EHR

How hospitals should deploy EHR to attract Docs

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This is a response I wrote to Brian Ahier’s post on HealthsystemCIO.com

Here’s an idea I raised a few months ago which discusses how to use EHR to your advantage in retaining ambulatory physicians. What prompted the idea was knowing of a hospital which spent nine figures on their EHR, only to find out that its functionality essentially ended inside its four walls. At the time nobody wrote that it wouldn’t pass muster. This idea may die before anyone finishes reading the comment; if not perhaps it merits at least a look-see.

From the perspective of the business model of the hospital, what do we know?

• Hospitals work at attracting and retaining good physicians
• In many markets, ambulatory physicians may choose to send their patients to any one of a number of hospitals
• The competition to attract patients and physicians is building
• The hospital and physicians both benefit if they are:

o On the same EHR
o On an EHR which interfaces easily

What if we change the question being asked, or at least change what constitutes a desirable answer from the perspective of the hospital? Let us go back to what we know.

• Non-hospital based doctors will not be part of the calculation to determine if the hospital meets Meaningful Use.
• Each of those doctors benefit from implementing and EHR system, and they will either qualify for stimulus money or be fined.
• Those same doctors and their patients benefit from having a seamless relationship with a hospital.
• None of those doctors has anything close to what can be considered an actual IT department.

o If 400 providers who practice at your hospital have to select an EHR, how many dozens of different EHRs will they select
o Not only do the providers lack the skills to select a good system, they lack the skills to implement it successfully.
o Most IPAs are not even offering a recommendation

What happens if we rephrase the question and ask, “What steps can a hospital take to:”

• Make ambulatory doctors want to send their patients to them
• Make it easy for the patient/physician/hospital relationship to appear seamless
• Possibly be paid for facilitating the EHR for their ambulatory physicians

If it were my hospital, here’s what I would do:

• Pull together a plan to figure out how a hospital could offer an EHR solution for each of the ambulatory doctors. This EHR solution could:

o Be the same EHR or one which can integrate with their EHR
o Be offered as a managed services solution
o Be offered as an outsourced solution

• Figure out what information is needed to determine the viability of offering its ambulatory doctors an EHR solution:

o Staffing
o Marketing
o Incentives
o Cost
o Roll-out
o Training

• Determine if the ambulatory doctors can somehow sign-over their incentive payments to the hospital.

o If yes, the incentive payment from 400 ambulatory doctors could fund about $18 million of the roll-out cost
o If not, there are still a number of great business reasons to think about helping the doctors get on the hospital’s EHR.

What is the long-term ROI, say five years and beyond, of having an ambulatory doctor send its patients to a given hospital? I bet it exceeds the cost of installing an ambulatory EHR.

What are the risks of HIT and EHR?

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It is refreshing to know that the voices I am hearing need not be my own.  When I try to summarize the issues for my own edification, I always circle back to the same few issues.

• No single person is both responsible and in authority regarding HIT and EHR. Provider-world pauses with each new pronouncement from Washington as though the missing EHR Dead Sea Scrolls had just been discovered in the reflecting pool.
• Those who implemented EHR did so without any idea that rules would be imposed after the fact.
• EHR is expected to serve two business models:

o Washington’s N x M patient/doctor connectivity effort
o A provider’s unique business objectives, none of which have anything to do with a patient in Atlanta being able to connect to a doctor in Anchorage.
• What model would providers be following if there were no Meaningful Use
• If the current EHR national rollout model was any good, providers would be racing to the front of the line to implement EHR instead of having to be offered rebates.
• The national rollout plan lacks viability for several reasons:

o No standards
o HIEs are each being developed in their own vacuum
o A horde of vendors whose mission does not tie to the national rollout or the providers’ business model and who have no incentive to adopt standards
o The requirements and dates for Meaningful Use will probably change once providers have tailored their systems to meet Stage 1
o The requirements for Stages 2 & 3, which may cost providers six zeroes preceded by some number greater than five, don’t exist.
o An ROI can’t be calculated on meeting Meaningful Use
o Both the likelihood and the impact of healthcare reform on HIT and EHR, just got vaguer by some order of magnitude.

I firmly believe the right EHR and CPOE will be great for hospitals. Providers will be better served by finding answers to the question, “What’s in it for me,” rather than, “What do they want me to do?” Unless of course, providers want them running their business.

What are the success factors for EHR?

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I just arrived in-country—I was in Wisconsin for two weeks.  I’ve been to forty-seven states, and Wisconsin has to be one of the friendliest.

