Rants & Musings

Relative (Non) Value Units (RVUs)

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Below is my lastest post in HealthSystemCIO.com.

http://healthsystemcio.com/2010/12/01/relative-non-value-units/

This issue has been troubling me ever since a doctor told me her hospital was implementing it.  It is good to know that there are no patents on bad business ideas—that way everybody gets a chance to use them.  Sometimes bad ideas come with misnomer labels that suggest they are less evil—Meaningful Use is a good example of a misnomer idea, but that is not the topic of today’s discussion.

Permit me to illustrate this idea with an identical policy in another industry, one that I believe will hit home for many.  Think back to the last time a cable television technician came to your home to perform some piece of work; moving or adding an outlet, installing cable or internet.  (Before I started practicing medicine on-line, I spent many years consulting to the cable industry about how to improve their operations using the tools of IT.  I often rode with the technicians to observe how they did their work.)

During these times I noticed jobs when the technician did not have the time needed to complete the work described on the work order.  Rarely did the technician have time to complete any add-on work—work requested by the customer while the tech was at their home.

What really interested me was the answer to my question of ‘why’?  It comes down to the following.  When the technician leaves the service bay in the morning, the tech has a list of work orders that must be completed by the end of the day.  Each work order is worth a fixed number of points, and the technician is evaluated and paid in relation to the number of points earned.

Let’s say the tech is to install a new wall outlet; five points and 30 minutes may be assigned to that work order.  The tech arrives at the home only to learn the outlet is to be installed on an interior wall and the cable will have to by threaded through the wall via the attic; a sixty minute job.  If the tech stays to complete the work, it will only yield five points and delay his entire schedule by thirty minutes.

Either way, the process fails, and the customer is failed.  The tech will return tomorrow at double the cost to the company, but he will now be allocated 60 minutes for the work.  There is always time to do the work over, and never time to do it right.

This business process suggests the next customer is always valued more highly than the present customer.  This is why when you are being helped by a clerk in a store and the phone rings the clerk will stop servicing you—a paying customer—to service someone who merely wants to chat.

The process? Relative Value Units (RVUs), and it’s another misnomer.  An argument can be made to show RVUs have little or no relative value, but entire hospitals run on these, and IT builds systems to assign, track, and report on RVUs.  Is there a way for IT to demonstrate or report the impracticality of running a business in this manner?

 

The Prostate Apostate

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Every once in a while the world hands you something from out of the blue.  Sometimes it comes to you in the same way pigeons gift statues, other times it can come as a little bonus.

Driving to a client I was listening to NPR—Not for Polite Republicans.  Their story reported recent findings by a team of British scientists about the likelihood of men—their word, not mine—getting prostate cancer.  (While they felt the need to use the qualifier ‘men’ is beyond me, maybe the English should learn English.)

Regardless, the study found that men whose right index finger is longer than their right ring finger are thirty percent less likely to get prostate cancer.  This announcement had me, and probably a million other men, raise simultaneously their right hands and compare the length of the two digits in question.  No data was given for men who wear black socks with sneakers other than what is already understood about that subgroup; they have no game.

So, there I am staring at my fingers at six o’clock and trying to compare their length using the headlights of the approaching cars.  Indeed, my index finger is longer.

That was a nice way to start my day.  The physician went on to validate her findings using words so large they never would have made it past the New York Times editorial board.  I found myself nodding in agreement right up until she said, “And we can trace this gene all the way back to the point in evolution where we as fish came to live on land.”

It was at this point where I would have found the study more credible had she found that guys in their teens who had a crush on Karen Carpenter were thirty percent less likely to contract the disease.

It also made me wonder, just where would one find a fish’s prostate?

 

EHR… “You are not twenty anymore”

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There is a first time for everything.  Yesterday was the first time it occurred to me that there is a difference between being twenty and not being twenty.  A few days ago one of the women at the gym was bemoaning the fact that being forty wasn’t at all like being thirty–puhleeaasse.

My wife would have me point out her admonition of “You are not twenty anymore.”  Women do not understand that to men this phrase goes into our little brains and comes out reshuffled as the phrase “Just you wait and see.”

There are those who would have you believe that there is no single muscle that is connected to every other muscle, a muscle which if pulled will make every other muscle hurt.  I beg to differ.  I think I found it—I call it a my groinal—it’s connected to my adverse and inverse bent-egotudinals, the small transflexors located behind the mind’s eye.  I found the muscle while running back a kickoff during a Thanksgiving morning game of flag football.

