A thought for Thanksgiving

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May I take you on a tour of our homes—yours and mine?  Although we’ve never crossed one another’s thresholds, we’ve been there, at least if you live in America. Take the tour with me.  You enter through the front door.  On one side is the living room, on the other sits the dining room.  If you’re left-handed, as am I, the dining room is on the left and the living room is on the right.

The living room looks exactly like it did the day the movers dropped off your furniture.  It might as well be cordoned off with red velvet rope and polished brass stanchions.  It reminds me of taking the tour of Independence Hall, seeing the quill pen right where Mr. Hancock left it.  Nothing has been disturbed.

We don’t use our living room.  We vacuum and dust, just like everyone does.  We didn’t use it when I was young; I’m starting to think it might be a better spot for a hot tub.

Opposite the living room is the dining room.  One or two brass chandeliers, depending on your tastes.  Oriental rug, side board, hutch.  Ask a thief about the rest—bone china, a velvet lined box of silver dinner wear.  Candlesticks.  Hand cut lead crystal.  Linens; tablecloth and napkins.  That sort of covers it.

If your family is at all like mine, when the dining room isn’t being used for folding laundry, building 1,000 piece puzzles, or tax preparation, it is used for high holidays, proms, weddings and funerals.

We have a set of china I bought from England on eBay that is more translucent that Saran wrap.  We’ve probably used it a half dozen times.  It’s for those special occasions—like the passage of the healthcare reform bill.

Eight years ago this Thanksgiving I was sitting on the floor of the dining room, inspecting the dishes and silverware when I came upon an unopened box of off-white tapered candles that was tucked away under the starched Egyptian cotton linens.

It gave me pause.  The receipt was taped to the box—purchased five years ago.  Why?  In case we needed them.  In case there was an occasion so special as to warrant candles, better yet, candles in the dining room, with the china and lead crystal.  (Sounds a little like Colonel Mustard in the dining room with the lead pipe.)

At the rate we were going, the candles and china were so well preserved so as to survive an archeological dig in the year 3,000.  What is the correct candle lighting threshold?  What is yours?

I almost never had the chance to learn mine.  Less than two weeks after that Thanksgiving, while watching an episode of the Sopranos, I had difficulty breathing, a lot of difficulty.  Collapsing to the floor while trying to convince my wife I was fine was enough to get her to call for an ambulance.  I was having a heart attack.

Less we be distracted, these few paragraphs are about the candles, not the heart attack.  These days we burn the candles, stain the linens, and break the crystal and the china.

I used to think, wouldn’t it be neat if, or if I had the chance for a do-over I’d like to be.  How cool would it be to have been Ted Kennedy or Paul Newman?  Celebrity.  Impacting world events.  Able to pay John Edwards money for a haircut.  Why not want that?

One reason.  Each of us has the ability to choose to complain about tomorrow, an ability Messieurs Newman and Kennedy no longer have.  Too hot, too cold, too busy, too bored.  The question is, do we also have the smarts, the God-given wisdom, not to complain but just to be grateful for being.

I also had cancer twenty years ago.  I have vivid memories of wishing I was caught in traffic jam on I-75 in Dallas, yet I’m the same guy who often finds himself a nanosecond away from having a news helicopter filming my traffic road-rage.  My moments of clarity wax and wane as I’m sure do yours.

It’s difficult if not impossible to see your candles as you lie strapped to a gurney in the back of an ambulance.

I’ve been fortunate to have met some really special people on the Internet.  Smart people, generous people, people willing to share ideas diametrically opposed to mine.  People caught up in their lives and the lives of others.  People who in an awkward moment would think it might be great to trade their lot for that of another.  People who’d rather save their candles for a more important occasion.

No occasion will ever be any more important than the occasion of having tomorrow.  Let’s agree to light a lot of candles this year.

