Rants & Musings

My Whimsical Solution to the Immigration Problem

Posted by

0

What is all this discussion concerning legal migration and Borders?

Some people want to build a wall; some want to be the wall.  On one end, Mexico, the problem is illegal immigration.  On the other, Canada, the problem that is not being addressed is legal migration.  However, if not for Canada, we would have fewer comedians and television news anchors.

Here’s my take on the matter, an approach I think that has been overlooked.  If the problem is too difficult, reframe the problem to make it easier to solve.  The government defines the problem as one requiring the US to defend five thousand miles of borders.  Their idea—build a wall.  Perhaps they could outsource the solution to the Chinese, have them build The Great Wall, Version 2.0.  turn it into a sight-seeing opportunity, sort of a destination hot spot, and using the tourism dollars to pay back the Chinese.  This way, English-speaking people from around the world could come see the Wall, take in the Grand Canyon, and Hoover Dam, and leave their tourism dollars in the US.

Instead of wrestling with how to defend five thousand miles of border, what if the border was shorter?  How?  Buy Mexico, and bring the troops home from Afghanistan and overthrow Canada.  If we owned Mexico, it solves two problems.  One, the border we would then need to defend becomes just a few hundred miles, Guatemala and Belize.  They could get all the supplies needed for that wall from Home Depot.

Second, why do people from Mexico sneak into the US?  Because they want to come to America.  If we bought Mexico, Mexicans would already be in America, hence, there would be no need to come to America.  I realize this argument is a bit existential, but the argument might work.

Looking north, if Canada became the fifty-first state—of course we would try to force France to take Quebec—the northern border becomes the Arctic Circle.  At that point, the only people we would need to defend against would be the Intuits and Santa Claus.   If we were to get Canada, our petroleum reserves would increase, and we’d be able to purchase prescription medicines for less money.

Maybe the feds could learn a few things about security from Borders, the bookstore.  The security at their stores far outstrips the security at our borders.

Where Fish First Walked?

Posted by

0

This one is on my nickel—feel free to come back tomorrow.

Sometimes something gets stuck in my head and the only way to get it unstuck is to get the idea stuck in someone else’s head.  A few weeks ago I came across something on the news having to do with a Canadian paleontologist sitting on a pebbled beach in Quebec.  His life’s work revolved around finding the place where fish first walked from the sea—the very fact that he was interested in finding out where they first walked seems to imply that they (fish) have walked on more than one occasion.

I know some of you are thinking, ‘And your point in writing to us about this is…”.

The television spot went on with the fellow concluding that the interesting thing is not that fish walked—which I would have found sufficiently interesting—epochs later; yada yada yada—but that without them having walked none of us would be here.  It was alchemy in paleontology and the reporter was his Rapunzel.

What troubles me about this is he and his amanuensis, the reporter, with her eyes wide shut, somehow managed to create a dialogue around this notion as though it (the meaning of life) actually happened the way this fellow said it did.  Her interview was like watching two left-handed men learning to dance backward without either one knowing the woman’s part.

The voices in my head started screaming epitaphs at me.  The paleontologist’s mind tacked intuitively and lurched from idea to idea untouched by the clammy hand of logic.  His premise made as much sense to me as having an oboe player in a punk rock band, yet the erstwhile reporter, with her sang-froid composure, uttered nothing more than ‘uh-huh’ and looked as though she was watching time bend as he explained the wonders of the universe to her with his do-re-mi recitation of the facts.

Some people in front of a camera have the innate ability to insult our intelligence with boredom and futility.  His perfervid idea was stranded on the edge of reality and worked about as well as a poorly used preposition at the end of a sentence.  She listened and nodded and stared into the looking glass.  She never questioned whether the compass of his intellectual qualifications may have been missing its needle.

Therein lays the rub.  Simply saying something aphoristically on television does not make it true.  What was intended as an ephemeral interview now exists for the folly of all of us.  The man is guilty of sharing his ideas without having a hall pass to do so, but then again, are not we all.

Maybe that is how mermaids came to be.

Social CRM–Patients are like little thunderstorms

Posted by

1

The web never ceases to amaze me. I’ve gotten to the point if I can’t find something I’m looking for, no matter how obscure, I figure that I did something wrong in how I framed the search.

For example, I was trying to connect to a high school classmate, someone I hadn’t spoken with since before Al Gore invented the internet. This guy got a pair of boxing gloves for his 14th birthday. We each wore one, and jousted only long enough for us each to land a blow on the other’s nose. It hurt—a lot. We gave up boxing.

