I wrote this in reply to a blog written by Gwen Darling August 20 in Healthcare Informatics about how CIOs should staff to meet the demands of EHR.  Please share your thoughts.

When I lived in Colorado my friend and I decided that instead of running during our lunch break we would sit in on an aerobics class. Our plan was to hide away in the back of the class, watch the ladies, and then head back to the office. No sweat—literally, that was also part of the plan. Our thought process was that if women and other lower life forms could do it, how difficult could it be? We were mainly manly men; excuse the use of alliteration.

Within ten minutes we had to peel ourselves from the floor, barely able to lift our arms and legs. What we’d viewed as an hour of simple stretching coupled with an hour of looking like mainly manly men had reduced us to a pair of whimpering sissy boys. We also learned that if you sit in the back of the class that in order to exit you had to make it past all of the ladies as you dragged your carcass from the room.

Fast forward a few decades. I went to an exercise class called spinning. Sounds a little like ballet. It’s a stationary bike. A large TV hangs on a wall. Once again the room is packed with non-males, including my wife. My take on it is that it’s a bike class for women who’d rather watch Regis and pretend to exercise instead of actually breaking a sweat. What the heck; I was already there, why not humor her. The instructor smirked at me when I asked her to tune the TV to ESPN. She inserted a CD of The Killers, cranked it all the way up, and we started pedaling. Pyramids, intervals, uphill, more uphills. Twenty minutes into it my water bottle was empty, my towel soaked. The ladies, including my wife, were chatting away as though they were walking the dog.

Not everything changes with time. Sometimes it better to participate than to watch. Sometimes it’s better to watch. Sometimes, no matter how certain one is, one’s certainty is meant to be changed. Sometimes certainty is based on bad ideas. Like the certainty that comes from knowing, “We’re doing just fine, thank you very much.”

There’s a scene in Billy Crystal’s movie, City Slickers, where the guys are on their horses and one remarks, “We don’t know where we’re going, but we’re making really good time.”

What is that everyone holds with such certitude in healthcare? The efficacy of throwing IT at the problem? The certainty that the current reform plan is the best we can do?

According to National Geographic, a single ant or bee isn’t smart, but their colonies are. The study of swarm intelligence is providing insights that can help humans manage complex systems. The ability of animal groups—such as this flock of starlings—to shift shape as one, even when they have no leader, reflects the genius of collective behavior—something scientists are now tapping to solve human problems.  Two monumental achievements happened this week; someone from MIT developed a mathematical model that mimics the seemingly random behavior of a flight of starlings, and I reached the halfway point in counting backwards from infinity–the number–infinity/2.

Swarm theory. The wisdom of crowds. Contrast that with the ignorance of many to listen to those crowds. In the eighties it took Coca-Cola many months before they heard what the crowd was saying about New Coke. Where does healthcare EHR fit with all of this? I’ll argue that the authors of the public option felt that wisdom.  If you remember the movie Network, towards the end of the movie the anchorman–in this case it was a man, not an anchor person–besides, in the eighties, nobody felt the need it add he/she or it as some morphed politically correct collection of pronouns.  Whoops, I digress.  Where were we?  Oh yes, the anchor-person.  He/she or it went to the window and exhorted everyone to yell, “I’m mad as hell, and I’m not going to take it anymore.”  Pretty soon, his entire audience had followed his lead.

So, starting today, I begin my search for starlings.  A group whose collective wisdom may be able to help shape the healthcare EHR debate.  The requirements for membership is a willingness to leave the path shaped by so few and trodden by so many, to come to a fork in the road and take it. Fly in a new flock.  A flock that says before we get five years down the road and discover that we have created such an unbelievable mess that not only can we not use it, but that we have to write-off the entire effort and redo it, let us at least evaluate whether a strategic change is warranted.  The mess does not lie at the provider level.  It lies in the belief that hundreds of sets of different standards can be married to hundreds of different applications, and then to hundreds of different Rhios.

Where are the starlings headed?  Great question, as it is not sufficient simply to say, “you’re going the wrong way”.  I will write about some of my ideas on that later today.  Please share yours.

Now, when somebody asks you why you strayed from the pack, it would be good to offer a reasoned response.  It’s important to be able to stay on message.  Reform couldn’t do that and look where it is. Here’s a bullet points you can write on a little card, print, laminate, and keep in your wallet if you are challenged.

• Different standards
• Different vendors
• Different Rhios
• No EHR Czar

          Different Standards + Different Vendors + Different Rhios + No Decider = Failure

You know this, I know this.

To know whether your ready to fly in a new direction, ask yourself this question.  Do you believe that under the present framework you will be able to walk into any ER in the country and know with certainty that they can quickly and accurately retrieve all the medical information they need about you?  If you do, keep drinking the Kool Aid.  If your a starling, come fly with us and get the word out.  Now return your seat backs and tray tables to their upright and most uncomfortable positions.

Whether it’s vendors, Rhios, or HIEs, isn’t this what it’s all about?