Anyway, let us begin.  Not long after graduating with an MBA from Vanderbilt, I returned to Vandy to interview job candidates.  With me, was my adult supervisor, the VP of human resources—a stunning older woman; about thirty-five.  At dinner, she invited me to select the wine.  Not wanting to appear the fool, and trying to control my fawning, I pretended to study carefully the wine list.  Not having a clue, I based my selection entirely on price.  I had little or no knowledge of the subject; nonetheless, I placed the order with all the cock-sureness of a third-grader reciting the alphabet.

A few moments later Wine-man returned with a bottle, angled it towards me, and stood as rigid as a lawn statue.  After a few seconds my adult paused and motioned my attention towards Wine-man.  I remained nonplussed.  “You are supposed to tell him that the bottle he is holding is the one you ordered.”

“He knows it is what I ordered, that is why he brought it.”  I thought they were toying with me.

A few seconds later there was a slight popping sound and then Wine-man placed the cork before me on my napkin in a manner similar to how Faberge must have delivered his fabled egg to Tsar Alexander III for his wife Empress Fedorovna.  They were both staring at me, not the Tsar and the Empress—Wine-man and my adult.  “You are supposed to smell the cork.”  And so I did.

“Now what?”

“If it smells bad, it means the wine may be bad.”

To which I replied, “This is the Opryland Hotel—have you seen the wine prices?  They don’t sell bad wine.”  She nudged me with her elbow.  I could tell I was wowing her.  I smelled the cork.  “It smells like a cork,” I whispered to Wine-man.  He smiled and poured a half inch of wine in my glass.  I thought he was still pulling my lariat.

I looked bemusedly at the mostly empty glass, held it out to him, and asked him if I could have some more—I was thirsty.  Rather than embarrass me further, with a slight nod of her head my adult instructed the Wine-man that my sommelier class was over—any further proof of my inadequacies would be of limited marginal value.  Any chance that we would have gone dancing later that evening was about as flat as the wine.  I should have ordered a beer.  I was good at beer.

For those who are still reading, if you are wondering if I am actually going to make a point, here it comes.  I’m not fond of segues, so don’t blink.

Sometimes, a little guidance is helpful—even if it has to come in the form of being led around like camel with a ring through its nose.  One of my on-line friends, a nurse who teaches nursing—seems like a good fit–asked me what are the success factors for EHR.

Often, what is important in a leader is having the knowledge and temerity to ask the right question.  In healthcare it appears that the number of executives with answers may exceed the number asking questions.  Value is often measured by scarcity.   Good questions, especially around EHR and Meaningful Use, seem to be in short supply.

Here’s my take on some of the critical success factors:

  • Adult supervision—this is not defined by the age on your driver’s license
  • Invest time to plan your EHR plan; 6-9 months for a fair sized hospital
  • Actual written requirements (an RFP) that comes from your business strategy
  • A written healthcare information technology plan
  • Invest more than half of your time and effort in work flow alignment, change management, and training.
  • Should your plan seek to meet Meaningful Use
    • By when
    • How
    • What drives your strategy—Washington or your business model

Pretty simple things.  The right things usually are—like knowing what to do with the wine cork.

May I have receipt for my EHR in case I return it?

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The hospital we use just dedicated a new wing.  For months the job site was a maze of people, duct, and tools.  It cost $145 million.  There’s a plaque displaying the name of the architect, the contractor, the mayor, and the rest of the adults who made it happen.  While it was being built there were numerous permits, certifications, and sign-offs taped to the building.  Their purpose was to ensure the public that the adults were keeping an eye on things.  A phase of work couldn’t be started until the prior phase had all the requisite sign-offs.

Those in authority had to be licensed.  Had to be certified as qualified.

They have another project underway.  One that costs more than the new wing and impacts more people.  This one doesn’t have a blueprint.  There are no building permits.  No certifications.  No licensed professionals.  You can’t even see it.  There are no hard-hatted workers.  No foreman.  You know who’s in charge of the project?  A hospital executive—prior experience—zero.  Has he ever built one before?  No.  Does he know what to do when he encounters risks, pitfalls?  No.  There is one other person running the show—a vendor—that should let everyone get a good night’s sleep.

Would anyone let this same executive be in charge of building a new wing?  Of course not.  Why then do we not employ the same standards for what will turn out to be the most expensive and far reaching non-capital project that the hospital will ever undertake?  If you think you know, please share your answer.

By the way, I asked one of those executives how it was that he happened to be selected to lead the EHR project.  “I forgot to duck,” he quipped.  I guess that’s as good a reason as any.

My comments to Dr. Blumenthal’s Blog

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It says they are awaiting moderation–they could be waiting a long time.  Here they are.

I think hospitals need to give a lot of thought to whether it’s in their best interest to even try to meet MU.  Those who haven’t begin EHR and CPOE will be hard pressed to benefit.  There is more unknown than known about the impact of changing an entire business strategy in light of reform, the magnitude of Stage 2 and 3 requirements, no standards, 400 vendors–all lacking 2011 certification, hundreds of different HIE’s, and an N-HIN strategy that may not be viable.

