informatics

Is a Universal Patient Record a Solution?

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Today is the anniversary of the solving of Fermat’s last theorem.  As a long recovering mathematician, these types of thing interest me so I sought a copy of the proof and began reading.  The mathematics for librarians description of the proof is something like this:

  • The Pythagorean theorem states that for a right triangle the sum of the squares of the sides equals the square of the hypotenuse.
  • Fermat stated that the theorem only holds for a coefficient of 2, squaring, and that no other coefficient will work
  • This went unproven until recently

One might have thought that the solution could be solved by brute force using a computer.  How many numbers are there to be dealt with? If you approach the problem this way you’ve got to do it for infinitely many numbers. So, after you’ve done it for one, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a thousand numbers, how many, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a million, well, there’s still infinitely many left. In fact, you haven’t done very many, have you?  In fact, using this approach, you’ll never finish.  This got me thinking about our EHR system.

I think something has been lost in the confusion about a national EHR system.  After all, that’s the target right, a national system?  We only unleash the power of EHR if we are able to make it work out outside of the provider’s four walls.  Is it possible that perhaps the logic of how we have been viewing developing a solution for the problem is wrong?  I think it is.  Since the outset, the problem has been defined as how do we develop a system that will enable us to get everyone’s health records (let’s call an individual record A) to some arbitrary set of healthcare providers, call them P.  There are some 350 million A’s and for simplicity let’s agree that there are 100,000 P’s.  So now, the system to which everyone is working is the system that will enable all of the A’s to get to any combination of P’s.

See?  Now what happens if we place a few hundred Rhios and health information exchanges (HIEs) in between the A’s and the P’s?  Let’s label them G’s for gatekeepers.  So, in the current framework all the A’s (everybody’s health records) have to pass through all the G’s, make it up to the national network, then back through all the G’s and then sorted through all the P’s to the correct P.

How can we know this design will work for every possibility?  The only way is to test every combination of A’s, G’s and P’s.  It’s a difficult problem.  It becomes more difficult when we acknowledge that there are hundreds of EHR vendors supplying software to all of those P’s.  Many of those P’s will have modified the software, meaning that there are probably thousands of variations of EHR systems.  Oh, and did I mention that all of this is being done without any single set of standards?  That means my stuff will look different from your stuff, and the G’s will have to move different stuff, and from an “IT” perspective the EHRs at the end of the food chain will have to interpret different stuff and then update your stuff with their stuff.  That’s a lot of stuff.

So, if that is where things are, what can be done about it?  My take on a solution is that the problem with this model lies with the word in italics, ‘everyone’.  Every possible patient with every possible need getting to every possible provider.  How to solve this or at least simplify the magnitude of the problem?  One possible solution is to build out the EHR system and the network such that one patient’s record can go to one provider and have that record updated.  Would it not make more sense to build it for a single patient, create a universal patient record (UPR) that can handle all instances?  Do it right once.  Prove that it works and then replicate it instead of building millions of different ones and hoping they work?

EHR: Got a few minutes?

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Before we get started…I am on the plane yesterday, sitting in a middle seat.  An attractive woman fights her way down the aisle and sits next to me.  Five minutes later it happens again.  I felt like I had just won the USAir lottery.  The man who sits directly in front of me looks like the Taliban’s Mullah Omar, including the black turban.  Across the aisle is a screaming four-year-old.  For a second, I thought about executing a Jet-Blue exit strategy and deploying the emergency exit slide.

At a business dinner last night, we got into a conversation about driving habits.  The young woman across from me was explaining an incident for which she was pulled over for driving 94 miles an hour in her convertible Mercedes.  When the police officer asked her why she was driving so fast she told the officer she was trying to dry her hair.

Let’s roll back a few hours.  Got the time?

I am sitting at the airport holding my two two-dollar bottles of water scanning my options from among the array of shops.  Fast food.  The guy sitting across from me looked like he was eating Jell-O made from kelp.

Sundries.   Clothing, MSNBC—when did they get into retail?  Shoes, laptop devices, every possible cell phone accessory.  A nifty collection of watches at some kiosk.

