Who's Running the Show?

When reform collides with EHR…

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If I remember my physics correctly, there’s no discernable difference between screaming in a vacuum and not screaming in a vacuum, unless of course someone turns it on while you’re in it, and then by default, you’re screaming. That seemed to make sense to me during my run, but seeing it on the screen isn’t doing much for me. Ever since I tore my Achilles I can’t run as far, and I’ve gained a few pounds. I feel like I’m in my first trimester-running for two of us, sort of a Shamu in Nikes.

Enough about me.  Here’s the deal. There seems to be a slight shifting of the winds in terms of those who now believe reform will work.  The winds are blowing more towards the skeptics.  Who among us can articulate what is included in the reform effort in a single PowerPoint slide?  (Can you picture Ross Perot with his slides and wooden pointer?)  If we can’t explain the reform effort to ourselves, how then can we explain the business problem we’re trying to solve with EHR?  Until you’re comfortable articulating the benefits to your organization—not the ones spelled out on a dot-gov web site, you’re better off holding on to your checkbook.

The current EHR/healthcare reform effort violates Keynes’ third law of shopaholics anonymous–just because something you can’t afford and don’t need goes on sale doesn’t mean you have to buy it. (Unless of course it impresses your friends.)  In addition to the trillion dollar stimulus, maybe the government was awarded discount coupons–20% off on EHR if redeemed before the payors own the providers.

My latest piece on healthsystemCIO.com

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What Would You Do Without MU?

I was wondering how CIOs would approach the implementation of EMRs if they had never heard the term Meaningful Use. The more I thought about the question, the more I felt it merited discussion. If I were a CIO, I would not let these outside regulatory influences dictate my strategic decision making. As a member of the executive team, my responsibility is two-fold; to facilitate and improve patient care, and to contribute to the business as an advisor, someone whose actions positively impact the bottom line.

Some CIOs have been forced to abdicate their responsibility and to approach EHR as order takers. Sometimes the CEO/CFO/COO creates a directive mandating EHR. That said, their guidance may end. In other, more problematic cases, it doesn’t, and they also supply the name of the EHR vendor that must be used. The worst reaction to this pressure is to not challenge the issue of whether your organization will attempt to meet Meaningful Use. The concept is much more novel than it may appear.

What if Meaningful Use didn’t exist? Many hospitals undertook EHR without any hint of the fact that MU was coming — coming with money, penalties, and constraints. Many completed the implementation only to learn that to meet MU they are not done, far from it. In fact, they have just begun modifying their implementations, and paying big time for those changes.

Those who started EHR early did so under the notion that their efforts were working in concert with an established set of business goals. This is the right way to operate. Remember, EHR is voluntary — really. By default, that makes meeting MU voluntary. There is no hidden directive that states all those who implement an EHR must meet MU. Not meeting it may subject your organization to penalties, and these should be factored into your ROI calculation.

Let’s assume you have, or are going to implement, an EHR system. For large providers, it is difficult to develop a business argument for not having EHR. Now assume that MU does not exist. We already have seen examples of how having MU impacts HIT strategy, how would not having to plan around MU impact your EHR and HIT strategy? What other projects would be at the top of your list? What initiatives could you own if you did not shuffle resources away from your preferred strategy simply to chase MU? Instead, would you be addressing patient and physician churn? Implementing managed services opportunities? Aligning workflows? Developing a social media platform?

There is nothing wrong with assessing what you would be doing to support your hospital if there were no Meaningful Use. You can and should undertake that assessment and calculate its ROI. Then, instead of having a lone MU ROI, you have something else against which to compare it.

I am Stupified

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Got the T-shirt.

Did you know AIG got $79 billion?  There’s also our friends at Goldman.  This got me thinking—some would argue that it in itself is noteworthy.  There’s a reason nobody shed tears for these guys, and that is the average person has no connection to them other than what they hear on the evening news.  We never got a car loan or a mortgage from them, so when they were dangling over the precipice we wouldn’t have lost any sleep had they been allowed to fail.  Unfortunately, the reports of their death were greatly exaggerated.

American poet John Godfrey Saxe based the poem The Blind Men and the Elephant on a fable told in India many years ago.  The poem is about blind men trying to describe the elephant solely on what they are able to feel.  As they are all feeling a different part, they each think the elephant is something different from what it is and from what the other believes.

It feels like the reform effort involves an equally obtuse process—dozens of people in separate rooms, each with their own pad of paper and box of Crayolas. When they finished creating their vision of reform, the person with the biggest office stapled all the pages together with the big red stapler like the one they used in the movie Office Space.

Here’s how this all ties together—don’t blink or you may miss it.  People weren’t vocal about AIG and Goldman because we weren’t connected, because it wasn’t personal.  The opposite is true about healthcare reform.  We are connected.  It is personal.  This is what Washington doesn’t get.  If they don’t demonstrate that they get it, it will fail.

