Will the ARRA money be worth the effort?

According to the just released McKinsey study, the time has come for healthcare providers to set up a lemonade stand. Why? Because their findings indicate that the incentive money available to doctors may only offset about twenty percent of the costs of implementing EHR. You can read their analysis here:


I disagree with a few of the comments in the McKinsey paper. First, the paper begins with two comments, neither of which is accurate; “Mandated upgrades to healthcare IT…”, and “New regulations require…” Lest we forget, having an EHR is optional—choosing not to have one is probably not a smart business decision, but the decision is yours, not Washington’s. Meeting Meaningful Use is also optional. Regarding Meaningful Use, I think an argument can be made that providers are better off without it—you can read my reasoning in some of my prior posts.

So, ARRA money will only meet 20% of your EHR costs. This should not be a news flash. In fact, I think that for more than half of the providers, the ARRA money will not even cover the additional costs of meeting Meaningful Use, let alone the costs of implementing the EHR.

So, if you are seeking an ROI over the total cost of the EHR, and not simply an incentive payment to cover the cost of a gross of “EHR—Yes we can” t-shirts, what can you do?

Sometimes the simple answer is the best answer. I think the answer to this question is quite simple, and its simplicity is what makes it achievable. It is not an answer being looked at by many providers. Approach your EHR implementation as though Meaningful Use did not exist.

Too many providers set the goal of their EHR as completing the implementation. “They wanted an EHR and we gave them an EHR.” This passes neither the test of being necessary or sufficient.

What are your business goals for your EHR? I suggest two:

• Be more efficient

• Be more effective

If your EHR can help you do these two things, you will meet the other goals, goals like providing better care, reducing the number of errors, saving time, and eliminating processes that add not value. Therein lays the all too elusive ROI.

There is actually another way to get money for an EHR that functions well. Once the EHR is running, there is a huge volume of digital data throughout the organization that can be aggregated. The Blues (Cross and Shield, not Belushi and Aykroyd) offer money back to healthcare providers who are able to demonstrate that they have saved the Blues money. If providers prescribe generic medications, naturally it costs the Blues less money. The Blues will share their savings with the providers. The way a provider can capture those funds is to have an EHR that is capable of reporting the generic meds it prescribes to the payor.

It is worth a phone call to your EHR vendor to find out if your system can do that. If not, the best fall-back position could be the lemonade stand.

My latest post to healthsystemCIO.com

I think there is plenty of merit to quit chasing Meaningful Use and get on with your business.


saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

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Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

Is there a business argument for Meaningful Use?

I remember the first time I entered their home I was taken aback by the clutter. Spent and wet leaves and small branches were strewn across the floors and furniture. Black Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The windows.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.

And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

“Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives. Sort of like all the scurrying around Meaningful Use.  The normal has been subsumed by the abnormal, and in doing so has created an entire entity which is slowing devouring the resources of the organization.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid on a daily basis. When I talk with hospital executives they are marching headstrong into the Meaningful Use abyss.

It makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about it they always have an answer. It all boils down to something like, “We simply can’t turn down the money.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid.  It’s gotten to the point where no matter how goofy things get, as long as they are consistently goofy, there not goofy at all.

This is the mindset that enables leaders to be fooled by their own activity. Busy replaces thinking.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

The wildebeest postulate

The Kalahari; vast, silent, deadly. The end of the rainy season, the mid-day heat surpasses a hundred and twenty. One of the varieties of waterfowl, most notably the flame red flamingo that nested in the great salt pans in Botswana, has begun its annual migration. In the muck of one of the fresh-water pools that had almost completely evaporated, writhes a squirming black mass of underdeveloped tadpoles. A lone Baobab tree pokes skyward from the middle of the barren savanna. In its shade, standing shoulder to shoulder and facing out, a herd of wildebeest surveys the landscape for predators.  Sir David Attenborough and PBS can’t be far away.

