EHR: Men Behaving Badly

When I lived in Colorado my friend and I decided that instead of running during our lunch break we would sit in on an aerobics class. Our plan was to hide away in the back of the class, watch the ladies, and then head back to the office. No sweat—literally, that was also part of the plan. Our thought process was that if women and other lower life forms could do it, how difficult could it be? We were mainly manly men; excuse the use of alliteration.

Within ten minutes we had to peel ourselves from the floor, barely able to lift our arms and legs. What we’d viewed as an hour of simple stretching coupled with an hour of looking like mainly manly men had reduced us to a pair of whimpering sissy boys. We also learned that if you sit in the back of the class that in order to exit you had to make it past all of the ladies as you dragged your carcass from the room.

Fast forward a few decades. I went to an exercise class called spinning. Sounds a little like ballet. It’s a stationary bike. A large TV hangs on a wall. Once again the room is packed with non-males, including my wife. My take on it is that it’s a bike class for women who’d rather watch Regis and pretend to exercise instead of actually breaking a sweat. What the heck; I was already there, why not humor her. The instructor smirked at me when I asked her to tune the TV to ESPN. She inserted a CD of The Killers, cranked it all the way up, and we started pedaling. Pyramids, intervals, uphill, more uphills. Twenty minutes into it my water bottle was empty, my towel soaked. The ladies, including my wife, were chatting away as though they were walking the dog.

Not everything changes with time. Sometimes it is better to participate than to watch. Sometimes it’s better to watch. Sometimes, no matter how certain one is, one’s certainty is meant to be changed. Sometimes certainty is based on bad ideas. Like the certainty that comes from knowing, “We’re doing just fine, thank you very much.”

There’s a scene in Billy Crystal’s movie, City Slickers, where the guys are on their horses and one remarks, “We don’t know where we’re going, but we’re making really good time.”

What is that everyone holds with such certitude in healthcare IT? Is it the knowledge that even if EHR drops productivity by 20% it was still a good call? Is it that chasing Meaningful Use, even if it means forgoing supporting the business strategy is wise?

EHR: Managing the changes to your organization

I reside where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s a small space where only those who place principle over fees dare to tread.

Where to begin? How to build your team? (Those who wish to throw cabbages should move closer to the front of the room so as not to be denied a decent launching point.) There are two executives, I hasten to add, who will defend what I am about to offer, a CIO, and a CMIO, ideas from both of whom you’ve probably read.

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time the project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon. I believe that staffing only to execute today’s perceived demands will get me shot and will fail to meet the needs of hospital. I need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications for healthcare IT.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare issues from an IT perspective. They’ve also indicated that—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform. I disagree with that position.

Here’s a simplified version of the targets I think most of today’s CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them. Here’s what I think. You don’t have to believe this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since I’m writing, I used it.

Before I go there, may I share my reasoning? From a business perspective, many would say the business of healthcare (how it is run) is being moved from 0.2 to 2.0. The carrot? Stimulus funding—an amount—should you earn it, and you will probably want to since your CFO has already built it in to the budget—that will prove to be more of a rounding error than a substantive rebate. Large providers are being asked to hit complex, undefined, and moving targets. They are making eight and nine figure purchase decisions based in part on solving business problems they don’t articulate. If success is measured as on time, in budget, and functional and accepted, I estimate for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

The overriding business driver seems to be that the government has told providers to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on EHR than they would to build a new hospital wing. They don’t know what it should cost, yet they have a budget. They don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot. I’d staff with a heavy emphasis on the following subject matter experts:

  • PMO
  • Planning & Innovation
  • Flexibility
  • Change Management
  • PR & Marketing
  • And..Disaster Recovery

None of these high-level people need to have much if any understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime. That will account for about fifty percent of the success factors.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years from now there will not be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of Rhios, and mapped into a NHIN. Under the current model, standardization will not occur if only for the fact that there is no monetary value to those whose standards are not standard to make them so. This discussion is orders of magnitude more complex than cassettes and 8-tracks.

Interoperability, cost, and the lack of standardization will force a different solution. I think the solution will have to be something along the lines of a single, national, open, browser-based EHR. Can an approach to solving this be pieced together by looking at existing examples like airline reservations, ATM, OnStar, Amazon, FaceBook, and others? I believe so. Are some of my words and examples wrong? Count on it. Please don’t pick a fight over my lack of understanding of the technology.

