Some things in this universe will confound me until the day we are sucked into a black hole.  I can’t explain why my wife, an intelligent person by anyone’s standards, reads People Magazine, or why some people like to listen to Celine Deon.  Exchanging ideas with you about how to go about using EHR to help transform healthcare seems much simpler.

Sometimes I have an idea and I start to noodle on it.  The Brits call it “Having a think.”  It’s the kind of idea that makes me wonder where I left my crayons because I like to doodle while I noodle—I should mention that I find value in being someone who colors outside the lines.  It’s the type of idea that I know will be made better by the insight of others.

Here’s today’s crayon-induced idea.  We all know there is no bespoke business model for healthcare.  Each service provider’s business model is different, a difference mostly attributable to varied business processes.  If we’re in general agreement that there is no bespoke model, then we should be even more convinced that there is no bespoke EHR application—it goes without saying that vendors will try to convince you otherwise.

For those who thought healthcare was complex, look where it’s headed.  It’s going to get even uglier before it gets better.  Complexity can be measured a number of ways.  To keep it simple, let’s assign a value of ‘1’ to represent the complexity of a single healthcare provider.  So, how might we measure the additional marginal complexity created by having a national network of interoperable healthcare providers?  One way is to take the number of providers and multiply them by the number of relationships in the network—X number of providers times Y number of RHIOs equals the added degree of complexity.

It doesn’t matter what the real complexity is.  Whatever the actual complexity, it’s greater than ‘1’, and since your institution will be part of the connected network, your organization’s complexity has also increased.

Is there a way to manage the complexity?  To lower it?  To lower the risk to your organization?  Let’s discuss that in the next few iterations of this blog.  I look forward to hearing how you are managing it.

One of these days when I ask myself if it’s just me, somebody’s going to shout back, “Of course it’s just you!” It seems I do well until I am forced to interact with someone. Nobody ever suggested I take a job of receptionist. Did I just say ‘receptionist’? (Here’s the segue.)

So, I walk into the podiatrist–to have my slightly torn Achilles examined–there are twelve chairs and nineteen people in the small room.  The receptionist inquires, (this is a direct quote), “Is this the first time you’ve been here recently?”  Since I haven’t had the pleasure of speaking with most of you, you may not know that I’m one of those people who believe that if you are going to speak English, you might as well speak it correctly.  As her sentence was perfectly flawed, she left me no choice but to repeat it. “Is this the first time you’ve been here recently?” I asked rhetorically. She did not understand why I asked her what she had asked me. I thought of trying it another way. “Is this the first time I’ve been here, no. Have I been here recently, no. Is this the first time you’ve been here recently—I have no idea what you mean.”

Was it her fault there were no seats in the waiting room—no. Would that stop me from getting pithy the next time—probably not? Blame the Y chromosome for the attitude.  Maybe it’s a hunter-gatherer thing; something to do with the urge to cook everything over an open flame. I really am nice to children and dogs, really. I then asked how long I should expect to wait and she told me there was nobody in front of me.  Maybe the other 19 people were mannequins.

The doctor is a family friend.  He’s part of a ten physician practice with three locations.  Two therapy practices are semi-incorporated into their practice.  After the exam we chatted about EHR, and what plans they had.  it was a brief chat.  They’d received several sales calls.  He showed me the stack of brochures.  He summarized saying that they knew they ought to do something about it, but had no idea where to being or who to believe.  They had assigned the task to their youngest partner, believing that his age made him the most computer savvy.

He told me that the other specialists who officed in the building had opted for the same do nothing approach for reasons ranging from cost to lack of knowledge.  He asked my why if EHR was so important that nobody with any credibility had developed some sort of DIY EHR or EHR for Dummies.

I asked his assistant to send me an Outlook invitation for my next appointment.  She just smiled and and wrote the appoinment information on a small card.

Have you found anything or created anything along the lines of a DIY program that you found helpful?

If a blog fell in the woods and nobody commented on it is it still a blog? It’s a little like talking to myself, or singing in the shower–it always sounds better..It would be even better if you add your thoughts.

If one person started blogging on a train that left NY traveling 60 miles an hour, and another started blogging on a train leaving Seattle traveling at 55 miles an hours, when could someone in Denver read it?

If a tree falls in the forest and no one is around to see it, do the other trees make fun of it?

Just checking…

Talk about overcoming my own competancy–I should be kept far away from code.  My day would have been easier had I tried to install EHR in Aramaic.

I just got lost in thought. It was unfamiliar territory.

Apparently there’s an entire sub-community of RHIOs popping up around the country. From what I can tell these pseudo organizations are self-defined and originate out of their members; schools, rural providers, community health centers, and ambulatory EMRs. Some can be defined as virtual; some such as the VA, Kaiser, and even Wal-Mart have built what could be called RHIO equivalents.

Have you come across one of these?  How will they be incorporated into the national network?  Under what set of standards?

If you’re looking to add to the complexity you may want to follow in the footsteps of what some hospitals have done.  I don’t know if their approach was part of an overall strategy, or a result born out of necessity, one conscripted by the strictures of the self-imposed autonomy of the organization.  The only unifying element among the autonomous units is the brand.  The hospital executive I spoke with yesterday indicated that his hospital’s dilemma was the result of not having an EHR strategy.  Their radiology practice implemented an EHR, surgical another, oncology yet another, and so forth and so on.

