EHR: add three cups of technology and stir

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According to my neighbor, who is a woman, next week is the season premier for “Desperate Hot-wives”—her words, not mine. My wife refers to my little brain hiccups as Roemer-minutes, a little hitch in my git-along where the thinking part of my brain briefly vacations in the fifth dimension. Speaking of the fifth dimension, the dimension, not the sixties rock group, I was reading up on it the other day. There’s this professor of theoretical physics from Harvard, Lisa Randall, who happens to look a little like Marcia Cross who portrays Bree Van De kamp—actually she looks more like Jodi Foster. See how quickly this all ties together? Anyway, Dr. Randall has developed a theory about how the universe is warped—something many of us expected. According to her model, the reason gravity appears so weak is that the universe is actually warped by a hidden fifth dimension—must be why we haven’t seen it, because it’s hidden—and our gravity is just the leftovers from the dark side.

For the inherently curious, in mathematical terms her equation is, ds2=dr2+e-kr(dxm dxn hmn). That was helpful, wasn’t it? Here’s where it gets complicated. People in Europe will are testing the Large Hadron Collider to look for gravitons, theoretical particles of gravity. The collider smashes protons into one another, and if these theoretical particles appear then disappear that somehow proves the theory. However, and depending whether you’re a glass half-full or a glass half-empty kind of person, this is a rather big however, we could all die. This is where the distinctions between the meanings of the words possible and probable become rather important.


According to this whole other branch of physics, something quite unpleasant could happen, the creation of doomsday phenomena, including microscopic black holes that would grow instantaneously and swallow the earth, and strangelets that could transform the earth into a dead dense lump. Could it happen? Yes. Will it? Probably not. So there you have it.

Where does that leave us? Assuming that it does, leave us, that is, alive, it makes the notion of implementing EHR seem just a tad more simplistic. At least we won’t be creating any black holes. So, set your phasers for stun and let us begin again. To implement EHR in your organization you need a champion, a sponsor. Someone who isn’t afraid to say, ‘follow me’. As we said before, this type of project does not lend well to the notion of ‘add three cups of technology and stir’. The champion is needed not so much for figuring out the shape of things to come, but for their ability to cause those things to be implemented within the organization. This person should have ready access to resources, dollars, and the ear of someone very senior in your firm. Next time we’ll begin to take a look at the champion’s role.

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Reforming reform

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One of the things I’m not understanding is the approach.  I’m a big backer of reform.  The part I’m not getting is why we are trying to boil the ocean, eat the elephant in one bite, or throw long.  Did I miss any cheap metaphors?

I sense many feel the same.  It’s not the reform which doesn’t have the support, it’s the approach.  That nobody is able to to summarize the reform package on a single slide makes people think it’s because they don’t have a good enough grasp of what they are trying to accomplish.  That, plus the idea of a Big Bang theory of reform is what is halting the effort.

Break it down into manageable, explainable pieces.  Demonstrate you can successfully accomplish one peice and you will have support for the next piece.  Do it all at once and fail and reform is done.

saint

Hospital Impact – Healthy Choices: Nine Healthcare Bloggers Worth a Click

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Hospital Impact – Healthy Choices: Nine Healthcare Bloggers Worth a Click http://bit.ly/5KUlg

saint

Why I differ with Mr. Halamka’s EHR strategy

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Below is a comment I wrote September 30, 2009 to Government Health IT in response to an article written about a conversation the author had with John Halamka titled, “Halamka: How to build a long distance service for healthcare.” http://govhealthit.com/newsitem.aspx?nid=72152 Most people whose comments I’ve read regarding Mr. Halamka’s vision for how the national EHR roll out might work tend to be quite supportive.  I don’t think my comments fall into the supportive category.  That may account for why they have yet to appear in print.  So, in the spirit of full disclosure, here’s what I offered.

I wrote several weeks ago that we ought to look at the telecoms networks, ATMs, OnStar, or some existing platform. My argument for redoing the national roll out strategy along those lines is that it may provide a way to eliminate the middleman, the RHIOs and HIEs, whose only real role seems to be like a train station in the middle of going from NY to LA. If nobody ever gets on or off, why have it.

The critical success factor of the telecommunications networks is called an interconnect, it’s what gets the call from A to B and provides redundant carriage. It’s also what eliminates the need for a middleman.

The AP wrote today that the current EHR national roll out plan will not work http://ow.ly/rPOH. With all respect to those working so hard on the current roll out plan, I think we need a serious rethink about what type of plan is required for the EHR roll out to work instead of pushing water uphill trying to make the current plan work. Here’s some thoughts I had about how it might be approached.

https://healthcareitstrategy.com/2009/09/27/how-can-ehr-be-made-to-work/

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EHR: How do you avoid failing?

