EHR: Managing the changes to your organization

I reside where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s a small space where only those who place principle over fees dare to tread.

Where to begin? How to build your team? (Those who wish to throw cabbages should move closer to the front of the room so as not to be denied a decent launching point.) There are two executives, I hasten to add, who will defend what I am about to offer, a CIO, and a CMIO, ideas from both of whom you’ve probably read.

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time the project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon. I believe that staffing only to execute today’s perceived demands will get me shot and will fail to meet the needs of hospital. I need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications for healthcare IT.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare issues from an IT perspective. They’ve also indicated that—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform. I disagree with that position.

Here’s a simplified version of the targets I think most of today’s CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them. Here’s what I think. You don’t have to believe this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since I’m writing, I used it.

Before I go there, may I share my reasoning? From a business perspective, many would say the business of healthcare (how it is run) is being moved from 0.2 to 2.0. The carrot? Stimulus funding—an amount—should you earn it, and you will probably want to since your CFO has already built it in to the budget—that will prove to be more of a rounding error than a substantive rebate. Large providers are being asked to hit complex, undefined, and moving targets. They are making eight and nine figure purchase decisions based in part on solving business problems they don’t articulate. If success is measured as on time, in budget, and functional and accepted, I estimate for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

The overriding business driver seems to be that the government has told providers to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on EHR than they would to build a new hospital wing. They don’t know what it should cost, yet they have a budget. They don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot. I’d staff with a heavy emphasis on the following subject matter experts:

  • PMO
  • Planning & Innovation
  • Flexibility
  • Change Management
  • PR & Marketing
  • And..Disaster Recovery

None of these high-level people need to have much if any understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime. That will account for about fifty percent of the success factors.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years from now there will not be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of Rhios, and mapped into a NHIN. Under the current model, standardization will not occur if only for the fact that there is no monetary value to those whose standards are not standard to make them so. This discussion is orders of magnitude more complex than cassettes and 8-tracks.

Interoperability, cost, and the lack of standardization will force a different solution. I think the solution will have to be something along the lines of a single, national, open, browser-based EHR. Can an approach to solving this be pieced together by looking at existing examples like airline reservations, ATM, OnStar, Amazon, FaceBook, and others? I believe so. Are some of my words and examples wrong? Count on it. Please don’t pick a fight over my lack of understanding of the technology.

The point I am trying to drive home is that from a staffing perspective, lean towards staffing the unknown. Staff it with leaders, innovators, and people who can turn on a dime. Build like turning on a dime is the number one requirement. Don’t waste all of your resources on certification or meaningful use. If anyone asks you why, you can blame me. If you want a real reason, I have two. First, they won’t mean a thing three years from now. Second, if I am the person writing a rebate check, I want to know one and only one thing; can your system connect with the other system for which I am also writing a check.

However, when all is said and done, I call upon us to remember the immortal words of Mel Brooks “Could be worse, could be raining.”


My remarks to Brian Ahier’s insightful interview of Dr. Blumenthal

I encourage those who have not read Brian’s interview of Dr. Blumenthal on to make time to read it.

Brian also has a link to the audio.

Brian asked me to comment, and I was pleased to do so.  Here is what I wrote.

I enjoyed reading your interview with Dr. Blumenthal. Clearly he and the members of his team are working very hard on a number of difficult and rather diverse issues.

I have been wondering, how does one tell the story of EHR to someone who has no understanding of EHR? Not the story about the EHR system in a physician’s office, or the ungainly one in a hospital. The story to which I refer is the story of the national rollout of EHR and the drive for interoperability.

For me, the question of how to tell the story in a way to make it understandable raises a number of other questions. Is there a story, or is it a collection of short stories written by different people, guided by different principles and goals? Is there a plot? Does the story come together in a natural manner?

Sticking with the story theme for a moment—who are the main characters, do they relate to one another? Does it come to a meaningful conclusion, in fact, does it conclude?

Look at the various antagonists—EMR, EHR, PRH, Meaningful Use, Certification, HIEs, RECs, the N-HIN, interoperability, the ONC, CMS, ARRA, standards, vendors, and PR. I am sure I missed several.

Imagine if Random House allocated millions of dollars to publish and market a book which had yet to be put to paper. No plot, no outline. What if they hired a dozen writers, each with their own areas of expertise—and lack of expertise—and crossed their fingers.

Would they be more successful if they offered penalties and incentives to the writers—a garrote and stick approach? What if they changed the rules after the writers started? What if they left undefined numerous areas of rules, rules which will impact the story, and told the writers to keep pushing ahead?

