This link is to my latest post for healthsystemCIO.com. http://healthsystemcio.com/2010/06/10/how-the-c-suite-sees-the-cio/
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles: 
Contact me: 
paulroemer 
paulroemer 
paulroemer
Few things are perfect, and when you find something that is, it is worth examining. One thing that is perfect is baseball, at least some aspects of it.
Think with me for a minute. 1845. How much has changed since then? Just about everything. Do you know what has not changed—the distance between the bases—90 feet? This distance may seem insignificant or inconsequential.
In the last 165 years the distance between the bases remained unchanged. Equipment changed, improved. The players got bigger, faster, and stronger. It never dropped to eighty-nine feet; it never jumped to ninety-one feet.
To those who follow baseball, have you noticed how close many of the plays are at first base, or the closeness of the steals of second base? Can you imagine what would happen to the game of baseball if the distance was shortened to eighty-nine feet? Almost everyone stealing second base would be safe. If the distance was ninety-one feet they would all be out.
Somehow, 165 years ago those people got it right, got it absolutely right. Something as simple as a measurement along a dirt path has stood the test of time. There are not even any discussions about trying to improve it.
Remember the Titanic? If one measured all the time spent in its design, and all of the time it sailed before it sank, if you were a betting person you would have bet on the boat. Reasonable people would have bet on the boat. You would have been a fool to have bet it would have sunk.
You know what; the Titanic’s sinking was not a fluke. The laws of physics and ship design did not suddenly cease to work. Do not blame the iceberg. The Titanic was designed to sink—otherwise it would not have sunk.
What is often misjudged in business is the ill-informed notion that just because something has not collapsed it is not broken. Hospitals are starting to collapse. The business model of most of them almost ensures that left unchanged, many, many more will collapse. They have been designed to collapse. Just because they have yet to collapse does not mean they won’t, all it means is that they have not—yet.
Few things are perfect. What discussions there are about the business model are not about improving the model, they are about cutting costs. What do you have when there are no more costs to cut? You have a less costly dysfunctional model.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
You’ve probably figured out that I am never going to be asked to substitute host any of the home improvement shows. I wasn’t blessed with a mechanical mind, and I have the attention span bordering on the half-life of a gnat.
I’ve noticed that projects involving me and the house have a way of taking on a life of their own. It’s not the big projects that get me in over my head—that’s why God invented phones, so we can outsource—it’s the little ones, those fifteen minute jobs meant to be accomplished during half-time, between pizza slices.
Case in point—trim touch ups. Can, brush, paint can opener tool (screwdriver). Head to the basement where all the leftover paint is stored. You know exactly where I mean, yours is probably in the same place. Directions: grab the can with the dry white paint stuck to the side, open it, give a quick stir with the screwdriver, apply paint, and affix the lid using the other end of the screwdriver. Back in the chair before the microwave beeps.
That’s how it should have worked. It doesn’t, does it? For some reason, you get extra motivated, figure you’ll go for the bonus points, and take a quick spin around the house, dabbing the trim paint on any damaged surface—window and doorframes, baseboards, stair spindles, and other white “things”. Those of us who are innovators even go so far as to paint over finger prints, crayon marks, and things which otherwise simply needed a wipe down with 409.
This is when it happens, just as you reach for that slice of pizza. “What are all of those white spots all over the house?” She asks—you determine who your she is, or, I can let you borrow mine. You explain that it looks like that simply because the paint is still wet—good response. To which she tells you the paint is dry—a better response.
“Why is the other paint shiny, and the spots are flat?”
You pause. I pause, like when I’m trying to come up with a good bluff in Trivial Pursuit. She knows the look. She sees my bluff and raises the ante. Thirty minutes later the game I’m watching is a distant memory. I’ve returned from the paint store. I am moving furniture, placing drop cloths, raising ladders, filling paint trays, all under the supervision of my personal chimera. My fifteen-minute exercise has resulted in a multi-weekend amercement.
