planning

EHR: Men Behaving Badly

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

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

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

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

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

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

Spilt Tea: Why companies choose to fail

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At one time the single word Lubyanka was enough to bring normal Russians to their knees in terror.  Lubyanka is known best for being the headquarters of the Soviet secret police.  The basement of Lubyanka housed a prison which contained one hundred and eleven cells, cells used to hold and interrogate political prisoners during Russia’s purge.

Tea was provided to the prisoners twice each day.  A prisoner within each prison cell would place a teapot outside the cell. A prisoner, carrying a pail filled with tea, would pour tea from the pail into the teapot.

Tea spilled on to the floor.  The prisoner would clean the spilt tea with a rag.

Lubyanka’s prison operated for twenty-seven years.  Tea was served to the one hundred and eleven cells and spilled in front of each cell twice a day, seven hundred and thirty times a year.

Two million, one hundred eighty eight thousand spills.  The same number of cleanups.

Someone somewhere made the decision that it was easier or cheaper to spill and sop the water 2,188,000 times than it was to make pails with spouts on them.

What are the pails in your company?  What dumb, wasteful, redundant activities and processes have been left unchanged?

The most obvious one for most companies is call centers.

It is easier to take 2,188,000 calls each year about your bills than it is to fix the bills.  It is easier to take 2,188,000 calls each year about the bills than it is to get rid of the bills.  The same argument applies to a number of other processes.

And do you know where the fallacy in the argument is?  The fallacy comes from the erroneous belief that by having a call center, by answering calls you are actually providing your customers a service.

You are not.  All you are doing is wiping up spilt tea.

Showing Initiative–learning the hard way

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Were one to judge America by what they read from scanning the headlines of the magazines in the supermarket’s checkout lane, the only items of note are that Jennifer Aniston may or may not be pregnant, and that another one of the Kardashian’s was getting married—no word as to whether or not she is pregnant.  The headlines provided no indication that we are at war or that the economy has been outpaced by my daughter’s lemonade stand.

Anyway.  I have been reading Solzhenitsyn’s The Gulag Archipelago, which should be on every reading list for Genocide 101.  In the book he describes numerous offenses which could get a Russian sentenced to Stalin’s gulags.  Some estimates suggest more than sixteen million people were purged under Stalin’s regime—enough people whereby those in power had to continuously invent new offenses.

In one such description Solzhenitsyn recounts a conference for Stalin’s supporters.  Every public gathering was attended by several members of the NKVD, the bad guys.  At the conclusion of the conference its chairman called for a verbal salute to Stalin which resulted in all of those attending applauding.  The vigorous applause continued for eleven minutes because everyone was afraid to be the first to stop applauding.

To stop applauding was to show initiative, was to be an individual.  Exhausted, the chairman finally stopped clapping; immediately, so did everyone else.  The chairman, a loyal communist, was arrested.  During his interrogation the interrogator told him “Don’t ever be the first to stop applauding.”  Darwin’s natural selection, and how to grind people down with stupidity.

Nonetheless, we return to Beaver Cleaverville.

Do you ever sit in a meeting thinking it would be easier to design a revolving sliding door than to agree with or understand whatever is going on in the meeting around you?  You scan the room eying the flock of sheep each of who think of themselves as lions.  Once again, the Pickle Factory’s leader had confused motion with movement.  You scribble yourself a note using your favorite crayon—the cerulean blue, ‘I have seen our future and it needs work.’

“Well, here we are,” says the moderator outfitted in her J C Penney imitation Vera Wang pantsuit.  For years her mind had run just fast enough to enable her thoughts to always be in the same place.

“Yeah, here is where we are,” you mumble into your cupped hand. “We have been here before and we will be here again and again.”  The person across from you seems to be humming “It’s a long way to Tipperary.”

These meetings make about as much sense to you as the game the Afghan Pashtun tribesmen play—buzkashi—sort of like polo except instead of using a ball they use a headless goat.  The executives rampage through the offices each day dragging the headless carcass of their business strategy to meeting after meeting hoping to score, and the more meetings you attend the more you feel like the goat.

“What are we supposed to accomplish today?” You ask.

“Your guess is as good as mine,” replies the moderator, her mind making its way back from its visit to the land of ultima Thule.

“No, your guess is better than mine,” you say.  “It is your meeting.”  ‘Lock the gate,’ you are thinking, ‘before the village loses its idiot.’  Everything is running behind and the team wants to make up for lost time.  Your job is to try to convince them that you cannot make up for lost time; the best you can hope for is not to lose any more.

