Rants & Musings

The importance of due diligence

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What was your first car?  Mine was a 60’ something Corvair–$300.  Four doors, black vinyl bench seating that required hours of hand-stitching to hide the slash marks made by the prior owner, an AM radio, push-button transmission located on the dash.  Maroon-ish.  Fifty miles to the—quart—I carried a case of oil in the trunk.

I am far from mechanically inclined.  In high school I failed the ASVAB, Armed Services Vocational Aptitude Battery—the put the round peg in the round hole test.  Just to understand how un-complex the Corvair was, I, who hardly knows how to work the radio in a new car, rebuilt the Corvair’s alternator—must not have had many working parts.  I could see the street from the driver’s side foot well.

However, it had one thing going for it, turning the key often made it go—at least for the first three or four months during which I owned it.  Serves me right.  A guy in school who I didn’t know who was selling it pitched it to me as his dream car.  Not wanting to look stupid, I bought into the sales pitch.  Pretty poor due diligence.  An impulse purchase to meet what I felt was a social imperative—a date-mobile.

The last time I made a good impulse purchase was an ice cream sandwich on a hundred degree day.  Most other decisions could have used some good data.  The lack of good data falls on one person, me.

How good is the data you have for deciding to implement and EHR?  In selecting an EHR?  Did you perform the necessary due diligence?  How do you know?  It’s tedious, it can lack intellectual stimulation?  You want to be seen as someone who made a wise choice.

The difference between you and me is that when I learned I’d made a poor decision I bought a different car.  You can’t do that with an EHR.  You’re stuck looking at the street through the hole in the floor for a long time.

saint

A reply to Government Health IT on Meaningful Use

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A response to a post in Government Health IT. http://www.govhealthit.com/newsitem.aspx?nid=72187#

Although I can’t prove it, I’ll bet by 2012 the meaningful use standards will have gone the way of the first reform bill. Hospitals should not be making buying decisions that involve hitting standards that have no meaningful use.

However, if hospitals fail to be able to deliver on what the system can do and how well they roll it out within their organization, they have no one to blame but themselves. This is why I place such a premium on planning and establishing detailed functional requirements. Involve the users, excel at change management, and plan like the success of your organization depended on it.

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Healthcare 2.0, can you get there from here?

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From a business perspective, not clinical, the critical success factor for H2.0 relies on healthcare’s ability to move from being an 0.2 industry.

H0.2 is the “As-is” model.  H2.0 is the “To-be” model.  To reach H2.0 healthcare must bridge that functional, work flow, change management, user acceptance, and technical GAP.  The Gap will differ by provider.  There is no singular work plan to help providers know what they need to do to build a custom plan to bridge the gap.

None of this matters until the healthcare provider willingly acknowledges that they have a long way to go to get to anything that resembles H2.0.

H0.2 – H2.0 = GAP

If you don’t mind the gap,  H2.0 is just H2O–all wet

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A response to an ICMCC blog on Meaningful Use

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This reminds me of the old Wendy’s commercial, “Where’s the beef?”  The comment regards the posting, http://blog.icmcc.org/2009/10/02/meaningful-use-where-is-the-patient/comment-page-1/#comment-98522

I think three years from know we will see that meaningful use proved to be a smokescreen which demonstrated no meaningful use. I also think there is benefit in looking at why healthcare providers have to be offered money and subjected to potential fines to do something that is supposed to be good for them. In turn, why do they then need to be pushed into rolling it out according to someone’s timetable who’s not even a part of their organization.

1. Why are providers running from EHR instead of towards EHR?

2. Why do they have to be paid to implement EHR?

3. Why do they have to be cajoled to roll it out according to somebody else’s time table?

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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.

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Is EHR so distasteful that providers need incentive?

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Of what were we last speaking?  Do you ever wonder if perhaps you are the only person who was never photographed with one of the Kennedys?  That got me thinking about our presidents.  Yesterday NPR interviewed the person who spent eighty hours interviewing Clinton during the eight years during which he was allowed to park freely anywhere in DC.  See how this is already starting to come together?

The interviewer mentioned that Clinton described the Lewinski episode as a distraction.  I also employed several descriptors of that series of affairs—of course, the pun is intentional—but I must have overlooked calling it a distraction.  People on both sides of the dialog call the episode a stupid thing.  Here’s how I look at it—doing long division and forgetting to carry the one is ‘a stupid thing’; mixing a red sock with a load of whites is ‘a stupid thing’.  Sometimes politics can have us all screaming infidelities.

When I share my thoughts about these things, some look at me like they are staring at an unlabeled can of food.  I guess objectivity is only for the truly unimaginative.

So all of that thinking about presidents got me to thinking about Mr. Obama, reform, and EHR.  Remember that a lot of the original economic reform discussion had to do with TARP monies being almost tossed at the banks.  It was almost like a reverse bank holdup, making the banks take money.

Which now takes us to healthcare reform and EHR.  ARRA money and states like New York providing a stimulus to the stimulus.  What would make governments offer money for EHR?  How might we illustrate this?

Let’s say I offer my children a choice of two things to eat; broccoli and chocolate cake.  They make a bee-line for the cake.  The broccoli requires an incentive to get any takers.  I ask a few questions—they are prepared to suffer untold penalties instead of eating the broccoli.  There may be some financial incentive which will entice them to eat broccoli, but it will be pricey.  Telling them it’s good for them, or that they have to eat it makes no difference to short people—they want to be bribed.

Telling healthcare providers EHR is good for them, or that they have to do it makes no difference to tall people—they want to be bribed.  What does this signify?  What is it about EHR that requires incentives and some foreign force majeure to get the discussion underway?  It’s not as though the healthcare providers don’t want to do things that will improve their business.  What is it they know that we don’t?  What would make them run towards EHR rather than away from it?