Some things never change. I make my way across the freshly laid macadam to meet the school bus. Fifty feet in front of me is a young silver maple tree, the tips of its green leaves yielding only the slightest hint of the fall colors that are hidden deep within. The late afternoon sun casts a slender shadow across the sodded common area. One by one they come—soccer moms; big moms, little moms, moms who climb on rocks, fat moms, skinny moms, even moms with chicken pox—sorry, I couldn’t stop myself—as they will every day at this same time, seeking protection in its shade. My neighbors.  It’s only seventy-five today, yet they seek protection from the nonexistent heat, a habit born no doubt from bygone sweltering summer days. A ritual. An inability to change. In a few weeks the leaves will fall, yet they will remain in the shadow of what once was, standing shoulder to shoulder facing out, looking for the bus. A herd. Just like wildebeest.

The kids debus–I just made that word, hand me their backpacks, lunch boxes, and hundreds of forms for me to complete.  I look like a Sherpa making my way home from K-2.

I shared this perspective with the moms, and have halted most of my bleeding. I can state with some degree of certainty that they were not impressed with being compared to wildebeest. So here we go, buckle up. By now you’re thinking, “There must be a pony in here somewhere.”

Some things never change; it’s not for lack of interest, but for lack of a changer. For real change to occur someone needs to be the changer, otherwise it’s just a bunch of people standing shoulder to shoulder looking busy. How are you addressing the change that must occur for EHR to be of any value?  EHR is not about the EHR, it’s about moving from a 0.2 business model to 2.0.  Are you chasing ARRA incentive dollars simply because someone is writing a check?

Someone who sees the vision of what is is—sorry, too Clintonian—must lead.  Be change.

One of the great traits of wildebeest is that they are great followers.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

The change keeps changing

Hello to those whom I’ve yet to meet.  This is rather long, so you may wish to grab a sandwich.

I write to share a few thoughts.  I reside in the small place where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s where those who place principle over fees dare to tread.

Where to begin? How to build your provider executive team? (Those who wish to throw cabbages should move closer to their laptops so as not to be denied a decent launching point.)

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time your project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing a healthcare organization, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon, external influences—the implications of reform and Stages 2 and 3 of Meaningful Use, and a national roll out of EHR with no viable plan to get there.  Staffing only to execute today’s perceived demands will get people shot and will fail to meet the needs of hospital. To succeed we need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare implications of reform and IT.  They’ve also indicated—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform.  I somewhat disagree with that perspective.

Here’s a simplified version of the targets I think most of today’s hospital CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them.  Here’s what I think. You don’t have to accept this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since this is my piece, I used it.

Before we go there, may I share my reasoning? From a business perspective, many would say the business of healthcare must move from a 0.2 to a 2.0 business model. (This is not the same as the healthcare business—the clinical side.)  The carrot?  The ARRA incentives—an amount that for many providers will prove to be more of a rounding error than a substantive rebate.

Large healthcare providers are being asked to hit complex, undefined, and moving targets, and they are planning on adapting to reform and reforming their own business model while they implement systems which will change how everyone works.  Hospitals are making eight and nine figure purchase decisions based in part on solving business problems they have not articulated. If success is measured as being on-time, in-budget, and fully functional and accepted, for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

Their overriding business driver seems to be that the government told them to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on an EHR system than they would to build a new hospital wing.  Many don’t know what the EHR should cost, yet they have a budget. Many don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff to help ensure my success—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot.  I’d staff with a heavy emphasis on the following subject matter experts:

• Planning & Innovation
• Flexibility
• Change Management
• PR & Marketing

Contrary to popular belief, not all of these high-level people need to have great understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years for now the government would like us to believe there will be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of RHIOs, and mapped to a N-HIN.  Under the proposed model, standardization will not occur if only for the fact that there is no monetary value to those vendors whose standards are not standard.

Interoperability, cost, and the lack of standardization will force a different solution—one which is portable.  I think the solution will have to be something along the lines of a single, national, open, browser-based EHR.  It will be driven by consumers.  Consumers will purchase the next generation of super-smart portable devices that offer a combination of iPad/iPhone functionality.

The Personal Health (PRH) will have evolved to become the EMR.  How is this possible?  What do smart devices do?  They do one thing, billions of times each day, and they do it perfectly—they send and receive ones and zeros.  That is what today’s EMR are—ones and zeroes.  Those next-gen devices will be EMR-capable.  Why?  Because there are more than a hundred million customers who will keep buying these devices.

