Strategy

The effect of poor planning

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skate

I’ve always considered myself to be rather athletic, although I must have been on break when they handed out the coordination genes.  Perhaps that is why I tended towards individual efforts like running.

As it was, I was fairly good at ice skating as long as I was moving forward, the straighter the better.  Turning and stopping required an abundance of room, and an absence of other skaters.

Whoever came up with the notion that if you can ice skate you can roller skate was either lying through his teeth, or I became skating’s anti-matter.  At the time of my first attempt at roller skating I was unaware that ice and roller skills weren’t transferable.  Have I mentioned I like having an audience?  I decided to audition my roller skating skills at a public skating rink while on a first date.

The night was proceeding swimmingly.  I learned quickly that it I stayed to the edge and leaned towards the center of the rink, centrifugal force would keep me from falling.  My confidence in my abilities began to build.  Music boomed from the overhead speakers.  Several couples held hands, the more skilled ones crossed their arms in front of them and held hands.  I tried it and eased us into the first turn.  The song switched to Barry Manilow’s “I write the songs.”  To my misfortune, I knew the words, and began to serenade my date.  When I guy sings Barry Manilow in front of anyone but his own shadow, only two things can happen and they’re both bad.

We hit the second turn and I began to accelerate.  We sped past a number of couples.  I sang louder, concentrating more on the words than on the task of keeping us both upright.

For those unfamiliar with the design of roller skates I should explain what I perceive to be a flaw design flaw—one which you will note has been eliminated in roller blades.  The flaw?  On the front of each roller skate about an inch from the bottom is a round rubber device that resembles a stunted hockey puck.  It serves no known purpose other than to sucker punch novice skaters.  If you mistakenly try to build speed by pushing off with the toe of your roller skate—as you do in ice skating—you are actually hitting the emergency brake.  And because the brake is at the front of the skate, the physics is such that once your feet stop, the only direction the rest of your body can go is head over heels.

I looked like I had purposefully launched myself over a pommel horse.  During the first few seconds of my flight I was reluctant to let go of my date’s hands.  I thought that if we fell together that there was some small chance that I could shift the blame for the crash to her.  We separated at speed and created sort of a demolition derby for those around us, bodies piling up like logs awaiting entrance to a saw mill.  For the rest of the evening it felt like people were pointing at me as if to say, “Steer clear of him, he’s the one who took us all out.”

My one mistake caused a chain reaction of bad events and a severely hematomaed ego.  Bad things rarely happen in a vacuum.  There’s cause and effect, and the effect can be disastrous.  For those of you whose EHR program is underway who may have scrimped on the planning process—you know who you are—you may as well be the captain of the Titanic throwing refrigerant in the water.  There is no recovery from bad planning.

No matter what the shape of your EHR implementation, if you find yourself humming a few bars of “I write the songs”, only two things can happen and they’re both bad.

saint

The importance of due diligence

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What was your first car?  Mine was a 60’ something Corvair–$300.  Four doors, black vinyl bench seating that required hours of hand-stitching to hide the slash marks made by the prior owner, an AM radio, push-button transmission located on the dash.  Maroon-ish.  Fifty miles to the—quart—I carried a case of oil in the trunk.

I am far from mechanically inclined.  In high school I failed the ASVAB, Armed Services Vocational Aptitude Battery—the put the round peg in the round hole test.  Just to understand how un-complex the Corvair was, I, who hardly knows how to work the radio in a new car, rebuilt the Corvair’s alternator—must not have had many working parts.  I could see the street from the driver’s side foot well.

However, it had one thing going for it, turning the key often made it go—at least for the first three or four months during which I owned it.  Serves me right.  A guy in school who I didn’t know who was selling it pitched it to me as his dream car.  Not wanting to look stupid, I bought into the sales pitch.  Pretty poor due diligence.  An impulse purchase to meet what I felt was a social imperative—a date-mobile.

The last time I made a good impulse purchase was an ice cream sandwich on a hundred degree day.  Most other decisions could have used some good data.  The lack of good data falls on one person, me.

