Vendors-What's not to like?

IT Vendors: What’s not to like?

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We were being entertained at a friend’s house whose interior looked like it had been designed by one of those overly made up, energetic divorcees who only take cash.  The walls were painted a stark white; the overstuffed club chairs and the couch were upholstered in a soft white leather.  The white carpet was thick enough to hide a chiwawa.

The hostess locked askance at me when she saw me seated in the club chair.  Perhaps my outfit did not look good on white.  A paperback which looked out of place lay on the end table next to my glass of Ovaltine.   I picked it up and began to read the back cover to get a feel for the storyline…which got me thinking about writing and authors.

The paperback story filled five hundred and seventeen pages.  Whether they were well-written, whether there was a story nestled inside, could only be learned by reading the book.  I read many books, and I read often, especially when I travel.  When I am unprepared I am forced to purchase a book at one of the shops in the airport concourse.  The purchase decision lasts only as long as it takes to read the back cover—the publisher’s only chance to make a first and last impression.

Those first impressions have fooled me often.  Ten minutes into the book I wind up stuffing it into the kangaroo pouch in the seatback in front of me.  More often than I would like, I find that the person who wrote the book summary on the back flap is a better writer than the person who wrote the book.  The summary writer is able to create an interest in the story and a need to see how it ends, an interest and need for which the book’s author is unable to deliver.

The book is rarely better than the back cover suggests it will be.  Often it is as good, sometimes it is not.  The book summary is the upper limit for what you can expect by way of enjoyment.

It works the same way in business only instead of paperback books they use brochures.  Never trust the brochure.  Whatever is written in the vendor’s brochure is the upper limit of what you can expect to receive.  Those who remember the dismantling of nuclear arms remember the adage ‘Trust, but verify.”  When it comes to dealing with vendors, I suggest ignoring the part about trusting.

Take software vendors for example.  What’s not to like?

The product never leaves you feeling the way you felt after reading the brochure.  Remember the photos?  Attractive people, smartly dressed, ethnically diverse.  Their teeth bleached so white the reflection of the monitor is visible in their incisors.  Seated in their clutter-free offices, they are all smiling.

Did your users look like them when they started to use the product?  Did you get your brochure moment?  In order to find customers, vendors have to position their product in the most positive light.

Maybe there should be a cigarette-like warning printed on every software vendor’s brochure, something like this:

  • We hired the people pictured in the brochure—nobody is ever that happy
  • Most of you will never learn how to use all of the functionality
  • To have any chance of getting the software to do what you need it to do will probably cost you twice as much as you contracted
  • There is no way you will implement in the timeframe you discussed

They know, and we know, nobody implements brochures.  If we did, IT departments would be much smaller.  Maybe that is why vendors give away pens and T-shirts to all of their customers, to soften their sense of guilt.

Do you miss your IT vendor?

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Was Icarus’s problem one born of hubris, or did he simply need non-melting wax?  Wax on, wax off.  So there I was listening to NPR as I made the drive to Subway.  The person doing the speaking had the title, professor of economics.  His point—if you can call it that; the deficit and the debt are a result of the tax cuts.  Essentially, the reason we did not have enough money to pay for our spending was because we had not taxed enough.  I yelled at the radio loud enough for him to hear—the reason we did not have enough money to pay for our spending is that we spent too much.  My children will not be attending that university.

If you see someone screaming in their car, please wave—it could be me.

Summer vacations via car.  Makes me wonder what ever happened to station wagons—anyone who does not remember Richard Nixon may want to use Google to the term ‘station wagon’.  We had a sky blue Ford; others had the one with the faux wood-grain side panels like the one Chevy Chase drove in the movie Vacation.

I noticed last week as we drove from Pennsylvania and crossed into Maryland how the blacktop improved and how the shoulder plantings were more numerous and spiffier.  It was as though Maryland was showing off to make us feel we were entering a better place and leaving a worse one. On the return trip the same scenario was reversed as the road for the first mile back into Pennsylvania was much nicer than was the last mile of road in Maryland.

It makes me wonder why states do not put the same level of effort into the last mile to make you miss the place you were leaving.

Now let us think about your IT vendors.  Remember those guys?  The ones who when they courted you took you to dinners and baseball games and golfing.  You probably have one of their coffee mugs on your desk and a few dozen of their Rollerball pens and a commemorative golf towel clipped to you golf bag.  At the get-go everything was first class.  The vendor hoard was attentive and still picking up the lunch tab.

