EHR, where’s my hammer?

Posted by Paul Roemer

Those of you who’ve visited previously may have caught on to the fact that my wife likes to keep me away from bright shiny objects such as tools. Let me tell you about my first house, a two-story stucco building in Denver, built in 1902. My favorite part of the home was the brick wall. That is had a brick wall was not apparent when I purchased it.

I came home from work to find that my dog had eaten through the lath and plaster in the living room and there was the brick. I had to decide what to do. I knew nothing about lathing—I know that’s not really a word—or plastering. What to do. My only tool was a hammer, so I began to hammer. For those who haven’t done this, hundred year old plaster being pounded with a hammer makes a lot of dust. This process proved to be very slow.

What did I do? I bought a bigger hammer—such a guy approach to a problem, isn’t it? It took three hammers to get down to just bare brick. What would you have done? When your only tool is a hammer every problem looks like a nail.

As you go through the EHR planning process in your war room—you do have a war room, don’t you? (Try Sam’s Club, after all, they sell EHRs.) Get out the really big piece of paper, the one with your EHR design—you do have a really big piece of paper, don’t you? (Back to Sam’s.)

Next to the box on the paper labeled “Shiny New EHR” should be lots of empty space so you can draw in all of the other systems with which your EHR will have to interface. One of the readers of this blog wrote recently that his EHR had more than 400 interfaces.

EHR, if done correctly, will do much for patients, doctors, and administrators. It’s not a panacea. It won’t reach its potential unless you also integrate it with those systems that unlock its potential. Improving your efficiency and effectiveness takes more than merely an EHR system.

When your only tool is a hammer, you’d better hope every problem is a nail. What other tools are you using? Please share your ideas about what works well.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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What if GM were involved in EHR?

Posted by Paul Roemer

Goodness knows, the whole car thing did not work our too well for them

Do you ever think about the origination of some of your ideas? For me, the good and the bad just seem to materialize. Like the time a friend and I were hiking a peak in the Sangre de Cristo range in Colorado. It had taken the better part of six hours of circuitous climbing to reach the summit. It was late in the fall, and the temperatures were around freezing. Roiling storm clouds were racing towards us from the west.

If we returned by the same route we knew we’d be caught up in a storm that we were neither prepared nor dressed to handle. I spotted our car about six thousand feet below us. If we headed straight to it, I thought we could cut our descent time by about an hour. To do this though required that we make our own trail via a hunt and peck route of whatever the terrain permitted. We dropped the first fifteen hundred feet in a matter of twenty minutes using a glissade. This technique allows you to moonwalk and slide down a scree field, using your ice ax as a break.

After an hour we reached a point about two thousand feet above our car. It was sleeting, and the wind was whipping around the face of the mountain. There in the middle of nowhere stood a sign from the sheriff that read, “Devil’s Gulch, turn back.” Our choice was to reclimb the mountain or to ignore the sign and press on. I hate do-overs. How tough can this be, I goaded him? Be smart, kick it into high gear, and we’ll be done.

We pressed forward. Fifteen minutes later, we reached a four hundred foot limestone cliff. Between us and the next semi-reasonable terrain was a rather deadly looking wall of rock and scrub pine. My pack made me feel like it was forcing me forward, so I removed it and tossed it over, thinking I’d retrieve it later. Watching my pack bound from rock to rock for what seemed like more than a minute did nothing for putting me at ease.

We spent more time discussing each step than we spent taking it. Those four hundred feet took us two hours. Not my best idea, but it didn’t kill us.

So, during my run today, I had another idea. This one is about OnStar, the GM tracking system. I typed in to Google, “How does OnStar Work?” Lots of hits. The more I read, the more I began to feel like if one ignored the technology and focused on the concept a real argument could be made for pairing the idea, and a few others, and seeing what type of EHR network might be possible using a similar set of tools.

The OnStar concept is termed telematics, a combination of telecommunications and informatics. Telematics is the integration of computing, wireless communications, and GPS. It provides information to a mobile service like a phone, PDA, or laptop. It is used for sending, receiving, and storing information over very large networks. So, why is nobody having the conversation that says what if we image a similar network with added security that works from a healthcare provider’s office rather than a car.

OnStar doesn’t need Rhios. OnStar has a single set of standards. Now, instead of arguing why something like this can’t work in healthcare, isn’t there argument is seeing if it can?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

When nurses end their shift

Posted by Paul Roemer

Here’s a piece I submitted to a writing contest at NPR. It has nothing to do with healthcare save for the first sentence which NPR supplied. In case you are wondering, my 12-step program is progressing nicely.

The nurse left work at five o’clock. A twelve-hour shift—only lost one, better than some nights, worse than others. Two hours before sunup, the icy wind gnawed at her ankles. With her caffeine gauge on empty, she ducked into Starbucks, glancing waywardly at the plethora of coffees posted overhead on the menu board.

“Do you guys actually pay someone to think up all this stuff?” She asked rhetorically. The still groggy looking twenty-something guy behind the counter ignored her, not a bright move on his part. His hair looked like it was cut with an ax; an errant flap of it skittered over his right eye with each movement of his head. His right ear lobe was pierced in three places, although he only wore one earring. The nurse noticed a barbed-wire tattoo around his left bicep.

