EHR-step away from the scalpel

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So, I lunched today with a friend who is an executive at a healthcare consultancy.  She recently spent four days in a hospital, entering via the trauma center.  The purists among us would think, “If she only had a personal health record (PHR).”

As it turns out, she did.  From what I understood form our chat, the people in the hospital did not welcome her understanding of healthcare.  She handed someone on the trauma team her PHR from Google Health Vault.  According to her, she had downloaded enough data on her jump drive to where MRI’s were dripping from the USB.

At some point they determined she needed to have surgery because of something that appeared on her CAT scan.  Moments before seeing how well she could count backwards from 100, she was able to convince the surgeon that she did not require an operation because what they saw was a pre-existing condition which was documented on her PHR.  Step away from the scalpels.

I think the scalpel thing only served to spur her on.  After leaving the hospital, she requested a copy of her bill—all forty-three pages.  She read it, line by line.  They hate it when patients do that.  Her insurance covered everything, so it’s not like she was minding her pennies.  She was minding her sanity.  Seven hundred and some dollars for Tylenol.  She never took any Tylenol.  Somehow the billing system was tied to the fact that Tylenol was prescribed, independent of whether she actually took it.

Seventy-nine hundred dollars for a CT-scan.  Only ten times higher than the national average.

Where were the failure points?  People.  IT.  Process.  It’s a good thing she knew what she was doing or right now she’d be missing a thing-a-ma-jig—and they would have billed her for another Tylenol to manage that pain.

Without change management and work flow improvement, EHR will only make things worse.  There is a term of art for the intersection of work flows, people, and data—it’s called a mess.  To minimize the mess, to have any shot at an ROI, the sooner you employ adults to run the Program Management Office (PMO) for your EHR, the better your chances.

sainttop5

what’s your HIT group doing for you?

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duck

I love to cook and I belong to several internet food related sites. As an aside, one of my favorites is www.chowhound.com. Maybe it’s my personality, or lack of one, but I’m not a fan of recipes, at least not the details like measuring, ingredients, cook time, and temperature. I think that this is where the fact that I function with equal vigor from both hemispheres of my brain causes conflict—probably also explains why I had such a difficult time completing my math degree. If I don’t like the details, what else is there, you may ask? It’s more than the pictures, if that was all there was I’d be satisfied just cutting pictures out of Better Homes and Gardens magazine. I like the ideas those sites generate, but I also can’t stand to be encumbered by some silly set of rules. I guess I figure that with a set of rules anyone can be successful making that particular recipe, so where’s the challenge in that.

So anyway, I decided to smoke a nice sized duck on my grill. I rinsed the bird, trussed it, pricked the skin with a fork, stuffed it with a few blood oranges, and applied my homemade rub to the skin. The apple-wood chips were smoking nicely as I placed the bird, breast-side up on the roasting rack I had placed inside the cast-iron skillet. After turning down the burners I closed the lid. The grill, I should point out, is a seven-burner, infrared, stainless steel monstrosity with which one could probably roast an entire pig or forge iron ore into ingots. Total roasting time, about two hours. I checked the thermometer on the grill’s hood; it displayed a temperature of three hundred and fifty degrees–perfect, more or less.

It turns out that it can take as long as five minutes for the grill’s thermometer to register the correct temperature. The temperature dial on this particular model redlines at seven hundred degrees, high enough to produce spontaneous combustion. After two hours at 700 degrees, interesting things begin to happen to the carcass of a duck. Upon raising the lid the entire bird looked as though it had been spray painted a matte black. The roasting rack had melted. The leg bones appeared to have been charred from the inside out—they disintegrated the moment I touched them. I felt like a helpless doctor in the ER, there was nothing I could do to save it.

Have you ever felt that way when you try to understand how any of the healthcare IT projects are progressing? How’s EHR?  What’s the impact of reform on EHR?  Why aren’t we doing more with social media?  How come we don’t have a patient relationship management (PRM) system?  According to the reports that come across your desk, everything seems to be humming along nicely. In the committee meetings, seats are filled.  The emails imply all is fine.  Looking fine and being fine are not the same.  Looks can be deceiving. Ask the duck.

By the way, the duck fat did a great job of seasoning the iron skillet, so if that ever happens to you simply explain that what you were really doing was seasoning the pan.

saint

Pay attention to patients even when they’re not at your office.

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human-hamster-wheel-300x300

The wheel’s still turning, but the hamster is dead. One Brady short of a bunch. I like the ocean one because it reminds me of a bit done by the comic Ron White. In the bit he talks about the time he met a woman who was wearing a bathing suit made of sea shells which he held to his ear to find out if he could hear the ocean. Maybe you had to be there.

