My thoughts on “One EMR Vendor’s View of Meaningful Use”

Posted by Paul Roemer

What if Meaningful Use turns out to be no more relevant to EHR than agriculture is to bull fighting? Even worse, what if meeting Meaningful Use (MU) damages a provider’s business?

There is a world of difference between EHR and Meaningful Use. It is a square and rectangle proposition. All instances of MU require an EHR. However, all EHRs do not require MU.

When I evaluate changing a business strategy, I like to do so under the following test:

Is it necessary?
Is it sufficient?

For the strategy to be beneficial to an organization it must be both necessary and sufficient.

Let us begin with whether MU is necessary. Necessary for what—to make the provider’s caring for its patients better; to make their business better. MU does neither. Implementing an EHR, though it is optional, is important. So is meeting MU. The last time I checked, there were no long queues in Madison to grab an EHR, and no people camping outside of the CMS offices to be first in line for the ARRA money. MU does not pass the test of necessity.

Does MU pass the test of sufficiency? Is it adequate? Again, for what? The way to answer this question is to ask, “How would your organization implement EHR if MU did not exist”? your answer to this question defines what is necessary.

Much of MU has to do with how EHR is implemented and adopted. For all the attention vendors are paying to MU, it is a bit nonsensical. Most of the onus on MU is tied to the provider. The most the vendor can offer is that they will not do anything to encumber a provider’s chances of meeting MU. Many of these vendors are the ones who will require you to implement an upgraded version of their product in order to meet certification.

In closing, will the MU money run out? On the contrary, I think they will not be able to give it away.

The EHR Certification Myth

Posted by Paul Roemer

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial–like Kojak without the warmth.

Why is this a part of the overall plan? Is this planned failure? Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test. The certification test, by definition, is necessary. The Full test is both necessary and sufficient. It is possible to pass certification without passing the Full test. Therefore, the Full test is a stricter test. Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test? Same as always. Fully functional, on time, within budget, and user accepted. Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact: One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion: The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations. Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification. (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact: Most large, complex, expensive IT projects fail—they just do. This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed. Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion: Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak? You bet. Insurmountable? Doesn’t have to be.

What can you do to improve your chances of success? Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points. EHR Fail Safe Points? The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test. The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD. They need not have a slew of EHR implementation merit badges. The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built. They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR. Those skills are needed—in spades—and you need to budget for them. The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre. They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

What do you think?

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The EHR Certification Myth

Posted by Paul Roemer

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

Why is this a part of the overall plan? Is this planned failure? Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Here’s what can be concluded just based on the facts.

Fact: One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Bleak? You bet. Insurmountable? Doesn’t have to be.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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July is “take your EHR strategy to lunch month”

Posted by Paul Roemer

Several have written suggesting I toss my hat into the ring to serve as the EHR Strategy wonk or czar. I was in the process of thinking it through when I was awakened from my fuegue state by a loud noise–my ego crashing to the floor.

Some have suggested that a camel is a horse designed by a committee. Their point in saying that has something to do with how committees function less well than individuals–the problem with “group thinking.” Personally, I think the camel design seems rather functional.

Some have asked, what is it about the EHR universe that has you dehorting the EHR process as though you are some sort of savant–nobody really asked that, but I wanted a segue and that’s all I came up with.

It’s the committees. I feel a little like Quasimodo repining about the bells. Raise your hand if you are on an EHR committee. See? Now, if you think that not only has the committee not accomplished much, but believe that it may never accomplish much, lower your hand. Now look around. Not many hands still up.

Please take a look at this for a moment. Don’t try to understand it–it will only make your teeth hurt.