You have always known that companies which do not tolerate dissent have a tendency to ignore dissenting information but they remember the dissenters—the first person to stop clapping. In a company lacking second sight and new ideas, the old ideas are often divided evenly among the employees.  The death spiral of silence—people avoiding threats of being voted off the island have a tendency to refrain from making any statement that may show them to have an original thought.  Showing initiative can result in your being sent to the company’s gulag.

Have you noticed that the more a firm’s competitive edge erodes, the busier the firm appears to be?  Once you have fallen through the looking glass the only way out may be for you to walk back the cat, that is travel backwards to see how it is you and the others became trapped in this house of mirrors.  The problem with that strategy is that to undertake it requires you to show initiative.

The firm’s gulag is filled with people like you.  At least when you get there you will be able to commiserate with people of a similar ilk.

 

Planning: What I Learned in the Twelfth-Grade

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Planning is not all it is cracked up to be—it never was—but it is a whole lot better than the alternative; not planning.

A lot of plans fail.  Too many people equate planning to golfing; after all, how difficult can planning be?  Apparently, judging from the results of failed plans, pretty difficult.  There are planners, and then there are real planners.  Just like there are golfers and real golfers.  Those planners in the first group are the ones, who on occasion, have to throw something on paper and call it a plan.

Planning can get you in trouble.  An example?  Sure.  Twelfth grade—Operation Red Belt.  My friend, now an FBI agent, was looking for a way to meet a really cute girl in the eleventh grade.  The first time he saw her she was wearing a red belt—hence the name of the op.

Since Al Gore had yet to invent the internet, the only way to learn anything about her was to stalk her, a good skill for him to learn considering his career choice.  we put together a written plan.  Scrawled across the top of the paper were the words ‘Operation Red Belt.’  We even outlined a series of questions he should ask to prepare him should he ever get a chance to talk to her.

One night we followed her home from a basketball game, killing the lights in his car so we wouldn’t be spotted.  We learned she lived at the end of the street.  After she went indoors, rather than turning around in her drive, we proceeded down the dirt road that led past the home figuring we would execute a three-point-turn and make our escape.

Unaware of the culvert on the narrow and muddy dirt road, we only managed to skillfully execute points one and two of the required three points in the turn.  The passenger’s rear wheel was spinning wildly in the culvert.  Right about the same time the sky opened up and it began to pour.

In an age without cell phones, the great planners were hopelessly marooned. The only house on the street with its lights on was Red Belt’s.  Realizing we had no choice, we walked through the mud and rang the doorbell, hoping we would be allowed to use the phone to call his parents.

He father answered the bell and invited us in.  Plans do not always work the way they are designed to work and, the consequences of bad planning are a lot worse in business than they were in the twelfth grade.

EHR: Managing the changes to your organization

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

EHR: What Bugs You About It?

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16This is the time of year in the east when cinerescent caterpillar nests hang thickly from the trees, peppered tufts of cotton candy.  During these long, flavorless August days, the sky is a similar achromatic color.  My nine-year-old is concerned because I told her we are having caterpillar soup for dinner tonight—watch out for the crunchy bits.  Once again, it seems I’ve gotten off message.

I wonder how much of the difficulty surrounding EHR has to do with getting off message, much like we seem to have done with the reform discussion.  What difficulties?  Got time?  You can name more of them than can I.

What is off message?  It’s that the day-to-day tactics of implementing EHR office by office, and hospital by hospital have overshadowed the strategy, have displaced the business driver behind the mandate.  The focus became internal, not national.  Bits and bytes have overshadowed charts.

I doubt few, if any, can articulate a believable explanation of how a few years from now your medical records will accurately and expeditiously be delivered from where you live to the lone clinic on Main Street, Small Town, USA, to the nurse practitioner who at midnight is giving you an EKG.

It’s that fact, that we are not able to define how we get from A to B, let alone do so with multitudes of A’s and B’s, that to me suggests we are building something of which we have little comfort will do what we set out for it do.

Clearly, there are hundreds if not thousands of very talented and dedicated professionals focused on finding a solution.  However, it seems their efforts remain handcuffed by hundreds of competing products, no well-defined overriding set of requirements that would enable anyone to say with certainty, “Yes, that is it.  That captures what we need to do.  When we have done that, we are done.”

