For starters, I am curious as to what costs, if any, were sunk costs?  Are they suggesting that even the variable costs were too high?

What does this say about the EHR ROI for ambulatory care?  I think it could be saying three things.

1.  Perhaps it shows that there is some lower threshold in terms of the number of physicians in a practice needed to show a positive ROI
2.  Perhaps in these economic conditions it makes more sense to use a managed services approach for ambulatory EHR
3.  Perhaps this is a strong argument for purchasing a wrap-around EHR service

What do you think?

“Physician groups in Phoenix are canceling their EMR contracts as a result of training, functionality or affordability issues. This is especially prevalent among smaller physician groups, the report says.

The report said “deinstallation” due to financial issues is not unique to  physician groups or to Arizona. For example, in areas like Miami, where the economic downturn is threatening the profitability of hospitals, adoption of EMRs has been slow because of a lack of funding for such capital projects.”

http://www.healthcareitnews.com/news/study-deinstallation-emrs-phoenix-could-be-trend

Is it fair to characterize stimulus funds as an after the fact (post implementation) performance based rebate?  How do you think the feds will evaluate performance as relates to earn-out:
1.  Will it be based at all on how well it meets your internal needs, or
2.  Will it be entirely based on whether your EHR is able to fully connect with the NHIN?

Restated, is the stimulus money only there to help stimulate healthcare providers to build their EHR in such a manner that it is part of the national network?

Many organizations have a Program Management Office and a Program Steering Committee to oversee all aspects of the EHR.  Typically these include broad objectives like defining the functional and technical requirements, process redesign, change management, software selection, training, and implementation.  Chances are that neither the PMO or the steering committee has ever selected or implemented and EHR.  As such, it can be difficult to know how well the effort is proceeding.  Simply matching deliverables to milestones may be of little value if the deliverables and milestones are wrong.  The program can quickly take on the look and feel of the scene from the movie City Slickers when the guys on horseback are tyring to determine where they are.  One of the riders replies, “We don’t know where we’re going, but we’re making really good time.”

One way to provide oversight is to constantly ask the PMO “why.”  Why did we miss that date?  Why are we doing it this way?  Tell me again, why did we select that vendor?  Why didn’t we evaluate more options?  As members of the steering committee you are responsible for being able to provide correct answers to those questions, just as the PMO is responsible for being able to provide them to you.  The PMO will either have substantiated answers, or he or she won’t.  If the PMO isn’t forthcoming with those answers, in effect you have your answer to a more important question, “Is the project in trouble?”  If the steering committe is a rubber stamp, everyone loses.  To be of value, the committee should serve as a board of inquiry.  You your instincts to judge how the PMO responds.  Is the PMO forthcoming?  Does the PMO have command of the material?  Can the PMO explain the status in plain English?

So, how can you tell how the EHR effort is progressing?  Perhaps this is one way to tell.

A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick the cat up. The brother hesitated, then said, “I’m so sorry, but while you were away, the cat died.”

The man was very upset and yelled, “You know, you could have broken the news to me better than that. When I called today, you could have said the cat was on the roof and wouldn’t come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said he had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and won’t come down.”

If you ask the PMO how the project is going and he responds by saying, “The vendor’s on the roof and won’t come down,” it may be time to get a new vendor.

I was thinking the other day about my heart attack six years ago.  As I was awaiting my angioplasty it occurred to me that although I had a pretty good idea about what was about to happen, I had absolutely no input or information about who would be performing the procedure.  What I wanted was input and information somewhere between the extremes of ‘none at all’ and how to perform the procedure on myself—Type A personality.

I wouldn’t have felt they way if I was having a plantar wart removed, or repairing a broken bone, but we’re talking about my heart.  From the back of an ambulance nobody asks you who you want for a cardiologist, you go to whoever happens to work at the hospital.  It’s a little like getting a haircut—I go to whichever barber is available.

