EHR

May I borrow your pen?

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Have I written recently I’m not a fan of technology for unless someone knows what business problem they intend to solve? It’s not so much that I have anything against any of the technology or any particular technology or EHR vendor, it’s more that I think many are misjudging what the technology will do for them, what they have to do to it, and they forget to ask themselves how to best address the problems.

Whatever do you mean? Thanks for asking—here’s an example. When the United States first started sending astronauts into space, they quickly discovered that ballpoint pens would not work in zero gravity.

To combat the problem, NASA scientists spent a decade and $12 Billion to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300C.

The Russians used a pencil.

Have a meeting about how to best plan for and implement EHR in your hospital. One rule, all discussion should involve process, not technology. Try first to reach consensus about what to do, then look at how to do it. You may find out that all you need is a pencil.

Why do witches burn?

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Some argue that skewed logic is better than none at all. I’m not some people. What is skewed logic? It’s drawing an errant conclusion from a set of facts. If A and B, then C. For example, in Monty Python and the Holy Grail, there is the discussion to deduce if a woman is a witch.
Why do witches burn?
Villager: Because they’re made of…..wood?
B: Goooood!
Other Villagers: oh yeah… oh….
B: So. How do we tell whether she is made of wood?
One Villager: Build a bridge out of ‘er!
B: Aah. But can you not also make bridges out of stone?
Villagers: oh yeah. oh. umm…
B: Does wood sink in water?
One Villager: No! No, no, it floats!
Other Villager: Throw her into the pond!
Villagers: yaaaaaa!
B: What also floats in water? …
King Arthur: A Duck!
Villagers: (in amazement) ooooooh!
B: exACTly!
B: (to a villager) So, *logically*…
Villager: If…she…weighs the same as a duck……she’s made of wood.
B: and therefore…
Villager: A Witch!
All Villagers: A WITCH!

Let’s depict this like a business problem.


There you have it. So campers, where could we possibly heading with this? Here’s where. We’re starting a hospital; THEREFORE we need an ENR.  Washington is giving away money; therefore we need an EHR.

If that logic was correct, if that logic was both necessary and sufficient how would we know it? One way is we would see a bunch of doctors running towards EHRs rather than away from them. The reason this logic is faulty is that the lifeblood of the EHR is about one thing—the records.

So, if the EHR is made of wood and weighs the same as a duck…

How difficult are EHR, Reform, & Interoperability

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My daughter asked me to kill the bug in her room—Super Dad to the rescue.  That got me wondering.  Do most men think we excel at most things?  As I pondered weak and weary, I started to formulate this list.  I ask the men as they read through the list to score themselves on a ranking of one to five, with five being the highest, how they view their abilities in each area.  Ladies, feel free to play along on behalf of someone you know.

  1. Sunday Sports
  2. Getting a taxi
  3. Navigating
  4. Mowing the lawn
  5. Killing spiders
  6. Drawing a straight line by hand
  7. Multitasking
  8. Parallel parking
  9. Anything to do with fire
  10. Opening jars
  11. Sharpening a pencil with a knife
  12. Tipping
  13. Driving
  14. Cooking on the grill

Maybe this comes from that hunter-gatherer thing.  Total your score silently in your head—you can do this because you also happen to think you excel in math.  My guess is that 98% of us scored somewhere between 56 and 70, the majority leaning towards the higher end of the range.  Granted, these are simply opinions, nothing any of us has to prove.

However, when pushed most of us will back down on one or two things if we had to prove our prowess.  Take juggling for example.  Even an egoist will be reticent to rate himself an excellent juggler.

Here we go.  Why then when we (ladies, this also includes you) are faced with something challenging at work we do our best to convince ourselves and others that the task can be no more difficult than opening a jar, asking directions, or asking for help?  We prefer to fly solo, believing we will somehow figure it out on the way.

I cannot recall the last time I heard someone facing a big ugly IT project state anything like:

  • You’ve got the wrong person
  • I have no idea how to do this
  • There is no way this is going to work

EHR, reform, Meaningful Use, interoperability.  These are big ugly projects.  Some are projects for which only a scarce few have real subject matter expertise—a handful of which truly ‘get it’, and others for which no one is credentialed.  Yet when we hear the proclamations about how standards are coming, how the N-HIN will work, and how reform will impact healthcare over the next five years, they seem to be stated with such assurance so as to infer that these industry-altering programs are no more difficult than parallel parking.