How good is the data you have for deciding to implement and EHR?  In selecting an EHR?  Did you perform the necessary due diligence?  How do you know?  It’s tedious, it can lack intellectual stimulation?  You want to be seen as someone who made a wise choice.

The difference between you and me is that when I learned I’d made a poor decision I bought a different car.  You can’t do that with an EHR.  You’re stuck looking at the street through the hole in the floor for a long time.

saint

EHR: my 12-step program

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Sometimes I need to shift into neutral and allow myself the luxury to pause and reflect.  This afternoon I find myself reflecting on the past 35 years, coincidentally, the same number of years since I graduated from high school—it’s okay to fast forward to the end to see if I actually tie this into anything worth your time, I can’t guarantee anything as of yet.  If I don’t come through, I’ll owe you one.  Maybe I’ll write something so obtuse at the end about reform that you’ll feel as though the fault lies with you for not understanding me.

So, we are to meet tonight—I have seen none of them since I departed for the Air Force Academy.  There is a reason I haven’t seen anyone.  The part I don’t get is why at this time we’ve mutually decided to end our hibernation.  It’s a little like the emergence of the seventeen year locusts times two.

We have only Facebook to blame for this folly.  I must admit it has been rather entertaining seeing pictures of them as adults, and reading how they describe themselves.

During my senior year I pulled my hair back when I ran.  My hair is no longer pullable.  I am some twenty pounds heavier than my playing weight.  I considered the drive-through face lift on the way down today, but thought the bandages would give it away.

Do most people go through this, wondering if you’ll impress those for which you held with such low regard, and they for you?  (That sentence was a bugger to piece together.)  At what point do we say this is stupid and move forward?  I’m guessing it must happen at year thirty-six or beyond.

I don’t understand my motivation in agreeing to come.  Is there an entertainment factor, some degree of closure, an in-your-face moment?  Is it because you get to look the high school bully in the eye and pretend he’s the parking attendant, tossing him the key to your Mercedes and ordering him not to scratch it?  What is it about those four years as opposed to any other four years that draws people back?  There is definitely something voyeuristic to it.  No other four year period in anyone’s life could exert that same pull.  Maybe that speaks to the transitory pattern of our lives after high school.

It’s the only time when we saw the same hundreds of people day in and day out for four straight years.  Maybe it had to do with having no responsibility, or maybe it had to do with bell bottoms, platform shoes, and long hair.  Relationships were built in the hallways next to our lockers—sort of a premature cohabitation—and lasted until the bell rung for home room.  New ones—upgrades—began to blossom on the school bus on the way home.  It was the best of times; it was the worst of times.  It was Nixon and Led Zeppelin, Peter Max and 3.2 beer.

These people with whom I am about to reunite, we are strangers once removed—by tomorrow I will know if it would have been better to have left it that way.  Some of them will never be mistaken for someone who knew how to calibrate ground-to-air missiles—perhaps they think that of me.  Some are poltergeists who  think of themselves as the Zeitgeists of my generation—I do not know what that means, but it looked like a good sentence as I was typing it.

There’s less than two hours until the foot lights come up and the actors have to move downstage to their positions.  I’m guessing that only the boringly secure have decided to play themselves.  The twelve-steppers are deciding which character to play on opening night and rehearsing their lines with their spouse or significant other—a term by the way which held no meaning in high school.  Costumes lay strewn across the hotel bed as the actors decide on the perfect, here’s how I turned out after thirty-five years look.  I find myself torn between the erstwhile bon vivant prepster and the Barry Sonnenfeld, Men in Black look.

Anyway, I’ve waxed and waned to the degree where I now feel completely marginalized.  I wrote in my year book that I wanted to be president.  A lot of these people are a few fries short of a Happy Meal, but I think even they will discern quickly that I fell short of that goal.  Nonetheless, I wake each day intent on slaying my personal dragons.  You?  Here comes the segue.

The time is coming where we will need to decide which character we will play in the roll out of our EHR systems.  Are there those who will break from the pack, eschew what others will say about their approach, toss aside the conventional wisdom of being in lock-step with the majority, and decide to approach this as a solution to a business problem?