I don’t care who cuts my hair, what’s left of it, but I do care about who might have to operate on my heart.  Through some connections I have at CHOP I received the names of three cardiologists, I interviewed them, and made my decision.

This got me to thinking about how doctors might view this entire EHR issue.  I asked myself if I was a doctor, what would I want to know?  What is the proper balance of input and information I need to be able to make a reasoned decision on EHR?  It lays somewhere between, “I’ll code my own,” and “Call me when you’re done.”

I don’t want to buy something simply because a sales rep tells me it’s a good idea.  I also don’t want an associates degree in IT.  For me, the ideal solution would be to have someone bring me three or four good choices, provide me a business perspective of the pluses and minuses of each, and information about the cost, the impact to my practice, and the training.  Show me the cost breakdown of having my own versus having it run elsewhere.  Having enough information upon which to make an informed decision, once I’ve made it, I’d like to be able to do my work, and have whomever I’ve selected install it for me.

In effect, I’d like a “wrap around” EHR.  Perhaps it handles the practices in my office, perhaps the ones in my building.  Maybe someone else hosts it; maybe I can get it integrated with my billing.  I’d like it to include my federal reporting requirements.  I’d like it to facilitate peer learning, and have customizable work flows, on-line training via a learning management system (LMS), and help desk and support rolled into the package.  I want whoever is doing this to clean up my records and have them present in the new system.  I also need to know what will be done if my computer gets fried or the building blows up.  Lastly, I want somebody to manage this whole process on my behalf, somebody who can make sure that what I think I bought is what I get.

What do you think?

A large hospital with whom we’ve been meeting has significant work flow duplication across their revenue silos, both clinical and back office.  We are trying to help them understand the evolution of operating under a single set of work flows through shared services, in-sourcing, or outsourcing, and then aim for best practices.  That will provide for significant cost savings and a return on the EHR even if it’s years before the EHR moves beyond their 4 walls.

EHR without an intense review of its work flows and business rules really undermines the ROI.

The work flow effort can be started now, even prior to selecting and EHR.  What is your organization doing in this area?

The point of this entire discussion is the following:  It’s not about the EHR, it never was.  It’s about healthcare reform and how to transform the business.  The EHR is a healthcare tool.  Its singular purpose is to enable your hospital or clinic to radically transform its business.  If it can’t do that, it’s time to select another tool, or retool the one you have.

The purpose of this blog is to incite discussion around the topics of EHR, EMR, HIT, RHIOs, and NHIN.  Our intent is to see what we can do to further the discussion, and to drive solutions in the areas of risk, implementation, interoperability, and funding. There are plenty of sites that regurgitate facts on every aspect of EHR, and even more sites vying for your dollars.  Here, we’re vying for your opinion–what works, what doesn’t, and what can be done about it.

Please refrain from solicitations.  I’d like this to be a place where healthcare providers feel free to drop in without worrying that they will be asked to buy something.

I should note that I find most blogs rather stale and tedious to read.  I like to write as though we’re in conversation.  I enjoy an occasional rant and muse, and believe there’s always room for a little humor in everyone’s day.  I’ve also been known to be a stickler for good grammar.  I’m a left brained consultant in a right brained world, dishing out my own form of logic as the mood strikes.

Bear in mind, we’re professionals–don’t try this at home.  I look forward to your input, perhaps you’ll look forward to mine.

Paul

On one of the LinkedIn healcthcare groups someone inquired rather indelicately about the source of the data I posted.  I replied with the same degree of indelicacy with the following.

My “curious combination of exact figures and sweeping generalizations” comes from several places including HIT.gov and the New England Journal of Medicine. I posted a PowerPoint presentation on slideshare.com entitled, “EHR-Why Should I be Worried.” Unfortunately, the charts and data in the presentation were pasted directly from these same specious sources. “Things just get curiouser and cuiouser”—Lewis Carroll. Hopefully I’ve addressed the first question.

