meaningful use

There is no ‘I’ in team, but there is in failure

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As a guy, I am entitled to be a fan of badly made war movies if for no other reason than they are war movies and come with a built-in plot, which minimizes the need to think too much—which is why some are so fond of Meaningful Use, but lest I get ahead of myself.

One such film, A Bridge Too Far, starred everyone but Mel Brooks.  The movie depicts Operation Market Garden, the allied attempt to break through German lines and seize several bridges over the Lower Rhine in Arnhem in the occupied Netherlands.  The operation fails, with many of the allied soldiers killed or taken prisoner.

At the conclusion of the movie the British generals are assessing their performance in a formal manner only the British can pull off.  Ignoring the failures, the dead, and those captured by the Germans, the last lines are:

Lt. General Frederick “Boy” Browning: I’ve just been on to Monty. He’s very proud and pleased.
Major General Urquhart (played by Sean Connery): Pleased?
Lt. General Frederick “Boy” Browning: Of course. He thinks Market Garden was 90% successful.
Major General Urquhart: But what do you think?
Lt. General Frederick “Boy” Browning: Well, as you know, I always felt we tried to go a bridge too far.

For those who have not seen the movie, the allied failure resulted from having spread their resources too thinly, for trying to accomplish too much with too little with too little time.

A bridge too far.  A euphemism for biting off more than one should, for the idea not being amongst the best laid plans of mice and men, one having the intelligence of a bowl of mice.

EHR.  Meaningful Use. Accountable Care Organizations.  ICD-10.

Which of these is a hospital’s bridge too far?  Or, is it all of them.

 

Meaningful Use is a binary contest—you make it or you don’t

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If you haven’t begun the process of selecting and implementing an EHR, Meaningful Use may not be something with which to concern yourself.  The reason, you will probably not be done in time to collect the incentive money. How can that be stated with such assurance?

If you haven’t begun, there may be no rush to acquire an EHR, although the EHR vendors will not tell you that. Don’t cost yourself tens of millions get to have a chance at a few.

Meaningful Use will be delayed because few if any of the providers will pass the Meaningful Use Audit. Washington created a multi-billion dollar lottery, and they are having trouble finding any providers who are able to purchase tickets.

Now for those whose EHR implementation is well underway or up and running — should you try for the incentive money? That’s a valid question. Just because someone is offering you a check doesn’t mean you have to take the money. Here are some questions you ought to be able to answer prior to deciding if Meaningful Use is meaningful to you.

  • Meeting MU requires a shift in your direction; you take on the MU tasks and sacrifice some of what you were going to do
  • What are those tasks, what resources will they consume
  • What year is the best year for you to meet MU; 2011-2015?
  • Did you know you can still maximize incentive dollars if you pass MU in 2013?
  • However, that gives you almost no time to react to Stage 2 & 3 requirements

Meaningful Use is a binary contest — you make it or you don’t. The decision to meet Meaningful Use does not have to be binary. There is no way to collect for meeting 90 percent of the requirements. How might you financially calculate the probability of obtaining the incentives? Let’s begin with Stage 1—the easy one.

  • Calculate the maximum incentive you could receive
  • Multiply that figure by the degree of certainty you have that your plan will be completed on time — a number less than 1
  • Then multiply it by the probability you think exists for passing the audit, another number less than 1
  • Calculate your cost to complete Stage 1, then figure out your ROI — not much is it?
  • This makes evaluating Stage 2 & 3 calculations seem rather superficial.

Take time to evaluate your options. The only people who will look foolish are those who don’t know what questions to ask.

EHR: Children of the Corn

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Not in the Stephen King way.  During the late fall, my middle school friends and I would play among the withered corn stalks; capture the flag, building forts, and on occasion being more adventuresome.  On those more adventuresome occasions the adventure included matches.

It went something like this.  We would stand among the seven or eight foot tall sepia colored stalks, and remove several ears of corn, corn that had been allowed to dry on the husk.  We would peal back the leaves on husk, and strip the kernels from the bottom two-thirds of the husk.  The end product would look similar to a WW II German hand grenade—the stripped husk became the handle, the kernels on the top third were the “explosive” part, and provided the weight needed to make the grenade travel when thrown, and the dried leaves were the fuse.

The leaves were lit, closed our eyes, and let it fly.  Then we would rush through the stalks looking for signs of smoke.  By necessity, we were in a hurry.  The object of the game was to locate the grenade among the hundreds of corn stalks before it set the field on fire.  We were successful every time but one—must have been a pretty good throw.

