For those interested in a somewhat irreverent presentation on the business issues of Meaningful Use who won’t be attending the New England HFMA this Tuesday, here is an advanced copy of my presentation http://ow.ly/50etE
I’d like to know what you think…
The store for audiophile wannabe’s. Denver, Colorado. The first store I hit after blowing an entire paycheck at REI when I moved to Colorado.
The first thing I noticed was the lack of clutter, the lack of inventory. There were no amplifiers, because amplifiers were down market. There were a dozen or so each of the pre-amps, tuners, turntables, reel to reel tape decks, and these things called CD players. They also had dozens of speakers. At the back of the store was an enclosed 10 x 10 foot sound proof room with a leather chair positioned dead center.
When the ponytailed salesperson asked about my budget, like a rube I told him I didn’t have one. He beamed and took that to mean it was unlimited. It really meant I hadn’t thought of one. He asked me what I liked to listen to.
“Pink Floyd, Dark Side of the Moon.”
Within a few seconds I was seated in Captain Kirk’s chair, and Pink Floyd’s Brain Damage filled the room in pure digital quadraphonic sound. I was in love.
I lived a block and a half away. Since the equipment wouldn’t fit in my Triumph, I made several trips carrying home my new toys—gold plated monster cable, solid maple speakers that rested on nails so as to minimize distortion, a pre-amp, tuner, receiver, turntable, and stylus.
It wasn’t that I deliberately bought stuff I didn’t need. I walked in uneducated. I had never bought what I was looking at. I didn’t know how much to spend, nor what it would do for me. Looking back at that purchase decision, I bought specs I didn’t need. I didn’t realize it was possible to build audio technology that would meet performance specs beyond what I person could hear, heck beyond what anything could hear. Not understanding that possibility, I bought specs I couldn’t hear. I spent hundreds of dollars on features from which I would never receive value. You too?
It happens all the time. Stereos. Cars. Computers. Applications. Technology. Having bought it doesn’t mean it was needed, or that it was the right thing to do, or that it has an ROI, or that it meets the mission.
The cool thing is that even though I could not hear half the features of my new stereo, it looked really, really impressive.
Grab a soft-drink—this one is rather long. Please forgive any formatting mistakes–it looked good in Word.
I have never been one who thinks hit-and-run critiquing is fair. It is too easy to throw metaphorical tomatoes at an idea with which you disagree. As such, perhaps instead of just being critical of the national EHR rollout plan, here are a few ideas which may be worth exploring in more detail.
It just occurred to me that the ONC’s role, the Office of the National Coordinator, is just that—coordination. Who or what is the ONC supposed to be coordinating—among its various functions–the providers? There are the coordinators, and their constituents—the uncoordinated. I know at least one provider who already spent $400 million on its EHR. They didn’t get coordinated. I asked one of their executives who played a major oversight role in the implementation, with whom they worked at the ONC. She was not even familiar with the acronym.
I don’t think providers are looking to be coordinated—they are looking to be led. I also think they are looking to be asked and to be heard. They are looking for answers to basic questions like; why should we do this, what is in it for me—this has nothing to do with incentive dollars.
It often seems like the ONC has developed many solutions seeking a problem, filling their tool bag in the hope they brought along the right one. This is where I think we see a good portion of the disconnect. It is better to say we know where we are going, but getting there slowly, instead of, we don’t know where we are going but we are making really good time.
People don’t buy drills because they need a drill—they buy them because nobody sells holes—say it with me—holes. Providers need holes, not HIEs and RECs.
You understand the pressures you face much better than do I. Has anyone from the ONC asked you if they should reconsider their plan, their approach, their timing? Chances are good that you are not implementing EHR and CPOE because you have a vision or a business imperative of someday being able to connect your EHR to Our Lady of Perpetual Interoperability. CIOs and their peers are not spending eight or nine figures because you want a virtual national healthcare infrastructure. The C-team is investing its scarce resources to make its operation better, to reap the rewards of the promise of EHR.
The ONC is spending its resources towards a different goal, a virtual national healthcare infrastructure. The two goals do not necessarily overlap. I am reminded of the photo showing the driving of the Golden Spike—the connecting of the Union Pacific Railroad to the Central Pacific Railroad—the final link of the Transcontinental Railroad that in the 1870’s allowed Americans to cross the US by rail. What would have happened had the two railroads worked independently of each other? They would have built very nice railroads whose tracks would never have met, tracks dead ending in the middle of nowhere. Even if they almost met, say got within a few feet of each other, they would have failed.
