Some hospitals have more than one EHR–Why?

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I wrote this reply in response to a blog written by Jay Fischer titled,

Do Multi-EHR Hospitals fulfil Meaningful Use Compliance more Easily?

It is interesting that for such a “new” addition to the support systems and processes that support the business of healthcare, and for the relatively few of them that have been implemented in hospitals, we can have the discussion of whether there is enough merit in having more than one EHR.

Leading hospitals are discovering they do not need multiple departments to perform similar functions.  Some hospitals have more than one admissions department, payroll, human resources, information technology, and pharmacy.  The individual groups which “own” those functions argue strongly for why they need to maintain ownership.  I have yet to see an argument which is upheld under examination.

One HR department should be sufficient.  In a market where hospitals are scrambling to cut costs, we will see hospitals reducing the number of EHRs to a single EHR.  This will happen as other hospitals are implementing EHR on top of EHR.  Who knows, perhaps as hospitals work to get down to a single EHR, they will find a market for slightly used, previously owned EHR.

For sale, one EHR, used by a grandmother from Des Moines.  Make offer.  

Why should you reframe the EHR discussion?

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Are you one of the millions with recurring dreams of taking college exams?  I remain haunted by two, both which happen to be rebroadcasts of real events.

In the first, I had convinced my graduate school professor of operations management that since I took operations research in college that I could “audit” his class and be the teaching assistant.  I used the term auditing to mean I didn’t have to attend the class or do the home work.  From the school’s perspective, it did mean I had to take the final.  As I learned sitting at my desk, wishing I could think of any excuse to move my pencil across the pristine pages of the blue book, apparently there is a difference between operations research and operations management.  Whatever the difference was, it accounted for the blank pages staring up at me.

At the end of the exam the only marking in my book was the note I wrote to the professor, “I think we both know I know how to do this however, I froze.  If you need to fail me, I understand.”  He gave me a “C”.  I saw him when I visited Vanderbilt last year, and he recognized me and remembered the story—I like to keep my audience riveted.

The other dream has to do with my lone Poly-Sci class as an undergrad.  I am a proponent of the notion that I can answer almost any question provided I can reframe the question into one I can answer.  The exam instructed us to answer a question about a book I hadn’t read.  My only choice was to reframe the question, equating it to one from a book I had read.  I gave what I thought amounted to a fairly reasoned response to “my” version of the question.  The professor agreed that I had, and then wrote on the cover of the exam book that he too used the same device when he was in college.  It had not worked for him and he wasn’t going to allow it to work for me.

I think many of those grappling with EHR would benefit from reframing the question.  Many view the question as, “How do I accomplish what the folks in Washington want me to do?”  Sometimes that question might deserve an answer.  In the case of EHR I do not think it does.  In fact, I think answering the question, and then building a plan around your answer can make EHR more difficult, and it can move you away from your business goals.

A better question, at least for your hospital or practice is, “Does it make sense for me to accomplish what the folks in Washington want me to do?”  Has Washington demonstrated enough leadership over EHR, Meaningful Use, Interoperability, or reform to justify following?  Have they provided enough clarity, defined a set of business objectives, or justified their reasoning?  Does their reasoning fit your business model?

I bet it does not.

AN EHR introspective–my cardiologist and me

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I apologize for the formatting, it got away from me and I could not fix it

The doc did not smile
Nor did I on that day.
So we sat in his office
Wondering each what to say
It was me and my Doctor.
We sat there, we two.
And he said, “How I wish
You had something to do!”

“You drove all this way                                                                                                                                                                                           Your one visit a year.
You sit there like a plant                                                                                                                                                                                            This must seem quite queer.”

So all we could do was to
Sit! Sit! Sit! Sit!
And we did not like it.
Not one little bit.

And then
something went WHIRR!
How that whirr made us stir!

We looked
Then we saw her step in through the door
We looked
And we saw her
And we waited for more
And Nurse said to us,
“Why do you sit there like that?
I know this is clerical
You don’t know how to type.
But they said this would work
That it wasn’t just hype.”

The vendor’s fibs fooled the Nurse,                                                                                                                                                                       The doc patted her head,                                                                                                                                                                                             “It isn’t your fault                                                                                                                                                                                                           We have all been mislead”

“I know some good games we could play,”
Said the Nurse.
“I know some new tricks,”
Said the Nurse as she stewed.
“A lot of good tricks.
I will show them to you.
Your Doctor
Will not mind at all if I do.”