Call it an homage to the Kennedys.  Sort of made me fee like one of them—I think it was Ethyl.  Old guys versus new guys—I know it’s a poor word choice but you know what I mean which after all is why we’re both here.  Did I mention that everything aches, so much so that I tried dipping myself in Tylenol?

There are two types of people who play football, those who like to hit people and those who don’t like being hit.  I am clearly a member of the latter camp.  I used to be able to avoid being hit by being faster than the other guy.  This day I avoided getting hit by running away from the other guy.

The weird part is that my mind still pictures my body doing things just like the college kids on the field, and it feels the same, it just isn’t.  Two kids passed me–they were probably on steroids, and my only reaction was the parent in me wanting to ground the two of them.  Half the guys are moving at half the speed of the other guys.  At the end of each play, we find our side doubled over, our hands on our knees, our eyes scanning the sidelines for oxygen and wondering why the ground appears to be swaying.

As the game progresses, instead of running a deep curl pattern, I find myself saying things like, “I’ll take two steps across the line of scrimmage, hit me if I’m open.”  Thirty minutes later I’m trying to cut a deal with their safety, telling him, “I’m not in this play, I didn’t even go to the huddle.”  After that I’m telling the quarterback, “If you throw it to me, I’m not going to catch it, no matter what.”

All the parts are the same ones I’ve always had, but they aren’t functioning the way they should.  It’s a lot like assembling a gas grill and having a few pieces remaining—I speak from experience.  Unfortunately, implementing complex healthcare information technology systems can often result in things not functioning the way they should, even if you have all the pieces.  It helps to have a plan, have a better one than you thought you needed, have one written by people who plan nasty HIT systems, then have someone manage the plan, someone who can walk into the room and say, “This is what we are going to do on Tuesday, because this is what you should do on Tuesday on big hairy projects.”.

Then, if you pull your groinal muscle implementing EHR, try dipping yourself in Tylenol.

 

EHR–WWOD (What would Oprah do?)

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So, I’m watching the Alabama Auburn game and it suddenly strikes me, there are probably a lot of people trying to understand what it is a consultant does that we can’t do for ourselves.

For those who have a life, those who missed the game, Auburn entered the game undefeated and had a good chance to play for the national title.  Alabama opens the game with several well-scripted opening plays and grabbed an early lead.

Their first ‘n’ offensive plays were brilliant.  They were planned perfectly.

It became apparent they had not planned the however many of the ‘n + 1’ plays.  Their plan failed to go beyond what they’d already accomplished.

How does that apply to what you do, what I do, and why I think I can help you?  It is best described by comparing your brain to a consultant’s brain.  Your work brain functions exactly as it should.  It’s comprised of little boxes of integrated work activities, one for admissions and registration, one for diagnosis, another for care.  There’s probably another box for whatever it is the newsletter stated IT was doing three months ago and how that impacts what you do.  That’s your job.

Your boxes interface in some form or fashion with the boxes of the person next to you in the hospital’s basement cafeteria who is paying for her chicken, broccoli, and rice dish that reminds you of what you ate at crazy Uncle Bob’s wedding reception.  That interface is the glue that makes the hospital work.  It’s also the synapse, the connective tissue—I know it’s a weak metaphor, but it’s a holiday weekend—give me some slack—that tries to keep healthcare functioning in an 0.2 business model.

There are names for the connective tissue, you know it and I know it.  It’s called politics.  It’s derived from antiquated notions like, “this is how we’ve always done it”, “that’s radiology’s problem”, and “nobody asked me”,

At some point over the next week or two the inevitable happens; the need arises for you to add some tidbit of information.  Do you add it to an existing box, put it in an empty box, or ignore it?  This is where you must separate the wheat from the albumen—just checking to see how closely you’re following.

Your personal warehouse of boxes looks like the final scene in Raiders of the Lost Ark—acre after acre of dusty, full boxes, no Dewy-decimal filing system, and no empty box.  There are two rules at the hospital; one, bits of information must go somewhere, and two, nobody can change rule one.

The difference, and it’s a big one, is that consultants have an empty box.  It’s our Al Gore lockbox.  We were born that way.  It’s like having a cleft chin.  We also have no connective tissue to your organization.  No groupthink.  No Stepford Wives. No Invasion of the Body Snatchers to turn us into mindless pods.  Consultants may be the only people who don’t care.  Let me rephrase that.  We don’t care about the politics.  We don’t care that the reason the hospital has four IT departments is because the hospital’s leadership was afraid to tell the siloed docs that they couldn’t buy or build whatever they wanted.

Sometimes it comes down to your WWOD (what would Oprah do) moment.  Not ‘what do they want me to do’, not ‘what would they do’, not ‘what is the least disruptive’, not ‘what goes best with what the other hospital did’.

