Hospital

Patient Experience Management (PEM): Left Brainers, Right Brainers, and No Brainers

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Sometimes I feel a little like the ambassador from the planet Common Sense, and unfortunately very few of us speak the same language. Let’s see if we can segment the Patient Experience Management (PEM) population into left brainers, and right brainers. I am wrestling with an issue that I believe is a no-brainer.

One point, upon which both sides seem to agree, is that without the patients, PEM would be superfluous. The breakdown is that for a hospital to flourish in the long term, hospitals should re-engineer their business processes to facilitate the dissolution or substantive reduction of traditional customer service.  This extends beyond the cordial relationship of a nurse or a doctor and their patients in hospital beds.

In many, if not most instances, the very existence of traditional customer service provides a vehicle which acts as an enabler for failure. It gives hospitals permission to be mediocre in dealing with their interactions with their patients and physicians. In effect, traditional customer service is a tacit admission to the employees and the patients, “We don’t always get it right. We don’t always do our best.

Before deciding not to read further, ask yourself a few questions. The purpose of the questions is to try and articulate a quantifiable business goal for customer service, PEM.

1. Does customer service have planned revenue targets
2. Does it have its own P&L?
3. Does it have a measurable ROI?
4. What is the loaded cost for each patient and doctor interaction?
5. Could the costs of those interactions be eliminated by fixing something in operations?

If the answers to 1-3 are no, the answer to 4 is unknown, and the answer to 5 is yes, your hospital inadvertently made the decision to ignore revenues and to incur expenses that provide no value to your organization. I believe this premise can be proved easily.

The careers of many people are directly tied to the need to have customer service and call centers. Big is good. Bigger is better. Software, hardware, telecommunications, networks—more is better. Calls are the lifeblood of every call center. Without those calls, the call center dies. Calls are good, more calls are better.

When was the last time you were in a meeting when someone said something like, “In the last three years our patient call volume has continued to increase,” or, “Calls have gone up by forty percent.” That part may sound familiar. The phrase nobody has heard is, “We can’t continue to add that many calls.” Tenure and capital. That part of the business is managed with the expectation that the number of calls will continue to grow. And guess what? It does. How prophetic is that? Or is it pathetic? You decide.

Given that, how does the typical healthcare provider manage their customer service investment? Play with the numbers. In many organizations, if customer service management can show that patient satisfaction is holding steady, no matter how bad it is, and they can use the numbers to show that some indicator has moved in a favorable direction, other areas of the business are led to believe that customer service is performing well.

Memo to those executives who are authorizing customer service expenditures—I want to make sure there is no mistaking how I view the issue. If that is what you are hearing from your customer service managers, they either don’t understand their responsibility, or they understand it and they don’t want you to understand it.

To be generous, if patient satisfaction with regard to customer service is below ninety-five percent, your customer service is in serious need of a re-think. Just because patient satisfaction is not tanking faster does not mean customer service is functional.

Most executives know how to get numbers to paint whatever picture they need to paint. Beware the sleight of hand. Any time the customer service manager comes to you and says he is improving operations by reducing the average amount of time someone spends on the phone talking to a patient (average handle time), don’t believe anything else he tells you. Allow me to translate. When the customer service budget is tight (too many interactions and too few people with which to interact) the way to make it fit the budget is to make your people end the call quicker. Shorter calls mean more calls per hour. Note—speed buys you nothing, except for more repeat calls, less resolution, less patient satisfaction. It’s a measure of speed—IT IS NOT A MEASURE OF ACCOMPLISHMNET.

I’d be willing to bet that somewhere between twenty-five and fifty percent of calls from your patients and physicians can be addressed better via a combination of social media and the Internet.

EHR: Advice for your next CIO

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With all the efforts underway with EHR, it’s only natural that some efforts will have problems, and those leading the efforts may be replaced.

If you’re the new EHR lead, how do you know what to do tomorrow?  You walk in to your new office; a withered Ficus tree is leaning awkwardly against the far wall, vestiges of a spider’s web dangle from a dead leaf.

You place your yellowed coffee mug on the worn desk, change out of your sneakers, and after rubbing your feet, slip on a pair of black Bruno Magli pumps.  The feel of the supple leather relaxes you.

