Project Management’s Biggest Mistake

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Today’s headlines; Paula Dean drops two pants sizes and, based on six years of research in the Pacific Northwest, graduate researchers at Chicago’s School of Anthropology have confirmed that in fact, consultants do eat their young.

Observation may be one of our best teachers, but we often ignore what can be learned from it.  Here is a real-life example that occurred to me from having watched a human interest story on the local news about neighbors banding together to try and rescue someone’s pet cat which they surmised was stuck in a tree.

Here is the observation; how many cat skeletons have you seen in trees?  What can be learned?  Maybe cats do not need rescuing.

Project management and business in general have many similarities with cats stuck in trees.  Somebody thinks there is a problem, and like good little workers, we throw resources at the problem trying to rescue it.  We establish committees, have meetings, and create reports.  We discuss the problem, we recall what happened the last time we had this type of problem, we bring in experts whose skills are particularly attuned to solving this problem, and then we attack it.

The one thing we fail to do is to validate whether the perceived problem is really a problem.  Chances are that the cat in the tree is doing just fine and does not require any help. If it does, there is always gravity.

 

Redux–What people at HIMSS were afraid to say

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One image of HIMSS that will not escape my mind is the movie Capricorn One—one of OJ’s non-slasher films.  For those who have not seen it, the movie centers on the first manned trip to Mars.  A NASA Mars mission won’t work, and its funding is endangered, so feds decide to fake it just this once. But then they have to keep the secret…

The astronauts are pulled off the ship just before launch by shadowy government types and whisked off to a film studio in the desert.  The space vehicle has a major defect which NASA just daren’t admit. At the studio, over a course of months, the astronauts are forced to act out the journey and the landing to trick the world into believing they have made the trip.

Upon the return trip to Earth, the empty spacecraft unexpectedly burns up due to a faulty heat shield during reentry. The captive astronauts realize that officials can never release them as it would expose the government’s elaborate hoax.

I think much of what I saw at the show was healthcare’s version of Capricorn One.  Nothing deliberately misleading, or meant as a cover-up or a hoax.  Rather more like highlighting a single grain of sand and trying to get others to believe the grain of sand in an entire beach.

The sets for interoperability and HIEs served as the Martian landscape, minus any red dust.  There was a wall behind the stage from where the presentation interoperability was shown.  I was tempted to sneak behind it to see if I could find the Wizard, the one pulling all the nobs and using the smoke and mirrors to such great effect.  It was an attempt to make believers, to make people believe the national healthcare network is coming together, to make us believe it is working today and that it is coming soon to a theater near you.

After all, it must be real; we saw it.  People wearing hats and shirts emblazoned with interoperability were telling us this was so, and they would not lie to you.

The big-wigs, and former big-wigs—kudos to Dr. B. for all his hard work—were at the show for everyone to see, and to add a smidgen of credibility to the message.  They would not say this was going to happen if it were not—Toto, say this ain’t true.

The public relations were perfect, a little too perfect if you asked me.  Everyone was on message.  If you live in Oz and go to bed tonight believing all is right with the world, stop reading now.  If what you wanted from HIMSS was a warm and fuzzy feeling that everything is under control and that someone really has a plan to make everything work you probably loved it.

Here is the truth as this reporter saw it.  This is not for the squeamish, and some of it may be offensive to children under thirteen or C-suiters over forty.  In the general sessions nobody dared speak to the fact that:

  • Most large EHR implementations are failing.
  • Meaningful Use isn’t, and most hospitals will fail to meet it.
  • Hospital productivity is falling faster than are the Cubs chances of winning a pennant.
  • Most hospitals changed their business model to chase the check
  • Most providers will not see a nickel of the ARRA money—the check is not in the mail and it may never be.

The future as they see it is not here, and may never be, at least until someone comes up with a viable plan.  Indeed, CMS and the ONC have altered the future, but it ain’t what it used to be.  People speak to the need to disrupt healthcare.  Disrupt it is exactly what they have done.  The question is what will it cost to undo the disruption once reason reenters the equation?  What then is the future for many hospitals?

