Who's Running the Show?

EHR: What bugs you about it?

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This is the time of year in the east when cinerescent caterpillar nests hang thickly from the trees, peppered tufts of cotton candy.  During these long, flavorless August days, the sky is a similar achromatic color.  My nine-year-old is concerned because I told her we are having caterpillar soup for dinner tonight—watch out for the crunchy bits.  Once again, it seems I’ve gotten off message.

I wonder how much of the difficulty surrounding EHR has to do with getting off message, much like we seem to have done with the reform discussion.  What difficulties?  Got time?  You can name more of them than can I.

What is off message?  It’s that the day-to-day tactics of implementing EHR office by office, and hospital by hospital have overshadowed the strategy, have displaced the business driver behind the mandate.  The focus became internal, not national.  Bits and bytes have overshadowed charts.

I doubt few, if any, can articulate a believable explanation of how a few years from now your medical records will accurately and expeditiously be delivered from where you live to the lone clinic on Main Street, Small Town, USA, to the nurse practitioner who at midnight is giving you an EKG.

It’s that fact, that we are not able to define how we get from A to B, let alone do so with multitudes of A’s and B’s, that to me suggests we are building something of which we have little comfort will do what we set out for it do.

Clearly, there are hundreds if not thousands of very talented and dedicated professionals focused on finding a solution.  However, it seems their efforts remain handcuffed by hundreds of competing products, no well-defined overriding set of requirements that would enable anyone to say with certainty, “Yes, that is it.  That captures what we need to do.  When we have done that, we are done.”

Until that time, I think we all need to be concerned about the crunchy bits.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

Is the C-suite fiddling while EHR burns?

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There is an adage in the military—different spanks for different ranks.  If speaks to a double standard, the less egregious their punishment for similar offenses, similar misjudgments.

We see that every day in business, and we see it a lot in healthcare, especially in hospitals.  Physicians are held accountable for medical errors.  Hospitals pay millions for malpractice insurance knowing that mistakes will be made and people will be held accountable for their mistakes.

But what about on the business side?  Who is held accountable for business mistakes?  An acquisition that failed to deliver.  An expensive new service offering that bled the company dry.  A decline in the number of patients. The failure of a major IT initiative to deliver results.

Take EHR.  Some of you are saying, “Yes, please take it.”

  • Around sixty percent of the large EHR projects have failed in one respect or another
  • Most will not receive ARRA incentives
  • A large number of hospitals are on their second implementation of EHR
  • Some have productivity losses of thirty percent

Who is going to be fired for the two hundred dollar misstep?  The board?  Never.  The CEO—no.  The COO or CFO?  Unlikely.  The CIO?  That is the safe bet.

Did the CIO authorize the expenditure?  Nope.  Did the CIO get all the dollars needed to be successful, all the user support?  Unlikely.

In most cases the CIO has all of the responsibility and only some of the authority.  There are a handful of people in each organization tasked with the oversight of the large project.  They are the ones who should be asking the right questions, the ones who should be demanding answers.

A failed project, a failed strategy should not come as a surprise.  The only people who will be wearing EHR 2.0 T-shirts are those who authorized EHR 1.0.  How come these individuals are not accountable?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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EHR Czar posting

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One summer in college, I worked for the state roads commission in Maryland.  If you like being outdoors, getting a lot of exercise, driving around in the back of dump trucks drinking beer it was the perfect job.

The average day went like this.  Each morning we’d report to the facility at seven, and sit around for an hour as the supervisors received their assignments for the day.  It would take another hour to gather the tools needed to complete whatever project we were given.  On the road by nine, the two full-time employees inside the truck, my friend and I laying in the back on burlap bags..

