It’s embarrassing and it can show itself at awkward moments.  It’s called FDD.  How many of you are struggling with Functional Deficiency Disorder?

Most of you would agree that the basic components of an EHR system include:

Clinical Documentation

Data Export

Data Import

Decision Support System

ePrescribing

Order Management

Reporting Requirements

Results Management

Privacy and Security

That said, why is there such a disconnect between what it’s capable of doing and what it does?  EHR math spells it out this way:

Capability-Usability=FDD

I’ve been discussing this with a number of people who have stuff they want to sell healthcare providers.  They have a long list of what they think causes FDD.  Guess what?  They think most of the problems can be attributed to the providers.  Who’da thunk it?

For those who continue to suffer from FDD, have your people call my people, and we’ll do lunch.

Got the T-shirt.

Did you know AIG got $79 billion?  There’s also our friends at Goldman.  This got me thinking—some would argue that it in itself is noteworthy.  There’s a reason nobody shed tears for these guys, and that is the average person has no connection to them other than what they hear on the evening news.  We never got a car loan or a mortgage from them, so when they were dangling over the precipice we wouldn’t have lost any sleep had they been allowed to fail.  Unfortunately, the reports of their death were greatly exaggerated.

American poet John Godfrey Saxe based the poem The Blind Men and the Elephant on a fable told in India many years ago.  The poem is about blind men trying to describe the elephant solely on what they are able to feel.  As they are all feeling a different part, they each think the elephant is something different from what it is and from what the other believes.

It feels like the reform effort involves an equally obtuse process—dozens of people in separate rooms, each with their own pad of paper and box of Crayolas. When they finished creating their vision of reform, the person with the biggest office stapled all the pages together with the big red stapler like the one they used in the movie Office Space.

Here’s how this all ties together—don’t blink or you may miss it.  People didn’t care about AIG and Goldman because we weren’t connected, because it wasn’t personal.  The opposite is true about healthcare reform.  We are connected.  It is personal.  This is what Washington doesn’t get.  If they don’t demonstrate that they get it, it will fail.

Nancy Pelosi is the poster child for the reform effort.  Her unfavorable ratings are at two to one.  Sixty percent of Americans, also known as voters, are against the reform.  I’d also wager that nearly one hundred percent of those people have insurance, and rightly or wrongly, they believe that reform will take that from them.  There is a small but important distinction here.  They are not against reform per se; they are against the reform as is being discussed.  Moreover, the snowball rolling down hill that Washington can’t stop is that nobody can accurately describe what it is they’re against.

How can the average person know if this is going to work?  If it can’t be explained clearly on a single page, they will lose the voter.  Their opponents already have their message down to a page; the one bullet point is “public option.”

This one is pretty lengthy, so you may want to grab a snack.

Ever watch the show “This old House”? Something magical happens to a man when he watches somebody single-handedly rebuild a 6000 year old home in a 30 minute program. After that no task seems too complex.  The first rule of thumb is to remember that having a master’s degree from a reputable university qualifies you for about anything short of brain surgery.  The true Type A male will often carry that step further by reminding himself that given another week or two of study that even brain surgery would not be that difficult.

I did a project in one of my prior homes. It involved the simple task of rearranging bedroom furniture one Sunday afternoon; 15 minute project, total cost—nothing. After all, how difficult can that be? The actual moving of furniture involved nothing more than I’d planned. Only when I thought I was done did I notice that the television set was now located a good 20 feet away from the cable television outlet. The obvious solution would be to simply move the furniture back to its original position. Can’t do that. To move the furniture back is either admitting defeat, or that I wasn’t bright enough to realize that the cable outlet and the television would be on opposite ends of the planet by the time I finished. Besides, my wife had already seen the new arrangement and if I moved it back to its original position I would have to explain why.

So when she enters the room and asks why (she will ask, that’s her job) there is a 25 foot piece of black coaxial cable snaking its way diagonally across her bedroom carpeting I had better be prepared to answer. Sometimes if you’re quick, real quick, you can try and bluff your way around the problem with a technical answer. You can try and explain that all of the static electricity that was created by sliding furniture across the carpet has caused the sonic membrane surrounding the fiber optical transponders in the coax to be 6 ohms off the medium allowable temperature variation for the building codes in your neighborhood. What you’re really doing is stalling, allowing for a brief period of self-correction.

