The doctors’ thoughts on social media are probably correct
Posted by Paul Roemer on January 18, 2010
Some more thoughts on the post on KevinMD’s site stemming from Dr. Gwenn’s blog.
Justifiable on-line road rage. I run a consulting firm. You know what? I hate it—running the firm, that is. The consulting is great fun. I am guessing that being a physician is a lot like that. Very few of you became doctors to run a business, let alone one that is front and center on the evening news, Twitter, and every other blog on the planet. Add to that a government who is changing the business model without any thought to how it impacts your business. They want a nationalized healthcare system whereby each patient can be accessed by any doctor—that has nothing to do with your effort to treat actual people.
Interesting discussion, and the comments are spot on, especially the, “Where’s the beef” comments. It is silly to expect that overlaying a few technologies makes things better. This reminds me a little of Dorothy running around in ruby slippers, and the magic answer was clicking her heels three times. Unless K-mart had a big sale on ruby slippers, there is no quick win technology for doctors lining the shelves of Office Max.
To rub salt in the wound, the government is forcing more technology on physicians, namely EHR. If the technology was as great as the prognosticators write, doctors would be scrambling to be first in line. Has that happened? Of course not. Instead, the government is taking a Tony Soprano approach, offering rebates for doctors who take a course they don’t want to take, alternatively, burying bodies off the New Jersey Turnpike.
So, some tactical thoughts starting with EHR. Don’t do anything yet. You have at least a year. Yeah, you won’t get the ARRA money—that’s according to what’s written. Guess what? Nobody else will get it either. The ONC will have to change either the timing of Meaningful Use, or the rules, or both. I think they will push it back. Twelve to eighteen months from now, someone will offer a robust, shrink-wrapped solution that makes sense. If you’re interested, here’s a link to an audio interview I did for doctors about an EHR strategy—it’s just ideas, I’m not pushing anything. Go to EMRFIX.com and search for the link.
Other practical thoughts. There are a few hundred thousand doctors, none of whose Hippocratic Oath said anything about healthcare 2.0, or offered any training on how to get there, or whether you should even try to get there. Most of my physician friends set up their business model on a whim and a prayer, like all entrepreneurs do—like I did. There are probably as many business models for doctors as there are doctors. The good news is that some have done better figuring out the business side of healthcare than others. It’s not an ego thing. It’s not about being intellectually gifted and not being smart enough to figure out something as simple as running a business. Why? Smart has nothing to do with it. There are things to be learned from the efforts of others, and there are ways that some of the technologies can help.
Those things? Blocking and tackling. Business processes. Social media. Eliminate the rework. Eliminate whatever tasks that don’t add value to your business. Are there activities you can outsource? Payroll? Can you have someone design a website that will answer questions for your patients so they don’t have to call you? Can you collaborate with other doctors?
Just some ideas. You are justified in your angst.
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The doctors’ thoughts on social media are probably correct
Some more thoughts on the post on KevinMD’s site stemming from Dr. Gwenn’s blog.
Justifiable on-line road rage. I run a consulting firm. You know what? I hate it—running the firm, that is. The consulting is great fun. I am guessing that being a physician is a lot like that. Very few of you became doctors to run a business, let alone one that is front and center on the evening news, Twitter, and every other blog on the planet. Add to that a government who is changing the business model without any thought to how it impacts your business. They want a nationalized healthcare system whereby each patient can be accessed by any doctor—that has nothing to do with your effort to treat actual people.
Interesting discussion, and the comments are spot on, especially the, “Where’s the beef” comments. It is silly to expect that overlaying a few technologies makes things better. This reminds me a little of Dorothy running around in ruby slippers, and the magic answer was clicking her heels three times. Unless K-mart had a big sale on ruby slippers, there is no quick win technology for doctors lining the shelves of Office Max.
To rub salt in the wound, the government is forcing more technology on physicians, namely EHR. If the technology was as great as the prognosticators write, doctors would be scrambling to be first in line. Has that happened? Of course not. Instead, the government is taking a Tony Soprano approach, offering rebates for doctors who take a course they don’t want to take, alternatively, burying bodies off the New Jersey Turnpike.
