healthcare 2.0

Should you listen to the voices in your head?

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Well, for starters, if you don’t nobody else will.

Just because I’m paranoid, doesn’t mean the voices in my head aren’t real. What voices?  They don’t like it when I speak of them, so I am going to speak in parentheses so they do not hear me.)

Riding the in the car yesterday with my son, the radio was playing Barber’s adagio, a mournful and eerily melancholy piece. It has long been one of my favorites.  I tried to get my son to turn off his PSP long enough for him to try to develop an appreciation for it.

He asked me to tune the radio to what he calls ‘his’ station while I kept extolling the specific virtues of the adagio, of Barber, and of classical music in general. I intended to win him over to my way of thinking.

The phrases I used to bolster my opinion kept coming to me, although I knew not from where.  I soon reached the point where I knew that I was no longer speaking to him, but role playing the very same discussion I had had with my father when I was about the same age as my son. Déjà vu. I have become my father’s son. The voice in my head was my father’s and I was not even charging my father rent for the space.

Do you hear the voices? No, not those voices. The ones you hear at work when you realize that the person speaking to you is your other self. The same voice you hear when you go out after work with your friends and begin to talk shop. By the third glass of wine the conversation has shifted from swapping stories about the craziest patient to wondering aloud when the company is ever going to learn how to fix their business. By glass five, you’re fixing it for them, diagramming solutions on cocktail napkins.

A word of encouragement. Listen to the voices. I bet you’ve come up with some great ideas. They won’t do anyone any good locked up in your head. Let them out. Show someone who can do something about it what you wrote on the napkins.

Is wellness being overlooked?

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The following are my comments to Sue Schick’s blog, Are you ready to commit to a wellness program?

With all of the pronouncements coming from Washington about healthcare reform, it is easy to be waylaid by Gossamer eddies and side currents that pay little attention to one key area—health. There is plenty of discussion about insuring the uninsured, covering pre-existing conditions, and the rollout of a national healthcare model under the guise of healthcare information technology and facilitating the transport of electronic medical records.

I think Sue’s words are spot-on and timely. Even if nobody is going to pay for it, with so many Americans participating in the healthcare conversation, an entire industry being re-engineered, and a trillion dollars to fund the transformation, should not there be more attention paid to wellness, to proactively making one responsible for one’s own health?

Unfortunately, my perspective on this issue is shaped from having been there, done that, got the T-shirt—a heart attack at the age of forty-six. I’ve transformed myself from someone who took twenty-four years off between workouts to barely taking twenty-four hours off between workouts. I didn’t need an employer to sponsor a wellness program; all I needed was a ride in an ambulance.

There may be a lot of different ways to get someone’s attention around wellness, around being responsible. Those who want to be well will have to make that decision for themselves. No company can do it for you, but companies certainly can be supportive of your efforts to help yourself.

There has been a lot of conversation in the healthcare debate about what role the insurance companies have played in driving reform. Right or wrong, a number of stakeholders view payors as bad actors, as the raison d’être of reform.

Wellness seems to offer payors a way to put on the white hat, to be proactive. Patients understand that they do not pay their providers for their healthcare. In the event patients need a provider, patients pay the insurers, cross their fingers, and hope the insurers agree to cover the expense.

I am somewhat of a dilettante to the insurance side of the healthcare model, so I apologize in advance if I misspeak. Here’s my take as to the white hat opportunity, a way to take a leadership role in the matter of wellness. When you apply for insurance, you receive negative ratings for unhealthy and unsafe behaviors; smoking, health history, sky diving. However, if you run five days a week, maintain your weight, eat fish and refrain from drinking, you accrue no points for good behavior. In fact, you are rated as though you made no proactive attempts to manage your own health.

Auto insurance companies raise your rates for certain bad behaviors, and they lower them for certain good behaviors. No accidents for two years—the rate goes down. No traffic violations—the rate goes down. Behavior modification. I am aware of it and I manage my behavior to get lower rates.

Can a similar model work for health insurance? What would it take for payors to offer an incentive model for rewarding good behaviors?

What exactly is healthcare 2.0?

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I tend to take a slightly different bent on Healthcare 2.0, a bent which does not intentionally tie to the notion of Internet 2.0, but rather to the notion of an industry desperately needing to reinvent itself.

A few definitions may bring some sense to the discussion. I find it helpful to distinguish the business of healthcare from the healthcare business. I think of the healthcare business as the clinical side, and the business of healthcare as what it takes to make dollars and sense of it all.

Although the healthcare business in the United States is world class in many areas, in many hospitals the business of healthcare is mired in a 0.2 business model. It is often run like a franchised fiefdom of duplicative and ineffective cost and revenue silos—I’m going to duck for a moment in case anyone disagrees strongly with me.