The point I am trying to drive home is that from a staffing perspective, lean towards staffing the unknown. Staff it with leaders, innovators, and people who can turn on a dime. Build like turning on a dime is the number one requirement. Don’t waste all of your resources on certification or meaningful use. If anyone asks you why, you can blame me. If you want a real reason, I have two. First, they won’t mean a thing three years from now. Second, if I am the person writing a rebate check, I want to know one and only one thing; can your system connect with the other system for which I am also writing a check.

However, when all is said and done, I call upon us to remember the immortal words of Mel Brooks “Could be worse, could be raining.”


EHR Certification: Less valuable than a turnip

I was asked to give my opinion during an interview for an article on EHR certification.  As you know, I could benefit from the advice that implores one to keep their mouth shut less the whole world know you have nothing to say.  I had the right to remain silent, just not the ability.

I tend to think the certification process was something invented and supported by the large EHR vendors as a way to make the small vendors less relevant and as a way to slow the development of standards. As standards come into play, the EHR vendors furthest away from the standards, including the largest vendors, will become less relevant.

There is no legitimate business reason for having to certify a system AFTER having spent several hundreds of millions of dollars implementing it.

The logic behind the comment about there being no raison d’être for the existence of certification is as follows.

Certification, to be of value, must imply that the act of certifying–like the Good Housekeeping Seal of Approval–is intended to show that a certified EHR is somehow better (for healthcare) than a non-certified EHR.

The post-implementation impact of EHR is that far too many nine-figure EHRs have resulted in productivity losses of between ten and thirty percent. In English…a hospital spends a hundred million dollars on a system and as a result of having spend that money is only able to handle fewer patients than it could if it had spent a dollar on a turnip.  That same hospital, now operating less effectively, can do so with a certified EHR, and can qualify for Meaningful Use.

The certification process has failed to justify its existence or to bring any value to the process.  However, it has not failed to get hospitals to spend additional millions to comply.

According to the hospital CIOs and physicians I have spoken with it means the hospitals (physicians) are able to see fewer patients. This is because the physicians must spend more time searching, navigating, and typing. My cardiologist who works at a very prominent hospital in Philadelphia told me two memorable things about their $200 + million dollar EHR:

  1. The data is excellent if you are a patient or insurance company. You now have excellent data with which to sue us.
  2. My productivity is down thirty percent. The hospital has taken its most expensive and time-constrained resource and made us spend the majority of our time interfacing with a keyboard instead of our patients.

I would encourage you to ask others what additional benefit, if any, certification has brought to them and would they not have received those same benefits without implementation.  Certification is the lottery ticket hospitals must purchase to enter the Meaningful Use sweepstakes.  Meaningful Use has no Meaningful Use. Many hospitals will have purchased that lottery ticket but will not meet Meaningful Use. Hence, the cost to attain certification and the cost to attempt to meet Meaningful Use are wasted dollars.  Meaningful Use is binary Sudoku, you either get it or you do not.

July is “take your EHR strategy to lunch month”

Several have written suggesting I toss my hat into the ring to serve as the EHR Strategy wonk or czar.  I was in the process of thinking it through when I was awakened from my fuegue state by a loud noise–my ego crashing to the floor.

Some have suggested that a camel is a horse designed by a committee.  Their point in saying that has something to do with how committees function less well than individuals–the problem with “group thinking.”  Personally, I think the camel design seems rather functional.

Some have asked, what is it about the EHR universe that has you dehorting the EHR process as though you are some sort of savant–nobody really asked that, but I wanted a segue and that’s all I came up with.

It’s the committees.  I feel a little like Quasimodo repining about the bells.  Raise your hand if you are on an EHR committee.  See?  Now, if you think that not only has the committee not accomplished much, but believe that it may never accomplish much, lower your hand.  Now look around.  Not many hands still up.

Take a few minutes and work Meaningful Use into your EHR task time-line for processes, work flows, change management, training.  Need more time?  I’d need more time than I have, and when I finished I guarantee I couldn’t explain it to anyone.  This is what happens when people get into a room, have a charter, and try to do something helpful.  I am sure they are all nice people.  But be honest, does this make your day, or does it make you want to punish your neighbor’s cat–you may have to buy them a cat if they don’t already have one.