HIEs remind me of hand-to-hand fire bucket brigades.  It’s time we agree to use a truck.

You’ve probably figured out that I am never going to be asked to substitute host any of the home improvement shows.  I wasn’t blessed with a mechanical mind, and I have the attention span bordering on the half-life of a gnat.

I’ve noticed that projects involving me and the house have a way of taking on a life of their own.  It’s not the big projects that get me in over my head—that’s why God invented phones, so we can outsource—it’s the little ones, those fifteen minute jobs meant to be accomplished during half-time, between pizza slices.

Case in point—trim touch ups.  Can, brush, paint can opener tool (screwdriver).  Head to the basement where all the leftover paint is stored.  You know exactly where I mean, yours is probably in the same place.  Directions:  grab the can with the dry white paint stuck to the side, open it, give a quick stir with the screwdriver, apply paint, and affix the lid using the other end of the screwdriver.  Back in the chair before the microwave beeps.

That’s how it should have worked.  It doesn’t, does it?  For some reason, you get extra motivated, figure you’ll go for the bonus points, and take a quick spin around the house, dabbing the trim paint on any damaged surface—window and doorframes, baseboards, stair spindles, and other white “things”.  Those of us who are innovators even go so far as to paint over finger prints, crayon marks, and things which otherwise simply needed a wipe down with 409.

This is when it happens, just as you reach for that slice of pizza.  “What are all of those white spots all over the house?”  She asks—you determine who your she is, or, I can let you borrow mine.  You explain that it looks like that simply because the paint is still wet—good response.  To which she tells you the paint is dry—a better response.

“Why is the other paint shiny, and the spots are flat?”

You pause.  I pause, like when I’m trying to come up with a good bluff in Trivial Pursuit.  She knows the look.  She sees my bluff and raises the ante.  Thirty minutes later the game I’m watching is a distant memory.  I’ve returned from the paint store.  I am moving furniture, placing drop cloths, raising ladders, filling paint trays, all under the supervision of my personal chimera.  My fifteen-minute exercise has resulted in a multi-weekend amercement.

This is what usually happens when the plan isn’t tested or isn’t validated.  My plan was to be done by the end of halftime.  Poor planning often results in a lot of rework.  There’s a saying something along the lines of it takes twice as long to do something over as it does to do it right the first time—the DIRT-FIT rule.  And costs twice as much.  Can you really afford either of those outcomes?  Can you really afford to scrimp on the planning part of EHR?  The exercise of obtaining HER champions and believers is difficult.  If you don’t come out of the gate correctly, it will be impossible.

Back to my project.  Would you believe me if I said I deliberately messed up?  Maybe I did, maybe I didn’t, but the one think I know with certainty is that I now have half-times all to myself.

EHR, there’s a new groundswell against meaningful use. How do I know? I’m starting it now.

After lunch, if I’m in the right mood, I may start one against certification.

Do you ever think about the origination of some of your ideas?  For me, the good and the bad just seem to materialize.  Like the time a friend and I were hiking a peak in the Sangre de Cristo range in Colorado.  It had taken the better part of six hours of circuitous climbing to reach the summit.  It was late in the fall, and the temperatures were around freezing.  Roiling storm clouds were racing towards us from the west.

If we returned by the same route we knew we’d be caught up in a storm that we were neither prepared nor dressed to handle.  I spotted our car about six thousand feet below us.  If we headed straight to it, I thought we could cut our descent time by about an hour.  To do this though required that we make our own trail via a hunt and peck route of whatever the terrain permitted.  We dropped the first fifteen hundred feet in a matter of twenty minutes using a glissade.  This technique allows you to moonwalk and slide down a scree field, using your ice ax as a break.

After an hour we reached a point about two thousand feet above our car.  It was sleeting, and the wind was whipping around the face of the mountain.  There in the middle of nowhere stood a sign from the sheriff that read, “Devil’s Gulch, turn back.”  Our choice was to reclimb the mountain or to ignore the sign and press on.  I hate do-overs.  How tough can this be, I goaded him?  Be smart, kick it into high gear, and we’ll be done.

We pressed forward.  Fifteen minutes later, we reached a four hundred foot limestone cliff.  Between us and the next semi-reasonable terrain was a rather deadly looking wall of rock and scrub pine.  My pack made me feel like it was forcing me forward, so I removed it and tossed it over, thinking I’d retrieve it later.  Watching my pack bound from rock to rock for what seemed like more than a minute did nothing for putting me at ease.

We spent more time discussing each step than we spent taking it.  Those four hundred feet took us two hours.  Not my best idea, but it didn’t kill us.

So, during my run today, I had another idea.  This one is about OnStar, the GM tracking system.  I typed in to Google, “How does OnStar Work?”  Lots of hits.  The more I read, the more I began to feel like if one ignored the technology and focused on the concept a real argument could be made for pairing the idea, and a few others, and seeing what type of EHR network might be possible using a similar set of tools.

