Informatics, Is There Really an Impact?

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I posted the following to a post on the HIMSS Blog titled, Informatics, Is There Really an Impact?.  http://blog.himss.org/2010/09/16/informatics-%E2%80%93-is-there-really-an%C2%A0impact/#comment-434 What do you think?

I think there is an impact, but for all but a few the impact of informatics is not positive. It is however, exactly the one for which they planned—albeit not deliberately. I think the evidence supports the reasons for the abject pickle in which providers find themselves comes from the fact that most failures can be traced back to the very beginning of a provider’s efforts to implement EHR.

To compound matters, as these same providers look to implement Accountable Care Organizations (ACOs) to their existing business models, they will find themselves pickling their entire informatics effort.

A hospital CEO recently confided to me that his peers could not be less qualified when it comes to the skills needed to select an EHR system. He stated EHR decisions are being made based on what others have done, on conversations had at a trade show, or on a pitch from a vendor.

Now, before we start slamming the vendors and their products—as I can be fond of doing—I do not think most EHR failures have as much to do with the vendors as they have to do with the providers. Very little documented rigor exists when it comes to selecting an EHR vendor. In fact, I would wager many large providers issued a more detailed request for proposal (RFP) to select their cafeteria vendor than they did for the EHR.

I am a firm believer that if you cannot find something on Google, the reason you cannot find it is that it does not exist. Googling EHR RFP does not offer anything useful. Is that perhaps because there are not many providers who have developed a meaty EHR RFP?

There are a number of providers who are on version 2.0 for the EHR. They are doing so under the mistaken belief that the problems they encountered with version 1.0 had to do with the software. Looking at the large provider EHR landscape, there are providers who are switching from vendor A to vendor B. Now, if that was the only thing going on, one might find cause to blame vendor A. Unfortunately, other providers, some in the same town are switching from vendor B to vendor A which sort of leads one to suspect that perhaps the software is not the problem.

An argument can be made that if a provider selects its EHR from among the leading 5-7 vendors, they should have about an equal chance of having a successful implementation. At some providers, vendor A is working reasonably well. At other providers, vendor B is working reasonably well.

Of course, as the evidence supports, providers have about an equal chance of having an unsuccessful EHR implementation. Some providers are trying to make the argument that after implementing EHR—and spending an excess of one hundred million dollars—having a productivity loss of around twenty percent does not mean their EHR implementation failed.

I think one can state categorically that if your productivity drops twenty percent, your implementation failed. I think that if your EHR plan at the outset predicted a twenty percent productivity drop, your EHR project would never have been approved.

So, why the mess? If a provider ran a disaster recovery project on what went wrong, the most likely answers would come down to many of the items you listed in your post; a lack of requirements, poor planning, and a morbid lack of time and resources directed to process alignment and change management. Why is this the case? I think it is because the target providers are trying to hit has more to do with meeting Meaningful Use than with implementing an EHR that will meet their needs.

Two years from now when providers reassess informatics in light of the failure of ACOs, it will likely come down to these same issues. There is plenty of time to get these issues right. But then again, there is always plenty of time to do it twice.

 

What are the success factors for EHR?

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Not long after graduating with an MBA from Vanderbilt, I returned to Vandy to interview job candidates.  With me, was my adult supervisor, the VP of human resources—a stunning olderwoman; about thirty-five.  At dinner, she invited me to select the wine.  Not wanting to appear the fool, and trying to control my fawning, I pretended to study carefully the wine list.  Not having a clue, I based my selection entirely on price.  I had little or no knowledge of the subject; nonetheless, I placed the order with all the cock-sureness of a third-grader reciting the alphabet.

A few moments later Wine-man returned with a bottle, angled it towards me, and stood as rigid as a lawn statue.  After a few seconds my adult paused and motioned my attention towards Wine-man.  I remained nonplussed.  “You are supposed to tell him that the bottle he is holding is the one you ordered.”

“He knows it is what I ordered, that is why he brought it.”  I thought they were toying with me.

A few seconds later there was a slight popping sound and then Wine-man placed the cork before me on my napkin in a manner similar to how Faberge must have delivered his fabled egg to Tsar Alexander III for his wife Empress Fedorovna.  They were both staring at me, not the Tsar and the Empress—Wine-man and my adult.  “You are supposed to smell the cork.”  And so I did.

“Now what?”

“If it smells bad, it means the wine may be bad.”

To which I replied, “This is the Opryland Hotel—have you seen the wine prices?  They don’t sell bad wine.”  She nudged me with her elbow.  I could tell I was wowing her.  I smelled the cork.  “It smells like a cork,” I whispered to Wine-man.  He smiled and poured a half inch of wine in my glass.  I thought he was still pulling my lariat.

