EHR Incentive Payments: The line forms at the rear

Three AM.  A night not fit for man nor beast.  Billowing fog roiled out of the steam grates all but obscuring vast sections of the town.

I arrived early to secure my place in line—my first tail-gate party since leaving college.  The trunk of my car was loaded with my gear as I eased to the curb along Independence Avenue.  Orange traffic cones and blockades were scattered along the street in anticipation of the crowds.  The traffic officer checked my permit and directed me to my parking spot.

“We are anticipating a huge crowd,” he said.  “It looks like you are the first to arrive.”

“You look like you have done this before,” I remarked.

“Pretty much every day.  Ain’t a day goes by when the feds aren’t giving away truck loads of money for one thing or another.”

I unloaded my car—lawn chair, iPad, boom box, sleeping bag, and enough Starbucks to ensure I would need to use the Port-a-Potty well before the doors opened at eight AM.

I had expected the line to be wrapped around the block several times.  “Where are the others I asked?”

“I am not sure.  Dr. B. told us to expect to be overwhelmed,” responded the officer as he blew on this hands, and did the “my feet are freezing dance” on the pavement.

Sitting there for two hours I was undisturbed until two vans pulled alongside.  A warmly-dressed woman wearing a Mayo North Face jacket set up camp next to me.  “You look cold,” she said.  “In Minnesota, weather like this reminds us of spring.”

Disembarking from a big pretty white van with red stripes, curtains in the windows that looked like a big Tylenol was a man wearing shorts, flip-flops, with his hair tied back in a pony tail.  All he carried was a skate board.  “Rex Kramer,” he said as he extended his tanned hand to shake mine.  “You can call me ‘Dude’.  I’m from Kaiser.”  (As though the skate board and shorts were not a dead giveaway.)

“Where are the others?” I inquired.

Dude Kaiser and Spring Mayo looked at me like I had just told them I had implemented EHR on my MP3 player.  “Nobody else is coming,” quipped Spring.

“Surely, you jest.”

“I jest you not…and please don’t call me Shirley.”

I was worried for a moment whether she would ask me if I liked movies about gladiators.  Instead I asked, “Nervous?”


“First time?”

“No.  I’ve been nervous before.”  She slapped me back to reality and causing me to drop my poor imitation of Ted Striker.

Dude gave me his take on the EHR rebate situation.  “Nobody else is coming because nobody else can collect.”  I looked into his blue eyes with a stare of my own that suggested I was the deer that had just been run over by the pair of headlights to which everyone always references.

“When you factor in all of the critical success factors about EHR, certification, the RECs, HIEs, CPOE, and the N-HIN, a lack of standards, and interoperability, one thing is always overlooked.  And that one thing takes precedence over all the others.  KM.”

“And just what is KM?”

“Kaiser Money—any number that is followed by nine zeros.  It took us a long time to decide between spending that kind of cha-ching.  I tried to get them to buy a country from South America, but got no takers.”

“How much will you get for your investment?” I inquired.

I could see him doing the calculations in his head as he applied another coat of Hawaiian Tropic to his skin hoping the glow of the moon might enhance his tan. “Well, it’s difficult to say with any degree of certainty.  But when all is said and done, I estimate we’ll see somewhere between one-ten point four and one-ten point five.”


“No silly, dollars. By the way, you ever been to a Turkish prison?”

How the Grinch stole healthcare

Not much has changed since I wrote this two years ago…or has it?

Every Congressman Down in Congress-ville
Liked Health reform a lot…But the Payors,
Who lived just North of Congress-ville,
Did NOT!

The Payors hated Health Reform! The Congressional reform season!
And as everyone’s heard there is more than one reason.
Was it the fear of losing their monopoly right?
Worried, perhaps, that Congress might indict.
But I think that the most likely reason of all
May have been that the uninsured took them all to the wall.

Staring down from their man-caves with indemnifying frowns
At the warm lighted windows below in the town.
For they knew every Congressman down in Congress-ville beneath,
Canted an ear to hear Congress gnashing their teeth.

“If this reform passes, they’ll kill our careers!”
“Healthcare reform! It’s practically here!”
Then they growled, the ideologues’ fingers nervously drumming,
“We MUST find a way to keep Reform from coming!”