There are those who see the work of the ONC as a real value-add. I dare say that most of those are not hospital CIOs or physicians. Both groups define value-add and success differently.
This is not to say that providers would not accept all the help they can get. However, providers want the help to be…what is the word I am searching for—helpful—to them, to their issues. The ONC’s mission will not work until the providers successfully deliver what the ONC needs from them. How many providers must be Stage 7, Meaningful Use, Certified compliant for the virtual national healthcare infrastructure to work? Fifty percent? Eighty? Who knows.
So, the providers own the critical path. It is all about the providers, bringing fully functional EHR systems to hospitals and physicians. The numbers I have seen do not paint a promising picture. The critical path is in critical condition. Ten percent hospital acceptance and a sixty percent failure rate. Let’s say those numbers are wrong by a factor of three—thirty percent acceptance, and a twenty percent failure rate. Even those numbers do not bode well for ever achieving a virtual national healthcare infrastructure under the current plan. Subtract from those figures—supply your own if you would like—the churn figures—those hospitals that are on their second or third installation of EHR. Something is amiss.
In a more perfect world the ONC might consider shifting course to something aligned with the following:
• Segment its mission into two parts; one to build a virtual national healthcare infrastructure, and two, provide hands-on support individual hospitals’ and providers’ EHR initiatives.
• Standards
• Standards—I wrote that twice because it is important to both missions
o Let us be honest, the largest EHR vendors do not want standards. Why? Because if all else fails, their standards become the standards. They don’t phrase it this way, but one can assume, their business model calls for them to do what is best for them.
o The vendors do not want to open their APIs to the HIEs
• Do not set dates for providers which to be met require meeting rules which do not yet exist. If the government wants providers to meet its dates, the government must first meet some of its critical success factors—standards, for example.
• Mandate vendor standards for however many vendors make up ninety percent of the EHR install base for hospitals. Give vendors 18-24 months to agree to a set of standards and have them retrofit their applications.
• Use a garrote and stick approach on the vendors. Create a standards incentive program, heck, underwrite it. Pay the vendors to develop and get on a single set of standards—this will have a much more positive impact than REC and PR money. Many will say, especially those who have an incentive for this not to happen, this cannot be done. Of course it can.
• Processes. EHRs are failing in part due to not enough user involvement, not enough user authority and governance. There is no usable decompositionable process map of how a hospital functions. No Level Zero through Level Whatever You Need. No industry standard, mega-diagram, boxes and arrows, which can be laid on a table or hung on a wall that shows, “This is what we do. This is how it all ties together.”
• I am building this process map, along with a colleague. Why isn’t the ONC? It will not match you hospital. It may not match anyone’s hospital. What it will do is give someone a great base from which they can edit it. Why is this important? Because it will enable the users, IT, and the vendor to overlay the EHR application to show:
o which business and clinical areas are impacted
o the process interfaces
o duplicated processes
o processes with no value-add
o which other facilities have similar and differing processes
o where change management resources must be focused
o what needs to happen if an acquisition is made
The ONC must move from coordinating to leading. To do that they need the authority to mandate the execution of some of the items listed above.
Sarah Palin continues to receive national media coverage. Many hospitals continue to implement EHR without any measurable goals. (One of those is bad.)
The year is 2014. I had this dream the other night of having dropped my IQ when I was at the hospital, but I couldn’t remember which hospital, so off I went, hospital by hospital looking for my IQ—I realize there are those of you who believe this isn’t a great loss.
In the first hospital I visited, a photo of the new president hung behind the registration desk. Next to her photo—surprised some of you with that I bet—hung the photo of the Secretary of Hospital Sameness. For a while I wondered what someone in that position did day to day. The more hospitals I visited, the more apparent it became. The hospitals all looked very much alike, right down to dust on the fake Fichus tree next to the water fountain. For a while I thought that maybe I was driving in circles until I noticed that even though receptionists were all named Gladys, they wore different clothes. It was almost like visiting Stepford.
Does anyone have the sense that what reform will really accomplish is to reform away healthcare competition? There appears to be a move afoot towards the efficiency that is created by sameness—what I call the McDonalds healthcare model. Put one on every corner. Make them identical. Limit the options. Everyone gets a burger. Nobody gets a steak.
Eliminate waste. Does that mean eliminate ways of operating that differ from how the government permits them to operate? There is talk of pulling costs out of the system thereby making it more efficient. You tell me. Is the argument that there is so much inefficiency that by becoming efficient not only will we be able to cover everyone, but we will be able to do it at a cost below what it costs to care for far fewer people?