I looked bemusedly at the mostly empty glass, held it out to him, and asked him if I could have some more—I was thirsty.  Rather than embarrass me further, with a slight nod of her head my adult instructed the Wine-man that my sommelier class was over—any further proof of my inadequacies would be of limited marginal value.  Any chance that we would have gone dancing later that evening was about as flat as the wine.  I should have ordered a beer.  I was good at beer.

For those who are still reading, if you are wondering if I am actually going to make a point, here it comes.  I’m not fond of segues, so don’t blink.

Sometimes, a little guidance is helpful—even if it has to come in the form of being led around like camel with a ring through its nose.  One of my on-line friends, a nurse who teaches nursing—seems like a good fit–asked me what are the success factors for EHR.

Often, what is important in a leader is having the knowledge and temerity to ask the right question.  In healthcare it appears that the number of executives with answers may exceed the number asking questions.  Value is often measured by scarcity.   Good questions, especially around EHR and Meaningful Use, seem to be in short supply.

Here’s my take on some of the critical success factors:

  • Adult supervision—this is not defined by the age on your driver’s license
  • Invest time to plan your EHR plan; 6-9 months for a fair sized hospital
  • Actual written requirements (an RFP) that comes from your business strategy
  • A written healthcare information technology plan
  • Invest more than half of your time and effort in work flow alignment, change management, and training.
  • Should your plan seek to meet Meaningful Use
    • By when
    • How
    • What drives your strategy—Washington or your business model

Pretty simple things.  The right things usually are—like knowing what to do with the wine cork.

 

What are the risks of HIT and EHR?

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It is refreshing to know that the voices I am hearing need not be my own.  When I try to summarize the issues for my own edification, I always circle back to the same few issues.

• No single person is both responsible and in authority regarding HIT and EHR. Provider-world pauses with each new pronouncement from Washington as though the missing EHR Dead Sea Scrolls have just been discovered floating in the reflecting pool.
• Those who implemented EHR did so without any idea that rules would be imposed after the fact.
• EHR is expected to serve two business models:

o Washington’s N x M patient/doctor connectivity effort
o A provider’s unique business objectives, none of which have anything to do with a patient in Atlanta being able to connect to a doctor in Anchorage.
• What model would providers be following if there were no Meaningful Use
• If the current EHR national rollout model was any good, providers would be racing to the front of the line to implement EHR instead of having to be offered rebates.
• The national rollout plan lacks viability for several reasons:

o No standards
o HIEs are each being developed in their own vacuum
o A horde of vendors whose mission does not tie to the national rollout or the providers’ business model and who have no incentive to adopt standards
o The requirements and dates for Meaningful Use will probably change once providers have tailored their systems to meet Stage 1
o An ROI can’t be calculated on meeting Meaningful Use
o Both the likelihood and the impact of healthcare reform on HIT and EHR, just got vaguer by some order of magnitude.

I believe firmly the right EHR and CPOE will be great for hospitals. Providers will be better served by finding answers to the question, “What’s in it for me,” rather than, “What do they want me to do?” Unless of course, providers want them running their business.

 

Why we don’t allow horses do medical procedures or EHRs

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There are three or four basic rules those of us who write should use, unfortunately I do not know them. For those of my ramblings that seem long, it’s only because I have not had the time that is required to make them shorter. This I fear is one of those. I write to find out what I am thinking; if and why you read remains uncertain. All of us learned to write in elementary school—most then moved on to greater things—I remained trapped with the notion that being able to spell words more than one way may one day be regarded as a talent.

I found it is not a bad idea to get in the habit of writing down my thoughts–it saves me from having to verbally rake others with them. Some of my thoughts require little or no thought from those who read them, for the very simple reason, they made no such equivalent demand upon me when I wrote them. My goal in writing, other than to entertain myself is to create a somewhat humorous context to facilitate thinking. As one who enjoys the written word I understand that no urge is equal to the urge to edit someone else’s thoughts, as several of you have done with mine. It sometimes feels as though the best I can hope for in formulating a series of ideas about a topic is to borrow well from experts, those people whose have already made all the mistakes that can be made in a very narrow field. The need to write and share my opinions requires constantly trying to prove my opinion to an audience who may not be friendly, which is why silence may be better–silence is often the most difficult opinion to refute. Unfortunately, trapped inside every consultant is the urge to write; sometimes that urge is best left trapped inside.