At some point it comes down to, what is the right thing to do; what should we do.

Big, hairy healthcare IT projects come out of the shoot looking like Alabama did against Auburn.  The first however many moves are scripted perfectly.  Heck, you can download them off Google.  Worse yet, you can get your EHR vendor to print them for you.

The wheat from the albumen moment comes when you have to come up with an answer to the questions, “What do we do next,” and “Why doesn’t it work like they said it would?”

That’s why consultants have an open box.  You know what we are doing when our brain takes us to the open box?  Thinking.  No company politics to sidetrack us.  Everybody knows the expected answers, but often the expected answer is not the best answer.  Almost everybody knows what comes after A, B, C, and D.

Sometimes…E is not the right answer or the best answer.

A thought for Thanksgiving

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May I take you on a tour of our homes—yours and mine?  Although we’ve never crossed one another’s thresholds, we’ve been there, at least if you live in America. Take the tour with me.  You enter through the front door.  On one side is the living room, on the other sits the dining room.  If you’re left-handed, as am I, the dining room is on the left and the living room is on the right.

The living room looks exactly like it did the day the movers dropped off your furniture.  It might as well be cordoned off with red velvet rope and polished brass stanchions.  It reminds me of taking the tour of Independence Hall, seeing the quill pen right where Mr. Hancock left it.  Nothing has been disturbed.

We don’t use our living room.  We vacuum and dust, just like everyone does.  We didn’t use it when I was young; I’m starting to think it might be a better spot for a hot tub.

Opposite the living room is the dining room.  One or two brass chandeliers, depending on your tastes.  Oriental rug, side board, hutch.  Ask a thief about the rest—bone china, a velvet lined box of silver dinner wear.  Candlesticks.  Hand cut lead crystal.  Linens; tablecloth and napkins.  That sort of covers it.

If your family is at all like mine, when the dining room isn’t being used for folding laundry, building 1,000 piece puzzles, or tax preparation, it is used for high holidays, proms, weddings and funerals.

We have a set of china I bought from England on eBay that is more translucent that Saran wrap.  We’ve probably used it a half dozen times.  It’s for those special occasions—like the passage of the healthcare reform bill.

Eight years ago this Thanksgiving I was sitting on the floor of the dining room, inspecting the dishes and silverware when I came upon an unopened box of off-white tapered candles that was tucked away under the starched Egyptian cotton linens.

It gave me pause.  The receipt was taped to the box—purchased five years ago.  Why?  In case we needed them.  In case there was an occasion so special as to warrant candles, better yet, candles in the dining room, with the china and lead crystal.  (Sounds a little like Colonel Mustard in the dining room with the lead pipe.)

At the rate we were going, the candles and china were so well preserved so as to survive an archeological dig in the year 3,000.  What is the correct candle lighting threshold?  What is yours?

I almost never had the chance to learn mine.  Less than two weeks after that Thanksgiving, while watching an episode of the Sopranos, I had difficulty breathing, a lot of difficulty.  Collapsing to the floor while trying to convince my wife I was fine was enough to get her to call for an ambulance.  I was having a heart attack.

Less we be distracted, these few paragraphs are about the candles, not the heart attack.  These days we burn the candles, stain the linens, and break the crystal and the china.

I used to think, wouldn’t it be neat if, or if I had the chance for a do-over I’d like to be.  How cool would it be to have been Ted Kennedy or Paul Newman?  Celebrity.  Impacting world events.  Able to pay John Edwards money for a haircut.  Why not want that?

One reason.  Each of us has the ability to choose to complain about tomorrow, an ability Messieurs Newman and Kennedy no longer have.  Too hot, too cold, too busy, too bored.  The question is, do we also have the smarts, the God-given wisdom, not to complain but just to be grateful for being.

I also had cancer twenty years ago.  I have vivid memories of wishing I was caught in traffic jam on I-75 in Dallas, yet I’m the same guy who often finds himself a nanosecond away from having a news helicopter filming my traffic road-rage.  My moments of clarity wax and wane as I’m sure do yours.

It’s difficult if not impossible to see your candles as you lie strapped to a gurney in the back of an ambulance.

I’ve been fortunate to have met some really special people on the Internet.  Smart people, generous people, people willing to share ideas diametrically opposed to mine.  People caught up in their lives and the lives of others.  People who in an awkward moment would think it might be great to trade their lot for that of another.  People who’d rather save their candles for a more important occasion.

No occasion will ever be any more important than the occasion of having tomorrow.  Let’s agree to light a lot of candles this year.

