EHR: The 40-chicken crocodile

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Got a couple hundred million burning a hole in your pocket?  Why not buy an EHR?  Indeed.

Riddle me this Batman, “What is a 40 chicken crocodile?”

It is the number of chickens you have to feed it each day to keep it from eating you. What is the crocodile at your hospital?  Is it your EHR?

Let me recount to you a true story about the details of one of the EHR “success” stories.  A major hospital who selected their EHR from among one of what I like to call the oligopoly EHR Flavor of the Month Club.  You know the suspects.

Permit me to throw a wrench to those clairvoyants who think they know where this is going before I’ve even written it.  Admittedly, I have a tendency to throw metaphorical tomatoes in one direction—that of the vendors.  That’s because, they are often easy targets.  Slow down Pepito.

This hospital, and from what I was told, the vendor, did it right.  I am not sure I would have differed from the approach of either.  The hospital spent a few years in its vendor selection process, and they were very thorough.  They spent two years building their process maps, ensuring the vendor implemented the EHR to meet their needs, not the other way around.  Operations led the nine-figure project.

They implemented many of the support functions and a few of the specialty functions.  Here come the chickens.  After implementation, cash flow dropped by 80 percent for several months due to significant issues they encountered cleaning up the revenue side.  Doctors were instructed to cut their hours by fifty percent to allow them to learn to use the system.  Hours are still down by twenty percent, well more than a year later.  Users use about one-third of the functionality, even after a rigorous training program.

The hospital held off doing most of the clinical implementations for two years.

I asked for some recommendations.  What would you have done differently?  Here’s what I learned.  If you have a research organization you need to spend extra special attention to their workflows.  Managing post-go-live was a big issue to begin to offset productivity losses. Without a continuous process improvement program the EHR would not have been accepted. Do not pick a go-live date at the outset of the project as it causes the organization to be paralyzed simply to hit the date.  Testing was compromised to meet the go-live date. The post go-live issues are still being fought.  Do not let the design or build teams skimp on either reporting or testing, they are still playing catch-up.

So, after doing a pretty bang up job, at least from where I sit, there are still a lot of chickens being fed to the crocodile.  Wonder how many chickens it would have taken had the users not been as involved as they were.  How many had the users not spent two years pre-build defining processes?  A lot.  Now comes the rest of the clinical effort.  See you at the poultry counter.

 

HIE: Are two HIEs one too many?

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The is my most recent post at healthsystemcio.com

According to Wikipedia, Health information exchange (HIE) is defined as the mobilization of healthcare information electronically across organizations within a region, community or hospital system. HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged.

That seems really straight forward, at least to me. I find it helpful to whittle complex ideas down to a point that enables me to explain them to my parents, without either of us having to reach for the Tylenol.

In its simplest form, an HIE is a pipe, a pipe that transports ones and zeroes. Back in the days when I still had hair, one of my clients was the CEO of a large cable television company. He explained his business this way; “We are just like the water department. We put a pipe in the ground, send something through it, and every month people mail me money.”

He also sent ones and zeroes.

Now, there are those around us, apparently thousands of them, who have made it their mission to convince those in the minority that HIEs are far more complex than they really are. Maybe I just do not understand the concept of ones and zeroes.

You probably know that several hundred HIEs are in the process of being built—and they are all being built by people who have little to no experience building HIEs. Now, here is where everything gets a little hairy. Let us look back on the definition of an HIE and let us focus our conversation on building just one HIE. The tricky part about getting the HIE to work is that pesky little word “disparate,” as in disparate health information systems, and the last time I counted EHRs, I hit 300 before giving up.

That is where all that disparate clinical information comes from. However, when push comes to shove, the information from all of those different EHRs is pretty much the same, but the various EHR vendors just line up their ones and zeroes differently, thus enabling them to prevent others from playing in their sandbox.

There is another disparity surrounding HIEs, one that is unspoken. Suppose you and I decide to build an HIE, a good one. After some period of time, we get rid of all the little disparities among the various EHR vendors and are able to zip those little ones and zeroes from one end of the HIE pipe to the other. Let us also suppose we used a very long pipe, so we could use this HIE anywhere. It would work for a hospital, or at an Integrated Delivery Network (IDN), or across a region.

Our HIE is able to move our individual healthcare information from one end of the pipe to the other wherever the other end may be.

I forgot to mention the disparity. The unaddressed HIE disparity is the one created from having hundreds of HIEs, each designed in its own vacuum by people who have little experience filling vacuums. And when those HIEs have been built, what will they do? Exactly. They will move clinical information among disparate healthcare information systems. In laymen’s terms—ones and zeroes from EHR vendors who do not play well together.