Washington is building a healthcare model whose long term goal is to be able to connect each patient to any doctor.  Hospitals have a far different business model.  The sad thing is that none of the hospitals who have undertaken EHR had any idea that costly rules would be applied after the fact, they have no means to know what the next set of changes will be, or if the dates of meeting MU will be pushed back.  If the dates don’t move MU will be like hosting a lottery for which only a handful of people bought tickets.


As for ambulatory doctors, my recommendation is to wait until a firm shrink wraps EHR (software, implementation, training, change management, and work flow improvement.)  There’s no rush here either.


Should you consider skipping Meaningful Use?

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I am going through an analysis for my client, a hospital chain who has already installed EHR and CPOE to see if they should change their strategic direction to get the ARRA money, or continue along their original course.

It does not have to be an either or decision.  Their options are not do go for MU, to go for all of the money, to go for it at some combination of their hospitals, or to go for it later.  With so many unknowns, it may be best to slow down and evaluate the options. 2011 is around the corner, however you have five years, until 2015 until the penalties begin.

What’s your take?

Why doctors fail to embrace healthcare 2.0

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This is a reply I wrote to Kevin MD’s blog to a post written by Gwenn Schurgin O’Keeffe, MD, FAAP.

I view healthcare 2.0 with a bit of a twist from the Wikipedia definition, less from the perspective of social media and more from the vantage point of moving the business of healthcare from Version 1.0 to version 2.0.  I should note that I distinguish the business of healthcare (how it is run) from the healthcare business (the clinical side).

Having worked with executives in a number of industries, I think that for healthcare reform to be truly effective, the business of healthcare needs to evolve from an 0.2 model to a 2.0 model.  I think the same issues you raise still come into play; sheer panic, loss of control, loss of connection with patients, and blinders.

Going from an in-house business model to one being transformed by reform and Meaningful Use to a national healthcare model will exacerbate further those issues.  The in-house business of healthcare (how healthcare is run) was never built to handle a business model that will require every patient to be able to be connected to any doctor.  The system advances over the past few years—EHR, CPOE, and ePrescribing were implemented without any idea that the rules would change after the fact.

Will healthcare 2.0 offer huge advantages to how healthcare is run?  Absolutely.  The first question to answer before aiming for 2.0 is whose 2.0 model should you follow; yours or the government’s.  Are they the same?  No, and they are diverging even further as you read this.  The good news is that I think they will converge several years down the road.  What you need to decide is which model do you pursue before that happens.

Should you consider avoiding Meaningful Use?

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Where were we?

There are a few things stuck in my craw—imagine that.  One is Meaningful Use.  The other is also Meaningful Use.  Permit me to address these one at a time.  I’ll start with Meaningful Use.

Are you kidding me?  Who are these people?  To disguise that of whom I write, let’s invent some aliases, Dr. B and Dr. H.  For all the meetings, all the pronouncements, you’d think sooner or later one of them would state, “There is no way any of this makes sense.”

Why do you say that Paul?  May I?   What if you threw a party and nobody came?  What if you held a $40 billion lottery and nobody won?  Here are the rules.  A handful of people less than seven feet tall decide to buy homes in a community.  All the homes have door openings that are seven feet high.  New people move into the community.  One day the homeowner’s association mandates that all homeowners must build homes with door openings that are seven feet high.  Most homeowners ignore the mandate.  The association then decides to offer the homeowners rebates if they comply with the mandate, and penalize them if they don’t.  Most of the homeowners ignore the mandate.

Indifferent to the fact that their mandate isn’t working, the association decides to add new rules, rules that affect the homeowners who already built homes with seven foot tall doors, and those who didn’t.  One of the rules is that the seven foot tall doors must now be eight feet tall; another mandates that all roofs must be in the basement.  Homeowners who comply will win the lottery.  Those who don’t won’t.

How does the lottery pay out?  It doesn’t.  They made it impossible for anyone to get the money.   Suppose you gave a lottery and nobody won?  Suppose you made it so obtuse that nobody cared if they won.

That’s where I think we are with EHR.  The smart healthcare providers are asking themselves the question, “What if we make a business decision not to meet the Meaningful Use requirements?”  “What if we decide what is and isn’t meaningful.”

There are 2 “business models” in play—the national healthcare model, and the model your firm follows—they have different goals.  I asked my client, “When you made your selection of EHR, did you have any hint that the government was going to create rules to manage what it does?”  I assume their answer is a lot like yours—“Not at all.  We were worried about FDA oversight, but nothing like the stimulus.  The PQRI was available as an incentive to use ePrescribing, but really small potatoes.”