The so-called N-HIN will be the new Super Internet—not some cobbled together network of RHIOs.

Firms like Apple, Google, and Microsoft will drive this change.  We already buy everything they offer, in fact, we line up at midnight to do so.  By then, those firms will care less about selling the devices than they will about transporting the ones and zeroes that comprise the data.  Their current PHRs are their way of introducing themselves to consumers as players in healthcare.

The point I am trying to drive home is that from being able to adapt to change and reform, lean towards staffing the unknown.  Staff with leaders, innovators, and people who can turn on a dime. Build your organization like turning on a dime is your number one requirement. Don’t waste time and money worrying about Certification or Meaningful Use. If anyone asks you why, you can blame me.

If you want a real reason, I have two. First, they won’t mean a thing five years from now. Second, if I am the person writing an incentive check, I want to know one and only one thing—will your system connect with the other system for which I am also writing a check?  That is the government’s home run.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

How should a provider approach Meaningful Use?

New Headquarters?

The following is my reply to a post in HealthcareITNews from March 8.  The title of the post is, CONSUMERS WEIGH IN ON TOP 10 MEANINGFUL USE ARGUMENTS.  The link is, http://www.healthcareitnews.com/news/consumers-weigh-top-10-meaningful-use-arguments#comment-574

Of cabbages—and kings—

And why the sea is boiling hot—and whether pigs have wings. Lewis Carroll, Out of the Looking Glass. It is a nonsense story, one which cannot be argued.

As are Electronic Health Records (EHR) and Meaningful Use (MU)—at least to date. Measured against any reasonable set of standards, except on a one-off basis, the national rollouts of EHR and MU have failed. I expect it will be even more so next year.
You, the public, have the right to comment, and we have the right to tell you why your comments hold no water. I think it is the inverse of you have the right to remain silent, you just don’t have the ability. I am writing about the ONC and the bone they tossed calling for public comment. They are required to provide for public comment in order to remove the N and the P from the NPRM.

Who among us believes the rule making will markedly shift direction as a result of any of the public comments? That is unfortunate for if they were to shift direction they might find a direction. We don’t know where we are going, but we are making good time getting there. Figures suggest a failure rate of EHR implementations of somewhere between fifty and seventy percent. As healthcare IT resources become scarcer, I expect the failure rate to increase. As providers rush into EHR without a detailed strategy simply to grab the incentive money, there will be more expensive failures. More failed EHRs is not a way to measure progress.
The current cover of Government Health HIT magazine depicts a foot race to meet MU. There is no race if there are no entrants. There may be more people on the cover than will actually qualify for the race, even fewer who will reach the end.

We would be better served if the plan for national rollout of EHR were not written on an Etch-A-Sketch. We don’t know what will be included in Stages 2 and 3 of MU. When will fifty percent of providers have an EHR, not just the software, but one that actually boosts productivity? How about 70% or 80%? Ten years? I ask the same question of the Health Information Exchanges (HIEs). Without unilateral adoption there will be large gaps. Will the national network function with these gaps? To what extent? Will the records only make it part of the way from Patient A to Doctor X?

Having not solved the EHR program on their own, and having no viable plan, the government laid the burden of making EHR successful on the backs of the providers. The government tries to offset the burden by offering financial gratuities—and penalties—to the providers. Not exactly the second coming of the Three Wise Men. Trying to hit the ONC’s targets is a little like playing the confidence game, the shell game. Under which shell will providers find the rules, the plan?
What to do?

It is easy to criticize. Permit me to offer a few suggestions. To the hospitals, if you are not well along the EHR path, do not make a difficult effort more difficult by chasing Gossamer incentive dollars. Stick to your plan. You have multiple failure points which three years from now will make chasing those dollars look like a pipe dream. The failure points? Your plan, the implementation, meeting the MU requirements, passing the MU audit. It does not look very promising to me.

To those hospitals which haven’t started their EHR initiative, or are less than halfway through the passing the failure points, don’t cancel your summer vacation. You have a lot more time to get it right then you have to get it wrong. Pay no attention to the man—or woman; even I can have a moment—handing out the Monopoly money. You won’t be receiving any. From where I sit, that is good news. It will cost a lot more to perform disaster recovery on a poor implementation than the funds you would have received by meeting MU.