The new ones are identical in functionality to the one we just built, only now there are 500 of them.

Now to the meat of the issue. If we build an HIE correctly, and build it to be able to handle any disparity, is there any more need for HIE 2, since in theory HIE 2 will be able to do the same things as HIE 1?  Let us extend this same thinking from HIE 1 through HIE 500. At some point—irrespective of certain technical issues—can it be concluded that the total number of HIEs needed to move ones and zeroes is one?

Other than the redundancy and expense of building a few hundred things that each perform the same function, the real problem of having multiple HIEs is that each new HIE greatly increases the complexity of moving a personal health record from point A to point B. If HIE 2 is the same as HIE 1, we do not need HIE 2. If the two HIEs are not alike, when we try to transport a personal health record from a patient in HIE one and move it to a doctor in HIE 2, the disparity created between the two almost requires a new HIE to resolve the problem. We will have infinitely compound the complexity of moving ones and zeroes by deploying 500 HIEs and hundreds of thousands of healthcare providers and a few hundred million patients, and we have designed quite a mess.

And why does the mess exist? It exists to move those same ones and zeroes we were moving quite nicely by the HIE we built. One can argue that scale may create its own design issues, but those issues do not make this idea dead in the water. Issues of scale are solvable; those of compounded complexity are self-imposed due to an overzealous design.

The proposed way to solve the upcoming problem of compounded complexity is to build the National Health Information Network, the NHIN. We need the NHIN to act as a super HIE, to remove the disparities that result from having multiple disparate HIEs.

Adding further unwarranted complexity to the multi-HIE model is the fact that each HIE has resulted in several hundred providers designing and retooling their healthcare IT systems to adapt to these anomalous HIEs.

Sometimes the most difficult solution to envision is the least difficult one to implement.

 

ICD-10: the true cost of having no experience

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The thing I like least about flying has to do with my control issues; someone else controls the plane and there is nothing I can do about it.  The pilot’s voice seemed to say “Put yourself in my hands.”  Like nails, I thought, like carpentry nails.  As a result I find myself creating caricatures of the people seated around me—I can choose do that, or I can choose to rush the cockpit and wind up being a two-minute feature on CNN with the other passengers asking how I got the gun on board.

I get as excited about someone sitting next to me as a dog does about a new flee crawling around on his hind quarters.  Picture the woman who sat next to me.  I was tempted to ask her how she could dress like that but, I worried she would reply “From years of practice.”  She looked like a disaster victim might be expected to look—a tattered, grey wool blanket draped over her shoulders.  The only thing missing from the scene was a reporter standing over her asking her how she felt about the plane crash.  Her face was strong and equine, with a straight nose that veered slightly leeward.  As she gnawed angrily at her gum with her front teeth, her fingers gripped the armrests so tightly I could foresee the need to call a flight surgeon upon landing to amputate her arms at her wrists.

Anyway, that was my flight.  Yours?  Here’s the segue.

Picture the makeup of the attendees of your last meeting (circle the topic that best describes its purpose; EHR, Meaningful Use, ICD-10).  As I look around the conference table, sitting directly across from the bagels is Jackie.  Jackie has been a member of the IT team since the invention of punch cards.  Bill still prefers to use the “portable” Compaq suitcase PC he was issued during the time the US was playing Reggae hits over loudspeakers trying to coax Manuel Noriega out of Panama.  And Mindy has stormy eyes—sorry about that—Mindy has a coffee mug collection acquired at the going away parties for the prior seven CIOs.

Our Lady of Perpetual Billing’s hospital information technology A-team is waiting to see exactly what type of fertilizer is about to be loosed upon the windmill of their little shop of horrors.  They run a taught ship; nothing slips by them, and nobody can match their job performance.  The last unpaid claim was six years ago, and their efforts have made patient satisfaction so high that the hospital cafeteria’s reservations are booked solid through year end.

It is usually good to have experienced people.  People with twenty years of experience.  Is it twenty years of experience or twenty in one year’s worth of subject matter?  My son has three years of Pokémon experience which makes him an expert on all things Pokémon.   This turns out to be a pretty valuable skill as long as the conversation stays on point.  Unfortunately, being an expert on Pokémon does not translate as readily as he would like me to believe to other areas requiring his attention, areas like cleaning his room.