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I may have mentioned that I’m a runner. In high school and college I’d run anytime, anywhere. I ran cross country, indoor track, outdoor track, and AAU– kept my hair tied back in a ponytail—I miss the hair.

Those were the days. I was the captain of the cross-country team during my senior year. Behind the school was a long series of hills we used for training, and they were blocked from the coach’s view. I remember that one day I told the team it was okay to walk because we were out of the coach’s sight. I also remember when he took me aside after practice and said he didn’t think it was a good idea for the captain to tell the guys they could walk. He said he couldn’t see me but he sure could hear me. I also remember the time I had my mom dropped me off about half mile away from my girlfriend’s house so I could run, making it look like I ran the entire six miles.

My friends and I ran a few 50 mile races and a couple of marathons. But the strangest race we ever ran was one that lasted 24 hours. The event was a 24 hour mile relay. More than a dozen teams entered the event. Our team had seven runners. The idea behind the race was that each person would run around the track four times with a baton and then hand the baton to the next member of his team. If one member of the team was too tired to take his turn, that team was disqualified. The race started early on a Saturday morning. At the end of 24 hours, my team had run 234 miles. We were proud of what we had done. We were even prouder when we saw the article printed in our local paper the following week that we had set a world record for a seven-man team in a 24-hour relay.

I’d like to believe that the world record had something to do with the fact that we were a great group of runners. However, as I look back on it I tend to believe that the world record had more to do with the obscurity of the event than with the capability of the runners. I don’t know if that same event had been run before we ran it or was ever run afterwards. Who knows, we may still hold the record. I guess what I learned from that event, is that it is easier to be viewed as being excellent at something that isn’t done very often.  Obscure or not, it was a one-time event for us.

Doing something once makes it difficult if not impossible to prepare for the gotchas that lay in wait.  There are healthcare providers who are on their second and third attempt at implementing their electronic health records system (EHR).  This is not the type of event where practice makes perfect, far from it.  If you don’t get it right the first time, you’ve probably already laid waste to your most important stakeholders, the users.  They are difficult enough to get on board the first time.  The second time it becomes much more of a fool me once shame on me, fool me twice, shame on you.

How do you avoid second and third attempts of something as difficult as a full-blown EHR?  For some providers, it’s even worse in that they probably have multiple dissimilar instances of EHR already in place in parts of the hospital, instances that will have to be integrated to the corporate platform.  If you let the clinical side run the project, you run the risk of losing the IT side.  If you let the IT side run the project, you run the risk of losing the clinical side.

Who do you trust to run what could amount to a few hundred million dollar project, bring out the best skills of the team members, and make sure the vendor is operating in your best interest?  It’s a difficult question to answer.  The good news is that if you get it wrong you probably won’t have to worry about doing it over, that will probably be your one-time event.

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AP reports EHR plan will fail-now what?

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blazzing

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

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

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

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

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

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

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

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

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

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Healthcare Informatics: one time at band camp…

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Here’s a response I posted to a Healthcare Informatics article, by Mark Hagland, “Revenge of the Clinical Informaticists”.

The link is: http://healthcare-informatics.com/ME2/dirmod.asp?sid=349DF6BB879446A1886B65F332AC487F&nm=&type=Blog&mod=View+Topic&mid=67D6564029914AD3B204AD35D8F5F780&tier=7&id=5E2E36E45CB54ECA8D2B08DC3E4D679C

I wrote the following:

I wrote on this same topic yesterday, albeit with a slightly different bent.  Like you, I see two distinct groups who do not play well in the same sandbox—clinical and IT.  Having one group go to the other’s summer camp to pick up a few skills is not the same as pulling a few costly and hairy projects from the bowels of project hell any more than it would be to have an IT executive take an EMT course and then assume that person was qualified to perform surgery—this one time at band camp…

Before I get up on my stool and knock myself off, I know CMIOs and CIOs who have made HIT and EHR very successful.  To them I ask, do not rake me across the Twitter coals as I try to make a point.

There’s knowledge, and then there’s qualified.  Doctors do four years of medical school, they intern, and if they specialize, they throw in a few more years before they become the in-charge.  Years of training and practice before the doctor is allowed to run the show.  Why?  Because what they are about to undertake requires practice, tutelage, and expertise.  Most of the actual learning occurs outside the classroom.

There are those—not Mr. Hagland—who suggest that the skills needed to manage successfully something as foreboding as full-blown EHR can be picked up at IT Camp.  They do a disservice to seasoned IT professionals.

Most large IT projects fail.  I believe large EHR projects will fail at an even higher rate.  Most clinical procedures do not fail, even the risky ones.

What’s the spin line from this discussion?