How long does a hospital spend planning to build a new hospital wing? For large hospitals, the cost of your EHR will likely exceed the cost of the new wing. Plan accordingly. Invest six or nine months building a plan that might succeed.

For medium and small practices and solo providers you have nothing to lose by waiting a year months other than the resource problem. By then you will find very viable ASP and shrink-wrapped solutions.

Those who follow my blog, healthcareitstrategy.com, know I don’t write to garner favorable replies from those who think they’ve already got it figured out. I write for those who because of EHR have difficulty sleeping. Thanks for reading. As always, I appreciate your comments and disagreements.  

Why DC might be wrong on Meaningful Use

I watched recently Barry Levinson’s movie Liberty Heights about a handful of people in Baltimore growing up in the fifties.  In one scene the high school practices a civil defense drill.  For those who have never seen a civil defense drill, a number slightly smaller than those who have never seen a dodo bird, permit me to explain.

From the fifties through the early eighties the fear of the US and the Soviets—if you have to look it up, it is better that you stop reading—engaging in nuclear war seemed so imminent that school children participated regularly in drills to protect them from nuclear attack, nuclear winter, nuclear annihilation.  The exercise was called duck and cover.  Stay with me now—those in charge were quite serious about this.

In duck and cover, once you saw the flash of the nuclear explosion—assuming your retinas weren’t fused—you were supposed to get under a table, most likely a wooden one that would have already turned to ash, and assume the fetal—or fecal position.  Educated adults came up with this idea as a solution, people with PhDs.

Generations of kids, millions of kids practiced this drill several times a year.  Someone puts forth a directive.  Instead of challenging it, other reasoned adults wallow in their folly.

Duck and cover.  Lemmings off cliff.

EHR and Meaningful Use.  Lemmings off cliff.

Question it before you leap.  EHR is a great opportunity.  EHR under the government’s direction—this is the same institution who developed duck and cover.  EHR and Meaningful Use—if you find it meaningful, you would probably benefit from speaking with someone who does not share your perspective.

Meaningful Use from EHR’s Meaningful Muse.

My latest piece on healthsystemCIO.com

What Would You Do Without MU?

I was wondering how CIOs would approach the implementation of EMRs if they had never heard the term Meaningful Use. The more I thought about the question, the more I felt it merited discussion. If I were a CIO, I would not let these outside regulatory influences dictate my strategic decision making. As a member of the executive team, my responsibility is two-fold; to facilitate and improve patient care, and to contribute to the business as an advisor, someone whose actions positively impact the bottom line.

Some CIOs have been forced to abdicate their responsibility and to approach EHR as order takers. Sometimes the CEO/CFO/COO creates a directive mandating EHR. That said, their guidance may end. In other, more problematic cases, it doesn’t, and they also supply the name of the EHR vendor that must be used. The worst reaction to this pressure is to not challenge the issue of whether your organization will attempt to meet Meaningful Use. The concept is much more novel than it may appear.

What if Meaningful Use didn’t exist? Many hospitals undertook EHR without any hint of the fact that MU was coming — coming with money, penalties, and constraints. Many completed the implementation only to learn that to meet MU they are not done, far from it. In fact, they have just begun modifying their implementations, and paying big time for those changes.

Those who started EHR early did so under the notion that their efforts were working in concert with an established set of business goals. This is the right way to operate. Remember, EHR is voluntary — really. By default, that makes meeting MU voluntary. There is no hidden directive that states all those who implement an EHR must meet MU. Not meeting it may subject your organization to penalties, and these should be factored into your ROI calculation.

Let’s assume you have, or are going to implement, an EHR system. For large providers, it is difficult to develop a business argument for not having EHR. Now assume that MU does not exist. We already have seen examples of how having MU impacts HIT strategy, how would not having to plan around MU impact your EHR and HIT strategy? What other projects would be at the top of your list? What initiatives could you own if you did not shuffle resources away from your preferred strategy simply to chase MU? Instead, would you be addressing patient and physician churn? Implementing managed services opportunities? Aligning workflows? Developing a social media platform?

