Why we don’t allow horses do medical procedures or EHRs






There are three or four basic rules those of us who write should use, unfortunately I do not know them. For those of my ramblings that seem long, it’s only because I have not had the time that is required to make them shorter. This I fear is one of those. I write to find out what I am thinking; if and why you read remains uncertain. All of us learned to write in elementary school—most then moved on to greater things—I remained trapped with the notion that being able to spell words more than one way may one day be regarded as a talent.

I found it is not a bad idea to get in the habit of writing down my thoughts–it saves me from having to verbally rake others with them. Some of my thoughts require little or no thought from those who read them, for the very simple reason, they made no such equivalent demand upon me when I wrote them. My goal in writing, other than to entertain myself is to create a somewhat humorous context to facilitate thinking. As one who enjoys the written word I understand that no urge is equal to the urge to edit someone else’s thoughts, as several of you have done with mine. It sometimes feels as though the best I can hope for in formulating a series of ideas about a topic is to borrow well from experts, those people whose have already made all the mistakes that can be made in a very narrow field. The need to write and share my opinions requires constantly trying to prove my opinion to an audience who may not be friendly, which is why silence may be better–silence is often the most difficult opinion to refute. Unfortunately, trapped inside every consultant is the urge to write; sometimes that urge is best left trapped inside.

Much of the project management office consulting I do comes from having listened respectfully to very good advice, and then going away and doing the exact opposite. In general there appears to be a lack of strategy concerning EHR, making it like trying to jump a chasm in two leaps—it can’t be done. Without knowing what outcome you want to achieve, any path will take you there. This isn’t because the people in charge don’t see the solution—it is because most people have no familiarity with the scope and magnitude of the problem.

Large information technology projects like EHR are often dominated by two types of people: those who understand what they do not manage, and those who manage what they do not understand. If we are being honest, the end product of project management is making it more and more difficult for people to work effectively. It’s sort of like why we don’t allow horses do medical procedures—it would probably take way too much training. I think that many EHR projects are ineffective because those leading the charge attempt to rely upon reason for answers, thinking, “If we know one then we know two since one and one are two”.

To make the EHR efforts more effective, I humbly suggest we need to learn much more about what constitutes the “and”.

EHR technology makes it easier to do a lot of things, but some of the things it makes easier ought not to be done. The only reason to have an EHR system is to to solve specific business problems within the organization. Getting EHR to do want you want it to is ninety percent mental–the other fifty percent involves voodoo. If you don’t make mistakes during the process, you’re not working hard enough on the problem—and that’s a big mistake. Need I say more? Any complex system that works almost always comes from a simple system that works. The corollary is also true, if the current paper and manual records system didn’t deliver best practices, how can the more evolved ones be expected yield best practices?  EHR alone won’t make you better, it will just make you automated.

Success is a much more likely outcome when one builds upon success. Most EHRs have enough technology to handle anything that comes up, unless a provider forgets that the EHR is just a tool.  It took human error to create the problems we have with our health records processing.  Why then are we so quick to think that technology will fix them?

Misery not only loves company, it insists on it. That is why having a competent project management office (PMO) plays such a dominant role in the success or failure of the EHR. When the circumstances turn extraordinary, as they are in today’s economy, extraordinary measures are required. Plan, take time to deliberate, and when the time for action has arrived, stop thinking and get after it. The important thing to remember in deciding what action to take is not to search for new data points but to discover new ways to think about the ones you have. The direction of am EHR strategy may have limits, but perhaps it says more about the limits of imagination and common sense instead of the limits of what is possible. And remember this basic rule, when assessing common sense and imagination, always round up.

I’m not always disgruntled about that which I write, but I’m often far from gruntled. As graduate student I aspired to a stable job, I craved factual certainty and the respect of my peers—so I became a consultant. I soon learned that this is like wanting to be a vegetarian so you can work with animals. The only job I was fit for was consulting. This notion rested on my belief that I was not suited to work nine to five, and that consulting wasn’t quite like working. One of the nice things about consulting is that putting forth absurd ideas is not always a handicap. The good news is that consultants, when addressing things outside of their expertise are just as dumb as the next guy. I’ve always believed that being honest with my clients is the best policy—does that mean that if I chose to be dishonest I would be using second best policy? Oscar Wilde said, “If you want to tell people the truth, make them laugh, otherwise they’ll kill you.” That’s my hope with these little musings. Remember, we’re all in this alone.

The preceding was a pilfering of quotations.


EHR-step away from the scalpel

So, I lunched today with a friend who is an executive at a healthcare consultancy.  She recently spent four days in a hospital, entering via the trauma center.  The purists among us would think, “If she only had a personal health record (PHR).”

As it turns out, she did.  From what I understood form our chat, the people in the hospital did not welcome her understanding of healthcare.  She handed someone on the trauma team her PHR from Google Health Vault.  According to her, she had downloaded enough data on her jump drive to where MRI’s were dripping from the USB.