So, let’s get back to the issue of Jackie, Bill, and Mindy, and our collection of three IT projects.  We can all agree people with their level of experience are very good at what you need them to do, in fact, they are probably irreplaceable.  They know what to do from the moment they enter the building until the moment they leave.  They are in their comfort zone, even though the hospital may not be in its.

Somebody has to work on EHR, Meaningful Use, and ICD-10.  Do you pick people with twenty years of one-year experience?  You may not have a choice.  Twenty years of one-year experience may be the worst kind of experience to add to your team.  It is a given that nobody in your organization is pushing around a wheel barrow full of Meaningful Use or ICD-10 experience.

I spoke with the CIO of a large hospital and listened as he described the hospital’s ICD-10 initiative.  I did not have the heart to tell him that the use of the word “initiative” was overly ambitious.  The initiative was little more than a meeting of a half-dozen “experienced” people; people from operations, finance, and IT.  People who were very good at their jobs—naturally, they had been doing them for…say it with me…twenty years.  One of the CIO commemorative coffee mugs sat on the conference table.

These meetings generally begin and end with unblemished legal pads sitting in front of each participant.  Why?  Let us explore that question for a minute.  The group’s charter is to figure out what the hospital needs to do to be HIPAA 5010 ready by the end of 2011, has to be ICD-10 compliant by the end of 2012, and has to determine what it will cost and what resources will be needed.

Suppose that is your charter, or the charter of someone in your hospital.  How will those with twenty years of one-year experience help you?  What is the first thing you need to do?  What is the second?  What should the group be doing two weeks from Tuesday?

Maybe the best thing to write is “We do not know how to do this!  We need help.”

 

EHR: When you are in a hole, stop digging

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 March 21, 2011 07:05

I 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 one 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.  My total amount of rappelling experience was probably only a few more hours than hers.  Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her on the face of the cliff.

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 about a man who fell in a hole.  The man 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 an EHR vendor walks by—I know this isn’t the real story, but since I am the one writing I’ll tell it the way I want.  Where were we?  The vendor.  The man in the hole 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 down there?”  I asked.

“I fell in this 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?”  He asked.  “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?

Drafting someone to sort out your EHR problems doesn’t do anything other than add another name to the org chart.  Work plans and org charts are very similar in one key respect—they both have a lot of blank space between the all of the boxes.  And, that is where a lot of the problems arise—in the blank spaces, spaces that have to do with planning, process improvement, and change management.

Everyone is implementing an EHR, but not everyone is doing it correctly.  There is a very special set of IT skills needed to meet the challenges of a failed or failing project.  People with those skills are disaster recovery specialists.  They are the people who jump in the hole with you because they have been in the hole before and they know the way out.

Has Meaningful Use Optimisim Run Amuck?

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I make it a point to read every article Gienna Shaw writes for HealthLeadersMedia.com.  She consistently captures large amounts of information and packages it into a concise understanding of the material.  In the February issue of HealthLeaders http://www.healthleadersmedia.com/industry_survey/ she wrote a piece summarizing the results from their survey of organizations on their projected timeline for achieving Meaningful Use; Making Meaningful Progress.  I thought it might be helpful to offer readers a bit of a different perspective, something that may cause you to pause and wonder whether I am living on another planet, or whether it is the majority of those surveyed who migrated to Venus.

Were it only that the responses of those surveys were based in reality—the world would be a better place, the Cubs would win the World Series, and my son’s room would no longer resemble an obstacle course.

According to the survey findings, sixty-eight percent of those surveyed expect to achieve Meaningful Use by 2012, and that total climbs to seventy-seven percent by 2013—assuming the Mayan prediction of the world ending the year before prove false.  Things always look rosier when you have the luxury of ignoring other factors prior to answering the question of whether you will achieve Meaningful Use; like whether the EHR implementation will be successful and whether there is enough time to meet the dates they selected.

What else should one be considering when assessing the validity of this unbridled optimism?  Thanks for asking.  Here is my list:

