Strategy

Healthcare 2.0, can you get there from here?

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From a business perspective, not clinical, the critical success factor for H2.0 relies on healthcare’s ability to move from being an 0.2 industry in terms of how it is run as a business.

H0.2 is the “As-is” model.  H2.0 is the “To-be” model.  To reach H2.0 healthcare must bridge that functional, work flow, change management, user acceptance, and technical GAP.  The Gap will differ by provider.  There is no singular work plan to help providers know what they need to do to build a custom plan to bridge the gap.

None of this matters until the healthcare provider willingly acknowledges that they have a long way to go to get to anything that resembles H2.0.

H0.2 – H2.0 = GAP

If you don’t mind the gap,  H2.0 is just H2O–all wet.

One other thought.  There is a lot of discussion about Healthcare 2.0.  The discussion seems to suggest 2.0 is a destination point as though one can “arrive” at Healthcare 2.0.  Viewed this way, when healthcare arrives at 2.0, everyone else will be arriving at 3.0.  Unless the model evolves along a continuum, the journey may have been for naught.

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 their mind, 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 was 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 shop, 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 your 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.

Is it time to rethink your approach?

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So I’m making dinner the other night and I’m reminded of a story I heard a while back on NPR. The narrator and his wife were telling stories about their 50 year marriage, some of the funny memories they shared which helped keep them together. One of the stories the husband related was about his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf. She’d mix the ingredients in a large wooden bowl; 1 pound each of ground beef and ground pork, breadcrumbs, two eggs, some milk, salt, pepper, oregano, and a small can of tomato paste. She’d knead the mixture together, shape into loaves, and place the loaves into the one-and-a-half pound pan, discarding the leftover mixture. She would then pour a mixture of tomato paste and water, along with diced carrots and onions on top of the two loaf, and then garnish it with strips of bacon.

He went on to say that meatloaf night at home was one of his favorite dinners. His wife always prepared the dish exactly as she had learned from her mother. One day he asked her why she threw away the extra instead of cooking it all. She replied that she was simply following her mother’s recipe.  The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”

Therein lays the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing. Several of you have inquired as to how to incorporate some of the EHR strategy ideas in your organization, how to get out of the trap of continuing to do something the same way it’s been done, simply because that’s the way things are done. It’s difficult to be the iconoclast, someone who attacks the cherished beliefs of the organization. It is especially difficult without a methodology and an approach. Without a decent methodology, and some experience to shake things up, we’re no better off than a kitchen table amateur (KTA). A KTA, no matter how well-intentioned, won’t be able to affect change. The end results would be no better than sacrificing three goats and a chicken.

So, we’ll talk about how to define the problem, how to find a champion, and how to put together a plan to enable you to move the focus to developing a proper strategy, one that will be flexible enough to adapt to the changing requirements. But keep the goats and the chicken handy just in case this doesn’t work.

Controlling the patient dialog

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Remember when there were 200 firms in the Fortune 100?

How long ago was that? I think it was around the same time when people still thought you shouldn’t wear white after Labor Day. Time to drop-kick those white pumps to the back of the closet. What made me think of that bit of nonsense was a meeting I had recently with one of the sharpest people I’ve had the pleasure to meet professionally, and a classmate of mine from grad school. She happens to be the founder and president of one of the country’s go-to firms for dealing with business ethics. Having served as a board member for several publicly-traded firms, as well as chairing their audit committees, when the Andersen and Enron scandals hit she went looking for professionals who could help her help her firms. When she couldn’t find the help, she created it.

That conversation got me thinking and made me wonder why there were no longer 200 firms in the Fortune 100. Was it; is it, a matter of business ethics? How often do unethical practices come up when firms interact with their customers? A couple of takeaways from the meeting—for board members to be able to meet their obligation, they ought to do more than reply on the meeting book pulled together by the firm they serve. Simply relying on the book presumes ethical behavior, a presumption not always supported by fact—how much should one believe if the information is being provided by someone who purchased a $900 shower curtain?

What can they do? Due diligence is being reinvented, and the Social Network is leading the charge. One example is to go to Yahoo Chat to see what’s really being said about your organization. Other things I’ve done to obtain facts and opinions, things which particularly gauge how customers and employees feel about the firm include Google Reader, Facebook, Twitter, and YouTube, to name just a few. You don’t need patient focus groups to learn what’s being said, or to learn how good a job your hospital is doing. The patients already have a laser focus. In many instances the group lacking the focus is the healthcare provider.

Firms should focus on maintaining a strong Reputation Bank, one strong enough to be able to handle withdrawals, because you never know when there might be a run on the bank. Might be a good time to look at your own bank deposit slips.  Deposits can be made easily through the social media network.  You can’t stop patients from talking about you but you can shape what they say.