Warm regards, Paul

Taking Care of Patients (TCOP)–the business side

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That’s me in the back row–just kidding. There are approximately 640 muscles in the human body. Yesterday I pulled 639 of them. In anticipation of the onset of winter I’ve been ramping up my workouts, and at the moment am scarcely able to lift a pencil. I came across an article that describes the full body workout used by the University of North Carolina basketball players. It involves a ten-pound medicine ball, and 400 repetitions spread across a handful of exercises. I’m three days into it and giving a lot of thought about investigating what kind of workout the UNC math team may be using. At my son’s basketball practice last night, the parents took on the boys—they are ten. That 640th muscle, the holdout, now hurts as bad as the rest of them.

So, this morning I’m running on the treadmill, because it’s cold and the slate colored clouds look heavy with rain. While I’m running, I am watching the Military History Channel, more specifically a show on the Civil War’s Battle of Bull Run—I learned that that’s what the Yankees called it, they named the battles after the nearest river, the Rebs called it the Battle of Manassas, named after the nearest town. The historian doing the narration spoke to the wholesale slaughter that occurred on both sides. He equated the slaughter to the fact that military technology had outpaced military strategy. The armies lined up close together, elbow to elbow, and marched towards cannon fire that slaughtered them. Had they spread themselves out, the technology would have been much less effective.

Don’t blink or you’ll miss the segue. You had to know this was coming. Does your hospital have one of those designer call centers? You know the ones—wide open spaces, sky lights, sterile. Fabric swatches. The fabric of the chair matches that of the cubicle, which in turn are coordinated with the carpeting. Raised floors. Zillions of dollars of technology purring away underfoot. We have technology that can answer the call, talk to the caller, route the caller, and record the caller for that all important black hole called “purposes of quality.”

The only thing we haven’t been able to do is to find technology to solve the patient’s problems. Taking Care of Patients (TCOP), also known as Patient Experience Management (PEM).  We’ve used it to automate almost everything. If we remove all the overlaying technology, we still face the same business processes that were underfoot ten years ago. Call center technology has outpaced call center strategy. Call center technology hasn’t made call centers more effective, it’s made them more efficient. Call center strategies are geared towards efficiencies. Only when we design call center strategies around being more effective will the strategy begin to maximize the capabilities of the technologies.

 

EHR: Show me the money

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Every wonder how it is that all the billions in healthcare IT money came about?  I imagine it went something like this.

DC 1: Email those fellows over at HHS and tell them we should just make the doctors install Electronic Health Records (EHR).

DC 2: While we’re at it, how about we pay them a bonus to do it…

DC 1: …and we penalize them if they don’t.  Give them money with one hand and take it back with the other.

DC 2: How do we get EHRs to communicate?

DC 1: Make the states do figure it out.  They are looking for more money.

DC 2: I’ll email the governors and tell them we’ve got more billions to pass around.  Let them build some sort of Information Exchange.  They can set up committees and staff them with appointees.

DC 1: Then we can glue those together in some kind of national network.  Where are we going to get one of those?  Figure another ten billion for that.

DC 2: I’ll email the DOD, they are supposed to know something about building national networks.

DC 1: Just to get things kick-started, let’s email the troops and tell them we’ll sweeten the state pots a little more.  Get them to build these extension centers on a region by region basis.

All these dollars, so little value.  Most of it focused on trying to figure out how to get millions of somethings from point A to point B.

How did all those millions of emails get securely from point A to point B?  For a lot less than forty billion dollars isn’t it possible to figure out  how to get my health information to whomever needs it?  Email me, maybe we can come up with an idea for a network.

If you’re still puzzled, we can play hangman.  It has eight letters, starts with an ‘I’, and ends with ‘ternet’.

 

Job Opportunity: EHR business development

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A member of my network, Todd Eikenberry, told me about a job opportunity; it is posted below.  You can email him at  eik@eliterecruiters.com or call him at (317) 598-1400.

