Healthcare 2.0, can you get there from here?

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From a business perspective, not clinical, the critical success factor for H2.0 relies on healthcare’s ability to move from being an 0.2 industry in terms of how it is run as a business.

H0.2 is the “As-is” model.  H2.0 is the “To-be” model.  To reach H2.0 healthcare must bridge that functional, work flow, change management, user acceptance, and technical GAP.  The Gap will differ by provider.  There is no singular work plan to help providers know what they need to do to build a custom plan to bridge the gap.

None of this matters until the healthcare provider willingly acknowledges that they have a long way to go to get to anything that resembles H2.0.

H0.2 – H2.0 = GAP

If you don’t mind the gap,  H2.0 is just H2O–all wet.

One other thought.  There is a lot of discussion about Healthcare 2.0.  The discussion seems to suggest 2.0 is a destination point as though one can “arrive” at Healthcare 2.0.  Viewed this way, when healthcare arrives at 2.0, everyone else will be arriving at 3.0.  Unless the model evolves along a continuum, the journey may have been for naught.

What are the voices telling you?

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My favorite thing about healthcare is having witnessed it up close and personal both as a cancer patient in the 80’s and as the survivor of a heart attack seven years ago.

I was fortunate enough to have testicular cancer before Lance Armstrong made it seem kind of stylish.  Caught early, it’s one of the most curable cancers.  As those who’ve undergone the chemo will attest, the cure is almost potent enough to kill you.

I self-diagnosed while watching a local news cast in Amarillo where I was stationed on one of my consulting engagements.  As we were having dinner, my fellow consultants voted to change the channel—I however had lost my appetite.  I went to my room, looked in Yellow Pages—see how times have changed—and called the first doctor I found.  This is one of those times when Never Wrong Roemer hated being right.

So, yada, yada, yada; my hair falls out in less time than it took to shower.  A few more rounds of chemo, the cancer’s gone and I start my see America recovery Tour, my wig and I visiting friends throughout the southeast.  If I had it to do over, I would go without the wig, but at twenty-seven the wig was my security blanket.  I don’t think it ever fooled anyone or anything—even my house plants snickered when I wore it around them.

I owned a TR-7 convertible—apparently it never lived up to its billing as the shape of things to come, more like the shape of things that never were.  My wig blew out of the convertible as I made my way through Smokey Mountain National Park.  I spent twenty minutes walking along the highway until I spotted what looked like a squirrel laying lifelessly on the shoulder—my wig.

The last stop on my tour was at a friend’s apartment in Raleigh.  Overheated from the long drive and the August sun, I decided to take a few laps in her pool.  I dove in the shallow end, swam the length of the pool, performed a near-flawless kick-turn and eased in to the Australian Crawl.  As I turned to gasp for air, I noticed I was about to lap my hair.  I also noticed a small boy, his legs dangling in the water, with a look of astonishment on his face.

My ego had reached rock bottom and had started to dig.  Realizing my wig wasn’t fooling anyone but me, I had one of those “know when to hold ‘em, know when to fold ‘em moments” and never again wore the wig after learning it was such a poor swimmer.

Do you get those moments, or get the little voice telling you that your EHR strategy isn’t fooling anyone?  It’s okay to acknowledge the voices as long as you don’t audibly reply to them during meetings—I Twitter mine.

Sometimes the voices ask why we didn’t evaluate the EHR vendors with a detailed RFP.  Other times they want to know how that correspondence course in project management is coming along.  It’s okay.  As long as you’re hearing the voices you still have a shot at recovery.  It’s only when they quit talking that you should start to worry.  Either that, or try wearing a wig.

 

Revisiting reform: Robbing Peter to pay Paul

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Why do you suppose there is so much discussion about revisiting healthcare reform, Reform 2.0?

Is it because Congress failed to acknowledge that ninety-eight percent of healthcare is local; Hyperlocal?  I think the answer is a resounding yes.  What is hyperlocal?  You know the saying, “All politics is local?”  Well, hyperlocal is local on steroids.  It’s moms and dads making choices about who will care for their family.  It’s the doctor down the street, not the doctor chosen by some system.

Individuals see healthcare reform as “What’s in it for them—them is defined as anyone other than me” and “What will it do to me?”  Reform 1.0 isn’t viewed as improving my healthcare, few see it as meCare.  That is why when viewed nationally so many are against the current version of reform.