At some point they determined she needed to have surgery because of something that appeared on her CAT scan.  Moments before seeing how well she could count backwards from 100, she was able to convince the surgeon that she did not require an operation because what they saw was a pre-existing condition which was documented on her PHR.  Step away from the scalpels.

I think the scalpel thing only served to spur her on.  After leaving the hospital, she requested a copy of her bill—all forty-three pages.  She read it, line by line.  They hate it when patients do that.  Her insurance covered everything, so it’s not like she was minding her pennies.  She was minding her sanity.  Seven hundred and some dollars for Tylenol.  She never took any Tylenol.  Somehow the billing system was tied to the fact that Tylenol was prescribed, independent of whether she actually took it.

Seventy-nine hundred dollars for a CT-scan.  Only ten times higher than the national average.

Where were the failure points?  People.  IT.  Process.  It’s a good thing she knew what she was doing or right now she’d be missing a thing-a-ma-jig—and they would have billed her for another Tylenol to manage that pain.

Without change management and work flow improvement, EHR will only make things worse.  There is a term of art for the intersection of work flows, people, and data—it’s called a mess.  To minimize the mess, to have any shot at an ROI, the sooner you employ adults to run the Program Management Office (PMO) for your EHR, the better your chances.


EHR Strategy, a call to action

EHR Strategy, What I Do & How I Can Improve Your Efforts

Several people have told me that I need to come right out and state the role I play in the Electronic Healthcare Records (EHR) space, and how my consulting firm will add value to your efforts.  Spell out your services, and state a call to action.  This writing will address that topic, and will be the only time I use your time to try to sell you on me.  If you’ll bear with me for a few minutes, I will explain why I write with such self-assurance that most organizations (Hospitals, clinics, IPAs, and providers) have the wrong EHR Strategy—or no recognizable strategy—and my equally self-assured belief that working together we will mitigate that problem.

Here are the facts around EHR:

  • Most large EHR projects have a high probability of failing—the larger the project, the higher the probability
  • Large EHRs may cost more than a new hospital wing—a number of people know of one truly outstanding hospital who spent more than $300,000,000 on their EHR
  • Hospitals are much more knowledgeable about the requirements of a hospital wing and what it will do for them than they are about their EHR strategy
  • All healthcare providers who have entered the EHR space have done so trying to hit the trifecta of moving Gossamer targets;
    • Certification
    • Meaningful use
    • Interoperability
    • Hundreds of vendors who have their own agenda at heart
    • So many individual, disparate, committees are working on standards…do we need to even go there?  Doesn’t each committee create its own standards—if so, where is the standardization?
    • If one removes DC from the loop, many providers can’t articulate the business problem they want the EHR to solve, nor can they articulate an ROI
    • Providers have budgets without requirements, budgets without any knowledge of what an EHR system should cost
    • An EHR should have a greater impact on patients, providers, and payors than any other single program, yet who is in charge?  What skill set to they have to do this?
    • Most providers do not have a plan, a qualified planner, a decider.  Who is reviewing and approving the plan?  What makes them credible?

Those are the reasons we are here.  Our job is to reposition those facts such that they improve your chances of being successful with your EHR selection and implementation.

You know what?  It’s not about the EHR.  It never should be.  The EHR system only accounts for about 20% of the projects success or failure.  It’s code.  The other 80% comes down to planning, conversion, change management, training, user acceptance (patient, doctors, nurses, and administrators), and workflow improvement.

You know what?  It’s about breaking down kingdoms between intra-hospital departments.

It’s about knowing that you can walk into the EHR war room and know that somebody is the decider.  That somebody is able to say, “This is what we are going to do first, second, and third, because that’s the only way we can improve your chances of having a successful EHR program.

That’s what we do.  Most people, given the opportunity, will fail 100% of the time performing open-heart surgery.  A mere handful will avert failing.  Most people will fail 100% of the time who are leading an EHR program will fail.  A mere handful will not.

We are the ERHPMO (Program Management Office).  We are your advocate in managing the EHR vendor to benefit you.  Needless to say, most vendors do not like having us on board.  We are vendor neutral, provider advocates.

We are the anti-Accenture business model.  We do not back up the bus and drop off the children.  We will not try to put 30 people on your project.  You do that—clinicians, and IT.  We pull up in a Prius, drop off a few grownups who’ve been there, done that, got the T-shirt.

We work hand in hand with Hospitals, IPAs, clinical providers, and doctors to help you successfully address some or all of the following;

  • understand the EHR landscape
  • create your EHR strategy, in-house versus SaaS
  • eliminate wasteful redundant costs via shared services analyses
  • define your requirements
  • issue an RFP
  • evaluate vendors
  • negotiate contracts with the vendors
  • plan and execute the change management
  • rationalize your EHR with other which may exist within your walls
  • define and rebuild workflows
  • develop and execute a training program for user acceptance

This is not the time to experiment, or hope you get it right.  To minimize the probability of failure, this is the time to bring in the adults.