Then they left; all of them.  You surmised the project must be over.  The vendor’s project manager no longer had you on his speed-dial—your number had been replaced with the number of his new golfing buddy, the CIO at Our Lady of Perpetual Implementations.

It makes me wonder why vendors do not put the same level of effort into the last mile of their implementation as they did the first mile.  If they did maybe your perception of them would be better.  Maybe the implementation would have gone better.

 

Redux–What people at HIMSS were afraid to say

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One image of HIMSS that will not escape my mind is the movie Capricorn One—one of OJ’s non-slasher films.  For those who have not seen it, the movie centers on the first manned trip to Mars.  A NASA Mars mission won’t work, and its funding is endangered, so feds decide to fake it just this once. But then they have to keep the secret…

The astronauts are pulled off the ship just before launch by shadowy government types and whisked off to a film studio in the desert.  The space vehicle has a major defect which NASA just daren’t admit. At the studio, over a course of months, the astronauts are forced to act out the journey and the landing to trick the world into believing they have made the trip.

Upon the return trip to Earth, the empty spacecraft unexpectedly burns up due to a faulty heat shield during reentry. The captive astronauts realize that officials can never release them as it would expose the government’s elaborate hoax.

I think much of what I saw at the show was healthcare’s version of Capricorn One.  Nothing deliberately misleading, or meant as a cover-up or a hoax.  Rather more like highlighting a single grain of sand and trying to get others to believe the grain of sand in an entire beach.

The sets for interoperability and HIEs served as the Martian landscape, minus any red dust.  There was a wall behind the stage from where the presentation interoperability was shown.  I was tempted to sneak behind it to see if I could find the Wizard, the one pulling all the nobs and using the smoke and mirrors to such great effect.  It was an attempt to make believers, to make people believe the national healthcare network is coming together, to make us believe it is working today and that it is coming soon to a theater near you.

After all, it must be real; we saw it.  People wearing hats and shirts emblazoned with interoperability were telling us this was so, and they would not lie to you.

The big-wigs, and former big-wigs—kudos to Dr. B. for all his hard work—were at the show for everyone to see, and to add a smidgen of credibility to the message.  They would not say this was going to happen if it were not—Toto, say this ain’t true.

The public relations were perfect, a little too perfect if you asked me.  Everyone was on message.  If you live in Oz and go to bed tonight believing all is right with the world, stop reading now.  If what you wanted from HIMSS was a warm and fuzzy feeling that everything is under control and that someone really has a plan to make everything work you probably loved it.

Here is the truth as this reporter saw it.  This is not for the squeamish, and some of it may be offensive to children under thirteen or C-suiters over forty.  In the general sessions nobody dared speak to the fact that:

  • Most large EHR implementations are failing.
  • Meaningful Use isn’t, and most hospitals will fail to meet it.
  • Hospital productivity is falling faster than are the Cubs chances of winning a pennant.
  • Most hospitals changed their business model to chase the check
  • Most providers will not see a nickel of the ARRA money—the check is not in the mail and it may never be.

The future as they see it is not here, and may never be, at least until someone comes up with a viable plan.  Indeed, CMS and the ONC have altered the future, but it ain’t what it used to be.  People speak to the need to disrupt healthcare.  Disrupt it is exactly what they have done.  The question is what will it cost to undo the disruption once reason reenters the equation?  What then is the future for many hospitals?

  • Hospitals on the whole will lose more much more money due to failing to be ready for ICD-10 than they will ever have seen through the ARRA lottery.
  • It make take years to recover the productivity loses from EHR and the recoup those revenues.
  • Hospitals spending money to design their systems to tie them into the mythical HIE/N-HIN beast will spend millions redesigning them to adapt to the real interconnect solution.
  • The real interconnect solution will be built bottom-up, from patients and their primary care physicians.
  • Standardized EMRs will reside in the cloud and patients will use the next generation of smart devices.  And like it or not, the winners will be Apple, Google, and Microsoft, not the ONC and CMS.  Why?  Because that is who real people go to to buy technology and applications.  A doctor still does not know which EHR to buy or how to make it work.  Give that same doctor a chance to buy a solution on a device like an iPad and the line of customers will circle the block.

And when doctors are not seeing patients they can use the device to listen to Celine Dion.  This goes to show you there are flaws with every idea, even some of mine.

(I published this post one year ago, just after the Orlando HIMSS.  It appears to still be valid today. Comments?)