So, some tactical thoughts starting with EHR. Don’t do anything yet. You have at least a year. Yeah, you won’t get the ARRA money—that’s according to what’s written. Guess what? Nobody else will get it either. The ONC will have to change either the timing of Meaningful Use, or the rules, or both. I think they will push it back. Twelve to eighteen months from now, someone will offer a robust, shrink-wrapped solution that makes sense. If you’re interested, here’s a link to an audio interview I did for doctors about an EHR strategy—it’s just ideas, I’m not pushing anything. Go to EMRFIX.com and search for the link.
Other practical thoughts. There are a few hundred thousand doctors, none of whose Hippocratic Oath said anything about healthcare 2.0, or offered any training on how to get there, or whether you should even try to get there. Most of my physician friends set up their business model on a whim and a prayer, like all entrepreneurs do—like I did. There are probably as many business models for doctors as there are doctors. The good news is that some have done better figuring out the business side of healthcare than others. It’s not an ego thing. It’s not about being intellectually gifted and not being smart enough to figure out something as simple as running a business. Why? Smart has nothing to do with it. There are things to be learned from the efforts of others, and there are ways that some of the technologies can help.
Those things? Blocking and tackling. Business processes. Social media. Eliminate the rework. Eliminate whatever tasks that don’t add value to your business. Are there activities you can outsource? Payroll? Can you have someone design a website that will answer questions for your patients so they don’t have to call you? Can you collaborate with other doctors?
Just some ideas. You are justified in your angst.
Why doctors fail to embrace healthcare 2.0
This is a reply I wrote to Kevin MD’s blog to a post written by Gwenn Schurgin O’Keeffe, MD, FAAP.
I view healthcare 2.0 with a bit of a twist from the Wikipedia definition, less from the perspective of social media and more from the vantage point of moving the business of healthcare from Version 1.0 to version 2.0. I should note that I distinguish the business of healthcare (how it is run) from the healthcare business (the clinical side).
Having worked with executives in a number of industries, I think that for healthcare reform to be truly effective, the business of healthcare needs to evolve from an 0.2 model to a 2.0 model. I think the same issues you raise still come into play; sheer panic, loss of control, loss of connection with patients, and blinders.
Going from an in-house business model to one being transformed by reform and Meaningful Use to a national healthcare model will exacerbate further those issues. The in-house business of healthcare (how healthcare is run) was never built to handle a business model that will require every patient to be able to be connected to any doctor. The system advances over the past few years—EHR, CPOE, and ePrescribing were implemented without any idea that the rules would change after the fact.
Will healthcare 2.0 offer huge advantages to how healthcare is run? Absolutely. The first question to answer before aiming for 2.0 is whose 2.0 model should you follow; yours or the government’s. Are they the same? No, and they are diverging even further as you read this. The good news is that I think they will converge several years down the road. What you need to decide is which model do you pursue before that happens.
Who is responsible for your hospital’s HIT strategy, you or the ONC?
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
- Meet Meaningful Use later
- 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
How to improve EMR adoption-a guest blog
The well-written guest blog which follows is by Richard Hom, Public Policy Consultant, Richard Hom Consulting. http://grandrounds4ods.com. You can also find him on Twitter at grandrounds4ods. Thanks Richard for contributing.
Medical providers across the country are grappling with many medical care issues. Of the many, one that has received much attention, thought and talk has been computerized electronic medical records (EMR). Although not a novel idea, EMR use and adoption have regained center stage as economic stimulus funding from the Federal Government has been dangled as an added incentive.
The monetary incentive, though, has not overcome the resistance and hesitation that providers have toward EMRs. More urgent problems that preclude EMR adoption dwindling reimbursement, rising malpractice premiums and an array of private and public regulatory issues that smother provider authority. In this atmosphere of medical practice the promise of the benefits of EMR adoption has not outweighed the attention gained by the aforementioned issues.
If EMR adoption is to spread and embraced by the medical community, more tangible and direct benefits may be needed. For example, with EMR use, physician accountability is enhanced by legible and available documentation of patient care. Tying EMR use to malpractice premiums would be an attractive carrot, just as a non-smoker might benefit with health or automobile insurance.
Likewise, EMR use should benefit a physician’s patients by easing information sharing. Therefore, an initiative to lessen the burden of eligibility of benefits or referrals to specialists would be welcomed.
Finally, electronic presentation of Explanation of Medical Benefit forms (EOMBs), rejections and electronic resubmission should further invite greater EMR participation. In this one area alone, the blizzard of paper correspondence surrounding reimbursement is a significant problem area that may be lessened with EMRs and practice management software.