Much of the project management office consulting I do comes from having listened respectfully to very good advice, and then going away and doing the exact opposite. In general there appears to be a lack of strategy concerning EHR, making it like trying to jump a chasm in two leaps—it can’t be done. Without knowing what outcome you want to achieve, any path will take you there. This isn’t because the people in charge don’t see the solution—it is because most people have no familiarity with the scope and magnitude of the problem.

Large information technology projects like EHR are often dominated by two types of people: those who understand what they do not manage, and those who manage what they do not understand. If we are being honest, the end product of project management is making it more and more difficult for people to work effectively. It’s sort of like why we don’t allow horses do medical procedures—it would probably take way too much training. I think that many EHR projects are ineffective because those leading the charge attempt to rely upon reason for answers, thinking, “If we know one then we know two since one and one are two”.

To make the EHR efforts more effective, I humbly suggest we need to learn much more about what constitutes the “and”.

EHR technology makes it easier to do a lot of things, but some of the things it makes easier ought not to be done. The only reason to have an EHR system is to to solve specific business problems within the organization. Getting EHR to do want you want it to is ninety percent mental–the other fifty percent involves voodoo. If you don’t make mistakes during the process, you’re not working hard enough on the problem—and that’s a big mistake. Need I say more? Any complex system that works almost always comes from a simple system that works. The corollary is also true, if the current paper and manual records system didn’t deliver best practices, how can the more evolved ones be expected yield best practices?  EHR alone won’t make you better, it will just make you automated.

Success is a much more likely outcome when one builds upon success. Most EHRs have enough technology to handle anything that comes up, unless a provider forgets that the EHR is just a tool.  It took human error to create the problems we have with our health records processing.  Why then are we so quick to think that technology will fix them?

Misery not only loves company, it insists on it. That is why having a competent project management office (PMO) plays such a dominant role in the success or failure of the EHR. When the circumstances turn extraordinary, as they are in today’s economy, extraordinary measures are required. Plan, take time to deliberate, and when the time for action has arrived, stop thinking and get after it. The important thing to remember in deciding what action to take is not to search for new data points but to discover new ways to think about the ones you have. The direction of am EHR strategy may have limits, but perhaps it says more about the limits of imagination and common sense instead of the limits of what is possible. And remember this basic rule, when assessing common sense and imagination, always round up.

I’m not always disgruntled about that which I write, but I’m often far from gruntled. As graduate student I aspired to a stable job, I craved factual certainty and the respect of my peers—so I became a consultant. I soon learned that this is like wanting to be a vegetarian so you can work with animals. The only job I was fit for was consulting. This notion rested on my belief that I was not suited to work nine to five, and that consulting wasn’t quite like working. One of the nice things about consulting is that putting forth absurd ideas is not always a handicap. The good news is that consultants, when addressing things outside of their expertise are just as dumb as the next guy. I’ve always believed that being honest with my clients is the best policy—does that mean that if I chose to be dishonest I would be using second best policy? Oscar Wilde said, “If you want to tell people the truth, make them laugh, otherwise they’ll kill you.” That’s my hope with these little musings. Remember, we’re all in this alone.

The preceding was a pilfering of quotations.

 

US Healthcare–will you have to save your own life?

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I didn’t even bother to take my humor out of the jar today.  I am having one of those days with regard to healthcare when I just want to stick my head out the window and yell “I am mad as hell.”

We are fortunate in that through social networking sites like Twitter, Linkedin, and blogs, we have each met hundreds of very bright healthcare professionals.  Using the Kevin Bacon Seven Degrees of Separation test, I started believing that there was no healthcare question our mutual network could not answer.

I am afraid I may have found one of those unanswerable questions, and unfortunately, this question means a whole lot more than any bits and bytes question about healthcare IT, electronic health records, and patient experience management.

A few days ago I wrote of a friend of mine and mother of three youngsters who has Myelodysplastic syndromes (MDS).  According to what I have found online, she won’t have it next year; may not even have it in six months.

Her best shot was that one of her five siblings would be a match for the bone marrow transplant she needs.  They are not.

So here we are in a country whose healthcare system is capable of doing almost anything for anyone.  ‘Almost’ is the critical word.  Gifted physicians, billion dollar hospital systems, mammoth, global payors and pharma companies.

Where does that leave her, and where does that leave us if we have the misfortune of being in her position?  For starters, you need to learn how to raise money; a lot of it.  You need to get good at fundraising, and you need to do it quickly.  We started a web site to help the family cover the hundreds of thousands of dollars not covered by their insurance company, and believe it or not, it looks like through the generosity of many many people, we may have that part under control.

What next?  In less time than it takes to change your oil, and with no prior experience, you need to figure out how to run a successful bone marrow matching campaign.  We somehow stumbled upon the Be The Match Registry (www.marrow.org) and are learning on the fly how to put this in motion.

