healthcare 2.0

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

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

 

‘Twas the night before reform when all in the House

Were Tweeting and blogging and squawking like grouse

Their bill filled with zeroes and commas and flair

In hopes that the Senate would soon be there

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

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

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

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

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

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

The docs sat on the sidelines, bemoaning their fate,

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

On the lawn of the White House there arose such disdain

As the public fought reform from ‘Frisco to Maine.

MSNBC, neigh now Comcast, buttressed their base,

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

The words on the pages of the newly printed bill,

Hid nuance, erudition, obfuscation, and swill,

Do not read the details, adjectives and signs,

Do not worry how it impacts your bottom lines.

We are here to pretend we did that of import,

To Hell with Medicare, Medicaid, and the sort

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

And this year silly people, this year WE are Santa

On Boxer, on Biden, on Fienstein they came,

And we chortled, berated, and chided by name.

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

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

“This is about people you meet on the street.

People who must choose between their meds and to eat

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

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

And then in a twinkling I heard in my head,

The gnawing and chiding of Congress, who said,

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

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

Festooned all in new regs from NHS to VA

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

HITECH and ARRA are not making it fun,

RHIOs and RECs will soon come undone,

We’re paying the hospitals to do EHR

We know it seems silly, like we lowered the bar

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

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

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

Buying Canada would be cheaper and easier but wow

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

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

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

Make us more European, make our rich people skittish,

The tall socialist exclaimed as the dems shifted right,

Will Obamacare fail, have I lost all my might?

Healthcare 2.0, can you get there from here?

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From a business perspective, not clinical, the critical success factor for H2.0 relies on healthcare’s ability to move from being an 0.2 industry in terms of how it is run as a business.

H0.2 is the “As-is” model.  H2.0 is the “To-be” model.  To reach H2.0 healthcare must bridge that functional, work flow, change management, user acceptance, and technical GAP.  The Gap will differ by provider.  There is no singular work plan to help providers know what they need to do to build a custom plan to bridge the gap.

None of this matters until the healthcare provider willingly acknowledges that they have a long way to go to get to anything that resembles H2.0.

H0.2 – H2.0 = GAP

If you don’t mind the gap,  H2.0 is just H2O–all wet.

One other thought.  There is a lot of discussion about Healthcare 2.0.  The discussion seems to suggest 2.0 is a destination point as though one can “arrive” at Healthcare 2.0.  Viewed this way, when healthcare arrives at 2.0, everyone else will be arriving at 3.0.  Unless the model evolves along a continuum, the journey may have been for naught.

Revisiting reform: Robbing Peter to pay Paul

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Why do you suppose there is so much discussion about revisiting healthcare reform, Reform 2.0?

Is it because Congress failed to acknowledge that ninety-eight percent of healthcare is local; Hyperlocal?  I think the answer is a resounding yes.  What is hyperlocal?  You know the saying, “All politics is local?”  Well, hyperlocal is local on steroids.  It’s moms and dads making choices about who will care for their family.  It’s the doctor down the street, not the doctor chosen by some system.

Individuals see healthcare reform as “What’s in it for them—them is defined as anyone other than me” and “What will it do to me?”  Reform 1.0 isn’t viewed as improving my healthcare, few see it as meCare.  That is why when viewed nationally so many are against the current version of reform.

It’s not that nobody is interested in providing healthcare to those who don’t have it.  What concerns people who do have healthcare is their belief—which may have nothing to do with reality—is that to provide healthcare to those who don’t have it requires that those who have it to give up some of their benefits.  Those with healthcare coverage see reform 1.0 as a zero sum game; for someone to be better off I have to become worse off.

What has people talking about trying to kill the bill is that nobody who currently has healthcare believes they will see any net gain benefit from the bill—they will see a net loss.  If any benefit will accrue to those who presently have healthcare, they certainly can’t articulate the benefit.

To gain support for Reform 2.0, or whatever it comes to be called, reform must incorporate first person interests, not just second or third.  Does that sound selfish?  It may be.  However, they are toying with reforming a fifth of the economy and a service of which eighty percent of the people are generally pleased.  Robbing Peter to pay Paul, and doing so at a cost of a trillion dollars to tens of millions of Peters has not garnered a groundswell of support.  No PR firm has demonstrated that they are clever enough to make this appear to be a good idea.