All day I’ve been operating as though I was one Brady short of a bunch—I actually have cufflinks with Marcia Brady’s picture on them, but we’ll save that for another day. The day’s highlight revolved around my daughter’s doubleheader field hockey matches–third and fourth grade girls. Their opponents looked better, older. In fact, I thought I saw one or two of them drive themselves to the field. Forty-eight degrees, first game at 8 AM. Not enough time to grab breakfast and get to the game on time. I dropped my daughter at the field and headed to a nearby convenience store to buy her a donut. As I pulled into the parking lot I noticed that I needed gas, so I figured why not multi-task it. I inserted the nozzle in the tank, went into the store, purchased a donut, and proceeded to drive away.

For the metrics lovers, those who like order over chaos, those whose desk is always neat, have you discovered my Brady moment? My purpose in going to the store was to buy a donut, not gas. My mind was focused on the donut, not on the gas. Once the donut was resting safely on the passenger’s seat my mission was over, or so I thought. Something was gnawing at me as I pulled away from the pump, something that flared at me in my rearview mirror. I knew what it was a full second before my body got the message to react to it. “Hit the break,” my mind screamed. I could see what remained of the black gas pump hose as it pirouetted helplessly behind my car. I fully expected the entire gas station to be consumed by a giant fireball like the one at the conclusion of the movie Rambo. Once I was convinced that neither I nor–it turns out that neither nor does not violate the rule of using a double negative in a sentence–anyone else in the vicinity was in mortal danger, I exited my car and walked to the pump.

My first reaction, and I don’t know why, was to see if the pump was still charging my credit card. Selfish? That means that subconsciously I had already made the decision to flee, but that I didn’t want to flee if my charge card was still open. I retrieved the severed hose from the ground and inserted it in the pump, thereby closing out the sale on my credit card. I looked around. There wasn’t anyone who had witnessed my little AARP moment. Since they hadn’t, I figured why bother anyone. Kismet; my turn on the hamster wheel.

I’m convinced it’s the little things that determine whether your initiatives succeed or fail. It’s usually nothing tricky, nothing that requires two commas worth of new technology. It’s being focused and being committed to excellence in the menial tasks which comprise each patient interaction, especially those that occur outside of the office. What little things are being overlooked in your practice?  Could social media solve some of these?  In a heartbeat, and for a cost that would surprise you.

Oh, and don’t forget to hang up the hose when you’re done.

black saint 2

Reform: Congress must answer, “What’s in it form me?”

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If reform fails to pass, what’s the reason?

Is it because Congress ignored that ninety-eight percent of healthcare is local; Hyperlocal?  I think the answer is a resounding yes.  What is hyperlocal?  You know the saying, “All politics is local?”  Well, hyperlocal is local on steroids.  It’s moms and dads making choices about who will care for their family.  It’s the doctor down the street, not the doctor chosen by some system.

I think individuals see the bill as “What’s in it for them—them is defined as anyone other than me” and “What will it do to me?”  HR 3200 isn’t viewed as improving my healthcare, nobody sees it as meCare.  That is why when viewed nationally so few are behind it.

It’s not that nobody is interested in providing healthcare to those who don’t have it.  What concerns people who do have healthcare is their belief—which may have nothing to do with reality—is that to provide healthcare to those who don’t have it requires that those who have it to give up some of their benefits.  Those with healthcare see reform as a zero sum game.

What has people trying to kill the bill is that nobody who currently has healthcare believes they will see any net gain benefit from the bill—they will see a net loss.  If any benefit will accrue to those who presently have healthcare, they certainly can’t articulate the benefit.

To gain support for HR3200, Reform 3.0, or whatever it comes to be called the bill must address first person interests, not second or third.  Does that sound selfish?  It may be.  However, they are toying with reforming a fifth of the economy and a service of which eighty percent of the people are generally pleased.

For reform to pass, Congress must learn to conjugate the care verb: First person—iCare, meCare Second and third person—heCare, sheCare, theyCare, youCare. That about covers all the various forms of caring.

What Congress hasn’t come to grips with is that there is no meCare in heCare, sheCare, or theyCare—hence, people don’t care to support reform.

What do you think?

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A question on reform

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If reform becomes Obama’s Kryptonite, does that make him a lame duck with three years to go?

What happens to the EHR roll out and ARRA if reform doesn’t pass?

