One thing your IT vendor will never tell you

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Permit me to let you in on a little secret—most firms have no idea how to manage their IT applications vendors.

In turn, this means they are managing you.  By the way, this is a bad thing.

The best way I have found to understand this problem is to liken what IT vendors tell you to what magicians tell their audience.  Bear with me.  If you have ever attended a magic show or watched one on television you will note that the best magicians tell you prior to their performance that they are going to lie to you.  In order for a magician’s performance to work on you any magician has to get you to suspend your belief.

A magician tells the audience that everything else you are about to hear and see is a lie.  And then they tell you they are going to cut someone in half, they do it, and your eyes are so amazed that somehow your brain forgets the bit about being lied to, about being led down a path of suspending your beliefs.

The difference between magicians and IT vendors is that IT vendors forget to mention at the outset—or at any other time—that not everything they tell you is true.  Things like what their system will cost, what it will do and how long it will take.

And because they do not tell you they are lying, once you have suspended your belief, you forget to unsuspend it.  Hence, you are caught up in their fantasy world and you foolishly believe what they tell you.

For the most part, IT vendors are not the people you want next to you in the EHR, ERP, or any IT foxhole.  In the dog-eat-lemming world of IT, never forget that the term ‘partner’ is an oxymoron.  IT is a business and the goal of every business is to maximize profits.  The best ways to maximize profits are to reduce costs and to increase revenues.  The only way to do so is for vendors to increase your costs.

Keep your eyes and ears open the next time your vendor offers to cut someone in half.

EHR: Managing the changes to your organization

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I reside where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s a small space where only those who place principle over fees dare to tread.

Where to begin? How to build your team? (Those who wish to throw cabbages should move closer to the front of the room so as not to be denied a decent launching point.) There are two executives, I hasten to add, who will defend what I am about to offer, a CIO, and a CMIO, ideas from both of whom you’ve probably read.

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time the project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon. I believe that staffing only to execute today’s perceived demands will get me shot and will fail to meet the needs of hospital. I need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications for healthcare IT.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare issues from an IT perspective. They’ve also indicated that—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform. I disagree with that position.

Here’s a simplified version of the targets I think most of today’s CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them. Here’s what I think. You don’t have to believe this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since I’m writing, I used it.

Before I go there, may I share my reasoning? From a business perspective, many would say the business of healthcare (how it is run) is being moved from 0.2 to 2.0. The carrot? Stimulus funding—an amount—should you earn it, and you will probably want to since your CFO has already built it in to the budget—that will prove to be more of a rounding error than a substantive rebate. Large providers are being asked to hit complex, undefined, and moving targets. They are making eight and nine figure purchase decisions based in part on solving business problems they don’t articulate. If success is measured as on time, in budget, and functional and accepted, I estimate for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

The overriding business driver seems to be that the government has told providers to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on EHR than they would to build a new hospital wing. They don’t know what it should cost, yet they have a budget. They don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot. I’d staff with a heavy emphasis on the following subject matter experts:

  • PMO
  • Planning & Innovation
  • Flexibility
  • Change Management
  • PR & Marketing
  • And..Disaster Recovery

None of these high-level people need to have much if any understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime. That will account for about fifty percent of the success factors.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years from now there will not be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of Rhios, and mapped into a NHIN. Under the current model, standardization will not occur if only for the fact that there is no monetary value to those whose standards are not standard to make them so. This discussion is orders of magnitude more complex than cassettes and 8-tracks.

Interoperability, cost, and the lack of standardization will force a different solution. I think the solution will have to be something along the lines of a single, national, open, browser-based EHR. Can an approach to solving this be pieced together by looking at existing examples like airline reservations, ATM, OnStar, Amazon, FaceBook, and others? I believe so. Are some of my words and examples wrong? Count on it. Please don’t pick a fight over my lack of understanding of the technology.

The point I am trying to drive home is that from a staffing perspective, lean towards staffing the unknown. Staff it with leaders, innovators, and people who can turn on a dime. Build like turning on a dime is the number one requirement. Don’t waste all of your resources on certification or meaningful use. If anyone asks you why, you can blame me. If you want a real reason, I have two. First, they won’t mean a thing three years from now. Second, if I am the person writing a rebate check, I want to know one and only one thing; can your system connect with the other system for which I am also writing a check.

However, when all is said and done, I call upon us to remember the immortal words of Mel Brooks “Could be worse, could be raining.”

 

EHR: What Bugs You About It?

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16This is the time of year in the east when cinerescent caterpillar nests hang thickly from the trees, peppered tufts of cotton candy.  During these long, flavorless August days, the sky is a similar achromatic color.  My nine-year-old is concerned because I told her we are having caterpillar soup for dinner tonight—watch out for the crunchy bits.  Once again, it seems I’ve gotten off message.

