Hospital

Has Meaningful Use Optimisim Run Amuck?

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I make it a point to read every article Gienna Shaw writes for HealthLeadersMedia.com.  She consistently captures large amounts of information and packages it into a concise understanding of the material.  In the February issue of HealthLeaders http://www.healthleadersmedia.com/industry_survey/ she wrote a piece summarizing the results from their survey of organizations on their projected timeline for achieving Meaningful Use; Making Meaningful Progress.  I thought it might be helpful to offer readers a bit of a different perspective, something that may cause you to pause and wonder whether I am living on another planet, or whether it is the majority of those surveyed who migrated to Venus.

Were it only that the responses of those surveys were based in reality—the world would be a better place, the Cubs would win the World Series, and my son’s room would no longer resemble an obstacle course.

According to the survey findings, sixty-eight percent of those surveyed expect to achieve Meaningful Use by 2012, and that total climbs to seventy-seven percent by 2013—assuming the Mayan prediction of the world ending the year before prove false.  Things always look rosier when you have the luxury of ignoring other factors prior to answering the question of whether you will achieve Meaningful Use; like whether the EHR implementation will be successful and whether there is enough time to meet the dates they selected.

What else should one be considering when assessing the validity of this unbridled optimism?  Thanks for asking.  Here is my list:

  • EHR Failure Rate:  published data suggests EHR failures range between 30-70%.  If we use a conservative figure of 40% we can see that optimistic forecasts of 77% achieving Meaningful Use by 2013 is wrong by a factor of two.  If forty percent of implementations fail, and seventy-seven percent meet Meaningful Use, somebody needs to check the math.
  • Of those systems that have already failed, many of whom are very notable hospitals, they had the luxury of time.  They had as much time as they needed to fail.  Today we have less time to fail, which to me means failure percentages will increase.  For those who have yet to fail, if your goal is meeting Meaningful Use by 2013, watch out.  If you dash for the cash, plan for an EHR do-over.  Remember, there is a binary trap associated with meeting Meaningful Use—it is all or nothing.  There are no dollars awarded for having tried really hard.
  • When was the last time you tried to hire a very experienced EPIC or McKesson resource?  Recent figures suggest a Healthcare IT resource shortfall of fifty percent.  This shortfall will greatly reduce the number of organizations which have any chance of meeting Meaningful Use by the dates they themselves specified.
  • How’s that HIPAA 5010/ICD-10 project coming along?  A high percentage of organizations have not even started the HIPAA 5010 tasks that should have been completed in 2010.  More money will be lost through not meeting ICD-10 than will have been awarded in the EHR rebate lottery.
  • Once your EHR is implemented, what percentage of your IT resources will you need to allocate simply to meet Meaningful Use’s stage one requirements?  One outstanding hospital found that number to be eighty percent over three years.
  • At least with EHR there are people who have current EHR experience.  There is no pool of ICD-10 been-there done-that resources.  So, where do you allocate your scarce resources, EHR or ICD-10?  Either answer you give yields a bad outcome.

So, what is the best approach for the C-Suite?  Meeting Meaningful Use is not mandatory.  Time need not be your enemy.  Why not implement EHR correctly?  Why not adjust your plans so that instead of trying to squeeze every possible dollar out of Meaningful Use you simply try to make EHR work by 2015?  This way you avoid the penalty and give yourself a decent shot of success.

No ARRA money will be awarded for being optimistic.  However, once you tell the CFO to plan for a twenty million dollar ARRA windfall in 2011 or 2012 you better deliver it because you know darn well that he or she has already made plans to spend that money.

I think if we were to check the results of this survey two years from now we would find that less than forty percent of hospitals will have achieved Meaningful Use by the end 2013.

EHR: Is time your greatest enemy?

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The following is my response to an article in Health Data Management regarding an article which argued that time is the enemy of a good EHR implementation. (http://www.healthdatamanagement.com/blogs/Quammen_big_bang_EHR-42096-1.html#read)

I agree fully with the premise of a big bang rather than a phased in approach, but for the following reasons I respectfully disagree if the reason for going all out is because there is not enough time.