Then Doctor and I
Did not know what to say.
My doctor was out of ideas
For this day.

“Have no fear!” said the Nurse.
“I will not let you fail.
For you see, here’s a pen                                                                                                                                                                                           And over here is some mail

With a pen in my hand!
I can write on this part                                                                                                                                                                                               And before anyone knows it                                                                                                                                                                                     This will look like your chart.

“Look at me!
Look at me now!” said the Nurse.
My doc was still typing                                                                                                                                                                                                     And he uttered a curse,

“We have had this dumb system                                                                                                                                                                                    We have had it three years                                                                                                                                                                                       And I like it less now                                                                                                                                                                                                         It still brings me to tears”

“And look,” said the Nurse!
“Your EKG is taped to the wall!
But that is not all!
Oh, no.
That is not all…”

“Look at me!
Look at me!
Look at me NOW!
Charting is a lost art                                                                                                                                                                                                     And you have to know how.
I can take your B P
The doc will listen to your heart!
And between the two of us                                                                                                                                                                                       We’ll annotate your chart.”

And I sat on the bed.
My shirt askew on the chair                                                                                                                                                                                             I asked, “Do I like this?”
“Oh, like you really care.”
“This is not a good deal,”
Is what I said to my doc.
“I came here to see you                                                                                                                                                                                               Not to stare at the clock.”

“You sit there and type                                                                                                                                                                                                      But you haven’t a clue                                                                                                                                                                                                 This is not the same work                                                                                                                                                                                                As you used to do.”

“There were times when I’d come here                                                                                                                                                                   And you’d take off your hat,                                                                                                                                                                                      Times when I’d come here                                                                                                                                                                                       And we’d sit here and chat”

“We’d talk how I feel                                                                                                                                                                                                         And things that would matter                                                                                                                                                                                    But now your sit there and type                                                                                                                                                                                  And I hear the keys clatter”

“You’d ask of my meds                                                                                                                                                                                               And inquire of my health                                                                                                                                                                                           And now with this system                                                                                                                                                                                             The conversation’s gone stealth.”

“I must use the system.
We’ve paid quite a lot!”
Even though I don’t care                                                                                                                                                                                               It can sit there and rot.”
“It will NOT go away.
I cannot make it work!
Did not ask what I wanted
Makes me look like a jerk.”

And my doc he ran out.
And, then, fast as a fox,
My doc in his Cole Haans
Came back in with a box.

A big EHR box.
And I gave it a look                                                                                                                                                                                                              “Now along with this box,
All we got was this book.”

Then he stood on his desk
And with a tip of his shoe                                                                                                                                                                                               “This time” he said                                                                                                                                                                                                           “I have something to do.”

“My productivity’s down,                                                                                                                                                                                     Thirty percent by my count,                                                                                                                                                                                         And the attributes of this system                                                                                                                                                                         They want me to flount.”

“It’s only good for two things
neither one is for me                                                                                                                                                                                                        It helps payors and auditors                                                                                                                                                                                       So to them it seems free.”

“They can get all our data                                                                                                                                                                                                  And use it to sue                                                                                                                                                                                                                 Yet for me it is useless                                                                                                                                                                                                       I have not a clue.”

“Oh dear!” said the Nurse,                                                                                                                                                                                                 I call this game…Make EHR Fly,
If I kick hard enough,                                                                                                                                                                                                      It will go to the sky.”

“You cannot play that game...
Oh dear.
What a shame!
What a shame!
What a shame!”

Then he shut off the System
Back in the box with the hook.
And the Nurse went away
With a sad kind of look.

“That is good,” said the doc.
“It has gone away. Yes.
But my boss will come in.
He will find this big mess!”
“And this mess is so big
And so deep and so tall,
We cannot clean it up.
There is no way at all!”

The CIO came in
And he said to us two,
“Did you have any fun?
Tell me. What did you do?”

And doctor and I did not know
What to say.
Should we tell him
The things that we did here today?

Should we tell him about it?
Now, what SHOULD we do?
Well…
What would YOU do
If your CIO asked YOU?

