Hospital

Hospital CIOs: Something to think about

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My new post in healthsystemCIO.com CIOs Must Paint a Real EMR/ACO Picture…http://ow.ly/3w7Al

Patient Relationship Management-Master of the Jedi Order

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They don’t call me Yoda for nothing. This little rant is for those acolytes drinking the Kool Aid of disbelief, the recipe that says one day, if we stay the course, this will all get better.  These are those who believe the light at the end of the tunnel isn’t a train.
For the next few minutes try and disassociate yourself from your responsibilities at work and become a patient.  Recall a time when you’ve been a dissatisfied patient and afterward felt the need to interact with your provider. If you’re totally honest, the forthcoming interaction should quicken your pulse. Cold beads of sweat appear on your forehead, your palms feel a little clammy, and you feel an unexplained need to microwave your neighbor’s cat.

The transition is faster than Clark Kent in a phone booth. A mild mannered and pedestrian acolyte transformed into a right-winged, Myers-Briggs INTJ A-Type with a passion for metaphorically devouring the unfortunate person awaiting your phone call.

As you think about managing the equity of your patients think about it from the perspective of the patient, goodness knows they do. That relationship is black and white—there are no shades of gray. It’s good versus evil, Yoda versus Darth Vader.

Patients Experience Management versus Patient Experience Management.  See that little ‘s’ tacked on to the word patient?  One letter makes a world of difference.  Patients do experience the decisions of your hospital’s management, and oftentimes that experience is unpleasant.  That experience can involve a broad range of issues–billing, insurance, dispute management, scheduling, prescriptions.

I think with most patient interactions the patients believe that the person on the other end of the line (think hospital customer service person) is incented to make them go away as quickly as possible and at the lowest possible expense to the provider.

For most patients, patient loyalty is a thing of the past.

With whom do you do business? Why? For any product that is even close to being a commodity, I deal with the firm who I find to be the least offensive, the one that will irritate me the least. That’s why I buy cars on eBay so I never again have to hear the phrase, “What’s it going to take to get you into that car?” If you find yourself doing that, why is it such a stretch to believe so many patients feel the same way? That said, could it be rather naïve to believe your hospital’s current approach to patient relationship management will make any difference?

CIO shift, happens–or shift happens

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Another comment of mine to Barbara Quack’s post; http://ducknetweb.blogspot.com/2010/12/cio-confidence-in-meaningful-use-drops.html#comment-form

I think you hit the nail on the head.  I think a lot of this can be attributed to the fact that stuff rolls down hill and that shift happens.

In healthcare, as in every significant industry, part of the problem seems to come from the fact that CIOs are often considered to be part of the C-suite in name only.  There are several notable exceptions to this observation, CIOs who drive business strategy instead of merely implementing the business strategy that was developed in the “real” C-suite.  Many C-suiters perceive the real role of the CIO is to apply technology to accomplish what they (the C-suite) want done.

Many executives, CFOs, CMOs, COOs, and CEOs regard the position of CIO such that the “C” (chief) and “O” (officer) are honorariums; officers in name only, officers with commensurately sized offices located on the third floor or in an offsite location.  Responsibility often without authority.

I think the issue of Meaningful Use is a clear example of how the practice works.  I worked with a large group of hospitals whose CIO had a detailed IT strategy and plan—projects, ROIs, resources, and capital.  His plan was tied to the business plan which he helped author.

He did EHR and CPOE before EHR was de rigueur.  Then along came Meaningful Use.  Without any understanding of the business issues or consequences associated with meeting Meaningful Use, the C-er’s and the board decided that not meeting Meaningful Use was not up for discussion.  The analysis was thorough, but unimportant.

In a nutshell, the organization which had already implemented EHR and CPOE because of his thought leadership—and long before DC got into the EHR thought leadership business—was instructed to meet Meaningful Use, all else be damned.  The “all else” included whatever it was that eighty percent of his IT staff would have worked on during the next three years.

For the sake of a check, the IT strategy was sacrificed, and the IT strategy’s alignment to the business strategy was sacrificed.  Did they get the check?  Will they pass the Meaningful Use audit?  IT will be blamed if they fail to meet Meaningful Use.  They will be blamed when they fail to deliver all of the other parts of their original plan.  And, they will be blamed if the standards shift in mid-stream.  Why?  Shift happens.  Responsibility often without authority.

“Memo from the CFO: How’s that whole ICD-10 initiative coming?  Holler if I can do anything.”