2011 requirements

For hospitals, 10% of all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) directly entered by an authorizing physician must be made through a computerized physician order entry process. Individual physicians still must use CPOE for all orders, even if electronic interfaces with receiving entities are not available. The initial draft did not specify the required percentage for hospitals and did not address the electronic interface issue.
Physicians must be able to check insurance eligibility electronically from public and private payers, when possible, and submit claims electronically. This was not in the initial draft.
Patients must receive timely electronic access to their health information, including lab results, medication and problem lists, and allergies. The initial draft did not include the word “timely.”
Physicians must implement one clinical decision rule relevant to specialty or high clinical priority. This was not in the initial draft.
Physicians must record patient smoking status and advance directives. This was not in the initial draft.
Physicians must report ambulatory quality measures to CMS. This was not in the initial draft.
Physicians must maintain an up-to-date list of current and active diagnoses based on ICD-9 or SNOMED. The initial draft did not specify use of the two classification sets.

2013 requirements

Specialists must report to relevant external disease or device registries that are approved by CMS. This was not in the initial draft.
Hospitals must conduct closed-loop medication management, including computer-assisted administration. This was not in the initial draft.
All patients must have access to a personal health record populated in real time with health data. This was moved up from 2015 in the initial draft.

Additional provisions

Patients’ access to EHRs may be provided via a number of secure electronic methods, such as personal health records, patient portals, CDs or USB drives.
CMS will determine how submitting electronic data to immunization registries applies to Medicare and Medicaid meaningful-use requirements.
CMS may withhold federal stimulus payments from any entity that has a confirmed privacy or security violation of the Health Insurance Portability and Accountability Act, but it may reinstate payments once the breach has been resolved.

Source: Health IT Policy Committee

See? Take a few minutes and work this into your EHR task time-line for processes, work flows, change management, training. Need more time? I’d need more time than I have, and when I finished I guarantee I couldn’t explain it to anyone. This is what happens when people get into a room, have a charter, and try to do something helpful. I am sure they are all nice people. But be honest, does this make your day, or does it make you want to punish your neighbor’s cat–you may have to buy them a cat if they don’t already have one.

What to do? Here’s my take on it. Plan. Evaluate the plan. Test the plan. Know before you start that the plan can handle anything any committee tosses your way. Let people who know how to run large projects into the room. Seek their counsel, depend on them for their leadership. If the plan is solid, the result has a better chnace of surviving the next committee meeting

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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What benefit is there to meeting Meaningful Use?

Posted by Paul Roemer

Commercials bug me. Big surprise.

You have probably seen the commercial for the Sleep Number Bed. A bare mattress, a glass of wine on the mattress, a bowling ball is dropped on the mattress. The glass of wine does not spill. That makes some people rush out and buy the mattress. Why? For the security in knowing that just in case they leave a glass of wine on their mattress and then happen to drop a bowling ball on it, the wine will not spill.

That dog don’t hunt unless you happen to be opening a bowling alley/Motel 6. The company is trying to entice you on the merits of doing something by asking you to make the leap of faith by equating the bowling ball falling on the bed to having your spouse get in or out of the bed without disturbing your sleep.

A feint. A maneuver designed to distract or mislead you from the real purpose. Meaningful Use. Certification. A feint. Designed to distract or mislead you from the reason you need an EHR. The terms of Meaningful Use, that is, what is meaningful to your organization should be set by your organization, not some national standard applicable to every hospital in the country. Hospitals are not ubiquitous—the Meaningful Use standards are. How can a single set of standards be in line with what you require?

What’s the feint? Certification, cash incentives, Regional Extension Centers. A full court press trying to get hospitals to do what the feds want it to do in order to meet their goal of a nationwide interconnected healthcare system.

What proof, other than a check, has anyone offered that you benefit from meeting Meaningful Use?

Should you try to meet Meaningful Use? I think not. There is no ROI, and the full set of standards have yet to be published. What should you do? Have a glass of wine, or better yet—go bowling. Don’t forget to buy one of those snazzy bowling shirts.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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EHR Groundswell

Posted by Paul Roemer

EHR, there’s a new groundswell against meaningful use. How do I know? I’m starting it now.

