Are you suggesting that coconuts migrate? (Not at all, but a swallow could grip it by its husk.)

Sometimes I get reactions from my clients which suggest that my ideas have people questioning if I just fell out of the stupid tree and hit every branch on the way down, especially when what we’re discussing seems to move from the theoretical and towards the heretical. However, there was a presentation I made to one of my clients where I had the entire room believing that i might as well have been suggesting that coconuts migrate.

Allow me to set the stage. I presented to the CIO of one of the largest providers in Europe a vision for what their IT strategy should be. This was an 0.2 firm requiring a 2.0 solution.  As you can guess, it was fairly easy to suggest that better alternatives were available to them, but if you’re a member of the Flat Earth Socitey you’re not going to believe anything until someone is able to literally change your perspective.

During my presentation I wrote on the white board that I would help them choose between three alternatives. At this point, a British colleague and good friend, came to the front of the room—uninvited, removed the marker from my hand, erased the word ‘between’, and penned the word ‘amongst’. “We choose between two things, and amongst three or more,” he said with a grin and then returned to his seat. I suggested that since English was not the native language of our client that his point was probably lost on them, to which he stated that his point was directed at me whose native language was supposed to be English. God save the queen. He also tried to make the point on more than one occasion that the American War of Aggression with England did not end in 1783 with a victory for America, but with a British retreat.

Anyway, we were choosing between three alternatives, at least I was. After about ten minutes of explaining what could be achieved and how it might be structured, I was interrupted again, this time by the CIO. He too took my marker, concluding that I was a coconut. It took me about thirty minutes to convince him that everything I’d presented was not only achievable, but already operational in a number of their competitors.

So, as we head down the EHR path with our Project Management Executive, the person who will be spearheading the internal effort to affect change, we must find a way to make sure the executive is properly equipped. For starters, the executive needs to have, and to be able to communicate a vision, a vision for the change, for how it will impact the organization, and an ability to communicate it.

Those of you who’ve visited previously may have caught on to the fact that my wife likes to keep me away from bright shiny objects such as tools.  Let me tell you about my first house, a two-story stucco building in Denver, built in 1902.  My favorite part of the home was the brick wall.  That is had a brick wall was not apparent when I purchased it.

I came home from work to find that my dog had eaten through the lath and plaster in the living room and there was the brick.  I had to decide what to do.  I knew nothing about lathing—I know that’s not really a word—or plastering.  What to do.  My only tool was a hammer, so I began to hammer.  For those who haven’t done this, hundred year old plaster being pounded with a hammer makes a lot of dust.  This process proved to be very slow.

What did I do?  I bought a bigger hammer—such a guy approach to a problem, isn’t it?  It took three hammers to get down to just bare brick.  What would you have done?  When your only tool is a hammer every problem looks like a nail.

As you go through the EHR planning process in your war room—you do have a war room, don’t you?  (Try Sam’s Club, after all, they sell EHRs.)  Get out the really big piece of paper, the one with your EHR design—you do have a really big piece of paper, don’t you?  (Back to Sam’s.)

Next to the box on the paper labeled “Shiny New EHR” should be lots of empty space so you can draw in all of the other systems with which your EHR will have to interface.  One of the readers of this blog wrote recently that his EHR had more than 400 interfaces.

EHR, if done correctly, will do much for patients, doctors, and administrators.  It’s not a panacea.  It won’t reach its potential unless you also integrate it with those systems that unlock its potential.  Improving your efficiency and effectiveness takes more than merely an EHR system.

When your only tool is a hammer, you’d better hope every problem is a nail.  What other tools are you using?  Please share your ideas about what works well.

It’s hot and muggy; a hazy pall seems to levitate before me.  We call it Pennsylvania in summer.  Chest pain yesterday, nitro in gym bag.  Intervals today.  I hate running intervals as much now as I did in high school, but they’re better for the heart than just running distance.  Twenty-four 110’s.  Did I mention it was hot?

I am on the high school track.  The football team is/are—where are all the English majors when you need them—going through their drills.  Running and thinking.  That’s a good combination for me.  After two laps I’m glistening, after three I’m soaked through.  That’s when it hits me.

Practice.  Offensive and defensive drills.  Blocking and tackling.  Run the option.  Block the punt.  Come back tomorrow and do it again.  Do it until you get it right.  Do it until you can get it right in the game.  Pretty neat idea all this practicing.