I wonder how much of the difficulty surrounding EHR has to do with getting off message, much like we seem to have done with the reform discussion.  What difficulties?  Got time?  You can name more of them than can I.

What is off message?  It’s that the day-to-day tactics of implementing EHR office by office, and hospital by hospital have overshadowed the strategy, have displaced the business driver behind the mandate.  The focus became internal, not national.  Bits and bytes have overshadowed charts.

I doubt few, if any, can articulate a believable explanation of how a few years from now your medical records will accurately and expeditiously be delivered from where you live to the lone clinic on Main Street, Small Town, USA, to the nurse practitioner who at midnight is giving you an EKG.

It’s that fact, that we are not able to define how we get from A to B, let alone do so with multitudes of A’s and B’s, that to me suggests we are building something of which we have little comfort will do what we set out for it do.

Clearly, there are hundreds if not thousands of very talented and dedicated professionals focused on finding a solution.  However, it seems their efforts remain handcuffed by hundreds of competing products, no well-defined overriding set of requirements that would enable anyone to say with certainty, “Yes, that is it.  That captures what we need to do.  When we have done that, we are done.”

Until that time, I think we all need to be concerned about the crunchy bits.

What do you think?

EHR: 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.

EHR: Every time you redesign, God kills a kitten

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Again on the project failure?  Yes.  Why?  Trying to head it off at the pass.  Source, The Bull Report.

Fifty-seven percent of failures are due to bad communication.  What’s that?  Poor grammar?  No.  Not enough meetings?  Doubtful.

It’s about PMO.  A hired gun?  Perhaps.  An advocate who will manage the vendor on your behalf.  What’s the rest of the hired gun’s job description?  It is all the blue stuff in the graph.

And now it is time to view this discussion in light of healthcare.  The chances of your ‘two-comma’ project failing are legion.  Why? Nobody has a good history of having done EHR; if they have experience it is likely because their first implementation failed.  EHR is not like implementing ERP.  The is no ROI at the end of the rainbow.  The business driver seems to be Meaningful Use which has caused many hospitals to glide over things like process improvement and change management and breaking down the tribal barriers among organizations.

The good news is that being a bad dresser will not hurt the project.

 

 

EHR Certification: Less valuable than a turnip

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I was asked to give my opinion during an interview for an article on EHR certification.  As you know, I could benefit from the advice that implores one to keep their mouth shut less the whole world know you have nothing to say.  I had the right to remain silent, just not the ability.

I tend to think the certification process was something invented and supported by the large EHR vendors as a way to make the small vendors less relevant and as a way to slow the development of standards. As standards come into play, the EHR vendors furthest away from the standards, including the largest vendors, will become less relevant.

There is no legitimate business reason for having to certify a system AFTER having spent several hundreds of millions of dollars implementing it.

The logic behind the comment about there being no raison d’être for the existence of certification is as follows.

Certification, to be of value, must imply that the act of certifying–like the Good Housekeeping Seal of Approval–is intended to show that a certified EHR is somehow better (for healthcare) than a non-certified EHR.

The post-implementation impact of EHR is that far too many nine-figure EHRs have resulted in productivity losses of between ten and thirty percent. In English…a hospital spends a hundred million dollars on a system and as a result of having spend that money is only able to handle fewer patients than it could if it had spent a dollar on a turnip.  That same hospital, now operating less effectively, can do so with a certified EHR, and can qualify for Meaningful Use.

The certification process has failed to justify its existence or to bring any value to the process.  However, it has not failed to get hospitals to spend additional millions to comply.

According to the hospital CIOs and physicians I have spoken with it means the hospitals (physicians) are able to see fewer patients. This is because the physicians must spend more time searching, navigating, and typing. My cardiologist who works at a very prominent hospital in Philadelphia told me two memorable things about their $200 + million dollar EHR:

  1. The data is excellent if you are a patient or insurance company. You now have excellent data with which to sue us.
  2. My productivity is down thirty percent. The hospital has taken its most expensive and time-constrained resource and made us spend the majority of our time interfacing with a keyboard instead of our patients.

I would encourage you to ask others what additional benefit, if any, certification has brought to them and would they not have received those same benefits without implementation.  Certification is the lottery ticket hospitals must purchase to enter the Meaningful Use sweepstakes.  Meaningful Use has no Meaningful Use. Many hospitals will have purchased that lottery ticket but will not meet Meaningful Use. Hence, the cost to attain certification and the cost to attempt to meet Meaningful Use are wasted dollars.  Meaningful Use is binary Sudoku, you either get it or you do not.