  • Rule 1—large EHR projects will fail at an alarming rate
  • Rule 2—sending a doctor to band camp probably won’t change rule one

Don’t believe me?  Ask friends in other industries how their implementation of an ERP or manufacturing system went.  There are consulting firms who make a bundle doing disaster recovery work on failed IT projects.  They circle the halls like turkey vultures waiting for CIO or project manager carrion.

Back to Rule 1 for a moment.  How can I state that with such assurance?  Never before in the history of before—I know that’s not a proper phrase—has any single industry attempted to use IT to:

  • impart such radical charge (patients, doctors, employees)
  • impart it on a national basis
  • hit moving and poorly defined targets—interoperability, meaningful use, certification
  • take guidance from nobody—there is no EHR decider
  • implement a solution from amongst hundreds of vendors
  • implement a solution with no standards
  • move from an industry at 0.2 to 2.0 business practices
  • concurrently reform the entire industry

Just what should a CMIO be able to do?  What are the standards for a CMIO?  To me, they vary widely.  Is a CMIO considered an officer in the same sense as the other “O’s” in the organization, or is it simply a naming convention?  The answer to that question probably depends on the provider.

Here’s how I think it should work—I realize nobody has asked for my opinion, but this way I’ll at least provide good fodder for those who are so bold as to put their disagreement in writing.

I love the concept of the CMIO and think it is essential to move the provider’s organization from the 0.2 model to the 2.0 model.  Same with the CIO.  However, getting them to pool their efforts on something like EHR is likely to fail as soon as one is placed in a position of authority over the other.  It’s sort of like getting the Americans and French to like one another.

I liken the CMIO’s value-add to that of the person providing the color commentary on ESPN—it adds meaning and relevancy.  The CMIO owns and answers a lot of the “what” and the CIO owns and answers a lot of the “How”.

Still unanswered are the “Why” and “When”.  A skill is needed that can state with assurance, “Follow me.  Tomorrow we will do this because this is what needs to be done tomorrow.”  That skill comes from an experienced Project Management Officer, the PMO.  It does not come from someone who “we think can handle the job.”  Nobody will respect that person’s ability, and if they can’t lead, yo can plan on doing the project over.

Oh, if anyone is still reading, here’s my original post; https://healthcareitstrategy.com/2009/09/28/what-should-be-the-role-of-the-cmio/

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Social Media, an example

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social-mediaA cold wind is blowing in from the north, blowing so hard that at times that the rain seems to be falling sideways, echoing off the windowpanes like handfuls of pea gravel. The leaves from the walnut trees, that had prematurely yellowed, dance a minuet as they slowly make their way to the ground in the woods. It feels like the first day of fall, a day for jeans, a long sleeve shirt, and a pair of long woolen socks. The temperature has nosedived. On a normal day, the first indication of sunrise would have begun to push the darkness from the sky. But today is not a normal day. The clouds are hanging low and gray against the dark sky.

The garage door creaked and moaned as it rose along the aluminum track. Halogen headlights pierced the darkness. Its driver, an unkempt and rather rotund woman in her 40s eased the car down her driveway and proceeded through the still slumbering neighborhood. She was a friendless woman, who along with her husband and daughter kept to herself. The neighborhood children were afraid of her, too frightened to retrieve a ball if it fell into her yard.

“Were those your dogs barking? I was asleep,” she screeched as she hurriedly exited the car wearing her oversized pajamas. The site alone was enough to frighten children and a few grown men. “I’m going to find out whose dogs were barking,” she chided. “And when I do, someone will be hearing from me. I took my last neighbors o court because their dog barked. I don’t like children. I don’t like dogs. I don’t like yard work, and I don’t want to be invited to any community activities.” I feel pretty confident she won’t have to worry about being swamped by invitations.

It was actually almost ten in the morning the day she registered her complaint—dawn to some people I guess. Three days later, the letter arrived in the mail. The return address indicated it was from a homeowners association. The letter stated that if we couldn’t control the barking of our dogs that we would be reported to the community board of directors. For second, we didn’t know how to react—then we started to laugh. The reason for the laughter was simple; my wife is on the Board of Directors. It’s like the East German Stasi is alive and well and living in Pennsylvania. I can picture this woman hiding behind her drapes, her little steno pad in hand, recording each and every bark that disrupts her bliss.

She’s a tattletale, a 40-something whose problem solving skills never grew beyond that of a third grader. She lives right next door, 100 feet away. We’ve only seen her three times in the 28 months we’ve lived here. Six months ago she sent us a fax, complaining about something or other. A fax, mind you. To her next door neighbor. This is too easy. It’s social networking run amok. She has become my poster child for bad manners, a benchmark against which all subsequent social networking commentaries will be measured.