By ten, we had unloaded the tools, and scoped the work.  Most days we’d forget one or two tools needed to complete the work, radio back to the facility to have someone deliver it to us, and practice sitting on our shovels until we were fully outfitted.  It didn’t make sense to start the work knowing lunch was only thirty minutes out, so on most days we would simply wait until after lunch.  By one o’clock, our bellies full, we began our assignment—fix a guardrail, shovel some gravel, install a road sign, scoop a dead deer of the road.

The foreman, Butch, knew the location of every liquor store in the county.  Happy hour in the dump truck usually began at three—one case of beer for the two men in the front, one case of beer for my friend and me in the back.  We’d lay there with our shirts off as the supervisor chauffeured us around the county trying to kill time until we could return to the service bay.

I wonder if they need any help this summer.

One of the things I remember about that summer was a job posting in the service shed.  The posting was for a supervisor/foreman.  The single qualification was the requirement of having completed education through grade five—the “Are you smarter than a fifth grader” test.

I have no segue.  I am wondering if there is a posting in the ONC service shed for an EHR Czar.  If there were, what would be the requirements?

WANTED: EHR Czar—Fourth graders need not apply.

Count me in.

A Perfect Metaphor

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Few things are perfect, and when you find something that is, it is worth examining.  One thing that is perfect is baseball, at least some aspects of it.

Think with me for a minute. 1845.  How much has changed since then?  Just about everything.  Do you know what has not changed—the distance between the bases—90 feet?  This distance may seem insignificant or inconsequential.

In the last 165 years the distance between the bases remained unchanged.  Equipment changed, improved.  The players got bigger, faster, and stronger.  It never dropped to eighty-nine feet; it never jumped to ninety-one feet.

To those who follow baseball, have you noticed how close many of the plays are at first base, or the closeness of the steals of second base?  Can you imagine what would happen to the game of baseball if the distance was shortened to eighty-nine feet?  Almost everyone stealing second base would be safe.  If the distance was ninety-one feet they would all be out.

Somehow, 165 years ago those people got it right, got it absolutely right.  Something as simple as a measurement along a dirt path has stood the test of time.  There are not even any discussions about trying to improve it.

Remember the Titanic?  If one measured all the time spent in its design, and all of the time it sailed before it sank, if you were a betting person you would have bet on the boat.  Reasonable people would have bet on the boat.  You would have been a fool to have bet it would have sunk.

You know what; the Titanic’s sinking was not a fluke. The laws of physics and ship design did not suddenly cease to work.  Do not blame the iceberg.  The Titanic was designed to sink—otherwise it would not have sunk.

What is often misjudged in business is the ill-informed notion that just because something has not collapsed it is not broken.  Hospitals are starting to collapse.  The business model of most of them almost ensures that left unchanged, many, many more will collapse.  They have been designed to collapse.  Just because they have yet to collapse does not mean they won’t, all it means is that they have not—yet.

Few things are perfect.  What discussions there are about the business model are not about improving the model, they are about cutting costs.  What do you have when there are no more costs to cut?  You have a less costly dysfunctional model.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Strategy Millstones, should that read Milestones?

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If you like adventure, here’s a site to check, http://www.jfk50mile.org/.  This is an annual event whose origin came about during the cold war.  Fortunately for both of us, the entry date has already passed.  The thought behind the JFK fifty-mile hike/run was that because of the possibility of a nuclear attack, each American should be in good enough shape to cover fifty miles in a day.

I participated in the event twice—I wrote participated because to state that I ran the entire way would be misleading— and I can state with certainty that almost no Americans are close to being able to complete this.  The event is run in the fall starting in Boonsboro, Maryland.  It takes place along the Appalachian Trail and the C&O Canal and various other cold, rain soaked, and ice and leaf covered treacherous terrains.

We ran it in our late teens or early twenties, the time in your life when you are indestructible and too dumb to know any better.  One of my most vivid memories of the event was that on the dozen or so miles along the mountain trail, leaves covered the ground.  By default that meant they also covered the rocks along the trail, thus hiding them.  That we were running at elevation—isn’t everyone since you can’t not run at at least some elevation, (that may be the worst sentence every written) but you know what I mean—meant the prior night’s rain resulted in the leaf covered rocks being sheathed in black ice.  That provided a nice diversion, making us look like cows on roller skates—roller blades had yet to catch on outside of California.

