Rants & Musings

How many Sigmas does it take to change a hospital?

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I wrote this in response to some comments I received on my piece in HospitalImpact.org.

I do not advocate assembly line medicine, especially at a hospital. I go out of my way to stay out of the healthcare business, the clinical side of healthcare, an area in which I have no background other than having been a patient.

If the hip replacement analogy was a poor choice–my bad. The point of the piece was not the hip replacement, rather the seemingly inability to answer basic business questions relating to how the business of healthcare is run.

I think there is a need for the independence and the je ne sais quoi nature of care. I just happen to think that the business of healthcare and the healthcare business can coexist in a more business-like manner. There are hospitals which get it right, and those which get it much less right.

Some of it has to do with costs, some with waste–wasted time, wasted opportunity, some with ineffectiveness, and some with planning. If one hospital can do X for thirty percent less than another, I think it is worth exploring what accounts for the delta. If another hospital can perform twenty percent more procedures with the same level of resources, that is worth investigating. There is no point keeping metrics unless one is willing to improve them.

I am not big on efficiency. In many cases, efficiency implies speed. It is possible to perform poor processes at a speed which will make your head spin. Lots of hospitals are toying with Lean. Lean works best with a valid set of processes. Without a valid set of processes–best processes–there are not enough Sigmas to justify the expense.

Then there are the cost cutting advocates. Cost cutting is a dead end strategy.  Every manager worth their salt can cut costs–less than one in a hundred can increase revenues. What do you do when there are no more costs to cut? Are you more effective, or net-net did you simply replace the brewed coffee with Folgers? Want to cut costs? Lock the doors. But that does not solve anything.

If none of these questions can be answered today, what happens in five years? New entrants will have gobbled up many profitable services and will be able to do so because they do not have “Big Box” overhead. Reform will have forced another business model on large providers. Payors and pharma will continue to battle for their share of each healthcare dollar.

I think hospitals can grab an even larger portion of that dollar, but I do not think they can do it without changing how they approach the business of 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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Who should be able to answer these business questions?

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I wrote this piece for Hospital Impact, published April 22, 2010.  (Not the title I would have chosen.)

http://www.hospitalimpact.org/index.php/2010/04/22/planting_the_seed_why_assembly_line_medi?blog=1&c=1&page=1&more=1&title=planting_the_seed_why_assembly_line_medi&tb=1&pb=1&disp=posts

Now that spring is in full bloom, I’ve been doing a little gardening. My dogs are the anti-gardeners. No sooner do I turn my back after planting something, there they are, happily digging away and ceremoniously digging it up. I don’t know if that’s because they don’t like the particular plant, or just happen to disagree with where I planted it.

Today I discovered the youngest dog uprooted a plant and replaced it with a Reece’s Peanut Butter Cup. Perhaps she wanted to grow a candy tree.

One thing that always confuses me about gardening is this: When I plant a one-gallon shrub, I dig a two-gallon hole. I place the gallon shrub in the two-gallon hole and proceed to fill the remaining one gallon hole with the two gallons of dirt lying next to it. Without fail, there is never enough dirt to fill the hole. Perhaps you can tell me what I am doing wrong.

Here is another area of confusion for me: When you walk or are wheeled into a hospital, neither you nor anyone else knows the answer to anything.

That is astonishing. Nobody can tell you:

* With whom you will interact.
* How long you will stay.
* What will happen to you.
* How it will happen to you.
* When it will happen to you.
* Who will be doing the happening.
* Exactly when it will happen.
* Whether it will need to happen again.
* What it will cost.
* What you will be charged.
* What will be covered.
* How much you will owe.

I am stupefied. How can anyone run a business like this? My daughter knows what her lemonade stand costs per cup. Wendy’s knows the cost of a bag of fries and a large Frosty. Porsche knows the cost of a Cabriolet, the cost of the shift knob, when the wheels will arrive at the factory, when they will be placed on the car, who will build it, who will inspect it, and who will sell it. They can tell you exactly who will touch the car, when they will touch it, and what those people will do to it.

The only thing anyone at a hospital may be able to tell you is whether HBO is billed separately. If I wanted to fly into space with the Russians, I would know the answer to each of those questions. The cost, for example: $50 million.

Why can’t a hospital do this? Because it doesn’t know the answers. It is not because anyone is keeping this information a secret–it’s because they really don’t know. The truly strange thing is that they seem to be okay with not knowing.