  • EHR Failure Rate:  published data suggests EHR failures range between 30-70%.  If we use a conservative figure of 40% we can see that optimistic forecasts of 77% achieving Meaningful Use by 2013 is wrong by a factor of two.  If forty percent of implementations fail, and seventy-seven percent meet Meaningful Use, somebody needs to check the math.
  • Of those systems that have already failed, many of whom are very notable hospitals, they had the luxury of time.  They had as much time as they needed to fail.  Today we have less time to fail, which to me means failure percentages will increase.  For those who have yet to fail, if your goal is meeting Meaningful Use by 2013, watch out.  If you dash for the cash, plan for an EHR do-over.  Remember, there is a binary trap associated with meeting Meaningful Use—it is all or nothing.  There are no dollars awarded for having tried really hard.
  • When was the last time you tried to hire a very experienced EPIC or McKesson resource?  Recent figures suggest a Healthcare IT resource shortfall of fifty percent.  This shortfall will greatly reduce the number of organizations which have any chance of meeting Meaningful Use by the dates they themselves specified.
  • How’s that HIPAA 5010/ICD-10 project coming along?  A high percentage of organizations have not even started the HIPAA 5010 tasks that should have been completed in 2010.  More money will be lost through not meeting ICD-10 than will have been awarded in the EHR rebate lottery.
  • Once your EHR is implemented, what percentage of your IT resources will you need to allocate simply to meet Meaningful Use’s stage one requirements?  One outstanding hospital found that number to be eighty percent over three years.
  • At least with EHR there are people who have current EHR experience.  There is no pool of ICD-10 been-there done-that resources.  So, where do you allocate your scarce resources, EHR or ICD-10?  Either answer you give yields a bad outcome.

So, what is the best approach for the C-Suite?  Meeting Meaningful Use is not mandatory.  Time need not be your enemy.  Why not implement EHR correctly?  Why not adjust your plans so that instead of trying to squeeze every possible dollar out of Meaningful Use you simply try to make EHR work by 2015?  This way you avoid the penalty and give yourself a decent shot of success.

No ARRA money will be awarded for being optimistic.  However, once you tell the CFO to plan for a twenty million dollar ARRA windfall in 2011 or 2012 you better deliver it because you know darn well that he or she has already made plans to spend that money.

I think if we were to check the results of this survey two years from now we would find that less than forty percent of hospitals will have achieved Meaningful Use by the end 2013.

What is IT’s role in Accountable Care Organizations?

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I published this article today in healthsystemcio.com (http://ow.ly/4ecmg), and thought you might find it interesting. Please feel free to comment.

 

 

 

When was the last time you looked at a hospital bill, or one sent directly from your physician? The reason I ask is I have been spending some time trying to develop a clear enough picture of Accountable Care Organizations (ACOs) to describe them easily. After all, ACOs are not something you can touch and see. You cannot just walk up to the third floor of Our Lady of Perpetual Billing and be shown an ACO.

 

I think it is extremely important to understand what an ACO is before trying to build one. Much of the difficulty in building an ACO has to do with the fact that something, in fact a great many somethings, will have to change for an ACO to function. The question then becomes, change from what to what?

Back to the hospital bill. Scan through the list of charges, and then press the F5 key to let me know when you are ready. Now, highlight all the line items that charge you for the care you received … I found the same thing; there are not any. Volume versus value. Caring for you versus doing stuff to you. The bill of charges under today’s business model is a blow-by-blow description of what was done to you; x-rays, medicines given, IVs, etc.

Hospital billing is not unlike a hotel bill; it is just longer and you do not earn frequent illness points. Embedded in your hospital bill are charges for food and cable television, just like you had been staying at the Four Seasons.

So, as we move from volume to value, how will that impact healthcare information technology, assuming anyone remains standing after Meaningful Use and ICD-10? I keep preaching about how the hospital’s business model must change in order to understand what will be required of IT. To do so, let us compare two very different business models and their operations, both of which are in the same industry.

Hyundai and Bentley. Volume to value. Just-in-time manufacturing versus don’t-rush-me manufacturing. Nobody would argue with the fact that the information systems and business processes needed to run Hyundai’s business are very different from those of Bentley.

I watched a show on how Bentleys are built. A team of people is assigned to each car. Depending on the car’s options, some people roll off the team and others are added, but the team “owns” the car from start to finish, and each subsequent person inspects the work of the prior person.

At Hyundai, it is not apparent that anyone “owns” the car. People have line responsibility; they own a piece of a process. I could be the “left lug nut guy,” having absolutely no responsibility for the rest of the car.

I think this is the degree of change an ACO will require in order to be effective. We will have to change from being lug nut specialists to becoming care owners. This then brings us back to the question of what IT systems will be needed to charge for and manage care.

Unlike moving from ICD-9 to ICD-10, there is no mapping model to guide the change from today’s business model to an ACO model. Three IVs and one MRI do not translate well to 4.5 Accountable Care Units (ACUs) which are then billed at whatever happens to be the going rate.