How do you understand it? Are costs being removed, or simply moved? If someone with no access to healthcare suddenly has healthcare—a good thing by almost anyone’s standards—the reasoned person knows costs have just increased. (Healthcare theorem 1: The cost to provide healthcare to 2 people is greater than or equal to the cost to provide it to one person.) If costs have increased, how does one make a believable argument that the basis for reform is cost reduction?
I try hard not to be too cynical, but sometimes I think, why bother. By the way, I found my IQ. Thanks for asking.
When you think about it, companies begin to die the day they are born. Some last longer than others, and some are reborn after they die–think GM. Others may be caught in a death by stagnation spiral. Microsoft may be a good example–has their lack of innovation caught up to them, or is Windows 37.9 considered innovative?
Disruption. If you do not like the word, here are a few others that work just as well–disassemble, dismantle, unhinge, and disengage. Disruption is only a first step. Once you disrupt you then must rebuild. Knowing what to rebuild is the critical success factor.
My new favorite business toy is Prezi.com. This Prezi link is for a speech I gave last year at ICSI on why disruption is not only good for hospitals, but may in fact be a survival imperative.
For those who like to read bullet points, this presentation may not be for you. I welcome your feedback on the tool and the ideas, especially since I wrote very little text. I approach presenting ideas by trying to get the audience to listen to what is said rather than simply reading slides–otherwise I my being there would be superfluous. Besides, people don’t take notes at the movies, why should they during a talk.
The other night as I’m sitting on a hard bleacher watching my seven-year-olds baseball practice I noticed the mom sitting next to me looking a little forlorn. Being naturally inquisitive, I asked if everything was okay.
“I lost his glove,” she replied.
Noticing a glove on her son’s hand, she saw my look of confusion. “Not his. My husband’s. I had it with me last Thursday, and I left it here.”
“I don’t suppose this was a new glove. Judging by the look on your face I’d say this was his favorite glove, and was probably handed down from his father. Autographed by Mantle and Maris in 1961. Fifty years old, supple, broken in, fold flat as a sheet of paper.”
“Fifty-five years,” she corrected as she lowered her eyes.
“It’s rained the last three days,” I told her, which caused her to grimace even more. Having nothing better to do, I flayed her emotions. “I bet that glove meant the world to him. He probably planned on giving it to your son in a few years. The glove probably reminds him of the big events in his life, every scar, each stain on the leather, points to something important. You know, if it was outside for a few days, the field mice will have chewed on the leather.”
She brushed away a tear, and headed to the lost and found.
“Any luck?” I asked when she returned. She shook her head in despair. “In some countries, if a wife does something life that, the husband can sever the relationship, literally,” I said as I made a slashing motion with my hand. She made the briefest of smiles. At least she knew I was pulling her lariat. Reeling her in, I continued.
“You’re not thinking of spending the night at home, are you? If you are, you should at least call someone and let them know of your plans. He’ll heal over time,” I told her. “But he won’t forget it. Twenty years from now the two of you will be watching something on TV, and something will remind him of the glove YOU lost.”
Fast forward to last Wednesday night. My daughter and I are getting out of the car so I can coach her and her softball team in the playoff game.
“Is your glove in the trunk?” I asked. This is after I spent several minutes grilling her at home about whether she had everything she needed for her game.
“I hope so,” she said shamelessly as I popped the trunk for her. “You hope so?” I repeated with an edge in my voice.
“It’s not here Daddy,” she said as she searched the trunk.
I left her with her friends and drove home to look for it. Ten minutes. Nothing. For some reason, I looked in the trunk. There it was. Death by 1,000 cuts.
Does it all come down to baseball gloves? “I hope so.” What kind of a response is that?
Will these EHR expenditures improve our operations? I hope so.
Can you confirm for me that Patient Experience Management won’t fall any further? I hope so.
Are we ready for the reform changes coming to the business model? I hope so.
Will we meet Meaningful Use? I hope so.
Do you think we should continue to employ you? I hope so.
Below is a response I wrote to a blog on customer experience management. I would love to hear what you think. http://www.ceforprofit.com/2010/08/defining-customer-experience-implications-and-all/comment-page-1/#comment-3111
One thing businesses have been slow to realize is they have lost control of the customer conversation, and as such, at least from the customer’s perspective, have forfeited their right to control the customer experience.
Traditional customer relationship management (CRM) has always been a Push. A manages B. Organizations manage customers. Sort of reminds me of cowboys trying to manage a herd of cattle into the cow-pen for slaughter. Organizations have only been marginally successful at “managing” their customers.