A few years back I bought a Polar watch to help me track my running.  It measures heart rate, altitude, temperature, distance, rate, laps, and tracks and calculates my average pace.  What do I use it for when I run—the time—never took the time to learn how to use the other functions?

I also have a few antique watches—the kind you have to wind.  The only thing they do is keep time.  Then there is my Tag Heuer—a name I am not able to pronounce.  It is waterproof down to 300 meters.  I quit diving four years before I even found the watch—but it seems to work well in the shower.  It appears to have more Jewels in the back than the crown of a dictator from a third-world country.

The next time you are in a meeting, or sitting across from someone, look at their watch and see if you can read the time.  You may be able to estimate how much they paid for it by how much exposure it has on their wrist.  Some watches look like they have enough gadgetry to have been a prop in a Bond movie.  Altimeter, lunar phases, time zones in countries to which they have never traveled.  The face of the watch is so decked-out with features and functions that have nothing to do with keeping time that you may as well settle for knowing the moon is waxing.

My Polar watch is an allegory for EHRs that are failing and underperforming.  Lots of features, very little utility.  EHR implementations that do well seem to be those designed to go shallow on functionality and cut a wide swath utility.  Those that go deep into the functionality and narrow on utility are gathering dust.

Is there any good news?  Sure—when you turn on the computer monitor, you’ll notice a little digital clock in the lower right corner.  You may have wasted $200 million on the EHR, but you’ll always know the right time.

Kind Regards,

Paul

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

EHR: What’s in it for me?

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Field of Dreams.  Best guy movie of all times?  Forgive me, but I don’t usually start my day being PC.  (I don’t end it that way either.)  Pardon me as I wipe a tear.  Want to have a catch Dad?  For those of you whose minds don’t immediately shift to the shooting of Old Yellar, you’re on the wrong blog.

First there’s the field.  It’s green.  The same green God made when he made green.  There’s a cross-hatched pattern to the cut, the white lines brilliantly juxtaposed.  The air smells of peanuts and dogs.

Baseball, as spoken by James Earl Jones:

“Ray. People will come, Ray. They’ll come to Iowa for reasons they can’t even fathom. They’ll turn into 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 off to the bleachers and sit in their short sleeves 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’d 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, is a part of our past, Ray. It reminds us of all that once was good, and it could be again. Ohhhh, people will come, Ray. People will most definitely come…”

This is the twelve step nightmare for anyone who had a father.  At the end of the movie there is a dialog between Ray Kinsella and Shoeless Joe Jackson:

Ray Kinsella: I did it all. I listened to the voices, I did what they told me, and not once did I ask what’s in it for me.
Shoeless Joe Jackson: What are you saying, Ray?
Ray Kinsella: I’m saying? What’s in it for me?

Amidst all the confusion, amidst all the regulation, where does that leave you?  Ask, “What’s in it for me?”  What’s in it is whatever you put into it.  Drive this process to your benefit.  Build an EHR because it benefits you, not because it’s forced upon you.

EHR Short Cuts

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How able are you to conjure up your most brainless moment—don’t worry, we aren’t on the EHR part yet.

As I was running in San Diego I was passed by a harem of seals—Navy Seals.  Some of them were in better shape than me, I couldn’t judge the fitness of the others as they ran by me too fast.  That got me thinking.  For those who having been regular readers, you’ll know this is where I have a tendency to drive myself over a cliff.

Seeing the Seals took me back to my wistful days as a cadet at the US Air Force Academy.  Coincidentally, my hair looked then a lot like it looks now.  One of the many pastimes they tossed our way for their amusement and our survival was orienteering; sort of map reading on steroids.  One night they took us to the foothills of the Colorado Rockies, paired off the doolies, gave us a set of map coordinates, a compass, map, and flashlight.  The way training worked, those who proved to be the fastest at mastering skills fared better than those who weren’t.  Hence, there was plenty of incentive to outperform everyone; including getting yourself to believe you could do things better than you could, sort of a confidence building program.

