Do EHR vendors have a built-in bias?
Posted by Paul Roemer on June 26, 2009
I write from the perspective of hospitals and physicians who are required to pass tests of certifiable, meaningful use, and interoperability. As would be expected, comments made by EHR vendors are quite different from miine. Forgive me for stating the obvious–their job is to get you to buy what their firm sells, to make you a believer.
There are more than four hundred firms who have something to sell you, something they believe will make your life better. How do you know which one of them is offering something that may work for you? How can you tell? Heck, how can you tell which product will still be viable in three years?
A question worth considering. As passionate as the vdenors’ sales reps are, when a sales rep moves from Vendor A to Vendor B, does their passion remain with Vandor A? Of course not. The new “best thing since slided bread” is the thing offered by Vendor B.
Where does that leave you? For starters, don’t buy it on faith. Don’t buy it just because somebody else bought it–is their judgement better than yours? You need a way to make an objective decision about some very subjective information. One way to do that is to turn the subjective issues into quantifiable business requirements.
What do you think?
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You’re no Aristotle
Everything is written with the idea of persuading the reader; either explicitly—what is written is true, or implicitly—what is written is informative or funny, thereby persuading you that the author is informative or funny. Aristotle employed three forms of rhetorical persuasion; pathos, ethos, and logos. For those of you thinking, “Yeah, but you’re no Aristotle,” you’ll get no argument from me, but you have to admit, it’s a good likeness.
I basically write from whatever stream of clatter happens to be knocking about at the time. For me, writing is a little like speaking in parenthesis, only a little quieter and with more ambiguity. So, what is lurking up there at the moment? Sure you want to know?
I’m trying to convince my son the futility of not doing something correctly the first time he does it, arguing that it takes twice as long to do it wrong as it does to do it correctly. I call it the DIRT-FIT Principle—Do It Right the FIrst Time. For instance—loading the dishwasher. It takes a certain amount of time after clearing the counter to place the dishes, glasses, and utensils in the dishwasher pell-mell. It takes twice as long to redo it. The same principle applies to making his bed, putting away his shoes, and brushing his teeth.
The same principle applies to implementing an EHR system. It costs twice as much to put it in twice as it does to implement it correctly the first time. I bet you know a hospital who is busily implementing EHR 2.0. There is the difference between EHR implementations and sons. Implementations have the right not to do it correctly the first time—my son doesn’t.
Do EHR vendors have a built-in bias?
I write from the perspective of hospitals and physicians who are required to pass tests of certifiable, meaningful use, and interoperability. As would be expected, comments made by EHR vendors are quite different from miine. Forgive me for stating the obvious–their job is to get you to buy what their firm sells, to make you a believer.
There are more than four hundred firms who have something to sell you, something they believe will make your life better. How do you know which one of them is offering something that may work for you? How can you tell? Heck, how can you tell which product will still be viable in three years?
A question worth considering. As passionate as the vdenors’ sales reps are, when a sales rep moves from Vendor A to Vendor B, does their passion remain with Vandor A? Of course not. The new “best thing since slided bread” is the thing offered by Vendor B.
Where does that leave you? For starters, don’t buy it on faith. Don’t buy it just because somebody else bought it–is their judgement better than yours? You need a way to make an objective decision about some very subjective information. One way to do that is to turn the subjective issues into quantifiable business requirements.
What do you think?
What’s the deal with reform?
In the sixties, the initial funding for Medicare or Medicaid was sixty-five million dollars. For purposes of this discussion, it does not matter which one. It’s now more than a trillion. Most floods start as a trickle. Stay with me and see if this makes sense.
One cold night, as an Arab (this is not profiling, I pasted it from the web) sat in his tent, a camel gently thrust his nose under the flap and looked in. “Master,” he said, “let me put my nose in your tent. It’s cold and stormy out here.” “By all means,” said the Arab, “and welcome” as he turned over and went to sleep.
A little later the Arab awoke to find that the camel had not only put his nose in the tent but his head and neck also. The camel, who had been turning his head from side to side, said, “I will take but little more room if I place my forelegs within the tent. It is difficult standing out here.” “Yes, you may put your forelegs within,” said the Arab, moving a little to make room, for the tent was small.
Finally, the camel said, “May I not stand wholly inside? I keep the tent open by standing as I do.” “Yes, yes,” said the Arab. “Come wholly inside. Perhaps it will be better for both of us.” So the camel crowded in. The Arab with difficulty in the crowded quarters again went to sleep. When he woke up the next time, he was outside in the cold and the camel had the tent to himself.
Here’s my take on where we are. I know you didn’t ask, I simply sensed you wanted to know. Reform will pass. What kind of reform? Who knows? Very few of us. Who cares? A large number of those voting on it, those whose winter condos lay inside the 495 corridor don’t care.
