Video Game Theory applied to Healthcare IT

My twelve-year-old son overheard a conversation I was having about EHR, Meaningful Use, and ICD-10, and I watched his eyes glaze over.  So I tried to explain it to him in terms I thought he might understand.  Maybe this explanation is the one I should have used with my client.

John and Sally have a thousand dollars in the bank.  They pool some of their money and have a hundred dollars to spend on video games.  The game they really want, Project From Hell, costs sixty dollars.  About half the people who play Project From Hell never make it to the end, and never get the chance to claim their prize.  It takes two years to play, and one or both of them could be eliminated from the game for failing to play well.

The second game is a take-off on Faust, Sell Your Soul to the Devil.  To play this game, you must first beat Project From HellSell Your Soul costs thirty dollars.  However, the upside is that if you win, which is not very likely, you can earn two dollars.

The third game, Bet Your Savings, is the most intriguing.  All kids who have a computer must play Bet Your Savings, which costs thirty-five dollars.  The way Bet Your Savings works is that if you do not play, or if you play and lose, ten percent of the money in your bank account disappears.

I asked my son which games John and Sally should buy.  He said if they bought Project From Hell and Sell Your Soul, they would only have ten dollars left, and that the reward from Sell Your Soul, two dollars, was not worth much.  He also noted they do not have enough money to buy all three, and that since Bet Your Savings was mandatory, unless John and Sally wanted to automatically lose ten percent of their savings, they must choose Bet Your Savings.

He decided they should buy Project From Hell and Bet Your Savings.

By now you have figured out the Project from Hell is your EHR, Sell Your Soul is Meaningful Use, and Bet Your Savings is your ICD-10 initiative.

Resources are scarce.  Do you have enough money to do Meaningful Use and ICD-10 correctly?  Many hospitals do not, and yet they are charging full tilt at meeting Meaningful Use to possibly net a few dollars.  Many hospitals have not invested enough to meet ICD-10.

Where should you place your limited resources?  If you are still confused, feel free to ask my son.


I remember the first time I entered their home I was taken aback by the clutter.  Wet leaves and small branches were strewn across the floors and furniture. Black, Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The open windows, the stuff blows right in.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.  And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

Trying to assume the role of thought leader I asked, “Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked at me like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives.  Sort of like Patient Experience Management (PEM). The normal has been subsumed by the abnormal, and in doing so is slowing devouring the resources of the hospital.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid daily. When I talk to people about a statistic that indicates that 500 people called yesterday about their bill, and everyone looks calm and collected, it makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about the high call volume they always have an answer, the same answer.  “Billing calls are usually around 500 a day.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid. It’s gotten to the point where no matter how bad things get, as long as they are consistently bad, there not bad at all.

This is the mindset that enables the PEM manager (I know you don’t have one—I am being facetious) to be fooled by his or her own metrics. When is someone going to understand that repeatedly having thousands of people calling to tell your organization you have a problem, means you have a problem?

It would probably take less than a week to pop something on your web site, and post a YouTube video explaining how to read the bill.  Next week, do the same thing and help patients understand how to file claims and disputes—granted, you may need more than a week for this one.



Some thoughts on Ethics

Ethics–if all it required was an understanding of the English (the language, not the British) then there wouldn’t be much to say.

I am not someone who believes there is a need for ethics training. The rules for what constitutes ethical behavior have not changed. Something is either ethical or it isn’t. What has changed are the boundaries. Individuals constantly shift the boundaries, expanding the realm of what is ethical. In the minds of most individuals, those boundaries differ by person and by situation.

I operate from a mindset that ethical boundaries are fixed. As an example, consider the boundaries between the US and its neighbors. Those are fixed. That doesn’t mean there aren’t those who don’t like where the boundary is between the US and Canada, or those who would argue that the boundary should be different, or those who believe the boundary is different. Disliking the positioning of the boundary, or disbelieving the positioning of the boundary does not invalidate the boundary.

When people expand the boundaries for what they choose to call ethical behavior, they rarely do so at their own peril. Generally, they do so for their own convenience, they do so to remove any latent feelings of guilt. Each time they move the boundary, it makes it that much easier to move it the next time. Taken to its limit, at some point there are no boundaries.

Setting larger boundaries in some sense allows people to draft their own sets of Commandments, like little mini-Moseses descending from Mount Sinai with their sets of ethics. Unlike Moses’ stoned-carved commandments, the mini-Moseses draft theirs on an Etch-A-Sketch, making them much easier to change.