We were deposited in a large copse—I’ve always liked that word—of trees—I don’t know, but it seems adding trees to the phrase is somewhat redundant.  We had to orient ourselves and then figure out how to get to five consecutive locations.  The sun had long since set as we made our way through the treed canyon and back up a steep ravine.  After some moments of searching we found the marker indicating we were at point Able.  The group started to examine the information that would direct our journey to point Bravo.

While they honed their skills, I was examining the map, taking some bearings with the compass, and trying to judge the terrain via the moonlight.  My roommate, a tall lanky kid from Dothan, Alabama asked why I didn’t appear to be helping.

“Look at this,” I replied.  “Do you see that light over there, just to the right of that bluff?  I think I’ve found us a shortcut.”

“What about it?”  Asked Dothan.

“If my calculations are correct, that light is about here,” I said and showed them on my map.  “It can’t be more than a hundred yards from point Delta.”

“So?”

“So why go from Alpha to Bravo to Charlie to Delta, if we can go right to Delta from here?  That will knock off at least an hour.”  I had to show my calculations a few times to turn them into believers, but one by one they came aboard.  The moon disappeared behind an entire bank of thunderheads.  We were uniformly upbeat as we made our way in the growing blackness through the national forest.  Unlike the way most rains begin, that night the sky seemed to open upon us like a burst paper bag.

“Get our bearing,” I instructed Dothan.  As it was my idea, I was now the de facto leader.  As we were in a gully, getting our bearings required Dothan to climb a large evergreen.

“I don’t see it,” he hollered over the wind-swept rain squalls.  I scurried up, certain that he was either an idiot or blind.

“Do you see the light?”  They asked me.  I looked again.  Checked my map.  Checked my compass.  “It has to be there,” I yelled.

A voice floated up to me.  To me I thought it probably sounded a lot like the voice Moses heard from God as he was building the Ark.  (Just checking to see if you’re paying attention.)  “What if they turned off the light?”

I almost fell out of the tree like an apple testing the laws of gravity.  What if someone had turned off the light?  There was no ‘what if’ to consider.  That is exactly what happened.  Some inconsiderate homeowner had turned off their porch light and left us stranded.

Fast forward.  We were lost, real lost.  We didn’t finish last, but we did earn extra exercise the next day, penalized for being creative.  Who’da thunk it?

Short cuts.  When they work, you’re a headliner.  When they fail, chances are you’re also a headliner—writing the wrong kind of headlines.  I hate being redundant, but with EHR we may be dealing with the single largest expenditure in your organization.  It will cost twice as much to do it over as it will to do it right.  If you haven’t done this before—I won’t embarrass anyone by asking for a show of hands—every extra day you add to the planning process will come back to you several fold.  There may be short cuts you can take, but planning should not be one of them.  How much should we plan?  How long should it take?  Who should participate?  We will look at each of those questions in some detail.  For now, let’s answer those three questions with; more than you think, longer than you’ve planned for it to take, and different skills than you’re currently using.

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

My profiles: LinkedInTwitter
My blog: Healthcare IT Strategy My thoughts on “One EMR Vendor’s View of Meaningful Use”

EHR–One time at band camp…

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Like many of you, I see two distinct groups who do not play well in the same sandbox—clinical and IT.  Having clinicians go to the HIT summer camp to pick up a few skills is not the same as pulling a few costly and hairy projects from the bowels of project hell any more than it would be to have an IT executive take an EMT course and then assume that person was qualified to perform surgery—this one time at band camp…

Before I get up on my stool and knock myself off, I know CMIOs and CIOs who have made HIT and EHR very successful.  To them I ask, do not rake me across the Twitter coals as I try to make a point.

There’s knowledge, and then there’s qualified.  Doctors do four years of medical school, they intern, and if they specialize, they throw in a few more years before they become the in-charge.  Years of training and practice before the doctor is allowed to run the show.  Why?  Because what they are about to undertake requires practice, tutelage, and expertise.  Most of the actual learning occurs outside the classroom.

There are those who suggest the skills needed to manage successfully something as foreboding as full-blown EHR can be picked up at HIT Camp.  This does a disservice to seasoned IT professionals.