You spot the three envelopes that are stacked neatly on the credenza.  A hand-written note on Crane stationary reads, “If there is an emergency, open the first envelope”.  You place the three envelops in your YSL attaché case, and go about trying to salvage the EHR implementation.

Three weeks pass.  Things are not going well.  You are summoned to meet with the hospital’s COO.  After checking your makeup, you retrieve the first envelope and read it.  “Blame me,” it reads.  You were going to do that anyway.

Two more months.  The vendor has become a sepsis in the lifeblood of the organization—pretty good word for a math major.  You are summoned to meet with the CEO.  After checking your makeup, you bang your first on your desk, tipping over your coffee, and spilling it all over your Dolce & Gabbana suit.  You don’t have time to change.  You retrieve the second envelope and read it.  “Blame the budget,” it reads.  You were going to do that anyway.

Six months.  Deadlines missed.  Staff quit.  Vendor staff doubles.  Vendor output cut by half.

You are summoned before the board.  You no long check your makeup—you haven’t worn makeup since the day you publically went mano y mano with the head of the cardiology department inside the surgical theater, demanding to see his updated work flows.  You still haven’t been able to get the blood off of your Hermès scarf that he used as a towel.  You are dressed in a pair of faded jeans and your son’s black AC/DC T-shirt, the one with the skull on the back.  You don’t care.

As you reach in the desk drawer for the third envelope, you realize you haven’t had a manicure in four months.  You feel like a disenfranchised U.S Postal employee.  You have become the poster child for the human genome project run amuck.  Somebody is going to lose their DNA today.

You open the third envelope.  “Prepare three envelopes,” it reads.  You were going to do that anyway.

How should a provider approach Meaningful Use?

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Of cabbages—and kings— And how does all that focus on Meaningful Use affect ones’ ability to address ICD-10?

And why the sea is boiling hot—and whether pigs have wings. Lewis Carroll, Out of the Looking Glass. It is a nonsense story, one which cannot be argued.

As are Electronic Health Records (EHR) and Meaningful Use (MU)—at least to date. Measured against any reasonable set of standards, except on a one-off basis, the national rollouts of EHR and MU have failed. I expect it will be even more so next year.
You, the public, have the right to comment, and we have the right to tell you why your comments hold no water. I think it is the inverse of you have the right to remain silent, you just don’t have the ability. I am writing about the ONC and the bone they tossed calling for public comment. They are required to provide for public comment in order to remove the N and the P from the NPRM.

Who among us believes the rule making will markedly shift direction as a result of any of the public comments? That is unfortunate for if they were to shift direction they might find a direction. We don’t know where we are going, but we are making good time getting there. Figures suggest a failure rate of EHR implementations of somewhere between fifty and seventy percent. As healthcare IT resources become scarcer, I expect the failure rate to increase. As providers rush into EHR without a detailed strategy simply to grab the incentive money, there will be more expensive failures. More failed EHRs is not a way to measure progress.
The current cover of Government Health HIT magazine depicts a foot race to meet MU. There is no race if there are no entrants. There may be more people on the cover than will actually qualify for the race, even fewer who will reach the end.

We would be better served if the plan for national rollout of EHR were not written on an Etch-A-Sketch. We don’t know what will be included in Stages 2 and 3 of MU. When will fifty percent of providers have an EHR, not just the software, but one that actually boosts productivity? How about 70% or 80%? Ten years? I ask the same question of the Health Information Exchanges (HIEs). Without unilateral adoption there will be large gaps. Will the national network function with these gaps? To what extent? Will the records only make it part of the way from Patient A to Doctor X?

Having not solved the EHR program on their own, and having no viable plan, the government laid the burden of making EHR successful on the backs of the providers. The government tries to offset the burden by offering financial gratuities—and penalties—to the providers. Not exactly the second coming of the Three Wise Men. Trying to hit the ONC’s targets is a little like playing the confidence game, the shell game. Under which shell will providers find the rules, the plan?
What to do?

It is easy to criticize. Permit me to offer a few suggestions. To the hospitals, if you are not well along the EHR path, do not make a difficult effort more difficult by chasing Gossamer incentive dollars. Stick to your plan. You have multiple failure points which three years from now will make chasing those dollars look like a pipe dream. The failure points? Your plan, the implementation, meeting the MU requirements, passing the MU audit. It does not look very promising to me.

