Rants & Musings

Should you listen to the voices in your head?

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Well, for starters, if you don’t nobody else will.

Just because I’m paranoid, doesn’t mean the voices in my head aren’t real. What voices?  They don’t like it when I speak of them, so I am going to speak in parentheses so they do not hear me.)

Riding the in the car yesterday with my son, the radio was playing Barber’s adagio, a mournful and eerily melancholy piece. It has long been one of my favorites.  I tried to get my son to turn off his PSP long enough for him to try to develop an appreciation for it.

He asked me to tune the radio to what he calls ‘his’ station while I kept extolling the specific virtues of the adagio, of Barber, and of classical music in general. I intended to win him over to my way of thinking.

The phrases I used to bolster my opinion kept coming to me, although I knew not from where.  I soon reached the point where I knew that I was no longer speaking to him, but role playing the very same discussion I had had with my father when I was about the same age as my son. Déjà vu. I have become my father’s son. The voice in my head was my father’s and I was not even charging my father rent for the space.

Do you hear the voices? No, not those voices. The ones you hear at work when you realize that the person speaking to you is your other self. The same voice you hear when you go out after work with your friends and begin to talk shop. By the third glass of wine the conversation has shifted from swapping stories about the craziest patient to wondering aloud when the company is ever going to learn how to fix their business. By glass five, you’re fixing it for them, diagramming solutions on cocktail napkins.

A word of encouragement. Listen to the voices. I bet you’ve come up with some great ideas. They won’t do anyone any good locked up in your head. Let them out. Show someone who can do something about it what you wrote on the napkins.

Is wellness being overlooked?

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The following are my comments to Sue Schick’s blog, Are you ready to commit to a wellness program?

With all of the pronouncements coming from Washington about healthcare reform, it is easy to be waylaid by Gossamer eddies and side currents that pay little attention to one key area—health. There is plenty of discussion about insuring the uninsured, covering pre-existing conditions, and the rollout of a national healthcare model under the guise of healthcare information technology and facilitating the transport of electronic medical records.

I think Sue’s words are spot-on and timely. Even if nobody is going to pay for it, with so many Americans participating in the healthcare conversation, an entire industry being re-engineered, and a trillion dollars to fund the transformation, should not there be more attention paid to wellness, to proactively making one responsible for one’s own health?

Unfortunately, my perspective on this issue is shaped from having been there, done that, got the T-shirt—a heart attack at the age of forty-six. I’ve transformed myself from someone who took twenty-four years off between workouts to barely taking twenty-four hours off between workouts. I didn’t need an employer to sponsor a wellness program; all I needed was a ride in an ambulance.

There may be a lot of different ways to get someone’s attention around wellness, around being responsible. Those who want to be well will have to make that decision for themselves. No company can do it for you, but companies certainly can be supportive of your efforts to help yourself.

There has been a lot of conversation in the healthcare debate about what role the insurance companies have played in driving reform. Right or wrong, a number of stakeholders view payors as bad actors, as the raison d’être of reform.

Wellness seems to offer payors a way to put on the white hat, to be proactive. Patients understand that they do not pay their providers for their healthcare. In the event patients need a provider, patients pay the insurers, cross their fingers, and hope the insurers agree to cover the expense.

I am somewhat of a dilettante to the insurance side of the healthcare model, so I apologize in advance if I misspeak. Here’s my take as to the white hat opportunity, a way to take a leadership role in the matter of wellness. When you apply for insurance, you receive negative ratings for unhealthy and unsafe behaviors; smoking, health history, sky diving. However, if you run five days a week, maintain your weight, eat fish and refrain from drinking, you accrue no points for good behavior. In fact, you are rated as though you made no proactive attempts to manage your own health.

Auto insurance companies raise your rates for certain bad behaviors, and they lower them for certain good behaviors. No accidents for two years—the rate goes down. No traffic violations—the rate goes down. Behavior modification. I am aware of it and I manage my behavior to get lower rates.