I’m back. This 0.2 business model is being forced into a 2.0 model whether it wants to go there or not. Whether it is capable of making the journey is debatable. The model is regulated, and is about to be reregulated—to what—nobody knows. What national leadership there is is busy waving the magic IT wand thinking that will facilitate the transition from the dark ages and support the business model of National Healthcare—which, by the way, has little if anything to do with the model providers need to run their business.

EHR, if done wrong will be nothing more than a multi-multi-million dollar scanner. Providers will indeed be paperless. However, paper is not the problem. The goal should not be the elimination of paper as though paper is a bad thing. If efficiency equates to speed, to doing something faster, the goal should not be efficiency. It is possible to streamline bad processes and do them faster.

To get to Healthcare 2.0 using my definition, to redefine the business of healthcare, providers must move towards being effective, towards solving business problems, eliminating waste and duplication, retaining doctors and patients, and running it like a real business.

My best – Paul

Why let your EHR vendor run your hospital?

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Healthcare Failures Magazine (HFM)  “It is not everyone who can finish dead last in the CIO of the Year competition.  How do you account for your total lack of accomplishment?”

PR:  “It was not as easy as it may appear.  I think it had to do with believing that my EHR vendor knew more about running a hospital than did we.”

HFM “Why do you say that?”

PR:  “They told me their EHR it had been implemented “As Is” at a number of hospitals and was running fine.  I was convinced that all hospitals are basically the same; admissions, treatment, discharge.  Besides, it saved a lot of money not having to customize it and do all that stuff about workflows.”

HFM “What about the change management?”

PR:  “Yeah, well I guess you could say that part kind’a blew up on me.  It didn’t take long to learn that our hospital didn’t function at all like their software.  According to our doctors, they didn’t think this vendor had ever been in a hospital, let alone run one.”

Who defines your vision?  Who is your chief imaginist, the person responsible for defining the type of hospital you hope to operate five years from now?  Do you want it to be your EHR vendor?  Probably not?  Is it your vendor?  It may well be.  Why? Do you want to outsource your imagination and your future to your vendor?

Without a detailed and comprehensive work flow improvement and change management program the only thing you will implement is your EHR vendor’s vision of how a hospital should function.  You’ll be just like each of their other clients.  Is that what your business model calls for, is it satisfactory?

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.

How Can Healthcare Technologies Help Revive Healthcare?

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The following well-delivered blog was written by Matthew Browning RN, MSN, APRN is CEO of YourNurseIsOn.com.   I hope you find it as insightful as I did.  Thank you Matthew for contributing.

As Paul has so poignantly illustrated in his recent articles on EHRs, Meaningful Use, CPOE, etc., the reality and the practicality of many of these systems, with their constantly moving goalposts and expectations, does not live up to the dreams and the promises being made. Millions of dollars are being wasted on the pursuit of a nebulous standard that is being corrupted by various factions, some fighting for openness, transparency and patient portability versus those wanting the control, ownership and monitoring of our personal medical records and data. If you are betting millions of dollars on these systems prudence dictates that you must be sure they are market ready and will meet regulatory approval. Besides, their are cutting-edge health 2.0 companies that will give you EHR systems for free.

While this drama has been forefront in the public eye, many new, easy to implement solutions have entered the marketplace to help get the daily business of healthcare done in ways never before possible. There are patient reminder services, staff communications tools, inventory control systems, waste management technologies and social media sites to connect facilities and their communities. Even without the spotlight, without government involvement, without the millions in promised taxpayer dollars and without the traditional healthcare company heavyweights, real change is being effected in healthcare delivery today.

What are some of the expectations we have of these types of real solutions in the healthcare environment? Well, as a nurse, I expect these technologies to make my life ‘easier’ if you will. They should help increase the amount of hours I spend at a patient’s bedside because every study shows that is the number one indicator of patient outcomes. The technology should make me more efficient in delivering the care my patients need: save steps when looking for supplies; decrease repetitive procedures; encourage efficient workflow and decrease the amount of time I must spend on non-nursing duties. Technology should enable collaborative, real-time communications with my employers, colleagues and even patients where we communicate at our best- from work, home, or on mobile devices and computers. Technologies can monitor patient status and notify caregivers when extra attention is needed, or can allow me to change my status from available to occupied or unavailable for care flow management.

As a business owner or investor, these technologies must be present and functioning today, must make the things we currently do every day more efficient and less costly, and should increase our abilities to communicate, manage, market, sell and make a profit or remain sustainable. We would like to increase our customer’s satisfaction with our services, increase their word of mouth and serve their needs while they are here. Since our customers are patients we would like technologies that help us decrease patient recidivism, infections rate, injuries and mortalities while improving patient outcomes. Since our staff is healthcare providers we would like technologies that increase employee moral, retention, satisfaction and productivity while decreasing turnover, absenteeism, vacancy rates, overtime costs and agency usage.