In tenth grade biology, we bet him five dollars that he wouldn’t jump out of the second floor window. The teacher, who knew of the bet, turned her back to write on the blackboard. He jumped. Go straight to the office, do not pass GO, do not collect $200. We used to see how fast his red and white Mach II Mustang would go railing down Route 40. He was the guy you voted best person to keep away from bright shiny objects. The last I heard he went to a teaching college.

Anyway, I Googled him—from the imperative verb Google—I Google, you Google, he, she or it Googles. I can’t tell you his name for reasons that will soon become apparent. Google spits back links to things like military intelligence, think tank, counterinsurgency, small wars, and army major.  I think I’ve made a spelling mistake—this cannot be the same guy who jumped out of classroom window—and I add his middle initial to the search criteria. Up pops a link to CNN’s Larry King—the air date—just days after 9/11. The topic of the show; ‘the hunt for Osama Bin Laden’. To quote Lewis Carroll, “things keep getting curiouser and curiouser.”

The web. Social networking. A great tool if you’re one the outside searching, deadly in the hands of your customers.

If your firm is targeted, you are pretty much defenseless. Each patient is capable of creating their own digital perception of your hospital. True or false, makes no difference. Patients are like little thunderstorms popping up everywhere. Healthcare providers scurry around like frightened mice passing out umbrellas and pretending it’s not raining. They’re late, their patients are wet, and they are telling everyone. Very few firms have learned that they can’t put the rain back into the clouds.

Sort of reminds me of the line in the movie Young Frankenstein, “Could be worse, could be raining.” It’s raining, and even the best firms have run out of umbrellas. What is your firm doing about it?

 

Is the C-suite Fiddling while EHR Burns?

Posted by

0

There is an adage in the military—different spanks for different ranks.  If speaks to a double standard, the less egregious their punishment for similar offenses, similar misjudgments.

We see that every day in business, and we see it a lot in healthcare, especially in hospitals.  Physicians are held accountable for medical errors.  Hospitals pay millions for malpractice insurance knowing that mistakes will be made and people will be held accountable for their mistakes.

But what about on the business side?  Who is held accountable for business mistakes?  An acquisition that failed to deliver.  An expensive new service offering that bled the company dry.  A decline in the number of patients. The failure of a major IT initiative to deliver results.

Take EHR.  Some of you are saying, “Yes, please take it.”

  • Around sixty percent of the large EHR projects have failed in one respect or another
  • Most will not receive ARRA incentives
  • A large number of hospitals are on their second implementation of EHR
  • Some have productivity losses of thirty percent

Who is going to be fired for the two hundred million dollar misstep?  The board?  Never.  The CEO—no.  The COO or CFO?  Unlikely.  The CIO?  That is the safe bet.

Did the CIO authorize the expenditure?  Nope.  Did the CIO get all the dollars needed to be successful, all the user support?  Unlikely.

In most cases the CIO has all of the responsibility and only some of the authority.  There are a handful of people in each organization tasked with the oversight of the large project.  They are the ones who should be asking the right questions, the ones who should be demanding answers.

A failed project, a failed strategy should not come as a surprise.  The only people who will be wearing EHR 2.0 T-shirts are those who authorized EHR 1.0.  How come these individuals are not accountable?

Whatever happened to Healthcare Reform?

Posted by

0

I wrote a piece last year titled ‘Robbing Peter to Pay Paul’.  Yesterday I read a thoughtful post by Kim Chandler McDonald which offered a very similar albeit somewhat different perspective on the topic of where the focus on healthcare really lies.  Kim wrote on ‘meHealth’, taking the responsibility for eHealth as the only real way to create an ROI in the space http://ow.ly/5NCPN.  For those who enjoy reading something by someone who knows the difference between an adverb and a potted plant and can actually write a proper sentence I encourage you to take a read.

Mine was on heCare and sheCare and it also speaks to the individual but does so without any attempt to disguise my belief that healthcare reform missed the mark http://ow.ly/5NDet.  Kim wrote asking what if anything has changed in the period since I penned my piece.  For those who may have missed it, and to borrow from FDR, my premise was that the only thing to fear about healthcare reform was reform itself.

For all the talking that healthcare reform created, the silence on the topic has risen to a new crescendo.  The only thing that has changed concerning reform is that the silence has grown louder.

Why has reform missed the mark and what can be done about it?  Permit me a moment to illustrate.  I would ask that all the altruists reading this post take one step forward—wait a minute Sparky, where are you going?  The reform package efforted (simple past tense and past participle of effort) to be all things to all people, especially to those who have been disenfranchised under the current system.