This is what usually happens when the plan isn’t tested or isn’t validated. My plan was to be done by the end of halftime. Poor planning often results in a lot of rework. There’s a saying something along the lines of it takes twice as long to do something over as it does to do it right the first time—the DIRT-FIT rule. And costs twice as much. Can you really afford either of those outcomes? Can you really afford to scrimp on the planning part of EHR? The exercise of obtaining EHR champions and believers is difficult. If you don’t come out of the gate correctly, it will be impossible.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
If you like adventure, here’s a site to check, http://www.jfk50mile.org/. This is an annual event whose origin came about during the cold war. Fortunately for both of us, the entry date has already passed. The thought behind the JFK fifty-mile hike/run was that because of the possibility of a nuclear attack, each American should be in good enough shape to cover fifty miles in a day.
I participated in the event twice—I wrote participated because to state that I ran the entire way would be misleading— and I can state with certainty that almost no Americans are close to being able to complete this. The event is run in the fall starting in Boonsboro, Maryland. It takes place along the Appalachian Trail and the C&O Canal and various other cold, rain soaked, and ice and leaf covered treacherous terrains.
We ran it in our late teens or early twenties, the time in your life when you are indestructible and too dumb to know any better. One of my most vivid memories of the event was that on the dozen or so miles along the mountain trail, leaves covered the ground. By default that meant they also covered the rocks along the trail, thus hiding them. That we were running at elevation—isn’t everyone since you can’t not run at at least some elevation, (that may be the worst sentence every written) but you know what I mean—meant the prior night’s rain resulted in the leaf covered rocks being sheathed in black ice. That provided a nice diversion, making us look like cows on roller skates—roller blades had yet to catch on outside of California.
There were several places along the trail where the trail seemed to fork—I’m not going to say and I took it—and it wasn’t clearly marked. Runners could easily take the wrong fork (or should that be Tine?). I think it would have been helpful had the race organizers installed signs like, “If you are here, you are lost.” Hold on to that thought, as we may need it later.
Some number of hours after we began we reached the C&O Canal, twenty-six miles of flat terrain along the foot path. It’s difficult to know how well I was doing in the fifty-mile race, in part because I had never run this distance and because there we no obvious mile markers, at least so I thought. Then we noticed that about every five and a half to six minutes we would pass a numbered white marbled marker that was embedded along the towpath. Mile stones. At the pace we were running, we anticipated we would finish high in the rankings. As fast as we were running, we were constantly being passed, something that made no sense. That meant that a number of people were running five minute miles, which we knew they couldn’t do after running through the mountains, or…Or what?
The only thing we knew with any certainty at the end of the day was that the markers with which we used to determine our pace and measure how far we’d run were not mile markers. We never figured out why they were there or how far apart they were, but we greatly underestimated their distance and hence our progress.
It doesn’t really matter whether you call them mile stones or milestones. What matters is whether they serve a valid purpose. If they don’t, milestones become millstones. Milestones are only useful if they are valid, and if they are met. Otherwise, they are should’ a, could’ a, would’ as—failure markers, cairns of missed goals and deliverables.
How are your milestones? Are they valid? What makes them valid? Are they yours, or the vendors? All things to think about as you move forward.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
Today it feels like I got a little too befuddled, steered into the skid, and took a left into the dementia cul-de-sac. I like to dig a little esoteric hole right up front to test myself—hopefully I won’t overshoot.
One billion, two hundred and twenty million. That’s the number of hits on Google for ‘hotel’. A fairly competitive business one could easily surmise. A business in which one would benefit by trying to attract and retain customers, especially loyal customers. Their tagline is, ‘It happens at the Hilton’. You know what they say, ‘It happens’–it certainly does, ‘It’ happened to me. I’m standing at the Hilton Honors desk, checking in to the hotel. I’m in Memphis. Tennessee is one of the friendliest places I’ve ever been. The people are genuine. We go through the niceties of how my flight was, and what I’m doing in Memphis. Yada, yada. I then provide the clerk with my Hilton Honors number.
“I’m afraid you don’t exist, Mr. Roemer.”
I have the right to remain silent; I just don’t have the ability. I can feel it coming. I’m about to have a Roemer-minute. You know the feeling, when the words are going to jump pass the lips before you have the chance to go into lock down mode. I’m a bit of a stickler for English, so I press him to do better with his statement. “Here I am”—I am Sam, Sam I am, I wanted to add, but I didn’t know how up to speed his was with his Green Eggs and Ham reading. “How can I not exist?”
