Redux–What people at HIMSS were afraid to say

One image of HIMSS that will not escape my mind is the movie Capricorn One—one of OJ’s non-slasher films.  For those who have not seen it, the movie centers on the first manned trip to Mars.  A NASA Mars mission won’t work, and its funding is endangered, so feds decide to fake it just this once. But then they have to keep the secret…

The astronauts are pulled off the ship just before launch by shadowy government types and whisked off to a film studio in the desert.  The space vehicle has a major defect which NASA just daren’t admit. At the studio, over a course of months, the astronauts are forced to act out the journey and the landing to trick the world into believing they have made the trip.

Upon the return trip to Earth, the empty spacecraft unexpectedly burns up due to a faulty heat shield during reentry. The captive astronauts realize that officials can never release them as it would expose the government’s elaborate hoax.

I think much of what I saw at the show was healthcare’s version of Capricorn One.  Nothing deliberately misleading, or meant as a cover-up or a hoax.  Rather more like highlighting a single grain of sand and trying to get others to believe the grain of sand in an entire beach.

The sets for interoperability and HIEs served as the Martian landscape, minus any red dust.  There was a wall behind the stage from where the presentation interoperability was shown.  I was tempted to sneak behind it to see if I could find the Wizard, the one pulling all the nobs and using the smoke and mirrors to such great effect.  It was an attempt to make believers, to make people believe the national healthcare network is coming together, to make us believe it is working today and that it is coming soon to a theater near you.

After all, it must be real; we saw it.  People wearing hats and shirts emblazoned with interoperability were telling us this was so, and they would not lie to you.

The big-wigs, and former big-wigs—kudos to Dr. B. for all his hard work—were at the show for everyone to see, and to add a smidgen of credibility to the message.  They would not say this was going to happen if it were not—Toto, say this ain’t true.

The public relations were perfect, a little too perfect if you asked me.  Everyone was on message.  If you live in Oz and go to bed tonight believing all is right with the world, stop reading now.  If what you wanted from HIMSS was a warm and fuzzy feeling that everything is under control and that someone really has a plan to make everything work you probably loved it.

Here is the truth as this reporter saw it.  This is not for the squeamish, and some of it may be offensive to children under thirteen or C-suiters over forty.  In the general sessions nobody dared speak to the fact that:

  • Most large EHR implementations are failing.
  • Meaningful Use isn’t, and most hospitals will fail to meet it.
  • Hospital productivity is falling faster than are the Cubs chances of winning a pennant.
  • Most hospitals changed their business model to chase the check
  • Most providers will not see a nickel of the ARRA money—the check is not in the mail and it may never be.

The future as they see it is not here, and may never be, at least until someone comes up with a viable plan.  Indeed, CMS and the ONC have altered the future, but it ain’t what it used to be.  People speak to the need to disrupt healthcare.  Disrupt it is exactly what they have done.  The question is what will it cost to undo the disruption once reason reenters the equation?  What then is the future for many hospitals?

  • Hospitals on the whole will lose more much more money due to failing to be ready for ICD-10 than they will ever have seen through the ARRA lottery.
  • It make take years to recover the productivity loses from EHR and the recoup those revenues.
  • Hospitals spending money to design their systems to tie them into the mythical HIE/N-HIN beast will spend millions redesigning them to adapt to the real interconnect solution.
  • The real interconnect solution will be built bottom-up, from patients and their primary care physicians.
  • Standardized EMRs will reside in the cloud and patients will use the next generation of smart devices.  And like it or not, the winners will be Apple, Google, and Microsoft, not the ONC and CMS.  Why?  Because that is who real people go to to buy technology and applications.  A doctor still does not know which EHR to buy or how to make it work.  Give that same doctor a chance to buy a solution on a device like an iPad and the line of customers will circle the block.

And when doctors are not seeing patients they can use the device to listen to Celine Dion.  This goes to show you there are flaws with every idea, even some of mine.

(I published this post one year ago, just after the Orlando HIMSS.  It appears to still be valid today. Comments?)

The True Measure Of Success For HIT Systems

My newest post in healthsystemcio.com.  Feedback appreciated.

The title of the book on the lap of the person sitting next to me was “Cost Justifying Usability”. My cynicism jumped immediately to Def-Con 4.

Cost Justifying Usability. Did the author get his inspiration for the title at the Shopping-For-New-Ideas store? Now, before you laugh too hard, recall that many inane ideas make gobs of money, such as thePet Rock and Chia Pet. For every book, there must be an audience. I can only believe that the intended audience for this epic must be senior business executives.