As a patient we expect to have these technologies make us feel well cared for, valued and respected. We do not want to fill out the same form multiple times, we want our complete, accurate, legible medical record available on demand- where ever we may be. We want scheduling software that eliminates waiting room ‘lay overs’ or technology that let’s US bill THEM when we have to wait 😉 We need to be able to research our hospitals and providers effectiveness, complaints, pricing and availability- or we will go to those who allow us to see this info. We want technologies that allow us  to age in place at home, or to help make our nursing homes better staffed and safer.           Technologies can keep us in touch with loved ones and families when separated by distance or circumstance and can connect us with providers from around the world or world renowned experts. It can be deployed cheaply, widely and quickly. It doesn’t have to do everything but it must do something well…and keep learning to do it better. Technology cannot be allowed to become an obstacle to doing business and continuing progress. We must harness its power to effectively achieve our healthcare objectives while faced with a seemingly insurmountable combination of increasing patient population contrasted with our shrinking supply of healthcare professionals. That is both the promise and the reality of technology in healthcare today. Your thoughts and comments are essential to continue the discussion and guide the adoption of technologies today in the healthcare arena. What are YOUR thoughts, wishes, needs and concerns about the state of technology in healthcare today??

About the author:

Matthew Browning RN, MSN, APRN is CEO of YourNurseIsOn.com a healthcare staff communications company. Mr. Browning is a frequent speaker, contributing author, tireless change agent and fierce advocate for Health 2.0, Patient’s Rights, Healthcare Technology, Aging at Home and Nursing. Matthew lives in New Haven, CT with his wonderful wife, Phoebe, and their energetic son, AJ. He can be contacted by email at Matthew@YourNurseIsOn.com , on Twitter @MatthewBrowning or feel free connect on LinkedIn at http://www.linkedin.com/in/matthewbrowning .

The doctors’ thoughts on social media are probably correct

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Some more thoughts on the post on KevinMD’s site stemming from Dr. Gwenn’s blog.

Justifiable on-line road rage.  I run a consulting firm.  You know what?  I hate it—running the firm, that is.  The consulting is great fun.  I am guessing that being a physician is a lot like that.  Very few of you became doctors to run a business, let alone one that is front and center on the evening news, Twitter, and every other blog on the planet.  Add to that a government who is changing the business model without any thought to how it impacts your business.  They want a nationalized healthcare system whereby each patient can be accessed by any doctor—that has nothing to do with your effort to treat actual people.

Interesting discussion, and the comments are spot on, especially the, “Where’s the beef” comments.  It is silly to expect that overlaying a few technologies makes things better.  This reminds me a little of Dorothy running around in ruby slippers, and the magic answer was clicking her heels three times.  Unless K-mart had a big sale on ruby slippers, there is no quick win technology for doctors lining the shelves of Office Max.

To rub salt in the wound, the government is forcing more technology on physicians, namely EHR.  If the technology was as great as the prognosticators write, doctors would be scrambling to be first in line.  Has that happened?  Of course not.  Instead, the government is taking a Tony Soprano approach, offering rebates for doctors who take a course they don’t want to take, alternatively, burying bodies off the New Jersey Turnpike.

So, some tactical thoughts starting with EHR.  Don’t do anything yet.  You have at least a year.  Yeah, you won’t get the ARRA money—that’s according to what’s written.  Guess what?  Nobody else will get it either.  The ONC will have to change either the timing of Meaningful Use, or the rules, or both.  I think they will push it back.  Twelve to eighteen months from now, someone will offer a robust, shrink-wrapped solution that makes sense.  If you’re interested, here’s a link to an audio interview I did for doctors about an EHR strategy—it’s just ideas, I’m not pushing anything.  Go to EMRFIX.com and search for the link.

Other practical thoughts.  There are a few hundred thousand doctors, none of whose Hippocratic Oath said anything about healthcare 2.0, or offered any training on how to get there, or whether you should even try to get there.  Most of my physician friends set up their business model on a whim and a prayer, like all entrepreneurs do—like I did.  There are probably as many business models for doctors as there are doctors.  The good news is that some have done better figuring out the business side of healthcare than others.  It’s not an ego thing.  It’s not about being intellectually gifted and not being smart enough to figure out something as simple as running a business.  Why?  Smart has nothing to do with it.  There are things to be learned from the efforts of others, and there are ways that some of the technologies can help.

Those things?  Blocking and tackling.  Business processes.  Social media.  Eliminate the rework.  Eliminate whatever tasks that don’t add value to your business.  Are there activities you can outsource?  Payroll?  Can you have someone design a website that will answer questions for your patients so they don’t have to call you?  Can you collaborate with other doctors?

Just some ideas.  You are justified in your angst.

Why doctors fail to embrace healthcare 2.0

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This is a reply I wrote to Kevin MD’s blog to a post written by Gwenn Schurgin O’Keeffe, MD, FAAP.

