What do processes have to do with EHR success?

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As a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR? The reason is simple. The taxonomy of most, if not all EHR systems, is that they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

 

Family Experience Management–not just the Patient

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If you are at all like me, when you need information on a topic, you go to Google.  Moreover, if the information you seek does not appear on Google, my mindset tells me the information does not exist.  Google is perceived as the repository of all things written since a caveperson—although I do not think cavepersons are thought of as being politically correct—painted the design of the first iPad on the wall of the cave with the foreskin of a newt.  If a particular idea or bit of information is not on Google, I tend to think the bit for which I am looking does not exist.

Because of the breadth and width of all the collected data, it is difficult to come up with a data request for which there is no response.  Experience shows even if you search on a meaningless phrase, Google will return to you several links that match.

Until yesterday, at least for the search I entered—Family Experience Management (FEM).  Of all the billions of bits of information, my search yielded one hit.  Being curious, I clicked on the link, and the result did not even include the phrase.

So, we are entering unchartered territory, defining a new concept.  This is a little like getting to name a new planet.

Patient Experience Management (PEM) is what got me thinking about the FEM concept, or the lack of the concept.  As we discussed per the McKinsey study, PEM is at the top of the mind of most hospital CEOs and COOs for the next several years.  The study also reported that although PEM is of such high priority, few hospitals are doing anything about PEM because hospital executives do not know who within their organization “owns” the patient.

Ignoring for the moment that this says something about one’s ability to lead, the value of a PEM initiative is it leads to patient retention, lower costs, and is good for business.  PEM, as I look at it, is not limited to streamlining the ER, or allowing patients to park closer to the hospital.  Good PEM enhances and improves every interaction the patient has with the hospital.  The more interactions your PEM program touches, the more benefits to the hospital; at least that is the theory.

But, what if there is more to it?  Is there a way to bring about more benefit by redefining and subsequently implementing a PEM program?  I think there is.

Unlike other services people purchase, healthcare, purchased via a hospital, is purchased and “used” collaboratively; patients, family, and friends are all involved in many aspects of the service.  People other than just the patient help with scheduling appointments, transportation, visiting, care, picking up medications, talking with doctors and nurses, billing, and interfacing with payers. It is kind of like MCI’s Friends and Family program, only the bill is much larger.

So, when hospitals begin to think through how to ‘manage’ the patient experience, managing the patient is but one of the stakeholders they ought to address.  The other interesting takeaway from looking at FEM instead of simply PEM are the social CRM and social networking implications.  As the number of stakeholders increases, so does the size of the social network that is willing to make their experience with the hospital the talk of the town.

 

EHR’s Gordian knot

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There were four of us, each wearing dark suits and sunglasses, uniformly walking down the street, pausing at a cross-walk labeled “consultants only”—I think it’s a trick because a lot of drivers seem to speed up when they see us. We looked like a bad outtake from the movie Reservoir Dogs. We look like that a lot.

Why do you consult, some ask? It beats sitting home listening to Michael Bolton or practicing my moves for, So You Think You Can Dance, I tell them.

Listening to the BBC World News on NPR whilst driving, there’s one thing I always come away with—they’re always so…so British. No matter the subject—war or recession—I feel like I should be having a proper pot of tea and little cucumber sandwiches with the crusts removed; no small feat while navigating the road.

Today’s conversation included a little homily about the Gordian knot with which the company Timberland is wrestling, questioning whether as a company Timberland should do well, or do good. (Alexander the Great attempted to untie such a knot, and discovered it had no end (sort of like a Möbius strip, a one-sided piece of paper–pictured above. (For the truly obtuse, among which I count myself, the piece of paper can be given a half twist in two directions; clockwise and counter-clockwise, thereby giving it handedness, making it chiral—when the narrative gets goofy enough, sooner or later the Word dictionary surrenders as it did with chiral.))) I’m done speaking in parentheses.

Should they do well or good? Knowing what little command some people have of the English language, those listeners must have wondered, why ask a redundant question. Why indeed? That’s why I love the English, no matter the circumstances they, they refuse to stoop to speaking American.

Back to Gordo and his knot. That was the point of the knot. One could not have both—sorry for the homonym. Alexander knew that since the knot had no end, the only way to untie it was to cut it. The Gordian knot is often used as a metaphor for an intractable problem, and the solution is called the “Alexandrian solution”.

To the question; Well or good. Good or evil. Are the two choices mutually exclusive? For an EHR? They need not be. The question raised by the BBC was revenue-focused (doing well) versus community or green-focused (doing good). My question to the reader is what happens if we view EHR with this issue as an implication, a la p→q.Let’s review a truth table:

if P equals if Q equals p→q is
define requirements increase revenues TRUE
play vendor darts increase revenues FALSE
ignore change management increase revenues FALSE
no connectivuty increase revenues FALSE
new EHR software increase revenues FALSE
change processes increase revenues TRUE
eliminate waste increase revenues TRUE
decrease redundancy increase revenues TRUE
Strong PMO increase revenues TRUE

From a healthcare provider’s perspective the answers can be surprising; EHR can be well and good, or not well and not good.  The Alexandrian solution for EHR is a Alexandrian PMO.