The real impact of the EHR resource shortage

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(AP) New York.  It is Reservoir Dogs 2.0 only this time the terrorists appear to be a clean-shaven group of EPCI subject matter experts. Reuters is reporting that early this morning the group of EPIC consultants, each one armed to the teeth with iPads and wireless mice and Blackberrys was last seen forcing a rag-tag group of hospitalists and CIOs into a windowless, upper floor room of the convention center.  It is rumored that a senior analyst from McKesson was also a member of the terrorist group, albeit in a non-billable role.

CMS has long been suggesting that with the huge shortage of skilled EHR specialists that sooner or later those with the knowledge would rise up and hold the providers hostage.

A spokesperson for the terrorists with a background in CPOE released a list of their demands.  They demand to have their rates tripled, to have an organic smoothie machine placed in the hospital cafeteria, and the right to remain employed even though the EHR will drop productivity by thirty percent.

One terrorist who demanded anonymity stated “I do not know why everyone looks so surprised that their EHR software does not work.  Nobody asked if it would work, they just wanted us to install it.”

EHR: What are your Bona Fides?

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The photo comes from my Robert Redford look alike period.

Do you ever awaken wishing you were all you used to think you were before you figured out you weren’t?  Me either.  I’m someone who has these kind of days when it’s best to keep me away from shiny objects.

During college, I spent several summers volunteering for a group called Young Life at their camps throughout the US.  Silver Cliff was one of their camps in the mountains of Colorado.  Each week we’d take in a few hundred high school kids from throughout the US, and give them the opportunity to do things and challenge themselves in new ways; everything from riding horses to rappelling.

The prior summer I was the head wrangler at one of their camps—I had never ridden a horse prior to being placed in charge of the riding program.  This summer is was the person running the rappelling program.  Needless to say, I had never done that before either.

We received a day’s worth of instruction before we were turned loose on the kids.  One of the first things we had to learn was that the ropes and harness, if properly secured to the carabineers and figure eight, would actually keep you from falling to your death.  The first test was jumping from a platform way up in a tree while on belay.  After a few moments of white-knuckle panic, I stepped over the edge and was belayed safely to the ground.

From there, we scouted a place for the rappel, and found two suitable cliffs, each with about a hundred foot vertical drop.  Watching my first rappel must have reminded others of what it would have been like watching a chimp learn how to use tools for the first time.  After several tentative descents, I was able to make it safely to the bottom in a single jump.

Each day we’d run a few dozen kids through the course, ninety-nine percent of whom had never rappelled, or ever wanted to rappel.  To convince them that it was safe and that they could complete it, I would instruct them in the technique as I hung backwards over the chalk face of the limestone cliff.

Each day we’d have one or two kids who wanted nothing to do with my little course.  Occasionally, while on belay, one of them would freeze half way down the cliff, and I’d have to belay down and rescue them.

Once or twice I’d have an attractive female counselor on belay, her knowing that I was the only thing keeping her from being a Rorschach stain on the rocks below.  Scared, and looking for a boost of confidence, “She’d ask, how long have you been doing this?” I’d look at my watch and ask her how many days ago was Sunday.  I viewed it as an opportunity to have a little fun with her—sort of like turning to your friend in the checkout line in 7-eleven and saying loud enough for others to hear, “I thought we agreed we weren’t going to use our guns.” I also hoped maybe even having to go on a heroic rescue.

How long have you been doing this?  That’s seems like a fair question to ask of anyone in a clinical situation.  It’s more easily answered when you are in someone’s office and are facing multiple framed and matted attestations of their skills.  Seen any good EHR or HIT certificates on the walls of the people entrusted with the execution of the EHR endowment?  Me either.  I have a cardiologist and he has all sorts of paper hanging from his wall.  Helps to convince me he knows his stuff.  Now, if I were to pretend to be a cardiologist—I’ve been thinking of going to night school—I’d expect people would expect to see my bona fides.

Shouldn’t the same logic apply to spending millions of EHR dollars?  Imagine this discussion.

“What do you do?”

“I’m buying something for the hospital I’ve never bought.”

“Why?”

“The feds say we’ve got to have it.”

“Oh.  What’s it do?”

“Nobody really knows.”

“How long have you been doing this?”

“How many days ago was Sunday?”

“What’s it cost?”

“Somewhere between this much,” he stretches out his arms, “And this much,” stretching them further.

“Do the doctors want this?”

“Some do.  A lot don’t.”

“How will you know when you’re done if you got it right?”

“Beats me.”

“Sounds like fun,” she said, trying to fetter a laugh.

Sounds like fun to me too.

A Tongue-in-cheeky Editorial: Recess is Over

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(This piece will be more interesting if you can get someone to hum The Battle Hymn of the Republic while you read it.)

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, and 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 the other day, 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 today, you could have said the cat had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and will not come down.”

The economy is on the roof and will not come down.