In summary, a cash incentive may attract medical providers, but only those providers who already may have successful office workflow processes and may require only a cash incentive. For the remaining, though, relief from the paper flow, claims submission,and malpractice premiums may be the carrot that will move more providers to EMR adoption.
Should you consider avoiding Meaningful Use?
Where were we?
There are a few things stuck in my craw—imagine that. One is Meaningful Use. The other is also Meaningful Use. Permit me to address these one at a time. I’ll start with Meaningful Use.
Are you kidding me? Who are these people? To disguise that of whom I write, let’s invent some aliases, Dr. B and Dr. H. For all the meetings, all the pronouncements, you’d think sooner or later one of them would state, “There is no way any of this makes sense.”
Why do you say that Paul? May I? What if you threw a party and nobody came? What if you held a $40 billion lottery and nobody won? Here are the rules. A handful of people less than seven feet tall decide to buy homes in a community. All the homes have door openings that are seven feet high. New people move into the community. One day the homeowner’s association mandates that all homeowners must build homes with door openings that are seven feet high. Most homeowners ignore the mandate. The association then decides to offer the homeowners rebates if they comply with the mandate, and penalize them if they don’t. Most of the homeowners ignore the mandate.
Indifferent to the fact that their mandate isn’t working, the association decides to add new rules, rules that affect the homeowners who already built homes with seven foot tall doors, and those who didn’t. One of the rules is that the seven foot tall doors must now be eight feet tall; another mandates that all roofs must be in the basement. Homeowners who comply will win the lottery. Those who don’t won’t.
How does the lottery pay out? It doesn’t. They made it impossible for anyone to get the money. Suppose you gave a lottery and nobody won? Suppose you made it so obtuse that nobody cared if they won.
That’s where I think we are with EHR. The smart healthcare providers are asking themselves the question, “What if we make a business decision not to meet the Meaningful Use requirements?” “What if we decide what is and isn’t meaningful.”
There are 2 “business models” in play—the national healthcare model, and the model your firm follows—they have different goals. I asked my client, “When you made your selection of EHR, did you have any hint that the government was going to create rules to manage what it does?” I assume their answer is a lot like yours—“Not at all. We were worried about FDA oversight, but nothing like the stimulus. The PQRI was available as an incentive to use ePrescribing, but really small potatoes.”
The national healthcare model under development will create an infrastructure such that every patient can be connected to each physician via a series of HIEs and the N-HIN. To get there, they need you—they can’t do it without you. What do they need from you? Participation. Participation by having and EHR, ePrescribing, and CPOE.
Even if it were to work, what’s in it for you? Very little. They know that—that’s why there are payments and penalties. Most hospitals like the idea of implementing EHR. Given the choice those same hospital executives would choose to listen to an entire Celine Dion CD if it would allow them to skip implementing CPOE.
If there are not many good business reasons to meet Meaningful Use, why should you build an entire strategy around it? You wouldn’t paint your hospital pink simply because Washington said you should, although given a choice between the two ideas, pink sounds pretty good. Let’s say you take them up on meeting Meaningful Use. You build your strategy, drop current initiatives, implement these systems, train your people—then what? Indeed. What happens if the government changes its mind? Moves the dates, changes the requirements?
In order to go for Meaningful Use you must be able to suspend your ability to think rationally. If you do not think the HIE and N-HIN model will work—I have not met anyone who thinks it will—why even give Meaningful Use another thought.
My client is a group of 14 hospitals—they could get millions of ARRA dollars. If you don’t have more than one hospital, your ARRA rebate will be much less. They have already installed EHR and CPOE. To get the millions they have to spend millions. What happens if they spend it and the feds change their direction? What then? What do they do with the eight or nine figures of systems they build to follow Washington’s lead? Take them out? Modify them? What happens to their business model as a result of all of this “leadership” from the ONC?
What should you do? That’s up to you. Here’s an idea or two. First, ask yourself what your EHR/HIT strategy would be if there was no ARRA money. (You do have a written HIT strategy, don’t you?) Second, decide if you think that the current national roll out strategy will work. Third, figure out what you won’t be able to do if you have to invest even more time and money meeting Meaningful Use. Next, add up all the money it will cost you to meet their requirements and compare that to what they will pay you. I bet the costs are more than the rebate.
I think Meaningful Use won’t exist in 3-5 years. I think the N-HIN won’t be available by then either.