To those hospitals which haven’t started their EHR initiative, or are less than halfway through the passing the failure points, don’t cancel your summer vacation. You have a lot more time to get it right then you have to get it wrong. Pay no attention to the man—or woman; even I can have a moment—handing out the Monopoly money. You won’t be receiving any. From where I sit, that is good news. It will cost a lot more to perform disaster recovery on a poor implementation than the funds you would have received by meeting MU.

How long does a hospital spend planning to build a new hospital wing? For large hospitals, the cost of your EHR will likely exceed the cost of the new wing. Plan accordingly. Invest six or nine months building a plan that might succeed.

For medium and small practices and solo providers you have nothing to lose by waiting a year months other than the resource problem. By then you will find very viable ASP and shrink-wrapped solutions.

Those who follow my blog, healthcareitstrategy.com, know I don’t write to garner favorable replies from those who think they’ve already got it figured out. I write for those who because of EHR have difficulty sleeping. Thanks for reading. As always, I appreciate your comments and disagreements.

How to handicap selecting your EHR

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Several years ago I was invited to go on the ultimate boys’ toys, weekend getaway. A dozen of us flew from Denver to Utah, and then drove to a point somewhere west of Bozeman Montana. It was to be a weekend of sport, a weekend of competition, and a more than occasional libation. To say that the people who organized the trip came from money would be a major understatement. They were in the oil bid’ ness. The father of one of the guys was the CEO of the second or third largest petroleum company in North America. We stayed at his ranch, a 12 bedroom log cabin in the middle of Nowhere, Montana, which is about 20 miles west of Next to Nowhere, Montana.

The weekend’s activities included fly fishing, duck hunting, and Gin Rummy. Each participant was given a handicap rating in each event. The idea behind the rating was that if you are weak in one event, you were paired with an individual who is skilled in that event. In theory, that would level the playing field among the teams. Since I have never fly-fished or hunted I was odd man out. But I was game, and it’s amazing how good one can become at something when one has to fight their way through it.

Let the games begin. We started the competition with a full day of fly-fishing. Our destination was the Madison River, an impressive, fast running, expanse of snow melt. The stretch we would finish was about 150 feet wide, and its average depth was somewhere between waist and chest high. As I would soon learn the bottom was covered with what appeared to be the equivalent of moss covered bowling balls. I was instructed by one of the more experienced fishermen to tie a nymph to the end of the tippet. For those of you who are as novice to the sport as I was, a nymph is an artificial lure which mimics an insect larva. It is designed to lure fish who feed along the bottom, not the nubile young woman referenced in Greek mythology.

We fished for several hours. My legs ached from trying to maintain my balance in the strong current. I was about ready to admit defeat when the tip of my rod bent sharply into the water. Standing perpendicular to the current, I could see as the brightly speckled back of a large rainbow trout turned upstream. Naturally, I turned upstream with it and began to try to reel him in. First mistake. It was at that point that I first realized that the height of the water was now about level with my chest waders. Second mistake. The guys on the other part of the river and along the bank were yelling at me. I thought it was words of encouragement. Final mistake. As it turns out, they were trying to convince me not to turn upstream. At the exact moment that I faced stream head on, was the exact moment my feet lost purchase with those moss covered bowling balls of which I wrote. Turning yet again to my physics, I quickly recalled the equation; force equals mass times acceleration. Instantaneously, I was swept downstream, still clutching my fly rod in my right hand.

Wayne Newton’s first law of fluid mechanics took over; waders, no matter how good they are, if positioned in a plane that is horizontal to the river will fill rapidly with water, just as mine did. The choice with which I was faced was do I save myself and lose the fish, or do I try and land the fish? One of the shortcomings of maleness—I was going to use maledom until I Googled it—is that we rarely have actual choices, especially when we are around other males or for that matter, females. Naturally, I opted to land the fish. My reel had become dislocated from my rod. I remember grabbing the reel and stuffing it down my waders, and as I tried to float my body as though it was a raft without a rudder towards the river’s nearest bank, I began to reel in the monofilament with a hand over hand motion. After several minutes I was standing dripping wet and proudly displaying a 19 inch rainbow trout.