Some adults get to practice.  I refer to what I do as my consulting practice—my father still has no idea what idea what I do for a living but I’m okay with that.  He was a spy and he still won’t tell me what he did.  Lawyers and doctors practice—I hope it means something other than they are still trying to get it right.

Know where this is headed?  See, that wasn’t too difficult—remember, the desk is hard, the task is difficult. (My one takeaway from eighth grade English.)  Who doesn’t get to practice, doesn’t even have a coach?  Bingo, the EHR Project Management Executive.  It would be better if they did.  Imagine this conversation:

“Sorry Charlie, hit the showers.”

“Why Coach?”

“Your change management isn’t working for you today.  You’re leaving processes untouched.”

“It was the docs’ fault.  They just toy with me.  Treat me like a wonk and tell IT jokes behind my back.”

“Your game plan is coming apart.”

“But I didn’t get to practice, we didn’t even get to warm up.  I’ll do better next time.”

“Which next time is that Charlie?  With whose money?  These are The Bigs, Charlie.  Only grownups play here.  I’m afraid I’m going to have to send you back down to Single A.”

“Private practice.?”

“Sorry Charlie”—sounds like the tuna commercial.

You’ve got one shot at this, no warmups, no practicesm there are no do-overs, and you are gambling millions.  DIRT-FIT  Do It Right The FIrst Time

Okay, so today was going to be one of those days when I wasn’t going to allow myself to be stupified–at least no more than was really required.

Then it sneaks up smack dab in the middle of a call, and from what I’ve been able to determine, people find it annoying if you burst out laughing on the call.  (They are not annoyed at all if you simply write about them provided they don’t read it.)

What got me going is this statement, “We’ve budgeted $X for EHR.”

Really?  You did this all by yourself?

The facts as I understood them are as follows:

• Never bought an EHR
• Don’t know how big they are, if they are blue or green, come gift-wrapped, or if you need two people to carry it
• No input from vendors about EHR
• no discussions with others abot what an EHR system costs

So, with absolutely no information how does one determine how much they need to spend?  This is not like going to the supermarket for a gallon of Soy Milk–not that anyone would want to do that.

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

Why is this a part of the overall plan?  Is this planned failure?  Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test.  The certification test, by definition, is necessary.  The Full test is both necessary and sufficient.  It is possible to pass certification without passing the Full test.  Therefore, the Full test is a stricter test.  Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test?  Same as always.  Fully functional, on time, within budget, and user accepted.  Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact:  One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion:  The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations.  Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification.  (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact:  Most large, complex, expensive IT projects fail—they just do.  This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed.  Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion:  Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak?  You bet.  Insurmountable?  Doesn’t have to be.

What can you do to improve your chances of success?  Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points.  EHR Fail Safe Points?  The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test.  The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD.  They need not have a slew of EHR implementation merit badges.  The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built.  They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR.  Those skills are needed—in spades—and you need to budget for them.  The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre.  They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

What do you think?

There were four of us, each wearing dark suits and sunglasses, uniformly walking down the street, pausing at a cross-walk labeled “consultants only”—I think it’s a trick because a lot of drivers seem to speed up when they see us. We looked like a bad outtake from the movie Reservoir Dogs. We look like that a lot.

Why do you consult, some ask? It beats sitting home listening to Michael Bolton or practicing my moves for, So You Think You Can Dance, I tell them.

Listening to the BBC World News on NPR whilst driving, there’s one thing I always come away with—they’re always so…so British. No matter the subject—war or recession—I feel like I should be having a proper pot of tea and little cucumber sandwiches with the crusts removed; no small feat while navigating the road.

Today’s conversation included a little homily about the Gordian knot with which the company Timberland is wrestling, questioning whether as a company Timberland should do well, or do good. (Alexander the Great attempted to untie such a knot, and discovered it had no end (sort of like a Möbius strip, a one-sided piece of paper–pictured above. (For the truly obtuse, among which I count myself, the piece of paper can be given a half twist in two directions; clockwise and counter-clockwise, thereby giving it handedness, making it chiral—when the narrative gets goofy enough, sooner or later the Word dictionary surrenders as it did with chiral.))) I’m done speaking in parentheses.

Should they do well or good? Knowing what little command some people have of the English language, those listeners must have wondered, why ask a redundant question. Why indeed? That’s why I love the English, no matter the circumstances they, they refuse to stoop to speaking American.

Back to Gordo and his knot. That was the point of the knot. One could not have both—sorry for the homonym. Alexander knew that since the knot had no end, the only way to untie it was to cut it. The Gordian knot is often used as a metaphor for an intractable problem, and the solution is called the “Alexandrian solution”.