I remember my mother asking me why my corduroy jacket smelled of smoke.  I didn’t have the courage to tell her it was because we were using our jackets to try to beat out the flaming stalks.

Segue, albeit not much of one.  A lot of healthcare providers are also in a hurry to implement EHR.  The fuse is burning away.  The fuse is the timeline to get the ARRA incentives, or at least to avoid the penalties.  That means implementations are being rushed, which in turn means implementations will fail.

If anything can be stated with certainty it is the following; it will cost much more to revise a failed EHR implementation than whatever incentive money may have been received had it worked.  Speed is costly.  So is putting in an EHR that does not do what you need it to do.  There are no business benefits to getting the EHR box on your to-do-list “checked.”

When your haste to implement EHR causes you to fail to meet Meaningful Use, how will you explain to your mother why your jacket smells like smoke?

 

Will-o’-the-Wisp Optimism about EHR

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Will-o’-the-Wisp Optimism about EHR

Comment by PaulRoemer Dec 14, 2010, 11:36 AM EST

 

I think many of the definitions of “using” mean the EHR vendor has left the building, and so by default physicians are “using” the system.

If you happen to be one of the many hospitals whose productivity has declined by twenty percent two years after the EHR implementation, that does not constitute use, and it certainly does not constitute meaningful use, at least in any way that is meaningful to the hospital. Practice management systems are still in disarray, and the business processes are probably less effective than before the hospital spent eight or nine figures to get usability below where it had been. That’s not much of an ROI under any standards.

Some CFOs believe they can create an ROI by adding back the incentive money they may or may not receive. They should also figure in what the cost is of such a large productivity loss.

They are then faced with answering the question about how they will implement an ACO model on top of processes that have been made more ineffective due to implementing EHR.

While optimism is nice, it may be very misguided.

 

What can the ONC learn from the 80% of hospitals who are not on board with EHR?

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The ONC’s State of the Union Message will be delivered this week over a two-day period.  Rather than attend, I have decided to wait until the operatic version of the meeting is available on YouTube.  Mind you, I am convinced of the good intentions of their efforts, but to write I am skeptical of their results would be unfair in that my optimism would have to increase substantially for me to reach skeptical.

I am disappointed to report Chicken Little’s “The sky is falling” keynote presentation at the ONC event has been omitted from the agenda in favor of continuing to get others to believe that not only is Meaningful Use is meaningful, but also relevant.  I am not being intentionally trite, in fact, just the opposite.

The question unanswered by the ONC is does their stick and garrote approach make it relevant from a business perspective?  Its only relevance seems to be that without complying, hospitals’ revenues will decline.  Why will those revenues decline?  Is it because the hospitals made a poor business decision, lost patients to a competitor, or could not manage their expenses?  Of course not.  Their revenues will decline for one reason, and one reason alone—the ONC will give them less money for services they perform.

There are almost two-thousand hospitals in the US.  What percentage of them will complete EHR in time to reap their full incentive payment?  I think we can agree with a high degree of confidence that the number will be less than 20%–I’m guessing it will be closer to ten percent.  How many of those will then re-implement a certified version of EHR?  And then, what percentage of the remainder will pass the Meaningful Use audit?  You can probably fit all of those hospitals CEOs in a Hyundai mini-van.

If these figures are close to accurate, one might thing the issues at the forefront of the ONC’s efforts ought to be working with the other 80-90%.  They have tried to add that focus through incentive payments.  When that didn’t take the ONC created the Regional Extension Centers (RECs).  What percentage of the majority of hospitals is benefiting from using the RECs?  Will hospitals and doctors be able to link to the HIEs and into the N-HIN?  Me thinks not.

I have begun to think Mark Twain’s story Tom Sawyer may have been prescient when viewed in the light of EHR and Meaningful Use.  In particular is the part where Tom gets others to whitewash the fence.  Is it possible the ONC’s vision is limited to equipping people with giant paintbrushes who are, sadly short of a giant pot of paint?

Is their existing plan one which is executable?  Just because they have a plan, if most of the country’s hospitals have not bought into it, does not that simply make it a plan in name only?  Even if they buy into it does not, in and of itself make it viable.

If eighty percent of the hospitals are not on board, what can be learned from their lack of response?  Is it due simply to a lack of effort, as some would have us believe, or is there something more to it?  I think the lack of response by the majority of hospitals should lead us to conclude that something important about the strategy is lacking, to conclude that something is amiss.  If someone asked me—and just to give you comfort, nobody has—my conclusion is that more would be gained by the ONC holding a two-day listening session instead of a two-day speaking session.

Can eighty percent of the hospitals have no message worth hearing?