For reform to pass, Congress must learn to conjugate the care verb: First person—iCare, meCare Second and third person—heCare, sheCare, theyCare, youCare. That about covers all the various forms of caring.

What Congress hasn’t come to grips with is that there is no meCare in heCare, sheCare, or theyCare—hence, people don’t care to support reform.

What do you think?

What is meant by Healthcare 0.2 and 2.0?

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Last night I was explaining to my sister-in-law my notion about healthcare 0.2 and the need to transform it to healthcare 2.0.  She had no idea what I meant.  That’s a problem—not because she’s my wife’s sister but because she an executive at one of the top children’s hospitals.

I figured that if she didn’t understand what I meant, I may have also confused others—sort of like typing with a keyboard full of marbles.

I’ve written that healthcare is a 0.2 business being forced towards 2.0—H2.0.  What exactly do I mean by Health 0.2?  It could just as easily be 0.5 or 0.7.  The idea behind the label is that there is a large gap between where the healthcare business is, H0.2, and the future of the healthcare business, H2.0.

Permit me to share how I distinguish between the business of healthcare and the healthcare business.

  • The business of healthcare—clinical, care, patients
  • The healthcare business is paper intensive and duplicative and includes support business functions like:
    • Human resources
    • IT
    • Payroll
    • Vendor relationship management (VRM)
    • Patient relationship management (PRM)
    • Registration…and so forth

Successfully bridging the 0.2 to 2.0 GAP replies equally on foresight and planning.  For the change brought about by the bridge to take hold, change needs to be an ongoing event.

To begin the assessment, healthcare leaders must undertake an honest assessment of the organization’s strengths and weaknesses.  Sounds simple.  It’s not.  Hospitals are noted for their fiefdoms, and the fiefs, run mostly by doctors, aren’t big on being told there’s a better way to do things, nor are they keen on giving away control.

To change how the business is run, to make it more effective, and thus more efficient, requires that the major business functions be retooled.  This requires Change Management, which may require a change in management.

 

 

Informationweek Healthcare Article on Meaningful Use

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This link takes you to an interesting and well-written article written by Anthony Guerra.  Even if he didn’t quote me in the piece, it would still be worth reading.

http://www.informationweek.com/news/healthcare/leadership/showArticle.jhtml?articleID=227500796

Is a Universal Patient Record a Solution?

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Today is the anniversary of the solving of Fermat’s last theorem.  As a long recovering mathematician, these types of thing interest me so I sought a copy of the proof and began reading.  The mathematics for librarians description of the proof is something like this:

  • The Pythagorean theorem states that for a right triangle the sum of the squares of the sides equals the square of the hypotenuse.
  • Fermat stated that the theorem only holds for a coefficient of 2, squaring, and that no other coefficient will work
  • This went unproven until recently

One might have thought that the solution could be solved by brute force using a computer.  How many numbers are there to be dealt with? If you approach the problem this way you’ve got to do it for infinitely many numbers. So, after you’ve done it for one, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a thousand numbers, how many, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a million, well, there’s still infinitely many left. In fact, you haven’t done very many, have you?  In fact, using this approach, you’ll never finish.  This got me thinking about our EHR system.

I think something has been lost in the confusion about a national EHR system.  After all, that’s the target right, a national system?  We only unleash the power of EHR if we are able to make it work out outside of the provider’s four walls.  Is it possible that perhaps the logic of how we have been viewing developing a solution for the problem is wrong?  I think it is.  Since the outset, the problem has been defined as how do we develop a system that will enable us to get everyone’s health records (let’s call an individual record A) to some arbitrary set of healthcare providers, call them P.  There are some 350 million A’s and for simplicity let’s agree that there are 100,000 P’s.  So now, the system to which everyone is working is the system that will enable all of the A’s to get to any combination of P’s.

See?  Now what happens if we place a few hundred Rhios and health information exchanges (HIEs) in between the A’s and the P’s?  Let’s label them G’s for gatekeepers.  So, in the current framework all the A’s (everybody’s health records) have to pass through all the G’s, make it up to the national network, then back through all the G’s and then sorted through all the P’s to the correct P.

