planning

A scathing rebuke of EHR

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I encourage anyone with an EHR or thinking of getting an EHR to read this.  I do not think it is a unique story.

I recently spent an hour with my cardiologist.  He is employed by a very large teaching hospital.  After checking my vitals, listening to my heart, and asking a few questions, he moved from the exam table to the keyboard—where he remained.

Click…click…click

The focus of our conversation quickly moved away from me and onto him—more accurately to his Hospital’s three-year-old EHR system.  I learned quickly from him that calling it a system was somewhat optimistic.

Here is what I learned from him about the hospital’s EHR:

  • It is possible to take your most expensive and most trained resource away from what they do and have them spend forty-five minutes of the hour performing a clerical task—data entry.
  • Productivity is down at least thirty percent.
  • He called EHR the “Silent intruder in the room.”
  • “What are the benefits?” I asked.  “It does a great job collecting data for those who may want to use it against us in a law suit.”
  • “What about interoperability?”  “Not in my lifetime,” he replied.
  • “It makes everyone’s job easier but mine and the nurses.”
  • “Did anyone speak to you about what you needed from an EHR?”  He is still laughing.
  • He needed his nurse to help him schedule my next appointment.
  • “How would you react if I asked if what the hospital implemented was nothing more than a hundred million dollar scanner?”  “I would not disagree with that assessment.”

The good news is that he is arranging a meeting for me with the hospital’s CEO to see what I can do to help.

My take?  I was the other intruder in the room.  

Why should you reframe the EHR discussion?

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Are you one of the millions with recurring dreams of taking college exams?  I remain haunted by two, both which happen to be rebroadcasts of real events.

In the first, I had convinced my graduate school professor of operations management that since I took operations research in college that I could “audit” his class and be the teaching assistant.  I used the term auditing to mean I didn’t have to attend the class or do the home work.  From the school’s perspective, it did mean I had to take the final.  As I learned sitting at my desk, wishing I could think of any excuse to move my pencil across the pristine pages of the blue book, apparently there is a difference between operations research and operations management.  Whatever the difference was, it accounted for the blank pages staring up at me.

At the end of the exam the only marking in my book was the note I wrote to the professor, “I think we both know I know how to do this however, I froze.  If you need to fail me, I understand.”  He gave me a “C”.  I saw him when I visited Vanderbilt last year, and he recognized me and remembered the story—I like to keep my audience riveted.

The other dream has to do with my lone Poly-Sci class as an undergrad.  I am a proponent of the notion that I can answer almost any question provided I can reframe the question into one I can answer.  The exam instructed us to answer a question about a book I hadn’t read.  My only choice was to reframe the question, equating it to one from a book I had read.  I gave what I thought amounted to a fairly reasoned response to “my” version of the question.  The professor agreed that I had, and then wrote on the cover of the exam book that he too used the same device when he was in college.  It had not worked for him and he wasn’t going to allow it to work for me.

I think many of those grappling with EHR would benefit from reframing the question.  Many view the question as, “How do I accomplish what the folks in Washington want me to do?”  Sometimes that question might deserve an answer.  In the case of EHR I do not think it does.  In fact, I think answering the question, and then building a plan around your answer can make EHR more difficult, and it can move you away from your business goals.

A better question, at least for your hospital or practice is, “Does it make sense for me to accomplish what the folks in Washington want me to do?”  Has Washington demonstrated enough leadership over EHR, Meaningful Use, Interoperability, or reform to justify following?  Have they provided enough clarity, defined a set of business objectives, or justified their reasoning?  Does their reasoning fit your business model?

I bet it does not.

Why DC might be wrong on Meaningful Use

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I watched recently Barry Levinson’s movie Liberty Heights about a handful of people in Baltimore growing up in the fifties.  In one scene the high school practices a civil defense drill.  For those who have never seen a civil defense drill, a number slightly smaller than those who have never seen a dodo bird, permit me to explain.

