informatics

Why do you think projects fail?

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Again on the project failure?  Yes.  Why?  Trying to head it off at the pass.  Source, The Bull Report.

Failure_Cause_Survey.264

Fifty-seven percent of failures are due to bad communication.  What’s that?  Poor grammar?  No.  Not enough meetings?  Doubtful.

It’s about PMO.  A hired gun?  Perhaps.  An advocate who will manage the vendor on your behalf.  What’s the rest of the hired gun’s job description?  All the blue stuff in the graph..

The good news is that being a bad dresser will not hurt the project.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

The Services We Offer

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What we have here is a failure to communicate, and unfortunately the failure is mine.

It has been a week of learning.  According to one of the thought leaders in healthcare, whom I’ve known for more than a year, he does not understand what services my firm offers hospitals, and he thinks others may have the same problem.

He suggested it would be helpful to spell it out, service by service.  So here goes.

Program Management:

We work with hospital CIOs and COOs as their advocate by serving as the program management officer (PMO).  We define functional requirements, select software, and manage IT applications vendors for enterprise applications like EHR, CRM, and ERP.

Operational Efficiency:

We work with the hospital C-suite to identify, define, and implement a unique set of business processes and business rules, eliminating duplicated processes and those which do not add value.  The output is a single set of best practices processes and rules.

Change Management:

Enterprise applications will alter business processes and impact most employees and patients.  Without a rigorous change management effort, the impact of the application on the hospital’s processes and people will be a disaster.  We figure out what must change, how it will change, and how to pull it off.

Patient Relationship Management (PEM):

This is the hospital equivalent of Customer Relationship Management (CRM).  On a PEM project we define the requirements, select an application vendor, define the processes, and manage the project to completion.

Please let me know if you need help with any of these.

Have I erred on the side of stupidity?

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Twice in the span of twelve hours, I received unsolicited and honest feedback from two individuals whose opinion I value, about my attempt to share with you my thoughts about a range of issues concerning the business of healthcare.  One came from my father; since he holds that role he is allowed to offer unsolicited advice any time he wants, and I am entitled to listen to his advice.  The other bit of advice came in response to an email I wrote.  He is one of you, and he wrote the following:

I agree with many of your points and disagree with a few of them, and regardless, it’s a compelling, buzz-worthy angle that gets a lot of re-tweets and what have you, but I think it’s worth considering how these positions are affecting your ability to land consulting gigs in HIT. People want to hire consultants that they think will help them succeed, that think positively and pragmatically, and that are problem solvers (as opposed to problem recognizers): “we can do this together…I’ve had success before and if you let me, I will help you succeed…” that kind of thing. Just my 2 cents. It’s a trade-off, I know. You want to be honest and forthcoming, so I see the dilemma.

This was like being hit by lightening twice in the same day, so I thought I should take time to consider their input.  The feedback led me to ask if there are others who share the same opinion.  Is it possible my ramblings are about as well received, as I would be if I were to walk the streets of Tehran wearing a Star-of-David t-shirt?  What portion of readers drag my postings to their email folder entitled, “Kill him Later”?

Some believe a more effective use of consultants would be to compost them and use the energy generated to power a weed-eater.

Please permit me a few lines to try to explain my thought process for writing in my particular style and tone.  Before I began expressing my opinions on healthcare, I began reading what I considered the best healthcare blogs and editorials.  The first thing I learned is that I had nothing to offer of value on the clinical side of healthcare, so I focused my efforts on discovering what business issues providers dealt with, and which ones might benefit from receiving professional help—a consultant’s twelve-step program for problem solving.

I did a lot of homework; in addition to reading, I interviewed more than a hundred healthcare executives.  What was my takeaway?  One CEO told me the most needed skill on the business side of healthcare was “adult supervision”.  I did not charge in with uncorroborated opinions.  I used LinkedIn discussion groups to pose hundreds of questions about possible problems, studied the responses, and used them as a basis to formulate ideas about what was broken and what needed to be done to fix it.

I should note many of the blogs I read shared two traits; they often stated the same facts available on other blogs, and they rarely seemed to question the efficacy of the impact many of the Healthcare IT initiatives would have on operating healthcare’s business model—ours is not to wonder why, ours is but to do or die.