Your EHR vendor’s biggest secret

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I am working on a novel, my second.  It involves a serial killer. There is something richly cathartic about killing someone with bits and bytes. If you are in a bad mood, it can be calming. If the killing does not provide the calming effect I had hoped to achieve, rekilling him in a more vengeful manner usually does the trick.

The novel involves the skills of an FBI profiler. If you have read any of the books on profiling you would think it an exact science.  Chapter by chapter the writer extols the successes of profiling—this profile worked, that one worked.  According to how it is spelled out in the book, one would want to ask, if profiling is so successful, why do they not use it on every case?

Perhaps because there are unwritten chapters, chapters that never make it into the profiler’s handbook.  The reason those chapters do not make it to the book is because it sort of defeats the purpose to print cases in which the profiles that were created did not match that of the killer’s—white male in his mid-thirties, wooden leg, drives a Prius, and enjoys watching Dancing with the Stars.

When I thought about it, it occurred to me that business software is pitched a lot like profiling serial killers.  You never hear about the bits that do not work.

Think back to when you and your colleagues watched various processes of your software being demonstrated—add a patient or a customer, schedule an appointment, write a new script.  The functionality was so smooth it brought a tear of hopefulness to the eyes of the prospective users.

In a recent conversation I learned of a patient scheduling system that had more than five-thousand user screens.  That is a five followed by three zeroes; almost enough to have a separate screen for each patient.

Like the author of the book on profiling who only wrote about the cases on which his technique worked, software vendors only show potential buyers those processes that function smoothly. In an EHR system, vendors show how their software works in a real-life setting with only one thing missing, a patient with which it must interact.  A rather critical missing part of the functionality puzzle if you ask me.

The entire situation, that of acquiescing over time to having to use bad software, reminds me of the experiment of the frog and the pot of water; drop a frog in a pot of boiling water and it leaps out, place it in a pot of water and gradually raise the temperature and the frog will remain in the pot until it is cooked to death.

Users of bad software are a lot like frogs in a pot. They never quite get up the moxie needed to jump out of the pot. More often than not they allow their situation to worsen until it is too late.

EHR: How is your EHR vendor performing?

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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 an 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 trying 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 our productivity crash? 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 committee is a rubber stamp, everyone loses.  To be of value, the committee should serve as a board of inquiry.  Use 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.

Why IT projects Fail

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The mind is a terrible thing.  Last night I stumbled across part of the movie Kill Bill Volume 2. There is a character in Volume 2 named Esteban Vihaio, an eighty-something Mexican—for lack of a more erudite word—pimp.  His is a small role, but performed beautifully.  Uma Thurman, our ninja protagonist, meets Esteban and asks him ‘Where’s Bill?”

With a thick, refined Spanish accent, Esteban repeats the question, drawing out the name “Where is Beeeeeeel?”

Anyway, today I am on the phone.  And can you guess the name of the person with whom I am speaking?  That’s right, I was talking to Beeeeeeel.  He did not have a Spanish accent; nonetheless, I could not stop the voices in my head from trying to translate every phrase so that it sounded like Mr. Esteban.  Needless to say, the call went downhill rapidly.

When I think about software implementations the phrase “Help, I’ve failed and I can’t get up” comes to mind.

For many people, the goal of a software implementation is to get to the end, to see the vendor leave.  In many minds, that signals that the work is done, and the departure of the vendor signals that the software was implemented correctly.  Not true Mon Chéri.

In case you did not get the email, IT has become big business in most corporations, and it takes a group of highly paid bureaucrats to administer it.  And you know what happens when you give the bureaucrat a clipboard and ask them to oversee the implementation of a new email system, by the time the dust settles you have spent a few million dollars on a new sales force automation tool—Rube Goldberg on steroids.

Once you start spending it is difficult to stop.  And people do not keep spending in the hope of reaping additional ROI; they do so in order to try to salvage a project that in its current state is a white elephant.  Most of the cost of an IT project is to get it to do what you thought it would do.  This is a classic example of when you are in a hole, stop digging, or at least let me hand you a bigger shovel.

Why You Should Never Trust the Vendor’s Brochure

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We were being entertained at a friend’s house whose interior looked like it had been designed by one of those overly made up, energetic divorcees who only take cash.  The walls were painted a stark white; the overstuffed club chairs and the couch were upholstered in a soft white leather.  The white carpet was thick enough to hide a chiwawa.