There were several places along the trail where the trail seemed to fork—I’m not going to say and I took it—and it wasn’t clearly marked.  Runners could easily take the wrong fork (or should that be Tine?).  I think it would have been helpful had the race organizers installed signs like, “If you are here, you are lost.”  Hold on to that thought, as we may need it later.

Some number of hours after we began we reached the C&O Canal, twenty-six miles of flat terrain along the foot path.  It’s difficult to know how well I was doing in the fifty-mile race, in part because I had never run this distance and because there we no obvious mile markers, at least so I thought.  Then we noticed that about every five and a half to six minutes we would pass a numbered white marbled marker that was embedded along the towpath.  Mile stones.  At the pace we were running, we anticipated we would finish high in the rankings.  As fast as we were running, we were constantly being passed, something that made no sense.  That meant that a number of people were running five minute miles, which we knew they couldn’t do after running through the mountains, or…Or what?

The only thing we knew with any certainty at the end of the day was that the markers with which we used to determine our pace and measure how far we’d run were not mile markers.  We never figured out why they were there or how far apart they were, but we greatly underestimated their distance and hence our progress.

It doesn’t really matter whether you call them mile stones or milestones.  What matters is whether they serve a valid purpose.  If they don’t, milestones become millstones.  Milestones are only useful if they are valid, and if they are met.  Otherwise, they are should’ a, could’ a, would’ as—failure markers, cairns of missed goals and deliverables.

How are your milestones?  Are they valid?  What makes them valid?  Are they yours, or the vendors?  All things to think about as you move forward.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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How to calculate Meaningful Use’s ROI

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Just to make sure we are all turned to the same page in our Cliff Notes on Meaningful Use, today’s conversation is, “There is no “R” in ROI.”

Are you familiar with the Abilene paradox?  It is a paradox in which a group of people collectively decide on a course of action that is counter to the preferences of any of the individuals in the group.  It involves a common breakdown of group communication in which each member mistakenly believes that their own preferences are counter to the group’s and, therefore, does not raise objections.

I think it occurs more often than we think.  Try to recall the last meeting you attended in which you really disagreed with something that was said.  Chances are you knew some of the others in the meeting well enough to know they also disagreed.  The reason you know they also disagreed is because you had discussed the topic.  However, none of you raised your disagreement during the meeting.  Why?  Because you did not want to rock the boat.

It is similar to a pseudoconsensus.  Pluralistic ignorance.  These create a bystander effect—people are more likely to speak out about an issue when they are alone with someone than when others are present.

After further consideration I think we must consider the very real possibility that there is no ROI for Meaningful Use.  I write this in all sincerity.  Healthcare executives march in lock-step or group think to achieve the myth of finding an ROI for Meaningful Use.  The ROI is healthcare’s quest for the Holy Grail, albeit without the Monty Python sound track.  They cannot proceed without one, so they set the target, figure out what data will demonstrate that they have hit it, and disregard the reams of data that does not support the ROI.

What if the government came out with a standard stating all hospitals ought to buy, install, and use a fifty million dollar transplant device that also flosses the patient’s teeth?  This initiative is “optional”, but the government will pay the hospital a two hundred thousand dollar rebate.  There are several types of transplant flossers—the ones that deliver that fresh mint taste cost extra.

If we were having a business discussion about the ROI for the transplant device, healthcare executives would be foaming at the mouth about how impossible it would be to calculate an ROI, and rightly so.  They would argue all hospitals are different, they have different cost structures, the devices are all different.