Intent on continuing the conversation, even if it was to remain one-sided, the nurse inquired, “I suppose you guys have a marketing think-tank to invent the product names. That word “Grande,” that’s Italian, right?”

Twenty-Something occupied himself by steaming a pot of skim milk.

“So, help me think this through,” she implored. “Since Grande is the one in the middle, it must be Italian for medium. And, “Venti,” that must mean large. Right? So, here’s where I’m confused. The one labeled, “Tall.” Something tells me that doesn’t translate to small in any language. If you take a small cup of coffee, and make people order it as a tall cup of coffee, maybe they will actually think it’s larger than it really is. QED. Quod erat demonstrandum. That’s Latin for cut the crap.”

The nurse knew she was jousting in soliloquies with an idiot. Nonplussed, Twenty-Something merely rolled his eyes and asked her what she wanted.

The nurse was usually not a half-caff, double mocha, skimmed latte kind of person. In fact, it troubled her that some people were—troubled her a lot. The person she had hogtied and left in the trunk of her car was one of them; he hadn’t known when to shut up, so she had done it for him. By the time she had checked on him during her break, he’d frozen solid.

“Any ideas?” The Twenty-Something foolishly pressed the nurse.

“What do you recommend for somebody who just wants a cup of coffee?”

“Do you want regular or decaf?”

“What’s the strongest you have?”

“Ethiopian.”

“Give me your largest.”

“Shall I leave room for cream?” asked Twenty-Something.

She looked at the prices. Two dollars for a cup of coffee. Why would anyone pay that much and then hide the taste of the coffee with cream, she wondered? “No cream. Instead, give me a latte grande with skim milk.”

“One grande latte,” Twenty-Something replied, correcting her syntax. “Is that all?”

“Better give me a large orange juice. That’s what’s it’s called, isn’t it, or is that also a grande?”

Her wit was lost on Twenty-Something. “Large,” she murmured through her teeth. “And a bagel, plain.”

“Toasted? Cream cheese?” She knew he was toying with her.

She’s had enough, grabbed the coffee, and headed for the door.

He hollered for her to pay, but the look she gave him told him to let it go.

Too bad the trunk couldn’t hold two. She’d come back tomorrow to visit the boy.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The EHR Certification Myth

Posted by Paul Roemer

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

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

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.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Ramblings of an itinerant mind

Posted by Paul Roemer

This post has nothing to do with anything heady, nothing to do with healthcare. I’ll pause for a minute while those of you who have better things to do with your time click the ‘X’ in the upper right corner.

Is there a time when regressing in your private life seems awfully attractive? Play along with me for a minute. My wife and children are headed to Miami for a month; thirty days, 720 hours—I’ll defer to you to figure out the minutes.

While I am not looking forward to having them gone, I am looking forward to my Ponce de León hours of rebirth; finding my archived inner-self. I may start by watching every Clint Eastwood movie—in order—smoking the Parodi beef-jerky cigars Clint favored in his B-movie westerns. Lots of ill-advised scratching. Socks skewed asunder in a forensic CSI Hansel and Gretel manner from one room to the next—follow the yellow brick road. An ADHD month where I am able to accomplish everything that never made it to my to-do list.

What if via a time machine you were metaphorically single for a month? I watch the Science Channel enough to know that a time machine requires one to travel faster than the speed of light which according to the laws of physics is mathematically impossible. But suppose.

My first initiative—the Celine Dion CDs will be placed on the coffee table as coasters or tossed off the deck as though they were ninja shurikens (stars). I then block “Dancing with the Stars” from the cable box. People Magazine is used as fireplace tinder even though the temperature outside exceeds 90. I get a thirty-day reprieve from the ‘just shoot me now’ question, “Should I do this or that,” knowing if I select column A she will select column B.

Pulse and BP both drop. The lawn begins to grow. Prior to the return of my family, I will be able to hide a giraffe in the grasses of my suburban savanna. The anticipation of next thirty days reminds me of the book, The Cat in the hat Comes Back, knowing full well I will have to dedicate a few days removing all of the pink spots which have accumulated. Paraphrasing…

“Then their mother came in and asked what did you do,

Did you have any fun; tell me what did you do?

Should I tell her about it?
Now, what SHOULD I do?
Well…
What would YOU do
If their mother asked YOU?”

That is how it appears to my inner Braveheart character. The real me cowers knowing I do not have what Madeline Albright so inappropriately referred to as the cajones to pull this off—I am pretty certain she was also two spheres short of having the cajones of acting with the dignity required of her position—forgive me for being impolitic.

I am well trained. The lawn will be mowed, the cover will be placed on the grill when it is not in use, the hose will be coiled neatly, the dishes will be aligned anally in the dishwasher, utensils upright and not spooning with one another. The dust balls will surrender to the vacuum, and the plants will be watered.

Life goes on and so shall I. The dream was good while it lasted. I do not know if it is fear or cowardice which takes precedence.