Many providers have already demonstrated that time is certainly the enemy.  They have had enough time to spend four hundred million dollars and get EHR wrong, and are in the process of doing the same thing with another vendor.  There is a notable shortage of CIOs wearing EHR 2.0 T-shirts—fail once and you are done.  The attitude seems to be that there is plenty of time to do it wrong and not enough time to do it correctly.

Poor EHR implementations are creating a brand new market for HIT consultants—disaster recovery. The New England Journal of Medicine noted that more than sixty percent of EHR implementations fail.  An even higher percentage will fail to meet Meaningful Use, which is why everyone is in such a rush to implement—the Dash for the Cash.

Providers are sacrificing their own business strategy to get a check for trying to meet a set of standards that have no meaning and no benefit other than to have them fit into a more nationalized healthcare model—something they would never have done on their own.

The first question a provider should ask is “do we want to meet Meaningful Use”.  If the answer is yes, the next question they should ask is “by when?”  Given the rash of failures, providers should figure out what they need to do to avoid being the next hundred million dollar failure.  Paying to do EHR twice or to recover from a failed implementation will far exceed any funds they will have received from the EHR Rebate program.

The problem many will find is that there is no “R” in the Meaningful Use ROI calculation.  The productivity of some of the best providers in the country is still down twenty percent two years after implementation.

If providers want an ROI, they would be much better served by taking their time and doing what they need to do to make EHR do what they need it to do, and to focus their attentions on ICD-10.  The amount of money they will lose from failing to meet ICD-10 will far exceed the EHR rebate.

Patient Experience Management as healthcare’s Watergate

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Below is the text of my article in Hospital Impact.

Patient Experience Management as healthcare’s Watergate

March 9th, 2011

by Paul Roemer

For the second straight year, HealthLeadersreports that Patient Experience Management (PEM) is one of the top three priorities for healthcare executives. A McKinsey study of 1,000 executives showed that for 90 percent of executives it ranked first or second.

Those results put my mind at ease on the issue about as much as Iran’s Amadinejad claiming its nuclear efforts are only targeted at improving the yield of their turnip harvest.

Recall the tagline of the McKinsey study–none of the executives knew who actually owned the patient experience, so little was planned for addressing this priority. However, several hospitals were expected to offer more heart-healthy alternatives in the basement cafeteria–I love strong leaders. Be on the lookout for the Amadinejad Turnip-Melt.

[More:]

Anyway, I digress.

Healthcare’s Watergate. Follow the money. Yet, there is no money to follow in two key areas, at least not an amount that suggests hospitals view either area with the same degree of import with which they speak to them. What are they?

  • Patient Experience Management (outflow)
  • Our old friend, Meaningful Use (inflow)

Missing is the planned expenditure that would come even close to making Patient Experience Management a priority. Don’t believe me? Print out a copy of your organization’s strategy, its budget, or its general ledger, and sort all of the planned expenditures from greatest to least. Stop reading when you reach the line item for Patient Experience Management.

Meanwhile, I am going for a run. If you find it before I return, wait for me, but you will not have found it by then.

You did not find the dollar amount budgeted for PEM did you?

Just to stay consistent, there is not much of a Meaningful Use windfall flowing out of CMS and into your neighborhood healthcare services provider either.

In general, money for what seem to be very high operational priorities is dribbling along so slowly so as to suggest these initiatives had prostate problems in the offing.

In addition to the fact there was no booth at HIMSS to showcase the most singularly spoken of topic, Meaningful Use, there was also no booth on Patient Experience Management. There was not a single PEM vendor. Why? Because the vendors know PEM, for now, is a unicorn-like ACOs–and nobody has ever seen a unicorn, so why bother trying to sell unicorn horn polish?