Immediate Opening:

Market Leading Provider of EHR/Practice Management Software

Please Contact:

Todd Eikenberry, Managing Partner

Elite Recruiters

Office    317-598-1400

Mobile  317-439-7901

eik@eliterecruiters.com

 

East Region Manager- Healthcare IT Organizations
Overview:
Manages the activities and responsibilities associated with forming strategic alliances with a variety of government agencies, including Regional Extension Centers (REC), State Designated Entities (SDE) for Healthcare Information Exchanges (HIE), and State-affiliated Healthcare Information Technology (HIT) programs.  Actively engages with key contacts in these agencies to ensure that Company is approved for HIT initiatives that align with products and services.  Works closely with Local Field Sales personnel as necessary to achieve approved status and/or drive product sales through previously approved relationships.

The person filling this position can live anywhere in the Eastern half of the U. S., but must be near a major airport.  The successful candidate must have considerable HIT sales or marketing experience.  Travel will be required approximately 50% of the time.
Responsibilities:
  • Identifies and develops relationships with key executives and contacts within RECs, SDEs and/or State HIT organizations.  Owns responsibility for formalizing and/or winning approval of relationships with these entities, including formal contracts, group purchases, recommended vendor lists, etc.  Also interacts with other local/federal agencies/contacts as required.
  • Coordinates internal resources to ensure that we respond appropriately and in a timely fashion to REC/SDE formal and informal requests, including RFPs/RFIs.  Serves as the primary point of contact between the REC/SDE and Company resources, including Field Sales, Marketing, Operations, Client Services, Finance, Legal, Accounting, etc.
  • Maximizes Company revenue by coordinating requirements to provide marketing/sales support, demonstration requirements and REC/SDE strategic partner engagement to execute REC/SDE-facilitated marketing and/or implementation programs in the field to ensure long term success of the Company-REC/SDE relationship.
  • Maintains an active understanding of relevant business, technological, and industry trends to assist in expanding market leadership and influencing future product direction.
  • Provides reports and updates to management and also ensures that whatever reporting requirements may be necessary to comply with SDE needs/contracts are met.
Qualifications:
Education:  Bachelor’s Degree highly preferred.  Equivalent experience will be considered.

Experience: 3 – 5 years of Healthcare Information Technology and Electronic Health Records sales and/or marketing experience is a minimal requirement to be considered for this position.

 

 

Patient Experience Management: How to begin

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Here is my new post on http://www.healthsystemcio.com

Patient Experience Management (PEM) is not about Patients, but it is often designed just that way.  The problem lies with the plurality, the pesky little “s” that takes the design and implementation away from an individual patient, and places the focus on patients.

Other industries grapple with the same problem, only with them the issue comes about when designing and implementing systems and processes around customers instead of a customer.

Do you recall the talking points of the recent McKinsey survey about patient experience management?  The study made drew two conclusions.  First, ninety percent of hospital executives responded that improving PEM was their first or second priority within the next three to five years.  Second, those same individuals stated they did not expect much to happen regarding PEM because they did not know who in their organization ‘owned’ the PEM business problem.

Ignoring that issue, if only for the reason that almost everyone else seems to be taking the same approach, what if a hospital wanted to move forward and deal with PEM in a meaningful way—not meaningful as in the term Meaningful Use—but in a way whereby having a PEM system actually yielded something for the hospital?

Few industries have done a stellar job with Customer Experience Management (CEM).  What can be learned from their failures?  Plenty.  The failure of CEM systems originates at the get-go. The organization does a poor job of defining its business problem, deciding it needs a system to manage its customers, as though all customers are the same.  With that as its target, it goes out and finds and implements such a system.

Here is the problem from the perspective of PEM, and in some regards for EHR.  Whatever system you choose for PEM, CEM, or for that matter EHR has been designed to address thousands of individuals as a single entity called “our patients” or “our customers.”  The system is build upon managing the experiences of a core set of patient attributes.  Chances are good that whatever PEM system you select—they really are pretty much the same—will address roughly seventy percent of the functional requirements of this entity called “our patients.”