Remember the game Trivial Pursuit?  There was an inverse relationship between how certain I was of an answer and the certainty with which I asserted it.  If I said the answer quickly and with enough confidence I could occasionally convince the other players not to even check the answer on the back of the card.  For example, if the question is “name the bird who lays its eggs in the nest of another bird,’ and you belt out, ‘racket-tailed coquette,’ you just may pull it off.

It’s just an observation on my part, but why is it that when the nice people in charge tell us that they know what they are doing to me it sounds like they are yelling, racket-tailed coquette.’

“Are the best intentions of EHR Half-Full or Half Empty?”

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Doublethink. Functioning simultaneously on two contradictory beliefs and accepting both as true. By definition, one must be false, unless of course you are living in a parallel universe, in which case you’re in need of more help than I can deliver. George Orwell defined it as, “A vast system of mental cheating”—on yourself, I might add.

What does doublethink accomplish and why does it exist with varying degrees within each of us? First, it allows us to overcome our own competence. I think that’s worth repeating, overcoming our own competence. We know better and yet we talk ourselves out of accepting what we know, creating an equal and offsetting false belief.

Second, it acts as a safety net. How? Let’s say we are one hundred percent confident in Belief A. Well, almost. There’s always that little nagging disbelief, that little devil on the shoulder trying to convince you otherwise. Sort of like ‘buyer’s remorse’—only we’ll call it believer’s remorse. Just in case Belief A is wrong, maybe I should have a backup belied, Belief B. Jeckyll and Hyde.

How does that impact one in the EHR problem?  Buckle up. Most people with whom I’ve worked are very passionate about what they do and are paladins of their methods.  Sort of EHR young Turks.  Belief A. They do everything they can for the program.

While sincerely believing in the importance of EHRs, here’s what else I’ve observed.  Much of that belief envelopes the limited notion of believing that nothing lays outside of their skill set. They often recognize it more as a desire than a belief.  They know fully that they will face challenges which are new to them.  They know fully that many implementations have failed and that they need to spend more effort on change management and work flow alignment than was budgeted.  The list of challenges for which they lack the expertise never empties.  They know the light at the end of the tunnel is just a train. They know fully that solving the current problem only seems to reveal the next one.  Belief B.

So, we’ve come full circle. We outwardly profess we can do what others have failed to do, yet in our heart of hearts we believe that you may never see an ROI. Doublethink.

Which gets us back to our original question, “Are the best intentions Half-Full or Half Empty?”

HealthsystemCIO.com–a few thoughts

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These are my comments to the post by Steve Huffman, VP & CIO, Memorial Health System.

Well written Steve. I think part of what is being missed by Washington is that in their effort to mandate providers move to facilitate a nationalized healthcare model; they have overlooked a few things. For starters, I think the EHR discussion has shrouded the fact that EHR is voluntary. Unfortunately, very few providers look at EHR as a decision they should evaluate—do I or do I not do EHR. Instead, they eschew that question, and view the need to do EHR as a decision that was made for them.

• Two business models are in play, a national model and the one used by providers. In the end game, even though it is only mentioned in the privacy of their own policy rooms—and not streamed on CSPAN—the national model is ultimately being designed to connect every doctor to every patient—one big hospital under thousands of roofs. The other model is the provider’s singular business model. It’s a patient-centric model (the healthcare business) and a business model (the business of healthcare). The two models have different goals and different requirements.

• If the model Washington is pushing were attractive, providers would be knocking one another down tying to be first in line to implement it. Clearly, that is not happening. Instead, Washington is offering billions in rebates, and there are still few takers.

• There is no viable plan on how to get from here to there—none, nada, zip. Instead of a coherent plan coming from them, they have put the monkey on the back of the providers, guiding them with carrots and sticks. Washington launched this idea without a much of a plan, and after the fact saddled the providers with three innocuous stages of rules—two of which remain undefined. They have yet to convince providers that they have a way to make sense out of having 400 different EHR vendors, no set of standards, hundreds of unique HIEs—I know you can’t have hundreds of anything and label it as unique—which bespeaks–the problem–and realistically expect it to work.

Why change your business rules and work flows to try to meet a plan that has stability of having been drafted on an Etch-A-Sketch? There are plenty of valid business reasons to evaluate changing the way providers work. There are huge potential gains in safety, care, efficiency, and effectiveness. These gains vary by organization. They vary based on the unique requirements of each organization. Properly planned and implemented, and EHR program with change management on workflow improvement can facilitate taking the business of healthcare from an 0.2 model to a 2.0 model.
Done poorly, and EHR will prove to be nothing more than a multi-million dollar scanner.