Here’s the real kicker for hospitals that have more than two beds. If you have not yet selected your EHR vendor you shouldn’t even be thinking about meeting Meaningful Use for the first year because you can’t there in the time available to you. That take’s the pressure off, doesn’t it.
How good is your vision?
So, there I was thinking about all the times I didn’t get the invitations to the technical savants meetings.
I remember when Compaq came out with their first portable PC. It was about the size of a suitcase and twice as heavy. There was no way I’d ever have a need to lug around a computer. A few years later my boss showed me his new cell phone—beige and about the size of a shoe box. I remember asking him why he needed a phone and not being impressed by his answer. Another piece of technology that would never get off the ground.
A few years later, out popped the internet. A friend of mine showed it to me. I asked him what he does with it. He replied that it was good for sending messages to his brother. I suggested he use the phone.
I think the fault I had was I looked at those three things from the perspective of the technology. It didn’t occur to me to look at it from the perspective of what business problems could they solve.
Technology, from the standpoint of its functionality, is often vastly under employed. This happens not because of limitations of the technology, but limitations of vision. I needed to not ask, what am I able to do with this, rather, what might I be able to do with this.
For example, let’s look at the fascination, or lack of it, around implementing an Electronic Health Records system (EHR). By the time the dust has settled on your implementation, say three to five years—by the way, that means you missed the deadline to get the ARRA money, what does the industry look like?
Do you buy the EHR that meets what the industry looks like today, or did you give it enough thought so that your EHR functions at the level needed to support your business in 2015?
Should you consider disregarding Meaningful Use?
Here’s a reply I wrote to a FierceHealthIT on some of Dr. B’s comments on Meaningful Use.
I know of a hospital who has already implemented a top tier EHR costing millions. This organization ‘gets it’. They are currently building a work-plan to see what additional work they must do to meet Meaningful use in time to qualify for 100% of the ARRA money. First blush—it will take tremendous amount of work for them to do it, but they will get there—if they choose to do so. They have a choice and the fact that they know that is their trump card.
If a hospital hasn’t even begun the EHR process, as more than 80% have not, coupled with the more than fifty percent failure rates, I’d estimate their chances their chances of making the deadline at less than 1/3.
So, what to do? Stop and think. Ask the right questions. You have a choice of two strategies. Let ARRA money drive your decision, possibly implement it wrong, and probably miss the deadline. Then what do you have? Not much. Strategy number two; define your requirements, figure out what business problems you need the EHR to help solve, and buy the best one for you. Confused? Map out two work-plans for yourself. One work-plan that shows what you would have to do and what you would have to spend to meet the ARRA requirements. Draft a second work-plan that shows what you would have to do to implement what you really want. Compare the two plans and determine your deltas, your gaps.
Are you going to chase this for ARRA money? Because someone in Washington thinks you should do this?
Answer this question first. Is every hospital the same? Are you as good as the best, better than the worst? The EHR vendors think the answer is yes. Keep you processes the same, skip change management, and the implementation will be a breeze. We make every hospital look and operate the same. When did the EHR vendors become the best practice savants? The government thinks the answer is yes—that is why they are holding everyone to the same Meaningful Use standard.
One standard does not fit all hospitals—nor should it. Set your own standards and decide for yourself if you fit your version of Meaningful Use. ARRA money will end—then what? You’re stuck with your EHR. Get one you need.
CMIO Magazine » Blog Archive » Paul Roemer – What may be driving the Meaningful Use announcement
Paul Roemer – What may be driving the Meaningful Use announcement
Written by Alex on January 11, 2010 – 11:31 am
I often write not because I have something that needs to be said, but to try to explain something to myself. If I get to a point where I think I understand an issue, I’ll make it public to see if the comments reflect my understanding, or to see if I need to have another go at my own thought process. Which leads me to this—
Let’s back up the horses for a minute and return from whence we came. EHR. The idea was simple. Two groups; patients and doctors. Create a way to transport securely the medical records of any patient (P) to any doctor (D).
For the time being, let’s keep this at the level that can be understood by a third grader. What two things do I need to satisfy this P:D relationship? Data standards and a method of transport.
Do we have them? We do not. That being the case, what fury hath the ONC wrought? (1 Roemer 9:17) if you don’t have what you need, and you don’t have either the authority or a plan to get what you need, you must facilitate (fund) the creation of workarounds to fill the void.
At some point, the conversation must have quickly shifted from, “We need standards and transport”, to, “Since we don’t have standards and a means of transport, we must come up with other ways to try to make this work.” Now, I don’t believe this is literally what happened, but I think one could see how it might have evolved.