You don’t suppose it has something to do with broccoli, do you?

For those who enjoy Dana Carvey, here’s a link to his song about chopping broccoli.

http://www.youtube.com/watch?v=gO57XRDDodk

saint

EHR: my 12-step program

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Sometimes I need to shift into neutral and allow myself the luxury to pause and reflect.  This afternoon I find myself reflecting on the past 35 years, coincidentally, the same number of years since I graduated from high school—it’s okay to fast forward to the end to see if I actually tie this into anything worth your time, I can’t guarantee anything as of yet.  If I don’t come through, I’ll owe you one.  Maybe I’ll write something so obtuse at the end about reform that you’ll feel as though the fault lies with you for not understanding me.

So, we are to meet tonight—I have seen none of them since I departed for the Air Force Academy.  There is a reason I haven’t seen anyone.  The part I don’t get is why at this time we’ve mutually decided to end our hibernation.  It’s a little like the emergence of the seventeen year locusts times two.

We have only Facebook to blame for this folly.  I must admit it has been rather entertaining seeing pictures of them as adults, and reading how they describe themselves.

During my senior year I pulled my hair back when I ran.  My hair is no longer pullable.  I am some twenty pounds heavier than my playing weight.  I considered the drive-through face lift on the way down today, but thought the bandages would give it away.

Do most people go through this, wondering if you’ll impress those for which you held with such low regard, and they for you?  (That sentence was a bugger to piece together.)  At what point do we say this is stupid and move forward?  I’m guessing it must happen at year thirty-six or beyond.

I don’t understand my motivation in agreeing to come.  Is there an entertainment factor, some degree of closure, an in-your-face moment?  Is it because you get to look the high school bully in the eye and pretend he’s the parking attendant, tossing him the key to your Mercedes and ordering him not to scratch it?  What is it about those four years as opposed to any other four years that draws people back?  There is definitely something voyeuristic to it.  No other four year period in anyone’s life could exert that same pull.  Maybe that speaks to the transitory pattern of our lives after high school.

It’s the only time when we saw the same hundreds of people day in and day out for four straight years.  Maybe it had to do with having no responsibility, or maybe it had to do with bell bottoms, platform shoes, and long hair.  Relationships were built in the hallways next to our lockers—sort of a premature cohabitation—and lasted until the bell rung for home room.  New ones—upgrades—began to blossom on the school bus on the way home.  It was the best of times; it was the worst of times.  It was Nixon and Led Zeppelin, Peter Max and 3.2 beer.

These people with whom I am about to reunite, we are strangers once removed—by tomorrow I will know if it would have been better to have left it that way.  Some of them will never be mistaken for someone who knew how to calibrate ground-to-air missiles—perhaps they think that of me.  Some are poltergeists who  think of themselves as the Zeitgeists of my generation—I do not know what that means, but it looked like a good sentence as I was typing it.

There’s less than two hours until the foot lights come up and the actors have to move downstage to their positions.  I’m guessing that only the boringly secure have decided to play themselves.  The twelve-steppers are deciding which character to play on opening night and rehearsing their lines with their spouse or significant other—a term by the way which held no meaning in high school.  Costumes lay strewn across the hotel bed as the actors decide on the perfect, here’s how I turned out after thirty-five years look.  I find myself torn between the erstwhile bon vivant prepster and the Barry Sonnenfeld, Men in Black look.

Anyway, I’ve waxed and waned to the degree where I now feel completely marginalized.  I wrote in my year book that I wanted to be president.  A lot of these people are a few fries short of a Happy Meal, but I think even they will discern quickly that I fell short of that goal.  Nonetheless, I wake each day intent on slaying my personal dragons.  You?  Here comes the segue.

The time is coming where we will need to decide which character we will play in the roll out of our EHR systems.  Are there those who will break from the pack, eschew what others will say about their approach, toss aside the conventional wisdom of being in lock-step with the majority, and decide to approach this as a solution to a business problem?

I dare say that most will choose the path most traveled.  The path that says how wrong can I possibly be by doing what everyone else is doing.  Those who act on what they know is right, those who look for an EHR solution that rates future flexibility higher than the ability to conform to non-existing standards, higher than the gossamer guidelines of certification and meaningful use, will find that not only have they leapfrogged their peers, they will find that they have selected wisely.

Those who choose to follow the crowd may find themselves hibernating with the cicadas.

saint

Reforming reform

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One of the things I’m not understanding is the approach.  I’m a big backer of reform.  The part I’m not getting is why we are trying to boil the ocean, eat the elephant in one bite, or throw long.  Did I miss any cheap metaphors?

I sense many feel the same.  It’s not the reform which doesn’t have the support, it’s the approach.  That nobody is able to to summarize the reform package on a single slide makes people think it’s because they don’t have a good enough grasp of what they are trying to accomplish.  That, plus the idea of a Big Bang theory of reform is what is halting the effort.

Break it down into manageable, explainable pieces.  Demonstrate you can successfully accomplish one peice and you will have support for the next piece.  Do it all at once and fail and reform is done.

saint

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.

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If a Certified system is so special, offer a certification warranty

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I think that certifying the EHR product prior to installing it is worthless. Certification to me means that the product is capable of performing some function.   If certification is of any value, the fact that it’s certified means it should still be certifiable after it’s installed.

We all know that that is not the case. If the feds think it’s so important to certify the EHR products, let’s certify them after installation.   The large vendors are the ones pushing certification.  They do it for one reason, to limit competition.  If the vendors think certification somehow implies that their product is somehow better because it has been certified, let them offer a cost free warranty and re-certify it after installation.

It’s an easy test.  Let’s see how many of them respond to this plan.

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