Have your people call my people–we’ll do lunch.

 

EHR: This is not a trick question

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Okay, so today was going to be one of those days when I wasn’t going to allow myself to be stupified–at least no more than was really required.

Then it sneaks up smack dab in the middle of a call, and from what I’ve been able to determine, people find it annoying if you burst out laughing on the call.  (They are not annoyed at all if you simply write about them provided they don’t read it.)

What got me going is this statement, “We’ve budgeted $X for EHR.”

Really?  You did this all by yourself?

The facts as I understood them are as follows:

  • Never bought an EHR
  • Don’t know how big they are, if they are blue or green, come gift-wrapped, or if you need two people to carry it
  • No input from vendors about EHR
  • No discussions with others abot what an EHR system costs

So, with absolutely no information, how does one determine how much they need to spend for an EHR?  This is not like going to the supermarket for a gallon of Soy Milk–not that anyone would want to do that.

Healthleaders Media: E-Health Systems: For Love or Money?

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The following are the comments I posted to Gienna’s article, http://ow.ly/3FWTP

Nicely written Gienna.  My concerns from the get go regarding Meaningful Use (MU) and Certification are:

  • Is Meaningful Use meaningful
  • If so, to whom

 

My answer to both questions is it is meaningful, on paper, to the ONC and CMS.  It is meaningful with the respect that it does one thing.

 

  • Meaningful Use changes the course of a healthcare provider’s business strategy from whatever internal course it was pursuing to one having a national focus.

If you do not believe me, look at your resource plan for meeting MU.  Some hospitals are having to redirect more than fifty percent of their IT resources away from whatever they were doing for the hospital to meet the MU requirements.

The article reports several sets of numbers which I think are at best misleading.  I think those hospitals who meet MU will do so much later than are being reported.  Few will make it in time to capture the full EHR “rebate”.  As such, the pool of available money to go back to hospitals is overstated, as are the number of hospitals who will receive it.

There is a broad chasm between those who expect to receive money and the amount they expect to receive, and how much will paid be paid to how many.

Now, with respect to whether any of this is meaningful; how many hospitals would have been willing to sacrifice their business strategy and spend millions of dollars to try to meet such a gossamer directive if this was tied to any other directive originating out of Washington?

Let us take something so outlandish as to be silly just to try to illustrate the point; paining your hospital pink.  If Washington offered similar sums of money and if one had to spend similar resources to earn it, would a hospital’s executive team approve the expenditure?  What is the business reason that makes MU so different?

The other issue I have with their optimistic MU adoption forecasts is the following.  Meeting MU is binary.  That is, there are no points for getting close.  A hospital which meets ninety-five percent of the criteria receives the same rebate as a hospital which meets none of the criteria.  Zero.  Using their own figures, if hospitals meet it by 2016, all they will have done is spent millions to receive zero payout.

As you calculate the ROI for EHR/MU be sure to include the following:

  • Will your EHR implementation be successful?  The latest figures I have seen suggest that your odds of having a successful implementation of EHR are less than one in two.
  • If you are “successful” will you meet it in time to potentially qualify for the full amount—if not, decrease what you expect to receive.
  • Will you complete the requirements to your satisfaction—if not, multiply your expected payout by a number less than one?
  • Will you pass the MU audit?  Some will not.  That is why there is an audit.  If you do not pass, you can reapply at a later date, but you will no longer be entitled to the full amount.  Again, multiply your expected payout by a number less than one.

And, here’s the kicker.  Here is the calculation most hospitals have overlooked.  How much has your productivity dropped since you implemented EHR?  A heads up for hospitals who have not completed their implementation—a large number of hospitals have spent in excess of a hundred million dollars only to see their productivity still twenty percent below what it was without EHR.

What does such a productivity loss do to your ROI calculation?  There is no language from ONC and CMS stating that such a productivity loss is meaningful.

 

Will you help me on ICD-10?

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I am in the process of writing an article on what hospitals are doing regarding the move to ICD-10 and want to schedule brief calls with anyone willing to discuss their efforts.

The article will not disclose the name of the organization or any individuals.

Please let me know if you are willing to participate or know of someone who would.

I am also looking for an ICD-10 work plan to review.

Thank you for any help you can provide.

EHR: where’s my hammer?

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Those of you who’ve visited previously may have caught on to the fact that my wife likes to keep me away from bright shiny objects such as tools.  Let me tell you about my first house, a two-story stucco building in Denver, built in 1902.  My favorite part of the home was the brick wall.  That it had a brick wall was not apparent when I purchased the home.

I came home from work to find that my dog had eaten through the lath and plaster in the living room and there was the brick.  I had to decide what to do.  I knew nothing about lathing—I know that’s not really a word—or plastering.  What to do.  My only tool was a hammer, so I began to hammer.  For those who haven’t done this, hundred-year-old plaster being pounded with a hammer makes a lot of dust.  This process proved to be very slow.

