PMO

EHR-step away from the scalpel

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So, I lunched today with a friend who is an executive at a healthcare consultancy.  She recently spent four days in a hospital, entering via the trauma center.  The purists among us would think, “If she only had a personal health record (PHR).”

As it turns out, she did.  From what I understood form our chat, the people in the hospital did not welcome her understanding of healthcare.  She handed someone on the trauma team her PHR from Google Health Vault.  According to her, she had downloaded enough data on her jump drive to where MRI’s were dripping from the USB.

At some point they determined she needed to have surgery because of something that appeared on her CAT scan.  Moments before seeing how well she could count backwards from 100, she was able to convince the surgeon that she did not require an operation because what they saw was a pre-existing condition which was documented on her PHR.  Step away from the scalpels.

I think the scalpel thing only served to spur her on.  After leaving the hospital, she requested a copy of her bill—all forty-three pages.  She read it, line by line.  They hate it when patients do that.  Her insurance covered everything, so it’s not like she was minding her pennies.  She was minding her sanity.  Seven hundred and some dollars for Tylenol.  She never took any Tylenol.  Somehow the billing system was tied to the fact that Tylenol was prescribed, independent of whether she actually took it.

Seventy-nine hundred dollars for a CT-scan.  Only ten times higher than the national average.

Where were the failure points?  People.  IT.  Process.  It’s a good thing she knew what she was doing or right now she’d be missing a thing-a-ma-jig—and they would have billed her for another Tylenol to manage that pain.

Without change management and work flow improvement, EHR will only make things worse.  There is a term of art for the intersection of work flows, people, and data—it’s called a mess.  To minimize the mess, to have any shot at an ROI, the sooner you employ adults to run the Program Management Office (PMO) for your EHR, the better your chances.

sainttop5

The effect of poor planning

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I’ve always considered myself to be rather athletic, although I must have been on break when they handed out the coordination genes.  Perhaps that is why I tended towards individual efforts like running.

As it was, I was fairly good at ice skating as long as I was moving forward, the straighter the better.  Turning and stopping required an abundance of room, and an absence of other skaters.

Whoever came up with the notion that if you can ice skate you can roller skate was either lying through his teeth, or I became skating’s anti-matter.  At the time of my first attempt at roller skating I was unaware that ice and roller skills weren’t transferable.  Have I mentioned I like having an audience?  I decided to audition my roller skating skills at a public skating rink while on a first date.

The night was proceeding swimmingly.  I learned quickly that it I stayed to the edge and leaned towards the center of the rink, centrifugal force would keep me from falling.  My confidence in my abilities began to build.  Music boomed from the overhead speakers.  Several couples held hands, the more skilled ones crossed their arms in front of them and held hands.  I tried it and eased us into the first turn.  The song switched to Barry Manilow’s “I write the songs.”  To my misfortune, I knew the words, and began to serenade my date.  When I guy sings Barry Manilow in front of anyone but his own shadow, only two things can happen and they’re both bad.

We hit the second turn and I began to accelerate.  We sped past a number of couples.  I sang louder, concentrating more on the words than on the task of keeping us both upright.

For those unfamiliar with the design of roller skates I should explain what I perceive to be a flaw design flaw—one which you will note has been eliminated in roller blades.  The flaw?  On the front of each roller skate about an inch from the bottom is a round rubber device that resembles a stunted hockey puck.  It serves no known purpose other than to sucker punch novice skaters.  If you mistakenly try to build speed by pushing off with the toe of your roller skate—as you do in ice skating—you are actually hitting the emergency brake.  And because the brake is at the front of the skate, the physics is such that once your feet stop, the only direction the rest of your body can go is head over heels.

I looked like I had purposefully launched myself over a pommel horse.  During the first few seconds of my flight I was reluctant to let go of my date’s hands.  I thought that if we fell together that there was some small chance that I could shift the blame for the crash to her.  We separated at speed and created sort of a demolition derby for those around us, bodies piling up like logs awaiting entrance to a saw mill.  For the rest of the evening it felt like people were pointing at me as if to say, “Steer clear of him, he’s the one who took us all out.”

My one mistake caused a chain reaction of bad events and a severely hematomaed ego.  Bad things rarely happen in a vacuum.  There’s cause and effect, and the effect can be disastrous.  For those of you whose EHR program is underway who may have scrimped on the planning process—you know who you are—you may as well be the captain of the Titanic throwing refrigerant in the water.  There is no recovery from bad planning.