The hostess locked askance at me when she saw me seated in the club chair.  Perhaps my outfit did not look good on white.  A paperback which looked out of place lay on the end table next to my glass of Ovaltine.   I picked it up and began to read the back cover to get a feel for the storyline…which got me thinking about writing and authors.

The paperback story filled five hundred and seventeen pages.  Whether they were well-written, whether there was a story nestled inside, could only be learned by reading the book.  I read many books, and I read often, especially when I travel.  When I am unprepared I am forced to purchase a book at one of the shops in the airport concourse.  The purchase decision lasts only as long as it takes to read the back cover—the publisher’s only chance to make a first and last impression.

Those first impressions have fooled me often.  Ten minutes into the book I wind up stuffing it into the kangaroo pouch in the seatback in front of me.  More often than I would like, I find that the person who wrote the book summary on the back flap is a better writer than the person who wrote the book.  The summary writer is able to create an interest in the story and a need to see how it ends, an interest and need for which the book’s author is unable to deliver.

The book is rarely better than the back cover suggests it will be.  Often it is as good, sometimes it is not.  The book summary is the upper limit for what you can expect by way of enjoyment.

It works the same way in business only instead of paperback books they use brochures.  Never trust the brochure.  Whatever is written in the vendor’s brochure is the upper limit of what you can expect to receive.  Those who remember the dismantling nuclear arms remember the adage ‘Trust, but verify.”  When it comes to dealing with vendors, I suggest ignoring the part about trusting.

Take software vendors for example.  What’s not to like?

The product never leaves you feeling the way you felt after reading the brochure.  Remember the photos?  Pretty people, smartly dressed, ethnically diverse.  Their teeth bleached so white the reflection of the monitor is visible in their incisors.  Seated in their clutter-free offices, they are all smiling.

Did your users look like them when they started to use the product?  Did you get your brochure moment?  In order to find customers, vendors have to position their product in the most positive light.

Maybe there should be a cigarette-like warning printed on every software vendor’s brochure, something like this:

  • We hired the people pictured in the brochure—nobody is ever that happy
  • Most of you will never learn how to use all of the functionality
  • To have any chance of getting the software to do what you need it to do will probably cost you twice as much as you contracted
  • There is no way you will implement in the timeframe you discussed

They know, and we know, nobody implements brochures.  If we did, IT departments would be much smaller.  Maybe that is why vendors give away pens and T-shirts to all of their customers, to soften their sense of guilt.

Healthcare IT meets Ben & Jerry’s

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The idea for this blog came about after reading a PowerPoint presentation by Doctor Alberto Borges.  All mistakes can be attributed to me.

When one is witness to the number of external influencers trying to shape policy on healthcare, reform, and healthcare IT, the best one can hope for is that hidden somewhere under the pile is a pony.

But let’s be real—the pony has suffocated.

While it is okay to point the finger of blame at the usual suspects—payors, lobbyists, and the lawmakers—let us not forget to ensure to point out the role paid by the healthcare IT applications vendors.

“Who me?” You ask.

Decrease costs, increase quality, decrease errors.  I did not invent these words; they are written on your websites.

Prior to 2008 the value of EHR vendors’ stocks plummeted.  Look at them now.  How does one explain the difference?  Can the gains be attributed to vendors having rewritten their applications?  New technological innovations?  If not, what else could it be?

Meaningful Use.  Meaningful Use tied to Medicare payments and a twenty billion dollar incentive to get providers to do something they otherwise would not have done.  Could life be any better if you are sitting in the EHR Tower’s corner office?

What if we think about the issue this way?  Let us suppose all of the leading ice cream manufacturers lobbied Congress to push for including ice cream machines in all new cars starting in 2012…silly idea, but then again, so is Meaningful Use.  Not only do the ice cream machines have to be installed, but they have to be able to communicate with one another.  That way, if I happen to rent a car, the ice cream machine in my rental will already know what type of ice cream I like to eat.

Now we already know that no car buyers and no car builders will think much of being forced to buy or make cars with pre-installed ice cream makers.  But, perhaps there is a way around that.  Maybe in some self-serving way the Cookies and Cream lobby can convince Washington of the merits of pushing through their agenda.