How can we know this design will work for every possibility?  The only way is to test every combination of A’s, G’s and P’s.  It’s a difficult problem.  It becomes more difficult when we acknowledge that there are hundreds of EHR vendors supplying software to all of those P’s.  Many of those P’s will have modified the software, meaning that there are probably thousands of variations of EHR systems.  Oh, and did I mention that all of this is being done without any single set of standards?  That means my stuff will look different from your stuff, and the G’s will have to move different stuff, and from an “IT” perspective the EHRs at the end of the food chain will have to interpret different stuff and then update your stuff with their stuff.  That’s a lot of stuff.

So, if that is where things are, what can be done about it?  My take on a solution is that the problem with this model lies with the word in italics, ‘everyone’.  Every possible patient with every possible need getting to every possible provider.  How to solve this or at least simplify the magnitude of the problem?  One possible solution is to build out the EHR system and the network such that one patient’s record can go to one provider and have that record updated.  Would it not make more sense to build it for a single patient, create a universal patient record (UPR) that can handle all instances?  Do it right once.  Prove that it works and then replicate it instead of building millions of different ones and hoping they work?

Will the ARRA money be worth the effort?

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According to the just released McKinsey study, the time has come for healthcare providers to set up a lemonade stand. Why? Because their findings indicate that the incentive money available to doctors may only offset about twenty percent of the costs of implementing EHR. You can read their analysis here:

http://www.mckinseyquarterly.com/Health_Care/Strategy_Analysis/Reforming_hospitals_with_IT_investment_2653

I disagree with a few of the comments in the McKinsey paper. First, the paper begins with two comments, neither of which is accurate; “Mandated upgrades to healthcare IT…”, and “New regulations require…” Lest we forget, having an EHR is optional—choosing not to have one is probably not a smart business decision, but the decision is yours, not Washington’s. Meeting Meaningful Use is also optional. Regarding Meaningful Use, I think an argument can be made that providers are better off without it—you can read my reasoning in some of my prior posts.

So, ARRA money will only meet 20% of your EHR costs. This should not be a news flash. In fact, I think that for more than half of the providers, the ARRA money will not even cover the additional costs of meeting Meaningful Use, let alone the costs of implementing the EHR.

So, if you are seeking an ROI over the total cost of the EHR, and not simply an incentive payment to cover the cost of a gross of “EHR—Yes we can” t-shirts, what can you do?

Sometimes the simple answer is the best answer. I think the answer to this question is quite simple, and its simplicity is what makes it achievable. It is not an answer being looked at by many providers. Approach your EHR implementation as though Meaningful Use did not exist.

Too many providers set the goal of their EHR as completing the implementation. “They wanted an EHR and we gave them an EHR.” This passes neither the test of being necessary or sufficient.

What are your business goals for your EHR? I suggest two:

• Be more efficient

• Be more effective

If your EHR can help you do these two things, you will meet the other goals, goals like providing better care, reducing the number of errors, saving time, and eliminating processes that add not value. Therein lays the all too elusive ROI.

There is actually another way to get money for an EHR that functions well. Once the EHR is running, there is a huge volume of digital data throughout the organization that can be aggregated. The Blues (Cross and Shield, not Belushi and Aykroyd) offer money back to healthcare providers who are able to demonstrate that they have saved the Blues money. If providers prescribe generic medications, naturally it costs the Blues less money. The Blues will share their savings with the providers. The way a provider can capture those funds is to have an EHR that is capable of reporting the generic meds it prescribes to the payor.

It is worth a phone call to your EHR vendor to find out if your system can do that. If not, the best fall-back position could be the lemonade stand.

How does Heisenberg’s Uncertainty Principle affect EHR?

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One of the great things about social media is its ability to infer attributes of both the readers and the writer.  When you finally meet your virtual pen pal the mind wanders—I thought he sounded taller.

There are those among us who when they picture me writing, see me sitting at my desk, wearing my baby seal-skin slippers, and supping on a bowl of loggerhead turtle soup.