Recently, I reconnected with a good friend whom I haven’t seen in years. He is the vice president of finance for a large hospital. He used to be an accountant–a very detailed and precise profession, unless you’re one of the guys who used to do Enron’s books. (The only thing I remember about accounting is that debits are by the window and credits are by the door–if I’m in the wrong room, I’m at a total loss.) This business must drive him nuts!

And so I’ve been wondering; would hospitals be more profitable if:

* They had a P&L by patient?
* They had a P&L per procedure?
* The steps for the same procedure, say a hip replacement, were identical each time?
* They had answers to any of the questions you read above?

Of course they would!

Some areas of healthcare already discovered this tautology–Lasik, endoscopy, the Minute Clinic. Assembly-line medicine. Some people say those words with an expression on their face as though they’d just found a hair in their pasta. The office of my Lasik surgeon looked more impressive than the lobby of my Hyde Park hotel. It may leave a bad taste in the mouth of some, but for others, they are laughing all the way to the bank.

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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Healthcare 2.0, Web 2.0, etc

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I am a huge fan of the phrase, “What if?”  Thinking is vastly underrated, especially by those who don’t—think, that is.  Where are all the what-iffers?

On the overrated side are the 2.0’s and 3.0’s.  Those terms connote a handful of things, none of which are particularly helpful.  It is as though those in the web 2.0 club see themselves as having arrived; as being somewhere better than those still mired in the one-dot-oh’s that comprise their cloistered universe.  Maybe it is just a level of enlightenment or attainment which comes from having been to the mountain top.  They Tweet with their David Attenboroughish British accents, revealing tidbits information heretofore unknown to the 1.0 crowd.

May I suggest the problem with the dot-ohs is the notion that there is some sort of deliverable, some point at which one is no longer striving to get to the oh-ness because one has arrived.  Then what?  I think that is why the uptake of the dot-oh concepts by the C-suiters is so low.  Web 2.0.  Health 2.0.  Social Media 2.0.  They are still paying for all the one-dot-oh initiatives, initiatives which for the most part failed to deliver.

There is no end point, no date in late October where anyone can say with any credibility, “We’ve arrived at the dot-oh end point.  It is a silly notion to believe that any of these initiatives are ever complete or exist in isolation.  I propose we use new nomenclature, something which suggest does not have an endpoint.  A transcendental number, a number with no end.  Irrational—like me.  Pi—π.  Health π.  Web π.  Social media π.

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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New Patient-friendly CRM–Smidge.com

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For those who don’t have time for 140 characters, or who don’t have much to say, I’ve created an alternative, smidge.com. The Urban Dictionary defines a smidge as a small amount of something, short for smidegeon.

This will revolutionize the interaction between patients and physicians. We all know how patients can be. Why should hospitals continue to enable them? We let them call us, fax us, email us, and tweet us. Enough already.

It’s time hospitals show a little backbone, show the patients who’s in charge. Let them know, “We’re mad as hell and we’re not going to take it anymore.”

Here’s how smidge.com works. Each time a patient interacts with your hospital, give the patient their smidegeon account. Explain to them that this is their private way to communicate with you. It’s instantaneous, totally secure, and it operates 7 x 24 x 365. No more navigating IVRs, no more being placed on hold, no longer will they be transferred to another agent, never again will they be monitored for quality control purposes. Let the customers know that anytime they want to smidge, the world is theirs.

Explain to them that your hospital is doing away with archaic forms of interacting; closing its call centers, throwing away is fax machines, and deleting is presence on the web. What are the advantages to your hospital? They’re almost too many to document. Think of the capital savings. No more IT expenditures to support those millions of whining patients. No more CSRs complaining about not being allowed to browse the web, or about not getting their mid-morning break.

And now for the best part. In order to minimize bandwidth and storage costs, each smidegeon only allows the user to use each letter of the alphabet one time, meaning the largest smidge can’t exceed 26 characters. That being the case, there will no longer be any justification for the patient complaining that your hospital did not resolve their problem. The roles will be reversed. The upper hand will now go to the hospital.

How? Let’s look at an example. The patient wants to smidge the following change of address information, “We are moving on October 13 to 1175 Harmony Hill Road, Spokane, Washington.” Since smidges don’t allow numbers, we’ve already simplified the message, and the ease of entry. Now, if we translate the message into a correctly formatted smidegeon, we get the following message, “We ar moving ctb Hny l d Spk f u b d.” Now, how can you be expected to understand that kind of nonsense? If you can’t understand it, how can patients possibly blame you?

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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I’d hate to be thought of as superfluous

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If you and I agreed on everything, one of us wouldn’t be needed.