What has been so disappointing is learning in spite of all the healthcare resources we have in this country, the heavy lifting, at least in her case, must be done by the people least qualified to do any lifting; the family of the one fighting the battle.

Statistically, our healthcare system is capable of healing almost every disease.  This is all well and good if you are writing an article for the NEJM—that is, as long as the law of large numbers comes into play, patients can be optimistic.  Where the whole process breaks down is over a single letter, an ‘s’.

Patients to patient.  When you take it down to the level of a particular patient, someone who breathes and cries, someone with a family, the person who has no control over their illness winds up being the one who must take control.  They must do it rapidly, they must do it well, and they must do it without any prior experience.

What is even more unfortunate is her case is not unique.  There are thousands like her fighting their own battles, and these people are caught somewhere between a system unable to help them and a system unwilling to help them.

I sit here on the sidelines with such limited healthcare skills I am lucky if I put on a band-aid with the correct side facing up.  Matters of life and death should not be left to those of us without any experience in life and death.  We may actually wind up being able to help her, but if we do it will only be by God’s grace, tenacity, and dumb luck.

So, today is published a 277 page tome about certifying a healthcare IT application.  You know what—I do not care.  I may tomorrow, but tonight I just want to wallow in my ineptitude and my anger.

If you happen to know anything about MDS or bone marrow drives that may be helpful to us helping her, please let me know.

Thanks for letting me rant.

 

A few blogging tips from a wanna’ be writer

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Several of you have written asking me to share some of my ideas and tips about blogging, so here goes.

Observation leads me to believe most bloggers do not know a good sentence from a turnip.  If I find myself rewriting someone else’s sentence instead of reading their blog, I quit reading.

Another observation I have made is many people who consider themselves to be writers do not know how to tell a story.  Now, I am not talking about Mark Twain kinda’ storystelling, just the basics.

Writing is difficult—those who would have written “writing is hard”—just proved my point.  The task is difficult; the object is hard—eighth grade English class.

If you want to write well, be prepared to work.  One of my favorite sayings is “if I had more time I would have written less.”

My overriding rule to myself is not to be redundant.  If all I am doing is writing about the same topic as others, or offering the same perspective, I am just wasting air.  I go out of my way to be contrarian, and I do so for the same reason.

Just because Word or dictionary.com warns you that the word you just typed is not a word is irrelevant.  If it helps tell the story, use it.  Also, only people with small minds believe there is only one way to spell each word.

I write conversationally, and I do so purposefully.  I find it helpful to use tools—analogies and allegories to tell a story, to set a stage, or to draw in the reader.  I use other such devices, but I do not know the names of devices any more than I know participles.

There are those who would guide your writing by telling you to make an outline before you type your first word.  Bollocks.  I don’t make an outline before I speak to someone, so why would I do so when I write to someone?

Now that I think about it, the last sentence sums up how I write.  I write to one person; you, not to an audience.  I guess I write this way believing that I will never get the words right enough to please a thousand strangers, but I can probably get them close enough to please one person.

I use the same approach for public speaking—I never use notes, figuring that if I don’t already know the material well enough to speak extemporaneously—I just spelled that right; surprised the heck out of me—I ought to let someone else speak.  Some people think that is really brave however, most just think I am being lazy.

Getting ideas can be a bit of a bugger.  I find the writing comes easier than the ideas.  If you have kids, write about what you observe and then try to tie their antics into the story you are telling.

I keep a Word file titled ‘blog ideas,’ I email myself ideas and new words, and jot down things on scraps of paper.  Keep a jar of adverbs on your night-stand ‘cause you never know when you may need them.  I know the New York Times is written at the level of a ninth grader, but I give my readers credit for being more curious that the average ninth graders.

If you find yourself wanting to slam someone in your blog, slam yourself and figure out how to tie that in to the point you are making.  If you slam others, you will lose others.

There are those who would have you believe that your writing must pass the artificial tests prescribed by the politically correct mentalists.  I have never had a politically correct moment and do not intend to start any time soon.  You can get away with this by using humor, but using humor is even more difficult than knowing what a participle is—sorry for the preposition.

If any of this is helpful, feel free to steal it.  If not, thank you for reading.

 

Modern Healthcare: Not enough time for PCAST goals?

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Below are the comments I submitted to their recent article–http://www.modernhealthcare.com/article/20101222/BLOGS02/312229999&newCommentId=4948192#comments

It is difficult being the lone duck screaming “the sky is falling,” but, I feel someone has to be the schismatist before we all wind up drowning in the Kool-Aid.