For, tomorrow, they knew…

…Stumbling home from the tavern at a quarter past two What each Congressman, intern, and page just might just do And then all the milieu. Oh the milieu, the milieu
Which the Payors hated more than their mom’s Mulligan stew.

Then all the Congressmen, the left and the right, would sit down and meet.
And they’d meet! And they’d meet!
And they’d MEET! MEET! MEET! MEET!
Implement full provision; cover pre-existing…how sweet
That was something the Payors couldn’t stand in the least!

And THEN they’d do something Payors liked least of all!
Every Congressman down in Congress-ville, the tall and the small,
Would stand close together, their Healthcare bells ringing.
With Blackberrys-in-hand, the Congress would start pinging!

They’d ping! And they’d ping!
And the more the Obligators thought of the Congressman-Health-Ping
The more they each thought, “I must stop reform-ing!
“Why for all of these years we’ve put up with it now!
We MUST stop health Reform from coming!
…But HOW?”

Then they got an idea!
An awful idea!
THE Indemnifiers

“I know what to do!” The CEO Payor laughed in his throat.
And he made a quick Congressional hat and a coat.
And he chuckled, and clucked, “What a great Payor raucous!
“With this coat and this hat, I’ll look just like Saint Bacchus!”

“All I need is a pass…”
The Payor looked around.
Since Congressional passes are scarce, there was none to be found.
Did that stop the old Payor…?
No! The Payor simply said,
“If I can’t find a pass, I’ll make one instead!”
So he called his aide Max. Then he took some red paper
And he dummied up the pass and he started this caper.

He loaded some bags
And some old empty sacks
On a Benz 550
And he rode with old Max.

Then the Payor called, “Dude!”
And the Benz started down
To the offices where the Congressmen
Lay a-snooze in their town.

All their windows were dark. Quiet snow filled the air.
All the Congressmen were dreaming sweet dreams of healthcare
When the Payor came to the first office in the square.
“This is stop number one,” The old Warrantist – a winner
And he slipped passed the guard, like sneaking to a State Dinner.

Then he slid down the hallway, Harry Reid was in sight.
Reid was chumming Pelosi, he planned quite a night.
He got nervous only once, for a moment or two.
Then he realized that the leadership hadn’t a clue
Then he found the Congressional stimuli all hung in a row.
“These Stimuli,” he grinned, “are the first things to go!”

The Payor slithered and slunk, with a smile somewhat mordant,
Around the old Cloakroom, looking quite discordant!
There were copies of the bill stuffed in jackets and on chairs, Why, he even found a copy tucked under the stairs
And he stuffed them in bags. Then the Payor, very neatly,
Started humming the jingle from Blue Cross; rather Cheeky!

Then he slunk to the Senate Chamber, the one facing East
He took the Senators’-copies!—didn’t mind in the least!
He cleaned out that Chamber and almost slipped on the floor.
Saw an Internet router, and thought of Al Gore

Then he stuffed all the copies in the trunk of his Benz.
And he thought to himself, “Why don’t I have friends?” “There’s always Tiger,” he said with no jest But TW’s being chased by reporters, those pests.

The Payor spotted the Grinch having trouble with his sacks
And he lent him a hand—he offered him Max Max was quite pleased, for he knew this December,
That the Grinch would become the Payor’s newest board member.

The Grinch was all smiles–he’d made quite a killing
Offering to help pillage if the Payor was willing.
He stared at the Payor and asked, “New glasses?”
The Payor simply smiled, saying “These people are such (You did that to yourself, not me.)

And, you know, that old Payor was so smart and conniving
When he next saw Pelosi he found himself smiling!
“Why, my dear little Nanc’,” the Bacchus look-alike stiffened,
“Botox in this light makes you look like a Griffin.”
“I’m taking these bills home,” he said pointing to the copy.
“There’s a comma on one page that looks way too sloppy.”

And his fib fooled the Griffin. Then he patted her head
And he gave her a wink, and he sent her to bed
And as Speaker Pelosi shuffled off to her army,
The Payor said to himself, “What a waste of Armani!”