We cooked the fish and played Rummy until about three in the morning, awoke at four, grabbed our shotguns and headed out into the darkness without so much as a cup of coffee. Round three of the competition was to be duck hunting. To this day I’m still unclear as to why we had to hunt ducks while it was still dark. Weren’t there any ducks who needed shooting at brunch time, I inquired? Twelve guys, who collectively smelled like a distillery, and who are operating on an hour of sleep, armed with loaded shotguns, trod through a willow thicket as dawn approached. As I neared the river bank, a startled duck shot skyward. I raised my over and under twelve-gauge shotgun, sort of took aim, and fired a volley. The duck seemed to pause in midair, and then fell like a rock into the racing water. I watched helplessly as my quarry floated away from me. I looked downstream and was pleased to see two men fishing from a rowboat. The duck floated right towards them. A man reached down, retrieved my duck, and dropped it in his boat. He then waved to me. Thinking he was being friendly I returned his wave. He then rowed away with my duck.

It was a great three days. Part of what made the weekend fun with not having to excel at each event. It helped knowing that in areas where my skills were not as good, I could count on the skills of others and vice versa. The idea behind this approach was to build competitive and level teams. That approach works well in mano y mano events like those I described. It works much less well in EHR, HIT and healthcare reform in general.  I’m trying to recall if I wrote previsouly about a meeting I attended with a former hospital CEO.  His take on EHR was the total inability of his peers to have any precience regarding their approach to EHR.  According to him, very intelligent people were making very unintelligent decisions, committing their entire institution to strategies made with almost no data.  Some people can give a better explanation for why they bought their car than they can for why they selected their EHR.   That’s the wrong way to handicap this event.

There are two ways to handicap your EHR.  One way is to look at the program from the perspective of risk assessment and assess–handicap–the risks.  The other way to to be a detriment to the program’s success.  One of these is bad.

AN EHR Vendor Selection Strategy–Vendor Darts

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Is there a best Electronic Health Records system? Perhaps Cerner, EPIC, GE, or McKesson?  For those who have followed my writing, you’re probably thinking my answer is “None of the above.”

I’ll do one better, and I write this with the utmost sincerity—it does not really matter which vendor you select.  As the EHR vendors reading this pull themselves off the floor, permit me to explain why.  Researching the question this is very little information to support the notion that any of the major hospital EHR systems quantitatively stands out from the others.

There are a few sites that offer user assessments across a range of functions, but those have at most three opinions—not enough to consider statically significant.  There are plenty of EHR scorecards and comparison tools, just not many scores.  The vendors’ sites do a poor job of differentiating themselves from their competitors.  Vendors use superlatives and qualifiers in an attempt to differentiate themselves.  When one considers the basic functions that make an EHR an EHR, the top vendors all have them.  No vendor highlights major clinical or business problems that their solution solves that another vendor does not solve.  Instead, they state they do something better, easier, more flexibly—none of which can be measured by prospective clients.

Imagine, if you were an EHR vendor, and you knew that your product did things to benefit a hospital better than the other vendors, wouldn’t you have an independent competitive assessment, some sort of “Consumer Report” chart and evidence to support why you are better?  Of course you would.  You would highlight your superlatives.  I have not seen one that would be very helpful.  The only information I found that might be worth a read comes from Klas Research.  However, the names of the modules rated are vendor specific, and none of the vendors use the same names.  It will give you a feel for how a small sample rated features within a given vendor, but there is no data to suggest how those ratings compare among vendors.

Even if there was a good comparison, the other thing to learn from this is all the areas that aren’t listed imply that the vendor is either no better or perhaps worse than the competition.  Cream rises to the top—we are left to choose among brands of milk.

One vendor may have a better medical dictionary than another, yet that same vendor will lack rigor in decision support.  No single vendor seems to have their customers doing back flips in their testimonials.  Some score high in their ability to deliver a complete inpatient solution and fail in their ability to integrate with other vendors.  Others hurt themselves during the implementation, user support, response time, and the amount of navigation required to input data.  Some EHR vendors posit their systems as being better at meeting Meaningful Use or passing all of the Certification requirements.  Ask them to name a single installed client for which they have met these.