And guess what’s coming around the corner?  The new hot topic to roll down hill will be the decision that comes out something like this; “Memo from the CEO: The board decided we need to be seen as an Accountable Care Organization by the end of 2012.  Holler if I can do anything.”

Information Technology—IT.  “That must be where we keep all the technology in case we need it.”  Just send out a request and one of those technology guys will put it in for us.

There is only one thing that will stop this train from making the office of the CIO the bucket into which the downhill water is running.  Lead.  Plan.  Instead of planning for what technology and IT resources you need to deliver to meet their orders, draft a healthcare strategy instead of an IT strategy.  Bring forth a business plan addressing business problems that uses technology as a solution to solve the problems.

Define what is needed, on top of what you already need, to meet ICD-10.

Define what is needed, on top of what you already need, to make ACOs viable.

If you wait to respond to their IT orders, it will be too late.

What is troubling hospitals? What isn’t?

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I wrote this as a comment to Barbara Duck’s fine post in her blog, http://ow.ly/3tFPx

Part of the problem, at least in my mind is that many of the large and small provider business models are trapped in what any MBA student would label an 0.2 model. The two biggest adversaries to provider’s success and limiting their ability to change, the two industries constraining the providers’ ability to run a profitable business, pharmaceuticals and the payors, exercise power that comes from their scale.

Add to that complexities brought to bear by other large external influencers—the rule-makers, makes it almost impossible to know what business model to build and under which to operate because providers must build strategies designed to hit unknown and moving targets; reform, regulation, and Medicaid, Medicare. Whatever strategy they design will be ineffective by the time it is implemented.

It is important to note that healthcare providers represent the only industry which does not know the cost of ninety percent of the services they deliver. They do not know what something costs, but they do know what they charge. Even the identical procedure at the same hospital will produce a different bill. How does one run a business suing those pricing models?

You may or may not know that Shakespeare spelled his own name five different ways. While that worked out okay for him, using that as a pricing model—I know this analogy is a stretch—makes no sense.

Compare hospital pricing to McDonald’s who knows how profits will be impacted if they so much as add another pickle to a hamburger.
Nobody can tell you what a tonsillectomy costs, or the profit earned from the procedure. Even for hospital IDNs, the same service will be priced differently, will be charged differently, and will be reimbursed differently.

Through acquisition and mismanagement many hospitals have multiple occurrences of large business processes; to name a few—admissions, IT, HR, payroll, pharmacy.

The time has come to separate the hospital business model into two components; the business of healthcare—how it is run, and the healthcare business—the care component. Care is delivered using a best-process model, whereas some will argue the business of healthcare is often managed no better than a lemonade stand.

There are no measures used by hospitals that allow them to calculate the ROI of a patient or a physician over five or ten years. There is no Patient Equity Management process to reduce patient or physician churn.

Large hospitals have spent more than $100,000,000 to implement failed EHRs—sixty percent of them fail. Hospitals are rushing through their implementations to try to secure minimal ARRA payments. Many hospitals are on EHR 2.0 thinking that by changing their EHR vendor they will have a better chance of succeeding. To that model they hope to incorporate ACOs.

Maybe before they boldly go where no man has gone before, they should pause and come up with a real plan of attack.

Patient Experience Management: Who is your Chief Patient Officer?

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(This column is not outsourced to Mexico.)

How many chiefs can you name? C-Levels, not Indians. I found these–COO, CIO, CTO, CMO, CMIO, CEO, CAO, CFO, Chief Purchasing Officer, Chief Network Officer, Chief Engineering Officer, Chief Benefits Officer, Chief Development Officer, Chief Brand Officer, Chief Staff Officer, Chief Health Officer, Chief Legal Officer, Chief Quality Officer.

Besides who gets the corner office, these titles demonstrate a firm’s commitment to those areas of their business, and these positions provide that business sector visibility all the way to the top of the firm. There’s a certain cachet that comes from having your sector of the business headed by a C-Level. Those are the ‘in’ jobs, the jobs to which or to whit one is supposed to aspire. You never see anyone clambering for a B-Level position. B-Level is the repository for all non C-Level jobs.

Remember Thanksgiving dinner when you were a child—apologies to those of who aren’t from the colonies. Anyway, if yours was anything like mine, there were two tables, the nice dining room table for the adults, and the smaller card table for the children, the B-Level guests.