That being the case, you may want to use Steve’s methodology and ask him where you can go to buy a supply of the Composition books he uses.

Something to consider…

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Did you know that having an EHR is not required?

Since it’s not, wouldn’t it make sense to approach EHR like you would any other business problem?

Project Management lessons from Alice and Wonderland

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During my career I’ve been involved with hundreds of project teams, some quite gifted, others whose collective intellect was rivaled only by simple garden tools.  I’ve been asked often if I can define what distinguishes the two types of teams.  For me it always comes down to leadership.  It doesn’t matter how hard the people work, it matters how well they are lead.  Does the leader know what to do tomorrow?

That got me to thinking.  Are there some leadership secrets, some project management gems that may have been overlooked?  Rather than offering traditional mish-mash consulting jargon, I thought it would be helpful to find a common ground by which we can form a basis for this discussion.  Hence the following narrative: Everything I learned about project management I learned from Alice in Wonderland.

So, you have spent tens of millions on an electronic health records system.  Some did so without even defining their requirements.  The project is chugging along, new regulations and penalties are appearing through the diaphanous mist like the Cheshire Cat’s toothy grin.

“Well! I’ve often seen a cat without a grin,” thought Alice.  “But a grin without a cat! It’s the most curious thing I ever saw in my life!”


How fast must you run so as not to lose ground?  How many milestones do you have to meet, how many due dates do you have to check?  What can be learned from the Red Queen in Alice in Wonderland?  She told Alice, “It takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast.”




For the EHR project to progress it requires extraordinary effort.  This begs a question of the project leader, where does the project need to go?  In a conversation with the Cheshire Cat Alice asks,

“Would you tell me, please which way I ought to go from here?” “That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where,” she said.
“Then, it doesn’t matter which way you go.” “So long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

If you only walk long enough.  What is enough for a three year project?  When are you done?  When the money runs out; when there are no more tasks in the work plan.  It seems many EHR projects are much bigger than allowed for by the plan.  They get big, impossibly big.  A lot of that size comes from underestimating the effort to support workflow improvement, change management, and user acceptance.

“Sorry, you’re much too big.  Simply impassible,” said the Doorknob to Alice.   “You mean impossible?” “No, impassible.  Nothing’s impossible.”

We don’t have the benefit of getting advice from talking doorknobs which is why we get so stymied when confronted with having to do the impossible. What is impassible or impossible for your project?  It might be deciding or knowing when to stop.

Alice laughed. “There’s no use trying,” she said: “one can’t believe impossible things.”
“I daresay you haven’t had much practice,” said the Queen. “When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”

Believing it does not make it so.  Never has, never will.  Belief does not beget success.  Planning does.  Defining your requirements may.  There is no shortage of ex-CIOs who believed their EHR vendor.

Then there’s the skill of managing your EHR vendor.  Perhaps Eaglet said it best, “Speak English! I don’t know the meaning of half those long words, and I don’t believe you do either!”

There will always be those select members of every project team who are so dense that light bends around them; those who have not learned that it is better to keep their mouth shut and appear unintelligent than to open it and remove any doubt; those who have the right to remain silent, who just don’t have the ability.

“You couldn’t deny that, even if you tried with both hands.”

“I don’t deny things with my hands,” Alice objected.

“Nobody said you did,” said the Red Queen. “I said you couldn’t if you tried.”

Do you find yourself sitting through a status meeting unable to tell if the project is moving backwards or forwards, unable to tell what is hiding around the bend?  You think so hard your head feels like your ears are trying to switch places with your eyes.  When all else fails, try this bit if advice.

“Fan her head!” the Red Queen anxiously interrupted. “She’ll be feverish after so much thinking.”  A little thinking won’t hurt, who knows; in small doses it might even be beneficial.

Now, let’s assume you’ve got yourself all worked up.  You and your team are pouring over your work plan, trying to decide what’s left to accomplish, or what can’t be accomplished.  How do you know what’s what and which is which?

“Begin at the beginning,” the King said, very gravely.  “And go on till you come to the end: then stop.”

I’ll take the King’s advice and do the same.

EHR: Why the rush?