  • Hospitals on the whole will lose more much more money due to failing to be ready for ICD-10 than they will ever have seen through the ARRA lottery.
  • It make take years to recover the productivity loses from EHR and the recoup those revenues.
  • Hospitals spending money to design their systems to tie them into the mythical HIE/N-HIN beast will spend millions redesigning them to adapt to the real interconnect solution.
  • The real interconnect solution will be built bottom-up, from patients and their primary care physicians.
  • Standardized EMRs will reside in the cloud and patients will use the next generation of smart devices.  And like it or not, the winners will be Apple, Google, and Microsoft, not the ONC and CMS.  Why?  Because that is who real people go to to buy technology and applications.  A doctor still does not know which EHR to buy or how to make it work.  Give that same doctor a chance to buy a solution on a device like an iPad and the line of customers will circle the block.

And when doctors are not seeing patients they can use the device to listen to Celine Dion.  This goes to show you there are flaws with every idea, even some of mine.

(I published this post one year ago, just after the Orlando HIMSS.  It appears to still be valid today. Comments?)

The True Measure Of Success For HIT Systems

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My newest post in healthsystemcio.com.  Feedback appreciated.

The title of the book on the lap of the person sitting next to me was “Cost Justifying Usability”. My cynicism jumped immediately to Def-Con 4.

Cost Justifying Usability. Did the author get his inspiration for the title at the Shopping-For-New-Ideas store? Now, before you laugh too hard, recall that many inane ideas make gobs of money, such as thePet Rock and Chia Pet. For every book, there must be an audience. I can only believe that the intended audience for this epic must be senior business executives.

Imagine yourself being one of those executives. Someone finds you lying on the floor in the fetal position and suggests you read the book. How should you respond?

  • I assumed usability was the antecedent  for buying that system
  • We just spent $300 million dollars on an enterprise system. Does making it usable cost extra?
  • They told us the drop-dead date is March 21. Drop-dead is the perfect phrase; we only measured cost and speed — nobody thought to measure usability?

What is the title of the antithetical book—Cost Justifying Unusability or, Cost Justifying Failure?

The statement most in HIT are afraid to utter is that most HIT spend has no ROI. There is no ROI because the usability measure of most of the largest HIT systems (enterprise and EHR) is negative — productivity is showing a net loss instead of a net gain.

Usability is not the same as user acceptance. User acceptance for these unusable systems will approach 100 percent. Why? Because users have no other option. And then there is Meaningful Use — an odd phrase because it has nothing to do with users. An EHR can pass Meaningful Use and have low user acceptance and the usability factor of hammering a nail with a banana.

If the healthcare industry needs to be convinced that a cost justification for usability is required before anyone takes the issue seriously, perhaps a moniker change is in order — HIT to OBIT.

Call me silly, but I think the time has come to do away with how we measure the success of all business systems projects. Was the system usable — did it increase ROI, did it make the organization more effective, and did it enable innovation? Only two approaches to measure need be used.

  1. On time, on budget, high user acceptance, unusable:             failure
  2. Not on time, not within budget, usable:                                        success

No matter what else happens, if the best your business system project does is to give you back performance similar to what you had without the system, a reasoned executive would say the investment in the system was wasted. It then stands to reason that if the new system delivered worse performance than what you had previously, it too is a wasted investment.

When I talk with some seasoned executives in HIT about the success or failure of their EHR system, I pause for a second waiting for someone to say, “Pay no attention to the small man behind the curtain.” Their standard of measure? See above, Approach 1. Some would have you believe it is heretical to say that spending a hundred million dollars on a system whose usability is poor was a waste of money. Most of those who defend the spend are those who did the spending.

Ask the users if they think the money was well spent. These three quotes came from a physician whose hospital spent $400 million on a name-brand EHR.

  1. “Their (the hospital’s) most expensive resource spends a lot of time doing data entry.”
  2. “The data is very good if you are a patient or an insurance company that wants to sue us.”
  3. “My productivity is still down thirty percent.”

Imagine yourself as a hospital executive and answer the following question. Which of these two pieces of information is more valuable: knowing your EHR passed Meaningful Use or, learning from your users that the EHR is unusable? In HIT, there are two rules:

  1. The usability measure of most EHRs is unacceptable.
  2. Paying more for your EHR than the next guy or gal does not change Rule 1.

Your EHR vendor’s biggest secret

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I am working on a novel, my second.  It involves a serial killer. There is something richly cathartic about killing someone with bits and bytes. If you are in a bad mood, it can be calming. If the killing does not provide the calming effect I had hoped to achieve, rekilling him in a more vengeful manner usually does the trick.

The novel involves the skills of an FBI profiler. If you have read any of the books on profiling you would think it an exact science.  Chapter by chapter the writer extols the successes of profiling—this profile worked, that one worked.  According to how it is spelled out in the book, one would want to ask, if profiling is so successful, why do they not use it on every case?