EHR productivity need not be awful

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I wrote this in response to a question I posted on a LinkedIn discussion group.

I have met with CIOs and CMIOs who have spent well over $100 million on name-brand systems-wide EHRs whose productivity in the exam room after more than two years is 20-30% less than it was before they implemented the EHR.  Two of those hospitals are replacing their EHR and expecting different results.

I watch some physicians spend more than half their time with a patient sitting at a keyboard clicking and navigating while the patient sits there.  I watched it happen to me in an exam.  My physician knows what I do and asked me if there was a way to improve his face-time.

That got me thinking about how to do that.  Most hospital EHRs are very broad and complex systems.  They are designed to do a multitude of things that go well beyond the  interactions needed to document what occurs during the exam.  My review of those systems indicates that in many cases their breadth makes it difficult for them to render effective and efficient service during an exam–too many clicks, and difficult navigation.
Most physicians are much more effective writing than typing, selecting options from a slew of drop-down menus, and finding their ways around a maze of screens.

My reference to the term GUI is meant as a placeholder, perhaps I should have called it an ambulatory EMR front-end.  Whatever its label, I believe there are inexpensive solutions that can be implemented alongside large EHRs that can make the doctor more productive.  The fact that nobody is doing this does not mean it cannot be done.

I have seen EHRs that serve ambulatory care providers that are highly effective and do not neutralize the patient-doctor interaction.  I have seen a doctor be fully functional in as little as 30 minutes.  Some physicians use the increased productivity to spend more time with patients, and some use it to see more patients.

I think it is also an important cost and ROI consideration.  If a hospital spends $200 million on an EHR, and their result is a productivity decrease of twenty percent, the total cost of their EHR is substantially higher than $200 million.

Why bother with an RFP for EHR?

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HIT Strategy; without one, do not take out your checkbook.  Buying what your neighbor bought, and assuming they did their homework, is not a strategy.  Buying something because the sales-rep told you they had an amazing list of client references is not a strategy.  These are shortcuts.  Have you noticed none of the EHR providers were not wearing “I love my EHR” T-shirts at the last HFMA meeting?

My rule of thumb about Google is that if I cannot find something it is because it does not exist.  There are no good EHR RFPs available on Google.  Here are a few thoughts on RFPs in case you want to use one—by the way, a good RFP makes a great addition to a vendor contract as it provides a written audit trail of what they contracted to do.

  1. The RFP should have an exhaustive list of requirements.  It is designed to separate one vendor from another, not make them all appear to be equally capable.
  2. The requirements should be addressed in a way to help a provider know what business capabilities the vendor offers, not to show how pretty their screens are.
  3. The RFP should not mirror your current business.  Your goal is not to simply automate what you do, but to do it better.  That means change.  Without change your EHR will simply be an expensive scanner.
  4. Along that same thinking, I have yet to see an RFP that mentions a single requirement about making the provider’s business more efficient or more effective.  Here’s why.  if each provider tells you their system can perform the same tasks as the other systems, you have not learned anything to cause you to pick one vendor over another.  If they say their system is efficient, make them supply you with details about the number of clicks, screen navigations, and times needed to do the ten tasks you do most often.  If they say they are twice as fast as Vendor A, make them prove it, make them prove it in your office.  Contact vendor A and find out who is telling the truth.  If they each have the same functionality, and one vendor takes half the time to perform a task, that fact should be included in your decision.  How important is 30 seconds?  How many 30-second improvements are there with each patient?  If there are four, and you see 30 patients a day, and your practice has eight doctors, you’ve either just saved a total of eight hours a day to spend more time talking to your patients, or to add patients.
  5. The other important part of the RFP that is often either overlooked or under assessed is the specialization of the EHR.  Warning: A large vendor has probably has at least one implementation covering each specialty; cardiology, orthopedics, urology.  Having one or a few clients in a specialty does not mean their product was designed to serve that market.  It may mean their clients did not do a very good job selecting tem as their vendor.
  6. That brings us to references.  A large vendor may have a thousand or more providers installed.  When you ask to check their references, which ones are they likely to parade in front of you—the ones who like their product.  The other 990 are kept in their lock-box.  Whoever they give you to talk to will be those who they feel are least likely to say something negative.
  7. How should you check references?  Most vendors will give you as a contact either a top administrator or someone in IT.  That will tell you very little.  Once you learn the name of the organization, call them.  “This is doctor so-and-so, and I am calling to speak with one of your physicians.”  Whatever this person tells you will be of much more value than having someone who not use the system tell you how much they like it.

Anyway, those are my thoughts.  There are a range of savings available if you have a good EHR strategy, pick a good system, and implement it correctly.  If you pick the wrong one, you do not need to worry about calculating your ROI—there won’t be one.