Why doesn’t matter which vendor a hospital selects?  The reasoning holds not because all hospitals are the same, rather, it holds because were one to perform a very detailed comparison of the leading EHR vendors with a Request for Proposal (RFP), they would prove to be quite similar.  You might find significant separation if you only compared ten functional requirements.  You would expect to find less separation by comparing several hundred, and quite a similarity if you compare a thousand or more requirements.  The more you look, the more they seem the same.

Although the vendors will differ with respect to individual requirements, when evaluated on their entire offering across a broad range of requirements I would expect each to score within one standard deviation of the other.  You may be equally served playing a round of Vendor Darts.  However, make sure you sharpen the heads of each vendor prior to throwing them to make sure they stick to the dart board.

Reason 2.  It is possible to find hospitals who will give outstanding references for each of the leading vendors.  It is equally possible to find users in hospitals who have implemented one of the “leading” vendors’ systems who will readily tell you that the purchasing the system is the worst business decision they ever seen.  More to the point, every vendor A has probably had at least one of its implementations uprooted and replaced by vendors B, C, or D.  The same can be said for vendors B, C, and D.

If this is a fair assessment, what accounts for the difference?  How can we account for why one hospital loves a given EHR system and another one hates the same system?  Chances are they both needed about the same solution.  Chances are they received about the same solution.

Here’s the difference.  The hospital who thinks they made a good choice:

  • Had a detailed strategy and implementation plan
  • Paid as much or more attention to process alignment, change management, and training as they did to the implementation
  • Managed the vendor instead of being managed by the vendor.

Simply put—the problem is not the EHR system.

One other thought.  “Pay no attention to the man behind the curtain—the Great Oz.”  Do not put your scarce capital into a solution just because it offers or promises either Certification or Meaningful Use.  Yes, there is much discussion about both of these.  The industry stops and holds its collective breath each time a new set of stone tablets are brought forth from the ONC or CMS.  You can meet Meaningful Use with a Certified system and still wind up with a system the users hate and that does not support your business model.

Here is something else I cannot explain.  For those hospitals replacing a one hundred million dollar EHR with another hundred million dollar EHR, why do they think the second system will be any better?  If the systems are not materially different, the only way to get a different result is by changing behavior, not changing systems.  Why make the same mistake twice?  What could be so wrong with the first implementation that an expenditure of far less than another hundred million could not solve?

What is the cost of EHR 2.0 not working?

The User’s Role in EHR–a PowerPoint presentation

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This link will take you to a Slideshare,net presentation that defines how a healthcare provider’s users can take control of the EHR project.  I welcome your comments.

http://www.slideshare.net/paulroemer/the-users-role-in-ehr

EHR Strategy: It’s all about thawing Chicken

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Success and failure are often separated by the slimmest of margins. Sometimes you have to be prepared to think on your feet to out think unfavorable circumstances. Sometimes success hinges on how you present your idea. It is possible to force the circumstances via rapid evolution to pass from problem, to possible solution, to believable, to heroic? I believe so.

Permit me to illustrate with frozen chicken. Several hours before dinner I threw the frozen chicken breasts into the sink, choosing to thaw them with water instead of the microwave. Some twenty minutes later while checking emails I wondered what we were having for dinner. Not to be outdone by own inadequacies, I remembered we were having chicken. I remembered that we were having chicken because I remembered turning on the hot water. The only thing I couldn’t remember was turning off the hot water.

I raced to the kitchen. My memory was correct. Grabbing every towel I could find, I soaked up the puddles from the hardwood flooring, thinking while mopping about how I might answer to my wife if she happened to return to a kitchen that looked like the Land of Lakes. My first reaction, admittedly poor, was to tell her that I thought the countertop wasn’t level and that the only way to know for sure was to see which direction the water ran. Telling her the truth never entered my mind.

Once the major puddles had been removed, I worked on version two of the story, quickly arriving at a version of the truth that was more palatable—tell her I decided to wash all the towels. Why not get bonus points instead of getting in trouble? Version three looked even better. Since I was wiping the floor with the towels, instead of telling her I washed the towels, why not double the bonus points? I decided to wash the floor, and wash the towels. Husband of the year can’t be far off.

A few hours have passed. The floor is dry—and clean, the towels are neatly folded and back in the linen closet, and the chicken is on the grill. All the bases covered. A difficult and embarrassing situation turned into a positive by quick thinking.