Not wanting to be superfluous, when I came to the fork in the road, I chose not to take a me-too position.  Instead, I threw metaphorical tomatoes and tried to get people interested in looking at the business model in a more disruptive manner.  Often, I did this by taking extreme positions on issues in the hope I might hit a hot button, and someone would think, “Perhaps we ought to talk to the tomato thrower and see if he can help us”.

My approach may prove to be less than brilliant.  What’s your take?

How the C-suite sees the CIO

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This link is to my latest post for healthsystemCIO.com.  http://healthsystemcio.com/2010/06/10/how-the-c-suite-sees-the-cio/

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

Does it come in blue?

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The store for audiophile wannabe’s. Denver, Colorado. The first store I hit after blowing an entire paycheck at REI when I moved to Colorado. 

The first thing I noticed was the lack of clutter, the lack of inventory. There were no amplifiers, because amplifiers were down market. There were a dozen or so each of the pre-amps, tuners, turntables, reel to reel tape decks, and these things called CD players. They also had dozens of speakers. At the back of the store was an enclosed 10 x 10 foot sound proof room with a leather chair positioned dead center.

When the ponytailed salesperson asked about my budget, like a rube I told him I didn’t have one. He beamed and took that to mean it was unlimited. It really meant I hadn’t thought of one. He asked me what I liked to listen to.

“Pink Floyd, Dark Side of the Moon.”

Within a few seconds I was seated in Captain Kirk’s chair, and Pink Floyd’s Brain Damage filled the room in pure digital quadraphonic sound. I was in love.

I lived a block and a half away. Since the equipment wouldn’t fit in my Triumph, I made several trips carrying home my new toys—gold plated monster cable, solid maple speakers that rested on nails so as to minimize distortion, a pre-amp, tuner, receiver, turntable, and stylus.

It wasn’t that I deliberately bought stuff I didn’t need. I walked in uneducated. I had never bought what I was looking at. I didn’t know how much to spend, nor what it would do for me. Looking back at that purchase decision, I bought specs I didn’t need. I didn’t realize it was possible to build audio technology that would meet performance specs beyond what I person could hear, heck beyond what anything could hear. Not understanding that possibility, I bought specs I couldn’t hear. I spent hundreds of dollars on features from which I would never receive value. You too?

It happens all the time. Stereos. Cars. Computers. Applications. Technology. Having bought it doesn’t mean it was needed, that it was the right thing to do, that it has an ROI, or that it meets the mission.

What must the ONC do to make EHR a success?

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The following is my second reply to Brain Ahier’s interview of Dr. Blumenthal.  The purpose of this post was to outline some steps the ONC could take to retrofit its EHR strategy.  PLease let me know what you think.

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, or the providers? There are the coordinators, and its 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 they need—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.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

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

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

The Russians used a pencil.

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

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

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

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

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

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

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

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

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

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

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

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

How to raise healthcare IT costs without really trying

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Like anyone needs my advice as to how to do that. Go ahead, have at it. Go shopping. Shop to you drop. How much do you need? Suppose we open the coffers. How much; another million? Ten Million? Twenty-five, fifty? $100,000,000? This is a one-time offer, so make sure you ask for everything you need

What if I told you this money is available provided you correctly answer a few basic questions. Reasonable? I’d hope so for a hundred million dollars.

1. What will you do with the money that you haven’t already done?

2. Has anyone else every done that?

3. If yes, did it work for them?

4. If no, why not, and what makes you think it will work for you?

5. Will these additional funds;

5a. Get you the ARRA money?

5b. Enable you to see more patients?

5c. Help you retain and attract physicians?

5d. Increase patient safety?

6. What is your mission?

7. Why isn’t your mission the KPIs listed in question 4?

8. Are other hospitals spending the amount you are requesting?

9. Did that amount of funding allow them to meet the criteria specified in question 5?

10. If no, what makes you think you can do it?

If your CFO asked these questions, would you think them reasonable? If not, prepare 3 envelopes (see Google)

If you don’t buy the right EHR and implement it correctly, you’ve just spend a hundred million dollars to scan charts.  Somebody will be held accountable for the money.