Customer Experience Management (CEM), CRM’s big brother, is at least a thought in the right direction. However, most firms still do not “get it.” The ungotten “it” is that customers have taken over the sandbox and they are not going to give it back. Customers are now managing vendors, and the vendors have yet to figure that out.
Most firms can print a report titled “My customers” or “Our customers.” The single most important error with these reports is the use of the pronouns ‘my’ and ‘our’. Firms no longer own customers. More accurately, customers now hold the power. Customers now have “My vendor” reports; vendors they have researched and hand-culled.
If a firm wants to check out how well they are managing the customer experience all they have to do is to Google themselves, or search for themselves on YouTube. See what people are saying about them. Not much of it is favorable, but much of it is viral. Videos, blogs, Tweets, and chat rooms.
Manage that? Too little too late. Customers are issuing virtual RFPs. Whether customers want a large screen television or a hip replacement, they go to the web. They find out your pricing, how well you service your customers. They make informed decisions. Most organizations have a long way to go just to get back into the battle to make it a fair fight. The first step is for them to learn how they are being managed by their customers and then to learn what to do about it.
Now that spring is in full bloom, I’ve been doing a little gardening. My dogs are the anti-gardeners. No sooner do I turn my back after planting something, there they are, happily digging away and ceremoniously digging it up. I don’t know if that’s because they don’t like the particular plant, or just happen to disagree with where I planted it.
Today I discovered the youngest dog uprooted a plant and replaced it with a Reece’s Peanut Butter Cup. Perhaps she wanted to grow a candy tree.
One thing that always confuses me about gardening is this: When I plant a one-gallon shrub, I dig a two-gallon hole. I place the gallon shrub in the two-gallon hole and proceed to fill the remaining one gallon hole with the two gallons of dirt lying next to it. Without fail, there is never enough dirt to fill the hole. Perhaps you can tell me what I am doing wrong.
Here is another area of confusion for me: When you walk or are wheeled into a hospital, neither you nor anyone else knows the answer to anything.
That is astonishing. Nobody can tell you:
* With whom you will interact.
* How long you will stay.
* What will happen to you.
* How it will happen to you.
* When it will happen to you.
* Who will be doing the happening.
* Exactly when it will happen.
* Whether it will need to happen again.
* What it will cost.
* What you will be charged.
* What will be covered.
* How much you will owe.
I am stupefied. How can anyone run a business like this? My daughter knows what her lemonade stand costs per cup. Wendy’s knows the cost of a bag of fries and a large Frosty. Porsche knows the cost of a Cabriolet, the cost of the shift knob, when the wheels will arrive at the factory, when they will be placed on the car, who will build it, who will inspect it, and who will sell it. They can tell you exactly who will touch the car, when they will touch it, and what those people will do to it.
The only thing anyone at a hospital may be able to tell you is whether HBO is billed separately. If I wanted to fly into space with the Russians, I would know the answer to each of those questions. The cost, for example: $50 million.
Why can’t a hospital do this? Because it doesn’t know the answers. It is not because anyone is keeping this information a secret–it’s because they really don’t know. The truly strange thing is that they seem to be okay with not knowing.
Recently, I reconnected with a good friend whom I haven’t seen in years. He is the vice president of finance for a large hospital. He used to be an accountant–a very detailed and precise profession, unless you’re one of the guys who used to do Enron’s books. (The only thing I remember about accounting is that debits are by the window and credits are by the door–if I’m in the wrong room, I’m at a total loss.) This business must drive him nuts!
And so I’ve been wondering; would hospitals be more profitable if:
* They had a P&L by patient?
* They had a P&L per procedure?
* The steps for the same procedure, say a hip replacement, were identical each time?
* They had answers to any of the questions you read above?
Of course they would!
Some areas of healthcare already discovered this tautology–Lasik, endoscopy, the Minute Clinic. Assembly-line medicine. Some people say those words with an expression on their face as though they’d just found a hair in their pasta. The office of my Lasik surgeon looked more impressive than the lobby of my Hyde Park hotel. It may leave a bad taste in the mouth of some, but for others, they are laughing all the way to the bank.
I wrote this in response to some comments I received on my piece in HospitalImpact.org.
I do not advocate assembly line medicine, especially at a hospital. I go out of my way to stay out of the healthcare business–the clinical side of healthcare–an area in which I have no background other than having been a patient. There seems to be an inability to answer basic business questions relating to how the business of healthcare is run.