I do not see how the national EHR rollout story comes together. Now or some distant tomorrow—at least not under this approach. Is the approach viable? Having a few disparate successes does not make me a believer. Call me a cock-eyed nihilist.
Once every so often, an announcement is made that another single hospital reached Stage 7. One among thousands. Why do I view this from the vantage point of a glass half-empty? For me, the existing approach is one of guidance and facilitation. There are no long lines of providers trying to beat the others to the front of the EHR line. There have been several hundred million dollar do-overs.

If we circle back to the providers for a second, three of the largest causes of failure include the arbitrary setting of go-live dates without knowing what needs to be done or can be done in that time frame; second, letting IT and the vendor drive and manage the project; third, not getting users to define what they need and then having IT replicate those needs. IT does not need an EHR.

As I look at the government’s national rollout of EHR I see the same three problems. Who are the government’s users? Doctors, clinicians, and hospitals. There are fixed dates, many having undefined requirements. These are causing some providers to dash for the cash. Who is driving the rollout—the government’s users, or the government. They way the rollout is structured, the users have all of the responsibility and little of the authority. This is a government led IT project. Where are their users? They are running their practices and hospitals. They have one ear open towards, reform, another to the garrote and stick project rollout approach, another to EHR, and yet another to their business model. They have run out of ears.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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Call me a cock-eyed nihilist

I offered the following comment to Kent Bottles post,

My New Year’s Resolution: To See the World Clearly (Not as I Fear or Wish It to Be).’s-resolution-to-see-the-world-clearly-not-as-i-fear-or-wish-it-to-be/#comment-131

As this is the first Monday of the New Year, I had not planned on thinking, at least not to the extent necessary to offer comment on your blog.  I distilled it to three points—perhaps not the three about which you wrote, but three that tweaked my interest—happiness, counterfeit, and healthcare clarity.

Suppose one argues that happiness lives in the short-term.  It is something that one spends more time chasing than enjoying, something immeasurable, and once attained has the half-life of a fruit fly.  I do not think it is worthy of the chase if for no other reason that it cannot be caught.  As such, I choose to operate in the realm of contentment.  Unlike happiness, I think one can choose contentment.

There are those who would have us believe that contentment, with regard to healthcare, comes about through clarity, and that clarity comes from contentment—the chicken and the roaders.  Those are the ones who argue that reform, any reform, is good.  Where does the idea of counterfeit come into play?  I think it is the same argument, the one which states that any reform, even something counterfeit, is good.  The healthcare reform disciples argue that reform in itself is good; be it without objective meaning,purpose, or intrinsic value.  Therein lays the clarity, even if the clarity is counterfeit.

Call me a cock-eyed nihilist, the abnegator.  I am not content.  My lack of contentment comes not from what is or isn’t in the reform bill.  It stems from the fact that reform, poorly implemented, yields an industry strapped to change, an industry that may require greater reform just to get back to where it was.

Healthcare IT reform, HIT, will have to play a key role in measuring to what degree reform yields benefit.  Without a feasible plan, HIT’s role will be negative.  There are those who feel such a plan exists.  Many of those are the same people who believe the sun rises and sets with each announcement put forth by the ONC.

I think the plan, one with no standards, one that will not yield a national roll out of EHR, is fatally flawed.  I think that is known, and rather than correcting the flaws, the ONC has taken a “monkey off the back” approach by placing the onus on third parties, and offering costly counterfeit solutions like Meaningful Use, Certification, Health Information Exchanges, and Regional Exchange Centers.  If the plan had merit, providers would be leapfrogging one another to implement EHR, rather than forcing the government to pay them to do it.

Should HIT make the Top 10 list for medical advances for 2009?

Below is a reply I made to a report that HIT was one of the top medical advances for 2009.  It came from
Great point.  An advance requires movement.  I do not think an 8% penetration with a 60% failure rate and high churn is the type of movement that would qualify.  If anything, it appears more like a retreat or stagnation.
User acceptance is so low that the feds are offering $40 billion in incentives and penalties if that doesn’t work.
Acceptance will not be enhanced by the addition of regional extension centers (RECs); appointed committees with no more HIT expertise than the folks at K-Mart.
It will be hindered further  by similarly provisioned RHIOs building HIEs that are as different from one another as snowflakes, 400 vendors with no standards, and no incentives to create any.
Then there is the N-HIN, Meaningful Use, and Certification, all of which exacerbate the national roll out of EHR to the point where it the current plan will fail.
My take?  Meaningful Use and Certification will not exist in 3 years and firms like Apple, MS, and Google will be the N-HIN.