However, I don’t think ethical behavior need stem from nor be limited to any religious belief. It need not be employed because of some fear of punishment, but because of a love of righteousness and out of respect for others.

Integrity is doing what’s right even if nobody is watching. A person of ethics knows what’s right even if nobody is asking, and ethical behavior requires action in order to be expressed.


Should HIT make the Top 10 list for medical advances for 2009?

Below is a reply I made to a report that HIT was one of the top medical advances for 2009.  It came from
Great point.  An advance requires movement.  I do not think an 8% penetration with a 60% failure rate and high churn is the type of movement that would qualify.  If anything, it appears more like a retreat or stagnation.
User acceptance is so low that the feds are offering $40 billion in incentives and penalties if that doesn’t work.
Acceptance will not be enhanced by the addition of regional extension centers (RECs); appointed committees with no more HIT expertise than the folks at K-Mart.
It will be hindered further  by similarly provisioned RHIOs building HIEs that are as different from one another as snowflakes, 400 vendors with no standards, and no incentives to create any.
Then there is the N-HIN, Meaningful Use, and Certification, all of which exacerbate the national roll out of EHR to the point where it the current plan will fail.
My take?  Meaningful Use and Certification will not exist in 3 years and firms like Apple, MS, and Google will be the N-HIN.

can you apply social media to Patient Relationship Management (PRM)

A consultant was on one side of the river; his client was on the other side. The client hollered, “How do I get to the other side?”  The consultant thought for a moment and hollered back, “You are on the other side.”—don’t try this at home kids, we’re professionals.

It goes without saying that rarely am I regarded as one with a high capacity of tolerance.   When things get tough or when meetings are exceedingly dull I like to go to my happy place. Sometimes I get to go to my happy place when I least expect it. Like the time my coffee machine started leaking all over the floor.

Having met such unheralded success repairing my mixer, naturally I took apart my Capresso coffee maker. Not many parts. I put it back together thinking the simple act of dismembering it might have caused it to self-heal. Fill it. Turn it on. Puddle. I called Capresso started to explain my problem. Before I had a chance to finish the rep told me what caused the problem, asked for my address, and said they would mail a new gasket overnight for free, as in F-R-E-E. No proof of purchase needed.

Talk about managing the customer experience and taking the lead on social networking.  What types of things could you be doing to improve Patient Relationship Management (PRM)?  How could social networking help you improve PRM?

Let’s talk.

Should you hire a swim coach?

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.

May I have a receipt for the EHR in case I need to return it?

rman1560lThe hospital we use just dedicated a new wing.  For months the job site was a maze of people, duct, and tools.  It cost $145 million.  There’s a plaque displaying the name of the architect, the contractor, the mayor, and the rest of the adults who made it happen.  While it was being built there were numerous permits, certifications, and sign-offs taped to the building.  Their purpose was to ensure the public that the adults were keeping an eye on things.  A phase of work couldn’t be started until the prior phase had all the requisite sign-offs.

Those in authority had to be licensed.  Had to be certified as qualified.

They have another project underway.  One that costs more than the new wing and impacts more people.  This one doesn’t have a blueprint.  There are no building permits.  No certifications.  No licensed professionals.  You can’t even see it.  There are no hard-hatted workers.  No foreman.  You know who’s in charge of the project?  A hospital executive—prior experience—zero.  Has he ever built one before?  No.  Does he know what to do when he encounters risks, pitfalls?  No.  There is one other person running the show—a vendor—that should let everyone get a good night’s sleep.

Would anyone let this same executive be in charge of building a new wing?  Of course not.  Why then do we not employ the same standards for what will turn out to be the most expensive and far reaching non-capital project that the hospital will ever undertake?  If you think you know, please share your answer.

By the way, I asked one of those executives how it was that he happened to be selected to lead the EHR project.  “I forgot to duck,” he quipped.  I guess that’s as good a reason as any.


Cast, Blast, and Gin Rummy

duckSeveral years ago I was invited to go on the ultimate boys’ toys, weekend getaway. A dozen of us flew from Denver to Utah, and then drove to a point somewhere west of Bozeman Montana. It was to be a weekend of sport, a weekend of competition, and a more than occasional libation. To say that the people who organized the trip came from money would be a major understatement. They were in the oil bid’ ness. The father of one of the guys was the CEO of the second or third largest petroleum company in North America. We stayed at his ranch, a 12 bedroom log cabin in the middle of Nowhere, Montana, which is about 20 miles west of Next to Nowhere, Montana.

