.  I can get through entire days uttering no more than ‘uh-huh,’ a condition to which I attribute having exited the womb not fully-formed.  Writing is different than the spoken word.  For one thing writing is infinitely easier and more pleasingly voyeuristic, for it can be more entertaining to write about venomous ideas, not enough to kill my prey, simply to stun it.

Where then do ideas originate?  They are not like sex in a packet where all you have to do is add water.  The lack of thinking has led us to a tragic age most refuse to take tragically.  Thought patterns are aborted before they germinate, as though the thinker was taking intellectual contraceptives.  But believe it or not, I often find myself hoisted high on the petard of my own self-induced mesanic naivetés.  When a spark of a thought enters my mind, I rarely let it go quietly into that good night.  Instead I tear at it like Henry VIII coming off a forced diet—I know I mixed the metaphor, but I liked it.

I know rarely how my mind moves me from thoughts A to B.  Today proved no different.  Take the Poken.  This device is the newest technological mind-nibblet—a tiny jump-drive device about the size of prune whose purpose in life is to help two individuals sync their personal contacts by pok-in’ their respective Pokens.

You have got to hand it to them, for it sounds like it could be more entertaining than syncing one’s Blackberry.  If I understand correctly the concept, if my Poken pokes your Poken the Pokii mate—Pokii may or may not be the correct form of the plural, but it will have to do for now.  Once the mating process has ended, and before mine finishes its cigarette, I have your contact information and you have mine.

This could be an interesting way to swap business contacts, but as I live in the land of the Jabberwocky my mind does not work that way.  “Then he got an idea, an awful idea. The Grinch got a wonderful, awful idea.”

I jested about the Poken a few days ago, and then I thought about how this device could be made to work in healthcare.  The Poken is a communication device, sending and receiving secure requests to the cloud to permit one to access and update contact information.  Not much of a healthcare offering doing that, but what if?  What if instead of letting me share my contact information with someone I select, it, or something like it, allowed me to share my personal health record with my physician?  What if my physician was able to update my health record using a similar device?

The EMR and PMR applications would be in the cloud.  The Poken would provide the “handshake.”  One fully functional EMR.  The rest is history.  Thanks for playing along.

Healthcare IT’s Black Hole

Last year scientists turned on the largest machine ever made, the Hadron Collider. It’s a proton accelerator. This all takes place in a donut-shaped underground tube that is 17 miles in circumference.

Fears about the collider centered on two things; black holes and the danger posed by weird hypothetical particles, strangelets, that critics said could transform the Earth almost instantly into a dead, dense lump. Physicists calculated that the chances of this catastrophe were negligible, based on astronomical evidence and assumptions about the physics of the strangelets. One report put the odds of a strangelet disaster at less than one in 50 million, less than a chance of winning some lottery jackpots—what they failed to acknowledge is that someone always wins the lottery, so negligible risk exists only in the mind of the beholder.

If I understand the physics correctly from my Physics for Librarians mail-order course—and that’s always a big if—once these protons accelerate to something close to the speed of light, when they collide, the force of the collision causes the resultant mass to have a density so massive that it creates a gravitational field from which nothing can escape. The two protons become a mini black hole. And so forth and so on. Pascal’s triangle on steroids. Two to the nth power (2ⁿ) forever. Every proton, neutron, electron, car, house, and so on.

The collider could do exactly what it was designed to do. Self fulfilling self destruction. Technology run amuck. Let’s personalize it. Instead of a collider, let’s build a national healthcare information network (N-HIN) capable of handling more than 1,000,000 transports a day. What are the rules of engagement?  Turn on the lights and let’s see how it functions.

Let’s say we need to get anybody’s record to anybody’s doctor.  That’s overly simplistic, but if we can’t make sense out of it at this level, the N-HIN is doomed.  The number of possible permutations, although not infinite, is bigger than big.  Can you see what can happen? Strangelets.  The giant sucking sound comes from ARRA and stimulus money as it is pulled in to the black hole.

So what is the present thought leadership proposing to fight the strangelets? Healthcare information exchanges (HIEs)—mini N-HINs.  Regional Exchange Centers (RECs).  A few million, a few billion.  Not only does their plan have them repeating the same flawed approach, they are relying on embedding the same bad idea, and doing it using hundreds of different blueprints.

Einstein defined insanity as doing the same thing over and over and expecting different results.

Stop the craziness. I want to get off.

It’s the end of the world as we know it…and I feel fine. R.E.M.

Redux–What people at HIMSS were afraid to say

One image of HIMSS that will not escape my mind is the movie Capricorn One—one of OJ’s non-slasher films.  For those who have not seen it, the movie centers on the first manned trip to Mars.  A NASA Mars mission won’t work, and its funding is endangered, so feds decide to fake it just this once. But then they have to keep the secret…

The astronauts are pulled off the ship just before launch by shadowy government types and whisked off to a film studio in the desert.  The space vehicle has a major defect which NASA just daren’t admit. At the studio, over a course of months, the astronauts are forced to act out the journey and the landing to trick the world into believing they have made the trip.