A few of you have asked, let’s say we buy into what you are saying, how do you propose we turn around our EHR approach? All kidding aside, it comes down to presentation. Clearly you can’t walk into a room with a bunch of slides showing that your EHR investment was wasted. The first step involves defining the quantitative returns that can be achieved by changing the focus of EHR away from ARRA money and Washington, and focusing on the business problems EHR will address.

So, how did the dinner turn out? I was feeling confident that I had sidestepped to worst of it. Overconfident, as it turned out. My son hollered from the basement, “Dad, why is all this water down here?”

Video Game Theory applied to Healthcare IT

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My twelve-year-old son overheard a conversation I was having about EHR, Meaningful Use, and ICD-10, and I watched his eyes glaze over.  So I tried to explain it to him in terms I thought he might understand.  Maybe this explanation is the one I should have used with my client.

John and Sally have a thousand dollars in the bank.  They pool some of their money and have a hundred dollars to spend on video games.  The game they really want, Project From Hell, costs sixty dollars.  About half the people who play Project From Hell never make it to the end, and never get the chance to claim their prize.  It takes two years to play, and one or both of them could be eliminated from the game for failing to play well.

The second game is a take-off on Faust, Sell Your Soul to the Devil.  To play this game, you must first beat Project From Hell.  Sell Your Soul costs thirty dollars.  However, the upside is that if you win, which is not very likely, you can earn two dollars.

The third game, Bet Your Savings, is the most intriguing.  All kids who have a computer must play Bet Your Savings, which costs thirty-five dollars.  The way Bet Your Savings works is that if you do not play, or if you play and lose, ten percent of the money in your bank account disappears.

I asked my son which games John and Sally should buy.  He said if they bought Project From Hell and Sell Your Soul, they would only have ten dollars left, and that the reward from Sell Your Soul, two dollars, was not worth much.  He also noted they do not have enough money to buy all three, and that since Bet Your Savings was mandatory, unless John and Sally wanted to automatically lose ten percent of their savings, they must choose Bet Your Savings.

He decided they should buy Project From Hell and Bet Your Savings.

By now you have figured out the Project from Hell is your EHR, Sell Your Soul is Meaningful Use, and Bet Your Savings is your ICD-10 initiative.

Resources are scarce.  Do you have enough money to do Meaningful Use and ICD-10 correctly?  Many hospitals do not, and yet they are charging full tilt at meeting Meaningful Use to possibly net a few dollars.  Many hospitals have not invested enough to meet ICD-10.

Where should you place your limited resources?  If you are still confused, feel free to ask my son.

 

EHR: Puppy Training Your Vendor

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To ensure we take an accurate look at the provider-vendor relationship, we must be willing to acknowledge that healthcare providers are from Mercury and the EHR vendors are from Pluto.  They exist in different orbits, and their business models are very far apart—they never intersect; not in space, and not on your project.

1. Have your own inside expert. Don’t rely on the vendor to tell you what you should be doing.  Never.  Ever.  Unless of course you think the vendor knows more about how you want to run your hospital than you do.  Remember, you select them—not the other way around.

Bringing a vendor into your hospital is a lot like bringing home a new puppy. Both need to know who runs the show. Don’t roll over.  They may not be looking to be led, but if you don’t lead them they will lead you.

You should have the expert on board at the outset, before you select the EHR vendor.  The expert should be your advocate.

2. Establish a specific executive liaison with your vendor.  This is not your new tennis partner.  This should be the person who has the authority to ensure your quantifiable wishes are being met, and whose responsibility it is to deliver the message to his troops, and marshal the resources necessary to get the job done.

3. Specify your contractual objectives. Ensure that the contract is aligned with the clinical and business objectives of the healthcare organization, not the vendor.  Before you can accomplish this, you have a lot of work to do with your team.  You must define your clinical and business objectives.  Often these two groups also have a Mercury and Pluto relationship.  Once you have these, your next task is to deliver these objectives to the vendor and have the vendor tell you in writing what they will meet, what they might meet, and what they can’t meet.  It would be nice to know these before you sign their contract.

4. Involve more people than just the IT staff. Need a rule of thumb, involve as many users as IT people—Mercury and Pluto.  You will need new processes, not just to squeeze an ROI from the EHR, but because many of your old ones have probably been around since the invention Band-Aid.