Applications vendors build solutions and hope to find a problem which matches the system they built.  If all your individual patients fit neatly into their vision of this “our patients” entity your worries are over.  If however, patients are different, which they are, they will have many needs which lie outside of the boundary of their application.  It is these set of needs—functional requirements—upon which the success or failure of your PEM will be based.  These same needs are the ones that are unmet today.  These are the ones, the outliers, which raise the ire of your patients and the ones lowering your organizations PEM scores; assuming you track this.

One way to solve this problem, in fact, to my knowledge to only way is to start by defining rigorously the functional requirements of one patient, a super-patient, which encompasses every requirement.  With this done, you have a PEM model, based on a single patient.  Now instead of having PEM requirements which lie outside of the boundaries or core competencies of what a vendor wants to sell you, you have a turbo charged set of requirements.  The diverse PEM requirements of your individual patients are contained within the capabilities of the defined super-patient.

If you approach PEM this way you have defined for yourself a solvable problem.  You now have a problem looking for a solution instead of a vendor with a solution looking for a problem.

HIT/EHR: A little adult supervision

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Among other things, EHR requires adult supervision like parenting.  My morning was moving along swimmingly.  Kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—I guess we could call them evergreens—to make them look snow-covered.  (I just em-dashed and em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  I may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things are other things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctor’s.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.

 

To some patients, EHR is a non-issue

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LAST CHRISTMAS

It is easy to remove one’s self from what is important as we trade metaphorical tomatoes about what is wrong with EHR, what may happen regarding reform, and why the N-HIN is DOA.  Debating healthcare IT on the internet is an esoteric and antiseptic conversation, one with few if any catastrophic implications to anyone other than the person trying to sell a used, hundred million dollar EHR on eBay.

We write about the fact that it is supposed to do something to benefit the patient.  Is there a more sterile word than patient?  Whether we use patient or patients, we keep it faceless, nameless, and ubiquitous.  They do not have to be real for us to accomplish our task; in fact, I think we do our best work as long as we keep them at arm’s length.

We calculate ROIs for EHR around people who exist to us only by their patient IDs.

What if these hominoid avatars turned out to be real people?  What if indeed?

Two weeks ago I learned of a real patient; a friend, thirty-seven, mother of three.  Lots of tests.  They call itmyelodysplastic syndromes, MDS—MDS sounds more polite.  One would think that because it has its own acronym that might infer good news.  It does not.

The thing I like best about Google is knowing that if an answer exists to a query, I can find it.  I may have to vary the syntax a few times, but sooner or later I will find that for which I am looking.  The converse can be quite disquieting, especially if you happen to enter a phrase like, ‘survival rates for MDS.’  After a few tries I realized that the reason I was not getting any hits to my query had nothing to do with poor syntax.  It had everything to do with a lack of survivors.

Last Christmas—rather strange title for a blog.  In this instance the title has nothing to do with anything religious.  It is simply a line in the sand, a statement with a high degree of probability.  Unfortunately, “Last Christmas” does not have the same meaning as the phrase, ‘this past Christmas.’

She has had thirty-eight Christmases.  Apparently, MDS is able to alter simple mathematical series.  If presented with the numerical series 1, 2, 3…37, 38, 39, and if we were asked to supply the next number, we would all offer the wrong answer—40.  In her case there may be no next number; the series will likely end with 39.  MDS math.

Then there are the three children, each one of them in the same grade as my three children.  They will be learning a different version of MDS math.  All the numerical series in their lives will reset and begin again with the value of one.  First Christmas since mom died.  First birthday since mom died.  Every life event will be dated based on its relationship to an awful life-ending event.

It will be their B.C and A.D.

EHR probably has very little value when you break it down to the level of an individual patient.  Stalin said something like, “one death is a tragedy, and a thousand deaths is a statistic.”  While it is unlikely that he was discussing patient outcomes, the import is the same.