Today’s systems calculate charges based on what was done to you — $86 million gazillion for the MRI. If requested, nobody in finance or information technology will be able to vivisect the bowels of SAP or Lawson and show you where the information is that records how much the MRI procedure costs. Few can explain how the business processes and information systems that support today’s lug-nut charging model can support and report how the hospital manages its business. Nobody even pretends to explain how effective those same processes and systems are at reporting the quality of care delivered.

The ACO model will require processes and systems that capture, allocate, and report costs. The ACO model will also require processes and systems that can aggregate people and procedures into ACUs and relate patient costs against those ACUs.

We do not have those systems. Since current hospital systems are incapable of really managing today’s business requirements, we should not adapt them to the ACO model.

 

EHR: Is time your greatest enemy?

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The following is my response to an article in Health Data Management regarding an article which argued that time is the enemy of a good EHR implementation. (http://www.healthdatamanagement.com/blogs/Quammen_big_bang_EHR-42096-1.html#read)

I agree fully with the premise of a big bang rather than a phased in approach, but for the following reasons I respectfully disagree if the reason for going all out is because there is not enough time.

Many providers have already demonstrated that time is certainly the enemy.  They have had enough time to spend four hundred million dollars and get EHR wrong, and are in the process of doing the same thing with another vendor.  There is a notable shortage of CIOs wearing EHR 2.0 T-shirts—fail once and you are done.  The attitude seems to be that there is plenty of time to do it wrong and not enough time to do it correctly.

Poor EHR implementations are creating a brand new market for HIT consultants—disaster recovery. The New England Journal of Medicine noted that more than sixty percent of EHR implementations fail.  An even higher percentage will fail to meet Meaningful Use, which is why everyone is in such a rush to implement—the Dash for the Cash.

Providers are sacrificing their own business strategy to get a check for trying to meet a set of standards that have no meaning and no benefit other than to have them fit into a more nationalized healthcare model—something they would never have done on their own.

The first question a provider should ask is “do we want to meet Meaningful Use”.  If the answer is yes, the next question they should ask is “by when?”  Given the rash of failures, providers should figure out what they need to do to avoid being the next hundred million dollar failure.  Paying to do EHR twice or to recover from a failed implementation will far exceed any funds they will have received from the EHR Rebate program.

The problem many will find is that there is no “R” in the Meaningful Use ROI calculation.  The productivity of some of the best providers in the country is still down twenty percent two years after implementation.

If providers want an ROI, they would be much better served by taking their time and doing what they need to do to make EHR do what they need it to do, and to focus their attentions on ICD-10.  The amount of money they will lose from failing to meet ICD-10 will far exceed the EHR rebate.

Patient Experience Management as healthcare’s Watergate

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Below is the text of my article in Hospital Impact.

Patient Experience Management as healthcare’s Watergate

March 9th, 2011

by Paul Roemer

For the second straight year, HealthLeadersreports that Patient Experience Management (PEM) is one of the top three priorities for healthcare executives. A McKinsey study of 1,000 executives showed that for 90 percent of executives it ranked first or second.

Those results put my mind at ease on the issue about as much as Iran’s Amadinejad claiming its nuclear efforts are only targeted at improving the yield of their turnip harvest.

Recall the tagline of the McKinsey study–none of the executives knew who actually owned the patient experience, so little was planned for addressing this priority. However, several hospitals were expected to offer more heart-healthy alternatives in the basement cafeteria–I love strong leaders. Be on the lookout for the Amadinejad Turnip-Melt.

[More:]

Anyway, I digress.

Healthcare’s Watergate. Follow the money. Yet, there is no money to follow in two key areas, at least not an amount that suggests hospitals view either area with the same degree of import with which they speak to them. What are they?

  • Patient Experience Management (outflow)
  • Our old friend, Meaningful Use (inflow)

Missing is the planned expenditure that would come even close to making Patient Experience Management a priority. Don’t believe me? Print out a copy of your organization’s strategy, its budget, or its general ledger, and sort all of the planned expenditures from greatest to least. Stop reading when you reach the line item for Patient Experience Management.

Meanwhile, I am going for a run. If you find it before I return, wait for me, but you will not have found it by then.

You did not find the dollar amount budgeted for PEM did you?

Just to stay consistent, there is not much of a Meaningful Use windfall flowing out of CMS and into your neighborhood healthcare services provider either.

In general, money for what seem to be very high operational priorities is dribbling along so slowly so as to suggest these initiatives had prostate problems in the offing.