Until that time, I think we all need to be concerned about the crunchy bits.

What do you think?

EHR: When you’re in a hole, stop digging

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rappelling_1_1I was thinking about the time I was teaching rappelling in the Rockies during the summer between my two years of graduate school.  The camp was for high school students of varying backgrounds and their counselors.  On more than one occasion, the person on the other end of my rope would freeze and I would have to talk them down safely.

Late in the day, a thunderstorm broke quickly over the mountain, causing the counselor on my rope to panic.  No amount of talking was going to get her to move either up or down, so it was up to me to rescue her.  I may have mentioned in a prior post that my total amount of rappelling experience was probably no more than a few more hours than hers.  Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her.

The sky blackened, and the wind howled, raining bits of rock on us.  I remember that only after I locked her harness to mine did she begin to relax.  She needed to know that she didn’t have to go this alone, and she took comfort knowing someone was willing to help her.

That episode reminds me of a story I heard about a man who fell in a hole—if you know how this turns out, don’t tell the others.  He continues to struggle but can’t find a way out.  A CFO walks by.  When the man pleads for help the CFO writes a check and drops it in the hole.  A while later the vendor walks by—I know this isn’t the real story, but it’s my blog and I’ll tell it any way I want.  Where were we?  The vendor.  The man pleads for help and the vendor pulls out the contract, reads it, circles some obscure item in the fine print, tosses it in the hole, and walks on.

I walk by and see the man in the hole.  “What are you doing there?”  I asked.

“I fell in the hole and don’t know how to get out.”

I felt sorry for the man—I’m naturally empathetic—so I hopped into the hole.  “Why did you do that?  Now we’re both stuck.”

“I’ve been down here before” I said, “And I know the way out.”

I know that’s a little sappy and self-serving.  However, before you decide it’s more comfortable to stay in the hole and hope nobody notices, why not see if there’s someone who knows the way out?

Merely appointing someone to run your EHR effort doesn’t do anything other than add a name to an org chart.

EHR: Every time you redesign, God kills a kitten

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Again on the project failure?  Yes.  Why?  Trying to head it off at the pass.  Source, The Bull Report.

Fifty-seven percent of failures are due to bad communication.  What’s that?  Poor grammar?  No.  Not enough meetings?  Doubtful.

It’s about PMO.  A hired gun?  Perhaps.  An advocate who will manage the vendor on your behalf.  What’s the rest of the hired gun’s job description?  It is all the blue stuff in the graph.

And now it is time to view this discussion in light of healthcare.  The chances of your ‘two-comma’ project failing are legion.  Why? Nobody has a good history of having done EHR; if they have experience it is likely because their first implementation failed.  EHR is not like implementing ERP.  The is no ROI at the end of the rainbow.  The business driver seems to be Meaningful Use which has caused many hospitals to glide over things like process improvement and change management and breaking down the tribal barriers among organizations.

The good news is that being a bad dresser will not hurt the project.

 

 

EHR: What are your Bona Fides?

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The photo comes from my Robert Redford look alike period.

Do you ever awaken wishing you were all you used to think you were before you figured out you weren’t?  Me either.  I’m someone who has these kind of days when it’s best to keep me away from shiny objects.

During college, I spent several summers volunteering for a group called Young Life at their camps throughout the US.  Silver Cliff was one of their camps in the mountains of Colorado.  Each week we’d take in a few hundred high school kids from throughout the US, and give them the opportunity to do things and challenge themselves in new ways; everything from riding horses to rappelling.

The prior summer I was the head wrangler at one of their camps—I had never ridden a horse prior to being placed in charge of the riding program.  This summer is was the person running the rappelling program.  Needless to say, I had never done that before either.

We received a day’s worth of instruction before we were turned loose on the kids.  One of the first things we had to learn was that the ropes and harness, if properly secured to the carabineers and figure eight, would actually keep you from falling to your death.  The first test was jumping from a platform way up in a tree while on belay.  After a few moments of white-knuckle panic, I stepped over the edge and was belayed safely to the ground.

From there, we scouted a place for the rappel, and found two suitable cliffs, each with about a hundred foot vertical drop.  Watching my first rappel must have reminded others of what it would have been like watching a chimp learn how to use tools for the first time.  After several tentative descents, I was able to make it safely to the bottom in a single jump.

Each day we’d run a few dozen kids through the course, ninety-nine percent of whom had never rappelled, or ever wanted to rappel.  To convince them that it was safe and that they could complete it, I would instruct them in the technique as I hung backwards over the chalk face of the limestone cliff.