If you call me during July, and I do not answer the phone, I may be vacuuming or dusting. Please leave a message and I will get back to you after I run out of Pledge.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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EHR: What bugs you about it?

Posted by Paul Roemer

This is the time of year in the east when cinerescent caterpillar nests hang thickly from the trees, peppered tufts of cotton candy. During these long, flavorless August days, the sky is a similar achromatic color. My nine-year-old is concerned because I told her we are having caterpillar soup for dinner tonight—watch out for the crunchy bits. Once again, it seems I’ve gotten off message.

I wonder how much of the difficulty surrounding EHR has to do with getting off message, much like we seem to have done with the reform discussion. What difficulties? Got time? You can name more of them than can I.

What is off message? It’s that the day-to-day tactics of implementing EHR office by office, and hospital by hospital have overshadowed the strategy, have displaced the business driver behind the mandate. The focus became internal, not national. Bits and bytes have overshadowed charts.

I doubt few, if any, can articulate a believable explanation of how a few years from now your medical records will accurately and expeditiously be delivered from where you live to the lone clinic on Main Street, Small Town, USA, to the nurse practitioner who at midnight is giving you an EKG.

It’s that fact, that we are not able to define how we get from A to B, let alone do so with multitudes of A’s and B’s, that to me suggests we are building something of which we have little comfort will do what we set out for it do.

Clearly, there are hundreds if not thousands of very talented and dedicated professionals focused on finding a solution. However, it seems their efforts remain handcuffed by hundreds of competing products, no well-defined overriding set of requirements that would enable anyone to say with certainty, “Yes, that is it. That captures what we need to do. When we have done that, we are done.”

Until that time, I think we all need to be concerned about the crunchy bits.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

July is “take your EHR strategy to lunch month”

Posted by Paul Roemer

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.

Please take a look at this for a moment. Don’t try to understand it–it will only make your teeth hurt.

2011 requirements

For hospitals, 10% of all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) directly entered by an authorizing physician must be made through a computerized physician order entry process. Individual physicians still must use CPOE for all orders, even if electronic interfaces with receiving entities are not available. The initial draft did not specify the required percentage for hospitals and did not address the electronic interface issue.
Physicians must be able to check insurance eligibility electronically from public and private payers, when possible, and submit claims electronically. This was not in the initial draft.
Patients must receive timely electronic access to their health information, including lab results, medication and problem lists, and allergies. The initial draft did not include the word “timely.”
Physicians must implement one clinical decision rule relevant to specialty or high clinical priority. This was not in the initial draft.
Physicians must record patient smoking status and advance directives. This was not in the initial draft.
Physicians must report ambulatory quality measures to CMS. This was not in the initial draft.
Physicians must maintain an up-to-date list of current and active diagnoses based on ICD-9 or SNOMED. The initial draft did not specify use of the two classification sets.

2013 requirements

Specialists must report to relevant external disease or device registries that are approved by CMS. This was not in the initial draft.
Hospitals must conduct closed-loop medication management, including computer-assisted administration. This was not in the initial draft.
All patients must have access to a personal health record populated in real time with health data. This was moved up from 2015 in the initial draft.

Additional provisions

Patients’ access to EHRs may be provided via a number of secure electronic methods, such as personal health records, patient portals, CDs or USB drives.
CMS will determine how submitting electronic data to immunization registries applies to Medicare and Medicaid meaningful-use requirements.
CMS may withhold federal stimulus payments from any entity that has a confirmed privacy or security violation of the Health Insurance Portability and Accountability Act, but it may reinstate payments once the breach has been resolved.

Source: Health IT Policy Committee

See? Take a few minutes and work this 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 chnace of surviving the next committee meeting

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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What did you budget for EHR?

Posted by Paul Roemer

Okay, so today was going to be one of those days when I wasn’t going to allow myself to be stupified–at least no more than was really required.

Then it sneaks up smack dab in the middle of a call, and from what I’ve been able to determine, people find it annoying if you burst out laughing on the call. (They are not annoyed at all if you simply write about them provided they don’t read it.)

What got me going is this statement, “We’ve budgeted $X for EHR.”

Really? You did this all by yourself?

The facts as I understood them are as follows:

Never bought an EHR
Don’t know how big they are, if they are blue or green, come gift-wrapped, or if you need two people to carry it
No input from vendors about EHR
no discussions with others abot what an EHR system costs

So, with absolutely no information how does one determine how much they need to spend? This is not like going to the supermarket for a gallon of Soy Milk–not that anyone would want to do that.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The Joy of Sox–deliver a great presentation

Posted by Paul Roemer

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—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 is 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.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Is the C-suite fiddling while EHR burns?

Posted by Paul Roemer

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 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?

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Pale Rhino Consulting

Thought Leadership With A side Order Of Wit: Disrupting Healthcare Consumerism

Rants & Musings

EHR, where’s my hammer?

What if GM were involved in EHR?

When nurses end their shift

The EHR Certification Myth

Ramblings of an itinerant mind

EHR: What bugs you about it?