By the way, I need to borrow five chairs for a group photo I am taking of everyone eligible to receive Meaningful Use rebates.

Paul Roemer, MBA, is a healthcare strategist and Managing Partner of HealthcareITStrategy.com. Paul has more than thirty years of management consulting experience, starting with the Big 4 where he held national leadership positions, and the last fourteen years with his own international consulting firm. He has a passion for how we will live and function in the rapidly changing world of healthcare, and how information technology must provide for and help manage the change. He wrestles with how to turn the lack of information of what the business of healthcare will become, the lack of understanding of the issues, and the general lack of knowledge of the future into decisions we can make today to shape tomorrow. Paul has earned a presence on the national healthcare stage through his futuristic thought leadership, and is a recognized speaker and writer on a number of strategic healthcare issues.

EHR: How do you define progress?

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If you and I agreed on everything, one of us wouldn’t be needed.

Of the many special things associated with growing up in America, one is held dearly by every American eight-year old male who owned an AM transistor radio with an earplug; baseball–I am dating myself which is something I promised my counselor I wouldn’t do.

On hot summer nights in the 1960’s, Baltimore’s adults sat on their cement stoops nursing bottles of Carling beer and waiting for their window air conditioners to suck out the heat.  Their male offspring lay in bed, a plastic earplug dangling from their ear as they turned the dial of their transistor radio to find the lone radio station covering the Baltimore Orioles. In spite of the constant static, they faithfully kept score on a hand-drawn score sheet in their black and white Composition notebook.

My scorecard was homemade; carefully drafted using a pencil and something relatively straight to draw the lines that separated each of the nine innings. Unlike today, when the concept of team has given way to the concept of players whose loyalty lies with the highest bidder—free agents, the lineup for the Orioles rarely changed by more than a player or two each year.

The Orioles team pennant hung on my bedroom wall, and on my dresser was their team photo along with my membership card to the Junior Orioles. Next to me as I kept score was my tattered shoe box containing my collection of baseball trading cards, sorted by team and held together by rubber bands.  A few hundred stale sticks of pink powdered bubble gum that came with each five-pack of cards was stacked neatly in one end of the box. The cards for the opposing team were spread before me so I could get the lineup and study their batting statistics.

What made me think of this was that the last of our snow had melted, and opening day is less than a month away.  Last year my son and I went to a minor league game. Although the grass was just as green, and the hot dogs smelled the same, nothing was the same. Still, it beat a stick in the eye. Things change. Baseball changed, and nobody conferred with me before changing it. At the game I didn’t see a single person keeping a scorecard, let alone a dad teaching his son or daughter how to keep the score. The only constant throughout the game was the commercialization.

That’s progress. Or maybe not. Some progress is good. Some progress doesn’t exist even though everybody around it believes that it does.

Implementing new technology doesn’t in and of itself infer progress, it simply means you bought more technology. Not convinced? How is the productivity of your EHR?  Add up all the money you’ve spent on EHR and technology and recalculate your RIO.  Was it worth it?

Ray, people will come Ray. They’ll come to Iowa for reasons they can’t even fathom. They’ll turn up your driveway not knowing for sure why they’re doing it. They’ll arrive at your door as innocent as children, longing for the past. Of course, we won’t mind if you look around, you’ll say. It’s only $20 per person. They’ll pass over the money without even thinking about it: for it is money they have and peace they lack. And they’ll walk out to the bleachers; sit in shirtsleeves on a perfect afternoon. They’ll find they have reserved seats somewhere along one of the baselines, where they sat when they were children and cheered their heroes. And they’ll watch the game and it’ll be as if they dipped themselves in magic waters. The memories will be so thick they’ll have to brush them away from their faces. People will come Ray. The one constant through all the years, Ray, has been baseball. America has rolled by like an army of steamrollers. It has been erased like a blackboard, rebuilt and erased again. But baseball has marked the time. This field, this game: it’s a part of our past, Ray. It reminds of us of all that once was good and it could be again. Oh… people will come Ray. People will most definitely come.
-Terrance Mann in the movie, “Field of Dreams”

I tear up every time Ray asks, “Want to have a catch dad?”