Segue.

According to Heisenberg’s Uncertainty Principle (used in physics) certain pairs of physical properties cannot both be determined simultaneously.  That is, the more precisely one property is known, the less precisely the other can be measured. For instance, the next time you are standing by the side of the road, and cars are whizzing by you, try to decipher the speed of the car, and its exact location.  If I remember my math correctly, the first derivative is its velocity, the second, its acceleration.  To know exactly where the car is at a precise moment in time, the car must be stationary—as in not moving.  Thus, to ascertain its position, the position must be fixed.  The Heisenberg Uncertainty Principle requires that for someone to determine B, A must cease to be a variable.

The Uncertainty Principle can be represented as something like this:

One can see that as additional properties are tossed into the mix the probability of predicting any particular outcome goes to zero.

Thus follows Roemer’s EHR Uncertainty Principle—if you don’t know where you are going, you arrived a long time ago (A little like Pink Floyd’s, “How can you have any pudding if you don’t eat your meat?”).

The conflicting principles include;

·         Implementation date

·         Completion date

·         Final cost

·         Your functional requirements

·         The vendor’s capabilities

·         Acceptance testing

·         What should the EHR do

·         How do you know when you are done

·         Should you meet Meaningful Use

·         Will you receive the ARRA money

Here is the point of the allegory.  The chances of a physician group or hospital knowing the answer to all but one of the above principles are zero.

Permit me to throw a wrench into the loggerhead soup and let you know that not having the answers to all but one of the variables is okay.  That is the way projects work.

Since most of you implementing EHR have not ‘been-there, done-that’ with respect to implementing EHR, it is reasonable to expect there are more unknowns than knowns (spell-check indicates that it is not a word, but I know you are keeping up with me).

So, how can you use Heisenberg’s Uncertainty Principle to your advantage?  It is actually rather simple.  Do not allow your implementation to be guided by the unknowns.

·         Do not set an arbitrary budget for something you have never purchased

·         Do not set an arbitrary implementation deadline

Do what you must to make sure you implement an ERH that does what you need it to do.  Do not let yourself be constrained by principles whose only possible effect will be to derail your project.

If you are willing to take that risk, the other principles become moot (the correct terms is moot, not mute—look it up—sorry about the preposition).

If all else fails, consider getting a pair of the seal-skin slippers.

Paul M. Roemer

Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335

+1 (484) 885-6942

paulroemer@healthcareitstrategy.com

My profiles: 

My blog: Healthcare IT Strategy How to Revive a Failed EHR Implementation

“How many days ago was Sunday?”

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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.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

Do you need to fire Ferguson?

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It may be time to fire Ferguson.

I was listening to Imus the other day as he was interviewing the famous promoter, Jerry Weintraub.  The promoter relayed a story about one of his clients, John Denver.  Mr. Denver was constantly complaining about a number of things on one of his European tours, and he demanded the promoter come speak with him.  Here’s a replay of the conversation.

“Yes. Well, he was in Europe, and he was on tour. And everything was wrong. He hated everything. He hated the venues. He hated – the airplanes were no good. The sound systems were no good. Everything was no good. And he said to me, you know, I’m going to fire you; everything is wrong here. I said, yeah, I know, I know.

I sat down with him; I said, John, everything is going to be fine. He said, why? Why? I said, because I fired Ferguson. He said, why did you fire Ferguson? Why? What does firing him – going to do? I said, he’s been responsible for all the things that you’re troubled by: the hotels, the sound system, the venues, da, da, da, da. And he said, it’s going to be OK now? I said, yes, I’m putting other people in. Great.

And that evening, Denver and I went out to have something to eat. At dinner, I said to him, John, you know, I feel really terrible about firing Ferguson. He said, why? I said, because it’s not like you and it’s not like me. And John Denver said to me, I agree with you; it’s not like us. What can we do to help the guy? It’s really not like me. I got to help him. I said, I’ll put him in another area in the company. He’ll be fine. We’ll take good care of him. He said, that’s great, I feel so much better. Of course, there never was a Ferguson.”

Sometimes you need to shake things up a bit.  Do you need to fire Ferguson?

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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