Strategy

Why doctors fail to embrace healthcare 2.0

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This is a reply I wrote to Kevin MD’s blog to a post written by Gwenn Schurgin O’Keeffe, MD, FAAP.

I view healthcare 2.0 with a bit of a twist from the Wikipedia definition, less from the perspective of social media and more from the vantage point of moving the business of healthcare from Version 1.0 to version 2.0.  I should note that I distinguish the business of healthcare (how it is run) from the healthcare business (the clinical side).

Having worked with executives in a number of industries, I think that for healthcare reform to be truly effective, the business of healthcare needs to evolve from an 0.2 model to a 2.0 model.  I think the same issues you raise still come into play; sheer panic, loss of control, loss of connection with patients, and blinders.

Going from an in-house business model to one being transformed by reform and Meaningful Use to a national healthcare model will exacerbate further those issues.  The in-house business of healthcare (how healthcare is run) was never built to handle a business model that will require every patient to be able to be connected to any doctor.  The system advances over the past few years—EHR, CPOE, and ePrescribing were implemented without any idea that the rules would change after the fact.

Will healthcare 2.0 offer huge advantages to how healthcare is run?  Absolutely.  The first question to answer before aiming for 2.0 is whose 2.0 model should you follow; yours or the government’s.  Are they the same?  No, and they are diverging even further as you read this.  The good news is that I think they will converge several years down the road.  What you need to decide is which model do you pursue before that happens.

Who is responsible for your hospital’s HIT strategy, you or the ONC?

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Who is responsible for your hospital’s HIT strategy, you or the ONC?  Here are my thoughts regarding “What’s Next” and the “Gap Analysis”  with regard to the ONC’s interim final rule.  Remember, you don’t have to follow the IFR.

What’s Next:

  • Most if not all of the current HIT was built prior to government constraints
  • The ONC changed the rules after many hospitals already spent millions on EHR and CPOE
  • Nobody knows the staying power of the Meaningful Use rules or the impact of reform
    • Will the implementation be pushed back?  Quite possibly
    • Will the requirements be toughened?  Very likely
    • What if reform reduces revenue and increases demand?
    • What if existing doctor and nurse shortages grow worse?
    • What if some of the most vulnerable and expensive patients continue to have no coverage?
    • What if the ONC changes the rules?
    • What if reform cuts costs by eliminating “disproportionate share” payments?
    • What if there is a reduction in Medicare reimbursements?
    • More is unknown than is known about the impact on hospitals and physicians
    • There are two business models in play;
      • The ONC’s and reform’s nationalization and interoperability of healthcare
      • The mission of your organization
      • Do you build your HIT strategy to align with your hospital’s strategy or with the ONC’s strategy
      • Your pre-Meaningful Use HIT goals likely included:
        • Supporting your strategy
        • Consolidation for shared services
        • Clinical integration
        • Operational excellence
        • Reducing functional duplication between departments
        • Process improvement
        • EHR and CPOE implementation
        • Which of those goals would have to be altered because of Meaningful Use
        • What would your HIT strategy have been if there was no Meaningful Use

What’s the GAP between what you had planned and what your now have to consider?

  • How many millions will it take to meet Meaningful Use
  • What planned HIT projects must be delayed because of timing or resources
  • How do those millions compare to what you will receive from the ARRA funds
  • Even if the funds exceed the cost to get them, how do the changed systems impact your business model
  • You have a number of options to analyze regarding Meaningful Use:
    • Meet Meaningful Use later
      • A wait and see approach buys you time for the uncertainty to settle and for the impact of reform on HIT to become clearer
      • There is no requirement to be first
      • You have five years before Meaningful Use penalties begin
      • If the requirements expand as expected it will likely cost more to modify systems than to wait for a complete set of requirements
  • Do not meet Meaningful Use
  • Meet all of the Meaningful Use opportunities
  • Meet portions of Meaningful Use
  • What projects must be undertaken to achieve each option
  • Will those projects have long-term value for you, or is their only value meeting Meaningful Use
  • What process and change management implications are built into meeting Meaningful Use

Should you consider avoiding Meaningful Use?

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Where were we?

There are a few things stuck in my craw—imagine that.  One is Meaningful Use.  The other is also Meaningful Use.  Permit me to address these one at a time.  I’ll start with Meaningful Use.

Are you kidding me?  Who are these people?  To disguise that of whom I write, let’s invent some aliases, Dr. B and Dr. H.  For all the meetings, all the pronouncements, you’d think sooner or later one of them would state, “There is no way any of this makes sense.”