Expert: Providers must make IT investments on their own, have new implementation strategies

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Here is the link to an article in HealthcareITNews that quotes a few of the things we have been discussing on this site.

http://www.healthcareitnews.com/news/expert-providers-must-make-it-investments-their-own-have-new-implementation-strategies

EHR: when you are in a hole, stop digging

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I was thinking about the time I was teaching rappelling in the Rockies during the summer between my two years of graduate school.  The camp was for high school students of varying backgrounds and their counselors.  On more than one occasion, the person on the other end of my rope would freeze and I would have to talk them down safely.

Late in the day, a thunderstorm broke quickly over the mountain, causing the counselor on my rope to panic.  No amount of talking was going to get her to move either up or down, so it was up to me to rescue her.  I may have mentioned in a prior post that my total amount of rappelling experience was probably no more than a few more hours than hers.  Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her.

The sky blackened, and the wind howled, raining bits of rock on us.  I remember that only after I locked her harness to mine did she begin to relax.  She needed to know that she didn’t have to go this alone, and she took comfort knowing someone was willing to help her.

That episode reminds me of a story I heard about a man who fell in a hole—if you know how this turns out, don’t tell the others.  He continues to struggle but can’t find a way out.  A CFO walks by.  When the man pleads for help the CFO writes a check and drops it in the hole.  A while later the vendor walks by—I know this isn’t the real story, but it’s my blog and I’ll tell it any way I want.  Where were we?  The vendor.  The man pleads for help and the vendor pulls out the contract, reads it, circles some obscure item in the fine print, tosses it in the hole, and walks on.

I walk by and see the man in the hole.  “What are you doing there?”  I asked.

“I fell in the hole and don’t know how to get out.”

I felt sorry for the man—I’m naturally empathetic—so I hopped into the hole.  “Why did you do that?  Now we’re both stuck.”

“I’ve been down here before” I said, “And I know the way out.”

I know that’s a little sappy and self-serving.  However, before you decide it’s more comfortable to stay in the hole and hope nobody notices, why not see if there’s someone who knows the way out?

Merely appointing someone to run your EHR effort doesn’t do anything other than add a name to an org char
Kind Regards,

Paul

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

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Have I erred on the side of stupidity?

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Twice in the span of twelve hours, I received unsolicited and honest feedback from two individuals whose opinion I value, about my attempt to share with you my thoughts about a range of issues concerning the business of healthcare.  One came from my father; since he holds that role he is allowed to offer unsolicited advice any time he wants, and I am entitled to listen to his advice.  The other bit of advice came in response to an email I wrote.  He is one of you, and he wrote the following:

I agree with many of your points and disagree with a few of them, and regardless, it’s a compelling, buzz-worthy angle that gets a lot of re-tweets and what have you, but I think it’s worth considering how these positions are affecting your ability to land consulting gigs in HIT. People want to hire consultants that they think will help them succeed, that think positively and pragmatically, and that are problem solvers (as opposed to problem recognizers): “we can do this together…I’ve had success before and if you let me, I will help you succeed…” that kind of thing. Just my 2 cents. It’s a trade-off, I know. You want to be honest and forthcoming, so I see the dilemma.

This was like being hit by lightening twice in the same day, so I thought I should take time to consider their input.  The feedback led me to ask if there are others who share the same opinion.  Is it possible my ramblings are about as well received, as I would be if I were to walk the streets of Tehran wearing a Star-of-David t-shirt?  What portion of readers drag my postings to their email folder entitled, “Kill him Later”?

Some believe a more effective use of consultants would be to compost them and use the energy generated to power a weed-eater.

Please permit me a few lines to try to explain my thought process for writing in my particular style and tone.  Before I began expressing my opinions on healthcare, I began reading what I considered the best healthcare blogs and editorials.  The first thing I learned is that I had nothing to offer of value on the clinical side of healthcare, so I focused my efforts on discovering what business issues providers dealt with, and which ones might benefit from receiving professional help—a consultant’s twelve-step program for problem solving.

I did a lot of homework; in addition to reading, I interviewed more than a hundred healthcare executives.  What was my takeaway?  One CEO told me the most needed skill on the business side of healthcare was “adult supervision”.  I did not charge in with uncorroborated opinions.  I used LinkedIn discussion groups to pose hundreds of questions about possible problems, studied the responses, and used them as a basis to formulate ideas about what was broken and what needed to be done to fix it.

I should note many of the blogs I read shared two traits; they often stated the same facts available on other blogs, and they rarely seemed to question the efficacy of the impact many of the Healthcare IT initiatives would have on operating healthcare’s business model—ours is not to wonder why, ours is but to do or die.