What to do?  Here’s my take on it.  Plan.  Evaluate the plan.  Test the plan.  Know before you start that the plan can handle anything any committee tosses your way.  Let people who know how to run large projects into the room.  Seek their counsel, depend on them for their leadership.  If the plan is solid, the result has a better chance of surviving the next committee meeting

HIT: Your most solvable big problem

Two incompatible things are a type A personality and heart disease—I speak from experience.  I usually run six miles a day, three miles out and three miles back.  A few weeks ago I started hitting a wall after two to three miles and found myself having to jog/walk back to the car.  Wednesday I hit the wall after a mile, hands on my knees and gasping for air.

The air thing bothered me because that is what happened during my heart attack in 2002.  As I tried to make it back to my car I had to stop every few steps to catch my breath.  As I made it to a field and lay down several people stopped to ask if I needed help—this is where the incompatibility I mentioned comes into play.

I did not want to impose.  One of those who stopped happened to be a cardiology nurse and she was not taking no for an answer.  Dialing 911 she stated “I have an older gentleman, 60-65 having trouble breathing.”  That got my attention—all of a sudden my age seemed to be a much more important consideration to me than whether or not I could breathe.  “I am 55,” I corrected her.

Knowing how close I was to my home I tried unsuccessfully to get the EMTs to stop by my house before going to the hospital so I could get my laptop.  After three hours of tests, and without concluding why I had trouble breathing, they ruled out anything to do with my heart and sent me home.

I think knowing when to ask for help and accepting help relates a lot to healthcare IT; EHR, Meaningful Use, ICD-10.  These are each big, ugly projects.  There are several things that can happen on big, ugly projects, and most of them are bad.  This is especially true when the project involves doing something for the first time and when the cost of the project involves more than one comma.

Now we both know there is nobody with years of experience with Meaningful Use or ICD-10, and there are not many people who have one year’s experience.  So why ask for or accept help?  The truthful answer is because there are some people who know enough to know what to do tomorrow, and from where I sit the toughest part of every project is knowing what to do tomorrow—how to get started, and what to do the next day and the day after that.

Meaningful Use–Are you following the crowd?

I remember the first time I entered their home I was taken aback by the clutter. Spent and wet leaves and small branches were strewn across the floors and furniture. Black Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The windows.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.

And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

“Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives. Sort of like all the scurrying around Meaningful Use.  The normal has been subsumed by the abnormal, and in doing so has created an entire entity which is slowing devouring the resources of the organization.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid on a daily basis. When I talk with hospital executives they are marching headstrong into the Meaningful Use abyss.

It makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about it they always have an answer. It all boils down to something like, “We simply can’t turn down the money.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid.  It’s gotten to the point where no matter how goofy things get, as long as they are consistently goofy, they are not goofy at all.

This is the mindset that enables leaders to be fooled by their own activity. Busy replaces thinking.

What if there was no Meaningful Use?

On April 16, 1912 there was an article in the Daily Register in Anytown, Nebraska titled “Local Man Drowns.”  The article went on to note that a local man was lost at sea.  I paused for a moment trying to recall from my high school geography class the name of the ocean bordering Nebraska—there is not one.

It did not take long to realize that the newspaper was guilty of being more than a little parochial.  April 14, 1912 was the day the Titanic sunk.  The man in question had been lost at sea in much the same manner that the real headline of the story had been lost by the newspaper.

I think a lot of important healthcare IT headlines are being lost, and those loses can in large part be attributed to the puppet masters at the ONC and CMS.  It is difficult to swing a dead cat in a hospital cafeteria without hitting someone discussing Meaningful Use.  On the other hand, you could swing a blue whale without hitting someone talking about ICD-10.

The headlines are both buried and misinterpreted.  Some of the HIT headlines merit being repeated—feel free to use a highlighter on your screen to be able to locate the important ones.  Trying to meet Meaningful Use:

  • Is optional.
  • Does not mean you will meet it.
  • Could require most of your IT resources.
  • Means you may not have enough resources focused on ICD-10.

While these may appear to be trivial comments, misapplying your efforts could cost a large hospital more than tem million dollars.  Then figure another ten million to rectify the mess.

Ask yourself one question before you hire a pricey consulting firm to help you figure out how to meet Meaningful Use.

“What would we be doing if there was no Meaningful Use?”

Then do that.  Meeting Meaningful Use was never a part of your business strategy—you probably will not find it written in your three-year plan.  Did anyone sign off on the notion of spending millions of dollars to complete a task that has no ROI and has a reasonable probability of failing?

If it so happens that in pursuing your original strategy you can still meet Meaningful Use that is good.  The reverse is not so good.