In addition to the fact there was no booth at HIMSS to showcase the most singularly spoken of topic, Meaningful Use, there was also no booth on Patient Experience Management. There was not a single PEM vendor. Why? Because the vendors know PEM, for now, is a unicorn-like ACOs–and nobody has ever seen a unicorn, so why bother trying to sell unicorn horn polish?

By the way, I need to borrow five chairs for a group photo I am taking of everyone eligible to receive Meaningful Use rebates.

Paul Roemer, MBA, is a healthcare strategist and Managing Partner of HealthcareITStrategy.com. Paul has more than thirty years of management consulting experience, starting with the Big 4 where he held national leadership positions, and the last fourteen years with his own international consulting firm. He has a passion for how we will live and function in the rapidly changing world of healthcare, and how information technology must provide for and help manage the change. He wrestles with how to turn the lack of information of what the business of healthcare will become, the lack of understanding of the issues, and the general lack of knowledge of the future into decisions we can make today to shape tomorrow. Paul has earned a presence on the national healthcare stage through his futuristic thought leadership, and is a recognized speaker and writer on a number of strategic healthcare issues.

EHR: How do you define progress?

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If you and I agreed on everything, one of us wouldn’t be needed.

Of the many special things associated with growing up in America, one is held dearly by every American eight-year old male who owned an AM transistor radio with an earplug; baseball–I am dating myself which is something I promised my counselor I wouldn’t do.

On hot summer nights in the 1960’s, Baltimore’s adults sat on their cement stoops nursing bottles of Carling beer and waiting for their window air conditioners to suck out the heat.  Their male offspring lay in bed, a plastic earplug dangling from their ear as they turned the dial of their transistor radio to find the lone radio station covering the Baltimore Orioles. In spite of the constant static, they faithfully kept score on a hand-drawn score sheet in their black and white Composition notebook.

My scorecard was homemade; carefully drafted using a pencil and something relatively straight to draw the lines that separated each of the nine innings. Unlike today, when the concept of team has given way to the concept of players whose loyalty lies with the highest bidder—free agents, the lineup for the Orioles rarely changed by more than a player or two each year.

The Orioles team pennant hung on my bedroom wall, and on my dresser was their team photo along with my membership card to the Junior Orioles. Next to me as I kept score was my tattered shoe box containing my collection of baseball trading cards, sorted by team and held together by rubber bands.  A few hundred stale sticks of pink powdered bubble gum that came with each five-pack of cards was stacked neatly in one end of the box. The cards for the opposing team were spread before me so I could get the lineup and study their batting statistics.

What made me think of this was that the last of our snow had melted, and opening day is less than a month away.  Last year my son and I went to a minor league game. Although the grass was just as green, and the hot dogs smelled the same, nothing was the same. Still, it beat a stick in the eye. Things change. Baseball changed, and nobody conferred with me before changing it. At the game I didn’t see a single person keeping a scorecard, let alone a dad teaching his son or daughter how to keep the score. The only constant throughout the game was the commercialization.

That’s progress. Or maybe not. Some progress is good. Some progress doesn’t exist even though everybody around it believes that it does.

Implementing new technology doesn’t in and of itself infer progress, it simply means you bought more technology. Not convinced? How is the productivity of your EHR?  Add up all the money you’ve spent on EHR and technology and recalculate your RIO.  Was it worth it?

Ray, people will come Ray. They’ll come to Iowa for reasons they can’t even fathom. They’ll turn up your driveway not knowing for sure why they’re doing it. They’ll arrive at your door as innocent as children, longing for the past. Of course, we won’t mind if you look around, you’ll say. It’s only $20 per person. They’ll pass over the money without even thinking about it: for it is money they have and peace they lack. And they’ll walk out to the bleachers; sit in shirtsleeves on a perfect afternoon. They’ll find they have reserved seats somewhere along one of the baselines, where they sat when they were children and cheered their heroes. And they’ll watch the game and it’ll be as if they dipped themselves in magic waters. The memories will be so thick they’ll have to brush them away from their faces. People will come Ray. The one constant through all the years, Ray, has been baseball. America has rolled by like an army of steamrollers. It has been erased like a blackboard, rebuilt and erased again. But baseball has marked the time. This field, this game: it’s a part of our past, Ray. It reminds of us of all that once was good and it could be again. Oh… people will come Ray. People will most definitely come.
-Terrance Mann in the movie, “Field of Dreams”

I tear up every time Ray asks, “Want to have a catch dad?”

 

AP reports EHR plan will fail. Now what?

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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 the nationalization of 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 some 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.

That swishing sound you keep hearing is the sound of productivity in free fall.  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.