The OnStar concept is termed telematics, a combination of telecommunications and informatics.  Telematics is the integration of computing, wireless communications, and GPS.  It provides information to a mobile service like a phone, PDA, or laptop.  It is used for sending, receiving, and storing information over very large networks.  So, why is nobody having the conversation that says what if we image a similar network with added security that works from a healthcare provider’s office rather than a car.

OnStar doesn’t need Rhios.  OnStar has a single set of standards.  Now, instead of arguing why something like this can’t work in healthcare, isn’t there argument is seeing if it can?

The question was raised on the blog Software Advice.

I think the very question reinforces the magnitude of the issue. Providers have budgets for products whose cost they do not understand. They have implementation teams who have never implemented one. They are aiming at targets for certification and meaningful use, which from my perspective could just as well be written on an Etch-A-Sketch. Hundreds of committees work towards standards, a requirement forced upon them by hundreds of vendor applications and hundreds of Rhios.

The output of the recent HIT policy meeting shows just how befuddled the process is.

This is a mandated national roll out of EHR without half the required sources and almost none of the required leadership. Who is the decider?

The current failure rate for EHRs is understated due to the large number of small systems. The failure rate for those over $10 million will exceed the rate for large IT systems which is close to 80%.

A hospital CEO with who I met last month told me his peers are uniquely ill equipped to make these decisions. Decisions are based on what their friends did, what they read in a journal. They plan implementations based on meeting gossamer standards and tests. They do not base them on requirements.

Watch the dates move backwards. I think in 6-8 years the rolled out EHR will more closely resemble a single, national, browser-based open EHR.

This problem is not unsolvable, however it remains unsolved.

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Several have written suggesting I toss my hat into the ring to serve as the EHR Strategy wonk or czar.  I was in the process of thinking it through when I was awakened from my fuegue state by a loud noise–my ego crashing to the floor.

Some have suggested that a camel is a horse designed by a committee.  Their point in saying that has something to do with how committees function less well than individuals–the problem with “group thinking.”  Personally, I think the camel design seems rather functional.

Some have asked, what is it about the EHR universe that has you dehorting the EHR process as though you are some sort of savant–nobody really asked that, but I wanted a segue and that’s all I came up with.

It’s the committees.  I feel a little like Quasimodo repining about the bells.  Raise your hand if you are on an EHR committee.  See?  Now, if you think that not only has the committee not accomplished much, but believe that it may never accomplish much, lower your hand.  Now look around.  Not many hands still up.

Please take a look at this for a moment.  Don’t try to understand it–it will only make your teeth hurt.

2011 requirements

• For hospitals, 10% of all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) directly entered by an authorizing physician must be made through a computerized physician order entry process. Individual physicians still must use CPOE for all orders, even if electronic interfaces with receiving entities are not available. The initial draft did not specify the required percentage for hospitals and did not address the electronic interface issue.
• Physicians must be able to check insurance eligibility electronically from public and private payers, when possible, and submit claims electronically. This was not in the initial draft.
• Patients must receive timely electronic access to their health information, including lab results, medication and problem lists, and allergies. The initial draft did not include the word “timely.”
• Physicians must implement one clinical decision rule relevant to specialty or high clinical priority. This was not in the initial draft.
• Physicians must record patient smoking status and advance directives. This was not in the initial draft.
• Physicians must report ambulatory quality measures to CMS. This was not in the initial draft.
• Physicians must maintain an up-to-date list of current and active diagnoses based on ICD-9 or SNOMED. The initial draft did not specify use of the two classification sets.

2013 requirements

• Specialists must report to relevant external disease or device registries that are approved by CMS. This was not in the initial draft.
• Hospitals must conduct closed-loop medication management, including computer-assisted administration. This was not in the initial draft.
• All patients must have access to a personal health record populated in real time with health data. This was moved up from 2015 in the initial draft.

Additional provisions

• Patients’ access to EHRs may be provided via a number of secure electronic methods, such as personal health records, patient portals, CDs or USB drives.
• CMS will determine how submitting electronic data to immunization registries applies to Medicare and Medicaid meaningful-use requirements.
• CMS may withhold federal stimulus payments from any entity that has a confirmed privacy or security violation of the Health Insurance Portability and Accountability Act, but it may reinstate payments once the breach has been resolved.

Source: Health IT Policy Committee

See?  Take a few minutes and work this into your EHR task time-line for processes, work flows, change management, training.  Need more time?  I’d need more time than I have, and when I finished I guarantee I couldn’t explain it to anyone.  This is what happens when people get into a room, have a charter, and try to do something helpful.  I am sure they are all nice people.  But be honest, does this make your day, or does it make you want to punish your neighbor’s cat–you may have to buy them a cat if they don’t already have one.

What to do?  Here’s my take on it.  Plan.  Evaluate the plan.  Test the plan.  Know before you start that the plan can handle anything any committee tosses your way.  Let people who know how to run large projects into the room.  Seek their counsel, depend on them for their leadership.  If the plan is solid, the result has a better chnace of surviving the next committee meeting.