 

CHIME: Letter to the editor

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I wrote this today in response to what I felt was an overly optimistic depiction of how well hospitals are coping with EHR.  What is your take?

 

I am writing in response to the viewpoint you wrote recently.
While there is no doubt that some hospitals have made tremendous progress implementing EHR, and some executives believe they have a realistic shot of securing incentive payments, I am convinced that when all is said and done and the Meaningful Use audit has been completed, the number of hospital CFOs queued outside of CHS to pick up their checks could fit comfortably in a Hyundai.
What goods news there will be, albeit unannounced, will be that once CMS discovers they are holding a twenty-billion dollar lottery for which no one is able to claim their prize, they will be forced to relax the standards and move the dates.  In fact, I think MU for hospitals may disappear altogether.
I am a strong supporter of the benefits of implementing EHR.  However, EHR vendors have not exactly had to add extra chairs in their waiting rooms to accommodate all of their potential customers.  Perhaps the incentive payments and the RECs arose from observing the number of failed implementations and the number of hospitals who have not made much progress with EHR.
I think when one writes about the successes of EHR for large providers it is important to level-set the reader with some measure of perspective in terms of the total population of large providers.  One way to describe the relative number of successful EHR implementations as compared to the number of hospitals may be to say it is comparable to the handful of people who know how to use all of the features of Microsoft Word against those who do not.

 

 

Meaningful Use: Where’s the Pony?

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I often write not because I have something that needs to be said, but to try to explain something to myself.  If I get to a point where I think I understand an issue, I’ll make it public to see if the comments reflect my understanding, or to see if I need to have another go at my own thought process.  Which leads me to this—

Let’s back up the horses for a minute and return from whence we came.  EHR.  The idea was simple.  Two groups; patients and doctors.  Create a way to transport securely the medical records of any patient (P) to any doctor (D).

For the time being, let’s keep this at the level that can be understood by a third grader.  What two things do I need to satisfy this P:D relationship?  Data standards and a method of transport.

Do we have them?  We do not.  That being the case, what fury hath the ONC wrought?  (1 Roemer 9:17)  If you don’t have what you need, and you don’t have either the authority or a plan to get what you need, you must facilitate (fund) the creation of workarounds to fill the void.

At some point, the conversation must have quickly shifted from, “We need standards and transport”, to, “Since we don’t have standards and a means of transport, we must come up with other ways to try to make this work.”  Now, I don’t believe this is literally what happened, but I think one could see how it might have evolved.

Other ways.  What other ways?  The ONC loves me; it loves me not.  HITECH.  ARRA.  SO, they get to work and the plan they develop is “Take the monkey off our back and put it on the backs of the providers”.  Pay doctors to implement EHR.  Smote them if they don’t.  Stick and garrote management.  Write checks.  Big checks.  Lots of big checks.  Instead of coming up with a single transport plan and one set of standards, provide guidelines.  Make pronouncements.  Fund RHIOs and make them responsible for creating hundreds of unique transport plans and ask the RHIOs what progress they are making towards a single set of standards.  Get the monkey off your back.

Create artificial goalposts that get the HIT world all a-twitter every time the ONC makes a proclamation.  What goalposts?  Meaningful Use and Certification.  Just so there is no misinterpretation of what I think the issue is permit me to spell it out—Meaningful Use and Certification exist because there are no standards and there is no means of data transport.  Conversely, had the ONC developed standards and transport, there would be no discussion of Meaningful Use and no Certification.  Standards would have forced vendors to self-certify.

The other activity could be viewed as a feint.  Not one developed out of malice, rather one that came about from the void that resulted from the lack of a viable plan.  Meaningful Use and Certification are expensive workarounds for a failed or nonexistent national EHR rollout plan.  As are RHIOs and RECs.

The HIT world grinds to a halt at the very mention of any announcement from the ONC.  Their missives are available in PDF or stone tablets.  Imagine someone robs a bank, and as they exit the bank, they jaywalk on their way to their getaway car.  The police missed the robbery, and focus all their efforts on the secondary issue, the jaywalking.

The chain of events has caused the focus to move away from the primary issues of no standards and no plan, and towards a plethora of secondary issues, issues for which hundreds of people are responsible and no single person has authority.

The model is in such disarray that by the end of 2013 any ONC pronouncements on Meaningful Use and Certification won’t be able to buy time on MTV.

