This is my new post in healthsystemcio.com, I’d like to get your thoughts.
http://healthsystemcio.com/2010/09/30/you-dont-need-an-md-to-fix-patient-experience-management/
The MU Carrot: Only Fools Rush In http://ping.fm/V67bM
Can you blame providers if they fail Meaningful Use?
I don’t wake up each day planning to be at odds with ninety-eight percent—I’m probably being overly generous assuming two percent of the people are as jaded as me—of the HIT community, maybe I just come by it naturally.
The first time I heard of RECs (regional extension centers) the first thing that came to mind was playgrounds, something akin to what the Police Athletic League might find useful. Five hundred and ninety-eight million dollars. They tried 597 and determined it wouldn’t be enough and figured 599 would be too much, but 598 million was just right. Then Goldilocks made her way over to the porridge—sorry for turning left at the fairy tale ramp.
A large part of the success or failure of reform hinges on the success or failure of EHR. Accordingly, the government made the egregious decision to manage the process of building and rolling out a national EHR down at the molecular level. They have involved themselves at the front-end, at the vendor level, and at the back-end. The more anxious they become, the more money they waste, adding another guise to get the healthcare providers to take their eyes off the ball. Five hundred ninety-eight million “we’re just here to help you” dollars.
This money could be spent to pay the top EHR vendors to create one set of standards and modify their systems to fit those standards.
Meaningful Use. Don’t get me started. How can I fault thee; let me count the ways. Those tested early for Meaningful Use will be examined less rigorously than those tested later. This is like the IRS saying that if you file your taxes in February, don’t worry about those silly little math errors. Healthcare will be the only industry whose software quality assurance check occurs after they pass the fail-safe point, the point of no return.
With good leadership providers should know EHR will pass meaningful use before implementing the system. If they fail to pass Meaningful Use, shame on them.
Informationweek Healthcare Article on Meaningful Use
This link takes you to an interesting and well-written article written by Anthony Guerra. Even if he didn’t quote me in the piece, it would still be worth reading.
http://www.informationweek.com/news/healthcare/leadership/showArticle.jhtml?articleID=227500796
Bloggers, do you need readers? then read this
After beating my head against a turnip for the past year pretending I knew something about social media, today I discovered I actually know a lot less about how the web works than I had been giving myself credit for knowing.
Let’s say your blog lived alone in the woods. The question awaiting an answer is, “If it fell over, would anyone have read it?”
My approach and I think the approach of many has been to drag people one at a time into the woods and show them the blog. Fortunately, several of you were kind enough to take the walk with me and many of you have come back time and time again. However, “The woods are lovely, dark, and deep. But I have promises to keep, and miles to go before I sleep.” Robert Frost and I both.
In the space of a year, one reader at a time, this little copse has been visited by over thirty-thousand kind souls, some of whom are still wandering around, searching for their Hansel and Gretel breadcrumbs, and trying to find their way back to places where my thoughts on healthcare and strategy are mere rumors.
Last month I started a humorous missive to try to quell the voices in my head. Getting readers to this blog, The World According to Roemer: Are Men Really Necessary, proved much more difficult. Few people wanted to walk hand in hand with me into my woods.
After six weeks of posting daily, I had almost reached one thousand reads—a readership roughly equivalent to the number of people who have read the Meaningful Use standards. I tried everything I could think of to find people with enough time on their hands to enter my self-contrived twelve-step program. I wore funny hats when I wrote, networked my network, and the more I wrote, the more the readership seemed to redline.
So, this morning I started playing around with the question, what would happen if instead of taking people one at a time to the woods I brought the woods to the people? Well that is what I tried, and in the past two hours, the total number of people who have read my new blog has increased twenty-two percent.
Here is what I learned in case you would like to try it as well. I use Word Press as my platform. No particular reason, I just do. The dashboard view has a link that allows the blogger to share their posts by creating visible links on your post to all of the social media sites. This enables the blogger to push the post to others who would not have read it, and it enables those who read it to do the same—this is what I meant by bringing the woods to the people.
Anyway, I hope this helps.
EHR: What questions remain unanswered?
“We need to talk about your TSP reports.” Office Space—Possibly the best movie ever made. Ever worked for a boss like Lumbergh? Here’s a smart bit of dialog for your Friday.
Peter Gibbons: I work in a small cubicle. I uh, I don’t like my job, and, uh, I don’t think I’m gonna go anymore.
Joanna: You’re just not gonna go?
Peter Gibbons: Yeah.
Joanna: Won’t you get fired?
Peter Gibbons: I don’t know, but I really don’t like it, and, uh, I’m not gonna go.
Joanna: So you’re gonna quit?
Peter Gibbons: Nuh-uh. Not really. Uh… I’m just gonna stop going.
Joanna: When did you decide all that?
Peter Gibbons: About an hour ago.
Joanna: Oh, really? About an hour ago… so you’re gonna get another job?
Peter Gibbons: I don’t think I’d like another job.