So what does this have to do with patient care? You tell me. Let’s go from the premise that the C-Level positions are an accurate reflection of you firm’s focus. Why are we in business? If you go from the premise it must be because of finance, marketing, IT, Purchasing, or any of a dozen other things. The only thing missing in this view of the firm is the patient. The only entity without a seat at the grownup’s table is the person in the firm responsible for the patient. It seems to me a firm’s very existence, it’s raison d’être, is the patient. If that’s true, when do they get to eat with the grownups?

McKinsey published a study conducted with 1,000 CEOs and COOs to rank their top 5 initiatives over the next five years.  Ninety percent of them ranked Patient Experience Management as either their first or second priority.  The punch line of the study was that they did not know who in their organization “owned” the patient.  How is that for leadership?

If they don’t own the patient, I am willing to bet the patient owns them. If that is the case, Social CRM, S-CRM, will not be doing these executives any favors.

 

How measuring Brittan can improve your EHR success

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So, last night I am watching NOVA.  The episode discussed fractal geometry and aired the same time as the Green Bay-New England game.  Admittedly, not a typical Y-chromosome choice, but interesting none-the-less.

A fractal is a fragmented geometric shape that can be split into parts, each of which is a reduced-size copy of the whole.  Simple enough.  Common examples of fractals include the branching of trees, lightning, the branching of blood vessels, and snowflakes.  I am willing to bet I think of many of the ideas on which I ruminate in a fractal manner.

In the seventies the mathematician Benoît Mandelbrot discovered that fractals could be described mathematically.

It turns out that a shoreline is another example of a fractal.  For example, let’s say you wanted to determine the length of the coast of Brittan by measuring it instead of just using Google.  The coastline paradox says the measured length of the coastline depends on the scale of measurement.  The smaller the scale of measurement, the longer the measurement becomes.  Thus, you would get a longer measurement if you measured the coastline with a ruler than with a yardstick.  This paradox can be extrapolated to show that the measured length increases without limit as the unit of measures tends towards zero.  In the first picture, using a 200 km ruler, the coastline measures 2,400 km.

In this photo, using a 50 km ruler, the coastline measures 3,200 km.

I’m not sure why this idea needed to be discovered, it seems a little obvious—more information yields more informed results.

A few years ago I was hired by a firm to report to their board on their vendor selection process.  The firm was about to issue a two-page RFP to two vendors.  I convinced the firm to redo the process.  They ultimately issued an RFP of more than a thousand requirements and selected a vendor who was not on their original list.

Again it seems obvious, but being obvious doesn’t always result in smart behavior.  If you’re getting ready to spend eight to nine figures on and EHR, wouldn’t you like some degree of confidence that you selected the best one for your hospital?

One thing is certain, albeit less obvious, the more due diligence you give EHR, the higher your chances of success will be when you try to build out an ACO business model.

 

EHR: Should you hire a swim coach?

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Swimming with guppies.

Got the new bike, got the new bike shoes, got the uni (uniform-not unitard).  I’ve written about my desire to compete in a triathlon.  Actually, I miswrote.  My desire is not to compete, it’s more accurately a desire not to make a fool of myself during the swim, more specifically not to drown.

The swimming is one of those events where having the coolest outfit doesn’t help, as there are no coolest swimming outfits (men do not let men wear Speedos).  There aren’t enough North Face labels for me to wear to make me look like I know what I’m doing in a pool.

What to do?  Here’s my thinking.  I made a new friend, and as a bonus, she happens to be pretty sharp on the pharma side of healthcare.  She swims—fast.  She swims—a lot.  Did I mention she swims?  Longtime readers know I like to color outside the lines.  Maybe I could hire her to take my place during that part of the race.  Then we get back to the issue of the uni.  One way or another that becomes an issue for one of us.

She offered to teach me.  Lesson one was today.  Lesson two will begin right after the EMTs finish their CPR on me.  Rule one, no matter how cool you think you are, you can’t breathe under water.  That took a few laps to master.  More breathing, stroke, legs.  Lots to learn.

“Let’s get a pool boy to help you not drag your legs,” she suggested.

I have difficulty passing up the opportunity to comment.  She could see I had the broccoli in the headlights look in my eyes.  “You hold it between your legs and it helps you float.”

I scanned the pool.  There we the two of us…and the lifeguard.  “It looks like he’s busy,” I offered somewhat sheepishly.  “Besides, if that’s what it takes, I think we’re both better off if I drag my legs.” (A little un-PC pool humor, but why not, I was already wet and being out swum.

So, what does this have to do with why we’re here?  Here’s the take away.  Sometimes, no matter how smart, no matter how big your ego, you need help.  Sometimes it makes a huge difference to have someone on your side who’s been there, done that, got the T-shirt.