Rule One: There are some awful diseases that will kill people.

Rule Two: Doctors are not allowed to change Rule One.

I guess it goes to show us that as we debated things that we view as being crucial components of whatever lies under the catch-all phrase of healthcare, when it comes down to someone you know who you know is probably not going to get better, they do not seem very important.


Why is implementing EHR like getting kids to eat broccoli?

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Do you ever wonder if perhaps you are the only person who was never photographed with one of the Kennedys?  That got me thinking about our presidents.  NPR interviewed the person who spent eighty hours interviewing Clinton during the eight years during which he was allowed to park freely anywhere in DC.  See how this is already starting to come together?

The interviewer mentioned that Clinton described the Lewinski episode as a distraction.  I also employed several descriptors of that affairs—and yes, the pun is intentional—but I must have overlooked calling it a distraction.  People on both sides of the aisle called the episode a stupid thing.  Perhaps we should define the term ‘stupid thing’—doing long division and forgetting to carry the one is ‘a stupid thing’; mixing a red sock with a load of whites is ‘a stupid thing’.  Sometimes politics can have us all screaming infidelities.

When I share my thoughts about these things, some look at me like they are staring at an unlabeled can of food and trying to guess the contents.  Perhaps objectivity is only for the truly unimaginative.

Here comes the segue.  All of that thinking about presidents got me to thinking about Mr. Obama, reform, and EHR.  A lot of the original economic reform discussion had to do with TARP monies being tossed at the banks.  It was almost like a reverse bank holdup as the feds made the banks take money.

Which now takes us to healthcare reform and EHR.  ARRA money and states like New York providing a stimulus to the stimulus.  What is so distasteful about EHR that it makes governments offer money to get providers to implement it?  How might we illustrate this?

Let’s say I offer my children a choice of two things to eat; broccoli and chocolate cake.  What happens?  My kids make a bee-line for the cake.  The broccoli requires an incentive to get any takers.  My children are prepared to suffer untold penalties instead of eating the broccoli.  There may be some financial incentive which will entice them to eat broccoli, but it will be pricey.  Telling them it’s good for them, or that they have to eat it makes no difference to short people—they need to be bribed.

Telling healthcare providers EHR is good for them, or that they have to do it makes no difference to tall people—they want to be bribed.  What does this signify?  What is it about EHR that requires incentives and some foreign force majeure to get the discussion underway?  It’s not as though the healthcare providers don’t want to do things that will improve their business.  What is it they know that we don’t?  What other than money would make them run towards EHR rather than away from it?

You don’t suppose it has something to do with broccoli, do you?

For those who enjoy Dana Carvey, here’s a link to his song about chopping broccoli.

http://www.youtube.com/watch?v=gO57XRDDodk

 

EHR: How important is due diligence?

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What was your first car?  Mine was a 60’ something Corvair–$300.  Four doors, black vinyl bench seating that required hours of hand-stitching to hide the slash marks made by the serial killer who was the prior owner, an AM and a radio, push-button transmission located on the dash.  Maroon-ish.  Fifty miles to the quart of oil—I carried a case of oil in the trunk.  One bonus feature was the smoke screen it provided to help me elude potential terrorists.

I am far from mechanically inclined.  In high school I failed the ASVAB, Armed Services Vocational Aptitude Battery—the put the round peg in the round hole test.  Just to understand how un-complex the Corvair was, I, who hardly knows how to work the radio in a new car, rebuilt the Corvair’s alternator—must not have had many working parts.  Due the the excessive amount of rusting I could see the street from the driver’s side foot well.

However, it had one thing going for it; turning the key often made it go—at least for the first three or four months.  Serves me right.  The guy selling the car pitched it as a date-mobile, alluding to the bench front seat.  Not wanting to look stupid, I bought it.  Pretty poor due diligence.  An impulse purchase to meet what I felt was a social imperative—a lean, mean, dating machine.