Joanna: Well, what are you going to do about money and bills and…
Peter Gibbons: You know, I’ve never really liked paying bills. I don’t think I’m gonna do that, either.
One more tidbit:
Peter Gibbons: Well, I generally come in at least fifteen minutes late, ah, I use the side door – that way
Lumbergh can’t see me, heh heh – and, uh, after that I just sorta space out for about an hour.
Bob Porter: Da-uh? Space out?
Peter Gibbons: Yeah, I just stare at my desk; but it looks like I’m working. I do that for probably another hour after lunch, too. I’d say in a given week I probably only do about fifteen minutes of real, actual, work.
I like to think of Peter as my alter-ego.
When I’m playing me in a parallel universe, I’m reading about a surfer dude cum freelance physicist, Garrett Lisi. Even the title of his theory, “An exceptionally simple theory of everything,” seems oxymoronic. He surfs Hawaii and does physics things—physicates—in Tahoe. (I just invented that word; it’s the verb form of doing physics, physicates.)
Ignoring that I can’t surf, and know very little physics, I like to think that Garrett and I have a lot in common. I already know Peter Gibbons and I do. So, where does this take us?
It may be apparent that I look at EHR from a different perspective than many of others involved in this debate; I’m the guy who doesn’t mind yelling ‘fire’ in a crowded theater. The guy who will never be invited to speak at the HIT convention unless they need a heretic to burn for the evening entertainment. I can live with that.
Like Garrett, I too see an exceptionally simple theory in everything, especially when it comes to improving business. It’s not rocket surgery, but then, it was never meant to be. You’ve seen the people running it, they are definitely not rocket surgeons—before someone writes, I know it should be scientists.
Sometimes I like to look at the problem from a different dementia—Word didn’t have a problem with that usage. I look at EHR and ask myself three questions:
1. Why do people really believe the existing national roll out plan will work?
2. How did the plan ever get so complex?
3. How much money will be wasted before people look for a realistic solution?
What do you think?
Is a Universal Patient Record a Solution?
Today is the anniversary of the solving of Fermat’s last theorem. As a long recovering mathematician, these types of thing interest me so I sought a copy of the proof and began reading. The mathematics for librarians description of the proof is something like this:
- The Pythagorean theorem states that for a right triangle the sum of the squares of the sides equals the square of the hypotenuse.
- Fermat stated that the theorem only holds for a coefficient of 2, squaring, and that no other coefficient will work
- This went unproven until recently
One might have thought that the solution could be solved by brute force using a computer. How many numbers are there to be dealt with? If you approach the problem this way you’ve got to do it for infinitely many numbers. So, after you’ve done it for one, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a thousand numbers, how many, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a million, well, there’s still infinitely many left. In fact, you haven’t done very many, have you? In fact, using this approach, you’ll never finish. This got me thinking about our EHR system.
I think something has been lost in the confusion about a national EHR system. After all, that’s the target right, a national system? We only unleash the power of EHR if we are able to make it work out outside of the provider’s four walls. Is it possible that perhaps the logic of how we have been viewing developing a solution for the problem is wrong? I think it is. Since the outset, the problem has been defined as how do we develop a system that will enable us to get everyone’s health records (let’s call an individual record A) to some arbitrary set of healthcare providers, call them P. There are some 350 million A’s and for simplicity let’s agree that there are 100,000 P’s. So now, the system to which everyone is working is the system that will enable all of the A’s to get to any combination of P’s.
See? Now what happens if we place a few hundred Rhios and health information exchanges (HIEs) in between the A’s and the P’s? Let’s label them G’s for gatekeepers. So, in the current framework all the A’s (everybody’s health records) have to pass through all the G’s, make it up to the national network, then back through all the G’s and then sorted through all the P’s to the correct P.
How can we know this design will work for every possibility? The only way is to test every combination of A’s, G’s and P’s. It’s a difficult problem. It becomes more difficult when we acknowledge that there are hundreds of EHR vendors supplying software to all of those P’s. Many of those P’s will have modified the software, meaning that there are probably thousands of variations of EHR systems. Oh, and did I mention that all of this is being done without any single set of standards? That means my stuff will look different from your stuff, and the G’s will have to move different stuff, and from an “IT” perspective the EHRs at the end of the food chain will have to interpret different stuff and then update your stuff with their stuff. That’s a lot of stuff.
So, if that is where things are, what can be done about it? My take on a solution is that the problem with this model lies with the word in italics, ‘everyone’. Every possible patient with every possible need getting to every possible provider. How to solve this or at least simplify the magnitude of the problem? One possible solution is to build out the EHR system and the network such that one patient’s record can go to one provider and have that record updated. Would it not make more sense to build it for a single patient, create a universal patient record (UPR) that can handle all instances? Do it right once. Prove that it works and then replicate it instead of building millions of different ones and hoping they work?
Is it time to rethink your approach?