 

AP reports EHR plan will fail. Now what?

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I just fell out of the stupid tree and hit every branch on the way down. But lest I get ahead of myself, let us begin at the beginning. It started with homework–not mine–theirs. Among the three children of which I had oversight; coloring, spelling, reading, and exponents. How do parents without a math degree help their children with sixth-grade math?

“My mind is a raging torrent, flooded with rivulets of thought cascading into a waterfall of creative alternatives.” Hedley Lamar (Blazing Saddles). Unfortunately, mine, as I was soon to learn was merely flooded. Homework, answering the phone, running baths, drying hair, stories, prayers. The quality of my efforts seemed to be inversely proportional to the number of efforts undertaken. Eight-thirty–all three children tucked into bed.

Eight-thirty-one. The eleven-year-old enters the room complaining about his skinned knee. Without a moment’s hesitation, Super Dad springs into action, returning moments later with a band aid and a tube of salve. Thirty seconds later I was beaming–problem solved. At which point he asked me why I put Orajel on his cut. My wife gave me one of her patented “I told you so” smiles, and from the corner of my eye I happened to see my last viable neuron scamper across the floor.

One must tread carefully as one toys with the upper limits of the Peter Principle. There seems to be another postulate overlooked in the Principia Mathematica, which states that the number of spectators will grow exponentially as one approaches their limit of ineptitude.

Another frequently missed postulate is that committees are capable of accelerating the time required to reach their individual ineptitude limit. They circumvent the planning process to get quickly to doing, forgetting to ask if what they are doing will work. They then compound the problem by ignoring questions of feasibility, questions for which the committee is even less interested in answering. If we were discussing particle theory we would be describing a cataclysmic chain reaction, the breakdown of all matter. Here we are merely describing the breakdown of a national EHR roll out.

What is your point?  Fair question.  How will we get the nationalization of EHR to work?  I know “Duh” is not considered a term of art in any profession, however, it is exactly the word needed.  It appears they  are deciding that this—“this” being the current plan that will enable point-to-point connection of an individual record—will not work, and 2014 may be in jeopardy—not the actual year, interoperability.  Thanks for riding along with us, now return your seat back and tray table to their upright and most uncomfortable position.

Even as some throw away their membership in the flat earth society, those same they’s continue to press forward in Lemming-lock-step as though nothing is wrong.

It is a failed plan.  It can’t be tweaked.  We can’t simply revisit RHIOs and HIEs.  We have reached the do-over moment, not necessarily at the provider level, although marching along without standards will cause a great deal of rework for healthcare providers.  Having reached that moment, let us do something.  Focusing on certification, ARRA, and meaningful use will prove to be nothing more than a smoke screen.

That swishing sound you keep hearing is the sound of productivity in free fall.  The functionality of most installed EHRs ends at the front door.  We have been discussing that point for a few months.  When you reach the fork in the road, take it.  Each dollar spent from this moment forth going down the wrong EHR tine will cost two dollars to overcome.

EHR–what do you do when your vendor leaves?

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The room was silent except for the humming noise made by the computers’ fans. It smelled of stale cigarettes and spilt hops.  The venetian blind the program manager had been wearing as a hula skirt lay bent and twisted next to the large aluminum trash can.  Other than the light coming from the smashed exit sign, the only other illumination came from the few remaining flat screen monitors.

I made my way across the floor of the EHR War Room, accidently kicking the empty bottle of Grey Goose.  I watched without interest as it spun around on the damp commercial carpeting as though it was playing a solo game of spin the bottle.

The ten page project plan hung in tatters on the far wall, itself the victim of a game of nacho-darts.  Of the thirty-five desks in the room, all but four were empty.  The empty desks sat barren; no computers, no user manuals—no scraps big enough for the other Whos’ mouces.