Of the many special things associated with growing up in this country, one is held dearly by every American eight-year old male who owned a flashlight and an AM transistor radio with an earplug. During those long hot summer nights when the adults sat on the back stoop nursing a bottle of Carling and waiting for their window air conditioners to suck out enough of the heat to make the inside of the house bearable, thousands of boys across the country lay under their bed covers, with a flimsy plastic earplug dangling from their ear as they continued to turn the dial to tune in the lone radio station covering the home team. In spite of the static, they faithfully kept score for their favorite baseball team in the back of their black and white Composition notebook.

The scorecard was homemade, carefully drafted using a pencil and something relatively straight to draw the lines that separated each of the nine innings. Unlike today, when the concept of team has given way to the concept of personnel whose loyalty lies with the highest bidder—free agents, the lineup for the home team rarely changed by more than a player, the pitcher, and had been mostly the same for years.

My team was the Baltimore Orioles. Their team pennant hung on my wall, a team photo was on my dresser along with my membership card to the Junior Orioles. Under the blanket with me was my taped-up shoe box containing my collection of baseball trading cards, sorted by team and held together by rubber bands I had removed from the Baltimore Sun. A few hundred stale sticks of the pink powdered bubble gum that came with each five-pack of cards was stacked neatly in one end of the box. The cards for the opposing team were spread before me so I could get the lineup and study their batting statistics.

What made me think of this was that yesterday my son and I went to see a minor league game. Although the grass was just as green, and the hot dogs smelled the same, nothing was the same. Still, it beat a stick in the eye. Things change. Baseball changed, and nobody conferred with me before changing it. I didn’t see a single person keeping a scorecard, let alone a dad teaching his son or daughter how to keep it. The only constant throughout the game was the commercialization, to the point where it made it difficult to simply follow the game.

That’s progress. Or maybe not. Some progress is good. Some progress doesn’t exist even though everybody around it believes that it does. Buying technology doesn’t in and of itself confer progress, it simply means you bought more technology. For those who are so fond of metrics, look up some ten-year old figures and see. See if patient satisfaction has increased. Still not convinced? Add up all the money you’ve spent on improvements and technology during those ten years and divide it by the percentage of decrease or increase of any decent metric. Was it worth it? I bet not.

Ray, people will come Ray. They’ll come to Iowa for reasons they can’t even fathom. They’ll turn up your driveway not knowing for sure why they’re doing it. They’ll arrive at your door as innocent as children, longing for the past. Of course, we won’t mind if you look around, you’ll say. It’s only $20 per person. They’ll pass over the money without even thinking about it: for it is money they have and peace they lack. And they’ll walk out to the bleachers; sit in shirtsleeves on a perfect afternoon. They’ll find they have reserved seats somewhere along one of the baselines, where they sat when they were children and cheered their heroes. And they’ll watch the game and it’ll be as if they dipped themselves in magic waters. The memories will be so thick they’ll have to brush them away from their faces. People will come Ray. The one constant through all the years, Ray, has been baseball. America has rolled by like an army of steamrollers. It has been erased like a blackboard, rebuilt and erased again. But baseball has marked the time. This field, this game: it’s a part of our past, Ray. It reminds of us of all that once was good and it could be again. Oh… people will come Ray. People will most definitely come.
-Terrance Mann in the movie, “Field of Dreams”

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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How daughters relate to EHR

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The other night as I’m sitting on a hard bleacher watching my seven-year-olds baseball practice I noticed the mom sitting next to me looking a little forlorn. Being naturally inquisitive, I asked if everything was okay.

“I lost his glove,” she replied.

Noticing a glove on her son’s hand, she saw my look of confusion. “Not his. My husband’s. I had it with me last Thursday, and I left it here.”

“I don’t suppose this was a new glove. Judging by the look on your face I’d say this was his favorite glove; thirty years old, supple, broken in, fold flat as a sheet of paper.”

“Twenty-five years,” she corrected as she lowered her eyes.

“It’s rained the last three days,” I told her, which caused her to grimace even more. Having nothing better to do, I flayed her emotions. “I bet that glove meant the world to him. He probably planned on giving it to your son in a few years. The glove probably reminds him of some of the big events in his life, every scar, each stain on the leather, points to something important. You know, if it was outside for a few days, the field mice will have chewed on the leather.”

She brushed away a tear, and headed to the lost and found.

“Any luck?” She shook her head in despair. “In some countries, if a wife does something life that, the husband can sever the relationship, literally,” I said as I made a slashing motion with my hand. She made the briefest of smiles. At least she knew I was pulling her lariat. Reeling her in, I continued.