So I’m making dinner the other night and I’m reminded of a story I heard a while back on NPR. The narrator and his wife were telling stories about their 50 year marriage, some of the funny memories they shared which helped keep them together. One of the stories the husband related was about his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf. She’d mix the ingredients in a large wooden bowl; 1 pound each of ground beef and ground pork, breadcrumbs, two eggs, some milk, salt, pepper, oregano, and a small can of tomato paste. She’d knead the mixture together, shape into loaves, and place the loaves into the one-and-a-half pound pan, discarding the leftover mixture. She would then pour a mixture of tomato paste and water, along with diced carrots and onions on top of the two loaf, and then garnish it with strips of bacon.
He went on to say that meatloaf night at home was one of his favorite dinners. His wife always prepared the dish exactly as she had learned from her mother. One day he asked her why she threw away the extra instead of cooking it all. She replied that she was simply following her mother’s recipe. The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”
Therein lays the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing. Several of you have inquired as to how to incorporate some of the EHR strategy ideas in your organization, how to get out of the trap of continuing to do something the same way it’s been done, simply because that’s the way things are done. It’s difficult to be the iconoclast, someone who attacks the cherished beliefs of the organization. It is especially difficult without a methodology and an approach. Without a decent methodology, and some experience to shake things up, we’re no better off than a kitchen table amateur (KTA). A KTA, no matter how well-intentioned, won’t be able to affect change. The end results would be no better than sacrificing three goats and a chicken.
So, we’ll talk about how to define the problem, how to find a champion, and how to put together a plan to enable you to move the focus to developing a proper strategy, one that will be flexible enough to adapt to the changing requirements. But keep the goats and the chicken handy just in case this doesn’t work.
Some good news to share
A lot of you have been generous with your time and knowledge in helping me learn a little something about healthcare.
I am pleased to share I have been invited to become a member of the Penn Medicine Cardiovascular Institute Leadership Council.
You now know which ERH you should have bought
This occurred to me while listening to a report on NPR that was comparing the Kindle to the iPad. The comparison made regarding a study conducted to assess the viability of using the devices in universities as e-Textbooks instead of paper textbooks. The Kindle was tested for a year; the iPad was tested next.
The traditional textbook prevailed over the Kindle; iPad may have reinvented the textbook. A winner and a loser for what many consider being the same device in different packages. Apple did the same thing for MP3 players and the cellular phone.
The conclusion about that Kindle was it was a bad imitation of its paper counterpart, saying it was simply a copy of what was on the paper but not as effective. To me, this sounds like the conclusion many physicians have made about their EHRs—a poor automation of a poorer set of processes. This is why user acceptance has been poor and why in many places productivity has fallen off the charts.
The study concluded some of the issues with the Kindle for both the students (think patients, and the professors (the physicians)—the analogous EHR function is noted within the parentheses has the following negatives. The Kindle:
- is less interactive than a piece of paper
- does not follow the layout of a textbook or the flow of the discussion (navigation)
- cannot easily handle full color illustrations and photographs (imaging)
- is more difficult to annotate (SOAP notes)
- takes longer to load the material, input data, and to search for information (clicks and drop downs)
- the users stopped reading Kindles as scholarly texts and began reading them as novels (how physicians read and chart)
- the students learned less and required additional time to learn the same amount (productivity)
- did not maintain pace with the discussion or activity (process)
The textbook winner, the iPad, creates multimedia functionality out of a book.
Just because you search for electronic book readers online, and up pop both the Kindle and the iPad, does not mean they are equal. You cannot expect a search engine to distinguish between them.
Here’s the punch line. Just because you Google EHRs and get a list of vendors does not make them equal. I know you know that.
I think most of EHRs are equal, equally dysfunctional. Sticking with the analogy of the Kindle and the iPad, most EHRs are Kindles. Most EHRs—in fact almost all of them; 99% of the 400—are to healthcare what Kindle is to textbooks; not much. For many, the chart is better.
If you already implemented EHR you learned your EHR, how well is it performing? I am willing to bet more than half have not met expectations, or expectations have been lowered to meet the performance. Let us look at the same scorecard we used above. If your EHR…
- is less interactive than a piece of paper
- does not follow the flow of the patient/doctor narrative
- cannot easily handle full color illustrations and photographs
- is more difficult to annotate than a paper chart (SOAP notes)
- takes longer to load the material, input data, and to search for information (clicks and drop downs)
- does not allow doctors to review notes and images the way they read charts
- requires additional time to read and document the same amount of information than paper charting (productivity)
- does not maintain pace with the patient discussion or activity (process)
…you have quite a mess on your hands. If this makes you a little weak in the knees, what does this type of performance imply about your chances of meeting Meaningful Use? Having a certified EHR will not make these problems disappear; you will simply have certified problems.
If you disagree with this assessment, please tell me why. If you agree with the assessment, what are you doing to try to fix it? I am willing to bet you a bag of licorice that it will not make things better.
Those who have read this far did not need to read this to know your EHR has not done what you needed it to do. The strange thing is very few know what to do about it.
Those who have yet to complete their EHR or have yet to begin the process will come to the same conclusion unless they find the hidden jewels that make up the one percent of EHRs that actually function better than a paper chart.
Pale Rhino Consulting 