After lunch, if I’m in the right mood, I may start one against certification.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The change keeps changing

Posted by Paul Roemer

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:

• PMO
• 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.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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What may be driving the Meaningful Use announcement

Posted by Paul Roemer

I often write not because I have something that needs to be said, but to try to explain something to myself. If I get to a point where I think I understand an issue, I’ll make it public to see if the comments reflect my understanding, or to see if I need to have another go at my own thought process. Which leads me to this—

Let’s back up the horses for a minute and return from whence we came. EHR. The idea was simple. Two groups; patients and doctors. Create a way to transport securely the medical records of any patient (P) to any doctor (D).

For the time being, let’s keep this at the level that can be understood by a third grader. What two things do I need to satisfy this P:D relationship? Data standards and a method of transport.

Do we have them? We do not. That being the case, what fury hath the ONC wrought? (1 Roemer 9:17) if you don’t have what you need, and you don’t have either the authority or a plan to get what you need, you must facilitate (fund) the creation of workarounds to fill the void.

At some point, the conversation must have quickly shifted from, “We need standards and transport”, to, “Since we don’t have standards and a means of transport, we must come up with other ways to try to make this work.” Now, I don’t believe this is literally what happened, but I think one could see how it might have evolved.

Other ways. What other ways? The ONC loves me; it loves me not. HITECH. ARRA. Take the monkey off our back and put it on the backs of the providers. Pay doctors to implement EHR. Smote them if they don’t. Write checks. Big checks. Lots of big checks. Instead of coming up with a single transport plan and one set of standards, provide guidelines. Make pronouncements. Fund RHIOs and make them responsible for creating hundreds of unique transport plans and ask the RHIOs what progress they are making towards a single set of standards. Get the monkey off your back.

Create artificial goalposts that get the HIT world all a twitter every time the ONC makes a proclamation. What goalposts? Meaningful Use and Certification. Just so there is no misinterpretation of what I think the issue is permit me to spell it out—Meaningful Use and Certification exist because there are no standards and there is no means of transport. Conversely, had the ONC developed standards and transport, there would be no discussion of Meaningful Use and no Certification. Standards would have forced vendors to self-certify.

The other activity could be viewed as a feint. Not one developed out of malice, rather one that came about from the void that resulted from the lack of a viable plan. Meaningful Use and Certification are expensive workarounds for a failed or nonexistent national EHR rollout plan. As are RHIOs and RECs, the six million dollars, and the forty billion dollars.

The HIT world grinds to a halt at the very mention of an announcement from the ONC. Their missives are available in PDF or stone tablets. Imagine someone robs a bank, and as they exit the bank, they jaywalk on their way to their getaway car. The police missed the robbery, and focus all their efforts on the secondary issue, the jaywalking.

The chain of events has caused the focus to move away from the primary issues of no standards and no plan, and towards a plethora of secondary issues, issues for which hundreds of people are responsible and no single person has authority.

I think that by the end of 2013 pronouncements on Meaningful Use and Certification won’t be able to buy time on MTV.

If any of this is close to being correct, what are the implications for a hospital looking to select and implement an EHR? Find the EHR that is best for your hospital. Not the one most likely to earn ARRA money. Not the one which will pass today’s Meaningful Use test. Define your requirements. What requirements? The ones you believe will most closely align with how the healthcare industry will look in 2015 and beyond. Meaningful Use will change. Reform will change. Funds will change. Reform will change again. Will your EHR be able to change?

The ONC’s recent Meaningful Use proclamation required 556 pages. If you occupy the C-suite of your hospital, I hope you don’t let those pages define your selection of an EHR. Some would argue that with so many pages that there must be a pony in there somewhere. From what I read, I’m in no hurry to rush out and buy a saddle.

What is wrong with the ONC’s 2010 budget?

Posted by Paul Roemer

Some comments I wrote to ahier.blogspot.com’s posting of the ONC’s 2010 budget.

Their mission, “ONC leads, coordinates, and stimulates public and private sector activities that promote the development, adoption, and use of health information technologies to achieve a healthier Nation” although offering nice sentiments, for $61 million, ought there not be a way to measure whether or not they achieved the mission? How does one know if they led, coordinated, and stimulated, and if so to what degree?