Why DC might be wrong on Meaningful Use

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I watched recently Barry Levinson’s movie Liberty Heights about a handful of people in Baltimore growing up in the fifties.  In one scene the high school practices a civil defense drill.  For those who have never seen a civil defense drill, a number slightly smaller than those who have never seen a dodo bird, permit me to explain.

From the fifties through the early eighties the fear of the US and the Soviets—if you have to look it up, it is better that you stop reading—engaging in nuclear war seemed so imminent that school children participated regularly in drills to protect them from nuclear attack, nuclear winter, nuclear annihilation.  The exercise was called duck and cover.  Stay with me now—those in charge were quite serious about this.

In duck and cover, once you saw the flash of the nuclear explosion—assuming your retinas weren’t fused—you were supposed to get under a table, most likely a wooden one that would have already turned to ash, and assume the fetal—or fecal position.  Educated adults came up with this idea as a solution, people with PhDs.

Generations of kids, millions of kids practiced this drill several times a year.  Someone puts forth a directive.  Instead of challenging it, other reasoned adults wallow in their folly.

Duck and cover.  Lemmings off cliff.

EHR and Meaningful Use.  Lemmings off cliff.

Question it before you leap.  EHR is a great opportunity.  EHR under the government’s direction—this is the same institution who developed duck and cover.  EHR and Meaningful Use—if you find it meaningful, you would probably benefit from speaking with someone who does not share your perspective.

Meaningful Use from EHR’s Meaningful Muse.

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.

How to raise healthcare IT costs without really trying

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Like anyone needs my advice as to how to do that. Go ahead, have at it. Go shopping. Shop to you drop. How much do you need? Suppose we open the coffers. How much; another million? Ten Million? Twenty-five, fifty? $100,000,000? This is a one-time offer, so make sure you ask for everything you need

What if I told you this money is available provided you correctly answer a few basic questions. Reasonable? I’d hope so for a hundred million dollars.

1. What will you do with the money that you haven’t already done?

2. Has anyone else every done that?

3. If yes, did it work for them?

4. If no, why not, and what makes you think it will work for you?

5. Will these additional funds;

5a. Get you the ARRA money?

5b. Enable you to see more patients?

5c. Help you retain and attract physicians?

5d. Increase patient safety?

6. What is your mission?

7. Why isn’t your mission the KPIs listed in question 4?

8. Are other hospitals spending the amount you are requesting?

9. Did that amount of funding allow them to meet the criteria specified in question 5?

10. If no, what makes you think you can do it?

If your CFO asked these questions, would you think them reasonable? If not, prepare 3 envelopes (see Google)

If you don’t buy the right EHR and implement it correctly, you’ve just spend a hundred million dollars to scan charts.  Somebody will be held accountable for the money.

Upgrade the coffee to Starbucks-$5. New bedpan-$50. New plasma monitors-$1,200. Knowing what you are doing—Priceless.

Health 2.0 Philadelphia « Healthcare IT: How good is your strategy?

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Health 2.0 Philadelphia

Posted by Paul Roemer on February 25, 2010

The new meetup.com group is up and running.

There is a distinction between the business of healthcare and the healthcare business. The first is more about managing the dollars and cents, and the latter is about delivering outstanding care. Many argue that the business of healthcare operates under an 0.2 business model. I believe that moving the business model to a 2.0 model by correctly deploying healthcare IT will benefit the business, the physicians, and the patients.

My vision is to make this group a place where local healthcare executives come to learn and exchange ideas in a non-threatening forum.

The purpose of the meet up is to network, exchange ideas, and learn from subject matter experts. I hope we can agree to make the meetings something of value as opposed to a forum for selling the products and services of some of the members.

Please think about joining us or sharing the link with someone.

http://www.meetup.com/Philadelphia-Healthcare-Technology-Health-2-0-Philadelphia/

This entry was posted on February 25, 2010 at 2:45 pm and is filed under Rants & Musings. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site. Edit this entry.

via healthcareitstrategy.com

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May I borrow your pen?

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Have I written recently I’m not a fan of technology for unless someone knows what business problem they intend to solve? It’s not so much that I have anything against any of the technology or any particular technology or EHR vendor, it’s more that I think many are misjudging what the technology will do for them, what they have to do to it, and they forget to ask themselves how to best address the problems.