I view healthcare 2.0 with a bit of a twist from the Wikipedia definition, less from the perspective of social media and more from the vantage point of moving the business of healthcare from Version 1.0 to version 2.0.  I should note that I distinguish the business of healthcare (how it is run) from the healthcare business (the clinical side).

Having worked with executives in a number of industries, I think that for healthcare reform to be truly effective, the business of healthcare needs to evolve from an 0.2 model to a 2.0 model.  I think the same issues you raise still come into play; sheer panic, loss of control, loss of connection with patients, and blinders.

Going from an in-house business model to one being transformed by reform and Meaningful Use to a national healthcare model will exacerbate further those issues.  The in-house business of healthcare (how healthcare is run) was never built to handle a business model that will require every patient to be able to be connected to any doctor.  The system advances over the past few years—EHR, CPOE, and ePrescribing were implemented without any idea that the rules would change after the fact.

Will healthcare 2.0 offer huge advantages to how healthcare is run?  Absolutely.  The first question to answer before aiming for 2.0 is whose 2.0 model should you follow; yours or the government’s.  Are they the same?  No, and they are diverging even further as you read this.  The good news is that I think they will converge several years down the road.  What you need to decide is which model do you pursue before that happens.

How good is your vision?

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So, there I was thinking about all the times I didn’t get the invitations to the technical savants meetings.

I remember when Compaq came out with their first portable PC.  It was about the size of a suitcase and twice as heavy.  There was no way I’d ever have a need to lug around a computer.  A few years later my boss showed me his new cell phone—beige and about the size of a shoe box.  I remember asking him why he needed a phone and not being impressed by his answer.  Another piece of technology that would never get off the ground.

A few years later, out popped the internet.  A friend of mine showed it to me.  I asked him what he does with it.  He replied that it was good for sending messages to his brother.  I suggested he use the phone.

I think the fault I had was I looked at those three things from the perspective of the technology. It didn’t occur to me to look at it from the perspective of what business problems could they solve.

Technology, from the standpoint of its functionality, is often vastly under employed.  This happens not because of limitations of the technology, but limitations of vision.  I needed to not ask, what am I able to do with this, rather, what might I be able to do with this.

For example, let’s look at the fascination, or lack of it, around implementing an Electronic Health Records system (EHR).  By the time the dust has settled on your implementation, say three to five years—by the way, that means you missed the deadline to get the ARRA money, what does the industry look like?

Do you buy the EHR that meets what the industry looks like today, or did you give it enough thought so that your EHR functions at the level needed to support your business in 2015?

What’s the deal with reform?

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In the sixties, the initial funding for Medicare or Medicaid was sixty-five million dollars.  For purposes of this discussion, it does not matter which one.  It’s now more than a trillion.  Most floods start as a trickle.  Stay with me and see if this makes sense.

One cold night, as an Arab (this is not profiling, I pasted it from the web) sat in his tent, a camel gently thrust his nose under the flap and looked in. “Master,” he said, “let me put my nose in your tent. It’s cold and stormy out here.” “By all means,” said the Arab, “and welcome” as he turned over and went to sleep.

A little later the Arab awoke to find that the camel had not only put his nose in the tent but his head and neck also. The camel, who had been turning his head from side to side, said, “I will take but little more room if I place my forelegs within the tent. It is difficult standing out here.” “Yes, you may put your forelegs within,” said the Arab, moving a little to make room, for the tent was small.

Finally, the camel said, “May I not stand wholly inside? I keep the tent open by standing as I do.” “Yes, yes,” said the Arab. “Come wholly inside. Perhaps it will be better for both of us.” So the camel crowded in. The Arab with difficulty in the crowded quarters again went to sleep. When he woke up the next time, he was outside in the cold and the camel had the tent to himself.

Here’s my take on where we are.  I know you didn’t ask, I simply sensed you wanted to know.  Reform will pass.  What kind of reform?  Who knows?  Very few of us. Who cares?  A large number of those voting on it, those whose winter condos lay inside the 495 corridor don’t care.

Will healthcare reform legislation be the 3 AM call of our generation?  Many raised this same question in 1993.  Would it be different had the republicans brought healthcare to the table?  We will never know.  It does not matter if the camel’s nose enters from the left side or the right side of the tent.  Others debate which end of the camel is in the tent.  It matters not.  Once the Chicago Cubs went to night games, we were forced to change how we look at the world.

There are many things in healthcare reform.  I think that the most important one is the government.  It’s like a bad stain, once it’s in, it’s difficult to remove.  You may choose to differ, but I think the crux of the discussion is not what the details are in the reform legislation, but that it exists.

I agree fully that reform is needed.  Unfortunately, once we let the government drive, we never again get the keys.  In for a penny, in for a pound—if you convert from the Euro, it still makes sense.