It’s not that nobody is interested in providing healthcare to those who don’t have it.  What concerns people who do have healthcare is their belief—which may have nothing to do with reality—is that to provide healthcare to those who don’t have it requires that those who have it to give up some of their benefits.  Those with healthcare coverage see reform 1.0 as a zero sum game; for someone to be better off I have to become worse off.

What has people talking about trying to kill the bill is that nobody who currently has healthcare believes they will see any net gain benefit from the bill—they will see a net loss.  If any benefit will accrue to those who presently have healthcare, they certainly can’t articulate the benefit.

To gain support for Reform 2.0, or whatever it comes to be called, reform must incorporate first person interests, not just second or third.  Does that sound selfish?  It may be.  However, they are toying with reforming a fifth of the economy and a service of which eighty percent of the people are generally pleased.  Robbing Peter to pay Paul, and doing so at a cost of a trillion dollars to tens of millions of Peters has not garnered a groundswell of support.  No PR firm has demonstrated that they are clever enough to make this appear to be a good idea.

For reform to pass, Congress must learn to conjugate the care verb: First person—iCare, meCare Second and third person—heCare, sheCare, theyCare, youCare. That about covers all the various forms of caring.

What Congress hasn’t come to grips with is that there is no meCare in heCare, sheCare, or theyCare—hence, people don’t care to support reform.

What do you think?

How the election will impact healthcare IT and EHR

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Here are my thoughts on how the election will impact healthcare IT and EHR.  This post can also be found at healthsystem cio.com at http://healthsystemcio.com/2010/11/03/healthcare-2-0-here-we-go-again/

The real healthcare 2.0

Just when you thought it was safe to get back into the water…

It is a strange day when the smartest people in the room are the ones who did absolutely nothing.  Whether doing nothing required divination and prescience or, merely resulted from having no idea which way to tack the boat need not be determined.

So, what exactly will be the impact on your IT and business strategies after the bloodletting in Washington?  How is the whole Meaningful Use strategy going to bear fruit?  Unfortunately, the most favorable answer to a large provider may be, “We don’t know.”  If nothing else, now that Washington again has a two party system and is hosting a tea-party—Blanche Lincoln will be drinking coffee, one can be certain reform will be stalled if not derailed.

Most of the verbiage prior to yesterday focused on how much of an impact healthcare reform would have on the election, a P implies Q argument.  I think those individuals were too busy minding the P’s and Q’s when they should have been focused on their Q’s and P’s.  that is, how much impact will the election have on healthcare reform.

Twelve months were invested in the first debate on healthcare reform.  Ten more have since passed.  In grouping periods of time, I find it helpful to develop naming conventions to distinguish between two events or periods of time.  To at least pretend to be apolitical, allow me to label the healthcare reform and all the dollars invested by large providers to prepare their organizations to meet it prior to November 2, 2010, BP Reform.  All things after the royal coach turned back into a pumpkin at the stroke of midnight shall be labeled AP Reform—I will let you sort out the acronym.

Did I mention that under AP Reform the new governors will be appointing the new state insurance commissioners?  These individuals will be the ones responsible for implementing AP Reform.  These same people are responsible for determining the medical loss ratio which plays into how much insurers must spend on Medicare.

On November 2, you could not walk the hospital corridors without bumping into something unknown about the impact of BP Reform.  Today the conversation is simpler in that everything is an unknown.  What happens to the $400 billion in Medicare cuts and the states enacting legislation to forbid mandatory insurance?

How will the election affect the financial sustainability of Health Information Exchanges (HIEs)?  This alone is enough to cause one to question the viability of the National Health Information Network.

Bearing in mind that it will take many months to sort out the impact of yesterday’s election on the healthcare IT implications of AP Reform, what topics might be worthy of consideration at the next meeting of the EHR Steering Committee?  Here are a few that come to mind for me:

  • Will the healthcare legislation change?  If so, how?
  • Will certification continue to exist?
  • What will happen to Meaningful Use?  Will the requirements change?  What about the deadlines?  Will the incentives remain as they are?
  • How will it impact HIEs and the N-HIN?
  • What will AP Reform do to the development of Accountable Care Organizations?  How will ACOs need to be supported and reported?
  • How will Patient Experience Management differ?
  • How should the organization’s strategic plan be altered?
  • What should our HIT plans look like?

The one thing I think we can agree on is that having an Electronic Health Records (EHR) system will be an integral part of whatever comes about.  What it is, how it gets there, how you implement it, and what it will be able to do remains up to you.