“In the system. You’ve expired—I checked my pulse to make sure I hadn’t—you’ve been deleted.”
“My reservation?”
“No, you. You are no longer an Honors Club member.”
Now I had it. I hadn’t expired, they expired me. Somebody had to think up that little gem of an idea, and somebody else had to approve it. They could have just pretended I was still in their little club and not said anything and everything would have been fine. Bambi 101. Thumper’s mother; ‘If you can’t say something nice, don’t say anything at all.” A clear violation of the rule. As competitive as the hospitality industry seems to be, how smart does one need to be to know that it is not a good idea to expire customers?
I was in the middle of my run today, four miles away from the parking lot. Next to the dirt trail was a bright orange Igloo water cooler with a hand-written note stating it was provided by a local running store.
What have you done for your patients recently? What makes you stand out?
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
Just to make sure we are all turned to the same page in our Cliff Notes on Meaningful Use, today’s conversation is, “There is no “R” in ROI.”
Are you familiar with the Abilene paradox? It is a paradox in which a group of people collectively decide on a course of action that is counter to the preferences of any of the individuals in the group. It involves a common breakdown of group communication in which each member mistakenly believes that their own preferences are counter to the group’s and, therefore, does not raise objections.
I think it occurs more often than we think. Try to recall the last meeting you attended in which you really disagreed with something that was said. Chances are you knew some of the others in the meeting well enough to know they also disagreed. The reason you know they also disagreed is because you had discussed the topic. However, none of you raised your disagreement during the meeting. Why? Because you did not want to rock the boat.
It is similar to a pseudoconsensus. Pluralistic ignorance. These create a bystander effect—people are more likely to speak out about an issue when they are alone with someone than when others are present.
After further consideration I think we must consider the very real possibility that there is no ROI for Meaningful Use. I write this in all sincerity. Healthcare executives march in lock-step or group think to achieve the myth of finding an ROI for Meaningful Use. The ROI is healthcare’s quest for the Holy Grail, albeit without the Monty Python sound track. They cannot proceed without one, so they set the target, figure out what data will demonstrate that they have hit it, and disregard the reams of data that does not support the ROI.
What if the government came out with a standard stating all hospitals ought to buy, install, and use a fifty million dollar transplant device that also flosses the patient’s teeth? This initiative is “optional”, but the government will pay the hospital a two hundred thousand dollar rebate. There are several types of transplant flossers—the ones that deliver that fresh mint taste cost extra.
If we were having a business discussion about the ROI for the transplant device, healthcare executives would be foaming at the mouth about how impossible it would be to calculate an ROI, and rightly so. They would argue all hospitals are different, they have different cost structures, the devices are all different.
The standards for Meaningful Use are arbitrary. The standards were developed by people who do not need to meet an ROI. There was no mandate in the development of those standards to create standards which when met would yield an ROI. Any attempt to force an ROI will naturally differ in a number of ways:
Somebody somewhere may hit a positive ROI on Meaningful Use, just like somebody playing darts may hit a bull’s eye. Any positive ROI will be accomplished more out of chance, and from having fit the data to a predetermined ROI rather than measuring the ROI against its true impact.
Implementing an EHR can be very good for a hospital. However, it should be a business decision for the hospital based on the same set of business rules the hospital would use to justify any other large expenditure. If the hospital achieves an ROI it will not be because of having followed an arbitrary set of standards. Any ROI for an EHR will come from having done it correctly. Hitting the figure any other way means two things; it was a coincidence, or you are in for trouble down the road.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
In Greek mythology, there was a not so nice man, Procrustes. He had an iron bed in which he invited wayfaring strangers to spend the night. Some of the strangers were too long for the bed and others were too short.
Apparently Procrustes liked things orderly and could be a tad anal when learning his guests did not fit. He would set on them with his smith’s hammer, to stretch the shorter ones to fit. If the guest proved too tall, Procrustes would amputate the excess length. Truth be told, nobody ever fit the bed exactly because Procrustes had two beds.