What did I do?  I bought a bigger hammer—such a guy approach to a problem, isn’t it?  It took three hammers to get down to just bare brick.  What would you have done?  When your only tool is a hammer every problem looks like a nail–or a wall.

As you go through the EHR planning process in your war room—you do have a war room, don’t you?  (Try Sam’s Club, after all, they sell EHRs.)  Get out the really big piece of paper, the one with your EHR design—you do have a really big piece of paper, don’t you?  (Back to Sam’s.)

Next to the box on the paper labeled “Shiny New EHR” should be lots of empty space so you can draw in all of the other systems with which your EHR will have to interface.  One of the readers of this blog wrote recently that his EHR had more than 400 interfaces.

EHR, if done correctly, will do much for patients, doctors, and administrators.  It’s not a panacea.  It won’t reach its potential unless you also integrate it with those systems that unlock its potential.  Improving your efficiency and effectiveness takes more than merely an EHR system.

When your only tool is a hammer, you’d better hope every problem is a nail.  What other tools are you using?  Please share your ideas about what works well.

EHR: The Migratory Patterns of Coconuts

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Are you suggesting coconuts migrate? (Not at all, but a swallow could grip it by its husk.)

Sometimes I get reactions from my clients which suggest that my ideas have people questioning if I just fell out of the stupid tree and hit every branch on the way down, especially when what we’re discussing seems to move from the theoretical and towards the heretical. However, there was a presentation I made to one of my clients where I had the entire room believing that i might as well have been suggesting that coconuts migrate.

Allow me to set the stage. I presented to the CIO of one of the largest providers in Europe a vision for what their IT strategy should be. This was an 0.2 firm requiring a 2.0 solution.  As you can guess, it was fairly easy to suggest that better alternatives were available to them, but if you’re a member of the Flat Earth Socitey you’re not going to believe anything until someone is able to literally change your perspective.

During my presentation I wrote on the white board that I would help them choose between three alternatives. At this point, a British colleague and good friend, came to the front of the room—uninvited, removed the marker from my hand, erased the word ‘between’, and penned the word ‘amongst’. “We choose between two things, and amongst three or more,” he said with a grin and then returned to his seat. I suggested that since English was not the native language of our client that his point was probably lost on them, to which he stated that his point was directed at me whose native language was supposed to be English. God save the queen. He also tried to make the point on more than one occasion that the American War of Aggression with England did not end in 1783 with a victory for America, but with a British retreat.

Anyway, we were choosing between three alternatives, at least I was. After about ten minutes of explaining what could be achieved and how it might be structured, I was interrupted again, this time by the CIO. He too took my marker, concluding that I was a coconut. It took me about thirty minutes to convince him that everything I’d presented was not only achievable, but already operational in a number of their competitors.

So, as we head down the EHR path with our Project Management Executive, the person who will be spearheading the internal effort to affect change, we must find a way to make sure the executive is properly equipped. For starters, the executive needs to have, and to be able to communicate a vision, a vision for the change, for how it will impact the organization, and an ability to communicate it.

 

Reinventing the healthcare insurance business model

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If there is a more obtuse business model than the one used by insurance companies I have not seen it.  While I am not an advocate of privatization—because I am a right-wing nut who favors capitalism—I do think there is a smarter way to earn profits.

Taken to its extreme, the ideal way for a payor to earn profits is for payors to take in money without ever having to pay out money.  This is the same model your cable company uses—people simply send them money every month, and never get it back.

To contrast the healthcare insurance model with an insurance model that actually provides some degree of benefit, one needs look no further than the automotive insurance model.  While nobody loves paying car insurance, we do so somewhat secure in the fact that if we are in an accident our insurance will cover us.

A large reason we feel this way is because we have a choice in which auto insurer we select.  If we do not like the coverage, we change providers.  Our employers do not tell us which auto insurer we must purchase, and yet they do when it comes to providing health insurance, and yet ninety-nine percent of the people who work for a firm drive, so the insurable population is about the same size for health and auto.

With health insurance, they best we can do when we are ill is hope our insurance will cover us, and we do so with the hidden expectation that it will not.

Health insurers need to change their model.  If a single payor changed its model to actually cover the claims made by its members it would not have to worry about being profitable because they would be beating people off with a stick.

Instead of hiring so many people to figure out how not to reimburse their members, why not change to model to one by which they actually provided their members with what those members need?

 

EHR productivity losses are rampant

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I remain stupified with how Meaningful Use continues to play itself out among hospitals.

What has me all a-twitter today is that there are no productivity thresholds tied to qualifying for incentive payments.  Many hospitals, even after two years of running EHR, report productivity losses of twenty percent or more.

Yet these hospitals can qualify for meeting Meaningful Use.  That sounds too much like ‘we do not know where we are going, but we are making really good time’.

Is there a pony hidden in there somewhere?  Where else can you spend a few hundred million dollars implementing a system, have your productivity fall off the charts, and be awarded a seal of approval and cash for how well the implementation went?

How far must one’s productivity drop before someone speaks up and says what the emperor does not want to hear?  Namely, you were probably better off before you implemented EHR.