Not with me yet?  A guy (man or woman guy—send me an email and let me know when we can let go of this PC thing and just write) is walking down the road, not watching where he’s going, and he/we/she/it falls into a deep hole.

An engineer walks by.  “Help me,” shouts Hole Person.

The engineer thinks for a moment, writes some ideas on a piece of paper and tosses them into the hole.

Several hours later, a finance guy walks by.  “Help me out (literally)” yells Hole Person.  The CFO tosses down a cheque (I use the Canadian spelling to distinguish it from someone from the Eastern Bloc as it would make no sense to toss another person into the hole.)

Days later, Hole Boy (not the same as Pool Boy in case anyone is still reading) is at the end of his rope.  The work plan failed. The Check bounced.

A consultant passed, saw the man, and hopped into the hole.

“Why did you do that?  Now we’re both stuck.”

The consultant smiled in a Grinch-like fashion—please see prior blog for the segue.  “I’ve been down here before, and I know the way out.”

Kind’ a like a swim coach.

EHR projects have more zeros than you can count.  What if you could hire someone who knew the way out?

I may know someone who can help.

 

Does ego get in the way of making change an imperative?

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My friends who have nicknamed me Dr. Knowledge or the Voice of Reason have seen me on those rare moments when the synapses were firing on all cylinders. There are others who have seen me in my less than knowledgeable moments.

For instance. There was the time I took my three young children to the movies. Upon returning home we heard the calming sound of water flowing; only it wasn’t calming since our home was not built with a stream running through it. After looking in the basement and seeing water streaming through the ceiling, I called our builder’s hot-line. I was furious at them and so told the handyman as he looked at the exposed rafters.

Undaunted, and convinced that the pipes were fine, he proceeded to the first floor to source the leak. I saw water coming through the wall and ceiling of the conservatory and gave him another piece of my mind—something my mother had always cautioned against so as to ensure I still had some left in case I needed it. We headed upstairs, through a bedroom, into my son’s bathroom. By this time we were wading. The sink faucet was in the on position, the drain was in the closed position, and I was in no position to blame the builder.

I learned that my son had been doing a ‘speriment’ with the soap. He told me it was my fault he didn’t turn off the faucet before we left because I told him, “come down stairs right now.” He no longer does ‘speriments’ in the sink and most of the waviness in the wallboard has subsided.

I hate being wrong, especially in front of an audience. Once I have an opinion about something, the planet has to shift on its axis before I’m likely to reconsider. I’ve found that to be true with building strategy to support a business that is undergoing radical change, especially when people are asked to consider not doing something, or are asked to consider doing something differently. There’s way too much, “That’s the way we’ve always done it,” and, “That’s the way corporate told us to do it.” What in your strategy would benefit if someone considered doing something differently?

This week I met with an MD and former hospital CEO who told me he is writing the business strategy for a group of hospitals.  When I queried him about what difficulties he was encountering he mentioned that everyone from the board on down “just does not have a clue.”  (And you thought it was just me.)  The things for which he concluded they do not have a clue are legion, including:

  • they have a budget, not a plan
  • they have never discussed integrating an IT strategy with the business strategy–which is just as well as they do not have an IT strategy
  • the are ready to select a name-brand EHR vendor and to spend close to $100 million, but they did no due diligence as to which vendor to select–seems one of their execs knows one of the vendor’s execs
  • they have more duplicative business processes than Imelda has shoes
  • they are all fired up about moving to an ACO model, but have zero understanding of how an ACO model will fit their organization

One may be successful using this approach to run a lemonade stand.  My guess is that the strategy will require a little tweaking to get it to work for a hospital group.

Warmest regards,

Dr. Knowledge.

 

What can the ONC learn from the 80% of hospitals who are not on board with EHR?

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The ONC’s State of the Union Message will be delivered this week over a two-day period.  Rather than attend, I have decided to wait until the operatic version of the meeting is available on YouTube.  Mind you, I am convinced of the good intentions of their efforts, but to write I am skeptical of their results would be unfair in that my optimism would have to increase substantially for me to reach skeptical.

I am disappointed to report Chicken Little’s “The sky is falling” keynote presentation at the ONC event has been omitted from the agenda in favor of continuing to get others to believe that not only is Meaningful Use is meaningful, but also relevant.  I am not being intentionally trite, in fact, just the opposite.