There are also good social networking opportunities, especially for large healthcare providers.  Such as?  Do you record the number of patient calls you get each year by call type?  The fully loaded cost of each call is probably somewhere around twenty dollars.  What percentage of those calls are resolved the first time?  What percentage of those calls could be answered  more effectively without the phone? How do you answer a call without a phone?  By having the caller get what they need from some form of social media site.  In less than a few months you could design a web site and YouTube presentation to explain your bills better than any single person could explain it on the phone.  You could provide a similar service for patients who need help contacting their insurance company, and need help dealing with that firm.  The ROI on social media is significant, and it’s nicer than sending a fax.

Well, that’s it for the moment. I’m off to the store. I think I’m going to buy a third dog.

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When you’re in a hole, stop digging

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rappelling_1_1I was thinking about the time I was teaching rappelling in the Rockies during the summer between my two years of graduate school.  The camp was for high school students of varying backgrounds and their counselors.  On more than one occasion, the person on the other end of my rope would freeze and I would have to talk them down safely.

Late in the day, a thunderstorm broke quickly over the mountain, causing the counselor on my rope to panic.  No amount of talking was going to get her to move either up or down, so it was up to me to rescue her.  I may have mentioned in a prior post that my total amount of rappelling experience was probably no more than a few more hours than hers.  Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her.

The sky blackened, and the wind howled, raining bits of rock on us.  I remember that only after I locked her harness to mine did she begin to relax.  She needed to know that she didn’t have to go this alone, and she took comfort knowing someone was willing to help her.

That episode reminds me of a story I heard about a man who fell in a hole—if you know how this turns out, don’t tell the others.  He continues to struggle but can’t find a way out.  A CFO walks by.  When the man pleads for help the CFO writes a check and drops it in the hole.  A while later the vendor walks by—I know this isn’t the real story, but it’s my blog and I’ll tell it any way I want.  Where were we?  The vendor.  The man pleads for help and the vendor pulls out the contract, reads it, circles some obscure item in the fine print, tosses it in the hole, and walks on.

I walk by and see the man in the hole.  “What are you doing there?”  I asked.

“I fell in the hole and don’t know how to get out.”

I felt sorry for the man—I’m naturally empathetic—so I hopped into the hole.  “Why did you do that?  Now we’re both stuck.”

“I’ve been down here before” I said, “And I know the way out.”

I know that’s a little sappy and self-serving.  However, before you decide it’s more comfortable to stay in the hole and hope nobody notices, why not see if there’s someone who knows the way out?

Merely appointing someone to run your EHR effort doesn’t do anything other than add a name to an org chart.

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What should be the role of the CMIO?

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leadDid you ever notice when you’re watching a sports movie that a down-and-out, last-place team can always be rallied into first place in one season by the simple addition of one player with a winning attitude?  Some people keep going to see Gone With the Wind thinking that if they see it enough times the south might win.  Fantasy works well in almost any setting where popcorn is served.

Unfortunately, they don’t serve popcorn in EHR planning sessions.  Perhaps that’s because there aren’t very many planning sessions.  If there were, and if they were held by people who knew what they were up against and how to deal with it, there would be far fewer failures.

There seems to be a rush amongst hospitals to hire Chief Medical Information Officers (CMIO).  Good.  Hospitals should benefit from their skills.  I am curious, what is the qualification or specific expertise that one must possess to be a CMIO?  Are these people officers in the firm in the same sense as CEO, COO, and CFO, or is it more of a naming convention, a way of stating that a doctor has an understanding of IT?

I raise this question because of a hospital I know acting in the belief that this could be the missing link in their EHR genome program.

From my perspective a CMIO is as necessary—but not sufficient—as a CIO, provided that each is used correctly.  Whichever one is placed in charge of EHR, the other will be slighted.  Not just them, but their organization.  If the “I” in CMIO only refers to an informatics degree, I see the role of a CMIO somewhat like that of a color commentator on ESPN.  Unless the CMIO has a successful track record of planning and implementing eight or nine figure information technology projects, I think the role of the CMIO should be limited to ensuring that the clinical side of the program is functional and effective.  In the same sense, the role of the CIO should be limited to non-clinical issues.

I recommend for large EHR programs that a hospital hire a seasoned Program Management Officer, one who can walk in the door and state with confidence, “This is what we are going to do tomorrow because this is what should be done.”

I recently ran the PMO for a large medical device manufacturer implementing a very pricey Product Lifecycle Management (PLM) system.  I knew with certainty the project was at risk the moment we walked past the smattering of cubicles which housed the PLM team.  There was no ‘I’ in team, there was no ‘ME’ in team, there weren’t enough people to play a good game of dodge ball.  There was no team.

Giving people the responsibility will not get the job done if they don’t have the skills to do it.  Who is leading your effort?  Should they be?  What should the minimum skill set be of someone who will manage this hundred million dollar spend?

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