Who certifies their work? Who determines if their work resulted in Meaningful Use? Before anyone gets excited by what they plan to do in 2010, let’s look at what they did in 2009.

1. What did the ONC accomplish, complete, put to bed?

2. What did they complete that facilitated the HIT work required of the providers?

There are no standards. There is no believable plan to obtain standards anytime soon. There is no viable national roll-out plan for EHR.

Instead of HIT/ARRA handouts, and HIE’s designed by hundreds of independent groups, and RECs designed by inexperienced appointed committees, why not use the $61 million to state that by such-and-such a date there will be a written and executable plan stating when we will have standards and a workable and believable roll-out plan?

They continue to promise funds to support an ill-conceived plan trying to get everyone on board, an approach that yields to the notion that “There must be a pony in there somewhere.” Ladies and gentlemen–there is no pony.

AP reports EHR plan will fail-now what?

Posted by Paul Roemer

I just fell out of the stupid tree and hit every branch on the way down. But lest I get ahead of myself, let us begin at the beginning. It started with homework–not mine–theirs. Among the three children of which I had oversight; coloring, spelling, reading, and exponents. How do parents without a math degree help their children with sixth-grade math?

“My mind is a raging torrent, flooded with rivulets of thought cascading into a waterfall of creative alternatives.” Hedley Lamar (Blazing Saddles). Unfortunately, mine, as I was soon to learn was merely flooded. Homework, answering the phone, running baths, drying hair, stories, prayers. The quality of my efforts seemed to be inversely proportional to the number of efforts undertaken. Eight-thirty–all three children tucked into bed.

Eight-thirty-one. The eleven-year-old enters the room complaining about his skinned knee. Without a moment’s hesitation, Super Dad springs into action, returning moments later with a band aid and a tube of salve. Thirty seconds later I was beaming–problem solved. At which point he asked me why I put Orajel on his cut. My wife gave me one of her patented “I told you so” smiles, and from the corner of my eye, I happened to see my last viable neuron scamper across the floor.

One must tread carefully as one toys with the upper limits of the Peter Principle. There seems to be another postulate overlooked in the Principia Mathematica, which states that the number of spectators will grow exponentially as one approaches their limit of ineptitude.

Another frequently missed postulate is that committees are capable of accelerating the time required to reach their individual ineptitude limit. They circumvent the planning process to get quickly to doing, forgetting to ask if what they are doing will work. They then compound the problem by ignoring questions of feasibility, questions for which the committee is even less interested in answering. If we were discussing particle theory we would be describing a cataclysmic chain reaction, the breakdown of all matter. Here we are merely describing the breakdown of a national EHR roll out.

What is your point? Fair question. How will we get EHR to work? I know “Duh” is not considered a term of art in any profession, however, it is exactly the word needed. It appears they are deciding that this—“this” being the current plan that will enable point-to-point connection of an individual record—will not work, and 2014 may be in jeopardy—not the actual year, interoperability. Thanks for riding along with us, now return your seat back and tray table to their upright and most uncomfortable position.

Even as those who are they throw away their membership in the flat earth society, those same they’s continue to press forward in Lemming-lock-step as though nothing is wrong.

It is a failed plan. It can’t be tweaked. We can’t simply revisit RHIOs and HIEs. We have reached the do-over moment, not necessarily at the provider level, although marching along without standards will cause a great deal of rework for healthcare providers. Having reached that moment, let us do something. Focusing on certification, ARRA, and meaningful use will prove to be nothing more than a smoke screen.

The functionality of most installed EHRs ends at the front door. We have been discussing that point for a few months. When you reach the fork in the road, take it. Each dollar spent from this moment forth going down the wrong EHR tine will cost two dollars to overcome. To those providers who are implementing EHR I recommend in the strongest possible terms that you stop and reconsider your approach.

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