The question unanswered by the ONC is does their stick and garrote approach make it relevant from a business perspective?  Its only relevance seems to be that without complying, hospitals’ revenues will decline.  Why will those revenues decline?  Is it because the hospitals made a poor business decision, lost patients to a competitor, or could not manage their expenses?  Of course not.  Their revenues will decline for one reason, and one reason alone—the ONC will give them less money for services they perform.

There are almost two-thousand hospitals in the US.  What percentage of them will complete EHR in time to reap their full incentive payment?  I think we can agree with a high degree of confidence that the number will be less than 20%–I’m guessing it will be closer to ten percent.  How many of those will then re-implement a certified version of EHR?  And then, what percentage of the remainder will pass the Meaningful Use audit?  You can probably fit all of those hospitals CEOs in a Hyundai mini-van.

If these figures are close to accurate, one might thing the issues at the forefront of the ONC’s efforts ought to be working with the other 80-90%.  They have tried to add that focus through incentive payments.  When that didn’t take the ONC created the Regional Extension Centers (RECs).  What percentage of the majority of hospitals is benefiting from using the RECs?  Will hospitals and doctors be able to link to the HIEs and into the N-HIN?  Me thinks not.

I have begun to think Mark Twain’s story Tom Sawyer may have been prescient when viewed in the light of EHR and Meaningful Use.  In particular is the part where Tom gets others to whitewash the fence.  Is it possible the ONC’s vision is limited to equipping people with giant paintbrushes who are, sadly short of a giant pot of paint?

Is their existing plan one which is executable?  Just because they have a plan, if most of the country’s hospitals have not bought into it, does not that simply make it a plan in name only?  Even if they buy into it does not, in and of itself make it viable.

If eighty percent of the hospitals are not on board, what can be learned from their lack of response?  Is it due simply to a lack of effort, as some would have us believe, or is there something more to it?  I think the lack of response by the majority of hospitals should lead us to conclude that something important about the strategy is lacking, to conclude that something is amiss.  If someone asked me—and just to give you comfort, nobody has—my conclusion is that more would be gained by the ONC holding a two-day listening session instead of a two-day speaking session.

Can eighty percent of the hospitals have no message worth hearing?

 

How will ACOs impact HIT?

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I know it makes you nervous to learn I have been thinking about something as there is no telling what may develop.  Feel free to use a highlighter on your screen if you find anything of interest.

The healthcare large provider business model looks more and more like its designed used to be the woman at kid’s birthday parties who makes animals and things out of balloons.  With the blue balloon she can make a giraffe, a bike from the green balloon, and a hippo from the pink one.

If she’s highly skilled she will build something complex using a number of different balloons.  Let us try to imagine watching her as she sets about to build a riding lawn mower.  With several popped balloons lying at her feet on the carpet she presents us with a green and yellow John Deere mower which used more than a dozen balloons.  Next, disregarding the pacifists at the party, she builds a B-1 bomber.   Her third assignment results in a McMansion with working Jacuzzi.

Each balloon creation is more complex than the preceding.  Being unimpressed I asked her if she could incorporate the design of the bomber into the design of the lawn mower.  The only rule—she was not allowed to pop any of the mower’s balloons.  If she was able to achieve that successfully, she would then have to incorporate the house onto the bomber onto the mower.

Balloons started popping and did not stop until there were none left, making it impossible to even save the mower.

Imagine a hospital’s pre-EHR business model as the lawn mower.  What happens next is that same business model is forced to adapt to EHR—like overlaying the bomber onto the mower.  Along comes accountable care organizations (ACOs).  House-bomber-mower.

This makes for an interesting planning exercise.  If we assume, as many have, that the existing hospital business model has been cobbled together over twenty to thirty years, retrofitting it will be no small task.  The problems we are seeing with many EHRs is that if implemented on top of the old business model, the odds for a failed EHR implementation are at least equal to the odds of a successful implementation.  For many, a “successful” implementation is viewed as one where productivity may be down by as much as twenty percent.

To the retrofitted EHR business model hospitals will soon try to implement the Healthcare IT demands of ACOs.  I recommend you first try these using balloons.  It will look prettier when it breaks; and will be much less expensive.

EHRs and ACOs are devilishly complex, and trying to implement them on a framework designed to support neither means that everything will work poorly.  (I was going to write that everything will work less well than planned, but it occurred to me given some of the plans I have seen that it will all work just as planned.)

I just read an article in a major trade organization stating “accountable care organizations must encourage patients to participate in the prevention of their care.”  That approach seems counter-intuitive to me, but maybe I am missing something.  Then again, it may all work just as planned.