Most large IT projects fail.  Large EHR projects fail at an even higher rate.  Most clinical procedures do not fail, even the risky ones.

What’s the spin line from this discussion?

  • Rule 1—large EHR projects fail at an alarming rate
  • Rule 2—sending a clinician to band camp probably won’t change rule one

Don’t believe me?  Ask friends in other industries how their implementation of an ERP or manufacturing system went.  There are consulting firms who make a bundle doing disaster recovery work on failed IT projects.  They line the halls like turkey vultures waiting for CIO or project manager carrion.

Back to Rule 1 for a moment.  How can I state that with such assurance?  Never before in the history of before—I know that’s not a proper phrase—has any single industry attempted to use IT to:

  • impart such radical charge (patients, doctors, employees)
  • impart it on a national basis
  • hit moving and poorly defined targets—interoperability, meaningful use, certification
  • take guidance from nobody—there is no EHR decider
  • implement a solution from amongst hundreds of vendors
  • implement a solution with no standards
  • move from an industry at 0.2 to 2.0 business practices
  • concurrently reform the entire industry

Just what should a CMIO be able to do?  What are the standards for a CMIO?  To me, they vary widely.  Is a CMIO considered an officer in the same sense as the other “O’s” in the organization, or is it simply a naming convention?  The answer to that question probably depends on the provider.

Here’s how I think it should work—I realize nobody has asked for my opinion, but this way I’ll at least provide good fodder for those who are so bold as to put their disagreement in writing.

I love the concept of the CMIO and think it is essential to move the provider’s organization from the 0.2 model to the 2.0 model.  Same with the CIO.  However, getting them to pool their efforts on something like EHR is likely to fail as soon as one is placed in a position of authority over the other.  It’s sort of like getting the Americans and French to like one another.

I liken the CMIO’s value-add to that of the person providing the color commentary on ESPN—it adds meaning and relevancy.  The CMIO owns and answers a lot of the “what” and the CIO owns and answers a lot of the “How”.

Still unanswered are the “Why” and “When”.  A resource is needed who can state with assurance, “Follow me.  Tomorrow we will do this because this is what needs to be done tomorrow.”  That skill comes from an experienced Project Management Officer, the PMO.  It does not come from someone who “we think can handle the job.”  Nobody will respect a PMO’s  ability if they do not have the requisite expertise.  EHR needs someone who can state from their experience, “One time at band camp…”   If the EHR can’t lead, or the team is not willing to follow the PMO, you can plan on doing the project over.

How does Heisenberg’s Uncertainty Principle affect EHR?

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One of the great things about social media is its ability to infer attributes of both the readers and the writer.  When you finally meet your virtual pen pal the mind wanders—I thought he sounded taller.

There are those among us who when they picture me writing, see me sitting at my desk, wearing my baby seal-skin slippers, and supping on a bowl of loggerhead turtle soup.

Segue.

According to Heisenberg’s Uncertainty Principle (used in physics) certain pairs of physical properties cannot both be determined simultaneously.  That is, the more precisely one property is known, the less precisely the other can be measured. For instance, the next time you are standing by the side of the road, and cars are whizzing by you, try to decipher the speed of the car, and its exact location.  If I remember my math correctly, the first derivative is its velocity, the second, its acceleration.  To know exactly where the car is at a precise moment in time, the car must be stationary—as in not moving.  Thus, to ascertain its position, the position must be fixed.  The Heisenberg Uncertainty Principle requires that for someone to determine B, A must cease to be a variable.

The Uncertainty Principle can be represented as something like this:

One can see that as additional properties are tossed into the mix the probability of predicting any particular outcome goes to zero.

Thus follows Roemer’s EHR Uncertainty Principle—if you don’t know where you are going, you arrived a long time ago (A little like Pink Floyd’s, “How can you have any pudding if you don’t eat your meat?”).

The conflicting principles include;

·         Implementation date

·         Completion date

·         Final cost

·         Your functional requirements

·         The vendor’s capabilities

·         Acceptance testing

·         What should the EHR do

·         How do you know when you are done

·         Should you meet Meaningful Use

·         Will you receive the ARRA money

Here is the point of the allegory.  The chances of a physician group or hospital knowing the answer to all but one of the above principles are zero.

