planning

How measuring Brittan can improve your EHR success

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So, last night I am watching NOVA.  The episode discussed fractal geometry and aired the same time as the Green Bay-New England game.  Admittedly, not a typical Y-chromosome choice, but interesting none-the-less.

A fractal is a fragmented geometric shape that can be split into parts, each of which is a reduced-size copy of the whole.  Simple enough.  Common examples of fractals include the branching of trees, lightning, the branching of blood vessels, and snowflakes.  I am willing to bet I think of many of the ideas on which I ruminate in a fractal manner.

In the seventies the mathematician Benoît Mandelbrot discovered that fractals could be described mathematically.

It turns out that a shoreline is another example of a fractal.  For example, let’s say you wanted to determine the length of the coast of Brittan by measuring it instead of just using Google.  The coastline paradox says the measured length of the coastline depends on the scale of measurement.  The smaller the scale of measurement, the longer the measurement becomes.  Thus, you would get a longer measurement if you measured the coastline with a ruler than with a yardstick.  This paradox can be extrapolated to show that the measured length increases without limit as the unit of measures tends towards zero.  In the first picture, using a 200 km ruler, the coastline measures 2,400 km.

In this photo, using a 50 km ruler, the coastline measures 3,200 km.

I’m not sure why this idea needed to be discovered, it seems a little obvious—more information yields more informed results.

A few years ago I was hired by a firm to report to their board on their vendor selection process.  The firm was about to issue a two-page RFP to two vendors.  I convinced the firm to redo the process.  They ultimately issued an RFP of more than a thousand requirements and selected a vendor who was not on their original list.

Again it seems obvious, but being obvious doesn’t always result in smart behavior.  If you’re getting ready to spend eight to nine figures on and EHR, wouldn’t you like some degree of confidence that you selected the best one for your hospital?

One thing is certain, albeit less obvious, the more due diligence you give EHR, the higher your chances of success will be when you try to build out an ACO business model.

 

EHR: work plans are necessary but not sufficient

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I wonder about things, little things, things I see on Nova or on Bizarre Foods.  Take water, more specifically, ice.  It floats.  The only solid that floats in its liquid state.  Most solids sink, not ice.  For those of you thinking boats float, they’re not considered to be solids—does that make them liquids?

It turns out that as water goes from four degrees centigrade, its densest point, and towards freezing, it becomes less dense and floats.  It’s volume increases by 9%, and part of that 9% is trapped air.  That air, even though you can’t see it, exists between the two H’s and the O.  which takes us to the following.

Have you spent much time studying work plans?  While there are more interesting ways to spend your time, there are times meant for writing them, and times meant for studying them.

Having a work plan can be a little like having a bike; nice, practical for some things, impractical for others.  Like with most things, there are work plans and there are work plans.  Some may not be worth the paper on which they are written.

Just like not everyone can write a book worth reading, not everyone can write a work plan worth implementing.  Lines on paper don’t necessarily yield a project of much value.  Remember how with the ice there are things between the H’s and O’s?  Well, with a lot of healthcare IT and EHR work plans, there are things between the tasks on the work plan, or at least there should be.  Can’t see them either.  Those things?  The missing tasks, the tasks that should have been in the plan, the tasks that would have given the plan a fighting chance to succeed.

Some gaps are good, like with ice.  Others can leave you hanging.

 

EHR: Should you hire a swim coach?

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Swimming with guppies.

Got the new bike, got the new bike shoes, got the uni (uniform-not unitard).  I’ve written about my desire to compete in a triathlon.  Actually, I miswrote.  My desire is not to compete, it’s more accurately a desire not to make a fool of myself during the swim, more specifically not to drown.

The swimming is one of those events where having the coolest outfit doesn’t help, as there are no coolest swimming outfits (men do not let men wear Speedos).  There aren’t enough North Face labels for me to wear to make me look like I know what I’m doing in a pool.