“You’re not thinking of spending the night at home, are you? If you are, you should at least call someone and let them know of your plans. He’ll heal over time,” I told her. “But he won’t forget it. Twenty years from now the two of you will be watching something on TV, and something will remind him of the glove YOU lost.”

Fast forward to last night. My daughter and I are getting out of the car so I can coach her and her softball team in the playoff game.

“Is your glove in the trunk?” I asked. This is after I spent several minutes grilling her at home about whether she had everything she needed for her game.

“I hope so,” she said shamelessly as I popped the trunk for her. “You hope so?” I repeated with an edge in my voice.

“It’s not here Daddy.”

I left her with her friends and drove home to look for it. Ten minutes. Nothing. For some reason, I looked in the trunk. There it was. Death by 1,000 cuts.

Does it all come down to baseball gloves?  “I hope so.”  What kind of a response is that?

Will these EHR expenditures help? I hope so.

Can you confirm for me that user satisfaction won’t fall any further? I hope so.

Are we ready for the changes coming to the business model?  I hope so.

Do you think we should continue to employ you? I hope so.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

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I got a little sidetracked today…

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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 barrista behind the counter ignored her, not a bright move.  His hair looked like it was cut with a mower; 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 Starbucks has 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.

The RHIO Answer

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It may be helpful as you read this to use your highlighter on the screen to accentuate the important parts or some white-out for the parts you don’t favor.

Do you ever kick an idea around, speaking about it, writing about it, until at some point you finally capture it in a way that makes sense to you?  That’s how I reason things through.  I write like I’m talking aloud and sometimes it lands in my lap.

That just happened to me as I was trying to get my arms around what it is about the concept of the RHIOs that has been bothering me.  Bear with me.  I was on LinkedIn emailing someone using the ‘send a message’ feature.  I was returning an email which she was returning which I had initiated.  The process works like this.  I get an email from LinkedIn telling me I have a message.  I go to LinkedInm read the message and send a reply via LinkedIn.  She receives an email indicating she has a message, goes to LinkedIn, and so forth and so on.

Do you see it?  In this scenario, what is the added value provided by LinkedIn?  Nothing.  It’s all hat and no cowboy.  LinkedIn serves simply as a pass through, contributing nothing.  I wrote in my message to her, “Send me your email address, I feel like I’m in my own RHIO.”

When is a RHIO not aRHIO?  When there’s no need for it.  Is there any functionality intended for the hundreds of RHIOs which couldn’t be dealt with at the N-HIN?  What do you think?

Which EHR mistake would you rather make?

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Which EHR mistake would you rather make?–My first post as a contributor to @healthsystemCIO http://ow.ly/1xDx5

When Children Parent

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It’s not easy being green—I think that is how the Grinch mat have felt when little Cindy-Lou-Who saw him stealing her Christmas tree.

Cindy Lou Who: “Santie Claus, why? Why are you taking our Christmas tree? Why?”
Narrator: But do you know, that old Grinch was so smart and so slick, that he thought up a lie and he thought it up quick.
Grinch: “Why my sweet little tot…”
Narrator: The fake Santie Claus lied…
Grinch: “…there’s a light on this tree that won’t light on one side. So I’m taking it home to my workshop, my dear. I’ll fix it up there, then I’ll bring it back here.”
Narrator: And his fib fooled the child. Then he patted her head, he got her a drink and he sent her to bed.

I’ve been a father for eleven years.  I have had heart disease for the last seven.  I was a smoker and stopped three and a half years ago.  My children knew the heart attack was a result of my smoking.  Those who have smoked know have difficult it is to stop.  I started again two months ago—sneaking around, burying the butts, washing clothes, gargling—doing whatever it took not to get caught.

My children had never seen me smoke—never until last night.  I snuck out on one of our decks to have a smoke.  One puff later, out pops my Cindy-Lou-Who.  She’s ten.

“Are you smoking Dad?  Why?”

I am not sure which one of us was more upset.  I stood there for a second wondering what to say, wondering if I had the where-with-all to create a Grinch-like fib—a lie.

A good lie may have made the situation disappear, at least temporarily.

One of our family rules is no lying.  I’ve told the children I will never lie to them, and they should never lie to me.  I had to decide which the greater wrong was, telling her a lie, or telling her that I was doing something she knew could kill me—something which would crush her.

I told her the truth.  Her face was expressionless.  She turned and walked away.

We talked.  It takes more than talking.  My wife told me my daughter told her she was upset and what upset her.

I previously tried hypnosis and acupuncture—both worked right up to the point when I got back in my car.  If anyone has any good ideas about how to attack this, please let me know.

My daughter is very smart, and pretty brave.  Now it is my turn.

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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