Will healthcare reform legislation be the 3 AM call of our generation? Many raised this same question in 1993. Would it be different had the republicans brought healthcare to the table? We will never know. It does not matter if the camel’s nose enters from the left side or the right side of the tent. Others debate which end of the camel is in the tent. It matters not. Once the Chicago Cubs went to night games, we were forced to change how we look at the world.
There are many things in healthcare reform. I think that the most important one is the government. It’s like a bad stain, once it’s in, it’s difficult to remove. You may choose to differ, but I think the crux of the discussion is not what the details are in the reform legislation, but that it exists.
I agree fully that reform is needed. Unfortunately, once we let the government drive, we never again get the keys. In for a penny, in for a pound—if you convert from the Euro, it still makes sense.
Is the N-HIN helathcare’s black hole?
Last year scientists turned on the largest machine ever made, the Hadron Collider. It’s a proton accelerator. This all takes place in a donut-shaped underground tube that is 17 miles in circumference.
Fears about the collider centered on two things; black holes and the danger posed by weird hypothetical particles, strangelets, that critics said could transform the Earth almost instantly into a dead, dense lump. Physicists calculated that the chances of this catastrophe were negligible, based on astronomical evidence and assumptions about the physics of the strangelets. One report put the odds of a strangelet disaster at less than one in 50 million, less than a chance of winning some lottery jackpots—what they failed to acknowledge is that someone always wins the lottery, so negligible risk exists only in the mind of the beholder.
If I understand the physics correctly from my Physics for Librarians mail-order course—and that’s always a big if—once these protons accelerate to something close to the speed of light, when they collide, the force of the collision causes the resultant mass to have a density so massive that it creates a gravitational field from which nothing can escape. The two protons become a mini black hole. And so forth and so on. Pascal’s triangle on steroids. Two to the nth power (2ⁿ) forever. Every proton, neutron, electron, car, house, and so on.
The collider could do exactly what it was designed to do. Self fulfilling self destruction. Technology run amuck. Let’s personalize it. Instead of a collider, let’s build a national healthcare information network (N-HIN) capable of handling more than 1,000,000 transports a day. What are the rules of engagement? Turn on the lights and let’s see how it functions.
Let’s say we need to get anybody’s record to anybody’s doctor. That’s overly simplistic, but if we can’t make sense out of it at this level, the N-HIN is doomed. The number of possible permutations, although not infinite, is bigger than big. Can you see what can happen? Strangelets. The giant sucking sound comes from ARRA and stimulus money as it is pulled in to the black hole.
So what is the present thought leadership proposing to fight the strangelets? Healthcare information exchanges (HIEs)—mini N-HINs. Regional Exchange Centers (RECs). A few million, a few billion. Not only does their plan have them repeating the same flawed approach, they are relying on embedding the same bad idea, and doing it using hundreds of different blueprints.
Einstein defined insanity as doing the same thing over and over and expecting different results.
Stop the craziness. I want to get off.
It’s the end of the world as we know it…and I feel fine. R.E.M.
Call me a cock-eyed nihilist
I offered the following comment to Kent Bottles post,
My New Year’s Resolution: To See the World Clearly (Not as I Fear or Wish It to Be).
As this is the first Monday of the New Year, I had not planned on thinking, at least not to the extent necessary to offer comment on your blog. I distilled it to three points—perhaps not the three about which you wrote, but three that tweaked my interest—happiness, counterfeit, and healthcare clarity.
Suppose one argues that happiness lives in the short-term. It is something that one spends more time chasing than enjoying, something immeasurable, and once attained has the half-life of a fruit fly. I do not think it is worthy of the chase if for no other reason that it cannot be caught. As such, I choose to operate in the realm of contentment. Unlike happiness, I think one can choose contentment.
There are those who would have us believe that contentment, with regard to healthcare, comes about through clarity, and that clarity comes from contentment—the chicken and the roaders. Those are the ones who argue that reform, any reform, is good. Where does the idea of counterfeit come into play? I think it is the same argument, the one which states that any reform, even something counterfeit, is good. The healthcare reform disciples argue that reform in itself is good; be it without objective meaning,purpose, or intrinsic value. Therein lays the clarity, even if the clarity is counterfeit.
Call me a cock-eyed nihilist, the abnegator. I am not content. My lack of contentment comes not from what is or isn’t in the reform bill. It stems from the fact that reform, poorly implemented, yields an industry strapped to change, an industry that may require greater reform just to get back to where it was.
Healthcare IT reform, HIT, will have to play a key role in measuring to what degree reform yields benefit. Without a feasible plan, HIT’s role will be negative. There are those who feel such a plan exists. Many of those are the same people who believe the sun rises and sets with each announcement put forth by the ONC.