What to do?  Here’s my thinking.  I made a new friend, and as a bonus, she happens to be pretty sharp on the pharma side of healthcare.  She swims—fast.  She swims—a lot.  Did I mention she swims?  Longtime readers know I like to color outside the lines.  Maybe I could hire her to take my place during that part of the race.  Then we get back to the issue of the uni.  One way or another that becomes an issue for one of us.

She offered to teach me.  Lesson one was today.  Lesson two will begin right after the EMTs finish their CPR on me.  Rule one, no matter how cool you think you are, you can’t breathe under water.  That took a few laps to master.  More breathing, stroke, legs.  Lots to learn.

“Let’s get a pool boy to help you not drag your legs,” she suggested.

I have difficulty passing up the opportunity to comment.  She could see I had the broccoli in the headlights look in my eyes.  “You hold it between your legs and it helps you float.”

I scanned the pool.  There we the two of us…and the lifeguard.  “It looks like he’s busy,” I offered somewhat sheepishly.  “Besides, if that’s what it takes, I think we’re both better off if I drag my legs.” (A little un-PC pool humor, but why not, I was already wet and being out swum.

So, what does this have to do with why we’re here?  Here’s the take away.  Sometimes, no matter how smart, no matter how big your ego, you need help.  Sometimes it makes a huge difference to have someone on your side who’s been there, done that, got the T-shirt.

Not with me yet?  A guy (man or woman guy—send me an email and let me know when we can let go of this PC thing and just write) is walking down the road, not watching where he’s going, and he/we/she/it falls into a deep hole.

An engineer walks by.  “Help me,” shouts Hole Person.

The engineer thinks for a moment, writes some ideas on a piece of paper and tosses them into the hole.

Several hours later, a finance guy walks by.  “Help me out (literally)” yells Hole Person.  The CFO tosses down a cheque (I use the Canadian spelling to distinguish it from someone from the Eastern Bloc as it would make no sense to toss another person into the hole.)

Days later, Hole Boy (not the same as Pool Boy in case anyone is still reading) is at the end of his rope.  The work plan failed. The Check bounced.

A consultant passed, saw the man, and hopped into the hole.

“Why did you do that?  Now we’re both stuck.”

The consultant smiled in a Grinch-like fashion—please see prior blog for the segue.  “I’ve been down here before, and I know the way out.”

Kind’ a like a swim coach.

EHR projects have more zeros than you can count.  What if you could hire someone who knew the way out?

I may know someone who can help.

 

Does ego get in the way of making change an imperative?

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My friends who have nicknamed me Dr. Knowledge or the Voice of Reason have seen me on those rare moments when the synapses were firing on all cylinders. There are others who have seen me in my less than knowledgeable moments.

For instance. There was the time I took my three young children to the movies. Upon returning home we heard the calming sound of water flowing; only it wasn’t calming since our home was not built with a stream running through it. After looking in the basement and seeing water streaming through the ceiling, I called our builder’s hot-line. I was furious at them and so told the handyman as he looked at the exposed rafters.

Undaunted, and convinced that the pipes were fine, he proceeded to the first floor to source the leak. I saw water coming through the wall and ceiling of the conservatory and gave him another piece of my mind—something my mother had always cautioned against so as to ensure I still had some left in case I needed it. We headed upstairs, through a bedroom, into my son’s bathroom. By this time we were wading. The sink faucet was in the on position, the drain was in the closed position, and I was in no position to blame the builder.

I learned that my son had been doing a ‘speriment’ with the soap. He told me it was my fault he didn’t turn off the faucet before we left because I told him, “come down stairs right now.” He no longer does ‘speriments’ in the sink and most of the waviness in the wallboard has subsided.

I hate being wrong, especially in front of an audience. Once I have an opinion about something, the planet has to shift on its axis before I’m likely to reconsider. I’ve found that to be true with building strategy to support a business that is undergoing radical change, especially when people are asked to consider not doing something, or are asked to consider doing something differently. There’s way too much, “That’s the way we’ve always done it,” and, “That’s the way corporate told us to do it.” What in your strategy would benefit if someone considered doing something differently?