I have been telling my clients to approach EHR and Meaningful Use as though Meaningful Use did not exist.  Given that the number of business uncertainties has just skyrocketed my counsel to large healthcare providers is to approach EHR with a narcissistic attitude.  Select and implement EHR as though Meaningful Use did not exist.  Why handcuff your EHR to constraints that will certainly change?

 

Could social media be the answer?

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The wheel’s still turning, but the hamster is dead. One Brady short of a bunch. I like the ocean one because it reminds me of a bit done by the comic Ron White. In the bit he talks about the time he met a woman who was wearing a bathing suit made of sea shells which he held to his ear to find out if he could hear the ocean. Maybe you had to be there.

All day I’ve been operating as though I was one Brady short of a bunch—I actually have cufflinks with Marcia Brady’s picture on them, but we’ll save that for another day. The day’s highlight revolved around my daughter’s doubleheader field hockey matches–third and fourth grade girls. Their opponents looked better, older. In fact, I thought I saw one or two of them drive themselves to the field. Forty-eight degrees, first game at 8 AM. Not enough time to grab breakfast and get to the game on time. I dropped my daughter at the field and headed to a nearby convenience store to buy her a donut. As I pulled into the parking lot I noticed that I needed gas, so I figured why not multi-task it. I inserted the nozzle in the tank, went into the store, purchased a donut, and proceeded to drive away.

For the metrics lovers, those who like order over chaos, those whose desk is always neat, have you discovered my Brady moment? My purpose in going to the store was to buy a donut, not gas. My mind was focused on the donut, not on the gas. Once the donut was resting safely on the passenger’s seat my mission was over, or so I thought. Something was gnawing at me as I pulled away from the pump, something that flared at me in my rearview mirror. I knew what it was a full second before my body got the message to react to it. “Hit the break,” my mind screamed. I could see what remained of the black gas pump hose as it pirouetted helplessly behind my car. I fully expected the entire gas station to be consumed by a giant fireball like the one at the conclusion of the movie Rambo. Once I was convinced that neither I nor–it turns out that neither nor does not violate the rule of using a double negative in a sentence–anyone else in the vicinity was in mortal danger, I exited my car and walked to the pump.

My first reaction, and I don’t know why, was to see if the pump was still charging my credit card. Selfish? That means that subconsciously I had already made the decision to flee, but that I didn’t want to flee if my charge card was still open. I retrieved the severed hose from the ground and inserted it in the pump, thereby closing out the sale on my credit card. I looked around. There wasn’t anyone who had witnessed my little AARP moment. Since they hadn’t, I figured why bother anyone. Kismet; my turn on the hamster wheel.

I’m convinced it’s the little things that determine whether your initiatives succeed or fail. It’s usually nothing tricky, nothing that requires two commas worth of new technology. It’s being focused and being committed to excellence in the menial tasks which comprise each patient interaction, especially those that occur outside of the office. What little things are being overlooked in your practice?  Could social media solve some of these?  In a heartbeat, and for a cost that would surprise you.

Oh, and don’t forget to hang up the hose when you’re done.

 

How’s the EHR vendor performing?

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Many organizations have a Program Management Office and a Program Steering Committee to oversee all aspects of the EHR.  Typically these include broad objectives like defining the functional and technical requirements, process redesign, change management, software selection, training, and implementation.  Chances are that neither the PMO or the steering committee has ever selected or implemented an EHR.  As such, it can be difficult to know how well the effort is proceeding.  Simply matching deliverables to milestones may be of little value if the deliverables and milestones are wrong.  The program can quickly take on the look and feel of the scene from the movie City Slickers when the guys on horseback are trying to determine where they are.  One of the riders replies, “We don’t know where we’re going, but we’re making really good time.”

One way to provide oversight is to constantly ask the PMO “why.”  Why did we miss that date?  Why are we doing it this way?  Tell me again, why did we select that vendor?  Why didn’t we evaluate more options?  As members of the steering committee you are responsible for being able to provide correct answers to those questions, just as the PMO is responsible for being able to provide them to you.  The PMO will either have substantiated answers, or he or she won’t.  If the PMO isn’t forthcoming with those answers, in effect you have your answer to a more important question, “Is the project in trouble?”  If the steering committee is a rubber stamp, everyone loses.  To be of value, the committee should serve as a board of inquiry.  Use your instincts to judge how the PMO responds.  Is the PMO forthcoming?  Does the PMO have command of the material?  Can the PMO explain the status in plain English?

So, how can you tell how the EHR effort is progressing?  Perhaps this is one way to tell.