The second posted opinion questioned my perspective on having writtenthat EHR implementations are difficult and tend to fail.  I wrote from the perspective of a hospital that is required to pass the tests of certifiable, meaningful use, and interoperability. Someone in the computer hardware industry (the holder of the second opinion is an EHR hardware vendor–I peaked at his profile) would see the situation from a different perspective,and would have more of a “what’s in it for me bias.”

Today the feds announced that the standards under which the CCHIT has issued certification should be expected to change significantly, therefore installations passing as certified today shouldn’t assume they will pass once standards are finalized.

The pain from EHR which we will all be facing is my opinion, part of which comes from doing my homework and talking with healthcare providers, some of which comes from being someone not known for drinking the Kool Aid.

Here’s my reasoning:

1. Only half the required HC IT people are in place.

2. None of the products (according to the government) passes the connect or interoperability test.

3. To be of any value, the EMR must connect to the EHR. The EHR must connect to other EHRs via the continuity of care record (CCR) and to the Rhio. The Rhios must connect to the NHIN. This house of cards doesn’t even exist.

4. There is no EHR czar. Can anyone answer this? Who is in charge, who has the authority, who can stand up and say, “I am the decider?”

5. The vendors each want their own standards (big surprise)

6. To me, we have a battle somewhat akin to the one between VHS and Betamax, only with many more technologies in play

7. EHR communicating with EHR ambulatory is worse than when I tried to get by on Spanish in Brazil (before someone feels the need to correct me on this–as they did in the LinkedIn discussion–the error is deliberate and is made to illustrate the point that 2 languages are being spoken.)

8. We are in the middle of a nationwide rollout of EHR.

9. The EHR vendors do not have the staff needed to perform the required number of installations.

10. In-house IT departments that still need an EHR have:
a. never acquired an EHR
b. never installed an EHR
c. never designed processes to support an EHR
d. etc.

I’ll close with this. If I have the only phone in the country, apart from its value to me, my phone is worth nothing. If you and I have the only 2 phones, it’s still worth about nothing. If there are a million phones interconnected then you have something of value.

I use this illustration because I did a fair amount of telco consulting, and a lot of that was with interconnects. When a call goes from point A to point B, more often than not the call passes through the networks of several phone companies. Each company must capture and report call detail records (these are much simpler than healthcare records) for the point of origin and the departure point. They aggregate this data to bill the customer for the call and then to mediate the bills amongst themselves. When was the last time you agreed with your phone bill?

The point is, this example is just telephone billing. Medical billing is much more complex, and EMRs and PHRs add another magnitude of complexity.

Do I think EHRs are complex? Yes. Do I think they will be ready in time? No. Will a working nationwide interconnect be in place in time. No. That’s my opinion, and I base it on my own curious and sweeping data.

What do you think?

Like anyone needs my advice as to how to do that. Go ahead, have at it. Go shopping. Shop to you drop. How much do you need? Suppose we open the coffers. How much; another million? Ten Million? Twenty-five, fifty? $100,000,000? This is a one-time offer, so make sure you ask for everything you need.

What if I told you this money is available provided you correctly answer a few basic questions. Reasonable? I’d hope so for a hundred million dollars.

1. What will you do with the money that you haven’t already done?

2. Has anyone else ever done that?

3. If yes, did it work for them?

4. If no, why not, and what makes you think it will work for you?

5. Will these additional funds;

a. Allow you to connect to your external providers?

b. Allow you to install something that connects to other EHRs?

c. Pass the meaningful use test?

6. What is your mission and objective for EHR?

7. Why isn’t your mission the questions raised in 5.a-5.c?

8. Have other hospitals spent the amount you are requesting?

9. Did that amount of funding allow them to meet the criteria specified in question 5?

10. If no, what makes you think you can do it?

If your CFO asked these questions, could you answer them? If not, prepare 3 envelopes (see Google)

New wireless mouse-$50. New plasma monitors-$1,200. Upgrade the coffee to Starbucks-$5. Working EHR–Priceless.