When Washington with an eyes-wide-shut management style gives you lemons, the only thing left to do is to find the humor in it.  Perhaps Thomas Paine was being prescient when he wrote “These are the times that try men’s souls.”  Maybe he should have used the word ‘tire’ instead of ‘try.’  I am reminded of the scene in Young Frankenstein when the next thing heard after Dr. Frankenstein tells Igor “Could be worse…could be raining” was a resounding clap of thunder.

Whoever is trying to fix Recession 2.0 is doing so without a hall pass—what has been tried has defied or defiled the laws of physics.  What had been a vibrant economy stepped off Checkhov’s veranda and bade farewell to the sisters of Prozorova while the sisters

It is raining while Washington scurries around like frightened mice passing out umbrellas and pretending the sun is shining.  Washington has not learned that they can’t put the rain back into the clouds.  The current economic plan—I know there is not one, but let us pretend—reads like a failure’s biography.

And now, with sang-froid calmness, Congress is on its summer recess—could there be a more apropos term to describe their daily activities—as opposed to all of their other recesses.  While there is some debate about whether recess should be canceled, to not so gives me the impression of Nero fiddling while DC burns.

Perhaps the misérables came closest to getting correct the conversation between the electorate and the elected when they caused Marie Antoinette, sans head, to eat her cake.  Their casus belli was the arrogance of the ruling class. We are not suffering as much from Washington’s arrogance as we are from the results of their collective ignorance and failure to lead.

The politicians’ camera-ready soliloquies have all the appeal of a cold omelet.  While some, like the Marines, run to the sound of the gun that is fired, the people in Washington do not.  Instead of running towards the sound of the gun many want to discuss the sound.  Others question whether there really was a gun and question who owned it and whose fault it was, but none are running on our behalf armed with ideas about how to solve the problem.

Is it not better to have tried to lead and to have failed than to have never have tried.  None are leading.  According to the voices in my head, the conundrum facing us seems to be that those in Washington believe that without being reelected they will be unable to lead because they will not be around to do the leading.  The overarching flaw in their understanding of their mission appears to be that instead of leading now, their efforts are always focused on winning the opportunity to not lead in their next term.

Any one of them could get reelected simply by trying to lead us to a solution.  The solution doesn’t even have to work.  Take the crayons out of the Crayola packet and try something.  The time to argue about who started the mess is over–we all own it, let us fit it.

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(This piece will be more interesting if you can get someone to hum The Battle Hymn of the Republic while you read it.)

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, and 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 the other day, 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 today, you could have said the cat had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and will not come down.”

The economy is on the roof and will not come down.

When Washington with an eyes-wide-shut management style gives you lemons, the only thing left to do is to find the humor in it.  Perhaps Thomas Paine was being prescient when he wrote “These are the times that try men’s souls.”  Maybe he should have used the word ‘tire’ instead of ‘try.’  I am reminded of the scene in Young Frankenstein when the next thing heard after Dr. Frankenstein tells Igor “Could be worse…could be raining” was a resounding clap of thunder.

Whoever is trying to fix Recession 2.0 is doing so without a hall pass—what has been tried has defied or defiled the laws of physics.  What had been a vibrant economy stepped off Checkhov’s veranda and bade farewell to the sisters of Prozorova while the sisters

It is raining while Washington scurries around like frightened mice passing out umbrellas and pretending the sun is shining.  Washington has not learned that they can’t put the rain back into the clouds.  The current economic plan—I know there is not one, but let us pretend—reads like a failure’s biography.

And now, with sang-froid calmness, Congress is on its summer recess—could there be a more apropos term to describe their daily activities—as opposed to all of their other recesses.  While there is some debate about whether recess should be canceled, to not so gives me the impression of Nero fiddling while DC burns.

Perhaps the misérables came closest to getting correct the conversation between the electorate and the elected when they caused Marie Antoinette, sans head, to eat her cake.  Their casus belli was the arrogance of the ruling class. We are not suffering as much from Washington’s arrogance as we are from the results of their collective ignorance and failure to lead.

The politicians’ camera-ready soliloquies have all the appeal of a cold omelet.  While some, like the Marines, run to the sound of the gun that is fired, the people in Washington do not.  Instead of running towards the sound of the gun many want to discuss the sound.  Others question whether there really was a gun and question who owned it and whose fault it was, but none are running on our behalf armed with ideas about how to solve the problem.

Is it not better to have tried to lead and to have failed than to have never have tried.  None are leading.  According to the voices in my head, the conundrum facing us seems to be that those in Washington believe that without being reelected they will be unable to lead because they will not be around to do the leading.  The overarching flaw in their understanding of their mission appears to be that instead of leading now, their efforts are always focused on winning the opportunity to not lead in their next term.

Any one of them could get reelected simply by trying to lead us to a solution.  The solution doesn’t even have to work.  Take the crayons out of the Crayola packet and try something.  The time to argue about who started the mess is over–we all own it, let us fit it.