While the goal is laudable, it did not pass the test of being both necessary and sufficient.  Its insufficiency is hampered by the fact that when we are ill altruism ends at our individual front doors.  It goes back to the notion of robbing Peter to pay Paul.  Do unto others, but do not undo unto me.

Most observers believe there is some dollar amount that contains the total spend available for healthcare and that to increase services to those less fortunate—the theyCare populous—means paying for it by removing services from those who presently have healthcare, the heCare and sheCare taxpayers.  And, it is those same people, the heCares and sheCares, whose support of reform has fallen silent.

While a rising tide may indeed lift all boats, it also drowns those tethered to the pier.

The Joy of Sox–deliver a great presentation

Posted by

0

It is an interesting exercise taking apart a one hour speech and repackaging it as a five minute talk—Twitterizing.  It goes to the quote, “I would have written less if I had more time.”  The corollary for presentations may be, if it does not fit one slide, it’s not properly thought out.

I think what a lot of presenters miss is having an understanding of what makes for a good presentation.  Here are a few of mine.

Presentation Rule 1—never bore the audience.  They are pulling for you to do well for your sake and theirs.

Presentation Rule 2—most of the audience can read.  If your slides are filled with text and bullet points, their natural inclination is to read what you’ve written.  They are doing this while you are reading aloud the very same text.  If they are reading, you become superfluous.

Presentation Rule 3—the audience cannot walk and chew gum at the same time (they can’t read your words and listen to you.)  For those presenters who favor text on their slides there are two choices; read from the slides, or try to offer commentary about the slides.  For those who do not read directly from their slides and want to offer commentary it gets even more awkward.  You look at the audience and see them reading the slide.  Your natural tendency is not to interrupt their reading because you are trying to be polite and you do not want them to miss your words of wisdom.  Then your mind starts to wonder if what you are about to say is so important if you should have written it on a slide.

Presentation Rule 4—if you wear wild looking socks, you had better be delivering one heck of a good talk.

Seth Godin’s philosophy about presentations is not wanting people taking notes based on what is on his slides, hence he uses pictures to convey an idea.  I have adopted his approach, choosing to hand-draw concepts from which I can then speak.  Since there is nothing of import on the slides, people start staring at you, something which will make a lot of presenters even more nervous.

The downside of this approach is that since everyone will now be listening instead of reading or writing, you better have something to say.  The issue then becomes how to craft your words in a way to get your audience to remember your message.

I favor analogies, examples, and the occasional cliché.

Will these steps work for you?  I hope they do.  I felt they were working pretty well for me last night right until the end.  An attractive woman approached me and said, “You look like Jack Nicholson, only not as unattractive”—so at least I’ve got that going for me.

July is “take your EHR strategy to lunch month”

Posted by

1

Several have written suggesting I toss my hat into the ring to serve as the EHR Strategy wonk or czar.  I was in the process of thinking it through when I was awakened from my fuegue state by a loud noise–my ego crashing to the floor.

Some have suggested that a camel is a horse designed by a committee.  Their point in saying that has something to do with how committees function less well than individuals–the problem with “group thinking.”  Personally, I think the camel design seems rather functional.

Some have asked, what is it about the EHR universe that has you dehorting the EHR process as though you are some sort of savant–nobody really asked that, but I wanted a segue and that’s all I came up with.

It’s the committees.  I feel a little like Quasimodo repining about the bells.  Raise your hand if you are on an EHR committee.  See?  Now, if you think that not only has the committee not accomplished much, but believe that it may never accomplish much, lower your hand.  Now look around.  Not many hands still up.

Take a few minutes and work Meaningful Use into your EHR task time-line for processes, work flows, change management, training.  Need more time?  I’d need more time than I have, and when I finished I guarantee I couldn’t explain it to anyone.  This is what happens when people get into a room, have a charter, and try to do something helpful.  I am sure they are all nice people.  But be honest, does this make your day, or does it make you want to punish your neighbor’s cat–you may have to buy them a cat if they don’t already have one.

What to do?  Here’s my take on it.  Plan.  Evaluate the plan.  Test the plan.  Know before you start that the plan can handle anything any committee tosses your way.  Let people who know how to run large projects into the room.  Seek their counsel, depend on them for their leadership.  If the plan is solid, the result has a better chance of surviving the next committee meeting

The Myth of EHR Certification

Posted by

0

EHR certification inspectors will swarm hospitals like fifty-year-old women to a Celine Dion concert.

Why is certification a part of the overall plan?  Is this planned failure?  Do they have reason to believe that a certain percentage of EHRs will fail certification?

Of course they do.