An Australian Blog worth my time, maybe yours

I had no knowledge of this until Heather Leslie wrote that I was quoted.  Independent of that nicety, it makes good presentation and argument of the pertinent issues.

As always, my best- Paul


Why I differ with Mr. Halamka’s EHR strategy

Below is a comment I wrote September 30, 2009 to Government Health IT in response to an article written about a conversation the author had with John Halamka titled, “Halamka: How to build a long distance service for healthcare.” Most people whose comments I’ve read regarding Mr. Halamka’s vision for how the national EHR roll out might work tend to be quite supportive.  I don’t think my comments fall into the supportive category.  That may account for why they have yet to appear in print.  So, in the spirit of full disclosure, here’s what I offered.

I wrote several weeks ago that we ought to look at the telecoms networks, ATMs, OnStar, or some existing platform. My argument for redoing the national roll out strategy along those lines is that it may provide a way to eliminate the middleman, the RHIOs and HIEs, whose only real role seems to be like a train station in the middle of going from NY to LA. If nobody ever gets on or off, why have it.

The critical success factor of the telecommunications networks is called an interconnect, it’s what gets the call from A to B and provides redundant carriage. It’s also what eliminates the need for a middleman.

The AP wrote today that the current EHR national roll out plan will not work With all respect to those working so hard on the current roll out plan, I think we need a serious rethink about what type of plan is required for the EHR roll out to work instead of pushing water uphill trying to make the current plan work. Here’s some thoughts I had about how it might be approached.


AP reports EHR plan will fail-now what?


I just fell out of the stupid tree and hit every branch on the way down. But lest I get ahead of myself, let us begin at the beginning. It started with homework–not mine–theirs. Among the three children of which I had oversight; coloring, spelling, reading, and exponents. How do parents without a math degree help their children with sixth-grade math?

“My mind is a raging torrent, flooded with rivulets of thought cascading into a waterfall of creative alternatives.” Hedley Lamar (Blazing Saddles). Unfortunately, mine, as I was soon to learn was merely flooded. Homework, answering the phone, running baths, drying hair, stories, prayers. The quality of my efforts seemed to be inversely proportional to the number of efforts undertaken. Eight-thirty–all three children tucked into bed.

Eight-thirty-one. The eleven-year-old enters the room complaining about his skinned knee. Without a moment’s hesitation, Super Dad springs into action, returning moments later with a band aid and a tube of salve. Thirty seconds later I was beaming–problem solved. At which point he asked me why I put Orajel on his cut. My wife gave me one of her patented “I told you so” smiles, and from the corner of my eye, I happened to see my last viable neuron scamper across the floor.

One must tread carefully as one toys with the upper limits of the Peter Principle. There seems to be another postulate overlooked in the Principia Mathematica, which states that the number of spectators will grow exponentially as one approaches their limit of ineptitude.

Another frequently missed postulate is that committees are capable of accelerating the time required to reach their individual ineptitude limit. They circumvent the planning process to get quickly to doing, forgetting to ask if what they are doing will work. They then compound the problem by ignoring questions of feasibility, questions for which the committee is even less interested in answering. If we were discussing particle theory we would be describing a cataclysmic chain reaction, the breakdown of all matter. Here we are merely describing the breakdown of a national EHR roll out.

What is your point?  Fair question.  How will we get EHR to work?  I know “Duh” is not considered a term of art in any profession, however, it is exactly the word needed.  It appears they  are deciding that this—“this” being the current plan that will enable point-to-point connection of an individual record—will not work, and 2014 may be in jeopardy—not the actual year, interoperability.  Thanks for riding along with us, now return your seat back and tray table to their upright and most uncomfortable position.

Even as those who are they throw away their membership in the flat earth society, those same they’s continue to press forward in Lemming-lock-step as though nothing is wrong.

It is a failed plan.  It can’t be tweaked.  We can’t simply revisit RHIOs and HIEs.  We have reached the do-over moment, not necessarily at the provider level, although marching along without standards will cause a great deal of rework for healthcare providers.  Having reached that moment, let us do something.  Focusing on certification, ARRA, and meaningful use will prove to be nothing more than a smoke screen.

The functionality of most installed EHRs ends at the front door.  We have been discussing that point for a few months.  When you reach the fork in the road, take it.  Each dollar spent from this moment forth going down the wrong EHR tine will cost two dollars to overcome.  To those providers who are implementing EHR I recommend in the strongest possible terms that you stop and reconsider your approach.