Can a similar model work for health insurance? What would it take for payors to offer an incentive model for rewarding good behaviors?

EHR: Why the rush?

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The following is a comment I wrote to the healthcareitnews.com post, “BLUMENTHAL: EHRS WILL BECOME ‘AN ABSOLUTE REQUISITE’ FOR DOCS”.

“The time has come,” the Walrus said, “To talk of many things: Of shoes and ships and sealing-wax, of cabbages and kings– …

The time has also come to ask the question, “Why the rush?”  Is the pronouncement that within the next ten years we will see widespread adoption of EHR in conflict with the timing of the Meaningful Use incentives?  It seems that way to me.

Whereas we may see an “upward slope in the adoption curve” within the next year or two as hospitals begin the process of selecting and implementing an EHR, we will not see so much as a hiccup in the slope of the Meaningful Use curve.

Why?  I think there are several explanations.

  • Not enough providers are far enough along to even attempt to pass a Meaningful Use audit.
    • Will they complete the requirements
    • If yes, will they pass the audit
    • Of those who have attempted to do the heavy lifting of EHR and CPOE, they do not know the Stage 2 & 3 requirements.  Those requirements may be enough to ensure nobody passes the audit.
    • To those providers just underway, whose board insists that they complete the installation in time to qualify for the incentives—good luck.  Many will make poor selection decisions which they will support with even worse implementations.
    • To those who have yet to start, there is no chance they will meet the target dates.

So what’s next?  What would you do if you were having a party and learned nobody could come that night?  You’d change the date.  Washington will do the same.

What does that mean if you are a provider?  I think it means you have enough time to do it right, even when the conventional wisdom is pushing you to hurry.

6 Management Lessons I Learned by Watching Tabitha’s Salon Takeover « Candid CIO

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6 Management Lessons I Learned by Watching Tabitha’s Salon Takeover

February 4, 2010 hospitalcio–>

I am in the process of a significant IT Reorganization.  The goals of the reorganization are:

  1. make IT Operations more reliable and
  2. improve the overall efficiency of the IT team so we can complete more projects (the demand keeps increasing).

One of the new IT leadership positions is a supervisor to manage the work of support techs in each of our 5 IT regions. As you would expect, the candidates are primarily the existing support techs. I have had the greatest time talking to these men and women about their interest in the position and their ideas to provide end users with a better service. They are talented, bright, optimistic people.  It has been a real energy boost for me.

For all of their raw talent, most are new to management. Providing them good mentorship will be key to their success.

Now there are libraries filled with books on management philosophies. But, that would require me to travel to a library, or to read a book.  Instead, I chose to watch some reality TV on Bravo. Tabitha’s Salon Takeover follows “celebrity hair stylist”, Tabitha, as she travels across the country helping struggling salons. It is my guilty pleasure.

The owners of these salons are usually in deep debt and losing money. Much of what Tabitha does is address poor management, including bad employee supervision.  The salon employees always have the same concerns, and as such, these have become the basis for my primer for supervising people for first-time managers:

  1. Employees want their manager to be present. There are various approaches to being present, some more effective than others. As Studer disciples will attest, effective rounding is a great tool.
  2. Employees want regular staff meeting where managers can communicate the big picture and where things are going.
  3. Employees want clearly defined, preferably written and measurable, performance expectations.
  4. Employees want opportunities for growth, including a plan for their continued education.
  5. Employees want feedback regarding their performance. They want to know when they are not meeting expectations and they REALLY want recognition for good work. Sending employees hand-written thank you notes is a Studer “must-have”.
  6. Employees want to be treated fairly. While low performers are often the biggest complainers about fairness, it is the high performers that are demotivated when they are treated the same as low performers. The Studer Group has great strategies for determining High, Middle and Low Performers and how to manage each group.

Should I tell our new managers to watch Tabitha’s Salon Takeover? Maybe that is not the best conclusion.  I think the real lesson is that inspiration to be a better manager is everywhere. If you are passionate about being better at something, think about it throughout the course of your day and it will find you.