Each day we’d have one or two kids who wanted nothing to do with my little course.  Occasionally, while on belay, one of them would freeze half way down the cliff, and I’d have to belay down and rescue them.

Once or twice I’d have an attractive female counselor on belay, her knowing that I was the only thing keeping her from being a Rorschach stain on the rocks below.  Scared, and looking for a boost of confidence, “She’d ask, how long have you been doing this?” I’d look at my watch and ask her how many days ago was Sunday.  I viewed it as an opportunity to have a little fun with her—sort of like turning to your friend in the checkout line in 7-eleven and saying loud enough for others to hear, “I thought we agreed we weren’t going to use our guns.” I also hoped maybe even having to go on a heroic rescue.

How long have you been doing this?  That’s seems like a fair question to ask of anyone in a clinical situation.  It’s more easily answered when you are in someone’s office and are facing multiple framed and matted attestations of their skills.  Seen any good EHR or HIT certificates on the walls of the people entrusted with the execution of the EHR endowment?  Me either.  I have a cardiologist and he has all sorts of paper hanging from his wall.  Helps to convince me he knows his stuff.  Now, if I were to pretend to be a cardiologist—I’ve been thinking of going to night school—I’d expect people would expect to see my bona fides.

Shouldn’t the same logic apply to spending millions of EHR dollars?  Imagine this discussion.

“What do you do?”

“I’m buying something for the hospital I’ve never bought.”

“Why?”

“The feds say we’ve got to have it.”

“Oh.  What’s it do?”

“Nobody really knows.”

“How long have you been doing this?”

“How many days ago was Sunday?”

“What’s it cost?”

“Somewhere between this much,” he stretches out his arms, “And this much,” stretching them further.

“Do the doctors want this?”

“Some do.  A lot don’t.”

“How will you know when you’re done if you got it right?”

“Beats me.”

“Sounds like fun,” she said, trying to fetter a laugh.

Sounds like fun to me too.

EHR: the Prefect Problem

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A perfect problem, in its existing state, is unsolvable.  The way most of us handle it is to click our heels together three times and hope it goes away.  We tend to work on imperfect problems, those that can be solved.

One of my college professors—way back when we still had inkwells on our desks—told me that if you cannot solve the problem the way it is stated, it is to your advantage to restate the problem.  I tried this on a final exam; the problem as it was stated was to contrast two philosophers, one of whom, having not read the book, I had no idea who he was. I restated the problem to contrast two philosophers I knew.  He wrote back on my exam saying I had made a nice effort at using the technique but that the philosopher I chose was the wrong one.

What is the difference between the two problem types?  The first step is the ability to understand what makes the perfect problem uniquely unfixable.  Perhaps a few examples would help.

  • The CEO imposed a deadline for the implementation of EHR.
  • CMS Meaningful Use rules do not fit with our operational strategy.
  • If we do not implement EHR by this date, we do not get the money.
  • We must meet Meaningful Use
  • We do not have enough resources from the EHR users to understand their processes.
  • We cannot continue to support these low-margin services
  • We do not have enough time to define our requirements
  • We cannot afford to spend the time required to assess our processes before we bring in the EHR vendor.

What can be done?  The easy answer is to plan for failure and do your best to minimize it.

What is another way to describe the above examples?  They are constraints.  They can all be rewritten using the word “can’t”.  Rewritten, we might say, “We had a chance to succeed, but because of X, Y, and Z we can’t.”  If that assessment is correct, you will fail, or at least under-deliver at a level that will be remembered for years to come.  That’s a legacy none of us wants.

There are a few solutions to this scenario.  You can eliminate the seemingly intractable constraints; the organization can determine to re-implement EHR and hope for different results; or they can simply find someone else to solve the perfect problem.

Experience teaches good leaders really want reasoned advice.  They want the members of the C-suite to tell them what must be done to be successful.  Good leaders do not accept “can’t”—not on the receiving end, not on the delivering end.

Some will argue, “This is the way our organization works.”  Even if that is true one must consider what is needed to make an exception to the constraint.  Would you accept this logic from a subordinate?  Of course not.  You’d demand a viable solution.  If you are being constrained in your efforts to solve a perfect problem, perhaps it is time to restate the constraints.

Maybe the solution to the perfect problem is to restate it in a manner that makes it imperfect—solvable.