From the fifties through the early eighties the fear of the US and the Soviets—if you have to look it up, it is better that you stop reading—engaging in nuclear war seemed so imminent that school children participated regularly in drills to protect them from nuclear attack, nuclear winter, nuclear annihilation.  The exercise was called duck and cover.  Stay with me now—those in charge were quite serious about this.

In duck and cover, once you saw the flash of the nuclear explosion—assuming your retinas weren’t fused—you were supposed to get under a table, most likely a wooden one that would have already turned to ash, and assume the fetal—or fecal position.  Educated adults came up with this idea as a solution, people with PhDs.

Generations of kids, millions of kids practiced this drill several times a year.  Someone puts forth a directive.  Instead of challenging it, other reasoned adults wallow in their folly.

Duck and cover.  Lemmings off cliff.

EHR and Meaningful Use.  Lemmings off cliff.

Question it before you leap.  EHR is a great opportunity.  EHR under the government’s direction—this is the same institution who developed duck and cover.  EHR and Meaningful Use—if you find it meaningful, you would probably benefit from speaking with someone who does not share your perspective.

Meaningful Use from EHR’s Meaningful Muse.

How to raise healthcare IT costs without really trying

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Like anyone needs my advice as to how to do that. Go ahead, have at it. Go shopping. Shop to you drop. How much do you need? Suppose we open the coffers. How much; another million? Ten Million? Twenty-five, fifty? $100,000,000? This is a one-time offer, so make sure you ask for everything you need

What if I told you this money is available provided you correctly answer a few basic questions. Reasonable? I’d hope so for a hundred million dollars.

1. What will you do with the money that you haven’t already done?

2. Has anyone else every done that?

3. If yes, did it work for them?

4. If no, why not, and what makes you think it will work for you?

5. Will these additional funds;

5a. Get you the ARRA money?

5b. Enable you to see more patients?

5c. Help you retain and attract physicians?

5d. Increase patient safety?

6. What is your mission?

7. Why isn’t your mission the KPIs listed in question 4?

8. Are other hospitals spending the amount you are requesting?

9. Did that amount of funding allow them to meet the criteria specified in question 5?

10. If no, what makes you think you can do it?

If your CFO asked these questions, would you think them reasonable? If not, prepare 3 envelopes (see Google)

If you don’t buy the right EHR and implement it correctly, you’ve just spend a hundred million dollars to scan charts.  Somebody will be held accountable for the money.

Upgrade the coffee to Starbucks-$5. New bedpan-$50. New plasma monitors-$1,200. Knowing what you are doing—Priceless.

May I borrow your pen?

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Have I written recently I’m not a fan of technology for unless someone knows what business problem they intend to solve? It’s not so much that I have anything against any of the technology or any particular technology or EHR vendor, it’s more that I think many are misjudging what the technology will do for them, what they have to do to it, and they forget to ask themselves how to best address the problems.

Whatever do you mean? Thanks for asking—here’s an example. When the United States first started sending astronauts into space, they quickly discovered that ballpoint pens would not work in zero gravity.

To combat the problem, NASA scientists spent a decade and $12 Billion to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300C.

The Russians used a pencil.

Have a meeting about how to best plan for and implement EHR in your hospital. One rule, all discussion should involve process, not technology. Try first to reach consensus about what to do, then look at how to do it. You may find out that all you need is a pencil.

“Are the best intentions of EHR Half-Full or Half Empty?”

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Doublethink. Functioning simultaneously on two contradictory beliefs and accepting both as true. By definition, one must be false, unless of course you are living in a parallel universe, in which case you’re in need of more help than I can deliver. George Orwell defined it as, “A vast system of mental cheating”—on yourself, I might add.

What does doublethink accomplish and why does it exist with varying degrees within each of us? First, it allows us to overcome our own competence. I think that’s worth repeating, overcoming our own competence. We know better and yet we talk ourselves out of accepting what we know, creating an equal and offsetting false belief.