To the question; Well or good. Good or evil. Are the two choices mutually exclusive? For an EHR? They need not be. The question raised by the BBC was revenue-focused (doing well) versus community or green-focused (doing good). My question to the reader is what happens if we view EHR with this issue as an implication, a la p→q.Let’s review a truth table:

From a healthcare provider’s perspective the answers can be surprising; EHR can be well and good, or not well and not good.  The Alexandrian solution for EHR is a Alexandrian PMO.

Have you people call my people–we’ll do lunch.

Most of the real work that needs to be done in EHR workflow improvement happens in the blank white space between the boxes on the org chart.  That’s where you’ll find a lot of the BRPs–Barely Repeatable Processes.

Looks like it came from the same people who write the tax codes.

‘‘(ii) AMOUNT.—Subject to clauses (iii) through (v),
the applicable amount specified in this subparagraph
for an eligible professional is as follows:
‘‘(I) For the first payment year for such professional,
$15,000 (or, if the first payment year for
such eligible professional is 2011 or 2012, $18,000).
‘‘(II) For the second payment year for such
professional, $12,000.
‘‘(III) For the third payment year for such
professional, $8,000.
‘‘(IV) For the fourth payment year for such
professional, $4,000.
‘‘(V) For the fifth payment year for such professional,
$2,000.
‘‘(VI) For any succeeding payment year for
such professional, $0.
‘‘(iii) PHASE DOWN FOR ELIGIBLE PROFESSIONALS
FIRST ADOPTING EHR AFTER 2013.—If the first payment
year for an eligible professional is after 2013, then
the amount specified in this subparagraph for a payment year for such professional is the same as the
amount specified in clause (ii) for such payment year
for an eligible professional whose first payment year
is 2013.

That cleared it up for me.  You?

What if hospitals paid to implement EHR for their docs in IPAs, group practices, and soloists, and paid for the expense by having those docs sign over their stimulus money to the hospital?

A hospital which I am not allowed to name spent well over a hundred million implementing onr of the brand name solutions and later discovered they couldn’t handle the outpatient docs.  They asked me for some ideas.

Here’s my take.  Assume there are 1,000 of those docs – IPAs, groups, solo, each of who have alliances to perhaps several hospitals.

If I am the first hospital, it behoves me to drive whatever standardization there may be in may favor by leeting them use mine rather than anything else.  Make it easy, they stay, they are the hospital’s customers too.

Seems like this would also do wonders for cert, menaingful use, and connectivity.

And, why not get paid for it?

EHR Buying Guide—Vendor darts

So, here’s the thing with what a lot of EHR vendors seem to view as the lower end of the food chain, chum worthy customers—IPAs, group and individual practices.

Vendor darts.  I can’t tell you the number of providers with whom I’ve spoke who’ve had to navigate the chum-filled water of vendors trolling for dollars.  Unfortunately, when they come to your door, most of you are ill equipped and ill prepared to know whether you need what they’re selling.

It’s like playing EHR vendor darts—by the way—you’re practice is the dartboard.  Vendors fling their offering at you and hope they stick—sometimes you have to sharpen them or they’ll simply bounce off.

Just between you and me, or among us—if you’re a stickler about English—I’ve played vendor darts for years, and it’s always difficult for the dartboard to win.  (I am speaking parenthetically so they can’t hear us.)  We both know this is meant to be somewhat tongue-in-cheek.  The EHR vendors are professionals, and they have the utmost belief in their product, just as they will if they change firms and have to sell another product—this is the unspoken dirty linen of software.

There are a few hundred purported EHR solutions.  Each is a little different.  Which one is best for you?  Do they know which one?  If we are honest, the answer is, no, they don’t.  They do not know, they cannot know what features their competitors offer.

They want you to stay focused on features.  I want you to stay focused on business problems.  What business problems of your do their features solve?  It’s a fair question.  They should be able to answer it, and you should be able to answer it.

Rule number 1:  Any time a vendor tells you, “This is how we get our system to do that”, means their system doesn’t do it.  Those words signal a workaround, not a workflow.  It means they want your business to adapt to their way of thinking how your business runs.

Rule number 2: Vendors hope you don’t know about Rule 1.

What can you do?

1. Work with someone who can spell out your requirements in detail.
2. Work with someone who can navigate the chum field on your behalf.
3. Assess some of the free EHR systems

Or, without meaning to be too gauche, contact me.