No matter what the shape of your EHR implementation, if you find yourself humming a few bars of “I write the songs”, only two things can happen and they’re both bad.

saint

Missed off-shoring; don’t worry, it’s coming here

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When is the last time anyone had anything good to say about the economic meltdown or the state of affairs of the affairs of state? What a mess. What if someone were to suggest that buried beneath all the manure there really is a pony waiting to be ridden–best to wipe the saddle first—and that the beneficiaries could be you?

Here’s what I’m thinking. What if one assumes that Mr. Obama winds up winning the election? Personal references aside; that appears to be what will happen. Let’s rewind to the beginning days of the new administration. Obama is promising to help fix the meltdown by increasing the number of employed among us–I was not comfortable suggesting his administration would be creating jobs as that is more difficult to accomplish when one is taxing the institutions which create those jobs—but this is not the proper venue for that topic. Okay, so the number of employed increases. How? Let’s see if there is an answer to that.

There has been a lot of negative discussion around the topics of BPO and ITO, Business Process Outsourcing and ITO, Information Technology Outsourcing. For purposes of this narrative, let’s make the terms outsourcing and off-shoring interchangeable. A simple way to view outsourcing is to assume there are three ways to do it;


1. Off-shoring
2. Near off-shoring
3. And On-shoring


Let’s define off-shoring to include places like India, China, and the Philippines. These countries lead the world in off-shoring because their supply of skilled, English speaking labor, can be purchased for less than what we can supply it. The large off-shoring firms have in some cases purchased off-shoring contracts at rates so low that no US firm can compete. These rates often mean that the off-shoring firms won’t begin to make money until the out years of their contracts. Next there are the near off-shorers; Mexico, and to a much lesser extent not that the dollar has melted, Canada. The On-shoring is us, the US.

So, here’s how I think this all starts to tie together. One way to add jobs is to not lose them—I didn’t say this was going to be taxing to understand. Another way to state that is that for those jobs that have been lost to off-shoring is to bring them home. How? Remember the comment about taxing the institutions that create the jobs? Well, this is simply a different type of tax, not on goods and services but one that is applied as a penalty. This type of tax penalizes a firm for behaving badly. What is their bad behavior? Giving jobs away. If the new administration, as expected, makes it painful to outsource, companies will have to look for other options. One option is Near Off-shoring. Now, Obama stated he is not a fan of NAFTA, the North American Free Trade Agreement. That will mean that it will not be a simple matter for companies to move the jobs closer to home, going from India to Mexico, or to source to Mexico rather than India.

Hence, the new off-shoring may be right in our own back yards. Welcome to the beach Iowa. How will this occur? The same way it happens when any municipality creates favorable economic conditions to attract any new business. We’ve seen it happen when communities do back-flips to get a new Toyota plant. Can’t you picture your local chamber of commerce pushing a slew of tax incentives to attract a national call center for Humana or all of the claims processing for Blue Cross?

So, what’s in it for me, you might ask yourselves? Well, the largest components of BPO are Finance and Accounting, HR, Procurement, and CRM, and the first three each have fairly significant call center components. While BPO will continue to grow-it’s project to triple between now and 2012, I think the market restrictions coupled with tax incentives will incent many firms to look more closely in their own back yards.

Should you off-shore or on-shore? If so, what portions of your business? To which supplier or suppliers? Instead, should you look at a shared services model? Those are difficult questions and should be treated as such. Outsourcing advisory an area where having expertise helps. It’s also an area where we’ve established a pretty good track record.

Most large hospitals have multiple occurrences of a handful of functions.  Most of those could go away and in doing so would improve the provider’s operations.

black saint 2

EHR: add three cups of technology and stir

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According to my neighbor, who is a woman, next week is the season premier for “Desperate Hot-wives”—her words, not mine. My wife refers to my little brain hiccups as Roemer-minutes, a little hitch in my git-along where the thinking part of my brain briefly vacations in the fifth dimension. Speaking of the fifth dimension, the dimension, not the sixties rock group, I was reading up on it the other day. There’s this professor of theoretical physics from Harvard, Lisa Randall, who happens to look a little like Marcia Cross who portrays Bree Van De kamp—actually she looks more like Jodi Foster. See how quickly this all ties together? Anyway, Dr. Randall has developed a theory about how the universe is warped—something many of us expected. According to her model, the reason gravity appears so weak is that the universe is actually warped by a hidden fifth dimension—must be why we haven’t seen it, because it’s hidden—and our gravity is just the leftovers from the dark side.