Second, it acts as a safety net. How? Let’s say we are one hundred percent confident in Belief A. Well, almost. There’s always that little nagging disbelief, that little devil on the shoulder trying to convince you otherwise. Sort of like ‘buyer’s remorse’—only we’ll call it believer’s remorse. Just in case Belief A is wrong, maybe I should have a backup belied, Belief B. Jeckyll and Hyde.

How does that impact one in the EHR problem?  Buckle up. Most people with whom I’ve worked are very passionate about what they do and are paladins of their methods.  Sort of EHR young Turks.  Belief A. They do everything they can for the program.

While sincerely believing in the importance of EHRs, here’s what else I’ve observed.  Much of that belief envelopes the limited notion of believing that nothing lays outside of their skill set. They often recognize it more as a desire than a belief.  They know fully that they will face challenges which are new to them.  They know fully that many implementations have failed and that they need to spend more effort on change management and work flow alignment than was budgeted.  The list of challenges for which they lack the expertise never empties.  They know the light at the end of the tunnel is just a train. They know fully that solving the current problem only seems to reveal the next one.  Belief B.

So, we’ve come full circle. We outwardly profess we can do what others have failed to do, yet in our heart of hearts we believe that you may never see an ROI. Doublethink.

Which gets us back to our original question, “Are the best intentions Half-Full or Half Empty?”

HealthsystemCIO.com–a few thoughts

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These are my comments to the post by Steve Huffman, VP & CIO, Memorial Health System.

Well written Steve. I think part of what is being missed by Washington is that in their effort to mandate providers move to facilitate a nationalized healthcare model; they have overlooked a few things. For starters, I think the EHR discussion has shrouded the fact that EHR is voluntary. Unfortunately, very few providers look at EHR as a decision they should evaluate—do I or do I not do EHR. Instead, they eschew that question, and view the need to do EHR as a decision that was made for them.

• Two business models are in play, a national model and the one used by providers. In the end game, even though it is only mentioned in the privacy of their own policy rooms—and not streamed on CSPAN—the national model is ultimately being designed to connect every doctor to every patient—one big hospital under thousands of roofs. The other model is the provider’s singular business model. It’s a patient-centric model (the healthcare business) and a business model (the business of healthcare). The two models have different goals and different requirements.

• If the model Washington is pushing were attractive, providers would be knocking one another down tying to be first in line to implement it. Clearly, that is not happening. Instead, Washington is offering billions in rebates, and there are still few takers.

• There is no viable plan on how to get from here to there—none, nada, zip. Instead of a coherent plan coming from them, they have put the monkey on the back of the providers, guiding them with carrots and sticks. Washington launched this idea without a much of a plan, and after the fact saddled the providers with three innocuous stages of rules—two of which remain undefined. They have yet to convince providers that they have a way to make sense out of having 400 different EHR vendors, no set of standards, hundreds of unique HIEs—I know you can’t have hundreds of anything and label it as unique—which bespeaks–the problem–and realistically expect it to work.

Why change your business rules and work flows to try to meet a plan that has stability of having been drafted on an Etch-A-Sketch? There are plenty of valid business reasons to evaluate changing the way providers work. There are huge potential gains in safety, care, efficiency, and effectiveness. These gains vary by organization. They vary based on the unique requirements of each organization. Properly planned and implemented, and EHR program with change management on workflow improvement can facilitate taking the business of healthcare from an 0.2 model to a 2.0 model.
Done poorly, and EHR will prove to be nothing more than a multi-million dollar scanner.

That being the case, you may want to use Steve’s methodology and ask him where you can go to buy a supply of the Composition books he uses.

Should you listen to the voices in your head?

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Well, for starters, if you don’t nobody else will.

Just because I’m paranoid, doesn’t mean the voices in my head aren’t real. What voices?  They don’t like it when I speak of them, so I am going to speak in parentheses so they do not hear me.)

Riding the in the car yesterday with my son, the radio was playing Barber’s adagio, a mournful and eerily melancholy piece. It has long been one of my favorites.  I tried to get my son to turn off his PSP long enough for him to try to develop an appreciation for it.