Other ways. What other ways? The ONC loves me; it loves me not. HITECH. ARRA. Take the monkey off our back and put it on the backs of the providers. Pay doctors to implement EHR. Smote them if they don’t. Write checks. Big checks. Lots of big checks. Instead of coming up with a single transport plan and one set of standards, provide guidelines. Make pronouncements. Fund RHIOs and make them responsible for creating hundreds of unique transport plans and ask the RHIOs what progress they are making towards a single set of standards. Get the monkey off your back.
Create artificial goalposts that get the HIT world all a twitter every time the ONC makes a proclamation. What goalposts? Meaningful Use and Certification. Just so there is no misinterpretation of what I think the issue is permit me to spell it out—Meaningful Use and Certification exist because there are no standards and there is no means of transport. Conversely, had the ONC developed standards and transport, there would be no discussion of Meaningful Use and no Certification. Standards would have forced vendors to self-certify.
The other activity could be viewed as a feint. Not one developed out of malice, rather one that came about from the void that resulted from the lack of a viable plan. Meaningful Use and Certification are expensive workarounds for a failed or nonexistent national EHR rollout plan. As are RHIOs and RECs, the six million dollars, and the forty billion dollars.
The HIT world grinds to a halt at the very mention of an announcement from the ONC. Their missives are available in PDF or stone tablets. Imagine someone robs a bank, and as they exit the bank, they jaywalk on their way to their getaway car. The police missed the robbery, and focus all their efforts on the secondary issue, the jaywalking.
The chain of events has caused the focus to move away from the primary issues of no standards and no plan, and towards a plethora of secondary issues, issues for which hundreds of people are responsible and no single person has authority.
I think that by the end of 2013 pronouncements on Meaningful Use and Certification won’t be able to buy time on MTV.
If any of this is close to being correct, what are the implications for a hospital looking to select and implement an EHR? Find the EHR that is best for your hospital. Not the one most likely to earn ARRA money. Not the one which will pass today’s Meaningful Use test. Define your requirements. What requirements? The ones you believe will most closely align with how the healthcare industry will look in 2015 and beyond. Meaningful Use will change. Reform will change. Funds will change. Reform will change again. Will your EHR be able to change?
The ONC’s recent Meaningful Use proclamation required 556 pages. If you occupy the C-suite of your hospital, I hope you don’t let those pages define your selection of an EHR. Some would argue that with so many pages that there must be a pony in there somewhere. From what I read, I’m in no hurry to rush out and buy a saddle.
By Paul Roemer
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The parabolic parable
The bad thing about being a former mathematician in my case is that the emphasis is on the word former. Sometimes I’m convinced I’ve forgotten more than I ever learned.—sort of like the concept of negative numbers. It’s funny how the mind works, or in my case goes on little vacations without telling me. This whole parabola thing came to me while I was running, and over the next few miles of my run I tried to reconstruct the formula for a parabola. No luck.
My mind shut that down and went off on something that at least sounded somewhat similar, parables. That got me to thinking, and all of a sudden I was focused on the parable of the lost sheep, the one where a sheep wanders off and the shepherd leaves his flock to go find the lost one, which brings us to where we are today.
Sheep and effort. Let’s rewind for a second. Permit me to put the patient lifecycle into physics for librarian style language—get the patient, keep the patient, lose the patient. These are the three basic boxes where providers focus resources. How well do we do in managing that lifecycle to our advantage? We have marketing and sales to get the patient, we have patients care to keep the patient. Can anyone tell me the name of the group whose job it is to lose the patient? Sorry, I should have said to not lose the patient. Freudian—actually, we probably have our pet names for the department who we fault for patients leaving.
Where do most providers spend the majority of their intellectual capital and investment dollars? Hint—watch their commercials. It’s to get the patient. Out comes the red carpet. They get escorted in with the white glove treatment. Once they’re in, the gloves come off, to everyone’s detriment. Nobody ever sees the red carpet again. A high percentage of a firm’s budget is to get the patients, and another large chuck for existing patients. Almost nothing is spent to retain exiting patients.
Existing versus exiting. Winning providers roll out the red carpet when patients exit. They do this for two reasons. One, it may cause a patient to return. Two, it changes the conversation. Which conversation? The one your ex-patient is about to have with the rest of the world. How does your firm want that conversation to go?
Pale Rhino Consulting 