Upon the return trip to Earth, the empty spacecraft unexpectedly burns up due to a faulty heat shield during reentry. The captive astronauts realize that officials can never release them as it would expose the government’s elaborate hoax.

I think much of what I saw at the show was healthcare’s version of Capricorn One.  Nothing deliberately misleading, or meant as a cover-up or a hoax.  Rather more like highlighting a single grain of sand and trying to get others to believe the grain of sand in an entire beach.

The sets for interoperability and HIEs served as the Martian landscape, minus any red dust.  There was a wall behind the stage from where the presentation interoperability was shown.  I was tempted to sneak behind it to see if I could find the Wizard, the one pulling all the nobs and using the smoke and mirrors to such great effect.  It was an attempt to make believers, to make people believe the national healthcare network is coming together, to make us believe it is working today and that it is coming soon to a theater near you.

After all, it must be real; we saw it.  People wearing hats and shirts emblazoned with interoperability were telling us this was so, and they would not lie to you.

The big-wigs, and former big-wigs—kudos to Dr. B. for all his hard work—were at the show for everyone to see, and to add a smidgen of credibility to the message.  They would not say this was going to happen if it were not—Toto, say this ain’t true.

The public relations were perfect, a little too perfect if you asked me.  Everyone was on message.  If you live in Oz and go to bed tonight believing all is right with the world, stop reading now.  If what you wanted from HIMSS was a warm and fuzzy feeling that everything is under control and that someone really has a plan to make everything work you probably loved it.

Here is the truth as this reporter saw it.  This is not for the squeamish, and some of it may be offensive to children under thirteen or C-suiters over forty.  In the general sessions nobody dared speak to the fact that:

  • Most large EHR implementations are failing.
  • Meaningful Use isn’t, and most hospitals will fail to meet it.
  • Hospital productivity is falling faster than are the Cubs chances of winning a pennant.
  • Most hospitals changed their business model to chase the check
  • Most providers will not see a nickel of the ARRA money—the check is not in the mail and it may never be.

The future as they see it is not here, and may never be, at least until someone comes up with a viable plan.  Indeed, CMS and the ONC have altered the future, but it ain’t what it used to be.  People speak to the need to disrupt healthcare.  Disrupt it is exactly what they have done.  The question is what will it cost to undo the disruption once reason reenters the equation?  What then is the future for many hospitals?

  • Hospitals on the whole will lose more much more money due to failing to be ready for ICD-10 than they will ever have seen through the ARRA lottery.
  • It make take years to recover the productivity loses from EHR and the recoup those revenues.
  • Hospitals spending money to design their systems to tie them into the mythical HIE/N-HIN beast will spend millions redesigning them to adapt to the real interconnect solution.
  • The real interconnect solution will be built bottom-up, from patients and their primary care physicians.
  • Standardized EMRs will reside in the cloud and patients will use the next generation of smart devices.  And like it or not, the winners will be Apple, Google, and Microsoft, not the ONC and CMS.  Why?  Because that is who real people go to to buy technology and applications.  A doctor still does not know which EHR to buy or how to make it work.  Give that same doctor a chance to buy a solution on a device like an iPad and the line of customers will circle the block.

And when doctors are not seeing patients they can use the device to listen to Celine Dion.  This goes to show you there are flaws with every idea, even some of mine.

(I published this post one year ago, just after the Orlando HIMSS.  It appears to still be valid today. Comments?)

EHR’s Two Types of Failure at your Hospital

"Kinetic productivity"

I have been rereading John Eldredge’s book Wild at Heart.  It seems his purpose for the book is to help men cope with their feelings of not measuring up to their father’s expectations.  It delivers its punch at much the same level as the last scene in the film Field of Dreams when the father and son have a chance for one last catch.

(I am pausing parenthetically for a moment for the men to wipe their collective eyes.)

Here comes the segue, so hold on to your EHRs.  Let us spend some time dealing with lost opportunity and failure.  What if we define two types of failures; kinetic failure and potential failure?

Kinetic Failure: the failure to achieve the possible

Potential Failure: the failure to achieve the probable

Viewed from the perspective of productivity, let us define X to represent the service provider’s pre-EHR productivity; the distance from P to A represents the productivity loss brought about by the EHR, and the distance from A to K represents the opportunity loss.

P——————————A—————————K

One can argue with some degree of reason that the purchase of an EHR was made with the reasonable assumption that in addition to improving quality and patient safety the EHR would improve productivity to some degree.  In fact, assuming the provider did any sort of cost benefit analysis or return on investment calculation, any ROI, if it exists lives somewhere along the path between A and K.