Not wanting to be superfluous, when I came to the fork in the road, I chose not to take a me-too position.  Instead, I threw metaphorical tomatoes and tried to get people interested in looking at the business model in a more disruptive manner.  Often, I did this by taking extreme positions on issues in the hope I might hit a hot button, and someone would think, “Perhaps we ought to talk to the tomato thrower and see if he can help us”.

My approach may prove to be less than brilliant.  What’s your take?

The most relevant EHR/EMR piece you will ever read

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According to the New England Journal of Medicine, somewhere north of fifty percent of EHR implementations fails.  Your odds of success are no greater than the flip of a coin.

What if there is a tool whose use can stop the failure of most EMR system implementations?  The purpose of this post is to let you know that there is a definitive solution to help small providers, clinics, IPAs, and hospitals.

What tasks of the EMR process is the primary cause for failure?  They are the tasks that are under budgeted, neglected, haphazardly addressed, or addressed by people who have no earthly idea how to perform them.

They are the same tasks that cause systems projects in other industries to fail.  If you do these tasks wrong, nothing else you do will make any difference—do-overs cost twice as much as your first failure.

The laundry list of those tasks is:

  • Defining your requirements—for physicians, nurses, staff—all of them.
  • Putting those requirements into an operable framework.
  • Ranking the requirements in a way to enable you to pick a good solution.
    • Technology Evaluation
    • Clinical Workflow Evaluation – Analysis of current clinical workflows.
    • Gap Analysis – Comparing current technical capabilities to desired capabilities.
    • EMR/Practice Management needs evaluation
    • ARRA Incentive Estimation
    • Qualified EMR vendor list
    • Vendor competitive bid assessment
    • Hardware requirements

I recently asked a hospital CEO, “What would you have done differently regarding your EHR selection?”

Here is a paraphrase of his response.

  • Invested much more time in understanding what system we should select and how we would use it.
  • My peers assumed someone else had already done all the up-front stuff (see the above list), and they selected their system solely on what others were using.  Alternatively, they picked a system based on a golf course conversation or something they saw at a trade show.

How many of your business and clinical requirements do you need to meet for your EHR selection to have any chance of succeeding?  The best answer is “All of them”.  How many requirements are needed to define your needs; one hundred, two hundred?  Not even close.

Try this exercise.  Search Google for “CRM RFP” or “ERP RFP”.  There are hundreds of useful responses.  Now search Google for “EHR RFP” or “EMR RFP”.  There are no useful responses.  (If you cannot find something on Google, it often means it does not exist.)  The healthcare industry is usually very good at sharing useful information.

I’ve been coaching executives for thirty years about how to get these tasks right.  In doing so, I developed something that made the software selection task winnable.  (This piece is not a Tony Robbins narrative, it is not about me; I am not selling anything.)

Here is what I did.  I built a Request for Proposal (RFP) for CRM and ERP.  I started with 1,000 requirements for each.  I license it to clients and work with them to edit it, to add new requirements, to delete requirements that did not apply to their organization.  They would use the result to select the application best suited to their firm.

This process never failed to benefit my clients.  I would take whatever new requirements they created and add them to my RFP.  My RFP became more robust.  Each time the RFP was issued I collected the responses from each of the vendors and built a database of what their applications could deliver.  I now have a few thousand functional and technical requirements, and up to date responses on what the applications vendors could deliver.

Why did I build this RFP?  The answer is simple.  I needed to create a reason for a firm to hire my firm instead of hiring one of the name-brand multi-national consulting firms.  The RFP served as a cost differentiator.  Instead of spending a million dollars to hire a name-brand firm to develop something from scratch, they could be months ahead, and at a lower cost by using a proven tool.

Therefore, here’s my point.  There is a firm that built a tool similar to mine, a tool to add to the probability of you selecting the best EMR/EHR for your firm.  It will not guarantee your success, but it will significantly reduce the chances of failure.

Clearly, even if you select the right system there are still many opportunities to fail.  The converse is that if you select the wrong EHR, it will fail.  That statement is not an opinion; it is a fact.

I’ve arranged a Go-to-meeting conference call with the CEO of that firm for the week of July 26.  This organization has built what I described; an RFP with more than a thousand unique requirements, an automated way to analyze the vendor responses, and a way to match your prioritized requirements to a short list of EHR vendors.  It will not be a sales pitch.  It is designed to be a question and answer session.  Who should participate?

  • Smaller providers whose only other option is to hire the person who set up their web site to manage their EMR selection
  • IPAs whose members are looking for advice about selecting a system to meet their specialization
  • Hospitals struggling with finding a defensible position for their selection.

If you are involved in the selection of an EMR/EHR, you should find an hour to assess the tool.  If you do not have the resources to make use of the tool, they do.  They can help you help yourselves.  I promise you, this will be the best use of sixty minutes you have had in a long time.  If you know someone who might benefit from this session, please forward this and have them contact me.  If you could benefit, simply respond to me.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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