That truth, having failed me, the only other option left was to try something close to the truth. I’m forced to say that I knew the cable would be at opposite ends of the room before I moved the furniture. My plan all along was to call the cable company and ask them to come to the house to install another outlet on the correct wall. It’s my wife’s job to inquire how much that will cost. This is a clear case of me answering her question without bothering to think. It’s important to have a clear understanding of the underlying issues before trying to resolve the problem. I mentioned that it should cost $40, and that we will only need to leave the cable strewn across the floor for a few days. It’s then her job to say that if we put the furniture back where it was we can solve both problems in 20 minutes. Besides, the cable technician left a mess the last time they did some work, and she wasn’t going to spend more money for poor service. Stay with me here, this is how it becomes her fault, and how it relates to a healthcare blog.

Once her issues were out in the open was a simple matter to devise a solution to address them. The solution needed to be implemented quickly and it needed to be free. My answer came quickly—too quickly. Eighty percent of the problem could be handled by simply running the cable along the floor board, and then under the bed. That only left 5 feet of cable between me and a happy marriage. Unfortunately, the 5 feet in question is from the foot of the bed to the television and runs across the major walkway of the room.

Undaunted, I asked for a little assistance to move the bed. This accomplished, I headed for the garage to find exactly the proper tools for the proper job. I returned five minutes later, tools in hand. I was surprised to see the look of dismay on her face. As it turns out, her dismay resulted because of the razor blade knife clutched in my hand. After 20 minutes of the best Boolean logic I could muster, I convinced her, or at least myself, that it would be a simple matter to cut a small hole in the carpet and force the cable underneath. After all, the bed would hide the hole.

The only other tool I thought I required was a roll of duct tape and a 4’11” broom handle. Women know we are confused about how to proceed the moment they see the duct tape. Most men, when cornered believe that enough duct tape, properly applied, can serve as a panacea for anything up to and including world hunger. You’ll note that I specified the exact length of the broom handle. It’s only after having attempted the project that I’m able to relate the length of the handle. Most men on a project, especially those being watched by their wife, wouldn’t bother to measure a length any more than they would ask directions while driving across Borneo with half a tank of gas.

As it turns out, I should’ve measured both the distance the cable had to travel under the carpet and the length of the broom handle prior to taping the cable to the handle and shoving a 4’11” broom handle under a 5 foot expanse of wall-to-wall carpet. The fact that the carpeting was wall-to-wall is key to understanding what lay ahead. Let’s make certain that the situation is spelled out clearly; the new carpet in our new home had a hole in it, a broom handle was now ensconced under the carpet, and my wife, perched on the bed with a disapproving look that would give carrion eaters a bad name, waited to see what I would do.

Walking to the wall and grasping the carpet as best I could, I pulled up a good 10 feet of it from the tacking, acting all the while like I would have to have done that even had the handle not been 1 inch too short. Leaning with my one arm on the newly exposed carpet tacks, I asked for help to remove the handle from beneath the rug. Once accomplished, and as I bled profusely, I looked for another proper tool to complete the task. Walking through the kitchen I wondered if the best tool could be there. Naturally, it was; one half of a pair of chopsticks; also known by its new technical name, a broom handle extender.

Five minutes later, the broom handle extender and cable were firmly duct taped to the broom handle and once again shoved under the carpet. They both went in, but no cable came out the other side. So, I retrieved the handle and surveyed the situation. The situation, as it turns out, was that in my hand was a perfectly good broom handle, a piece of coaxial cable, and no broom handle extender. The extender was now smack dab in the middle of the 5 foot expanse that I was trying to cross, the problem being that it was on the wrong side of the carpet—the underneath side. It was positioned perfectly. It was too far under to be reached from either end. In other words, it just became a permanent fixture in the bedroom.

Certainly, one small chopstick hidden beneath 400 square feet of carpeting was not a big problem to me. It was not a problem unless you happened to be walking barefoot across the carpet and you happened not to be the one who put it there. In that case, it became not unlike the fable, The Princess and the Pea.  My princess found it immediately.  In that fable, it was the princess could not sleep. In my case, I knew that the non-sleeper in the story would be me for as long as the chopstick remained under the carpet. Keeping my eyes focused firmly on the task at hand, I foolishly believed that if I could resolve the cable problem, the matter of the chopstick would resolve itself. One final trip to the garage led me to return with a second broom handle. The peanut gallery looked on in disbelief in my ability to finish what I had started without having to sell the house at a loss before I was through. The “I told you so’s” were being thought through in most of the major dialects of the Western Hemisphere.

This had ceased to be a project; it was now a quest. A mile of duct tape later, both broom handles were firmly attached to one another. Even if I destroyed every square foot of carpeting in the house, I would not lose this broom handle under the carpet. A minute later the cable emerged exactly where it should have, on the other side of the room. I pulled the out broom handle, attached the cable, and turned on the television. Everything worked, just as I had known it would.

Standing in front of the television, admiring my work in the new room arrangement, I noticed that I was now a good foot taller than when I began the project. Was this an illusion brought about by my success? As was quickly pointed out by my princess, the stature was more attributable to the fact that all of the carpet padding that used to lie between the end of the bed and the wall was now nicely compacted into a ball. The ball of padding was located in the same twilight zone the chopstick found, right in the middle of the walkway. Trying to correct the problem only made it worse. Each time I prodded the ball of padding with the broom handle it grew larger underfoot. Within minutes it looked as though I had managed to suck up every inch of padding from every room in the house and placed it between my wife and a good night’s sleep. Resorting to logic once again, I quickly pointed out that she should walk on it because she would no longer be able to feel the chopstick.

The next day I was on the phone scheduling an appointment with the carpet installation service. The carpet installer had to pull up most of the carpeting in the bedroom to be able to reach what she had affectionately labeled Chopstick Hill. I watched him work and I learned all about carpet padding and the installation of hardwood floors. He explained that it was lucky for me that he came over because our padding was not good quality padding and we would not have known that had he not pulled up the carpet. I asked him why I would want to spend $300 for new padding. Without responding, he just kept slamming his knee into the carpet installer, charging $100 for his efforts and my education.

I was so impressed with his discussion of hardwood floors that I almost bought one on the spot to surprise my wife. By now, we both know she wouldn’t have appreciated the surprise. Anybody who did not want to spend $40 on the cable repairman would probably have a little more trouble accepting $5,000 for a new floor. However, I was able to walk around with a silent smirk on my face for days knowing that had we done it my way from the start, call the cable man, we could’ve saved the $100 and never put a hole in the carpet.

Now that I think about it, I should have waited until she was out shopping.

This is what can happen when you try something on your own.  Start to finish, the EHR system will likely be the most costly and far reaching non-capital project ever undertaken by the hospital.  Sometimes it pays to get help.  Or, you may be able to wait until everybody is out shopping.

Actually, they’re here.  They moved next door Friday–dropped by for a chat.  Eventually we got around to the Revolutionary War.  His position isn’t so much that they lost, but rather retreated, and have not found an opportune time to return.

His wife mentioned her love of British gardens.  I asked her if she would look at my roses and tell me what I needed to do to make them healthier.  She looked a bit askance and asked, “Do you think that just because I lived in Britain I am a rose expert?”  Fair question.  (I was counting my blessings that I had not asked her about tea, or tried to explain why we don’t consider soccer to be a real sport.)

I understand her point.  Just because I spend time in my garage doesn’t make me an automotive expert.  For those who are reading ahead and wondering if I am foolish enough to suggest that there may be a corollary about doctors in hospitals and whether that gives them the expertise they need to run an EHR program, no.  I am not that foolish.

I was simply writing about roses.

Just kidding–sort of.  I’m thinking of reserving the URL.

I read recently in Time Magazine that one of the fastest growing areas of employment in the next decade is theatrical makeup.  I’m stupified.

Recent reports state that there are only half the needed number of trained healcare IT professionals, and that the EHR vendors are ill-equipped to handle the workload.

My take on this, you can build an entire career around this signle issue–the gift that keeps on giving.

Sarah Palin continues to receive national media coverage.  Hospitals continue to implement EHR without any measurable goals.  (One of those is bad.)

The year is 2013.  I had this dream the other night of having dropped my IQ when I was at the hospital, but I couldn’t remember which hospital, so off I went, hospital by hospital looking for my IQ—I realize there are those of you who believe this isn’t a great loss.

In the first hospital I visited, a photo of the new president hung behind the registration desk.  Next to her photo—surprised some of you with that I bet—hung the photo of the Secretary of Hospital Sameness.  For a while I wondered what someone in that position did day to day.  The more hospitals I visited, the more apparent it became.  The hospitals all looked very much alike, right down to dust on the fake Fichus tree next to the water fountain.  For a while I thought that maybe I was driving in circles until I noticed that even though receptionists were all named Gladys, they wore different clothes.  It was almost like visiting Stepford.

Does anyone have the sense that what reform will really accomplish is to reform away healthcare competition?  There appears to be a move afoot towards the efficiency that is created by sameness—what I call the McDonalds healthcare model.  Put one on every corner.  Make them identical.  Limit the options.  Everyone gets a burger.  Nobody gets a steak.

Eliminate waste.  Does that mean eliminate ways of operating that differ from how the government permits them to operate?  There is talk of pulling costs out of the system thereby making it more efficient.  You tell me.  Is the argument that there is so much inefficiency that by becoming efficient not only will we be able to cover everyone, but we will be able to do it at a cost below what it costs to care for far fewer people?

How do you understand it?  Are costs being removed, or simply moved?  If someone with no access to healthcare suddenly has healthcare—a good thing by almost anyone’s standards—the reasoned person knows costs have just increased.  (Healthcare theorem 1:  The cost to provide healthcare to 2 people is greater than or equal to the cost to provide it to one person.)  If costs have increased, how does one make a believable argument that the basis for reform is cost reduction?

I try hard not to be too cynical, but sometimes I think, why bother.  By the way, I found my IQ.  Thanks for asking.

“There is no use trying,” said Alice;
“one can’t believe impossible things.”
“I dare say you haven’t had much practice,” said the Queen.
“When I was your age, I always did it for half an hour a day.
Why, sometimes I’ve believed as many as
six impossible things before breakfast.”

There are a number of people who would have you believe impossible things.  I dare say some already have.  Such as?

“My EHR is certifiable.”

“They told me it will pass meaningful use.”

“We’re not responsible for Interoperability; that happens at the Rhio.”

“It doesn’t matter what comes out of the reform effort, this EHR will handle it.”

“We don’t have to worry about our workflow, this system has its own.”

Sometimes it’s best not to follow the crowd—scores of like-thinking individuals following the EHR direction they’ve been given by vendors.  Why did you select that package—because somebody at The Hospital of Perpetual Implementations did?

There is merit in asking, is your organization guilty of drinking the Kool Aid?  Please don’t mistake my purpose in writing.  There are many benefits available to those who implement an EHR.  My point is is that there will be many more benefits to those who select the right system, to those who know what business problems they expect to address, to those who eliminate redundant business functions, and those who implement proper change management controls.

If I remember my physics correctly, there’s no discernable difference between screaming in a vacuum and not screaming in a vacuum, unless of course someone turns it on while you’re in it, and then by default, you’re screaming. That seemed to make sense to me during my run, but seeing it on the screen isn’t doing much for me. Ever since I tore my Achilles I can’t run as far, and I’ve gained a few pounds. I feel like I’m in my first trimester-running for two of us, sort of a Shamu in Nikes.

Enough about me.  Here’s the deal. There seems to be a slight shifting of the winds in terms of those who now believe reform will work.  The winds are blowing more towards the skeptics.  Who among us can articulate what is included in the reform effort in a single PowerPoint slide?  (Can you picture Ross Perot with his slides and wooden pointer?)  If we can’t explain the reform effort to ourselves, how then can we explain the business problem we’re trying to solve with EHR?  Until you’re comfortable articulating the benefits to your organization—not the ones spelled out on a dot-gov web site, you’re better off holding on to your checkbook.

The current healthcare reform effort violates Keynes’ third law of shopaholics anonymous–just because something you can’t afford and don’t need goes on sale doesn’t mean you have to buy it. (Unless of course it impresses your friends.)  In addition to the trillion dollar stimulus, maybe the government was awarded discount coupons–20% off on EHR if redeemed before the payors own the providers.