If productivity is not improved, the service provider incurs an opportunity loss, a kinetic failure. At that point the best a service provider can hope to achieve is to not suffer a productivity loss.

One can also argue that the purchase of an EHR was made with the reasonable assumption that the implementation of EHR would not reduce productivity.

In many service providers EHR has resulted in a double hit to productivity; not only did they not achieve the productivity gains that were possible, they lost productivity.  A lot of people raise complaints when they speak about how much productivity costs.  One thing that is for certain, productivity costs a lot less than lost productivity.

This lost productivity, the kinetic failure, is the elephant in the service provider’s waiting room.  It has been poking its trunk through the door, and the only thing it wants once it gets its trunk through the door is to get all the way in the room.

Well, it is in the room, all the way in.

Part of the confusion facing providers is due to the fact that no matter how bad the productivity loss, a provider can still qualify as a meaningful user. That fact has led many providers to believe that since they can still qualify as such, that perhaps the productivity loss cannot be all bad news.

Let us look at a real example from a client of mine, a hundred and forty physician practice.  This practice had hit a barrier in terms of its ability to add patients, doctors, and staff.  It was running consistently an hour to an hour and a half behind with its patients.

The practice spent millions to implement an EHR.  Several months post implementation the practice was still running an hour behind.  Automating bad practices resulted in only one thing; the bad practices were completed faster.

To have any hope of avoiding kinetic failure and potential failure a healthcare practice must address how it runs its business.  Some business processes are duplicative, some are outdated, and some are wasteful.

Every one of those eats away at possible and probable productivity.  EHR was not designed to be a productivity windfall, but it clearly shines a spotlight on lost productivity.

Fortunately, even if your EHR has led to a productivity loss, all is not lost. Kinetic productivity can be regained, and potential productivity can be captured.  The path to productivity slices right through how the EHR is being used.  User Experience, UX, and usability, can and should be examined, redesigned and deployed.  This is not for the squeamish as it will cut through constraints like ‘We can’t do that’ and ‘We have always done it this way.’

Can’t and always must become productivity’s road kill.

Why IT projects Fail

The mind is a terrible thing.  Last night I stumbled across part of the movie Kill Bill Volume 2. There is a character in Volume 2 named Esteban Vihaio, an eighty-something Mexican—for lack of a more erudite word—pimp.  His is a small role, but performed beautifully.  Uma Thurman, our ninja protagonist, meets Esteban and asks him ‘Where’s Bill?”

With a thick, refined Spanish accent, Esteban repeats the question, drawing out the name “Where is Beeeeeeel?”

Anyway, today I am on the phone.  And can you guess the name of the person with whom I am speaking?  That’s right, I was talking to Beeeeeeel.  He did not have a Spanish accent; nonetheless, I could not stop the voices in my head from trying to translate every phrase so that it sounded like Mr. Esteban.  Needless to say, the call went downhill rapidly.

When I think about software implementations the phrase “Help, I’ve failed and I can’t get up” comes to mind.

For many people, the goal of a software implementation is to get to the end, to see the vendor leave.  In many minds, that signals that the work is done, and the departure of the vendor signals that the software was implemented correctly.  Not true Mon Chéri.

In case you did not get the email, IT has become big business in most corporations, and it takes a group of highly paid bureaucrats to administer it.  And you know what happens when you give the bureaucrat a clipboard and ask them to oversee the implementation of a new email system, by the time the dust settles you have spent a few million dollars on a new sales force automation tool—Rube Goldberg on steroids.

Once you start spending it is difficult to stop.  And people do not keep spending in the hope of reaping additional ROI; they do so in order to try to salvage a project that in its current state is a white elephant.  Most of the cost of an IT project is to get it to do what you thought it would do.  This is a classic example of when you are in a hole, stop digging, or at least let me hand you a bigger shovel.

Why You Should Never Trust the Vendor’s Brochure

We were being entertained at a friend’s house whose interior looked like it had been designed by one of those overly made up, energetic divorcees who only take cash.  The walls were painted a stark white; the overstuffed club chairs and the couch were upholstered in a soft white leather.  The white carpet was thick enough to hide a chiwawa.

The hostess locked askance at me when she saw me seated in the club chair.  Perhaps my outfit did not look good on white.  A paperback which looked out of place lay on the end table next to my glass of Ovaltine.   I picked it up and began to read the back cover to get a feel for the storyline…which got me thinking about writing and authors.

The paperback story filled five hundred and seventeen pages.  Whether they were well-written, whether there was a story nestled inside, could only be learned by reading the book.  I read many books, and I read often, especially when I travel.  When I am unprepared I am forced to purchase a book at one of the shops in the airport concourse.  The purchase decision lasts only as long as it takes to read the back cover—the publisher’s only chance to make a first and last impression.