Let’s describe two failure types; certification and Full test.  The certification test, by definition, is necessary.  The Full test is both necessary and sufficient.  It is possible to pass certification without passing the Full test.  Therefore, the Full test is a stricter test.  Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test?  Same as always.  Fully functional, on time, within budget, and user accepted.  Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact:  One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion:  The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations.  Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification.  (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact:  Most large, complex, expensive IT projects fail—they just do.  This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed.  Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion:  Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak?  You bet.  Insurmountable?  Doesn’t have to be.

What can you do to improve your chances of success?  Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points.  EHR Fail Safe Points?  The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test.  The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD.  They need not have a slew of EHR implementation merit badges.  The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built.  They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR.  Those skills are needed—in spades—and you need to budget for them.  The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre.  They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

 

Who lost the ‘R’ in EHR’s ROI?

Posted by

0

This is my latest post in healthsystemcio.com.

http://healthsystemcio.com/2011/07/14/standardization-lies-beyond-the-clinical-realm/#

As a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work—artistes.

Then there are the ERPs.  Remember The Flintstones and I Love Lucy?  Fred Flintstone was looking at a job advert for someone to put cotton in pill bottles; and Lucy got a job boxing bon bons.  ERPs are the easy business process to map, model, and structure. They are the perfect processes for large enterprise software vendors to automate.

EHRs contain both types of business processes, BRPs and ERPs.

How can you tell what type of business processes you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR?  The reason is simple. The taxonomy of most, if not all EHR systems, is that EHRs are designed to support ERPs. Unfortunately, most of the business processes that the EHR has to model are one-off processes, BRPs.  Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to fit BRPs into an ERP system.

Since much of the ROI in the EHR comes from being able to redesign the workflows, it stands to reason that the ‘R’ in ROI will be sacrificed, and the ‘I’ will be much higher than planned.

On the other hand, if one looks at a hospital’s non-clinical business processes almost all of those are ERPs.  Many of them are some combination of being outdated, duplicated, and rework.  If you are looking to recover your ROI and to decrease cost, these ERPs offer a good opportunity to do both.

What do you think?

 

Healthcare’s pre-mortem

Posted by

0

I call this my premortem of the large provider business model.  The new reform law is Washington’s Anschluss of the healthcare business model—the annexation of the old way of doing business.  With change, as with writing a novel, the most difficult part is to invent the end.  It is only difficult if someone actually gets to that part, the end.  Many large providers remain mired in the first chapter.

The term Ultima Thule refers to any distant place located beyond the “borders of the known world.”  That is where we are when it comes to trying to understand the implications in the realm of the known and unknown external influences on the business model of the large healthcare provider.  I tend to have a stygian mindset about how I think these influences will play out—when Washington sneezes, it is the providers who catch the cold.

Sometimes it is a matter of asking the right questions.  Unfortunately, when one asks questions, somebody always has answers.  The bad thing about answers is they often bring closure to the process of thinking.  In the short-term there may be a modus Vivendi between us—an agreement to agree to disagree, but in the long-term limiting one’s vision to the borders of the known world will prove fatal.

Gone are healthcare’s Elysian moments when leaders thought they could keep doing what they were doing as long as they did it a little better.  At some point, there are no more costs to cut.  Providers will not be able to get any Leaner.  The time has come to square the circle—something proven impossible in 1882 by Ferdinand Lindemann.  Squaring the circle is an attempt to construct a square with the same area of a given circle using Euclidian geometry.

Trying to retrofit today’s healthcare model to meet tomorrow’s business requirements seems to me to be a similar argument.  It can’t be done; you can’t get there from here.  That it cannot be done won’t stop people from trying.  The impossibility cannot be proven.  The proof will be apparent only when hospitals start to fail.  Only then will it be possible to “walk back the cat” to diagnostically deconstruct what failed hospitals should have done.

A purpose of intelligence is the ability to assess and predict.  The application of thinking and intelligence is the ability to assign relative importance to predictions.  Here’s my assessment and prediction.

To successfully change the large provider model one must disrupt it, not simply adjust it.  It has nothing to do with asking, “How can we do this better?” disruption requires that we ask, “Do we need to do this?”

For example, last week I met with the former CFO of a group of east-coast hospitals.  Each hospital had an orthopedic department.  The group also owned an orthopedic clinic.  The clinic was ranked among the top twenty orthopedic centers in the US.  None of the hospitals’ orthopedic departments was ranked in the top one hundred.  The CFO recommended the hospitals close their orthopedic departments and service those patients at the clinic.  This would improve quality and eliminate duplicative costs.  Great idea.  Unfortunately the board liked their hospitals to be able to offer all things to all people—quality and cost be damned.

Why?