Entry Filed under: Management, Philosophy. .

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Work would be better if more managers and executives shared Will’s passion for members of their team.

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Jihad Joe EHR selection

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When competing hypotheses are equal in other respects, the principle recommends selection of the hypothesis that introduces the fewest assumptions and postulates the fewest entities while still sufficiently answering the question. It is in this sense that Occam’s razor is usually understood.  There is no corollary that works with EHR vendors.

What if we look at HIT vendor selection logically?  Have you ever noticed at the grocery store how often you find yourself in the longest checkout line, or when you’re on the highway how often you find yourself in the slowest lane?  Why is that?  Because those are the lines and lanes with the most people, which is why they move the slowest.

If you are asked in which line is Mr. Jones, you would not be able to know for certain, but you would know that the most probable option is the one with the most people in it.  You are not being delusional when you think you are in the slowest lane, you probably are, you and all the people in front of you.  The explanation uses simple logic.  It’s called the anthropic principle– observations of our physical universe must be compatible with the life observed in it.

It can be argued that the business driver which shapes the software selection process of some is the aesthetics of efficiency, a Jihad Joe approach to expediency.  Buy the same system the hospital down the street bought, the one recommended by your golfing buddy, or the one that had the largest booth at the convention.  Or, one can apply the anthropic principle, rely on the reliability of large numbers and simply follow the market leader.

Might work, might not.  My money is on might not.  There’s still plenty of time to do it right.  If that fails, there will always be time to do it wrong later.  Of course, you can always play vendor darts.  If you do, you should sharpen them so they’ll stick better.

What should you think about HIEs

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Part of the problem I have with HIEs is similar to the old Wendy’s commercial, “Where’s the beef.” Only in this case the question becomes, “Where’s the value add?”

There are hundreds of them, HIEs that is. Each one developed autonomously. Some are built within a hospital which has more than one EHR. Others are being built to serve among a hospital group, and others are geographical. Which of the HIEs is being built by a team of people who have ever built one? To my knowledge, none.

Hundreds of HIEs being built independently from one another by people who’ve never before built an HIE. Hundreds being built to transport the electronic medical records of providers using a few hundred different EHRs, each EHR operating with different standards, none of which benefits from interacting with another.

What is the purpose of the HIE? It reminds me of this children’s’ icebreaker game where the children sit in a circle. The first child starts by whispering a phrase into the ear of the person sitting next to her. She can only say the phrase once. The child she whispers it to must then whisper it to the child next to her. This continues until it goes all the way around the circle. Usually, by the time the phrase gets back around to the original person, it is completely different.

Like shuffling an EMR from one place to the next through a series of intermediaries. What does it look like when it comes out the back end?

After all, what is the purpose of the HIE? It should act like a handoff, like a mini N-HIN. It does not modify the data, at least not intentionally. If there is a more complex way to get a person’s health record from point A to point B, I have not seen it. HIEs are healthcare’s Rube Goldberg mechanism.

I think that when all is said and done, HIEs will have faded away. Until then providers should keep their focus on developing an EHR which actually serves their business model.

EHR: the uncertainty of certitude « Healthcare IT: How good is your strategy?

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EHR: the uncertainty of certitude

Posted by Paul Roemer on February 3, 2010

When I was living in Colorado and much younger my friend and I decided that instead of running during our lunch break we would sit in on an aerobics class. Our plan was to hide away in the back of the class, watch the ladies, and then head back to the office. No sweat—literally, that was also part of the plan. Our thought process was that if women and other lower life forms could do it, how difficult could it be? We were mainly manly men; excuse the use of alliteration.

Within ten minutes we were peeling ourselves from the floor, barely able to lift our arms and legs. What we’d viewed as an hour of simple stretching coupled with an hour of looking like mainly manly men had reduced us to a pair of whimpering sissy boys. We also learned that if you sit in the back of the class that in order to exit you had to make it past all of the ladies as you dragged your carcass from the room.