Upgrade the coffee to Starbucks-$5. New bedpan-$50. New plasma monitors-$1,200. Knowing what you are doing—Priceless.

HealthsystemCIO.com–a few thoughts

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These are my comments to the post by Steve Huffman, VP & CIO, Memorial Health System.

Well written Steve. I think part of what is being missed by Washington is that in their effort to mandate providers move to facilitate a nationalized healthcare model; they have overlooked a few things. For starters, I think the EHR discussion has shrouded the fact that EHR is voluntary. Unfortunately, very few providers look at EHR as a decision they should evaluate—do I or do I not do EHR. Instead, they eschew that question, and view the need to do EHR as a decision that was made for them.

• Two business models are in play, a national model and the one used by providers. In the end game, even though it is only mentioned in the privacy of their own policy rooms—and not streamed on CSPAN—the national model is ultimately being designed to connect every doctor to every patient—one big hospital under thousands of roofs. The other model is the provider’s singular business model. It’s a patient-centric model (the healthcare business) and a business model (the business of healthcare). The two models have different goals and different requirements.

• If the model Washington is pushing were attractive, providers would be knocking one another down tying to be first in line to implement it. Clearly, that is not happening. Instead, Washington is offering billions in rebates, and there are still few takers.

• There is no viable plan on how to get from here to there—none, nada, zip. Instead of a coherent plan coming from them, they have put the monkey on the back of the providers, guiding them with carrots and sticks. Washington launched this idea without a much of a plan, and after the fact saddled the providers with three innocuous stages of rules—two of which remain undefined. They have yet to convince providers that they have a way to make sense out of having 400 different EHR vendors, no set of standards, hundreds of unique HIEs—I know you can’t have hundreds of anything and label it as unique—which bespeaks–the problem–and realistically expect it to work.

Why change your business rules and work flows to try to meet a plan that has stability of having been drafted on an Etch-A-Sketch? There are plenty of valid business reasons to evaluate changing the way providers work. There are huge potential gains in safety, care, efficiency, and effectiveness. These gains vary by organization. They vary based on the unique requirements of each organization. Properly planned and implemented, and EHR program with change management on workflow improvement can facilitate taking the business of healthcare from an 0.2 model to a 2.0 model.
Done poorly, and EHR will prove to be nothing more than a multi-million dollar scanner.

That being the case, you may want to use Steve’s methodology and ask him where you can go to buy a supply of the Composition books he uses.

What exactly is healthcare 2.0?

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I tend to take a slightly different bent on Healthcare 2.0, a bent which does not intentionally tie to the notion of Internet 2.0, but rather to the notion of an industry desperately needing to reinvent itself.

A few definitions may bring some sense to the discussion. I find it helpful to distinguish the business of healthcare from the healthcare business. I think of the healthcare business as the clinical side, and the business of healthcare as what it takes to make dollars and sense of it all.

Although the healthcare business in the United States is world class in many areas, in many hospitals the business of healthcare is mired in a 0.2 business model. It is often run like a franchised fiefdom of duplicative and ineffective cost and revenue silos—I’m going to duck for a moment in case anyone disagrees strongly with me.

I’m back. This 0.2 business model is being forced into a 2.0 model whether it wants to go there or not. Whether it is capable of making the journey is debatable. The model is regulated, and is about to be reregulated—to what—nobody knows. What national leadership there is is busy waving the magic IT wand thinking that will facilitate the transition from the dark ages and support the business model of National Healthcare—which, by the way, has little if anything to do with the model providers need to run their business.

EHR, if done wrong will be nothing more than a multi-multi-million dollar scanner. Providers will indeed be paperless. However, paper is not the problem. The goal should not be the elimination of paper as though paper is a bad thing. If efficiency equates to speed, to doing something faster, the goal should not be efficiency. It is possible to streamline bad processes and do them faster.

To get to Healthcare 2.0 using my definition, to redefine the business of healthcare, providers must move towards being effective, towards solving business problems, eliminating waste and duplication, retaining doctors and patients, and running it like a real business.

My best – Paul