The last thing the Payor needed to do,
Was to mess with these records systems, all four thousand and two.
So he drove to HHS, the DOD and the VA,
And stuffed mint jelly in their servers so their networks would not play

And the one EHR, that still worked in the DC
Was the one bought from CostCo and tucked under the tree.

Then he did some more damage
To HIEs, and the N-HIN,
Making the idea of a healthcare network
Just a has-been!

It was quarter past dawn…
None in Congress were his friends
All the Congressmen, still a-snooze
When he packed up his Benz,
Packed it up with their copies of reform in those bags! Stacked to the leather ceiling,
Manila envelopes with name tags!

Three miles away were the banks of the river,
He was poised with the bags all set to deliver!
“Pooh-pooh to the Congressmen!” he was Payor-ish-ly humming.
“They’re finding out now that no Reform is coming!
“They’re just waking up! I know just what they’ll do!
“Their mouths will hang open a minute or two
“The all the Congressman down in Congress-ville will all cry BOO-HOO!”

“That’s a noise,” grinned the Payor,
“That I simply must hear!”
So he paused and the Payor put a hand to his ear.
And he did hear a sound rising over the snow.
It started in low. Then it started to grow…

But the sound wasn’t sad!
Why, this sound sounded merry!
It couldn’t be so!
But it WAS merry! VERY!

He stared down at Congress-ville!
The Payor popped his eyes!
Then he shook!
What he saw was a shocking surprise!

Every Congressman down in Congress-ville, the tall and the small,
Was singing! Without any health reform at all!
The Congress didn’t care, a few were disgraces,
All they wanted, it seemed, was TV with their faces

And the Payor, with his Payor-feet knee deep in the muck,
Stood puzzling and puzzling: “Man, there goes my bucks.
It could be about healthcare! It could be global warming!
“It could be Al Qaeda, Afghanistan and desert storming”
And he puzzled three hours, `till his puzzler was sore.
Then the Payor thought of something he hadn’t before!
“Maybe Congress,” he thought, “simply needs a free ride.
“Maybe Congress,” he thought…just needs to look like they tried.

And what happened then…?
Well…in Congress-ville they say
That the Payor’s small wallet
Grew three sizes that day!
And the minute his wallet didn’t feel quite so tight,
He zoomed in his Benz passing through a red light
And he brought back the copies of the bill for reform!
And he……HE HIMSELF…!
The Payor calmed the whole storm!

Healthcare IT meets Ben & Jerry’s

The idea for this blog came about after reading a PowerPoint presentation by Doctor Alberto Borges.  All mistakes can be attributed to me.

When one is witness to the number of external influencers trying to shape policy on healthcare, reform, and healthcare IT, the best one can hope for is that hidden somewhere under the pile is a pony.

But let’s be real—the pony has suffocated.

While it is okay to point the finger of blame at the usual suspects—payors, lobbyists, and the lawmakers—let us not forget to ensure to point out the role paid by the healthcare IT applications vendors.

“Who me?” You ask.

Decrease costs, increase quality, decrease errors.  I did not invent these words; they are written on your websites.

Prior to 2008 the value of EHR vendors’ stocks plummeted.  Look at them now.  How does one explain the difference?  Can the gains be attributed to vendors having rewritten their applications?  New technological innovations?  If not, what else could it be?

Meaningful Use.  Meaningful Use tied to Medicare payments and a twenty billion dollar incentive to get providers to do something they otherwise would not have done.  Could life be any better if you are sitting in the EHR Tower’s corner office?

What if we think about the issue this way?  Let us suppose all of the leading ice cream manufacturers lobbied Congress to push for including ice cream machines in all new cars starting in 2012…silly idea, but then again, so is Meaningful Use.  Not only do the ice cream machines have to be installed, but they have to be able to communicate with one another.  That way, if I happen to rent a car, the ice cream machine in my rental will already know what type of ice cream I like to eat.

Now we already know that no car buyers and no car builders will think much of being forced to buy or make cars with pre-installed ice cream makers.  But, perhaps there is a way around that.  Maybe in some self-serving way the Cookies and Cream lobby can convince Washington of the merits of pushing through their agenda.