Nancy Pelosi has been the poster child for the reform effort.  Her unfavorable ratings are at two to one.  Sixty percent of Americans, also known as voters, are against the reform.  I’d wager that nearly one hundred percent of those people have insurance, and rightly or wrongly, they believe that reform will take that from them.  There is a small but important distinction here.  They are not against reform per se; they are against the reform as is being discussed.  Moreover, the snowball rolling down hill that Washington–and most of the east coast–can’t stop is that nobody can accurately describe what it is they’re against.

How can the average person know if reform will work?  If reform can’t be explained clearly on a single page, Washington will lose the voter–they have.  The opponents of reform had their message down to a page; the one bullet point is “change the bill.”

Project Management lessons from Alice and Wonderland

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During my career I’ve been involved with hundreds of project teams, some quite gifted, others whose collective intellect was rivaled only by simple garden tools.  I’ve been asked often if I can define what distinguishes the two types of teams.  For me it always comes down to leadership.  It doesn’t matter how hard the people work, it matters how well they are lead.  Does the leader know what to do tomorrow?

That got me to thinking.  Are there some leadership secrets, some project management gems that may have been overlooked?  Rather than offering traditional mish-mash consulting jargon, I thought it would be helpful to find a common ground by which we can form a basis for this discussion.  Hence the following narrative: Everything I learned about project management I learned from Alice in Wonderland.

So, you have spent tens of millions on an electronic health records system.  Some did so without even defining their requirements.  The project is chugging along, new regulations and penalties are appearing through the diaphanous mist like the Cheshire Cat’s toothy grin.

“Well! I’ve often seen a cat without a grin,” thought Alice.  “But a grin without a cat! It’s the most curious thing I ever saw in my life!”


How fast must you run so as not to lose ground?  How many milestones do you have to meet, how many due dates do you have to check?  What can be learned from the Red Queen in Alice in Wonderland?  She told Alice, “It takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast.”




For the EHR project to progress it requires extraordinary effort.  This begs a question of the project leader, where does the project need to go?  In a conversation with the Cheshire Cat Alice asks,

“Would you tell me, please which way I ought to go from here?” “That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where,” she said.
“Then, it doesn’t matter which way you go.” “So long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

If you only walk long enough.  What is enough for a three year project?  When are you done?  When the money runs out; when there are no more tasks in the work plan.  It seems many EHR projects are much bigger than allowed for by the plan.  They get big, impossibly big.  A lot of that size comes from underestimating the effort to support workflow improvement, change management, and user acceptance.

“Sorry, you’re much too big.  Simply impassible,” said the Doorknob to Alice.   “You mean impossible?” “No, impassible.  Nothing’s impossible.”

We don’t have the benefit of getting advice from talking doorknobs which is why we get so stymied when confronted with having to do the impossible. What is impassible or impossible for your project?  It might be deciding or knowing when to stop.

Alice laughed. “There’s no use trying,” she said: “one can’t believe impossible things.”
“I daresay you haven’t had much practice,” said the Queen. “When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”

Believing it does not make it so.  Never has, never will.  Belief does not beget success.  Planning does.  Defining your requirements may.  There is no shortage of ex-CIOs who believed their EHR vendor.

Then there’s the skill of managing your EHR vendor.  Perhaps Eaglet said it best, “Speak English! I don’t know the meaning of half those long words, and I don’t believe you do either!”

There will always be those select members of every project team who are so dense that light bends around them; those who have not learned that it is better to keep their mouth shut and appear unintelligent than to open it and remove any doubt; those who have the right to remain silent, who just don’t have the ability.

“You couldn’t deny that, even if you tried with both hands.”

“I don’t deny things with my hands,” Alice objected.

“Nobody said you did,” said the Red Queen. “I said you couldn’t if you tried.”

Do you find yourself sitting through a status meeting unable to tell if the project is moving backwards or forwards, unable to tell what is hiding around the bend?  You think so hard your head feels like your ears are trying to switch places with your eyes.  When all else fails, try this bit if advice.

“Fan her head!” the Red Queen anxiously interrupted. “She’ll be feverish after so much thinking.”  A little thinking won’t hurt, who knows; in small doses it might even be beneficial.

Now, let’s assume you’ve got yourself all worked up.  You and your team are pouring over your work plan, trying to decide what’s left to accomplish, or what can’t be accomplished.  How do you know what’s what and which is which?

“Begin at the beginning,” the King said, very gravely.  “And go on till you come to the end: then stop.”

I’ll take the King’s advice and do the same.

My comments to Dr. Blumenthal’s Blog

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It says they are awaiting moderation–they could be waiting a long time.  Here they are.