He asked me to tune the radio to what he calls ‘his’ station while I kept extolling the specific virtues of the adagio, of Barber, and of classical music in general. I intended to win him over to my way of thinking.

The phrases I used to bolster my opinion kept coming to me, although I knew not from where.  I soon reached the point where I knew that I was no longer speaking to him, but role playing the very same discussion I had had with my father when I was about the same age as my son. Déjà vu. I have become my father’s son. The voice in my head was my father’s and I was not even charging my father rent for the space.

Do you hear the voices? No, not those voices. The ones you hear at work when you realize that the person speaking to you is your other self. The same voice you hear when you go out after work with your friends and begin to talk shop. By the third glass of wine the conversation has shifted from swapping stories about the craziest patient to wondering aloud when the company is ever going to learn how to fix their business. By glass five, you’re fixing it for them, diagramming solutions on cocktail napkins.

A word of encouragement. Listen to the voices. I bet you’ve come up with some great ideas. They won’t do anyone any good locked up in your head. Let them out. Show someone who can do something about it what you wrote on the napkins.

EHR: Why the rush?

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The following is a comment I wrote to the healthcareitnews.com post, “BLUMENTHAL: EHRS WILL BECOME ‘AN ABSOLUTE REQUISITE’ FOR DOCS”.

“The time has come,” the Walrus said, “To talk of many things: Of shoes and ships and sealing-wax, of cabbages and kings– …

The time has also come to ask the question, “Why the rush?”  Is the pronouncement that within the next ten years we will see widespread adoption of EHR in conflict with the timing of the Meaningful Use incentives?  It seems that way to me.

Whereas we may see an “upward slope in the adoption curve” within the next year or two as hospitals begin the process of selecting and implementing an EHR, we will not see so much as a hiccup in the slope of the Meaningful Use curve.

Why?  I think there are several explanations.

  • Not enough providers are far enough along to even attempt to pass a Meaningful Use audit.
    • Will they complete the requirements
    • If yes, will they pass the audit
    • Of those who have attempted to do the heavy lifting of EHR and CPOE, they do not know the Stage 2 & 3 requirements.  Those requirements may be enough to ensure nobody passes the audit.
    • To those providers just underway, whose board insists that they complete the installation in time to qualify for the incentives—good luck.  Many will make poor selection decisions which they will support with even worse implementations.
    • To those who have yet to start, there is no chance they will meet the target dates.

So what’s next?  What would you do if you were having a party and learned nobody could come that night?  You’d change the date.  Washington will do the same.

What does that mean if you are a provider?  I think it means you have enough time to do it right, even when the conventional wisdom is pushing you to hurry.

Why let your EHR vendor run your hospital?

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Healthcare Failures Magazine (HFM)  “It is not everyone who can finish dead last in the CIO of the Year competition.  How do you account for your total lack of accomplishment?”

PR:  “It was not as easy as it may appear.  I think it had to do with believing that my EHR vendor knew more about running a hospital than did we.”

HFM “Why do you say that?”

PR:  “They told me their EHR it had been implemented “As Is” at a number of hospitals and was running fine.  I was convinced that all hospitals are basically the same; admissions, treatment, discharge.  Besides, it saved a lot of money not having to customize it and do all that stuff about workflows.”

HFM “What about the change management?”

PR:  “Yeah, well I guess you could say that part kind’a blew up on me.  It didn’t take long to learn that our hospital didn’t function at all like their software.  According to our doctors, they didn’t think this vendor had ever been in a hospital, let alone run one.”

Who defines your vision?  Who is your chief imaginist, the person responsible for defining the type of hospital you hope to operate five years from now?  Do you want it to be your EHR vendor?  Probably not?  Is it your vendor?  It may well be.  Why? Do you want to outsource your imagination and your future to your vendor?

Without a detailed and comprehensive work flow improvement and change management program the only thing you will implement is your EHR vendor’s vision of how a hospital should function.  You’ll be just like each of their other clients.  Is that what your business model calls for, is it satisfactory?