Each of these recommendations will actually help you and help your vendor be successful.  It will not be an adversarial relationship as long as you manage it.  If you don’t manage the relationship, you won’t have to worry about meeting Meaningful Use—you’ll be too busy selecting a replacement vendor.

One final thought, don’t let the vendor loose unsupervised on the oriental rugs.

 

What is the future of the EHR/N-HIN landscape?

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One may argue it is possible to build the real Brooklyn Bridge with nothing but toothpicks, and a lake filled with Elmer’s Glue.  Difficult yes; prudent, no.   Urban legend is when the United States first started sending astronauts into space, they quickly discovered that ballpoint pens would not work in zero gravity.  To combat the problem, NASA scientists spent a decade and $12 million to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300C.

The Russians used a pencil.

The ability to do something is not justification for doing it.  Nor is that fact that someone has put it forth as an idea.  The willingness to do something merely because everyone is doing it or because someone instructed it be done probably has nothing to do with a business strategy, or if it does, it shouldn’t.

In the next five to seven years the business of healthcare at the provider level will have the opportunity to change markedly—the unanswered question is, will it have the ability?  To answer that at the provider level—primarily hospitals and clinics—I believe one must distinguish between the business of healthcare (how the business is run) and the healthcare business (how the care is delivered).

In many respects, the business of healthcare and the strategy surrounding it is pinned to a 0.2 business model.  Certainly there are exceptions to any aphorism, but taken as a whole, there is plenty of room for improvement.  As one hospital CEO told me, “What we really lack is adult supervision.”

So, how exactly does the toothpick bridge apply to healthcare?   Here’s my take on the situation.

  1. It may be possible to build and roll out a national network of EMRs through EHRs connected by HIEs to an N-HIN—I don’t think will happen in the next five to seven years, especially if to be effective the network requires a minimal participation of somewhere between 70 to 80 percent of healthcare providers.
  2. Even if I am wrong, why would anyone build a national EHR network out of toothpicks?  Could they possibly have devised a more complex and costly approach?
  3. The government arrived late for the party, has only limited authority, and chose to provide cash incentives instead of direction or leadership.  They passed the responsibility of the success of the national EHR roll out to hundreds of thousands of healthcare providers.
  4. The providers are burdened by having no experience in the sector, hundreds of EHR systems from which to select, no standards, hundreds of HIEs, no viable plan, no one with singular authority, a timeline that cannot be meet, and an unwritten set of Meaningful Use requirements.

The plan sounds like something designed by Rube Goldberg.  Could it be done this way?  I do not think we will ever know.  Not necessarily because it will fail, but because I think the plan will be supplanted by a more realistic one from the private sector.

The government’s plan relies on a top-down approach—albeit with a missing top; from the government, to the providers, to the patients.

The private sector plan will come from firms like Apple, Google, and Microsoft.  It will work because it will be built from the bottom up; from the patients, to the providers, and back.  Personal Health Records (PHRs) will become EMRs.  This approach will allow them to flip their PHR users to EMR users, and will be adopted quickly by millions of customers (patients).  Their approach will have a small handful of decision makers calling the shots instead of hundreds.

This model’s other component will be driven from another direction, by large hospitals and clinics that connect to small hospitals, small practices, and ambulatory physicians via a SAAS model.  Something like this is underway today at the Cleveland Clinic using their offering, DrConnect.

I believe the approach will be refined even further as the distinction between PHRs and EMRs erodes.  Instead of requiring remote care providers to have their own mini-EHR integrated with their practice management system, they will be able to use the EHR of a large hospital.  I anticipate that they will be able to log on to the system to access their patients’ EMRs as though they were actually resident in the large hospital.  This will all but eliminate the role of Health Information Exchanges (HIEs).  It will also extend the reach of those large hospitals, and aid in the retention and recruiting of physicians.

Why is this important?  Because the federal plan, which won’t be viable for several years, is designed to use software solutions which address a current business issue.  By the time their networked solution is fully functional it will be well on its way to obsolescence.  The government is forcing the expenditure of more than a hundred billion dollars on a static offering to address a non-static issue.  Their approach will not be able to keep pace with the changes demanded by market forces.  It reminds me off building a plan to go to the moon based on where the moon was instead of where it will be.