Why isn’t EHR more successful?

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–the providers? There are the coordinators, and their 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 nobody sells holes—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.

What people at HIMSS were afraid to say

Posted by Paul Roemer

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.

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

Posted by Paul Roemer

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?

What must the ONC do to make EHR a success?

Posted by Paul Roemer

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.

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.

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.

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.

In a more perfect world the ONC might consider shifting course to something aligned with the following: