The opinions expressed by this author do not necessarily reflect the opinion of the author, nor were any consultants hurt in the writing of this editorial.

It may not matter what I think, but I think ‘it’s’ dead.  The problem is that the ‘it’ to which I refer depends on what your definition of it is.  That the ‘it’ is too obtuse to define underscores my belief that the possibility that healthcare reform as it is currently envisioned will materialize is only about fifty-fifty.

What are some leading indicators?  For starters, both Fox News and MSNBC appear to be in general agreement—albeit for different reasons—that the people, also known as voters, are not drinking the Kool Aid.  Why?  It has very little to do with whether the average person thinks everyone is entitled to healthcare.  A good portion of it may have to do with the part of us that doesn’t like being told what to do.  HMOs taught us to be that way.  Rightly or wrongly, the average person believes the government will only add to a series of restrictions telling us who we can see for care, and the type of care to which we are entitled.

Ignore if you can the thousand pages of regulation, that we already spent a trillion stimulus dollars, that we’d have to spend another trillion dollars on healthcare under the guise of decreasing the cost of healthcare, paying for reform with a tax increase, or that if reform is pushed back to 2010 Congress will vote for whichever option is most likely to get them re-elected.

Here’s what I think it all boils down to.  Nobody can fully and clearly articulate what the ‘it’ is.  Is it government mandated healthcare, coverage for all, cost reduction, shifting the cost burden, improving care, improving care for all, interoperable electronic health records, payor reform, equal access to equal services, improved quality of care, or improved efficiency?  It may be all of the above.  Preferences seem to differ depending on the individual who hopes to influence them.

What’s the impact on what your EHR Strategy ought to be?  It depends.  That was helpful, wasn’t it?  It depends on how many of the components of reform come to fruition, and to what degree.  If the goal of efficiency on a national level wins out over other goals, interoperability should have greater emphasis.  If it’s cost reduction and efficiency at the provider level, place your emphasis on CDRs and EMRs.  The problem, as I see it, is that the result of healthcare reform will likely be an amalgamation of most of the reform goals.

How does the uncertainty surrounding reform impact your HIT and EHR strategy today?  In defining your requirements, selecting and implementing a system, and redefining reform workflows.  If nothing else, the consequences of having the wrong strategy will be much greater in terms of an organization’s ability to drive real benefits from the EHR.  It will impact its ability to redesign its workflows, and it will either simplify or exacerbate change management and your ability to communicate outside of your own four walls.

Do you have EHR strategery meetings?  The next time you do, make sure you put the following on your agenda.  My conclusion is that the most important component of your EHR strategy is flexibility.  Do not skimp on flexibility—pay extra for it.  Build in flexibility.  Flexibility for what—that’s the big question, isn’t it?

What do you think?

You know how when your flight lands the flight attendant—even I can have a PC moment—says, “We’d like to thank you for flying with us.”  They’d like to thank you but they never do.  That aside, the purpose of this short muse is to thank you for reading and sharing your thoughts.

Thanks.

There’s been a lot of interesting discussion underway on a number of sites about a number of topics all having to do with some aspect of what ought providers be doing to optomize their chances of success around the issues of EHR, healthcare reform, workflow engineering, and so on.  Most of the discussion on the web focus on the fact that the train has already left the station and you should just hop on.  There is little or no discussion about whether a provider should stop and consider if that train is the best one for you.

Here’s an idea I’m offering. Would you be interested in getting together for a day or two to put this idea and a few others on the table and see what we come up with? We could do it in Philadelphia or DC in late August or September. The agenda can be whatever the attendees want it to be.  The take away/delevierable will also be defined by those attneding.

I’d be happy to sponsor it provided we have healthcare providers who are willing to contribute their ideas. This is not intended to be a conference for vendors and consultants to sell their wares.  You can contact me here or by email at paul.roemer@clintonrubin.com.

What topics would you like to see covered?

What discussion would you be willing to lead?

What format makes the most sense?  Breakout groups, presentations?

Sometimes it pays to hire an expert.  Given the uncertainty around standards and interoperability, selecting and implementing an EHR may be one of those times.
Maybe a real life example will help to illustrate the point. I had just purchased my first home. It was located not too far from downtown Denver and the home was built in 1898. Like most homes built in that era, this one lacked many of the things that we consider essential; closets, plumbing, electricity. There were few if any overhead lights in the house. As a new homeowner with a freshly minted MBA, I was on a pretty tight budget. One of the department stores in downtown Denver was going out of business and was selling everything including their fixtures. Being cost-conscious, I thought this may be an opportunity to find a bargain. So I grabbed my wire cutters and drove downtown.