The standards for Meaningful Use are arbitrary.  The standards were developed by people who do not need to meet an ROI.  There was no mandate in the development of those standards to create standards which when met would yield an ROI.  Any attempt to force an ROI will naturally differ in a number of ways:

  • by provider—size, structure, offering, geography
  • by their interpretation of Meaningful Use
  • by which EHR they implemented
  • when they began the implementation
  • how well they implemented the EHR

Somebody somewhere may hit a positive ROI on Meaningful Use, just like somebody playing darts may hit a bull’s eye.  Any positive ROI will be accomplished more out of chance, and from having fit the data to a predetermined ROI rather than measuring the ROI against its true impact.

Implementing an EHR can be very good for a hospital.  However, it should be a business decision for the hospital based on the same set of business rules the hospital would use to justify any other large expenditure.  If the hospital achieves an ROI it will not be because of having followed an arbitrary set of standards.  Any ROI for an EHR will come from having done it correctly.  Hitting the figure any other way means two things; it was a coincidence, or you are in for trouble down the road.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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My latest post to healthsystemCIO.com

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I think there is plenty of merit to quit chasing Meaningful Use and get on with your business.

http://healthsystemcio.com/2010/05/28/ten-catechisms-of-meaningful-use/

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Is there a business argument for Meaningful Use?

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I remember the first time I entered their home I was taken aback by the clutter. Spent and wet leaves and small branches were strewn across the floors and furniture. Black Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The windows.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.

And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

“Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives. Sort of like all the scurrying around Meaningful Use.  The normal has been subsumed by the abnormal, and in doing so has created an entire entity which is slowing devouring the resources of the organization.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid on a daily basis. When I talk with hospital executives they are marching headstrong into the Meaningful Use abyss.

It makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about it they always have an answer. It all boils down to something like, “We simply can’t turn down the money.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid.  It’s gotten to the point where no matter how goofy things get, as long as they are consistently goofy, there not goofy at all.

This is the mindset that enables leaders to be fooled by their own activity. Busy replaces thinking.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Are terrorists smarter than us?

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Sri Lanka has been in a twenty-six year civil war with the Tamil Tigers. NPR reported the leader of the Tigers was killed. Within a day, the Tamil Tigers’ web site posted a blurb stating that the leader was not killed—a la Monty Python—“I’m not dead yet.”

I’ll be brief. The bad guys. These bad guys live in the jungles, others live in the Afghan mountains. As far as I’ve been able to ascertain, they don’t use Cisco servers, they don’t have a call center. There’s no marketing department, no financial analysts, no freshly minted MBAs walking the hallways telling them what to do.  They have established virtual nations.

Yet as primitive as these groups are, they know the value of rapidly employing social networking to their advantage. What amazes me is not that they do it, but that most people reading this don’t have a proactive policy and the resources required to effectively manage their social media.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Is this a fair representation of the hospital business model?

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I have been looking for a way to represent pictorially the hospital business model and the forces which act upon it.  The picture below came to me last night while playing this board game with my daughter.  It is from the children’s game, Boobytrap.  The way the game is played is that the players try to remove the red, blue, and green pieces without causing the trap to spring and displace all of the pieces.

If we represent patients as the individual playing pieces and make the assumption that each side of the game exerts pressure on the model, I think it represents fairly the external forces with which the large provider model has to battle.  As the forces increase from some combination of costs, regulation, procedure price ceilings, and payor reimbursements, the number of patients in the model will decrease and may do so in a catastrophic manner.  Without a concurrent decrease in those four forces it is unlikely that the model will support additional patients.  Clearly, without changing the size of the board it is impossible to grow the number of patients beyond the board’s capacity.

A couple rules come into play.

  • The forces are all external.  They cannot be controlled or abated by the hospital.
  • The strengths of the various forces change over time
  • The forces result in some maximum number of patients which can be serviced under the hospital’s existing business model.
  • As each patient is lost, the stability of the model weakens.

Does this way of depicting the large provider business model ring true?  Does this help illustrate why the model must change?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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