In contemporary terms, a Procrustean Bed is an arbitrary standard to which compliance is forced. A Procrustean Solution involves fitting a business problem to a preconceived set of strictures.
Raise your hand if you have already figured out where this is headed. Preconceived. Arbitrary. Compliance. Strictures.
Do you spell Meaningful Use with an upper case Procrustean or one in lower case? I prefer the upper case. The business problem being fitted is the implementation of EHR. The preconceived sets of strictures are the Meaningful Use standards.
This in turn leaves the healthcare provider in what is best described as a Morton’s Fork scenario. Shall I explain? A Morton’s Fork is a choice between two equally unattractive alternatives—a dilemma. The concept originated in 1487 under the rule of Henry the VII as a result of tax policy to ensure everyone paid taxes. The argument was because the rich had enough money to buy things they must have enough money to pay taxes, and the poor who had bought nothing had saved their money, and thus had money with which to pay taxes. The two prongs of the fork—back then forks only had two prongs. Q. E. D.
The healthcare provider must choose between—as one may not choose among—two alternatives. Attempt to meet Meaningful Use—a Procrustean Solution—turn their business model inside out to meet the government’s Gossamer standards.
Attempting to meet the standards does not ensure they will in fact meet the standards. Should they only meet ninety-nine percent of the standards, they lose. The Pareto principle does not apply. There is no 80:20 rule. They will not receive any incentive money as Meaningful Use is an all or nothing game.
The second alternative is to not meet Meaningful Use. This choice may be voluntary, or involuntary—trying to meet Meaningful Use and failing. Alternative Two—it is said—will result in reimbursement penalties from Medicaid and Medicare.
I do not think those penalties will be implemented, or at least they will not be implemented in the documented timeframe.
I also do not think there is a Morton’s Fork, because I think Meaningful Use will disappear because it is so arbitrary and capricious—and because the number of large providers who will meet it could all drive to lunch at Morton’s in a Yugo, at which time they could dine with a fork from Morton’s.
We have now come full circle. My work here is through.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
Have I mentioned I am an unapologetically type A person, for the most part an off the chart Meyers Briggs INTJ? This morning I awoke feeling no more querulous than usual—that would change rather abruptly. In general, I make it a rule never to learn anything before having my first cup of coffee. Unfortunately, today wasn’t going to be one of those days. In fact, my mood was a direct result of the instrument pictured above.
These days I am using that to make my coffee as my normal espresso maker’s LED screen is displaying a message telling me my grinder is blocked—sounds a little like something two tablespoons of Pepto should be able to fix, doesn’t it? Google was not help—three hits, each instructing me to send it back to the dealer for a $350 repair. Sounds more like a response you’d get regarding a car, not a coffee maker.
I brought this pot home from my work in Madrid. It works using the same principles as a pressure cooker. Water is placed in the bottom; an espresso grind goes above the water.Steam is forced through the grind, past a metal sieve, and into the container where as it cools it is reconstituted as a liquid—coffee. Anyway, as my coffee is cooking, I notice the metal sieve sitting on the counter. It seemed like too much work to turn it off, rinse the pot, regrind the coffee, and wait the additional five minutes. I was too tired for a do-over.
Too bad for me. Now, I’m not sure if what happened next would be found under the topic of fluid mechanics, converting steam into thermal energy, or general explosives, but it would have made for an entertaining physics experiment. In what appeared to play out in slow motion like the Challenger explosion actually occurred in a fraction of a second. It seems that metal sieve does more than strain the grinds from the steam. It also prevents a thermonuclear reaction. Apparently when the pressure passes the fail-safe point, the reaction proceeds to the next logical step. That step, which I observed, involves coffee and grinds exiting the pot so rapidly that before I could blink they covered the walls, counters, and floors as far away as ten feet. (It was actually pretty impressive to watch.) I’ve been informed that once I finish writing I will be attending to the mess.
The scene reminded me of one of the forensic shows on cable. I halfway expected the medical examiner Henry Lee to walk through my door to examine the splatter pattern.
The choice I faced was to do it over, or deal with the consequences. I was in a hurry, consequences be damned—it turns out that it wasn’t the consequences that would be damned. My guess is that I’m looking at at least thirty minutes of cleanup work.