I think the plan, one with no standards, one that will not yield a national roll out of EHR, is fatally flawed. I think that is known, and rather than correcting the flaws, the ONC has taken a “monkey off the back” approach by placing the onus on third parties, and offering costly counterfeit solutions like Meaningful Use, Certification, Health Information Exchanges, and Regional Exchange Centers. If the plan had merit, providers would be leapfrogging one another to implement EHR, rather than forcing the government to pay them to do it.
Pass the salt
Okay campers, we’re going to jump right in to this one. There was a point not too long ago when the US was involved in the SALT talks, the Strategic Arms Limitation Treaty. For those too young to remember, the US and the Soviets—that’s what we used to call the Russians. Actually, they were called Russians before they got married and changed their name to Soviets which is neither here nor there.
This came about because the two countries were MAD at each other. Not in the usual sense, but in the sense of mutually assured destruction—of the world—several times over. Anyway, it finally occurred to both sides that perhaps we only needed enough weapons to blow up the world a few times instead of hundreds of times. What was the result? We’re still here. We’re here because the people who built the weapons agreed to greatly reduce their number of weapons. They learned how to function differently. Instead of saying we can’t do that, they took the approach of saying, “If we wanted to do that, how would we do it?” Getting rid of nuclear weapons—no small feat.
Segue. I realize this is a bit of a stretch just to make a point, but since we’ve come this far we might as well make it. What would you do if you came to work one day and received an email which read that your organization had decided against ever implementing an EHR?
To me that is a perfectly reasonable idea. Of course, I’m someone who wonders how the color purple feels. But why not stop all of this foolishness around EHR? Agree, or is killing EHR a foolish idea?
I think it’s much less foolish than implementing an EHR and having no reasonable expectation that it will work. The odds are that your EHR has a better chance of failing than it has of succeeding.
I have no problem with EHR. I do, however, have a problem with businesses constantly making the same mistakes, making EHR a multi-million dollar repository for their mistakes, and then complain about the fact that the EHR isn’t doing a good job.
What do you think?
What may be driving the Meaningful Use announcement
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.
How measuring Brittan can improve your EHR success
So, last night I am watching NOVA. The episode discussed fractal geometry and aired the same time as the Viking Bears game. Admittedly, not a typical Y chromosome choice, but interesting none-the-less.
A fractal is a fragmented geometric shape that can be split into parts, each of which is a reduced-size copy of the whole. Simple enough. Common examples of fractals include the branching of trees, lightning, the branching of blood vessels, and snowflakes. In the seventies the mathematician Benoît Mandelbrot discovered that fractals could be described mathematically.
It turns out that a shoreline is another example of a fractal. For example, let’s say you wanted to determine the length of the coast of Brittan by measuring it instead of just using Google. The coastline paradox says the measured length of the coastline depends on the scale of measurement. The smaller the scale of measurement, the longer the measurement becomes. Thus, you would get a longer measurement if you measured the coastline with a ruler than with a yardstick. This paradox can be extrapolated to show that the measured length increases without limit as the unit of measures tends towards zero. In the first picture, using a 200 km ruler, the coastline measures 2,400 km.
In this photo, using a 50 km ruler, the coastline measures 3,200 km.
I’m not sure why this idea needed to be discovered, it seems a little obvious—more information yields more informed results.
A few years ago I was hired by a firm to report to their board on their vendor selection process. The firm was about to issue a two-page RFP to two vendors. I convinced the firm to redo the process. They ultimately issued an RFP of more than a thousand requirements and selected a vendor who was not on their original list.
Again it seems obvious, but being obvious doesn’t always result in smart behavior. If you’re getting ready to spend seven to nine figures on and EHR, wouldn’t you like some degree of confidence that you selected the best one for your hospital?
What is wrong with the ONC’s 2010 budget?
Some comments I wrote to ahier.blogspot.com’s posting of the ONC’s 2010 budget.
Their mission, “ONC leads, coordinates, and stimulates public and private sector activities that promote the development, adoption, and use of health information technologies to achieve a healthier Nation” although offering nice sentiments, for $61 million, ought there not be a way to measure whether or not they achieved the mission? How does one know if they led, coordinated, and stimulated, and if so to what degree?
Who certifies their work? Who determines if their work resulted in Meaningful Use? Before anyone gets excited by what they plan to do in 2010, let’s look at what they did in 2009.
1. What did the ONC accomplish, complete, put to bed?
2. What did they complete that facilitated the HIT work required of the providers?
There are no standards. There is no believable plan to obtain standards anytime soon. There is no viable national roll-out plan for EHR.
Instead of HIT/ARRA handouts, and HIE’s designed by hundreds of independent groups, and RECs designed by inexperienced appointed committees, why not use the $61 million to state that by such-and-such a date there will be a written and executable plan stating when we will have standards and a workable and believable roll-out plan?
They continue to promise funds to support an ill-conceived plan trying to get everyone on board, an approach that yields to the notion that “There must be a pony in there somewhere.” Ladies and gentlemen–there is no pony.
Pale Rhino Consulting 