By the time the hospital had decided to implement EHR they learned they already had five, none of which could be interconnected.  An interesting problem.  What did they do?  Having no choice, their only option was to construct an EHR capable of connecting the five EHRs—a mini Rhio.

Not having a plan added a lot of additional cost.  It left them without any standardized processes and without much of an ROI.  At least now they are considering a managed services approach to handle their duplicated functions like billing, payroll, and IT.

We’d kicked around the concept of having a national EHR czar; maybe we need to ensure that we first have an internal EHR czar.

“The time has come,” the Walrus said, “To talk of many things: Of shoes–and ships–and sealing-wax–Of cabbages–and kings–And why the sea is boiling hot– And whether pigs have wings.”
And so it has come, the time, that is. What if we kick this discussion up a notch? Allow me to begin with some heresy—opinion or doctrine at variance with the orthodox or accepted doctrine. To do that, we are going to learn color outside of the lines.  And, what is the heresy?

“Do away with EHR,” he shouted. Those who haven’t stopped reading please bear with me. Most providers appear to be headed down the EHR highway. Why? Hold onto that question for a minute. What if instead of operating from the premise that everyone needs an EHR, we flipped the premise on its head. Nobody can have an EHR unless they can explain what business problem the EHR will address.

Here’s a brief segue—watch closely or you’ll miss it.  As I passed my ten year-olds bedroom, I asked him why it looked so clean.  “Mom made me do it,” was all he said.  Now that didn’t hurt—the segue—did it?

Mom made me do it.  Why are you getting an EHR?  “Obama made me do it.”  I’ll share my perspective just in case it may not be clear; implementing EHR because you are told to do it is not addressing a business problem.  While it may pass the test of necessity, it does not pass the more rigid test of being both necessary and sufficient.

Now for the tricky part, defining what constitutes a sufficient business case for spending all that money and tearing apart your way of doing business.  For those who have implemented EHR, and for those who are thinking about it, what is your business case?  Does it pass the test of necessary and sufficient if it never goes beyond your four walls?

I’d like to know what you think and what critical success factors you are using.

Last night as I’m sitting on a hard bleacher watching my seven-year-olds baseball practice I noticed the mom sitting next to me looking a little forlorn. Being naturally inquisitive, I asked if everything was okay.

“I lost his glove,” she replied.

Noticing a glove on her son’s hand, she saw my look of confusion. “Not his. My husband’s. I had it with me last Thursday, and I left it here.”

“I don’t suppose this was a new glove. Judging by the look on your face I’d say this was his favorite glove; thirty years old, supple, broken in, fold flat as a sheet of paper.”

“Twenty-five years,” she corrected as she lowered her eyes.

“It’s rained the last three days,” I told her, which caused her to grimace even more. Having nothing better to do, I flayed her emotions. “I bet that glove meant the world to him. He probably planned on giving it to your son in a few years. The glove probably reminds him of some of the big events in his life, every scar, each stain on the leather, points to something important. You know, if it was outside for a few days, the field mice will have chewed on the leather.”

She brushed away a tear, and headed to the lost and found.

“Any luck?” She shook her head in despair. “In some countries, if a wife does something life that, the husband can sever the relationship, literally,” I said as I made a slashing motion with my hand. She made the briefest of smiles. At least she knew I was pulling her lariat. Reeling her in, I continued.

“You’re not thinking of spending the night at home, are you? If you are, you should at least call someone and let them know of your plans. He’ll heal over time,” I told her. “But he won’t forget it. Twenty years from now the two of you will be watching something on TV, and something will remind him of the glove YOU lost.”

Fast forward to tonight. My daughter and I are getting out of the car so I can coach her and her softball team in the playoff game.

“Is your glove in the trunk?” I asked. This is after I spent several minutes grilling her at home about whether she had everything she needed for her game.

“I hope so,” she said shamelessly as I popped the trunk for her. “You hope so?” I repeated with an edge in my voice.

“It’s not here Daddy.”

I left her with her friends and drove home to look for it. Ten minutes. Nothing. For some reason, I looked in the trunk. There it was. Death by 1,000 cuts.

“I hope so.” What kind of a response is that?  Does it all come down to baseball gloves?  As a member of your executive team, you should be able to raise these types of questions of your EHR project manager.

Will this EHR application work with our ambulatory care providers?  I hope so.

Can you confirm for me that the EHR provider you chose will be in business in five years?  I hope so.

Is somebody handling the change management issues for EHR? I hope so.

Do you think we will pass the certification requirements for interoperability?  I hope so.

Will we both still be working here next year?  I hope so.

I almost fell out of my chair when I had this conversation last night with a reasoned and responsible IT executive at one of the best known hospitals in the US.  I’m paraphrasing only because my on-the-fly stenography skills are non-existent.

ME:                        “What is the hospital’s plan for linking outside specialists and physicians to your EHR?”

HOSPITAL:           “The term “plan” may be overly optimistic.”

ME:                        “How so?”  I asked with a bit of intrigue.

HOSPITAL:           “A lot of the doctors like to program as a hobby.”

ME:                        “You’re kidding, right?”

HOSPITAL:           “No.  We have a number of people building their own EHR.”

ME:                        “So, in effect you guys have lots of CIOs.  That should be fun watching you make that work.”

Clearly that’s not the real implication, but it does go a long way to the need for an EHR Czar, even within the confines of a single provider.

…are like the Mars and Venus of healthcare IT–Ambulatory is from Mars, Clinical is from Venus, at least that’s what it sounds like some days.

What’s your take on this?