Rants & Musings

Patient Relationship Management (PRM)-why men can’t boil water

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There was a meeting last week of the scions of the Philadelphia business community. The business leaders began to arrive at the suburban enclave at the appointed hour. The industries they represented included medical devices, automotive, retail, pharmaceutical, chemicals, and management consulting. No one at their respective organizations was aware of the clandestine meeting. These men were responsible for managing millions of dollars of assets, overseeing thousands of employees, and the fiduciary responsibility of international conglomerates. Within their ranks they had managed mergers and acquisitions and divestitures. They were group with which to be reckoned and their skills were the envy of many.

They arrived singularly, each bearing gifts. Keenly aware of the etiquette, they removed their shoes and placed them neatly by the door.

The pharmaceutical executive was escorted to the kitchen.

“Did your wife make you bring that?” I asked.

He glanced quickly at the cellophane wrapped cheese ball, and sheepishly nodded. “What are we supposed to do with those?” He asked as he eyeballed the brightly wrapped toothpicks that looked banderillas, the short barbed sticks a matador would use.

“My wife made me put them out,” I replied. “She said we should use these with the hors d’oeuvres.”

He nodded sympathetically; he too had seen it too many times. I went to the front door to admit the next guest. He stood there holding two boxes of wafer thin, whole wheat crackers. Our eyes met, knowingly, as if to say, “Et Tu Brutus”. The gentleman following him was a senior executive in the automotive industry. He carried a plate of freshly baked chocolate chip cookies. And so it went for the next 15 to 20 minutes, industry giants made to look small by the gifts they were forced to carry.

The granite countertop was lined with the accoutrements for the party. “It’s just poker,” I had tried to explain. My explanation had fallen on deaf ears. There is a right way and a wrong way to entertain, I had been informed. Plates, utensils, and napkins were lined up at one end of the counter, followed in quick succession by the crock pot of chili that had been brewing for some eight hours, the cheese tray, a nicely arrayed platter of crackers, assorted fruits, a selection of anti-pastas, cups, ice, and a selection of beverages. In the mind of our wives, independent of what we did for a living and the amount of power and responsibility we each wielded, we were incapable of making it through a four hour card game without their intervention.

I deftly stabbed a gherkin with my tooth pick. “Hey,” I hollered “put a coaster under that glass. Are you trying to get us all in trouble? And you,” I said to Pharmacy Boy, “Get a napkin and wipe up the chili you spilled. She’ll be back here in four hours, and we have to have this place looking just as good as when she left.”  I thought I was having the neighborhood guys over for poker; I was wrong. So were each of the other guys. We had been outwitted by our controllers, our spouses. Nothing is ever as simple as it first appears. We didn’t even recognize we were being managed until they made themselves known.

Who’s managing the show at your hospital, you or the patients?  The answer to that question depends on who owns the relationship, who controls the dialog.  If most of the conversation about your organization originates with them, the best you are doing is reacting to them as they initiate the social media spin, or try to respond once the phone started ringing.  It’s a pretty ineffective way of managing.  It’s as though they dealt the cards, and they know ahead of time that you are holding nothing.

There are times when my manager isn’t home, times when I wear my shoes inside the house—however, I wear little cloth booties over them to make certain I don’t mar the floor.  One time when I decided to push the envelope, I didn’t even separate the darks from the whites when I did the laundry.  We got in an hour of poker before I broke out the mop and vacuum.  One friend tried to light a cigar—he will be out of the cast in a few weeks.

Be afraid. Be very, very afraid.

saint 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 this a fair representation of the hospital business model?

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I have been looking for a way to represent pictorially the hospital business model and the forces which act upon it.  The picture below came to me last night while playing this board game with my daughter.  It is from the children’s game, Boobytrap.  The way the game is played is that the players try to remove the red, blue, and green pieces without causing the trap to spring and displace all of the pieces.

If we represent patients as the individual playing pieces and make the assumption that each side of the game exerts pressure on the model, I think it represents fairly the external forces with which the large provider model has to battle.  As the forces increase from some combination of costs, regulation, procedure price ceilings, and payor reimbursements, the number of patients in the model will decrease and may do so in a catastrophic manner.  Without a concurrent decrease in those four forces it is unlikely that the model will support additional patients.  Clearly, without changing the size of the board it is impossible to grow the number of patients beyond the board’s capacity.