Why do you say that Paul?  May I?   What if you threw a party and nobody came?  What if you held a $40 billion lottery and nobody won?  Here are the rules.  A handful of people less than seven feet tall decide to buy homes in a community.  All the homes have door openings that are seven feet high.  New people move into the community.  One day the homeowner’s association mandates that all homeowners must build homes with door openings that are seven feet high.  Most homeowners ignore the mandate.  The association then decides to offer the homeowners rebates if they comply with the mandate, and penalize them if they don’t.  Most of the homeowners ignore the mandate.

Indifferent to the fact that their mandate isn’t working, the association decides to add new rules, rules that affect the homeowners who already built homes with seven foot tall doors, and those who didn’t.  One of the rules is that the seven foot tall doors must now be eight feet tall; another mandates that all roofs must be in the basement.  Homeowners who comply will win the lottery.  Those who don’t won’t.

How does the lottery pay out?  It doesn’t.  They made it impossible for anyone to get the money.   Suppose you gave a lottery and nobody won?  Suppose you made it so obtuse that nobody cared if they won.

That’s where I think we are with EHR.  The smart healthcare providers are asking themselves the question, “What if we make a business decision not to meet the Meaningful Use requirements?”  “What if we decide what is and isn’t meaningful.”

There are 2 “business models” in play—the national healthcare model, and the model your firm follows—they have different goals.  I asked my client, “When you made your selection of EHR, did you have any hint that the government was going to create rules to manage what it does?”  I assume their answer is a lot like yours—“Not at all.  We were worried about FDA oversight, but nothing like the stimulus.  The PQRI was available as an incentive to use ePrescribing, but really small potatoes.”

The national healthcare model under development will create an infrastructure such that every patient can be connected to each physician via a series of HIEs and the N-HIN.  To get there, they need you—they can’t do it without you.  What do they need from you?  Participation.  Participation by having and EHR, ePrescribing, and CPOE.

Even if it were to work, what’s in it for you?  Very little.  They know that—that’s why there are payments and penalties.  Most hospitals like the idea of implementing EHR.  Given the choice those same hospital executives would choose to listen to an entire Celine Dion CD if it would allow them to skip implementing CPOE.

If there are not many good business reasons to meet Meaningful Use, why should you build an entire strategy around it?  You wouldn’t paint your hospital pink simply because Washington said you should, although given a choice between the two ideas, pink sounds pretty good.  Let’s say you take them up on meeting Meaningful Use.  You build your strategy, drop current initiatives, implement these systems, train your people—then what?  Indeed.  What happens if the government changes its mind?  Moves the dates, changes the requirements?

In order to go for Meaningful Use you must be able to suspend your ability to think rationally.  If you do not think the HIE and N-HIN model will work—I have not met anyone who thinks it will—why even give Meaningful Use another thought.

My client is a group of 14 hospitals—they could get millions of ARRA dollars.  If you don’t have more than one hospital, your ARRA rebate will be much less.  They have already installed EHR and CPOE.  To get the millions they have to spend millions.  What happens if they spend it and the feds change their direction?  What then?  What do they do with the eight or nine figures of systems they build to follow Washington’s lead?  Take them out?  Modify them?  What happens to their business model as a result of all of this “leadership” from the ONC?

What should you do?  That’s up to you.  Here’s an idea or two.  First, ask yourself what your EHR/HIT strategy would be if there was no ARRA money.  (You do have a written HIT strategy, don’t you?)  Second, decide if you think that the current national roll out strategy will work.  Third, figure out what you won’t be able to do if you have to invest even more time and money meeting Meaningful Use.  Next, add up all the money it will cost you to meet their requirements and compare that to what they will pay you.  I bet the costs are more than the rebate.

I think Meaningful Use won’t exist in 3-5 years.  I think the N-HIN won’t be available by then either.

Here’s the real kicker for hospitals that have more than two beds.  If you have not yet selected your EHR vendor you shouldn’t even be thinking about meeting Meaningful Use for the first year because you can’t there in the time available to you.  That take’s the pressure off, doesn’t it.

How good is your vision?

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So, there I was thinking about all the times I didn’t get the invitations to the technical savants meetings.

I remember when Compaq came out with their first portable PC.  It was about the size of a suitcase and twice as heavy.  There was no way I’d ever have a need to lug around a computer.  A few years later my boss showed me his new cell phone—beige and about the size of a shoe box.  I remember asking him why he needed a phone and not being impressed by his answer.  Another piece of technology that would never get off the ground.