Perhaps because there are unwritten chapters, chapters that never make it into the profiler’s handbook.  The reason those chapters do not make it to the book is because it sort of defeats the purpose to print cases in which the profiles that were created did not match that of the killer’s—white male in his mid-thirties, wooden leg, drives a Prius, and enjoys watching Dancing with the Stars.

When I thought about it, it occurred to me that business software is pitched a lot like profiling serial killers.  You never hear about the bits that do not work.

Think back to when you and your colleagues watched various processes of your software being demonstrated—add a patient or a customer, schedule an appointment, write a new script.  The functionality was so smooth it brought a tear of hopefulness to the eyes of the prospective users.

In a recent conversation I learned of a patient scheduling system that had more than five-thousand user screens.  That is a five followed by three zeroes; almost enough to have a separate screen for each patient.

Like the author of the book on profiling who only wrote about the cases on which his technique worked, software vendors only show potential buyers those processes that function smoothly. In an EHR system, vendors show how their software works in a real-life setting with only one thing missing, a patient with which it must interact.  A rather critical missing part of the functionality puzzle if you ask me.

The entire situation, that of acquiescing over time to having to use bad software, reminds me of the experiment of the frog and the pot of water; drop a frog in a pot of boiling water and it leaps out, place it in a pot of water and gradually raise the temperature and the frog will remain in the pot until it is cooked to death.

Users of bad software are a lot like frogs in a pot. They never quite get up the moxie needed to jump out of the pot. More often than not they allow their situation to worsen until it is too late.

How to save your EHR

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This link is to my article published today in healthsystemcio.com about the productivity loss brought about by EHR and what can be done about it. I would welcome your feedback.

 

http://healthsystemcio.com/2012/02/16/managing-change-not-avoiding-it-is-the-answer/

 

Thank you, Paul

Can you blame providers if they fail Meaningful Use?

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I don’t wake up each day planning to be at odds with ninety-eight percent—I’m probably being overly generous assuming two percent of the people are as jaded as me—of the HIT community, maybe I just come by it naturally.

The first time I heard of RECs (regional extension centers) the first thing that came to mind was playgrounds, something akin to what the Police Athletic League might find useful.  Five hundred and ninety-eight million dollars.  They tried 597 and determined it wouldn’t be enough and figured 599 would be too much, but 598 million was just right.  Then Goldilocks made her way over to the porridge—sorry for turning left at the fairy tale ramp.

A large part of the success or failure of reform hinges on the success or failure of EHR.  Accordingly, the government made the egregious decision to manage the process of building and rolling out a national EHR down at the molecular level.  They have involved themselves at the front-end, at the vendor level, and at the back-end.  The more anxious they become, the more money they waste, adding another guise to get the healthcare providers to take their eyes off the ball.  Five hundred ninety-eight million “we’re just here to help you” dollars.

This money could be spent to pay the top EHR vendors to create one set of standards and modify their systems to fit those standards.

Meaningful Use.  Don’t get me started.  How can I fault thee; let me count the ways.  Those tested early for Meaningful Use will be examined less rigorously than those tested later.  This is like the IRS saying that if you file your taxes in February, don’t worry about those silly little math errors.  Healthcare will be the only industry whose software quality assurance check occurs after they pass the fail-safe point, the point of no return.

With good leadership providers should know EHR will pass meaningful use before implementing the system. If they fail to pass Meaningful Use, shame on them.

Will National EHR Work?

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I’ve never been mistaken as one who is subtle.  Gray is not in my patois.  I am guilty of seeing things as right and left and right and wrong.  Sometimes I stand alone, sometimes with others, but rarely am I undecided, indecisive, or caught straddling the fence.  When I think about the expression, ‘lead, follow, or get out of the way,’ I see three choices, two of which aren’t worth getting me out of bed.

I do it not of arrogance but to stimulate me, to make a point, to force a dialog, or to cause action.  Some prefer dialectic reasoning to try to resolve contradictions, that’s a subtlety I don’t have.  Like the time I left the vacuum in the middle of the living room for two weeks hoping my roommates would get the hint.  That was subtle and a failure.  I hired a housekeeper and billed them for it.