A couple rules come into play.

  • The forces are all external.  They cannot be controlled or abated by the hospital.
  • The strengths of the various forces change over time
  • The forces result in some maximum number of patients which can be serviced under the hospital’s existing business model.
  • As each patient is lost, the stability of the model weakens.

Does this way of depicting the large provider business model ring true?  Does this help illustrate why the model must change?

saint 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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Something to consider…

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I found this on the web and thought I’d share it with you.

Chemistry in Hell
The following is an actual question given on a University of Washington chemistry midterm. The answer was so “profound” that the professor shared it with colleagues, which is why we now have the pleasure of enjoying it as well.

Bonus Question: Is Hell exothermic (gives off heat) or endothermic (absorbs heat)?
Most of the students wrote proofs of their beliefs using Boyle’s Law, (gas cools off when it expands and heats up when it is compressed) or some variant. One student, however, wrote the following:
First, we need to know how the mass of Hell is changing in time. So we need to know the rate that souls are moving into Hell and the rate they are leaving. I think that we can safely assume that once a soul gets to Hell, it will not leave. Therefore, no souls are leaving. As for how many souls are entering Hell, lets look at the different religions that exist in the world today. Some of these religions state that if you are not a member of their religion, you will go to Hell. Since there are more than one of these religions and since people do not belong to more than one religion, we can project that all souls go to Hell. With birth and death rates as they are, we can expect the number of souls in Hell to increase exponentially.

Now, we look at the rate of change of the volume in Hell because Boyle’s Law states that in order for the temperature and pressure in Hell to stay the same, the volume of Hell has to expand as souls are added. This gives two possibilities:

1. If Hell is expanding at a slower rate than the rate at which souls enter Hell, then the temperature and pressure in Hell will increase until all Hell breaks loose.

2. Of course, if Hell is expanding at a rate faster than the increase of souls in Hell, then the temperature and pressure will drop until Hell freezes over.

So which is it? If we accept the postulate given to me by Ms. Teresa Banyan during my Freshman year, “…that it will be a cold day in Hell before I sleep with you.”, and take into account the fact that I still have not succeeded in having sexual relations with her, then, #2 cannot be true, and thus I am sure that Hell is exothermic and will not freeze.

The student received the only “A” given.

saint 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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Wayne Newton’s 4th law of relative immobility

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Last night I was speaking with a woman at a gathering of graduates from my high school.  She got into the subject of reading glasses and then commented that she first learned she needed regular glasses since the age of four.

As she was not wearing glasses, I asked her if she’d had Lasik.  No, she said, “I always hated how I looked in them, so I quit wearing them in high school.”

“Don’t you miss being able to see things?” I asked.

“Not really.  This is how I’ve seen the world for the past thirty years.  I’ve grown comfortable with how I see the world.”

I think a lot of business leaders have the same perspective—sorry for the pun.  They get comfortable with how they see their world—comfortable with the issues and how to address them.  Given the choice, people will stay in their comfort zone.

Do you remember your physics?  Relative motion is the branch of physics that studies the motion of the body relative to the motion of another moving body (Newton).  For example, if you are in a train and another traveling at the same speed pulls alongside you, it appears to both set of passengers that neither train is moving.  If your train decelerates it will appear to you the other train has accelerated.

Now, take the perspective of someone standing on the platform viewing the two trains.  To that person, there is no illusion.  The bystander can see exactly what is happening; who is moving forward and who isn’t.

Business leaders get caught up in what I call Wayne Newton’s 4th law of relative immobility.  When they look out their windows at the executive in the hospital across the street, it appears they are both moving at the same speed and at the same direction.  That is how they have seen the world each day for the last several years.  They look at each other, wave, and then go about their business, knowing their competitor hasn’t passed them or changed course.