Warm regards, Paul

Taking Care of Patients (TCOP)–the business side

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That’s me in the back row–just kidding. There are approximately 640 muscles in the human body. Yesterday I pulled 639 of them. In anticipation of the onset of winter I’ve been ramping up my workouts, and at the moment am scarcely able to lift a pencil. I came across an article that describes the full body workout used by the University of North Carolina basketball players. It involves a ten-pound medicine ball, and 400 repetitions spread across a handful of exercises. I’m three days into it and giving a lot of thought about investigating what kind of workout the UNC math team may be using. At my son’s basketball practice last night, the parents took on the boys—they are ten. That 640th muscle, the holdout, now hurts as bad as the rest of them.

So, this morning I’m running on the treadmill, because it’s cold and the slate colored clouds look heavy with rain. While I’m running, I am watching the Military History Channel, more specifically a show on the Civil War’s Battle of Bull Run—I learned that that’s what the Yankees called it, they named the battles after the nearest river, the Rebs called it the Battle of Manassas, named after the nearest town. The historian doing the narration spoke to the wholesale slaughter that occurred on both sides. He equated the slaughter to the fact that military technology had outpaced military strategy. The armies lined up close together, elbow to elbow, and marched towards cannon fire that slaughtered them. Had they spread themselves out, the technology would have been much less effective.

Don’t blink or you’ll miss the segue. You had to know this was coming. Does your hospital have one of those designer call centers? You know the ones—wide open spaces, sky lights, sterile. Fabric swatches. The fabric of the chair matches that of the cubicle, which in turn are coordinated with the carpeting. Raised floors. Zillions of dollars of technology purring away underfoot. We have technology that can answer the call, talk to the caller, route the caller, and record the caller for that all important black hole called “purposes of quality.”

The only thing we haven’t been able to do is to find technology to solve the patient’s problems. Taking Care of Patients (TCOP), also known as Patient Experience Management (PEM).  We’ve used it to automate almost everything. If we remove all the overlaying technology, we still face the same business processes that were underfoot ten years ago. Call center technology has outpaced call center strategy. Call center technology hasn’t made call centers more effective, it’s made them more efficient. Call center strategies are geared towards efficiencies. Only when we design call center strategies around being more effective will the strategy begin to maximize the capabilities of the technologies.

 

EHR: Show me the money

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Every wonder how it is that all the billions in healthcare IT money came about?  I imagine it went something like this.

DC 1: Email those fellows over at HHS and tell them we should just make the doctors install Electronic Health Records (EHR).

DC 2: While we’re at it, how about we pay them a bonus to do it…

DC 1: …and we penalize them if they don’t.  Give them money with one hand and take it back with the other.

DC 2: How do we get EHRs to communicate?

DC 1: Make the states do figure it out.  They are looking for more money.

DC 2: I’ll email the governors and tell them we’ve got more billions to pass around.  Let them build some sort of Information Exchange.  They can set up committees and staff them with appointees.

DC 1: Then we can glue those together in some kind of national network.  Where are we going to get one of those?  Figure another ten billion for that.

DC 2: I’ll email the DOD, they are supposed to know something about building national networks.

DC 1: Just to get things kick-started, let’s email the troops and tell them we’ll sweeten the state pots a little more.  Get them to build these extension centers on a region by region basis.

All these dollars, so little value.  Most of it focused on trying to figure out how to get millions of somethings from point A to point B.

How did all those millions of emails get securely from point A to point B?  For a lot less than forty billion dollars isn’t it possible to figure out  how to get my health information to whomever needs it?  Email me, maybe we can come up with an idea for a network.

If you’re still puzzled, we can play hangman.  It has eight letters, starts with an ‘I’, and ends with ‘ternet’.

 

Job Opportunity: EHR business development

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A member of my network, Todd Eikenberry, told me about a job opportunity; it is posted below.  You can email him at  eik@eliterecruiters.com or call him at (317) 598-1400.

Immediate Opening:

Market Leading Provider of EHR/Practice Management Software

Please Contact:

Todd Eikenberry, Managing Partner

Elite Recruiters

Office    317-598-1400

Mobile  317-439-7901

eik@eliterecruiters.com

 

East Region Manager- Healthcare IT Organizations
Overview:
Manages the activities and responsibilities associated with forming strategic alliances with a variety of government agencies, including Regional Extension Centers (REC), State Designated Entities (SDE) for Healthcare Information Exchanges (HIE), and State-affiliated Healthcare Information Technology (HIT) programs.  Actively engages with key contacts in these agencies to ensure that Company is approved for HIT initiatives that align with products and services.  Works closely with Local Field Sales personnel as necessary to achieve approved status and/or drive product sales through previously approved relationships.