That’s what we do.  Sorry for the sales pitch.  Please let me know how we can help.



Cast, Blast, and Gin Rummy

duckSeveral years ago I was invited to go on the ultimate boys’ toys, weekend getaway. A dozen of us flew from Denver to Utah, and then drove to a point somewhere west of Bozeman Montana. It was to be a weekend of sport, a weekend of competition, and a more than occasional libation. To say that the people who organized the trip came from money would be a major understatement. They were in the oil bid’ ness. The father of one of the guys was the CEO of the second or third largest petroleum company in North America. We stayed at his ranch, a 12 bedroom log cabin in the middle of Nowhere, Montana, which is about 20 miles west of Next to Nowhere, Montana.

The weekend’s activities included fly fishing, duck hunting, and Gin Rummy. Each participant was given a handicap rating in each event. The idea behind the rating was that if you are weak in one event, you were paired with an individual who is skilled in that event. In theory, that would level the playing field among the teams. Since I have never fly-fished or hunted I was odd man out. But I was game, and it’s amazing how good one can become at something when one has to fight their way through it.

Let the games begin. We started the competition with a full day of fly-fishing. Our destination was the Madison River, an impressive, fast running, expanse of snow melt. The stretch we would finish was about 150 feet wide, and its average depth was somewhere between waist and chest high. As I would soon learn the bottom was covered with what appeared to be the equivalent of moss covered bowling balls. I was instructed by one of the more experienced fishermen to tie a nymph to the end of the tippet. For those of you who are as novice to the sport as I was, a nymph is an artificial lure which mimics an insect larva. It is designed to lure fish who feed along the bottom, not the nubile young woman referenced in Greek mythology.

We fished for several hours. My legs ached from trying to maintain my balance in the strong current. I was about ready to admit defeat when the tip of my rod bent sharply into the water. Standing perpendicular to the current, I could see as the brightly speckled back of a large rainbow trout turned upstream. Naturally, I turned upstream with it and began to try to reel him in. First mistake. It was at that point that I first realized that the height of the water was now about level with my chest waders. Second mistake. The guys on the other part of the river and along the bank were yelling at me. I thought it was words of encouragement. Final mistake. As it turns out, they were trying to convince me not to turn upstream. At the exact moment that I faced stream head on, was the exact moment my feet lost purchase with those moss covered bowling balls of which I wrote. Turning yet again to my physics, I quickly recalled the equation; force equals mass times acceleration. Instantaneously, I was swept downstream, still clutching my fly rod in my right hand.

Wayne Newton’s first law of fluid mechanics took over; waders, no matter how good they are, if positioned in a plane that is horizontal to the river will fill rapidly with water, just as mine did. The choice with which I was faced was do I save myself and lose the fish, or do I try and land the fish? One of the shortcomings of maleness—I was going to use maledom until I Googled it—is that we rarely have actual choices, especially when we are around other males or for that matter, females. Naturally, I opted to land the fish. My reel had become dislocated from my rod. I remember grabbing the reel and stuffing it down my waders, and as I tried to float my body as though it was a raft without a rudder towards the river’s nearest bank, I began to reel in the monofilament with a hand over hand motion. After several minutes I was standing dripping wet and proudly displaying a 19 inch rainbow trout.

We cooked the fish and played Rummy until about three in the morning, awoke at four, grabbed our shotguns and headed out into the darkness without so much as a cup of coffee. Round three of the competition was to be duck hunting. To this day I’m still unclear as to why we had to hunt ducks while it was still dark. Weren’t there any ducks who needed shooting at brunch time, I inquired? Twelve guys, who collectively smelled like a distillery, and who are operating on an hour of sleep, armed with loaded shotguns, trod through a willow thicket as dawn approached. As I neared the river bank, a startled duck shot skyward. I raised my over and under twelve-gauge shotgun, sort of took aim, and fired a volley. The duck seemed to pause in midair, and then fell like a rock into the racing water. I watched helplessly as my quarry floated away from me. I looked downstream and was pleased to see two men fishing from a rowboat. The duck floated right towards them. A man reached down, retrieved my duck, and dropped it in his boat. He then waved to me. Thinking he was being friendly I returned his wave. He then rowed away with my duck.

It was a great three days. Part of what made the weekend fun with not having to excel at each event. It helped knowing that in areas where my skills weren’t as good, I could count on the skills of others and vice versa. The idea behind this approach was to build competitive and level teams. That approach works well in mano y mano events like those I described. It works much less well in EHR, HIT and healthcare reform in general.  I’m trying to recall if I wrote previsouly about a meeting I attended with a former hospital CEO.  His take on EHR was the total inability of his peers to have any precience regarding their approach to EHR.  According to him, very intelligent people were making very unintelligent decisions, committing their entire institution to strategies made with almost no data.  Some people can give a better explanation for why they bought their car than they can for why they selected their EHR.   That’s the wrong way to handicap this event.