On the care side there is a need for the independence and the je ne sais quoi nature of care. However, the business of healthcare and the healthcare business can coexist in a more business-like manner. There are hospitals which get it right, and those which get it much less right.
Some of the ineffectiveness of running a hospital like a business has to do with costs, some with waste–wasted time, wasted opportunity, some with inefficiency, and some with poor planning. If one hospital can do procedure X for thirty percent less than another, it is worth exploring what accounts for the delta. If another hospital can perform twenty percent more procedures with the same level of resources, that is worth investigating. There is no point keeping metrics unless one is willing to improve them.
I am not big on efficiency. In most cases, efficiency implies speed. It is possible to perform poor processes at a speed which will make your head spin. Lots of hospitals are toying with Lean. Lean works best with a valid set of processes. Without a valid set of processes–best processes–there are not enough Sigmas to justify the expense. To those lauding how many Six-Sigma professionals they have employed, what have they done for you? Are you better off than those hospitals who only have Five-Sigma specialists? Would you be better served if you cranked it up a notch or two to Seven or Eight-Sigma gurus?
Then there are the cost cutting advocates. Cost cutting alone is a dead end strategy. Every manager can cut costs–less than one in a hundred can increase revenues. What do you do when there are no more costs to cut? Are you more effective, or net-net did you simply replace the brewed coffee with Folgers? Want to cut costs? Lock the doors. But that does not solve anything.
If none of these questions can be answered today, what happens in five years? New entrants will have gobbled up many profitable services and will be able to do so because they do not have “Big Box” overhead. Reform will have forced another business model on large providers. Payors and pharma will continue to battle for their share of each healthcare dollar.
I think hospitals can grab an even larger portion of that dollar, but I do not think they can do it without changing how they approach the business of healthcare.
I am at the airport; what’s new. I bought a cup of coffee from a cart vendor. The coffee was so bad it must have violated at least one of the laws of physics.
The person walking in front of me has just exited the first of two moving walkways. She had not walked it; rather she rode it, standing in the middle of the conveyance as though it was a ride at Six Flags. One hundred feet in front of her was walkway number two. She approached the moving platform with the same degree of trepidation one might expect of someone jumping from a plane for the first time. She steps on, begins to wobble and catches herself. Ride number two. I was tempted to ask her if the hundred feet she had just walked without the aid of a mechanical device had tired her so much that she could not take another step.
In my spare time I have been working (a little) on a talk on Meaningful Use I will be giving this month at New England’s HFMA conference. I have read about people who are afraid of public speaking—as though there was some other kind of speaking one could do—and I am unable to understand that fear. However, there are people who are afraid of the number thirteen, and I do not understand them either. Maybe that is because my undergraduate degree was in mathematics, and we learned early on that most numbers, while they may make fun of you or try to intimidate you cannot really hurt you. If I was going to be afraid of a number, I would imagine I would pick a cool number, something irrational like e, or perhaps an imaginary number. Wouldn’t it make more sense to be frightened of imaginary numbers?
Anyway. If you are at all like me—many of you are breathing a sigh of relief that you are not—you find it painful to listen to otherwise normal people who do not have the vaguest idea how to speak in front of more than one person. Most speakers are so uncomfortable with having to speak in public they make you feel uncomfortable.
Poor public speakers come in all shapes and sizes. Sometimes two speakers will try to tag-team a talk. This approach usually yields twice the ineptitude. It winds up looking like two left-handed men trying to dance backward, neither of whom knows the woman’s part. Then you get the speakers who speak without pausing; an acute grammarian could not hope to drive a comma between words with a sledgehammer. Some presenters, fear inscribed on their forehead like the mark of Cain and a tuberculoid pallor painted across their face, hold onto the podium for support as though were they to let go they would collapse like a wet noodle. Instead they stand totally erect like toy soldiers in a tin box.
Others spew forth catechisms of clichés, thinking the words of others are far better than any they could put forth of their own. A lot of speakers will try to impress you with the amount of facts they have collected. Charts, lists, bullet points. 3-Ds, Bars and Pies. The average person hearing a presentation will remember whether the speaker was entertaining. They will also remember three facts. Every slide of every presenter shows more than three things. People spent a lot of time putting more information on slides than anyone will ever remember.
Facts and information can be found on Google. Good speakers tell you a story.
Imagine—perhaps the most powerful word in the English language. Tell someone a story and your audience will learn forward and listen.
If you are ever asked to speak or to give a presentation here is one tidbit that may help you—speak like you were speaking to a good friend, only speak louder and wear a clean shirt.
Pale Rhino Consulting 