Fast forward a few decades. I went to an exercise class called spinning. Sounds a little like ballet. It’s a stationary bike. A large TV hangs on a wall. Once again the room is packed with non-males, including my wife. My take on it is that it’s a bike class for women who’d rather watch Regis and pretend to exercise instead of actually breaking a sweat. What the heck; I was already there, why not humor her. The instructor smirked at me when I asked her to tune the TV to ESPN. She inserted a CD of The Killers, cranked it all the way up, and we started pedaling. Pyramids, intervals, uphill, more uphills. Twenty minutes into it my water bottle was empty, my towel soaked. The ladies, including my wife, were chatting away as though they were walking the dog.

Not everything changes with time. Sometimes it better to participate than to watch. Sometimes it’s better to watch. Sometimes, no matter how certain one is, sometimes certainty is meant to be changed. Sometimes certainty is based on bad data. Like the certainty that comes from knowing, “We’re doing just fine, thank you very much.” What is it that everyone holds with such certitude in your firm?

The certitude of certainty.  Ain’t it grand being right?  Hear the story of the CIO, the vendor and the consultant driving through Iowa—please don’t ask what they were doing in Iowa, perhaps Nebraska was closed.  They see a black cow and the vendor says, “I never knew that the cows in Iowa were brown.”  The CIO says, “You are over-generalizing from the evidence.  All we can say is that some cows in Iowa are brown.”  The consultant shakes his head and quips, “You’re both certain and both wrong.  All we can infer logically is that there is at least one cow in Iowa, at least one side of which is brown.”

I return to the prior question.  What is it that everyone holds with such certitude in your firm?  The efficacy of throwing IT at a business problem?  That through rigorous investigation you selected an outstanding EHR?  That through minor due diligence you selected an EHR that may work okay if nobody looks too hard?  Or did you select a bunch of cows?

A herd of cows?  Of course I’ve heard of cows, there’s a bunch in Iowa.

This entry was posted on February 3, 2010 at 3:45 pm and is filed under EHR, Strategy, Vendors-What’s not to like?. Tagged: , , , . You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site. Edit this entry.

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What exactly is healthcare 2.0?

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I tend to take a slightly different bent on Healthcare 2.0, a bent which does not intentionally tie to the notion of Internet 2.0, but rather to the notion of an industry desperately needing to reinvent itself.

A few definitions may bring some sense to the discussion. I find it helpful to distinguish the business of healthcare from the healthcare business. I think of the healthcare business as the clinical side, and the business of healthcare as what it takes to make dollars and sense of it all.

Although the healthcare business in the United States is world class in many areas, in many hospitals the business of healthcare is mired in a 0.2 business model. It is often run like a franchised fiefdom of duplicative and ineffective cost and revenue silos—I’m going to duck for a moment in case anyone disagrees strongly with me.

I’m back. This 0.2 business model is being forced into a 2.0 model whether it wants to go there or not. Whether it is capable of making the journey is debatable. The model is regulated, and is about to be reregulated—to what—nobody knows. What national leadership there is is busy waving the magic IT wand thinking that will facilitate the transition from the dark ages and support the business model of National Healthcare—which, by the way, has little if anything to do with the model providers need to run their business.

EHR, if done wrong will be nothing more than a multi-multi-million dollar scanner. Providers will indeed be paperless. However, paper is not the problem. The goal should not be the elimination of paper as though paper is a bad thing. If efficiency equates to speed, to doing something faster, the goal should not be efficiency. It is possible to streamline bad processes and do them faster.

To get to Healthcare 2.0 using my definition, to redefine the business of healthcare, providers must move towards being effective, towards solving business problems, eliminating waste and duplication, retaining doctors and patients, and running it like a real business.

My best – Paul

Why let your EHR vendor run your hospital?

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Healthcare Failures Magazine (HFM)  “It is not everyone who can finish dead last in the CIO of the Year competition.  How do you account for your total lack of accomplishment?”