Friday’s party was a joint celebration of the project team for the EHR go-live.  The thirty-one members the vendor had supplied were in such a hurry to leave the project at the end of the party that two of them were almost trampled to death by their mates as they rushed the door.  The scene was reminiscent of the Running of the Bulls in Pamplona.

Sally’s desk sat next to the wall chart that displayed the daily decline in productivity.  Her head rested on her desk while her monitor’s coral reef screen saver displayed a single yellow tang swimming from left to right and back again.

Larry was staring aimlessly into a Styrofoam cup, using his index finger to stir what was left of a room temperature margarita.  “What now Boss?” He asked.  “We all know it does not do what it is supposed to do.  And, you know who they are going to blame; us.

“Well, at least we have the Meaningful Use money to look forward to,” chimed Sally.  “That should make them happy upstairs.”

“We spent more money on chips and salsa than we will see of the ARRA money,” I told her.  She slumped back to her desk.

What now indeed, I wondered.  What do we do once all the money has been spent and the subject matter experts leave?

“Maybe if we do not say anything nobody will know,” I offered.  “Let’s pretend we know something about ICD-10, keep our heads down, and try to look busy.”

What should we do?  What would you do if your mother asked you?

Is there a valid business argument for certification?

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Policy Committee Establishes Multiple EHR Certifiers

They are killing me.

How about that for strategic guidance.  If they state that the earth is flat, and create multiple certifiers, I guess it’s time for Elvis to leave the building.

May we consider this for a moment, just between the two of us?  We are paying them to come up with this, and I want a refund.

Does anyone esle take issue with this?  Here’s my problem–or at least the one I am legally allowed to disclose.

Certification, by definition, only exists because of a high possibility of systems being implemented that won’t do what some group deems they need to do.

Allow me to be a heretic for a few minutes.  Maybe certification is bad.  Catch your breath and think about it.  The only thing certification gets you is the possibility of stimulus rebates being made available to healthcare providers by people who have demonstrated all most no understanding of the business issues you face.  Is that possibly true?

For many, the rebates are nothing more than a rounding error.  Why build a system to be able to attest to goals which may not benefit your business?  In spite of how it’s written, I think certification and meaningful use won’t be known for a few years.  When it’s finally defined, it will have to do with how well your EHR connects to their network.  That’s what they want, that’s what the money is for interoperability.  The other issues are window dressing.

Build your EHR as though Washington and certification don’t exist.  Build it based on what it does for you, not on what they think it may do for them.

 

The EHR Deception

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As I was walking through the store, I spilled the coffee on the floor…

Two pounds of Sumatra espresso beans; dark roast.  I set the grinder to the finest setting, and without batting an eye, I dumped the two pounds of beans into the one-pound grinder hopper—should have batted an eye.  For those who may be wondering, coffee beans sound similar to hail hitting a window as they spill on to the floor.

The tool I was using did not have the capacity to do what I needed it to do.  So not only was the job not done, I had created quite a mess for myself.

This is a lot like EHR and ICD-10 only without the aroma—trying to complete a two-pound task with a one-pound tool—under scoping the problem.  Implementing the application accounts for about fifty percent of what needs to be done for either solution to be effective.

What is in the other pound, what bits are consistently underestimated?

  • Planning (with a capital P)
  • Process alignment, elimination, and optimization
  • Change management
  • Training

Here’s another thing I learned at the store.  If one pound of coffee costs twelve dollars, how much does two pounds of coffee cost?  That is right; the second pound also costs twelve dollars.  So, if EHR costs twelve million several times over to implement, doing all the other related tasks should also be budgeted for about the same amount.

Sometimes it is better to just stick with drinking tea.

 

Which EHR should you buy? Read & Learn

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

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

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

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

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

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

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

“How is your productivity?”  Asked the cynic.

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

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

 

 

Poken: How to push the EMR to the cloud

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

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

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

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

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

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

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

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

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

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

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