Permit me to throw a wrench into the loggerhead soup and let you know that not having the answers to all but one of the variables is okay.  That is the way projects work.

Since most of you implementing EHR have not ‘been-there, done-that’ with respect to implementing EHR, it is reasonable to expect there are more unknowns than knowns (spell-check indicates that it is not a word, but I know you are keeping up with me).

So, how can you use Heisenberg’s Uncertainty Principle to your advantage?  It is actually rather simple.  Do not allow your implementation to be guided by the unknowns.

·         Do not set an arbitrary budget for something you have never purchased

·         Do not set an arbitrary implementation deadline

Do what you must to make sure you implement an ERH that does what you need it to do.  Do not let yourself be constrained by principles whose only possible effect will be to derail your project.

If you are willing to take that risk, the other principles become moot (the correct terms is moot, not mute—look it up—sorry about the preposition).

If all else fails, consider getting a pair of the seal-skin slippers.

Paul M. Roemer

Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335

+1 (484) 885-6942

paulroemer@healthcareitstrategy.com

My profiles: 

My blog: Healthcare IT Strategy How to Revive a Failed EHR Implementation

How to Revive a Failed EHR Implementation

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My latest post on www.healthsystemCIO.com.  Here’s an idea I think merits consideration.

http://healthsystemcio.com/2010/07/30/how-to-revive-a-failed-ehr-implementation/

What do you think?

A little IT knowledge can kill you

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It almost killed me.  Curious?  I lived in Colorado for a dozen years, and spent almost every other weekend in the mountains, fly-fishing, skiing, climbing, and painting—any excuse would do.  Colorado has 54 peaks above fourteen thousand feet.  In my twelve years I climbed most of them.  Some solo; some with friends.

I owned almost everything North Face made, including a down sleeping bag with thermal protection which would have made me sweat on the moon and a one-burner propane stove which cranked out enough BTUs to smelt aluminum.  Two of my friends and felt we needed a bigger challenge than what Colorado’s peaks offered.

The dot in the photo is me.

We decided on a pair of volcanoes in Mexico, Pico de Orizaba and Popocatépetl—both over 18,000’.  We trained hard because we knew that people who didn’t died.  We trained with ropes, ice axes, carabineers, and crampons.  One day in early May we arrived at the base ofPico de Orizaba.  The man who drove us to the mountain made us sign the log book, that way they’d know who they were burying.  After a six hour ride from a town with less people than a K-Mart, we were deposited at a cinder-block hut—four walls, tin roof, dirt floor.  Base camp.

Before the sun rose we were hiking up ankle-deep volcanic ash; gritty, coarse, black sand.  The sand soon turned in to thigh-deep snow.  We took turns breaking trail, stopping only long enough to refill our water bottles by hand-pumping glacier melt from the runoff in the bottom of cobalt blue ice caverns carved from solid glacier.

Ice Cave we used to collect drinking water

Throughout the trek we passed crude wooden crosses that were stuck into the ash and snow, serving as grim reminders of those who’d gone before us.

We knew the signs of pulmonary edema, but were reluctant to acknowledge them when we first saw it.  It was about one the following morning when we decided to make camp.  My roommate was having trouble concentrating, and his speech was slightly slurred.  When we asked him if he was ill, he responded much like one would expect an alcoholic would respond when asked if he was okay to drive.  “I’m fine.”

We were at about 16,000’.  The slope seemed to be at about forty-five degrees.  The sheet of ice upon which we stood glistened from what little light the stars emitted.  I removed my tent pole from my pack and placed it on the ground—we were going to camp for the night.  We watched in awe as the pole gained speed and hurtled down the side of the volcano, quickly lost in the darkness.

Realizing my friend wasn’t doing well, and that I was now feeling somewhat punkish, we made the difficult decision to turn back.  The only survival for edema is to lose enough altitude until you reach an altitude where there is enough air pressure to force the oxygen into the blood.  Eighteen hours of climbing.  Pitch black.  And then it started to snow.  Any other time the view would have been awesome.  We headed down, me carrying my pack and his, he with our friend.