Whatever do you mean? Thanks for asking—here’s an example. When the United States first started sending astronauts into space, they quickly discovered that ballpoint pens would not work in zero gravity.

To combat the problem, NASA scientists spent a decade and $12 Billion to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300C.

The Russians used a pencil.

Have a meeting about how to best plan for and implement EHR in your hospital. One rule, all discussion should involve process, not technology. Try first to reach consensus about what to do, then look at how to do it. You may find out that all you need is a pencil.

Does reform need to be reformed?

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The following is the comment I posted to,

Kent Bottles: Is It Really Impossible to Control the Cost of Health Care in the U.S.?

Kent, your narrative should be mandatory reading for all those in Washington whose vision of reform stands in stark contrast to the piece. Then, before they are allowed to propose or vote on their vision, they should be forced to explain why their vision doesn’t address these issues.

In my non-luminary opinion, here’s where I think the reformists have failed. The notion of spending funds that don’t exist, to fix things that may not be broken, without fixing those that are could only come from Washington.

Permit me to over simplify things to make a point. When I look at healthcare, I see a three legged stool; pharma, the payors, and the providers—the three P’s. Not exactly in a pod, each working to their own benefits and operating under different business models—models which are in conflict. For example, many hospitals operate as not for profits, which conflicts with the for profit sectors.

I believe the present reform effort will increase the conflict. Why? Because the legislation is siloed—it looks a lot like the word ‘soiled’ which might also be part of the problem. The legislation does not seem designed to address healthcare as in integrated industry. The way reform is positioned, each nudge that is put to one leg of the stool will cause a reaction, an unfavorable one, to the other legs. It is a little like doing an experiment, changing multiple variables at once, and hoping for the best.

Two sides of the stool, the payors and pharma, have behemoths running the show. Among the behemoths, the business models in pharma are quite similar and the same holds for the payors.
I think it is important to distinguish between the business of healthcare (the dollars and cents) and the healthcare business (the clinical side). The provider segment is highly fragmented. There is no behemoth provider cartel. The business of healthcare, is the side most in need of reform. Each of the thousands of providers operates under their own business model. None of these businesses was designed to be interoperable—I do not use this term in the same sense being used by the ONC and CMS.

The business of healthcare, with all of its inefficiencies, is designed to operate within its four walls and across a limited geographical radius. The long term goal of healthcare reform, I believe, is to make the provider side appear as one giant services provider. Just because consolidation sort of worked for steel, the airlines, and the automotive industry does not mean it will work for delivering healthcare.

My final comment has to do with the payor side of healthcare, and I’ll start by acknowledging that this one is more than a little provocative, one for which I have not thought through a workable solution—I’ll leave that to those of you who aren’t grasping for metaphorical tomatoes to throw. I could be convinced to skip the rest of my comments if for a moment I thought that the business model of the payors was—let’s cover everyone who needs care for a fair cost. Ignore for the moment that my statement is naive.

We know that on a small scale it is possible for people to self-insure, to meet their needs without having to rely on payors. I’ll frame my final comment with a question—where is the value-add to healthcare from the payors?

Here is my issue with the current model. You want to go to the movie, you hand me ten dollars for an eight dollar ticket, and I pay the movie theater on your behalf and pocket the two dollars. In this instance I am merely the middle man, I manage the transaction. The theater gets no marginal benefit, and you get no marginal benefit.

Not complex enough? Let’s say someday millions of people want to go to the movies and a ticket will cost them eight dollars. Anticipating that, everyone pays me a dollar a day so that when the time comes they can go. On that day, I pay for movie tickets for those who want to go, pocket the difference, and I keep the money for those who don’t go.

In my small mind, that’s how I view the payor leg of the stool. I think the payors relish reform. I think the more they complain about how badly this will hurt them the more they may like it. It reminds me of the Uncle Remus story in which Brer Rabbitt pleading with Brer Bear and Brer Fox not to throw him into the briar patch.

What industry wouldn’t be salivating if they could find an additional thirty or forty million customers overnight? What if you could charge them a monthly fee and make the co-pay so high that you might not have to cover major medical claims? Does this sound absurd or does it sound a little like the mortgage banking industry? Fess for no service. I am not saying that this will happen in every case, but I do not think one can argue that this will never happen.