For the inherently curious, in mathematical terms her equation is, ds2=dr2+e-kr(dxm dxn hmn). That was helpful, wasn’t it? Here’s where it gets complicated. People in Europe will are testing the Large Hadron Collider to look for gravitons, theoretical particles of gravity. The collider smashes protons into one another, and if these theoretical particles appear then disappear that somehow proves the theory. However, and depending whether you’re a glass half-full or a glass half-empty kind of person, this is a rather big however, we could all die. This is where the distinctions between the meanings of the words possible and probable become rather important.


According to this whole other branch of physics, something quite unpleasant could happen, the creation of doomsday phenomena, including microscopic black holes that would grow instantaneously and swallow the earth, and strangelets that could transform the earth into a dead dense lump. Could it happen? Yes. Will it? Probably not. So there you have it.

Where does that leave us? Assuming that it does, leave us, that is, alive, it makes the notion of implementing EHR seem just a tad more simplistic. At least we won’t be creating any black holes. So, set your phasers for stun and let us begin again. To implement EHR in your organization you need a champion, a sponsor. Someone who isn’t afraid to say, ‘follow me’. As we said before, this type of project does not lend well to the notion of ‘add three cups of technology and stir’. The champion is needed not so much for figuring out the shape of things to come, but for their ability to cause those things to be implemented within the organization. This person should have ready access to resources, dollars, and the ear of someone very senior in your firm. Next time we’ll begin to take a look at the champion’s role.

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EHR: How do you avoid failing?

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I may have mentioned that I’m a runner. In high school and college I’d run anytime, anywhere. I ran cross country, indoor track, outdoor track, and AAU– kept my hair tied back in a ponytail—I miss the hair.

Those were the days. I was the captain of the cross-country team during my senior year. Behind the school was a long series of hills we used for training, and they were blocked from the coach’s view. I remember that one day I told the team it was okay to walk because we were out of the coach’s sight. I also remember when he took me aside after practice and said he didn’t think it was a good idea for the captain to tell the guys they could walk. He said he couldn’t see me but he sure could hear me. I also remember the time I had my mom dropped me off about half mile away from my girlfriend’s house so I could run, making it look like I ran the entire six miles.

My friends and I ran a few 50 mile races and a couple of marathons. But the strangest race we ever ran was one that lasted 24 hours. The event was a 24 hour mile relay. More than a dozen teams entered the event. Our team had seven runners. The idea behind the race was that each person would run around the track four times with a baton and then hand the baton to the next member of his team. If one member of the team was too tired to take his turn, that team was disqualified. The race started early on a Saturday morning. At the end of 24 hours, my team had run 234 miles. We were proud of what we had done. We were even prouder when we saw the article printed in our local paper the following week that we had set a world record for a seven-man team in a 24-hour relay.

I’d like to believe that the world record had something to do with the fact that we were a great group of runners. However, as I look back on it I tend to believe that the world record had more to do with the obscurity of the event than with the capability of the runners. I don’t know if that same event had been run before we ran it or was ever run afterwards. Who knows, we may still hold the record. I guess what I learned from that event, is that it is easier to be viewed as being excellent at something that isn’t done very often.  Obscure or not, it was a one-time event for us.

Doing something once makes it difficult if not impossible to prepare for the gotchas that lay in wait.  There are healthcare providers who are on their second and third attempt at implementing their electronic health records system (EHR).  This is not the type of event where practice makes perfect, far from it.  If you don’t get it right the first time, you’ve probably already laid waste to your most important stakeholders, the users.  They are difficult enough to get on board the first time.  The second time it becomes much more of a fool me once shame on me, fool me twice, shame on you.

How do you avoid second and third attempts of something as difficult as a full-blown EHR?  For some providers, it’s even worse in that they probably have multiple dissimilar instances of EHR already in place in parts of the hospital, instances that will have to be integrated to the corporate platform.  If you let the clinical side run the project, you run the risk of losing the IT side.  If you let the IT side run the project, you run the risk of losing the clinical side.