Imagine yourself being one of those executives. Someone finds you lying on the floor in the fetal position and suggests you read the book. How should you respond?

  • I assumed usability was the antecedent  for buying that system
  • We just spent $300 million dollars on an enterprise system. Does making it usable cost extra?
  • They told us the drop-dead date is March 21. Drop-dead is the perfect phrase; we only measured cost and speed — nobody thought to measure usability?

What is the title of the antithetical book—Cost Justifying Unusability or, Cost Justifying Failure?

The statement most in HIT are afraid to utter is that most HIT spend has no ROI. There is no ROI because the usability measure of most of the largest HIT systems (enterprise and EHR) is negative — productivity is showing a net loss instead of a net gain.

Usability is not the same as user acceptance. User acceptance for these unusable systems will approach 100 percent. Why? Because users have no other option. And then there is Meaningful Use — an odd phrase because it has nothing to do with users. An EHR can pass Meaningful Use and have low user acceptance and the usability factor of hammering a nail with a banana.

If the healthcare industry needs to be convinced that a cost justification for usability is required before anyone takes the issue seriously, perhaps a moniker change is in order — HIT to OBIT.

Call me silly, but I think the time has come to do away with how we measure the success of all business systems projects. Was the system usable — did it increase ROI, did it make the organization more effective, and did it enable innovation? Only two approaches to measure need be used.

  1. On time, on budget, high user acceptance, unusable:             failure
  2. Not on time, not within budget, usable:                                        success

No matter what else happens, if the best your business system project does is to give you back performance similar to what you had without the system, a reasoned executive would say the investment in the system was wasted. It then stands to reason that if the new system delivered worse performance than what you had previously, it too is a wasted investment.

When I talk with some seasoned executives in HIT about the success or failure of their EHR system, I pause for a second waiting for someone to say, “Pay no attention to the small man behind the curtain.” Their standard of measure? See above, Approach 1. Some would have you believe it is heretical to say that spending a hundred million dollars on a system whose usability is poor was a waste of money. Most of those who defend the spend are those who did the spending.

Ask the users if they think the money was well spent. These three quotes came from a physician whose hospital spent $400 million on a name-brand EHR.

  1. “Their (the hospital’s) most expensive resource spends a lot of time doing data entry.”
  2. “The data is very good if you are a patient or an insurance company that wants to sue us.”
  3. “My productivity is still down thirty percent.”

Imagine yourself as a hospital executive and answer the following question. Which of these two pieces of information is more valuable: knowing your EHR passed Meaningful Use or, learning from your users that the EHR is unusable? In HIT, there are two rules:

  1. The usability measure of most EHRs is unacceptable.
  2. Paying more for your EHR than the next guy or gal does not change Rule 1.

Can you blame providers if they fail Meaningful Use?

I don’t wake up each day planning to be at odds with ninety-eight percent—I’m probably being overly generous assuming two percent of the people are as jaded as me—of the HIT community, maybe I just come by it naturally.

The first time I heard of RECs (regional extension centers) the first thing that came to mind was playgrounds, something akin to what the Police Athletic League might find useful.  Five hundred and ninety-eight million dollars.  They tried 597 and determined it wouldn’t be enough and figured 599 would be too much, but 598 million was just right.  Then Goldilocks made her way over to the porridge—sorry for turning left at the fairy tale ramp.

A large part of the success or failure of reform hinges on the success or failure of EHR.  Accordingly, the government made the egregious decision to manage the process of building and rolling out a national EHR down at the molecular level.  They have involved themselves at the front-end, at the vendor level, and at the back-end.  The more anxious they become, the more money they waste, adding another guise to get the healthcare providers to take their eyes off the ball.  Five hundred ninety-eight million “we’re just here to help you” dollars.

This money could be spent to pay the top EHR vendors to create one set of standards and modify their systems to fit those standards.

Meaningful Use.  Don’t get me started.  How can I fault thee; let me count the ways.  Those tested early for Meaningful Use will be examined less rigorously than those tested later.  This is like the IRS saying that if you file your taxes in February, don’t worry about those silly little math errors.  Healthcare will be the only industry whose software quality assurance check occurs after they pass the fail-safe point, the point of no return.

With good leadership providers should know EHR will pass meaningful use before implementing the system. If they fail to pass Meaningful Use, shame on them.

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?”

“Yes.”

“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.”

“Million?”

“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 they’d PING! PING! PING! 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
GOT A WONDERFULLY, AWFUL IDEA!

“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.

THEN
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!

New thoughts on EHR and ARRA money

So, there I was, laying out my plans for 2012.  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.

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.