We arrived at the block hut around four that morning.  By then I was no longer making any sense.  My roommate had recovered, but I had become somewhat delirious—at least that’s what they told me later.  Not knowing right from left or wrong, I was determined to keep walking.  The two of them took turns laying on me to prevent me from sneaking out during the night.

A little knowledge almost killed us.  The scary thing is that we knew what we were doing.  We had trained at altitude, had a plan, worked the plan.  The plan shifted.  Sometimes shift happens.

It happens more with IT.  Much more.  Do you know what the chances are of any IT project ‘working’ that costs more than$7-10 million?  (Working is defined as having a positive ROI, a project that was delivered on time, withing the budget, and delivered the expected results.) (IT includes workflows, change management, training, etc.)  Two in ten.  Twenty percent.  That’s below the Mendosa Line—non baseball fans may have to look up that one.  Remember the last industry conference you attended?  Was it about EHR?  Pretty scary knowing most of them were planning for a failure.

Put your best efforts, your brightest people on planning the EHR.  Make them plan it, then make them plan it again, and then make them defend it, every piece of it.  If they don’t convince you they can do it in their sleep, you had better redo it.  Do they know what they’re planning to do?  Do they know why they’re planning to do it that way?  If they haven’t done it before, this may not be the best time for them to practice.  EHR is not a good project for stretching someone’s capabilities.

Planning is difficult to defend twice during the life of a large program.  First, at the beginning of the program when the C-Suite is in a hurry to see people doing things and signing contracts.  The second time planning is difficult to defend is the moment the C-I-Told-You-Sos are calling for your head for having such an inadequate plan.

How would I approach planning an EHR program for a hospital?  If we started in September, my goal would be to;

  • Have a dedicated and qualified PMO in place in four weeks
  • Begin defining workflows and requirements by October (I’m curious.  For those who have done or are doing this piece, how many FTE’s participated?  I ask because i think chances are good that your number is far fewer than I think would be needed.)
  • Issue a requirements document by mid-January.
  • Be able to recommend a vendor by the end of March.

That seems like a lot of time.  There are plenty who will tell you they can do ‘it’ quicker.  Good for them.  The best factor in your favor right now is time.

Reread this in a year and see where you are…

…See, I told you so.  Anyone want to go hiking?

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

How can you solve the EHR puzzle?

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Seth Godin wrote about the “Perfect Problem.”

A perfect problem, in its existing state, is unsolvable.  The way most of us handle it is to click our heels together three times and hope it goes away.  We tend to work on imperfect problems, those that can be solved.

What is the difference between the two?  The first step is the ability to understand what makes the perfect problem uniquely unfixable.  Perhaps a few examples would help.

  • The CEO imposed a deadline for the implementation of EHR.
  • CMS Meaningful Use rules do not fit with our operational strategy.
  • If we do not implement EHR by this date, we do not get the money.
  • We must meet Meaningful Use
  • We do not have enough resources from the EHR users to understand their processes.
  • We cannot continue to support these low-margin services
  • We do not have enough time to define our requirements
  • We cannot afford to spend the time required to assess our processes before we bring in the EHR vendor.

What can be done?  The easy answer is to plan for failure and do your best to minimize it.

What is another way to describe the above examples?  They are constraints.  They can all be rewritten using the word “can’t”.  Rewritten, we might say, “We had a chance to succeed, but because of X, Y, and Z we can’t.”  If that assessment is correct, you will fail, or at least under-deliver at a level that will be remembered for years to come.  That’s a legacy none of us wants.

There are a few solutions to this scenario.  You can eliminate the seemingly intractable constraints; the organization can determine to re-implement EHR and hope for different results; or they can simply find someone else to solve the perfect problem.

Experience teaches good leaders really want reasoned advice.  They want the members of the C-suite to tell them what must be done to be successful.  Good leaders do not accept “can’t”—not on the receiving end, not on the delivering end.