Time passes, and still the idea is not getting much purchase.  What happens next?  The ice cream manufactures get Congress to pass the Ice Cream Tech Act—ICTA.  And as part of the ICTA Act, Ben and Jerrys, Baskin Robbins, and Haagen Dazs convince our friends to offer the auto manufacturers a twenty-billion dollar rebate for building cars with built-in ice cream makers—ICTA Initiatives.

Now, why would the Ben’s and Jerry’s do this?  Good question.  They will do this because they know that without offering a large financial incentive the car company executives will not do what they want them to do.  Now to insert ice cream makers, you can imagine that the car companies will have to go way off message, will have to change their strategy, and will have to incur all sorts of costs that have nothing to do with selling cars.

And that brings us back to the start of this story.  There is a reason why EHR vendors needed to lobby Congress to put forth more than twenty billion dollars of lottery money, and that reason is healthcare providers would not be doing EHR the Meaningful Use way unless there was a monetary reason to do it.  There certainly is no business reason to do it.

And for the most part, if providers calculate an ROI on EHR, even factoring in the incentive payments, there is still no reasonable financial argument that can be made.  In fact, when the cost to meet Meaningful Use is factored in, the financial argument worsens.

So, what will happen?  Here is what we know so far.  The Meaningful Use deadlines draw closer, meaning there is less time left to get the incentive dollars.  Implementations of EHR continue to falter, be redone, and under deliver.  The result is that the purchase of EHR systems will slow, and many EHRs will be uninstalled.  When there is no time left to get the incentive dollars, only then will EHR implementations be driven by the needs of the providers, and the government will no longer be driving the process.


The Business Strategy of Meaningful Use

For those interested in a somewhat irreverent presentation on the business issues of Meaningful Use who won’t be attending the New England HFMA this Tuesday, here is an advanced copy of my presentation

I’d like to know what you think…

Why isn’t EHR more successful?

Grab a soft-drink—this one is rather long. Please forgive any formatting mistakes–it looked good in Word.

I have never been one who thinks hit-and-run critiquing is fair. It is too easy to throw metaphorical tomatoes at an idea with which you disagree. As such, perhaps instead of just being critical of the national EHR rollout plan, here are a few ideas which may be worth exploring in more detail.

It just occurred to me that the ONC’s role, the Office of the National Coordinator, is just that—coordination. Who or what is the ONC supposed to be coordinating—among its various functions–the providers? There are the coordinators, and their constituents—the uncoordinated. I know at least one provider who already spent $400 million on its EHR. They didn’t get coordinated. I asked one of their executives who played a major oversight role in the implementation, with whom they worked at the ONC. She was not even familiar with the acronym.

I don’t think providers are looking to be coordinated—they are looking to be led. I also think they are looking to be asked and to be heard. They are looking for answers to basic questions like; why should we do this, what is in it for me—this has nothing to do with incentive dollars.

It often seems like the ONC has developed many solutions seeking a problem, filling their tool bag in the hope they brought along the right one. This is where I think we see a good portion of the disconnect. It is better to say we know where we are going, but getting there slowly, instead of, we don’t know where we are going but we are making really good time.

People don’t buy drills because they need a drill—they buy them because nobody sells holes—say it with me—holes. Providers need holes, not HIEs and RECs.

You understand the pressures you face much better than do I. Has anyone from the ONC asked you if they should reconsider their plan, their approach, their timing? Chances are good that you are not implementing EHR and CPOE because you have a vision or a business imperative of someday being able to connect your EHR to Our Lady of Perpetual Interoperability. CIOs and their peers are not spending eight or nine figures because you want a virtual national healthcare infrastructure. The C-team is investing its scarce resources to make its operation better, to reap the rewards of the promise of EHR.

The ONC is spending its resources towards a different goal, a virtual national healthcare infrastructure. The two goals do not necessarily overlap. I am reminded of the photo showing the driving of the Golden Spike—the connecting of the Union Pacific Railroad to the Central Pacific Railroad—the final link of the Transcontinental Railroad that in the 1870’s allowed Americans to cross the US by rail. What would have happened had the two railroads worked independently of each other? They would have built very nice railroads whose tracks would never have met, tracks dead ending in the middle of nowhere. Even if they almost met, say got within a few feet of each other, they would have failed.