This week I met with an MD and former hospital CEO who told me he is writing the business strategy for a group of hospitals.  When I queried him about what difficulties he was encountering he mentioned that everyone from the board on down “just does not have a clue.”  (And you thought it was just me.)  The things for which he concluded they do not have a clue are legion, including:

  • they have a budget, not a plan
  • they have never discussed integrating an IT strategy with the business strategy–which is just as well as they do not have an IT strategy
  • the are ready to select a name-brand EHR vendor and to spend close to $100 million, but they did no due diligence as to which vendor to select–seems one of their execs knows one of the vendor’s execs
  • they have more duplicative business processes than Imelda has shoes
  • they are all fired up about moving to an ACO model, but have zero understanding of how an ACO model will fit their organization

One may be successful using this approach to run a lemonade stand.  My guess is that the strategy will require a little tweaking to get it to work for a hospital group.

Warmest regards,

Dr. Knowledge.

 

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?

 

How will ACOs impact HIT?

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I know it makes you nervous to learn I have been thinking about something as there is no telling what may develop.  Feel free to use a highlighter on your screen if you find anything of interest.

The healthcare large provider business model looks more and more like its designed used to be the woman at kid’s birthday parties who makes animals and things out of balloons.  With the blue balloon she can make a giraffe, a bike from the green balloon, and a hippo from the pink one.

If she’s highly skilled she will build something complex using a number of different balloons.  Let us try to imagine watching her as she sets about to build a riding lawn mower.  With several popped balloons lying at her feet on the carpet she presents us with a green and yellow John Deere mower which used more than a dozen balloons.  Next, disregarding the pacifists at the party, she builds a B-1 bomber.   Her third assignment results in a McMansion with working Jacuzzi.

Each balloon creation is more complex than the preceding.  Being unimpressed I asked her if she could incorporate the design of the bomber into the design of the lawn mower.  The only rule—she was not allowed to pop any of the mower’s balloons.  If she was able to achieve that successfully, she would then have to incorporate the house onto the bomber onto the mower.

Balloons started popping and did not stop until there were none left, making it impossible to even save the mower.

Imagine a hospital’s pre-EHR business model as the lawn mower.  What happens next is that same business model is forced to adapt to EHR—like overlaying the bomber onto the mower.  Along comes accountable care organizations (ACOs).  House-bomber-mower.

This makes for an interesting planning exercise.  If we assume, as many have, that the existing hospital business model has been cobbled together over twenty to thirty years, retrofitting it will be no small task.  The problems we are seeing with many EHRs is that if implemented on top of the old business model, the odds for a failed EHR implementation are at least equal to the odds of a successful implementation.  For many, a “successful” implementation is viewed as one where productivity may be down by as much as twenty percent.

To the retrofitted EHR business model hospitals will soon try to implement the Healthcare IT demands of ACOs.  I recommend you first try these using balloons.  It will look prettier when it breaks; and will be much less expensive.

EHRs and ACOs are devilishly complex, and trying to implement them on a framework designed to support neither means that everything will work poorly.  (I was going to write that everything will work less well than planned, but it occurred to me given some of the plans I have seen that it will all work just as planned.)

I just read an article in a major trade organization stating “accountable care organizations must encourage patients to participate in the prevention of their care.”  That approach seems counter-intuitive to me, but maybe I am missing something.  Then again, it may all work just as planned.

HIT/EHR: A little adult supervision

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Among other things, EHR requires adult supervision–kind of like parenting.

My morning was moving along swimmingly.  The kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—those of you more politically astute would call them evergreens—to make them look snow-covered.  (I just em-dashed an em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  It may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things it can be are things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR, a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctor’s.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.

Relative (Non) Value Units (RVUs)

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Below is my lastest post in HealthSystemCIO.com.

http://healthsystemcio.com/2010/12/01/relative-non-value-units/

This issue has been troubling me ever since a doctor told me her hospital was implementing it.  It is good to know that there are no patents on bad business ideas—that way everybody gets a chance to use them.  Sometimes bad ideas come with misnomer labels that suggest they are less evil—Meaningful Use is a good example of a misnomer idea, but that is not the topic of today’s discussion.