Some will argue, “This is the way our organization works.”  Even if that is true one must consider what is needed to make an exception to the constraint.  Would you accept this logic from a subordinate?  Of course not.  You’d demand a viable solution.  If you are being constrained in your efforts to solve a perfect problem, perhaps it is time to restate the constraints.

One of my college professors—way back when we still had inkwells on our desks—told me that if you cannot solve the problem the way it is stated, it is to your advantage to restate the problem.  Maybe the solution to the perfect problem is to restate it in a manner that makes it imperfect—solvable.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

“How many days ago was Sunday?”

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The photo comes from my Robert Redford look alike period.

Do you ever awaken wishing you were all you used to think you were before you figured out you weren’t?  Me either.  I’m someone who has these kind of days when it’s best to keep me away from shiny objects.

During college, I spent several summers volunteering for a group called Young Life at their camps throughout the US.  Silver Cliff was one of their camps in the mountains of Colorado.  Each week we’d take in a few hundred high school kids from throughout the US, and give them the opportunity to do things and challenge themselves in new ways; everything from riding horses to rappelling.

The prior summer I was the head wrangler at one of their camps—I had never ridden a horse prior to being placed in charge of the riding program.  This summer is was the person running the rappelling program.  Needless to say, I had never done that before either.

We received a day’s worth of instruction before we were turned loose on the kids.  One of the first things we had to learn was that the ropes and harness, if properly secured to the carabineers and figure eight, would actually keep you from falling to your death.  The first test was jumping from a platform way up in a tree while on belay.  After a few moments of white-knuckle panic, I stepped over the edge and was belayed safely to the ground.

From there, we scouted a place for the rappel, and found two suitable cliffs, each with about a hundred foot vertical drop.  Watching my first rappel must have reminded others of what it would have been like watching a chimp learn how to use tools for the first time.  After several tentative descents, I was able to make it safely to the bottom in a single jump.

Each day we’d run a few dozen kids through the course, ninety-nine percent of whom had never rappelled, or ever wanted to rappel.  To convince them that it was safe and that they could complete it, I would instruct them in the technique as I hung backwards over the chalk face of the limestone cliff.

Each day we’d have one or two kids who wanted nothing to do with my little course.  Occasionally, while on belay, one of them would freeze half way down the cliff, and I’d have to belay down and rescue them.

Once or twice I’d have an attractive female counselor on belay, her knowing that I was the only thing keeping her from being a Rorschach stain on the rocks below.  Scared, and looking for a boost of confidence, “She’d ask, how long have you been doing this?” I’d look at my watch and ask her how many days ago was Sunday.  I viewed it as an opportunity to have a little fun with her—sort of like turning to your friend in the checkout line in 7-eleven and saying loud enough for others to hear, “I thought we agreed we weren’t going to use our guns.” I also hoped maybe even having to go on a heroic rescue.

How long have you been doing this?  That’s seems like a fair question to ask of anyone in a clinical situation.  It’s more easily answered when you are in someone’s office and are facing multiple framed and matted attestations of their skills.  Seen any good EHR or HIT certificates on the walls of the people entrusted with the execution of the EHR endowment?  Me either.  I have a cardiologist and he has all sorts of paper hanging from his wall.  Helps to convince me he knows his stuff.  Now, if I were to pretend to be a cardiologist—I’ve been thinking of going to night school—I’d expect people would expect to see my bona fides.

Shouldn’t the same logic apply to spending millions of EHR dollars?  Imagine this discussion.

“What do you do?”

“I’m buying something for the hospital I’ve never bought.”

“Why?”

“The feds say we’ve got to have it.”

“Oh.  What’s it do?”

“Nobody really knows.”

“How long have you been doing this?”

“How many days ago was Sunday?”

“What’s it cost?”

“Somewhere between this much,” he stretches out his arms, “And this much,” stretching them further.

“Do the doctors want this?”

“Some do.  A lot don’t.”

“How will you know when you’re done if you got it right?”

“Beats me.”

“Sounds like fun,” she said, trying to fetter a laugh.

Sounds like fun to me too.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com