It pays to invest the time to do something right the first time. Sort of like dealing with patients. Let’s say a certain patient call takes nine minutes to handle correctly. As many of you have observed, there are two ways to go about this. You can do it over a period of several four minute calls because your people don’t want to get dinged for exceeding their handle time allotment, or you can allow the people to talk until the patient’s need is solved.
As patients, we know you prefer the first approach. The mere fact that patients have to listen to a recording telling us how important our call is makes us leery. I think everyone who is monitoring calls and call metrics needs to come over to my house for a cup of coffee and let the people do their jobs.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
I think there is plenty of merit to quit chasing Meaningful Use and get on with your business.
http://healthsystemcio.com/2010/05/28/ten-catechisms-of-meaningful-use/
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
Below is my proposal/synopsis for a management book I am writing on leadership. I look forward to any thoughts and ideas you’d be willing to share.
There Are No Pink Unicorns
If you are thinking, “Not another book on how to manage,” take a deep breath because that is exactly what this is, not another book on how to manage. It is a book on how to fail, something with which we are much more familiar.
Those management books are written by smart people, funny people, kids who climb on rocks…They are written by people with PhDs from places like Harvard and MIT, and for the most part are only understood by people with PhDs from Harvard and MIT.
Most management books are written with one objective—telling managers how to succeed, telling them how to lead. They are self-help books, most written by people who have never run anything more than a lemonade stand. Most of these books blur the line between Cosmo and The Economist, and what they —companies run by great leaders—are as rare as Pink Unicorns.
It is difficult to describe something to someone neither of you have seen. What were you doing the last time you saw a unicorn? How about a pink unicorn? When is the last time you met Genghis Kahn to swap leadership secrets, or spent time with your kindergarten teacher prepping for a board meeting?
The popular management books address leadership traits as “secrets.” That may part of the reason there are so many failed, failing, and underperforming businesses. Referring to leadership as a collection of secrets imbues leadership with a certain unimpeachable mystique, something available to a select few, and something akin to the search for the Holy Grail or Noah’s Ark. If great leadership or even good leadership is so difficult to witness and to attain, there is almost an implicit excuse for leader who require leadership help to fail.
That got me thinking; would there not be more benefit describing something familiar to everyone, something other than Pink Unicorns? Employees do not sit around the break room saying things like, “I sure hope Mr. Pufferdink figures out the secrets to why this place is so screwed up.” Instead they say, “This place is screwed up.” “Pufferdink is killing us.” “Our customers hate us.” They say these things to anyone who will listen—their spouse, the dog, the person sitting next to them on the flight to hell. They tell those people because if they told the people at work, one of two things will happen; nobody will listen and nothing will change, or they will be fired.
At one time or another we have each attended the identical happy hour meeting. It is the meeting where you and your colleagues, after several shaken dirty Grey Goose martinis, start to re-engineer your company. The remnants of the tortilla chips and salsa are pushed to the far corner of the bar table along with the salt and pepper shakers. You scoop the crumbs to the floor, remove your Mont Blanc pen from the inner pocket of your jacket, unscrew the cap, and begin to write on the damp bar napkins which held your drinks.
You realize quickly that your scribbles are melting on the wet napkins much like the wicked witch from the Wizard of Oz. You wipe the vodka rings from the table, grab a fistful of dry napkins from a passing waiter, and wistfully order another round of drinks for the new management team. Stay with me on this because I think this point is key—within two rounds of drinks you have probably outlined an accurate list of several of your firm’s major problems, have begun to outline ideas about how to fix them, and have defined barriers to the successful implementation of those solutions.
How to lead and manage are not secrets, nor should they be treated as such. The required skills do not require special conjuring by the three witches in Macbeth. They require observation, an ability to ask basic questions, a willingness to listen, and the courage to understand that you do not have all the answers.
There are no Pink Unicorns defines the questions, the pain points, and how to break the cycle of Pink Unicorns. It does so using language, ideas, and pictures that do not require a PhD to understand them.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com
My profiles:
Contact me: paulroemer paulroemer paulroemer
Pale Rhino Consulting 