I think hospitals need to give a lot of thought to whether it’s in their best interest to even try to meet MU.  Those who haven’t begin EHR and CPOE will be hard pressed to benefit.  There is more unknown than known about the impact of changing an entire business strategy in light of reform, the magnitude of Stage 2 and 3 requirements, no standards, 400 vendors–all lacking 2011 certification, hundreds of different HIE’s, and an N-HIN strategy that may not be viable.

Washington is building a healthcare model whose long term goal is to be able to connect each patient to any doctor.  Hospitals have a far different business model.  The sad thing is that none of the hospitals who have undertaken EHR had any idea that costly rules would be applied after the fact, they have no means to know what the next set of changes will be, or if the dates of meeting MU will be pushed back.  If the dates don’t move MU will be like hosting a lottery for which only a handful of people bought tickets.


As for ambulatory doctors, my recommendation is to wait until a firm shrink wraps EHR (software, implementation, training, change management, and work flow improvement.)  There’s no rush here either.


Who is responsible for your hospital’s HIT strategy, you or the ONC?

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Who is responsible for your hospital’s HIT strategy, you or the ONC?  Here are my thoughts regarding “What’s Next” and the “Gap Analysis”  with regard to the ONC’s interim final rule.  Remember, you don’t have to follow the IFR.

What’s Next:

  • Most if not all of the current HIT was built prior to government constraints
  • The ONC changed the rules after many hospitals already spent millions on EHR and CPOE
  • Nobody knows the staying power of the Meaningful Use rules or the impact of reform
    • Will the implementation be pushed back?  Quite possibly
    • Will the requirements be toughened?  Very likely
    • What if reform reduces revenue and increases demand?
    • What if existing doctor and nurse shortages grow worse?
    • What if some of the most vulnerable and expensive patients continue to have no coverage?
    • What if the ONC changes the rules?
    • What if reform cuts costs by eliminating “disproportionate share” payments?
    • What if there is a reduction in Medicare reimbursements?
    • More is unknown than is known about the impact on hospitals and physicians
    • There are two business models in play;
      • The ONC’s and reform’s nationalization and interoperability of healthcare
      • The mission of your organization
      • Do you build your HIT strategy to align with your hospital’s strategy or with the ONC’s strategy
      • Your pre-Meaningful Use HIT goals likely included:
        • Supporting your strategy
        • Consolidation for shared services
        • Clinical integration
        • Operational excellence
        • Reducing functional duplication between departments
        • Process improvement
        • EHR and CPOE implementation
        • Which of those goals would have to be altered because of Meaningful Use
        • What would your HIT strategy have been if there was no Meaningful Use

What’s the GAP between what you had planned and what your now have to consider?

  • How many millions will it take to meet Meaningful Use
  • What planned HIT projects must be delayed because of timing or resources
  • How do those millions compare to what you will receive from the ARRA funds
  • Even if the funds exceed the cost to get them, how do the changed systems impact your business model
  • You have a number of options to analyze regarding Meaningful Use:
    • Meet Meaningful Use later
      • A wait and see approach buys you time for the uncertainty to settle and for the impact of reform on HIT to become clearer
      • There is no requirement to be first
      • You have five years before Meaningful Use penalties begin
      • If the requirements expand as expected it will likely cost more to modify systems than to wait for a complete set of requirements
  • Do not meet Meaningful Use
  • Meet all of the Meaningful Use opportunities
  • Meet portions of Meaningful Use
  • What projects must be undertaken to achieve each option
  • Will those projects have long-term value for you, or is their only value meeting Meaningful Use
  • What process and change management implications are built into meeting Meaningful Use

EHR Tips for supplementing ARRA funding

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tipjar

The effect of poor planning

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skate

I’ve always considered myself to be rather athletic, although I must have been on break when they handed out the coordination genes.  Perhaps that is why I tended towards individual efforts like running.

As it was, I was fairly good at ice skating as long as I was moving forward, the straighter the better.  Turning and stopping required an abundance of room, and an absence of other skaters.

Whoever came up with the notion that if you can ice skate you can roller skate was either lying through his teeth, or I became skating’s anti-matter.  At the time of my first attempt at roller skating I was unaware that ice and roller skills weren’t transferable.  Have I mentioned I like having an audience?  I decided to audition my roller skating skills at a public skating rink while on a first date.

The night was proceeding swimmingly.  I learned quickly that it I stayed to the edge and leaned towards the center of the rink, centrifugal force would keep me from falling.  My confidence in my abilities began to build.  Music boomed from the overhead speakers.  Several couples held hands, the more skilled ones crossed their arms in front of them and held hands.  I tried it and eased us into the first turn.  The song switched to Barry Manilow’s “I write the songs.”  To my misfortune, I knew the words, and began to serenade my date.  When I guy sings Barry Manilow in front of anyone but his own shadow, only two things can happen and they’re both bad.