But you and I know why it looks that way to them.  The reason they have not been passed is because neither hospital is moving forward.  The reason they do not perceive a change of direction is that they are both moving in the same direction.  In actuality, there is no motion.  Only an outsider can see neither hospital is moving.

saint 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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Herman Melville’s take on healthcare’s business strategy

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Someone once summed up one of Fred Astaire’s screen tests with the following; “Can’t sing.  Can’t act.  Balding.  Can dance a little.”  Probably the same guy who evaluated my Mensa application.  I’ve been accused of having a similar outlook.  I once accosted a guy who was walking on water, accusing him of not being able to swim—but that was a looonnngggg time ago.

The internet is full of opinions, but hopefully not full enough. One of the reasons I chose math over English as my major was the affection I held for getting the right answer, or barring that being able to know precisely where my errant efforts led me away from the answer.

In my narrow-minded view of the universe the downside of English, literature—the soft studies—was the notion held by those who taught that there was more to be divined by the story than just the story.  Those who can do; those who can’t teach.  They displayed a Stepford mentality in their obdurate ability to outthink both the author and their students, to bring forth nascent ideas of the author’s hidden meaning.

Herman Melville wrote Moby Dick.  I am willing to bet he wrote it just the way he intended to.  Nobody has uncovered a frayed notebook of Melville having penned his thoughts about the real meaning of life from a cannibal’s perspective, or suggesting Queequeg was a misunderstood cross-dressing sycophant who was never close to his mother.  We don’t come away from our reading of Moby Dick  with a more in-depth ability to understand anything except for perhaps what it felt like to live aboard a whaling ship.

These interpretations are poppycock.  Art critics do the same thing as they bloviate about the hidden meaning behind what the artist really intended to convey, meaning only they can see.  Ever notice how none of these popinjays, these opiners present their opinions as fact?  Pretentious fops.

I write and paint.  Those who’ve read my missives know there is no buried meaning.  If I had wanted to convey something else I would have written something else.  If I use dark colors and bold brush strokes when I paint it is because I feel they add to what I want to show; it is not a reflection of having missed two days of Zoloft.

Nobody will ever know what Shakespeare intended to convey with his addition of the three witches in Macbeth, or whether Joyce Kilmer had ever seen a tree.  That said, I do have a few strong opinions about where this whole business model of healthcare is headed.  I think these types of opinions; along with the opposite opinions differ from the type offered up as truths in an English Lit class.  They differ in that at some point they will be proven right or wrong—time will tell.

As I have written, I think the large provider model—the business model—is seriously flawed.  Moreover, I think it may prove fatal.  Providers will run out of costs to cut, will run out of processes to re-engineer, and will have no more Italian marble with which to line the foyer.  The good news is that they will still have the machine that goes “Ping” just in case somebody needs it.

I do wonder how Melville would have expressed his ideas about healthcare.

saint 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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Hospital marketing strategies–my non sequiter

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I had piloted the Piper Cub for seven hours across endless miles of ocean.  The crash of my small plane left me alone on the uninhabited treeless atoll somewhere in the south Pacific.  I would have been sunburned badly if not for the shade cast by the thirty-foot tall New Jersey hospital’s billboard heralding its urology practice.  The billboard reminded me of the one I saw while solo kayaking the lower regions of Antarctica.  That billboard was from a hospital in Minot, North Dakota advertising its OB/GYN services.  Did you know there has never been a birth in Antarctica?

Hospital marketing has doubled in the last decade.  To whom are they marketing?  Appendectomies; twenty-percent off.  Maybe I’ll get two.  Perhaps I’ll buy some Plavix while I’m at it.

Ninety percent of hospital revenues result from a physician’s signature.  From where does the other ten percent originate, marketing?  Doubtful.  Do the billboards yield more physician signatures?

Hospital television advertising seems to focus its shotgun message in one of two areas; unsubstantiated claims of being the best or having the most, or having the latest and greatest machine that goes “Ping.”  You’ve seen the commercials broadcast to a television coverage area of a few million, advertising newly acquired technology for a non-elective procedure—that cost more than a few million—that less than a fraction of a single percentage of the population will need.  By the way, it is the same piece of technology that three other areas hospitals offer.