There are those who see the work of the ONC as a real value-add. I dare say that most of those are not hospital CIOs or physicians. Both groups define value-add and success differently.

This is not to say that providers would not accept all the help they can get. However, providers want the help to be…what is the word I am searching for—helpful—to them, to their issues. The ONC’s mission will not work until the providers successfully deliver what the ONC needs from them. How many providers must be Stage 7, Meaningful Use, Certified compliant for the virtual national healthcare infrastructure to work? Fifty percent? Eighty? Who knows.

So, the providers own the critical path. It is all about the providers, bringing fully functional EHR systems to hospitals and physicians. The numbers I have seen do not paint a promising picture. The critical path is in critical condition. Ten percent hospital acceptance and a sixty percent failure rate. Let’s say those numbers are wrong by a factor of three—thirty percent acceptance, and a twenty percent failure rate. Even those numbers do not bode well for ever achieving a virtual national healthcare infrastructure under the current plan. Subtract from those figures—supply your own if you would like—the churn figures—those hospitals that are on their second or third installation of EHR. Something is amiss.

In a more perfect world the ONC might consider shifting course to something aligned with the following:

• Segment its mission into two parts; one to build a virtual national healthcare infrastructure, and two, provide hands-on support individual hospitals’ and providers’ EHR initiatives.
• Standards
• Standards—I wrote that twice because it is important to both missions
o Let us be honest, the largest EHR vendors do not want standards. Why? Because if all else fails, their standards become the standards. They don’t phrase it this way, but one can assume, their business model calls for them to do what is best for them.
o The vendors do not want to open their APIs to the HIEs
• Do not set dates for providers which to be met require meeting rules which do not yet exist. If the government wants providers to meet its dates, the government must first meet some of its critical success factors—standards, for example.
• Mandate vendor standards for however many vendors make up ninety percent of the EHR install base for hospitals. Give vendors 18-24 months to agree to a set of standards and have them retrofit their applications.
• Use a garrote and stick approach on the vendors. Create a standards incentive program, heck, underwrite it. Pay the vendors to develop and get on a single set of standards—this will have a much more positive impact than REC and PR money. Many will say, especially those who have an incentive for this not to happen, this cannot be done. Of course it can.
• Processes. EHRs are failing in part due to not enough user involvement, not enough user authority and governance. There is no usable decompositionable process map of how a hospital functions. No Level Zero through Level Whatever You Need. No industry standard, mega-diagram, boxes and arrows, which can be laid on a table or hung on a wall that shows, “This is what we do. This is how it all ties together.”
• I am building this process map, along with a colleague. Why isn’t the ONC? It will not match you hospital. It may not match anyone’s hospital. What it will do is give someone a great base from which they can edit it. Why is this important? Because it will enable the users, IT, and the vendor to overlay the EHR application to show:

o which business and clinical areas are impacted
o the process interfaces
o duplicated processes
o processes with no value-add
o which other facilities have similar and differing processes
o where change management resources must be focused
o what needs to happen if an acquisition is made

The ONC must move from coordinating to leading. To do that they need the authority to mandate the execution of some of the items listed above.

EHR Strategy: It’s all about thawing Chicken

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?”

Has Meaningful Use Optimisim Run Amuck?

I make it a point to read every article Gienna Shaw writes for  She consistently captures large amounts of information and packages it into a concise understanding of the material.  In the February issue of HealthLeaders 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.

Healthleaders Media: E-Health Systems: For Love or Money?

The following are the comments I posted to Gienna’s article,

Nicely written Gienna.  My concerns from the get go regarding Meaningful Use (MU) and Certification are:

  • Is Meaningful Use meaningful
  • If so, to whom


My answer to both questions is it is meaningful, on paper, to the ONC and CMS.  It is meaningful with the respect that it does one thing.


  • Meaningful Use changes the course of a healthcare provider’s business strategy from whatever internal course it was pursuing to one having a national focus.

If you do not believe me, look at your resource plan for meeting MU.  Some hospitals are having to redirect more than fifty percent of their IT resources away from whatever they were doing for the hospital to meet the MU requirements.