A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick the cat up. The brother hesitated, then said, “I’m so sorry, but while you were away, the cat died.”

The man was very upset and yelled, “You know, you could have broken the news to me better than that. When I called today, you could have said the cat was on the roof and wouldn’t come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said he had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and won’t come down.”

If you ask the PMO how the project is going and he responds by saying, “The vendor’s on the roof and won’t come down,” it may be time to get a new vendor.

 

What is meant by Healthcare 0.2 and 2.0?

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Last night I was explaining to my sister-in-law my notion about healthcare 0.2 and the need to transform it to healthcare 2.0.  She had no idea what I meant.  That’s a problem—not because she’s my wife’s sister but because she an executive at one of the top children’s hospitals.

I figured that if she didn’t understand what I meant, I may have also confused others—sort of like typing with a keyboard full of marbles.

I’ve written that healthcare is a 0.2 business being forced towards 2.0—H2.0.  What exactly do I mean by Health 0.2?  It could just as easily be 0.5 or 0.7.  The idea behind the label is that there is a large gap between where the healthcare business is, H0.2, and the future of the healthcare business, H2.0.

Permit me to share how I distinguish between the business of healthcare and the healthcare business.

  • The business of healthcare—clinical, care, patients
  • The healthcare business is paper intensive and duplicative and includes support business functions like:
    • Human resources
    • IT
    • Payroll
    • Vendor relationship management (VRM)
    • Patient relationship management (PRM)
    • Registration…and so forth

Successfully bridging the 0.2 to 2.0 GAP replies equally on foresight and planning.  For the change brought about by the bridge to take hold, change needs to be an ongoing event.

To begin the assessment, healthcare leaders must undertake an honest assessment of the organization’s strengths and weaknesses.  Sounds simple.  It’s not.  Hospitals are noted for their fiefdoms, and the fiefs, run mostly by doctors, aren’t big on being told there’s a better way to do things, nor are they keen on giving away control.

To change how the business is run, to make it more effective, and thus more efficient, requires that the major business functions be retooled.  This requires Change Management, which may require a change in management.

 

 

Who was the person who put in our first EHR system?

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The first home I bought was in Denver.  Built in 1898, it lacked so many amenities that it seemed better suited as a log cabin.  There was not a single closet, perhaps because that was a time when Americans were more focused on hunting than gathering.  Compared to today’s McMansions, it was doll-house sized.

It needed work—things like electricity, water—did I mention closets?  I stripped seven coats of paint from the stairs.  Hand-built a fireplace mantle and a deck.  One day I arrived home only to find my dog had eaten through the lath and plaster wall of the space which served as my foyer/family room/ living room-cum-hallway.  I discovered the plaster and lathe hid a fabulous brick wall.

My choice was to patch the small hole, or remove the rest of the plaster.  I knew nothing of patching holes, but felt pretty confident about my demolition skills.  Within an hour I had purchased man-tools; two mauls, chisels, and a sledge hammer.  I worked through dinner and through the night.  The only scary moment came as the steel chisel I was using connected to the wiring of two sconces which were embedded in the plaster.  On cold nights I can still feel the tingling in my left shoulder.

As the first rays of dawn carved their way through the frosted beveled glass of the front door, I wondered why I never before had noticed that the glass was frosted.  I wiped two fingers along the frost.  A fine coating of white powder came off the glass leaving two parallel tracks resembling a cross-country ski trail.  I surveyed the room only to see that the air made it look like I was standing inside of a cloud.  The fine white powder was everywhere, covering my Salvation Army sofa, a semi-matching machine-loomed Oriental rug from the Far East (of Nebraska), a two-ton Sony television, and a component stereo system that had consumed most of my earnings.

Bachelor living can be entertaining.  One of my climbing buddies moved in with me.  The idea was I’d keep the rent low, and he’d help me by maintaining the house.  He didn’t help.  I made a list of duties; he didn’t help.  I left the vacuum in the middle of the floor, for two weeks and he walked around it.  I made him move out, and advertised for a female roommate—an idea I now wish I’d marketed.  A girl from church came over to see the place.  I turned my back on her to allow her to view the house with a degree of privacy.  When I returned I found her on her hands and knees cleaning the bathroom.  I was in love.  It was like having a big sister and mother.  She even asked if it was okay if since she was doing her laundry if she did mine at the same time.  Life was oh so good.