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The following is a comment I wrote to the healthcareitnews.com post, “BLUMENTHAL: EHRS WILL BECOME ‘AN ABSOLUTE REQUISITE’ FOR DOCS”.

“The time has come,” the Walrus said, “To talk of many things: Of shoes and ships and sealing-wax, of cabbages and kings– …

The time has also come to ask the question, “Why the rush?”  Is the pronouncement that within the next ten years we will see widespread adoption of EHR in conflict with the timing of the Meaningful Use incentives?  It seems that way to me.

Whereas we may see an “upward slope in the adoption curve” within the next year or two as hospitals begin the process of selecting and implementing an EHR, we will not see so much as a hiccup in the slope of the Meaningful Use curve.

Why?  I think there are several explanations.

  • Not enough providers are far enough along to even attempt to pass a Meaningful Use audit.
    • Will they complete the requirements
    • If yes, will they pass the audit
    • Of those who have attempted to do the heavy lifting of EHR and CPOE, they do not know the Stage 2 & 3 requirements.  Those requirements may be enough to ensure nobody passes the audit.
    • To those providers just underway, whose board insists that they complete the installation in time to qualify for the incentives—good luck.  Many will make poor selection decisions which they will support with even worse implementations.
    • To those who have yet to start, there is no chance they will meet the target dates.

So what’s next?  What would you do if you were having a party and learned nobody could come that night?  You’d change the date.  Washington will do the same.

What does that mean if you are a provider?  I think it means you have enough time to do it right, even when the conventional wisdom is pushing you to hurry.

Jihad Joe EHR selection

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When competing hypotheses are equal in other respects, the principle recommends selection of the hypothesis that introduces the fewest assumptions and postulates the fewest entities while still sufficiently answering the question. It is in this sense that Occam’s razor is usually understood.  There is no corollary that works with EHR vendors.

What if we look at HIT vendor selection logically?  Have you ever noticed at the grocery store how often you find yourself in the longest checkout line, or when you’re on the highway how often you find yourself in the slowest lane?  Why is that?  Because those are the lines and lanes with the most people, which is why they move the slowest.

If you are asked in which line is Mr. Jones, you would not be able to know for certain, but you would know that the most probable option is the one with the most people in it.  You are not being delusional when you think you are in the slowest lane, you probably are, you and all the people in front of you.  The explanation uses simple logic.  It’s called the anthropic principle– observations of our physical universe must be compatible with the life observed in it.

It can be argued that the business driver which shapes the software selection process of some is the aesthetics of efficiency, a Jihad Joe approach to expediency.  Buy the same system the hospital down the street bought, the one recommended by your golfing buddy, or the one that had the largest booth at the convention.  Or, one can apply the anthropic principle, rely on the reliability of large numbers and simply follow the market leader.

Might work, might not.  My money is on might not.  There’s still plenty of time to do it right.  If that fails, there will always be time to do it wrong later.  Of course, you can always play vendor darts.  If you do, you should sharpen them so they’ll stick better.

What should you think about HIEs

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Part of the problem I have with HIEs is similar to the old Wendy’s commercial, “Where’s the beef.” Only in this case the question becomes, “Where’s the value add?”

There are hundreds of them, HIEs that is. Each one developed autonomously. Some are built within a hospital which has more than one EHR. Others are being built to serve among a hospital group, and others are geographical. Which of the HIEs is being built by a team of people who have ever built one? To my knowledge, none.

Hundreds of HIEs being built independently from one another by people who’ve never before built an HIE. Hundreds being built to transport the electronic medical records of providers using a few hundred different EHRs, each EHR operating with different standards, none of which benefits from interacting with another.

What is the purpose of the HIE? It reminds me of this children’s’ icebreaker game where the children sit in a circle. The first child starts by whispering a phrase into the ear of the person sitting next to her. She can only say the phrase once. The child she whispers it to must then whisper it to the child next to her. This continues until it goes all the way around the circle. Usually, by the time the phrase gets back around to the original person, it is completely different.

Like shuffling an EMR from one place to the next through a series of intermediaries. What does it look like when it comes out the back end?

After all, what is the purpose of the HIE? It should act like a handoff, like a mini N-HIN. It does not modify the data, at least not intentionally. If there is a more complex way to get a person’s health record from point A to point B, I have not seen it. HIEs are healthcare’s Rube Goldberg mechanism.

I think that when all is said and done, HIEs will have faded away. Until then providers should keep their focus on developing an EHR which actually serves their business model.