Time passes, and still the idea is not getting much purchase.  What happens next?  The ice cream manufactures get Congress to pass the Ice Cream Tech Act—ICTA.  And as part of the ICTA Act, Ben and Jerrys, Baskin Robbins, and Haagen Dazs convince our friends to offer the auto manufacturers a twenty-billion dollar rebate for building cars with built-in ice cream makers—ICTA Initiatives.

Now, why would the Ben’s and Jerry’s do this?  Good question.  They will do this because they know that without offering a large financial incentive the car company executives will not do what they want them to do.  Now to insert ice cream makers, you can imagine that the car companies will have to go way off message, will have to change their strategy, and will have to incur all sorts of costs that have nothing to do with selling cars.

And that brings us back to the start of this story.  There is a reason why EHR vendors needed to lobby Congress to put forth more than twenty billion dollars of lottery money, and that reason is healthcare providers would not be doing EHR the Meaningful Use way unless there was a monetary reason to do it.  There certainly is no business reason to do it.

And for the most part, if providers calculate an ROI on EHR, even factoring in the incentive payments, there is still no reasonable financial argument that can be made.  In fact, when the cost to meet Meaningful Use is factored in, the financial argument worsens.

So, what will happen?  Here is what we know so far.  The Meaningful Use deadlines draw closer, meaning there is less time left to get the incentive dollars.  Implementations of EHR continue to falter, be redone, and under deliver.  The result is that the purchase of EHR systems will slow, and many EHRs will be uninstalled.  When there is no time left to get the incentive dollars, only then will EHR implementations be driven by the needs of the providers, and the government will no longer be driving the process.

 

One thing your IT vendor will never tell you

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Permit me to let you in on a little secret—most firms have no idea how to manage their IT applications vendors.

In turn, this means they are managing you.  By the way, this is a bad thing.

The best way I have found to understand this problem is to liken what IT vendors tell you to what magicians tell their audience.  Bear with me.  If you have ever attended a magic show or watched one on television you will note that the best magicians tell you prior to their performance that they are going to lie to you.  In order for a magician’s performance to work on you any magician has to get you to suspend your belief.

A magician tells the audience that everything else you are about to hear and see is a lie.  And then they tell you they are going to cut someone in half, they do it, and your eyes are so amazed that somehow your brain forgets the bit about being lied to, about being led down a path of suspending your beliefs.

The difference between magicians and IT vendors is that IT vendors forget to mention at the outset—or at any other time—that not everything they tell you is true.  Things like what their system will cost, what it will do and how long it will take.

And because they do not tell you they are lying, once you have suspended your belief, you forget to unsuspend it.  Hence, you are caught up in their fantasy world and you foolishly believe what they tell you.

For the most part, IT vendors are not the people you want next to you in the EHR, ERP, or any IT foxhole.  In the dog-eat-lemming world of IT, never forget that the term ‘partner’ is an oxymoron.  IT is a business and the goal of every business is to maximize profits.  The best ways to maximize profits are to reduce costs and to increase revenues.  The only way to do so is for vendors to increase your costs.

Keep your eyes and ears open the next time your vendor offers to cut someone in half.

Jihad Joe: EHR Vendors, What’s not to like?

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When competing hypotheses are equal in other respects, the principle recommends selection of the hypothesis that introduces the fewest assumptions and postulates the fewest entities while still sufficiently answering the question. It is in this sense that Occam’s razor is usually understood.  There is no corollary that works with EHR vendors.

What if we look at HIT vendor selection logically?  Have you ever noticed at the grocery store how often you find yourself in the longest checkout line, or when you’re on the highway how often you find yourself in the slowest lane?  Why is that?  Because those are the lines and lanes with the most people, which is why they move the slowest.

If you are asked in which line is Mr. Jones, you would not be able to know for certain, but you would know that the most probable option is the one with the most people in it.  You are not being delusional when you think you are in the slowest lane, you probably are, you and all the people in front of you.  The explanation uses simple logic.  It’s called the anthropic principle– observations of our physical universe must be compatible with the life observed in it.

It can be argued that the business driver which shapes the software selection process of some is the aesthetics of efficiency, a Jihad Joe approach to expediency.  Buy the same system the hospital down the street bought, the one recommended by your golfing buddy, or the one that had the largest booth at the convention.  Or, one can apply the anthropic principle, rely on the reliability of large numbers and simply follow the market leader.

Might work, might not.  My money is on might not.  There’s still plenty of time to do it right.  If that fails, there will always be time to do it wrong later.  Of course, you can always play vendor darts.  If you do, you should sharpen them so they’ll stick better.