It looked like they were having a fire sale. (That term will have more meaning in a few moments.) As I entered the store hundreds of people were scattered about, going from table to table loaded with purchases. Some people were walking out with shelves and fixtures, other people with shopping carts full of clothing. Looking up, I saw an attractive set of track lighting. It was located directly beneath a large table that was piled high with purses. I found a folding chair, and set it smack dab in the middle of the purses and climbed up. For the briefest of moments that seemed to settle the feeding frenzy that was occurring directly beneath me. Undaunted, they let me go about my work as they went about theirs, ripping and snatching purses and satchels from each other’s hands.

I rocked my feet back and forth on the chair’s plastic cushion to ensure I had correct purchase of the chair on the table. The light canisters were about a foot from my head. Just so you think I’m not a complete idiot I looked up to ensure that the lights were off. Even I knew you didn’t cut down a light that is lit. After all, did I mention I have an MBA? So here’s where it gets interesting. I reach up with my left hand and cut the wire that led from the light fixture and into the ceiling. In a fraction of a second I entered and left the Twilight Zone. Everyone in the store  experienced several of their senses at once. There was a bright flash of purple light, a large crackling sound, and the smell of burnt ozone.  Everyone appeared to be moving in slow motion. I reached up, pulled down the lights, hopped off the table, and made a beeline for my car.

After the tingling in my hands had subsided I reached over and looked at the wire cutters. For those of you not familiar with wire cutters I’ll describe what they should look like. They function much like a pair of scissors and the idea is for them to be able to strip off the plastic sheathing that surrounds the copper wire. Accordingly, there is a series of holes that run from small to large along the two sides of the blades. Behind that section, closest to the fulcrum, is the cutter, the part I used to slice through the wire. That part is not designed with a hole. Unfortunately, my wire cutters now had a freshly melted hole in that area. It appears that when I reached up to cut the wire the electricity was still on–which may account for the crackling sound, the smell of burnt ozone, and the purple flash.

By now, I was scared. I turned on the TV, the local news, to see if I needed to turn myself into the police, to see if in fact I was responsible for having burned down an entire store with several hundred people in it. So where does that leave us? Although this isn’t rocket surgery (just so you  know, that was intentional), there are times when it pays to hire somebody who’s done something at least one more time than you.  I’m pretty sure that when all is said and done, having someone manage the process of selection, implementaion, and workflow alignment may prove to be one of those times.

So if you want my advice, hire an electrician.

It may be helpful as you read this to use your highlighter on the screen to accentuate the important parts or some white-out for the parts you don’t favor.

Do you ever kick an idea around, speaking about it, writing about it, until at some point you finally capture it in a way that makes sense to you?  That’s how I reason things through.  I write like I’m talking aloud and sometimes it lands in my lap.

That just happened to me as I was trying to get my arms around what it is about the concept of the RHIOs that has been bothering me.  Bear with me.  I was on LinkedIn emailing someone using the ‘send a message’ feature.  I was returning an email which she was returning which I had initiated.  The process works like this.  I get an email from LinkedIn telling me I have a message.  I go to LinkedInm read the message and send a reply via LinkedIn.  She receives an email indicating she has a message, goes to LinkedIn, and so forth and so on.

Do you see it?  In this scenario, what is the added value provided by LinkedIn?  Nothing.  It’s all hat and no cowboy.  LinkedIn serves simply as a pass through, contributing nothing.  I wrote in my message to her, “Send me your email address, I feel like I’m in my own RHIO.”

When is a RHIO not aRHIO?  When there’s no need for it.  Is there any functionality intended for the hundreds of RHIOs which couldn’t be dealt with at the N-HIN?  What do you think?

Have you started to feel like the more you fill your plate at the EHR smorgasbord the more you start to notice things in a “Where’s Waldo” kind of way?  It can cause a kerfuffle even among the mugwumps.

For example, what evidence is there that building Rhios to support the national roll-out of EHR is the best way to go? Were the Rhios developed to offset the inequities from Etch-a-Sketch standards and a multitude of vendors? Are they meant to be disposable–will they disappear when the national network is fully functional?

Should they go away?

Been there, done that, got the T-shirt.  Everybody who thinks they have their arms around EHR and healthcare reform, take one step forward……whoa, where are you going Sparky?

The questions below resulted from a round-table discussion I had last week with six healthcare executives about EHR and healthcare reform. The topic we discussed was what questions should C-Level executives be prepared to answer and what questions should boards be asking. What do you think? Are their others you’d add?

Are we taking adequate advantage of stimulus funding to improve our readiness?

How is health care reform going to impact our business and when?

Are we doing enough to be ready to succeed in an environment where we get paid for outcomes rather than inputs?

Are we ready to comply with Federal policies for Electronic Health Record reporting an sharing?

Are we achieving our own business improvement standards? Do we have the right standards?

Are we ready to use web 2.0 technologies to improve clinical outcomes for our clients?

(Please excuse the quality of my drawing, it didn’t scan well.)