I dare say that most will choose the path most traveled.  The path that says how wrong can I possibly be by doing what everyone else is doing.  Those who act on what they know is right, those who look for an EHR solution that rates future flexibility higher than the ability to conform to non-existing standards, higher than the gossamer guidelines of certification and meaningful use, will find that not only have they leapfrogged their peers, they will find that they have selected wisely.

Those who choose to follow the crowd may find themselves hibernating with the cicadas.

saint

Hospital Impact – Healthy Choices: Nine Healthcare Bloggers Worth a Click

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Hospital Impact – Healthy Choices: Nine Healthcare Bloggers Worth a Click http://bit.ly/5KUlg

saint

Why I differ with Mr. Halamka’s EHR strategy

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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.” http://govhealthit.com/newsitem.aspx?nid=72152 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 http://ow.ly/rPOH. 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.

https://healthcareitstrategy.com/2009/09/27/how-can-ehr-be-made-to-work/

saint

AP reports EHR plan will fail-now what?

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blazzing

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.

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When you’re in a hole, stop digging

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rappelling_1_1I 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 chart.

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What should be the role of the CMIO?

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leadDid you ever notice when you’re watching a sports movie that a down-and-out, last-place team can always be rallied into first place in one season by the simple addition of one player with a winning attitude?  Some people keep going to see Gone With the Wind thinking that if they see it enough times the south might win.  Fantasy works well in almost any setting where popcorn is served.

Unfortunately, they don’t serve popcorn in EHR planning sessions.  Perhaps that’s because there aren’t very many planning sessions.  If there were, and if they were held by people who knew what they were up against and how to deal with it, there would be far fewer failures.

There seems to be a rush amongst hospitals to hire Chief Medical Information Officers (CMIO).  Good.  Hospitals should benefit from their skills.  I am curious, what is the qualification or specific expertise that one must possess to be a CMIO?  Are these people officers in the firm in the same sense as CEO, COO, and CFO, or is it more of a naming convention, a way of stating that a doctor has an understanding of IT?

I raise this question because of a hospital I know acting in the belief that this could be the missing link in their EHR genome program.

From my perspective a CMIO is as necessary—but not sufficient—as a CIO, provided that each is used correctly.  Whichever one is placed in charge of EHR, the other will be slighted.  Not just them, but their organization.  If the “I” in CMIO only refers to an informatics degree, I see the role of a CMIO somewhat like that of a color commentator on ESPN.  Unless the CMIO has a successful track record of planning and implementing eight or nine figure information technology projects, I think the role of the CMIO should be limited to ensuring that the clinical side of the program is functional and effective.  In the same sense, the role of the CIO should be limited to non-clinical issues.

I recommend for large EHR programs that a hospital hire a seasoned Program Management Officer, one who can walk in the door and state with confidence, “This is what we are going to do tomorrow because this is what should be done.”

I recently ran the PMO for a large medical device manufacturer implementing a very pricey Product Lifecycle Management (PLM) system.  I knew with certainty the project was at risk the moment we walked past the smattering of cubicles which housed the PLM team.  There was no ‘I’ in team, there was no ‘ME’ in team, there weren’t enough people to play a good game of dodge ball.  There was no team.

Giving people the responsibility will not get the job done if they don’t have the skills to do it.  Who is leading your effort?  Should they be?  What should the minimum skill set be of someone who will manage this hundred million dollar spend?

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How can EHR be made to work?

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I’ve never been mistaken as one who is subtle.  Gray is not in my patois.  I am guilty of seeing things as right and left and right and wrong.  Sometimes I stand alone, sometimes with others, but rarely am I undecided, indecisive, or caught straddling the fence.  When I think about the expression, ‘lead, follow, or get out of the way,’ I see three choices, two of which aren’t worth getting me out of bed.