PR:  “It was not as easy as it may appear.  I think it had to do with believing that my EHR vendor knew more about running a hospital than did we.”

HFM “Why do you say that?”

PR:  “They told me their EHR it had been implemented “As Is” at a number of hospitals and was running fine.  I was convinced that all hospitals are basically the same; admissions, treatment, discharge.  Besides, it saved a lot of money not having to customize it and do all that stuff about workflows.”

HFM “What about the change management?”

PR:  “Yeah, well I guess you could say that part kind’a blew up on me.  It didn’t take long to learn that our hospital didn’t function at all like their software.  According to our doctors, they didn’t think this vendor had ever been in a hospital, let alone run one.”

Who defines your vision?  Who is your chief imaginist, the person responsible for defining the type of hospital you hope to operate five years from now?  Do you want it to be your EHR vendor?  Probably not?  Is it your vendor?  It may well be.  Why? Do you want to outsource your imagination and your future to your vendor?

Without a detailed and comprehensive work flow improvement and change management program the only thing you will implement is your EHR vendor’s vision of how a hospital should function.  You’ll be just like each of their other clients.  Is that what your business model calls for, is it satisfactory?

How hospitals should deploy EHR to attract Docs

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This is a response I wrote to Brian Ahier’s post on HealthsystemCIO.com

Here’s an idea I raised a few months ago which discusses how to use EHR to your advantage in retaining ambulatory physicians. What prompted the idea was knowing of a hospital which spent nine figures on their EHR, only to find out that its functionality essentially ended inside its four walls. At the time nobody wrote that it wouldn’t pass muster. This idea may die before anyone finishes reading the comment; if not perhaps it merits at least a look-see.

From the perspective of the business model of the hospital, what do we know?

• Hospitals work at attracting and retaining good physicians
• In many markets, ambulatory physicians may choose to send their patients to any one of a number of hospitals
• The competition to attract patients and physicians is building
• The hospital and physicians both benefit if they are:

o On the same EHR
o On an EHR which interfaces easily

What if we change the question being asked, or at least change what constitutes a desirable answer from the perspective of the hospital? Let us go back to what we know.

• Non-hospital based doctors will not be part of the calculation to determine if the hospital meets Meaningful Use.
• Each of those doctors benefit from implementing and EHR system, and they will either qualify for stimulus money or be fined.
• Those same doctors and their patients benefit from having a seamless relationship with a hospital.
• None of those doctors has anything close to what can be considered an actual IT department.

o If 400 providers who practice at your hospital have to select an EHR, how many dozens of different EHRs will they select
o Not only do the providers lack the skills to select a good system, they lack the skills to implement it successfully.
o Most IPAs are not even offering a recommendation

What happens if we rephrase the question and ask, “What steps can a hospital take to:”

• Make ambulatory doctors want to send their patients to them
• Make it easy for the patient/physician/hospital relationship to appear seamless
• Possibly be paid for facilitating the EHR for their ambulatory physicians

If it were my hospital, here’s what I would do:

• Pull together a plan to figure out how a hospital could offer an EHR solution for each of the ambulatory doctors. This EHR solution could:

o Be the same EHR or one which can integrate with their EHR
o Be offered as a managed services solution
o Be offered as an outsourced solution

• Figure out what information is needed to determine the viability of offering its ambulatory doctors an EHR solution:

o Staffing
o Marketing
o Incentives
o Cost
o Roll-out
o Training

• Determine if the ambulatory doctors can somehow sign-over their incentive payments to the hospital.

o If yes, the incentive payment from 400 ambulatory doctors could fund about $18 million of the roll-out cost
o If not, there are still a number of great business reasons to think about helping the doctors get on the hospital’s EHR.

What is the long-term ROI, say five years and beyond, of having an ambulatory doctor send its patients to a given hospital? I bet it exceeds the cost of installing an ambulatory EHR.