A few years later, out popped the internet.  A friend of mine showed it to me.  I asked him what he does with it.  He replied that it was good for sending messages to his brother.  I suggested he use the phone.

I think the fault I had was I looked at those three things from the perspective of the technology. It didn’t occur to me to look at it from the perspective of what business problems could they solve.

Technology, from the standpoint of its functionality, is often vastly under employed.  This happens not because of limitations of the technology, but limitations of vision.  I needed to not ask, what am I able to do with this, rather, what might I be able to do with this.

For example, let’s look at the fascination, or lack of it, around implementing an Electronic Health Records system (EHR).  By the time the dust has settled on your implementation, say three to five years—by the way, that means you missed the deadline to get the ARRA money, what does the industry look like?

Do you buy the EHR that meets what the industry looks like today, or did you give it enough thought so that your EHR functions at the level needed to support your business in 2015?

Should you consider disregarding Meaningful Use?

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Here’s a reply I wrote to a FierceHealthIT on some of Dr. B’s comments on Meaningful Use.

I know of a hospital who has already implemented a top tier EHR costing millions.  This organization ‘gets it’.  They are currently building a work-plan to see what additional work they must do to meet Meaningful use in time to qualify for 100% of the ARRA money.  First blush—it will take tremendous amount of work for them to do it, but they will get there—if they choose to do so.  They have a choice and the fact that they know that is their trump card.

If a hospital hasn’t even begun the EHR process, as more than 80% have not, coupled with the more than fifty percent failure rates, I’d estimate their chances their chances of making the deadline at less than 1/3.

So, what to do?  Stop and think.  Ask the right questions.  You have a choice of two strategies.  Let ARRA money drive your decision, possibly implement it wrong, and probably miss the deadline.  Then what do you have?  Not much.  Strategy number two; define your requirements, figure out what business problems you need the EHR to help solve, and buy the best one for you.  Confused?  Map out two work-plans for yourself.  One work-plan that shows what you would have to do and what you would have to spend to meet the ARRA requirements.  Draft a second work-plan that shows what you would have to do to implement what you really want.  Compare the two plans and determine your deltas, your gaps.

Are you going to chase this for ARRA money?  Because someone in Washington thinks you should do this?

Answer this question first.  Is every hospital the same?  Are you as good as the best, better than the worst?  The EHR vendors think the answer is yes.  Keep you processes the same, skip change management, and the implementation will be a breeze.  We make every hospital look and operate the same.  When did the EHR vendors become the best practice savants?   The government thinks the answer is yes—that is why they are holding everyone to the same Meaningful Use standard.

One standard does not fit all hospitals—nor should it.  Set your own standards and decide for yourself if you fit your version of Meaningful Use.  ARRA money will end—then what?  You’re stuck with your EHR.  Get one you need.

You’re no Aristotle

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Everything is written with the idea of persuading the reader; either explicitly—what is written is true, or implicitly—what is written is informative or funny, thereby persuading you that the author is informative or funny. Aristotle employed three forms of rhetorical persuasion; pathos, ethos, and logos. For those of you thinking, “Yeah, but you’re no Aristotle,” you’ll get no argument from me, but you have to admit, it’s a good likeness.

I basically write from whatever stream of clatter happens to be knocking about at the time. For me, writing is a little like speaking in parenthesis, only a little quieter and with more ambiguity. So, what is lurking up there at the moment? Sure you want to know?

I’m trying to convince my son the futility of not doing something correctly the first time he does it, arguing that it takes twice as long to do it wrong as it does to do it correctly. I call it the DIRT-FIT Principle—Do It Right the FIrst Time. For instance—loading the dishwasher. It takes a certain amount of time after clearing the counter to place the dishes, glasses, and utensils in the dishwasher pell-mell. It takes twice as long to redo it.  The same principle applies to making his bed, putting away his shoes, and brushing his teeth.

The same principle applies to implementing an EHR system. It costs twice as much to put it in twice as it does to implement it correctly the first time. I bet you know a hospital who is busily implementing EHR 2.0.  There is the difference between EHR implementations and sons. Implementations have the right not to do it correctly the first time—my son doesn’t.

Do EHR vendors have a built-in bias?

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I write from the perspective of hospitals and physicians who are required to pass tests of certifiable, meaningful use, and interoperability. As would be expected, comments made by EHR vendors are quite different from miine.   Forgive me for stating the obvious–their job is to get you to buy what their firm sells, to make you a believer.

There are more than four hundred firms who have something to sell you, something they believe will make your life better. How do you know which one of them is offering something that may work for you? How can you tell? Heck, how can you tell which product will still be viable in three years?