Permit me to illustrate this idea with an identical policy in another industry, one that I believe will hit home for many.  Think back to the last time a cable television technician came to your home to perform some piece of work; moving or adding an outlet, installing cable or internet.  (Before I started practicing medicine on-line, I spent many years consulting to the cable industry about how to improve their operations using the tools of IT.  I often rode with the technicians to observe how they did their work.)

During these times I noticed jobs when the technician did not have the time needed to complete the work described on the work order.  Rarely did the technician have time to complete any add-on work—work requested by the customer while the tech was at their home.

What really interested me was the answer to my question of ‘why’?  It comes down to the following.  When the technician leaves the service bay in the morning, the tech has a list of work orders that must be completed by the end of the day.  Each work order is worth a fixed number of points, and the technician is evaluated and paid in relation to the number of points earned.

Let’s say the tech is to install a new wall outlet; five points and 30 minutes may be assigned to that work order.  The tech arrives at the home only to learn the outlet is to be installed on an interior wall and the cable will have to by threaded through the wall via the attic; a sixty minute job.  If the tech stays to complete the work, it will only yield five points and delay his entire schedule by thirty minutes.

Either way, the process fails, and the customer is failed.  The tech will return tomorrow at double the cost to the company, but he will now be allocated 60 minutes for the work.  There is always time to do the work over, and never time to do it right.

This business process suggests the next customer is always valued more highly than the present customer.  This is why when you are being helped by a clerk in a store and the phone rings the clerk will stop servicing you—a paying customer—to service someone who merely wants to chat.

The process? Relative Value Units (RVUs), and it’s another misnomer.  An argument can be made to show RVUs have little or no relative value, but entire hospitals run on these, and IT builds systems to assign, track, and report on RVUs.  Is there a way for IT to demonstrate or report the impracticality of running a business in this manner?

 

EHR… “You are not twenty anymore”

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There is a first time for everything.  Yesterday was the first time it occurred to me that there is a difference between being twenty and not being twenty.  A few days ago one of the women at the gym was bemoaning the fact that being forty wasn’t at all like being thirty–puhleeaasse.

My wife would have me point out her admonition of “You are not twenty anymore.”  Women do not understand that to men this phrase goes into our little brains and comes out reshuffled as the phrase “Just you wait and see.”

There are those who would have you believe that there is no single muscle that is connected to every other muscle, a muscle which if pulled will make every other muscle hurt.  I beg to differ.  I think I found it—I call it a my groinal—it’s connected to my adverse and inverse bent-egotudinals, the small transflexors located behind the mind’s eye.  I found the muscle while running back a kickoff during a Thanksgiving morning game of flag football.

Call it an homage to the Kennedys.  Sort of made me fee like one of them—I think it was Ethyl.  Old guys versus new guys—I know it’s a poor word choice but you know what I mean which after all is why we’re both here.  Did I mention that everything aches, so much so that I tried dipping myself in Tylenol?

There are two types of people who play football, those who like to hit people and those who don’t like being hit.  I am clearly a member of the latter camp.  I used to be able to avoid being hit by being faster than the other guy.  This day I avoided getting hit by running away from the other guy.

The weird part is that my mind still pictures my body doing things just like the college kids on the field, and it feels the same, it just isn’t.  Two kids passed me–they were probably on steroids, and my only reaction was the parent in me wanting to ground the two of them.  Half the guys are moving at half the speed of the other guys.  At the end of each play, we find our side doubled over, our hands on our knees, our eyes scanning the sidelines for oxygen and wondering why the ground appears to be swaying.

As the game progresses, instead of running a deep curl pattern, I find myself saying things like, “I’ll take two steps across the line of scrimmage, hit me if I’m open.”  Thirty minutes later I’m trying to cut a deal with their safety, telling him, “I’m not in this play, I didn’t even go to the huddle.”  After that I’m telling the quarterback, “If you throw it to me, I’m not going to catch it, no matter what.”