The last time I made a good impulse purchase was an ice cream sandwich on a hundred degree day.  Most of my other impulse decisions could have used some good data.  The lack of good data falls on one person, me.

How good is the data you have for deciding to implement an EHR?  In selecting an EHR?  Did you perform the necessary due diligence?  How do you know?  Gathering good data is tedious, and it can lack intellectual stimulation.  I think it affects the same side of our brain as when our better half asks us to stop and ask someone for directions; we like being impulsive, and have built a career based on having made decisions on good hunches.

The difference between you buying and EHR and me buying a clunker is that when I learned I’d made a poor decision I was able to buy a different car.  You can’t do that with an EHR that has more zeros in the price tag than the Dallas Cowboys front line.  Plenty of hospitals are on EHR 2.0–they also happen to be on CIO 2.0. while CIO 1.0 is out shopping for a Corvair.

The effect of poor planning

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I’ve always considered myself to be rather athletic, although I must have been on break when they handed out the coordination genes.  Perhaps that is why I tended towards individual efforts like running.

As it was, I was fairly good at ice skating as long as I was moving forward, the straighter the better.  Turning and stopping required an abundance of room, and an absence of other skaters.

Whoever came up with the notion that if you can ice skate you can roller skate was either lying through his teeth, or I became skating’s anti-matter.  At the time of my first attempt at roller skating I was unaware that ice and roller skating skills weren’t transferable.  Have I mentioned I like having an audience?  I decided to audition my roller skating skills at a public skating rink while on a first date.

The night was proceeding swimmingly.  I learned quickly that if I stayed to the edge and leaned towards the center of the rink, centrifugal force would keep me from falling.  My confidence in my abilities began to build.  Music boomed from the overhead speakers.  Several couples held hands, the more skilled ones crossed their arms in front of them and held hands.  I locked on to my date’s wrists and eased us into the first turn.  The song switched to Barry Manilow’s “I write the songs.”  To my misfortune–an the misfortune of everyone else, I knew the words, and began to serenade my date.  When an alpha-male sings Barry Manilow in front of anyone but his own shadow, only two things can happen and they’re both bad.

We hit the second turn and I began to accelerate.  We sped past a number of couples.  I sang louder, concentrating more on the words than on the task of keeping us both upright.

For those unfamiliar with the design of roller skates I should explain what I perceive to be a fatal design flaw—one which you will note has been eliminated in roller blades.  The flaw?  On the front of each roller skate about an inch from the bottom is a round rubber device that resembles a stunted hockey puck.  It serves no known purpose other than to sucker punch novice skaters.  If you mistakenly try to build speed by pushing off with the toe of your roller skate—as you do in ice skating—you are actually hitting the emergency brake.  And because the brake is at the front of the skate, the physics is such that once your feet stop, the only direction the rest of your body can go is head over heels.

I pushed off with the front of my foot; big mistake.

I looked like I had purposefully launched us over a pommel horse.  During the first few seconds of my flight I was reluctant to let go of my date’s hands.  I thought that if we fell together that there was some small chance that I could shift the blame for the crash to her.  We separated at speed and created sort of a demolition derby for those around us; bodies piling up like logs awaiting entrance to a saw mill.  For the rest of the evening it felt like people were pointing at me as if to say, “Steer clear of him, he’s the one who took us all out.”

My one mistake caused a chain reaction of bad events and a severely hematomaed ego.  Bad things rarely happen in a vacuum.  There’s cause and effect, and the effect can be disastrous.  For those of you whose EHR program is underway who may have scrimped on the planning process—you know who you are—you may as well be the captain of the Titanic throwing refrigerant in the water.  There is no recovery from bad planning.

No matter what the shape of your EHR implementation, if you find yourself humming a few bars of “I write the songs”, only two things can happen and they’re both bad.