A question worth considering.  As passionate as the vdenors’ sales reps are, when a sales rep moves from Vendor A to Vendor B, does their passion remain with Vandor A?  Of course not.  The new “best thing since slided bread” is the thing offered by Vendor B.

Where does that leave you?  For starters, don’t buy it on faith.  Don’t buy it just because somebody else bought it–is their judgement better than yours?  You need a way to make an objective decision about some very subjective information.  One way to do that is to turn the subjective issues into quantifiable business requirements.

What do you think?

Is the N-HIN helathcare’s black hole?

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Last year scientists turned on the largest machine ever made, the Hadron Collider. It’s a proton accelerator. This all takes place in a donut-shaped underground tube that is 17 miles in circumference.

Fears about the collider centered on two things; black holes and the danger posed by weird hypothetical particles, strangelets, that critics said could transform the Earth almost instantly into a dead, dense lump. Physicists calculated that the chances of this catastrophe were negligible, based on astronomical evidence and assumptions about the physics of the strangelets. One report put the odds of a strangelet disaster at less than one in 50 million, less than a chance of winning some lottery jackpots—what they failed to acknowledge is that someone always wins the lottery, so negligible risk exists only in the mind of the beholder.

If I understand the physics correctly from my Physics for Librarians mail-order course—and that’s always a big if—once these protons accelerate to something close to the speed of light, when they collide, the force of the collision causes the resultant mass to have a density so massive that it creates a gravitational field from which nothing can escape. The two protons become a mini black hole. And so forth and so on. Pascal’s triangle on steroids. Two to the nth power (2ⁿ) forever. Every proton, neutron, electron, car, house, and so on.

The collider could do exactly what it was designed to do. Self fulfilling self destruction. Technology run amuck. Let’s personalize it. Instead of a collider, let’s build a national healthcare information network (N-HIN) capable of handling more than 1,000,000 transports a day. What are the rules of engagement?  Turn on the lights and let’s see how it functions.

Let’s say we need to get anybody’s record to anybody’s doctor.  That’s overly simplistic, but if we can’t make sense out of it at this level, the N-HIN is doomed.  The number of possible permutations, although not infinite, is bigger than big.  Can you see what can happen? Strangelets.  The giant sucking sound comes from ARRA and stimulus money as it is pulled in to the black hole.

So what is the present thought leadership proposing to fight the strangelets? Healthcare information exchanges (HIEs)—mini N-HINs.  Regional Exchange Centers (RECs).  A few million, a few billion.  Not only does their plan have them repeating the same flawed approach, they are relying on embedding the same bad idea, and doing it using hundreds of different blueprints.

Einstein defined insanity as doing the same thing over and over and expecting different results.

Stop the craziness. I want to get off.

It’s the end of the world as we know it…and I feel fine. R.E.M.

Call me a cock-eyed nihilist

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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).

http://icsihealthcareblog.wordpress.com/2010/01/04/kent-bottles-my-new-year’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.

Pass the salt

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Okay campers, we’re going to jump right in to this one. There was a point not too long ago when the US was involved in the SALT talks, the Strategic Arms Limitation Treaty. For those too young to remember, the US and the Soviets—that’s what we used to call the Russians. Actually, they were called Russians before they got married and changed their name to Soviets which is neither here nor there.

This came about because the two countries were MAD at each other. Not in the usual sense, but in the sense of mutually assured destruction—of the world—several times over. Anyway, it finally occurred to both sides that perhaps we only needed enough weapons to blow up the world a few times instead of hundreds of times. What was the result? We’re still here. We’re here because the people who built the weapons agreed to greatly reduce their number of weapons. They learned how to function differently. Instead of saying we can’t do that, they took the approach of saying, “If we wanted to do that, how would we do it?” Getting rid of nuclear weapons—no small feat.

Segue. I realize this is a bit of a stretch just to make a point, but since we’ve come this far we might as well make it. What would you do if you came to work one day and received an email which read that your organization had decided against ever implementing an EHR?

To me that is a perfectly reasonable idea. Of course, I’m someone who wonders how the color purple feels. But why not stop all of this foolishness around EHR?  Agree, or is killing EHR a foolish idea?

I think it’s much less foolish than implementing an EHR and having no reasonable expectation that it will work.  The odds are that your EHR has a better chance of failing than it has of succeeding.

I have no problem with EHR.  I do, however, have a problem with businesses constantly making the same mistakes, making EHR a multi-million dollar repository for their mistakes, and then complain about the fact that the EHR isn’t doing a good job.

What do you think?