There is nothing wrong with assessing what you would be doing to support your hospital if there were no Meaningful Use. You can and should undertake that assessment and calculate its ROI. Then, instead of having a lone MU ROI, you have something else against which to compare it.

Do you believe Meaningful Use is best for you?

The area was cordoned off with yellow crime scene tape. Crime scene investigators searched the trampled grass, careful so as not to disturb the evidence. People and horses craned their necks to watch. The lead investigator knelt and retrieved a small piece of shell with a pair of tweezers. It looked like the dozens of other pieces they had already collected. The yolk was congealing at the base of the wall.

On the other side of the wall, a rookie patrolman noticed shoe imprints in the wet earth.
“Humpty-Dumpty was pushed,” he yelled to the lead investigator.

Humpty-Dumpty didn’t fall. Even long held beliefs can prove false. Not everything is the way it seems. Just because you believe something is true doesn’t make it so. Ask the Flat Earth Society; ask the people think the moon landing was faked. Sometimes it just requires a little more thought.

Sometimes you need to be the needle in the haystack. There’s not much value in being the hay.

Just because everyone believes chasing Meaningful Use is the right thing to do doesn’t make it so.  This is not a cause and effect relationship. The belief seems to be that meeting the standards set by the CMS is the best metric for determining the value of your EHR.  Wrong. They are only the best metric for determining if you will be receiving incentive money.

Believing something doesn’t make it true. Ask the person who pushed Humpty-Dumpty.

‘Twas the night before reform when all in the House…

‘Twas the night before reform when all in the House

Were Tweeting and blogging and squawking like grouse

Their bill filled with zeroes and commas and flair

In hopes that the Senate would soon be there

The voters were restless, and in need of good care,

And they whined and they pleaded and they yelled ‘don’t you dare’

“Don’t sidestep this issue, don’t do it for votes”

“Don’t kowtow to payors or we’ll be at your throats.”

With Pelosi and her Botox and while Reid took his nap

Didn’t care if the people put up with their (you rhyme it, I’m pretending to be neutral)

The docs sat on the sidelines, bemoaning their fate,

While payors dressed like succubi caroled “ain’t this great?”

On the lawn of the White House there arose such disdain

As the public fought reform from ‘Frisco to Maine.

MSNBC, neigh now Comcast, buttressed their base,

And Fox, aka Rupert, said it was all a disgrace.

The words on the pages of the newly printed bill,

Hid nuance, erudition, obfuscation, and skill,

Do not read the details, adjectives and signs,

Do not worry how it impacts your bottom line.

We are here to pretend we did that of import,

To Hell with Medicare, Medicaid and the sort

It’s voters we want, It’s our doxology, our mantra,

And this year silly people, this year WE are Santa

On Boxer, on Biden on Fienstein they came,

And we chortled, berated, and chided by name.

“What about seniors, and sick people” we cried?

“What about uninsured, don’t you care if they died”

“This is about people you meet on the street.

People who must choose between their meds and to eat

It’s about Lipitor, Xanax, Prozac and Viagra,

It’s about doing what’s right, do what’s right or we’ll bag ‘ya”

And then in a twinkling I heard in my head,

The gnawing and chiding of Congress, who said,

We cavorted and sucked up, the best we knew how,

We spent bucks, made payoffs, and said the time is now.

Festooned all in new regs from NHS to VA

There were those who suggested, this is not going to play,

HITECH and ARRA are not making it fun,

RHIOs and RECs will soon come undone,

We’re paying the hospitals to do EHR

We know it seems silly, like we lowered the bar

If that doesn’t work we will tax them instead,

Make them spend gobs of money, make their budgets bleed red.

Spend it, refund it, and print new money now,

Buying Canada would be cheaper and easier but wow

They want to sign something, sign it soon, sign it fast,

But don’t assume that they’ve read it from first page to last,

We could’a been more like France, like the Swiss or the British

Make us more European, make our rich people skittish,

The tall socialist exclaimed as the dems shifted right,

Will Obamacare fail, have I lost all my might?