Sometimes when one approach isn’t working it’s real easy to try something else.  And sometimes the something else gives you a solution in the form of a water-walker.  Healthcare IT and EHR aren’t ever going to be one of those sometimes.  There will be no water-walkers, no easy do-overs.  There won’t be anyone walking your hallways talking about their first wildly unsuccessful EHR implementation.  Nobody gets to wear an EHR 2.0 team hat.  Those who fail will become the detritus of holiday party conversations.  Who will be the topic of future holiday parties?  I’m just guessing, but I’m betting it will be those who failed to develop a viable Healthcare IT plan, whoever selected the EHR without developing an RFP, the persons who decided Patient Experience Management (PEM) was a waste of money.  The good news is that with all of those people leaving your organization there will be more shrimp for everyone else to eat.

I’d better go.  I just noticed somebody left the vacuum in the middle of the floor so I need to get cracking before my wife advertises for a female roommate.

EHR leadership isn’t always a democracy

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Cerealizable.

That’s my new word. I coined it the last time my wife was traveling and I was in charge of breakfast and making sure nobody missed the bus. Cerealizable is what happens when you walk into the kitchen and are confronted with two hungry dogs, three hungry kids, hair that needs brushing, homework assignments that need to be reviewed, and lunches that have to be packed.

Breakfast orders are shouted at me across the room as though I’m their short-order cook; pancakes, French toast, sausage, and who knows what else. What does one do? I was quickly headed down the path of self destruction, too many tasks and not enough taskers. I needed a light at the end of the tunnel and so I created one. I cerealized the problem; simplified it–turned into something I could solve. Go to the pantry, pull out the cardboard cereal boxes, three bowls, three spoons, and the gallon of milk. Check off breakfast.

In case you’re wondering, Cocoa Puffs still turn the milk brown, just like they did thirty years ago. Lunch orders began to be shouted across the bowls of cereal. Ham and cheese, PB&J, tuna–extra mayo, no celery. Once again small beads of perspiration formed quickly on my brow. For a moment I considered calling the school and telling them that all three were sick. That would solve the lunch problem, but it would also mean that the three of them would be home all day–my own private hostage situation. What to do? My coffee remained out of reach, still untouched. That explained the pending headache. Back to lunch. Cerealize it. “Everyone is buying lunch today,” I announced above the roar.

A half hour later, the din had subsided. I made a fresh cup of coffee and collected my thoughts. What had I learned from the exercise? Three things. One, some situations require leadership. Two, three children and one grownup is not time to establish a democracy. There is no Bill of Rights. To quote Mel Brooks, “It’s good to be the king.” Three, break the problem down into bite-sized pieces, don’t try to swallow the elephant whole.

That same approach works just as well with EHR grownups; clinical grownups and IT grownups. Improving the interaction takes leadership. Large, institution-changing projects involve pulling people out of their normal routines and relationships.  Solving problems will not involve a kumbaya moment–Program management is not a democracy. To succeed, the program champion, having created a vision, will have to break it down into bite-sized pieces.

 

EHR: there’s a difference between finished and done

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The phone rang last fall. It was the school nurse asking me if I would come pick up my seven year-old son. When I inquired as to the reason she informed me he exhibited the classic symptoms of the crud; tummy-ache, non-responsive, crying. She’s the nurse, so without better information, who was I to question her diagnosis?

We got into the car and the tears started to come again. “Do you feel like you’re going to be sick?” I asked as I looked at the leather upholstery. He didn’t answer me other than to whimper. He didn’t seem sick at breakfast. I remembered that he was crying last night, but that had nothing to do with his stomach. At first I thought it was related to the thunder. Nope. He was hugging his favorite dog, a five year-old Bichon.

We had learned a few weeks prior that the Bichon is ill and won’t ever be a six year-old Bichon. The person having the most difficulty with it is my youngest. I asked him if that was why he was crying in class and he confirmed that it was. Dads know everything, at least some times.

So, here’s the deal. The school nurse had done all the right things to diagnose my son’s problem, but she stopped short of determining what was wrong. Let’s try a more relevant situation from the perspective of an EHR implementation.  The word implementation sort of suggests that when you reach the point of having implemented that there’s nothing left to do.

There’s finished and then there’s complete.  Finished doesn’t mean the task is over until the system does what it was supposed to do.  Sort of like when W landed on the aircraft carrier.  If you didn’t do a good job of defining it up front you may never know the breadth of what was intended for the EHR.  In the case of EHR, done includes change management, work flow engineering, training, and user acceptance.

The point is, if it looks like you finished the EHR implementation, double check that you have before you take a bow. Technology alone will not an EHR implementation make, it is simply a part of the overall task.