I am not sure I understand the logic behind hospital marketing.  Does it merely stem from the fact that other businesses do it?  I have personal knowledge of one hospital’s chief marketing officer whose annual salary exceeds more than four hundred thousand dollars.  She had no prior experience in healthcare.

Would revenues drop precipitously if hospitals did not market themselves?

saint 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 your hospital’s strategy like everybody’s?

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In high school when my mother thought I needed to come down a peg or two she would call me, “Never Wrong Roemer.”  Today I prefer to go by, “Dr. Knowledge” or “The Voice of Reason.”  You can just call me Paul.

During my senior year of track I competed in the pole vault and I anchored the mile relay.  In the interest of transparency, I think it more appropriate to say I ran the fourth leg of the mile relay—anchoring implies more speed than I actually possessed. On good days, we fielded a mediocre team.

I never enjoyed running the 440.  It is for sprinters, and I am a distance runner.  One day however I unwittingly became a sprinter.  We were in a dual meet against Wilde Lake High School.  As always, the mile relay is the last event.  If we won the relay we would win the meet.

The fourth runner from Wilde Lake received the baton several seconds before me and had me by twenty yards.  I made up the distance between us midway through the first turn.  One inconsequential factor I did not know at the time is that two years later he would be participating in the Olympic trials in the 440.

It turned out not to be so inconsequential.  What happened after I pulled alongside of him remains a bit of a blur; the same kind of blur the Wile E. Coyote saw each time he thought he had caught the Road Runner.  Turns out I had outsmarted myself.  I was caught up in the moment which is nothing like being caught up in the reality of the situation.  I was in a competition I couldn’t win and I did not know it until it was too late.

Business is a lot like that.  Leaders get caught up in the ferocity of what is going on around them.  You’ve seen them; you work with them.  These are the same people who don’t have an opening on their calendar for six weeks, the same people who are busy putting out last month’s fires, who are hurriedly building defenses for whatever may be around the next corner.

Some of those intelligent and well meaning leaders are so focused on catching the runner in front of them that they lose sight of the race, lose sight of their role as leaders.  Some leaders approach healthcare strategy as a series of directionless sprints while others view it as a marathon in a pack of lemmings.  If everyone is running in the same direction, how wrong can their strategy be if they stay with the pack?

I think we will discover in the next several years many of those marathoners will drop out or be disqualified.  They are approaching a poorly marked turn, and if they fail to take it they will be overcome by one or more of a multitude of factors that will eventually lead to their demise.

While it is impossible to disprove a negative, time will tell.  My advice—next time you see a fork in the road, take it.

Then there was the time I asked my mother to drop me off a half mile away from my girlfriend’s house so she would think I ran the full eight miles to come see her.  But, we will leave that story for another time.

saint 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 market share

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The link below takes you to a post written by Software Advice’s Chris Thorman regarding the market share for inpatient and outpatient EHRs.  It is designed to be a collaborative piece, and Chris is asking for feedback and correction.  I found it to be a well-written and helpful piece, perhaps you also will.

http://www.softwareadvice.com/articles/medical/ehr-software-market-share-analysis-1051410/

saint 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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If only doctors were meerly apathetic about EHR

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For those who remember the television show M.A.S.H., this brief bit of dialogue was from Henry Blake to Hawkeye after one of Hawkeye’s patients died.

“There’s two rules about war.  Rule 1–in war young men die.  Rule 2–doctors can’t change Rule 1.”

There’s a similar way to apply that logic when it comes to EHR, HIT, and new IT systems.

Rule 1.  If doctors don’t use them, the systems will die.

Rule 2. Simply having an EHR doesn’t change Rule 1.

A survey by Nuance Communications shows that 90% of doctors are concerned about the usability of EHR.  Those results underscore the importance of process and changemanagement and training.

As I wrote previously, it’s not about the EHR, it’s about what you can do with it.

My person struggle with usability–We have a piano in our home even though nobody plays it.  For some reason I’m not permitted to understand, we pay to have it tuned twice a year.

saint 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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Revising your work flows?

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revised work flowAs 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.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process 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 they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

saint 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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