Circling back to how to reform reform. From my vantage point, the most advantageous reform idea would be to force multiples of payors to compete in every state. Competition could do wonders for cost control.

A final thought. Earlier this year a House committee passed legislation on “can’t fail” businesses. The Financial Services Committee voted on an amendment that would let regulators dismantle a firm, limit mergers and acquisitions, and force an end to activities deemed systemically risky. The financial industry opposed the measure, as part of legislation to overhaul Wall Street rules. This could be another opportunity for the camel—Washington—to get its nose further under the healthcare tent. There is nothing that limits the legislation to financial services. Call me a cock-eyed pessimist, but what is there to prevent Congress from deciding that the payors need to be dismantled, thereby ushering in a federal payor model? That would give them two legs of the stool. What if…?

Who is minding your patients, your equity?

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Did I mention that I like to sing? No? Don’t tell anyone, but I just downloaded some Tom Jones to my MP3 so I can belt out a rendition of Delilah while I’m running—I only do this when I’m certain nobody is around. This doesn’t quite foot with my college collection of albums from Pink Floyd, Genesis, and Queen.

Then there was the time I was on a date at a roller rink. I was probably dressed in a pair of tight fitting bell-bottoms, an equally tight fitting rayon shirt unbuttoned to who knows where—hold the laughter. My almost shoulder length hair half-hid a puka shell necklace.

It may be important to know that although I had ice skated, I had never roller skated. There are a few not so subtle differences between the two.  Most notably, the sadist who designed the roller skate must have thought it amusing to place a large round rubberized wheel on the front of the skate in much the same position as a car bumper. I have no idea what is supposed to do. What it does do is stop you on a dime, especially when you have no intent of stopping.

Let’s see if we can tie some of this together. I’ve never felt that I actually needed to know how to do something in order to develop my own unsubstantiated delusions of adequacy—that probably explains why I’ve been consulting all these years. Anyway, back at the roller rink.

Barry Manilow’s “I Write the Songs” was being piped overhead through speakers the size of a dishwasher. Feeling much too confident for my abilities, I dragged my date to the floor. We stood side by side. I grasped her hands in a crisscrossed fashion like I had seen skaters do on television. After circling the rink for half a lap—watching my feet the entire way—I thought I should further dazzle her by singing. I should point out that it is difficult to sing and simultaneously watch your feet, a fact I didn’t learn until I was airborne. This takes me back to the rubber wheel on the front of the roller skate. We crashed to the floor and quickly took out the next thirty or so couples who were following us. It looked like a conga line run amuck. For the next hour or so it seemed like everyone in the rink pointed at me as though they were trying to warn others to stay away.

I haven’t sung any Manilow since that fabled night. Maybe it has something to do with the fact that times change and tastes change. Now I listen to groups like Dashboard Confessional and Great Lake Swimmers. I still interface with those closeted Manilow fans. Gone are the bell-bottoms and platform shoes, replaced by micro-fiber trousers, Droids, and Cole Hahns. My collar-length hair has a more monastic cut.

I’ve aged, so has my generation.  Aged to the point where they now have the power. Those people own the decision making process in most hospitals.  They may be the people calling the shots in yours. How can you tell if the person wearing the eighties polyester is one of them? Walk past her humming a few bars of Mandy or Copacabana, or something from The Captain and Tennille, and see if she hums back.

Is your Patient Equity Management (PEM) strategy is as dated as the double knits?  Or did I get ahead of myself; does your hospital even have a PEM strategy?  Odds are that there is no PEM strategy, no PEM group or executive.

Hospitals are quite good at managing their assets.  I bet your hospital has someone who can tell you how many chairs, televisions, beds and bed pans you have.  Assets.  We count them because we don’t want to lose them.  That is how businesses are managed.

In today’s dollars over their lifetime the average person in the US will spend more than $600,000 on healthcare.  Patients.  Assets.  They are a big part of your hospital’s equity base.

Who is minding your patients, your equity?  I don’t mean the doctors and nurses.  Who is responsible for making sure discharged patients return to you the next time they need a hospital?  Who manages that relationship for the hundreds of days between hospital visits?  Probably nobody; at least nobody in your organization.  Wanna’ bet somebody in the hospital on the other side of town is studying how to turn that $600,000 patient into one of theirs?

In case you’re wondering, the episode at the skating rink was our last date.