Those first impressions have fooled me often.  Ten minutes into the book I wind up stuffing it into the kangaroo pouch in the seatback in front of me.  More often than I would like, I find that the person who wrote the book summary on the back flap is a better writer than the person who wrote the book.  The summary writer is able to create an interest in the story and a need to see how it ends, an interest and need for which the book’s author is unable to deliver.

The book is rarely better than the back cover suggests it will be.  Often it is as good, sometimes it is not.  The book summary is the upper limit for what you can expect by way of enjoyment.

It works the same way in business only instead of paperback books they use brochures.  Never trust the brochure.  Whatever is written in the vendor’s brochure is the upper limit of what you can expect to receive.  Those who remember the dismantling nuclear arms remember the adage ‘Trust, but verify.”  When it comes to dealing with vendors, I suggest ignoring the part about trusting.

Take software vendors for example.  What’s not to like?

The product never leaves you feeling the way you felt after reading the brochure.  Remember the photos?  Pretty people, smartly dressed, ethnically diverse.  Their teeth bleached so white the reflection of the monitor is visible in their incisors.  Seated in their clutter-free offices, they are all smiling.

Did your users look like them when they started to use the product?  Did you get your brochure moment?  In order to find customers, vendors have to position their product in the most positive light.

Maybe there should be a cigarette-like warning printed on every software vendor’s brochure, something like this:

  • We hired the people pictured in the brochure—nobody is ever that happy
  • Most of you will never learn how to use all of the functionality
  • To have any chance of getting the software to do what you need it to do will probably cost you twice as much as you contracted
  • There is no way you will implement in the timeframe you discussed

They know, and we know, nobody implements brochures.  If we did, IT departments would be much smaller.  Maybe that is why vendors give away pens and T-shirts to all of their customers, to soften their sense of guilt.

Healthcare IT: Musings of a drive-by mind

It takes a lot of energy to dislike someone, but sometimes it is worth the effort. It is not easy being a consultant.  One client required that I shout “unclean, unclean” as I passed through the hallways.  Maybe that is why I leave newspapers scattered around the floor of my desk, so nobody can sneak up on me without me being able to hear them.

I have a knack for complicating simple things, but the voices in my head tell me that is better than simplifying complicated things.  Either way, I appreciate those of you who continue to play along.  Just remember, if you choose to dine with the devil it is best to use a long spoon.

You’ve probably figured out that I am never going to be asked to substitute host any of the home improvement shows.  I wasn’t blessed with a mechanical mind, and I have the attention span bordering on the half-life of a gnat.

I’ve noticed that projects involving me and the house have a way of taking on a life of their own.  It’s not the big projects that get me in over my head—that’s why God invented phones, so we can outsource—it’s the little ones, those fifteen minute jobs meant to be accomplished during half-time, between pizza slices.

Case in point—trim touch ups.  Can, brush, paint can opener tool (screwdriver).  Head to the basement where all the leftover paint is stored.  You know exactly where I mean, yours is probably in the same place.  Directions:  grab the can with the dry white paint stuck to the side, open it, give a quick stir with the screwdriver, apply paint, and affix the lid using the other end of the screwdriver.  Back in the chair before the microwave beeps.

That’s how it should have worked.  It doesn’t, does it?  For some reason, you get extra motivated, figure you’ll go for the bonus points, and take a quick spin around the house, dabbing the trim paint on any damaged surface—window and doorframes, baseboards, stair spindles, and other white “things”.  Those of us who are innovators even go so far as to paint over finger prints, crayon marks, and things which otherwise simply needed a wipe down with 409.

This is when it happens, just as you reach for that slice of pizza.  “What are all of those white spots all over the house?”  She asks—you determine who your she is, or, I can let you borrow mine.  You explain that it looks like that simply because the paint is still wet—good response.  To which she tells you the paint is dry—a better response.

“Why is the other paint shiny, and the spots are flat?”

You pause.  I pause, like when I’m trying to come up with a good bluff in Trivial Pursuit.  She knows the look.  She sees my bluff and raises the ante.  Thirty minutes later the game I’m watching is a distant memory.  I’ve returned from the paint store.  I am moving furniture, placing drop cloths, raising ladders, filling paint trays, all under the supervision of my personal chimera.  My fifteen-minute exercise has resulted in a multi-weekend amercement.

This is what usually happens when the plan isn’t tested or isn’t validated.  My plan was to be done by the end of halftime.  Poor planning often results in a lot of rework.  There’s a saying something along the lines of it takes twice as long to do something over as it does to do it right the first time—the DIRT-FIT rule.  And costs twice as much.  Can you really afford either of those outcomes?  Can you really afford to scrimp on the planning part of IT?  The exercise of obtaining HER champions and believers is difficult.  If you don’t come out of the gate correctly, it will be impossible.

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