Take healthcare information technology, HIT.  One way or another I have become the polemic poster child of dissent, HIT’s eristical heretic.  I’ve been consulting for quite a while—twenty-five plus years worth of while.  Sometimes I see something that is so different from everything else I’ve seen that it causes me to pause and have a think.  Most times, the ball rattles around in my head like it’s auditioning for River Dance, and when it settles down, the concept which had led to my confusion begins to make sense to me.

This is not most times.  No matter how hard I try, I am not able to convince myself that the national EHR rollout strategy has even the slightest chance of working as designed.  Don’t tell me you haven’t had the same concern—many of you have shared similar thoughts with me.  The question is, what are we going to do about it?

Here’s my take on the matter, no subtlety whatsoever.  Are you familiar with the children’s game Mousetrap?  It’s an overly designed machined designed to perform a simple task.

Were it simply a question of how to view the current national EHR roll out strategy I would label it a Rube Goldberg strategy.  Rube’s the fellow noted for devising complex machines to perform simple tasks.  No matter how I diagram it, the present EHR approach comes out looking like multiple implementations of the same Rube Goldberg strategy.  It is over designed, overly complex.  For it to work the design requires that the national EHR system must complete as many steps as possible, through untold possible permutations, without a single failure.

Have you ever been a part of a successful launch of a national IT system that:

  • required a hundred thousand or so implementations of a parochial system
  • has been designed by 400 vendors
  • has 400 applications based on their own standards
  • has to transport different versions of health records in and out of hundreds of different regional health information networks
  • has to be interoperable
  • may result in someone’s death if it fails

Me either.

Worse yet, for there to be much of a return on investment from the reform effort, the national EHR roll out must work.  If the planning behind the national ERH strategy is indicative of the planning that has gone into reform, we should all have a long think.

I hate when people throw stones without proposing any ideas.  I offer the following—untested and unproven.  Ideas.  Ideas which either are or aren’t worthy of a further look.  I think they may be; you may prove me wrong.

For EHR to interoperate nationally, some things have to be decided.  Somebody has to be the decider.  This feel good, let the market sort this out approach is not working.  As you read these ideas, please focus on the whether the concept could be made to work, and whether doing so would increase the likelihood of a successful national EHR roll out.

  • Government redirects REC funds plus whatever else is needed to quickly mandate, force, cajole, a national set of EHR standards
    • EHR vendors who account for 90%–pick a number of you don’t like mine—use federal funds to adapt their software to the new standard
    • What happens to the other vendors—I have no idea.  Might they go out of business?  Yup.
    • EHR vendors modify their installed base to the standard
  • Some organization or multiple organizations—how many is a tactic so let’s not get caught up in who, how many, or what platform (let’s focus on whether the idea can be tweaked to make sense)—will create, staff, train its employees to roll out an EHR shrink-wrapped SaaS solution for thousands and thousands of small and solo practice
    • What package—needs to be determined
    • What cost—needs to be determined
    • How will specialists and outliers be handled—let’s figure it out
  • Study existing national networks—do not limit to the US—which permit the secure transfer of records up and down a network.  This could include businesses like airline reservations, telecommunications, OnStar, ATM/finance, Amazon, Gmail—feel free to add to the list.  It does no good to reply with why any given network won’t work.  Anyone can come up with reasons why this won’t work or why it will be difficult or costly to build or deploy.  I want to hear from people who are willing to think about how to do it.  The objective of the exercise is to see if something can be cobbled together from an existing network.  Can a national EHR system steal a group of ideas that will allow the secure transport of health records and thereby eliminate all the non-value-added middle steps (HIEs and RHIOs)?  Can a national EHR system piggyback carriage over an existing network?

We have reached the point of lead, follow, or get out of the way, and two of these are no good.

The Physics of EHR

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To read and complete this post you may use the following tools; graph paper, compass, protractor, slide ruler, a number two pencil, and a bag of Gummy Bears—from which to snack.  The following problem was on the final exam in my eleventh grade physics class.  Let us give this a shot and then see if we can tie it into anything relevant.

A Rhesus monkey is in the branch of a tree thirty-seven feet above the ground.  The monkey weights eight pounds.  You are hunting in Africa, and are three hundred and twenty yards from the monkey.  You have a bolt-action, reverse-bore (spins the shell counter-clockwise as it leaves the gun barrel) Huntington rifle capable of delivering a projectile at 644 feet per second.  The bullet weighs 45 grams.  The humidity is seventy percent, and the temperature in Scotland is twelve degrees Celsius.