A few weeks ago we were swimming.  My wife and children made it known that the day wasn’t going to be a success unless dad was in the pool. My ten year-old and I were standing on the edge of the pool beside the diving board when all of a sudden the board makes the characteristic sound of somebody springing off the end, “boiiinnngggg”. We both looked just in time to see a man complete one and a half flips through the air and make a perfect entry into the water. As the man surfaced, my son turned to me and said, “Dad, he looks like he’s the same age as you. Can you do that Dad?”

On most days, I’m quick enough to outthink my 10-year-old–this wasn’t most days. I could’ve done or should have done a number of things other than the thing I chose. Without a moment’s hesitation, I put my arm around my son, and said, “I can do that.” His eyes beamed. At that moment, my wife asked. “Do what?” Then she said the one thing that guaranteed that I would try and impress my son, “you can’t do that!” I can be told a lot of things. The one thing I can’t be told is that I can’t do something. I gave her my sunglasses–in return, she gave me the look. You know the look, the one that says, I thought I married somebody smarter than that.

There’s a gracefulness that happens when a tanned and toned athletic body glides through the air, seeming to levitate, suspending the laws of gravity, and making a graceful ripping sound as the hands cut through the surface of the water. Then there’s me. I visualized taking three steps, rising into the air, and beginning my somersault during the lift. Even the boiiinnnggg didn’t sound right as I left the board; it was more like the noise of someone playing the cello with a piece of celery. The nearby bathers recognized the sound, and leaned forward in anticipation. As I rose, two, perhaps three inches above the board, I began my tuck and roll. My son was pulling for me, my wife pulling him away from the site of the pending disaster.

In the sport of diving there are numerous sanctioned dives; inward pikes, back dives, forward somersaults. The ¾ flip is not one of them.  The sound of the ¾ flip is unmistakable. The flip ends in the reclining position; a nice position if you are in bed, a not so nice position if it’s your back smacking the water. Three fourths of most things is not good. You don’t watch ¾ of a movie, or fly ¾ of the way to your destination.  Three fourths of a healthcare network isn’t all that great, especially if you’re in the missing fourth.

What’s the likelihood this will work?  Are the chances of success greater to have numerous governing bodies builing their own?  Does something already exist that might be useful?  There’s been a lot of discussion recently about the network of Rhios.  That has me thinking about a few of the national networks that already exist–banking, Amazon, airline reservations, phone companies.  Is there something that can be learned from how they built theirs?  Does the healthcare network have to be built from scratch?  Is it possible to piggyback the transport of the information on an existing network?  What do you think?

Take the phone network as an example–forgive me if I step all over the technology here, it’s not my strong suit. If I call from Philadelphia, to San DIego, the call is transported on the backbone and routed across (handed off) several telcos, often via a route that if it was diagrammed would make no logical sense. There is built in redundancy and backup. Telco networks and billing systems are designed to use these “hand offs” via a system of interconnects and mediation. I don’t have the network built in to my land line, and I don’t need to know anything about how my call gets from point A to point B.

I’m wondering, can the same principle apply in healthcare. Since the networks don’t change the health record, can there be a collection of fail safe nodes whose sole purpose is to pass my health record from A to B, have it updated at B, and then pass it back? I know this is leaving out 99% of the difficulty, but can this idea work?

Maybe Monty Python said it best:

BEDEMIR: So, why do witches burn?
[pause]
VILLAGER #3: B–… ’cause they’re made of wood…?
BEDEMIR: Good!
CROWD: Oh yeah, yeah…
BEDEMIR: So, how do we tell whether she is made of wood?
VILLAGER #1: Build a bridge out of her.
BEDEMIR: Aah, but can you not also build bridges out of stone?
VILLAGER #2: Oh, yeah.
BEDEMIR: Does wood sink in water?
VILLAGER #1: No, no.
VILLAGER #2: It floats! It floats!
VILLAGER #1: Throw her into the pond!
CROWD: The pond!
BEDEMIR: What also floats in water?
ARTHUR: A duck.
CROWD: Oooh.
BEDEMIR: Exactly! So, logically…,
VILLAGER #1: If… she.. weighs the same as a duck, she’s made of wood.
BEDEMIR: And therefore–?
VILLAGER #1: A witch!

So, here’s my opinion on the future of certifiability. If it walks like a duck, but doesn’t talk like a duck to all the other ducks, it won’t be fully certified. If I controlled the purse strings and had told the country we spent $20 billion on a national network, my guess is that the one criteria that everyone will remember will be the network.

Is my doctor’s office connected to my hospital? If I’m on vacation 500 miles from home and my wife has to go to the ER, is her history there? It either is or it isn’t, black or white. Some will argue that there are shades of gray deserving of pseudo certification, but to the average person on the street, to Congress, to the physicians who’ll have to use it anything short of interoperability won’t count as a win.