All the parts are the same ones I’ve always had, but they aren’t functioning the way they should.  It’s a lot like assembling a gas grill and having a few pieces remaining—I speak from experience.  Unfortunately, implementing complex healthcare information technology systems can often result in things not functioning the way they should, even if you have all the pieces.  It helps to have a plan, have a better one than you thought you needed, have one written by people who plan nasty HIT systems, then have someone manage the plan, someone who can walk into the room and say, “This is what we are going to do on Tuesday, because this is what you should do on Tuesday on big hairy projects.”.

Then, if you pull your groinal muscle implementing EHR, try dipping yourself in Tylenol.

 

EHR–WWOD (What would Oprah do?)

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So, I’m watching the Alabama Auburn game and it suddenly strikes me, there are probably a lot of people trying to understand what it is a consultant does that we can’t do for ourselves.

For those who have a life, those who missed the game, Auburn entered the game undefeated and had a good chance to play for the national title.  Alabama opens the game with several well-scripted opening plays and grabbed an early lead.

Their first ‘n’ offensive plays were brilliant.  They were planned perfectly.

It became apparent they had not planned the however many of the ‘n + 1’ plays.  Their plan failed to go beyond what they’d already accomplished.

How does that apply to what you do, what I do, and why I think I can help you?  It is best described by comparing your brain to a consultant’s brain.  Your work brain functions exactly as it should.  It’s comprised of little boxes of integrated work activities, one for admissions and registration, one for diagnosis, another for care.  There’s probably another box for whatever it is the newsletter stated IT was doing three months ago and how that impacts what you do.  That’s your job.

Your boxes interface in some form or fashion with the boxes of the person next to you in the hospital’s basement cafeteria who is paying for her chicken, broccoli, and rice dish that reminds you of what you ate at crazy Uncle Bob’s wedding reception.  That interface is the glue that makes the hospital work.  It’s also the synapse, the connective tissue—I know it’s a weak metaphor, but it’s a holiday weekend—give me some slack—that tries to keep healthcare functioning in an 0.2 business model.

There are names for the connective tissue, you know it and I know it.  It’s called politics.  It’s derived from antiquated notions like, “this is how we’ve always done it”, “that’s radiology’s problem”, and “nobody asked me”,

At some point over the next week or two the inevitable happens; the need arises for you to add some tidbit of information.  Do you add it to an existing box, put it in an empty box, or ignore it?  This is where you must separate the wheat from the albumen—just checking to see how closely you’re following.

Your personal warehouse of boxes looks like the final scene in Raiders of the Lost Ark—acre after acre of dusty, full boxes, no Dewy-decimal filing system, and no empty box.  There are two rules at the hospital; one, bits of information must go somewhere, and two, nobody can change rule one.

The difference, and it’s a big one, is that consultants have an empty box.  It’s our Al Gore lockbox.  We were born that way.  It’s like having a cleft chin.  We also have no connective tissue to your organization.  No groupthink.  No Stepford Wives. No Invasion of the Body Snatchers to turn us into mindless pods.  Consultants may be the only people who don’t care.  Let me rephrase that.  We don’t care about the politics.  We don’t care that the reason the hospital has four IT departments is because the hospital’s leadership was afraid to tell the siloed docs that they couldn’t buy or build whatever they wanted.

Sometimes it comes down to your WWOD (what would Oprah do) moment.  Not ‘what do they want me to do’, not ‘what would they do’, not ‘what is the least disruptive’, not ‘what goes best with what the other hospital did’.

At some point it comes down to, what is the right thing to do; what should we do.

Big, hairy healthcare IT projects come out of the shoot looking like Alabama did against Auburn.  The first however many moves are scripted perfectly.  Heck, you can download them off Google.  Worse yet, you can get your EHR vendor to print them for you.

The wheat from the albumen moment comes when you have to come up with an answer to the questions, “What do we do next,” and “Why doesn’t it work like they said it would?”

That’s why consultants have an open box.  You know what we are doing when our brain takes us to the open box?  Thinking.  No company politics to sidetrack us.  Everybody knows the expected answers, but often the expected answer is not the best answer.  Almost everybody knows what comes after A, B, C, and D.

Sometimes…E is not the right answer or the best answer.