The person filling this position can live anywhere in the Eastern half of the U. S., but must be near a major airport.  The successful candidate must have considerable HIT sales or marketing experience.  Travel will be required approximately 50% of the time.
Responsibilities:
  • Identifies and develops relationships with key executives and contacts within RECs, SDEs and/or State HIT organizations.  Owns responsibility for formalizing and/or winning approval of relationships with these entities, including formal contracts, group purchases, recommended vendor lists, etc.  Also interacts with other local/federal agencies/contacts as required.
  • Coordinates internal resources to ensure that we respond appropriately and in a timely fashion to REC/SDE formal and informal requests, including RFPs/RFIs.  Serves as the primary point of contact between the REC/SDE and Company resources, including Field Sales, Marketing, Operations, Client Services, Finance, Legal, Accounting, etc.
  • Maximizes Company revenue by coordinating requirements to provide marketing/sales support, demonstration requirements and REC/SDE strategic partner engagement to execute REC/SDE-facilitated marketing and/or implementation programs in the field to ensure long term success of the Company-REC/SDE relationship.
  • Maintains an active understanding of relevant business, technological, and industry trends to assist in expanding market leadership and influencing future product direction.
  • Provides reports and updates to management and also ensures that whatever reporting requirements may be necessary to comply with SDE needs/contracts are met.
Qualifications:
Education:  Bachelor’s Degree highly preferred.  Equivalent experience will be considered.

Experience: 3 – 5 years of Healthcare Information Technology and Electronic Health Records sales and/or marketing experience is a minimal requirement to be considered for this position.

 

 

Patient Experience Management: How to begin

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Here is my new post on http://www.healthsystemcio.com

Patient Experience Management (PEM) is not about Patients, but it is often designed just that way.  The problem lies with the plurality, the pesky little “s” that takes the design and implementation away from an individual patient, and places the focus on patients.

Other industries grapple with the same problem, only with them the issue comes about when designing and implementing systems and processes around customers instead of a customer.

Do you recall the talking points of the recent McKinsey survey about patient experience management?  The study made drew two conclusions.  First, ninety percent of hospital executives responded that improving PEM was their first or second priority within the next three to five years.  Second, those same individuals stated they did not expect much to happen regarding PEM because they did not know who in their organization ‘owned’ the PEM business problem.

Ignoring that issue, if only for the reason that almost everyone else seems to be taking the same approach, what if a hospital wanted to move forward and deal with PEM in a meaningful way—not meaningful as in the term Meaningful Use—but in a way whereby having a PEM system actually yielded something for the hospital?

Few industries have done a stellar job with Customer Experience Management (CEM).  What can be learned from their failures?  Plenty.  The failure of CEM systems originates at the get-go. The organization does a poor job of defining its business problem, deciding it needs a system to manage its customers, as though all customers are the same.  With that as its target, it goes out and finds and implements such a system.

Here is the problem from the perspective of PEM, and in some regards for EHR.  Whatever system you choose for PEM, CEM, or for that matter EHR has been designed to address thousands of individuals as a single entity called “our patients” or “our customers.”  The system is build upon managing the experiences of a core set of patient attributes.  Chances are good that whatever PEM system you select—they really are pretty much the same—will address roughly seventy percent of the functional requirements of this entity called “our patients.”

Applications vendors build solutions and hope to find a problem which matches the system they built.  If all your individual patients fit neatly into their vision of this “our patients” entity your worries are over.  If however, patients are different, which they are, they will have many needs which lie outside of the boundary of their application.  It is these set of needs—functional requirements—upon which the success or failure of your PEM will be based.  These same needs are the ones that are unmet today.  These are the ones, the outliers, which raise the ire of your patients and the ones lowering your organizations PEM scores; assuming you track this.

One way to solve this problem, in fact, to my knowledge to only way is to start by defining rigorously the functional requirements of one patient, a super-patient, which encompasses every requirement.  With this done, you have a PEM model, based on a single patient.  Now instead of having PEM requirements which lie outside of the boundaries or core competencies of what a vendor wants to sell you, you have a turbo charged set of requirements.  The diverse PEM requirements of your individual patients are contained within the capabilities of the defined super-patient.

If you approach PEM this way you have defined for yourself a solvable problem.  You now have a problem looking for a solution instead of a vendor with a solution looking for a problem.

HIT/EHR: A little adult supervision

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Among other things, EHR requires adult supervision like parenting.  My morning was moving along swimmingly.  Kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—I guess we could call them evergreens—to make them look snow-covered.  (I just em-dashed and em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  I may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things are other things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctor’s.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.