Who do you trust to run what could amount to a few hundred million dollar project, bring out the best skills of the team members, and make sure the vendor is operating in your best interest?  It’s a difficult question to answer.  The good news is that if you get it wrong you probably won’t have to worry about doing it over, that will probably be your one-time event.

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Healthcare Informatics: one time at band camp…

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Here’s a response I posted to a Healthcare Informatics article, by Mark Hagland, “Revenge of the Clinical Informaticists”.

The link is: http://healthcare-informatics.com/ME2/dirmod.asp?sid=349DF6BB879446A1886B65F332AC487F&nm=&type=Blog&mod=View+Topic&mid=67D6564029914AD3B204AD35D8F5F780&tier=7&id=5E2E36E45CB54ECA8D2B08DC3E4D679C

I wrote the following:

I wrote on this same topic yesterday, albeit with a slightly different bent.  Like you, I see two distinct groups who do not play well in the same sandbox—clinical and IT.  Having one group go to the other’s summer camp to pick up a few skills is not the same as pulling a few costly and hairy projects from the bowels of project hell any more than it would be to have an IT executive take an EMT course and then assume that person was qualified to perform surgery—this one time at band camp…

Before I get up on my stool and knock myself off, I know CMIOs and CIOs who have made HIT and EHR very successful.  To them I ask, do not rake me across the Twitter coals as I try to make a point.

There’s knowledge, and then there’s qualified.  Doctors do four years of medical school, they intern, and if they specialize, they throw in a few more years before they become the in-charge.  Years of training and practice before the doctor is allowed to run the show.  Why?  Because what they are about to undertake requires practice, tutelage, and expertise.  Most of the actual learning occurs outside the classroom.

There are those—not Mr. Hagland—who suggest that the skills needed to manage successfully something as foreboding as full-blown EHR can be picked up at IT Camp.  They do a disservice to seasoned IT professionals.

Most large IT projects fail.  I believe large EHR projects will fail at an even higher rate.  Most clinical procedures do not fail, even the risky ones.

What’s the spin line from this discussion?

  • Rule 1—large EHR projects will fail at an alarming rate
  • Rule 2—sending a doctor to band camp probably won’t change rule one

Don’t believe me?  Ask friends in other industries how their implementation of an ERP or manufacturing system went.  There are consulting firms who make a bundle doing disaster recovery work on failed IT projects.  They circle the halls like turkey vultures waiting for CIO or project manager carrion.

Back to Rule 1 for a moment.  How can I state that with such assurance?  Never before in the history of before—I know that’s not a proper phrase—has any single industry attempted to use IT to:

  • impart such radical charge (patients, doctors, employees)
  • impart it on a national basis
  • hit moving and poorly defined targets—interoperability, meaningful use, certification
  • take guidance from nobody—there is no EHR decider
  • implement a solution from amongst hundreds of vendors
  • implement a solution with no standards
  • move from an industry at 0.2 to 2.0 business practices
  • concurrently reform the entire industry

Just what should a CMIO be able to do?  What are the standards for a CMIO?  To me, they vary widely.  Is a CMIO considered an officer in the same sense as the other “O’s” in the organization, or is it simply a naming convention?  The answer to that question probably depends on the provider.

Here’s how I think it should work—I realize nobody has asked for my opinion, but this way I’ll at least provide good fodder for those who are so bold as to put their disagreement in writing.

I love the concept of the CMIO and think it is essential to move the provider’s organization from the 0.2 model to the 2.0 model.  Same with the CIO.  However, getting them to pool their efforts on something like EHR is likely to fail as soon as one is placed in a position of authority over the other.  It’s sort of like getting the Americans and French to like one another.

I liken the CMIO’s value-add to that of the person providing the color commentary on ESPN—it adds meaning and relevancy.  The CMIO owns and answers a lot of the “what” and the CIO owns and answers a lot of the “How”.

Still unanswered are the “Why” and “When”.  A skill is needed that can state with assurance, “Follow me.  Tomorrow we will do this because this is what needs to be done tomorrow.”  That skill comes from an experienced Project Management Officer, the PMO.  It does not come from someone who “we think can handle the job.”  Nobody will respect that person’s ability, and if they can’t lead, yo can plan on doing the project over.

Oh, if anyone is still reading, here’s my original post; https://healthcareitstrategy.com/2009/09/28/what-should-be-the-role-of-the-cmio/

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