We hit the second turn and I began to accelerate.  We sped past a number of couples.  I sang louder, concentrating more on the words than on the task of keeping us both upright.

For those unfamiliar with the design of roller skates I should explain what I perceive to be a flaw design flaw—one which you will note has been eliminated in roller blades.  The flaw?  On the front of each roller skate about an inch from the bottom is a round rubber device that resembles a stunted hockey puck.  It serves no known purpose other than to sucker punch novice skaters.  If you mistakenly try to build speed by pushing off with the toe of your roller skate—as you do in ice skating—you are actually hitting the emergency brake.  And because the brake is at the front of the skate, the physics is such that once your feet stop, the only direction the rest of your body can go is head over heels.

I looked like I had purposefully launched myself over a pommel horse.  During the first few seconds of my flight I was reluctant to let go of my date’s hands.  I thought that if we fell together that there was some small chance that I could shift the blame for the crash to her.  We separated at speed and created sort of a demolition derby for those around us, bodies piling up like logs awaiting entrance to a saw mill.  For the rest of the evening it felt like people were pointing at me as if to say, “Steer clear of him, he’s the one who took us all out.”

My one mistake caused a chain reaction of bad events and a severely hematomaed ego.  Bad things rarely happen in a vacuum.  There’s cause and effect, and the effect can be disastrous.  For those of you whose EHR program is underway who may have scrimped on the planning process—you know who you are—you may as well be the captain of the Titanic throwing refrigerant in the water.  There is no recovery from bad planning.

No matter what the shape of your EHR implementation, if you find yourself humming a few bars of “I write the songs”, only two things can happen and they’re both bad.

saint

How’s the EHR vendor performing?

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cat

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 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.  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.

black saint 2

AP reports EHR plan will fail-now what?

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blazzing

I just fell out of the stupid tree and hit every branch on the way down. But lest I get ahead of myself, let us begin at the beginning. It started with homework–not mine–theirs. Among the three children of which I had oversight; coloring, spelling, reading, and exponents. How do parents without a math degree help their children with sixth-grade math?

“My mind is a raging torrent, flooded with rivulets of thought cascading into a waterfall of creative alternatives.” Hedley Lamar (Blazing Saddles). Unfortunately, mine, as I was soon to learn was merely flooded. Homework, answering the phone, running baths, drying hair, stories, prayers. The quality of my efforts seemed to be inversely proportional to the number of efforts undertaken. Eight-thirty–all three children tucked into bed.

Eight-thirty-one. The eleven-year-old enters the room complaining about his skinned knee. Without a moment’s hesitation, Super Dad springs into action, returning moments later with a band aid and a tube of salve. Thirty seconds later I was beaming–problem solved. At which point he asked me why I put Orajel on his cut. My wife gave me one of her patented “I told you so” smiles, and from the corner of my eye, I happened to see my last viable neuron scamper across the floor.

One must tread carefully as one toys with the upper limits of the Peter Principle. There seems to be another postulate overlooked in the Principia Mathematica, which states that the number of spectators will grow exponentially as one approaches their limit of ineptitude.

Another frequently missed postulate is that committees are capable of accelerating the time required to reach their individual ineptitude limit. They circumvent the planning process to get quickly to doing, forgetting to ask if what they are doing will work. They then compound the problem by ignoring questions of feasibility, questions for which the committee is even less interested in answering. If we were discussing particle theory we would be describing a cataclysmic chain reaction, the breakdown of all matter. Here we are merely describing the breakdown of a national EHR roll out.

What is your point?  Fair question.  How will we get EHR to work?  I know “Duh” is not considered a term of art in any profession, however, it is exactly the word needed.  It appears they  are deciding that this—“this” being the current plan that will enable point-to-point connection of an individual record—will not work, and 2014 may be in jeopardy—not the actual year, interoperability.  Thanks for riding along with us, now return your seat back and tray table to their upright and most uncomfortable position.

Even as those who are they throw away their membership in the flat earth society, those same they’s continue to press forward in Lemming-lock-step as though nothing is wrong.

It is a failed plan.  It can’t be tweaked.  We can’t simply revisit RHIOs and HIEs.  We have reached the do-over moment, not necessarily at the provider level, although marching along without standards will cause a great deal of rework for healthcare providers.  Having reached that moment, let us do something.  Focusing on certification, ARRA, and meaningful use will prove to be nothing more than a smoke screen.

The functionality of most installed EHRs ends at the front door.  We have been discussing that point for a few months.  When you reach the fork in the road, take it.  Each dollar spent from this moment forth going down the wrong EHR tine will cost two dollars to overcome.  To those providers who are implementing EHR I recommend in the strongest possible terms that you stop and reconsider your approach.

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