If any of this is close to being correct, what are the implications for a hospital looking to select and implement an EHR?  Simple; pind the EHR that is best for your hospital–not the one most likely to earn ARRA money.  Not the one which will pass today’s Meaningful Use test.  Define your requirements.  What requirements?  The ones you believe will most closely align with how the healthcare industry will look in 2015 and beyond.  Meaningful Use will change.  Reform will change.  Funds will change.  Reform will change again.  Will your EHR be able to change?

The EHRs were written before most people even heard of accountable care organizations (ACOs).  What do you think the chances are of an EHR supporting ACOs without someone having to take it apart with a hammer and chisel?

The ONC’s Meaningful Use proclamation is 556 pages.  If you occupy the C-suite of your hospital, I hope you don’t let those pages define your selection of an EHR.  Some would argue that with so many pages that there must be a pony in there somewhere.  From what I read, I’m in no hurry to rush out and buy a saddle.

How the election will impact healthcare IT and EHR

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Here are my thoughts on how the election will impact healthcare IT and EHR.  This post can also be found at healthsystem cio.com at http://healthsystemcio.com/2010/11/03/healthcare-2-0-here-we-go-again/

The real healthcare 2.0

Just when you thought it was safe to get back into the water…

It is a strange day when the smartest people in the room are the ones who did absolutely nothing.  Whether doing nothing required divination and prescience or, merely resulted from having no idea which way to tack the boat need not be determined.

So, what exactly will be the impact on your IT and business strategies after the bloodletting in Washington?  How is the whole Meaningful Use strategy going to bear fruit?  Unfortunately, the most favorable answer to a large provider may be, “We don’t know.”  If nothing else, now that Washington again has a two party system and is hosting a tea-party—Blanche Lincoln will be drinking coffee, one can be certain reform will be stalled if not derailed.

Most of the verbiage prior to yesterday focused on how much of an impact healthcare reform would have on the election, a P implies Q argument.  I think those individuals were too busy minding the P’s and Q’s when they should have been focused on their Q’s and P’s.  that is, how much impact will the election have on healthcare reform.

Twelve months were invested in the first debate on healthcare reform.  Ten more have since passed.  In grouping periods of time, I find it helpful to develop naming conventions to distinguish between two events or periods of time.  To at least pretend to be apolitical, allow me to label the healthcare reform and all the dollars invested by large providers to prepare their organizations to meet it prior to November 2, 2010, BP Reform.  All things after the royal coach turned back into a pumpkin at the stroke of midnight shall be labeled AP Reform—I will let you sort out the acronym.

Did I mention that under AP Reform the new governors will be appointing the new state insurance commissioners?  These individuals will be the ones responsible for implementing AP Reform.  These same people are responsible for determining the medical loss ratio which plays into how much insurers must spend on Medicare.

On November 2, you could not walk the hospital corridors without bumping into something unknown about the impact of BP Reform.  Today the conversation is simpler in that everything is an unknown.  What happens to the $400 billion in Medicare cuts and the states enacting legislation to forbid mandatory insurance?

How will the election affect the financial sustainability of Health Information Exchanges (HIEs)?  This alone is enough to cause one to question the viability of the National Health Information Network.

Bearing in mind that it will take many months to sort out the impact of yesterday’s election on the healthcare IT implications of AP Reform, what topics might be worthy of consideration at the next meeting of the EHR Steering Committee?  Here are a few that come to mind for me:

  • Will the healthcare legislation change?  If so, how?
  • Will certification continue to exist?
  • What will happen to Meaningful Use?  Will the requirements change?  What about the deadlines?  Will the incentives remain as they are?
  • How will it impact HIEs and the N-HIN?
  • What will AP Reform do to the development of Accountable Care Organizations?  How will ACOs need to be supported and reported?
  • How will Patient Experience Management differ?
  • How should the organization’s strategic plan be altered?
  • What should our HIT plans look like?

The one thing I think we can agree on is that having an Electronic Health Records (EHR) system will be an integral part of whatever comes about.  What it is, how it gets there, how you implement it, and what it will be able to do remains up to you.

I have been telling my clients to approach EHR and Meaningful Use as though Meaningful Use did not exist.  Given that the number of business uncertainties has just skyrocketed my counsel to large healthcare providers is to approach EHR with a narcissistic attitude.  Select and implement EHR as though Meaningful Use did not exist.  Why handcuff your EHR to constraints that will certainly change?

 

Can you blame providers if they fail Meaningful Use?

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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.

Informationweek Healthcare Article on Meaningful Use

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This link takes you to an interesting and well-written article written by Anthony Guerra.  Even if he didn’t quote me in the piece, it would still be worth reading.

http://www.informationweek.com/news/healthcare/leadership/showArticle.jhtml?articleID=227500796