An Australian Blog worth my time, maybe yours

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I had no knowledge of this until Heather Leslie wrote that I was quoted.  Independent of that nicety, it makes good presentation and argument of the pertinent issues.

http://aushealthit.blogspot.com/2009/10/is-thomas-beale-really-onto-something.html

As always, my best- Paul

saint

What is meant by Healthcare 0.2 and 2.0?

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eat_more_chickensized

Last night I was explaining to my sister-in-law my notion about healthcare 0.2 and the need to transform it to healthcare 2.0.  She had no idea what I meant.  That’s a problem—not because she’s my wife’s sister but because she an executive at one of the top children’s hospitals.

I figured that if she didn’t understand what I meant, I may have also confused others—sort of like typing with a keyboard full of marbles.

I’ve written that healthcare is a 0.2 business being forced towards 2.0—H2.0.  What exactly do I mean by Health 0.2?  It could just as easily be 0.5 or 0.7.  The idea behind the label is that there is a large gap between where the healthcare business is, H0.2, and the future of the healthcare business, H2.0.

Permit me to share how I distinguish between the business of healthcare and the healthcare business.

  • The business of healthcare—clinical, care, patients
  • The healthcare business is paper intensive and duplicative and includes support business functions like:
    • Human resources
    • IT
    • Payroll
    • Vendor relationship management (VRM)
    • Patient relationship management (PRM)
    • Registration…and so forth

Successfully bridging the 0.2 to 2.0 GAP replies equally on foresight and planning.  For the change brought about by the bridge to take hold, change needs to be an ongoing event.

To begin the assessment, healthcare leaders must undertake an honest assessment of the organization’s strengths and weaknesses.  Sounds simple.  It’s not.  Hospitals are noted for their fiefdoms, and the fiefs, run mostly by doctors, aren’t big on being told there’s a better way to do things, nor are they keen on giving away control.

To change how the business is run, to make it more effective, and thus more efficient, requires that the major business functions be retooled.

We’ll take a look at how a hospital might go about this.

sainttop5

What are the voices telling you?

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voices

My favorite thing about healthcare is having witnessed it up close and personal both as a cancer patient in the 80’s and as the survivor of a heart attack seven years ago.

I was fortunate enough to have testicular cancer before Lance Armstrong made it seem kind of stylish.  Caught early, it’s one of the most curable cancers.  As those who’ve undergone the chemo will attest, the cure is almost potent enough to kill you.

I self-diagnosed while watching a local news cast in Amarillo where I was stationed on one of my consulting engagements.  As we were having dinner, my fellow consultants voted to change the channel—I however had lost my appetite.  I went to my room, looked in Yellow Pages—see how times have changed—and called the first doctor I found.  This is one of those times when Never Wrong Roemer hated being right.

So, yada, yada, yada; my hair falls out in less time than it took to shower.  A few more rounds of chemo, the cancer’s gone and I start my see America recovery Tour, my wig and I visiting friends throughout the southeast.  If I had it to do over, I would go without the wig, but at twenty-seven the wig was my security blanket.  I don’t think it ever fooled anyone or anything—even my house plants snickered when I wore it around them.

I owned a TR-7 convertible—apparently it never lived up to its billing as the shape of things to come, more like the shape of things that never were.  My wig blew out of the convertible as I made my way through Smokey Mountain National Park.  I spent twenty minutes walking along the highway until I spotted what looked like a squirrel laying lifelessly on the shoulder—my wig.

The last stop on my tour was at a friend’s apartment in Raleigh.  Overheated from the long drive and the August sun, I decided to take a few laps in her pool.  I dove in the shallow end, swam the length of the pool, performed a near-flawless kick-turn and eased in to the Australian Crawl.  As I turned to gasp for air, I noticed I was about to lap my hair.  I also noticed a small boy, his legs dangling in the water, with a look of astonishment on his face.

My ego had reached rock bottom and had started to dig.  I had one of those “know when to hold ‘em, know when to fold ‘em moments” and never again wore the wig after learning it was such a poor swimmer.

Do you get those moments, or get the little voice telling you that your EHR strategy isn’t fooling anyone?  It’s okay to acknowledge the voices as long as you don’t audibly reply to them during meetings—I Twitter mine.

Sometimes the voices ask why we didn’t evaluate the EHR vendors with a detailed RFP.  Other times they want to know how that correspondence course in project management is coming along.  It’s okay.  As long as you’re hearing the voices you still have a shot at recovery.  It’s only when they quit talking that you should start to worry.  Either that, or try wearing a wig.

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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.

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