The article reports several sets of numbers which I think are at best misleading.  I think those hospitals who meet MU will do so much later than are being reported.  Few will make it in time to capture the full EHR “rebate”.  As such, the pool of available money to go back to hospitals is overstated, as are the number of hospitals who will receive it.

There is a broad chasm between those who expect to receive money and the amount they expect to receive, and how much will paid be paid to how many.

Now, with respect to whether any of this is meaningful; how many hospitals would have been willing to sacrifice their business strategy and spend millions of dollars to try to meet such a gossamer directive if this was tied to any other directive originating out of Washington?

Let us take something so outlandish as to be silly just to try to illustrate the point; paining your hospital pink.  If Washington offered similar sums of money and if one had to spend similar resources to earn it, would a hospital’s executive team approve the expenditure?  What is the business reason that makes MU so different?

The other issue I have with their optimistic MU adoption forecasts is the following.  Meeting MU is binary.  That is, there are no points for getting close.  A hospital which meets ninety-five percent of the criteria receives the same rebate as a hospital which meets none of the criteria.  Zero.  Using their own figures, if hospitals meet it by 2016, all they will have done is spent millions to receive zero payout.

As you calculate the ROI for EHR/MU be sure to include the following:

  • Will your EHR implementation be successful?  The latest figures I have seen suggest that your odds of having a successful implementation of EHR are less than one in two.
  • If you are “successful” will you meet it in time to potentially qualify for the full amount—if not, decrease what you expect to receive.
  • Will you complete the requirements to your satisfaction—if not, multiply your expected payout by a number less than one?
  • Will you pass the MU audit?  Some will not.  That is why there is an audit.  If you do not pass, you can reapply at a later date, but you will no longer be entitled to the full amount.  Again, multiply your expected payout by a number less than one.

And, here’s the kicker.  Here is the calculation most hospitals have overlooked.  How much has your productivity dropped since you implemented EHR?  A heads up for hospitals who have not completed their implementation—a large number of hospitals have spent in excess of a hundred million dollars only to see their productivity still twenty percent below what it was without EHR.

What does such a productivity loss do to your ROI calculation?  There is no language from ONC and CMS stating that such a productivity loss is meaningful.


EHR productivity losses are rampant

I remain stupified with how Meaningful Use continues to play itself out among hospitals.

What has me all a-twitter today is that there are no productivity thresholds tied to qualifying for incentive payments.  Many hospitals, even after two years of running EHR, report productivity losses of twenty percent or more.

Yet these hospitals can qualify for meeting Meaningful Use.  That sounds too much like ‘we do not know where we are going, but we are making really good time’.

Is there a pony hidden in there somewhere?  Where else can you spend a few hundred million dollars implementing a system, have your productivity fall off the charts, and be awarded a seal of approval and cash for how well the implementation went?

How far must one’s productivity drop before someone speaks up and says what the emperor does not want to hear?  Namely, you were probably better off before you implemented EHR.


New thoughts on EHR and ARRA money

So, there I was, laying out my plans for 2011.  I had started training to become the first person to cross the English Channel on horseback, but I was having difficulty finding a company to sponsor me.  Given my reputation as a water-walker, several firms indicated they would sponsor me to walk it, but I have never been one to do things the easy way.

Scratch the horse idea.

Then it hit me.  I’ve decided to retrace the footsteps of the Norwegian explorer Thor Heyerdahl in his quest to travel from Peru to Pacific Polynesia on a raft made from natural materials.  His book Kon-Tiki narrates his 101 day journey.

But since balsa wood is scarce, I will need some other readily available material I can lash together to build my vessel.  (Have you figured out where this is headed?)

With so many broken EHRs littering the dustbins, I figured why not?  I bought them for pennies on the million and had them shipped to the seaport of Callao.  I hired a few systems integrators to integrate the various platforms; McKesson and EPIC formed the major components of the hull, and several copies of AllScripts served as decking.

Launch is set for April 1 of this year.  My backup plan in case this fails is to use all of the unclaimed ARRA money, convert it into single dollar bills, and lay it on the water in front of me, bill by bill, for 4,000 miles.  I know this is a bit extravagant, but I hate to see all that money go to waste.