At the exact moment the monkey hears the rifle fire it will jump off the branch and begin to fall.  Using this information, exactly where do you have to aim to make sure you hit the monkey?

I used every piece of information available to try to solve this.  I made graphs and ran calculations until there was no more data left to crunch, computing angles and developing new formulas.  I calculated the curvature of the earth, and the effect Pluto’s gravitational pull had on the bullet.

The one thing that never occurred to me was that since the monkey was falling to the ground, so was the bullet—gravity.  The bullet and the monkey both fall at the same rate because gravity acts on both the same way.  So, where to aim to hit the monkey?  Aim at the monkey.

All of the other information was irrelevant, extraneous.  The funny thing about extraneous information is that it causes us to look at it, to focus on it.  We think it must be important, and so we divert attention and resources to it, even when the right answer is staring us in the eye.

Attempting to implement EHR is a lot like hunting monkeys.  We know what we need to do and yet we are distracted by all of this extraneous information that will hamper our chances of being successful with the EHR.  Two of the most obvious distractions are Meaningful Use and Certification.  The overarching goal of EHR is EHR; one that does what you need it to do.  If the EHR does not do that, everything else has no meaning.

EHR: How is your EHR vendor performing?

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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 trying 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 our productivity crash? 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 committee 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.

Who was the person who put in your first EHR system?

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The first home I bought was in Denver.  Built in 1898, it lacked so many amenities that it seemed better suited as a log cabin.  There was not a single closet, perhaps because that was a time when Americans were more focused on hunting than gathering.  Compared to today’s McMansions, it was doll-house sized.

It needed work—things like electricity, water—did I mention closets?  I stripped seven coats of paint from the stairs.  Hand-built a fireplace mantle and a deck.  One day I arrived home only to find my dog had eaten through the lath and plaster wall of the space which served as my foyer/family room/ living room-cum-hallway.  I discovered the plaster and lathe hid a fabulous brick wall.

My choice was to patch the small hole, or remove the rest of the plaster.  I knew nothing of patching holes, but felt pretty confident about my demolition skills.  Within an hour I had purchased man-tools; two mauls, chisels, and a sledge hammer.  I worked through dinner and through the night.  The only scary moment came as the steel chisel I was using connected to the wiring of two sconces which were embedded in the plaster.  On cold nights I can still feel the tingling in my left shoulder.

As the first rays of dawn carved their way through the frosted beveled glass of the front door, I wondered why I never before had noticed that the glass was frosted.  I wiped two fingers along the frost.  A fine coating of white powder came off the glass leaving two parallel tracks resembling a cross-country ski trail.  I surveyed the room only to see that the air made it look like I was standing inside of a cloud.  The fine white powder was everywhere, covering my Salvation Army sofa, a semi-matching machine-loomed Oriental rug from the Far East (of Nebraska), a two-ton Sony television, and a component stereo system that had consumed most of my earnings.

Bachelor living can be entertaining.  One of my climbing buddies moved in with me.  The idea was I’d keep the rent low, and he’d help me by maintaining the house.  He didn’t help.  I made a list of duties; he didn’t help.  I left the vacuum in the middle of the floor, for two weeks and he walked around it.  I made him move out, and advertised for a female roommate—an idea I now wish I’d marketed.  A girl from church came over to see the place.  I turned my back on her to allow her to view the house with a degree of privacy.  When I returned I found her on her hands and knees cleaning the bathroom.  I was in love.  It was like having a big sister and mother.  She even asked if it was okay if since she was doing her laundry if she did mine at the same time.  Life was oh so good.

Sometimes when one approach isn’t working it’s real easy to try something else.  And sometimes the something else gives you a solution in the form of a water-walker.  Healthcare IT and EHR aren’t ever going to be one of those sometimes.  There will be no water-walkers, no easy do-overs.  There won’t be anyone walking your hallways talking about their first wildly unsuccessful EHR implementation.  Nobody gets to wear an EHR 2.0 team hat.  Those who fail will become the detritus of holiday party conversations.  Who will be the topic of future holiday parties?  I’m just guessing, but I’m betting it will be those who failed to develop a viable Healthcare IT plan, whoever selected the EHR without developing an RFP, the persons who decided Patient Experience Management (PEM) was a waste of money.  The good news is that with all of those people leaving your organization there will be more shrimp for everyone else to eat.

I’d better go.  I just noticed somebody left the vacuum in the middle of the floor so I need to get cracking before my wife advertises for a female roommate.