The weekend’s activities included fly fishing, duck hunting, and Gin Rummy. Each participant was given a handicap rating in each event. The idea behind the rating was that if you are weak in one event, you were paired with an individual who is skilled in that event. In theory, that would level the playing field among the teams. Since I have never fly-fished or hunted I was odd man out. But I was game, and it’s amazing how good one can become at something when one has to fight their way through it.

Let the games begin. We started the competition with a full day of fly-fishing. Our destination was the Madison River, an impressive, fast running, expanse of snow melt. The stretch we would finish was about 150 feet wide, and its average depth was somewhere between waist and chest high. As I would soon learn the bottom was covered with what appeared to be the equivalent of moss covered bowling balls. I was instructed by one of the more experienced fishermen to tie a nymph to the end of the tippet. For those of you who are as novice to the sport as I was, a nymph is an artificial lure which mimics an insect larva. It is designed to lure fish who feed along the bottom, not the nubile young woman referenced in Greek mythology.

We fished for several hours. My legs ached from trying to maintain my balance in the strong current. I was about ready to admit defeat when the tip of my rod bent sharply into the water. Standing perpendicular to the current, I could see as the brightly speckled back of a large rainbow trout turned upstream. Naturally, I turned upstream with it and began to try to reel him in. First mistake. It was at that point that I first realized that the height of the water was now about level with my chest waders. Second mistake. The guys on the other part of the river and along the bank were yelling at me. I thought it was words of encouragement. Final mistake. As it turns out, they were trying to convince me not to turn upstream. At the exact moment that I faced stream head on, was the exact moment my feet lost purchase with those moss covered bowling balls of which I wrote. Turning yet again to my physics, I quickly recalled the equation; force equals mass times acceleration. Instantaneously, I was swept downstream, still clutching my fly rod in my right hand.

Wayne Newton’s first law of fluid mechanics took over; waders, no matter how good they are, if positioned in a plane that is horizontal to the river will fill rapidly with water, just as mine did. The choice with which I was faced was do I save myself and lose the fish, or do I try and land the fish? One of the shortcomings of maleness—I was going to use maledom until I Googled it—is that we rarely have actual choices, especially when we are around other males or for that matter, females. Naturally, I opted to land the fish. My reel had become dislocated from my rod. I remember grabbing the reel and stuffing it down my waders, and as I tried to float my body as though it was a raft without a rudder towards the river’s nearest bank, I began to reel in the monofilament with a hand over hand motion. After several minutes I was standing dripping wet and proudly displaying a 19 inch rainbow trout.

We cooked the fish and played Rummy until about three in the morning, awoke at four, grabbed our shotguns and headed out into the darkness without so much as a cup of coffee. Round three of the competition was to be duck hunting. To this day I’m still unclear as to why we had to hunt ducks while it was still dark. Weren’t there any ducks who needed shooting at brunch time, I inquired? Twelve guys, who collectively smelled like a distillery, and who are operating on an hour of sleep, armed with loaded shotguns, trod through a willow thicket as dawn approached. As I neared the river bank, a startled duck shot skyward. I raised my over and under twelve-gauge shotgun, sort of took aim, and fired a volley. The duck seemed to pause in midair, and then fell like a rock into the racing water. I watched helplessly as my quarry floated away from me. I looked downstream and was pleased to see two men fishing from a rowboat. The duck floated right towards them. A man reached down, retrieved my duck, and dropped it in his boat. He then waved to me. Thinking he was being friendly I returned his wave. He then rowed away with my duck.

It was a great three days. Part of what made the weekend fun with not having to excel at each event. It helped knowing that in areas where my skills weren’t as good, I could count on the skills of others and vice versa. The idea behind this approach was to build competitive and level teams. That approach works well in mano y mano events like those I described. It works much less well in EHR, HIT and healthcare reform in general.  I’m trying to recall if I wrote previsouly about a meeting I attended with a former hospital CEO.  His take on EHR was the total inability of his peers to have any precience regarding their approach to EHR.  According to him, very intelligent people were making very unintelligent decisions, committing their entire institution to strategies made with almost no data.  Some people can give a better explanation for why they bought their car than they can for why they selected their EHR.   That’s the wrong way to handicap this event.