I do it not of arrogance but to stimulate me, to make a point, to force a dialog, or to cause action.  Some prefer dialectic reasoning to try to resolve contradictions, that’s a subtlety I don’t have.  Like the time I left the vacuum in the middle of the living room for two weeks hoping my roommates would get the hint.  That was subtle and a failure.  I hired a housekeeper and billed them for it.

Take healthcare information technology, HIT.  One way or another I have become the polemic poster child of dissent, HIT’s eristical heretic.  I’ve been consulting for quite a while—twenty-five plus years worth of while.  Sometimes I see something that is so different from everything else I’ve seen that it causes me to pause and have a think.  Most times, the ball rattles around in my head like it’s auditioning for River Dance, and when it settles down, the concept which had led to my confusion begins to make sense to me.

This is not most times.  No matter how hard I try, I am not able to convince myself that the national EHR rollout strategy has even the slightest chance of working as designed.  Don’t tell me you haven’t had the same concern—many of you have shared similar thoughts with me.  The question is, what are we going to do about it?

Here’s my take on the matter, no subtlety whatsoever.  Are you familiar with the children’s game Mousetrap?  It’s an overly designed machined designed to perform a simple task.

Were it simply a question of how to view the current national EHR roll out strategy I would label it a Rube Goldberg strategy.  Rube’s the fellow noted for devising complex machines to perform simple tasks.  No matter how I diagram it, the present EHR approach comes out looking like multiple implementations of the same Rube Goldberg strategy.  It is over designed, overly complex.  For it to work the design requires that the national EHR system must complete as many steps as possible, through untold possible permutations, without a single failure.

Have you ever been a part of a successful launch of a national IT system that:

  • required a hundred thousand or so implementations of a parochial system
  • has been designed by 400 vendors
  • has 400 applications based on their own standards
  • has to transport different versions of health records in and out of hundreds of different regional health information networks
  • has to be interoperable
  • may result in someone’s death if it fails

Me either.

Worse yet, for there to be much of a return on investment from the reform effort, the national EHR roll out must work.  If the planning behind the national ERH strategy is indicative of the planning that has gone into reform, we should all have a long think.

I hate when people throw stones without proposing any ideas.  I offer the following—untested and unproven.  Ideas.  Ideas which either are or aren’t worthy of a further look.  I think they may be; you may prove me wrong.

For EHR to interoperate nationally, some things have to be decided.  Somebody has to be the decider.  This feel good, let the market sort this out approach is not working.  As you read these ideas, please focus on the whether the concept could be made to work, and whether doing so would increase the likelihood of a successful national EHR roll out.

  • Government redirects REC funds plus whatever else is needed to quickly mandate, force, cajole, a national set of EHR standards
    • EHR vendors who account for 90%–pick a number of you don’t like mine—use federal funds to adapt their software to the new standard
    • What happens to the other vendors—I have no idea.  Might they go out of business?  Yup.
    • EHR vendors modify their installed base to the standard
  • Some organization or multiple organizations—how many is a tactic so let’s not get caught up in who, how many, or what platform (let’s focus on whether the idea can be tweaked to make sense)—will create, staff, train its employees to roll out an EHR shrink-wrapped SaaS solution for thousands and thousands of small and solo practice
    • What package—needs to be determined
    • What cost—needs to be determined
    • How will specialists and outliers be handled—let’s figure it out
  • Study existing national networks—do not limit to the US—which permit the secure transfer of records up and down a network.  This could include businesses like airline reservations, telecommunications, OnStar, ATM/finance, Amazon, Gmail—feel free to add to the list.  It does no good to reply with why any given network won’t work.  Anyone can come up with reasons why this won’t work or why it will be difficult or costly to build or deploy.  I want to hear from people who are willing to think about how to do it.  The objective of the exercise is to see if something can be cobbled together from an existing network.  Can a national EHR system steal a group of ideas that will allow the secure transport of health records and thereby eliminate all the non-value-added middle steps (HIEs and RHIOs)?  Can a national EHR system piggyback carriage over an existing network?

We have reached the point of lead, follow, or get out of the way, and two of these are no good.

saint

Know when to ask for help

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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.  But 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?

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