It is not that I do not think ideas like a universal exchange language are not important; I think the fact this discussion even exists is because we have kidded ourselves for so long about how well EHR and interoperability are working that we have hung ourselves on our own petard.

Have we put the cart so far ahead of the horse that we have caught the horse from behind?  The discussion seems to be about walking before most have learned to crawl.  Lest we forget the issues, here are some observations we must keep at the forefront—what most hospital executives and CIOs face daily.

  • EHRs are not standard
  • Many EHR implementations have failed
  • More will fail Meaningful Use
  • Some hospitals are on EHR 2.0, switching from Vendor A to Vendor B, while others are switching from Vendor B to Vendor A—what does that tell us?
  • The current hospital business model is dysfunctional; as compared to other industries, hospitals are run more like a 0.2 model than a 2.0 model
  • EHRs were built to support a dysfunctional model, and those EHRs are built using outdated architectures
  • An ACO business model is not compatible with the present crop of EHRs—EHRs were not built with ACOs in mind—they are mutually exclusive concepts, at least with regard to today’s EHRs
  • For and ACO to be of value, to be effective to an organization, they must be joined to a different business model

Before we worry ourselves with future issues like compatibility with the EU and a universal exchange language, ought we not come up with a plan to make EHR viable one hospital at a time?

 

Hospital CIOs: Something to think about

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My new post in healthsystemCIO.com CIOs Must Paint a Real EMR/ACO Picture…http://ow.ly/3w7Al

Patient Experience Management-there are some easy answers

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There’s a reason penguins don’t play the viola—maybe that’s why they don’t have a home page. I used to try to approach things with an open mind, but people kept trying to put things like that in it. Did you ever notice that it’s difficult to encourage people to think outside the box especially if you haven’t seen evidence that the people inside the box are thinking? I’m sure there are those who think these ideas are mere snake oil, but who among you has ever seen a rusty snake?

There is often an inverse relation between the relevance of a document and its brevity. Roemer’s Law 17: the value of a patient user manual used in your call centers is approximately equal to the square root of the number of chapters. (That bit of insight is the equivalent of 4.6 raiments, where one raiment has been universally established as the amount of consulting insight needed to awe a frog for one hour.)

How many different patient user manuals are there in your patient call center? How many pages do those manuals occupy? I think user manuals are so long because call center managers believe busy people are effective people. People who aren’t busy all the time might start to think, and what good has ever come from that?

The United States Constitution is about 9,000 words—that’s about thirty pages. What is it about the interactions between patients and call center reps that requires more verbiage than the amount needed to keep 350,000,000 people living in prosperity and at peace with one another for more than 220 years?

For some people, work takes place in the fast lane. For me, it often takes place in oncoming traffic. To conclude, let’s agree to quit viewing things from the dark side of the sun. Sometimes instead of complaining about the darkness, it’s better to ignite a flame. The next time you are at your desk, open the user manuals, take out all the pages, and replace them with this one rule:

DO WHATEVER IT TAKES TO SOLVE THE PATIENT’S PROBLEM.

I guarantee that will improve performance. Some executives argue that the chances of something so patently absurd actually being true are a million to one. But consultants have calculated that million-to-one chances crop up nine times out of ten. It’s also fair to state that all mushrooms are edible, however it’s equally fair to state that some mushrooms aren’t edible more than once.

To those who want to prove me wrong, go ahead. Destroy the fabric of the universe, then call me.

 

New thoughts on EHR and ARRA money

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So, there I was, laying out my plans for 2011.  I had started training to become the first person to cross the English Channel on horseback, but I was having difficulty finding a company to sponsor me.  Given my reputation as a water-walker, several firms indicated they would sponsor me to walk it, but I have never been one to do things the easy way.

Scratch the horse idea.

Then it hit me.  I’ve decided to retrace the footsteps of the Norwegian explorer Thor Heyerdahl in his quest to travel from Peru to Pacific Polynesia on a raft made from natural materials.  His book Kon-Tiki narrates his 101 day journey.

But since balsa wood is scarce, I will need some other readily available material I can lash together to build my vessel.  (Have you figured out where this is headed?)

With so many broken EHRs littering the dustbins, I figured why not?  I bought them for pennies on the million and had them shipped to the seaport of Callao.  I hired a few systems integrators to integrate the various platforms; McKesson and EPIC formed the major components of the hull, and several copies of AllScripts served as decking.

Launch is set for April 1 of this year.  My backup plan in case this fails is to use all of the unclaimed ARRA money, convert it into single dollar bills, and lay it on the water in front of me, bill by bill, for 4,000 miles.  I know this is a bit extravagant, but I hate to see all that money go to waste.