The national healthcare model under development will create an infrastructure such that every patient can be connected to each physician via a series of HIEs and the N-HIN.  To get there, they need you—they can’t do it without you.  What do they need from you?  Participation.  Participation by having and EHR, ePrescribing, and CPOE.

Even if it were to work, what’s in it for you?  Very little.  They know that—that’s why there are payments and penalties.  Most hospitals like the idea of implementing EHR.  Given the choice those same hospital executives would choose to listen to an entire Celine Dion CD if it would allow them to skip implementing CPOE.

If there are not many good business reasons to meet Meaningful Use, why should you build an entire strategy around it?  You wouldn’t paint your hospital pink simply because Washington said you should, although given a choice between the two ideas, pink sounds pretty good.  Let’s say you take them up on meeting Meaningful Use.  You build your strategy, drop current initiatives, implement these systems, train your people—then what?  Indeed.  What happens if the government changes its mind?  Moves the dates, changes the requirements?

In order to go for Meaningful Use you must be able to suspend your ability to think rationally.  If you do not think the HIE and N-HIN model will work—I have not met anyone who thinks it will—why even give Meaningful Use another thought.

My client is a group of 14 hospitals—they could get millions of ARRA dollars.  If you don’t have more than one hospital, your ARRA rebate will be much less.  They have already installed EHR and CPOE.  To get the millions they have to spend millions.  What happens if they spend it and the feds change their direction?  What then?  What do they do with the eight or nine figures of systems they build to follow Washington’s lead?  Take them out?  Modify them?  What happens to their business model as a result of all of this “leadership” from the ONC?

What should you do?  That’s up to you.  Here’s an idea or two.  First, ask yourself what your EHR/HIT strategy would be if there was no ARRA money.  (You do have a written HIT strategy, don’t you?)  Second, decide if you think that the current national roll out strategy will work.  Third, figure out what you won’t be able to do if you have to invest even more time and money meeting Meaningful Use.  Next, add up all the money it will cost you to meet their requirements and compare that to what they will pay you.  I bet the costs are more than the rebate.

I think Meaningful Use won’t exist in 3-5 years.  I think the N-HIN won’t be available by then either.

Here’s the real kicker for hospitals that have more than two beds.  If you have not yet selected your EHR vendor you shouldn’t even be thinking about meeting Meaningful Use for the first year because you can’t there in the time available to you.  That take’s the pressure off, doesn’t it.

How good is your vision?

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So, there I was thinking about all the times I didn’t get the invitations to the technical savants meetings.

I remember when Compaq came out with their first portable PC.  It was about the size of a suitcase and twice as heavy.  There was no way I’d ever have a need to lug around a computer.  A few years later my boss showed me his new cell phone—beige and about the size of a shoe box.  I remember asking him why he needed a phone and not being impressed by his answer.  Another piece of technology that would never get off the ground.

A few years later, out popped the internet.  A friend of mine showed it to me.  I asked him what he does with it.  He replied that it was good for sending messages to his brother.  I suggested he use the phone.

I think the fault I had was I looked at those three things from the perspective of the technology. It didn’t occur to me to look at it from the perspective of what business problems could they solve.

Technology, from the standpoint of its functionality, is often vastly under employed.  This happens not because of limitations of the technology, but limitations of vision.  I needed to not ask, what am I able to do with this, rather, what might I be able to do with this.

For example, let’s look at the fascination, or lack of it, around implementing an Electronic Health Records system (EHR).  By the time the dust has settled on your implementation, say three to five years—by the way, that means you missed the deadline to get the ARRA money, what does the industry look like?

Do you buy the EHR that meets what the industry looks like today, or did you give it enough thought so that your EHR functions at the level needed to support your business in 2015?

Should you consider disregarding Meaningful Use?

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Here’s a reply I wrote to a FierceHealthIT on some of Dr. B’s comments on Meaningful Use.

I know of a hospital who has already implemented a top tier EHR costing millions.  This organization ‘gets it’.  They are currently building a work-plan to see what additional work they must do to meet Meaningful use in time to qualify for 100% of the ARRA money.  First blush—it will take tremendous amount of work for them to do it, but they will get there—if they choose to do so.  They have a choice and the fact that they know that is their trump card.

If a hospital hasn’t even begun the EHR process, as more than 80% have not, coupled with the more than fifty percent failure rates, I’d estimate their chances their chances of making the deadline at less than 1/3.

So, what to do?  Stop and think.  Ask the right questions.  You have a choice of two strategies.  Let ARRA money drive your decision, possibly implement it wrong, and probably miss the deadline.  Then what do you have?  Not much.  Strategy number two; define your requirements, figure out what business problems you need the EHR to help solve, and buy the best one for you.  Confused?  Map out two work-plans for yourself.  One work-plan that shows what you would have to do and what you would have to spend to meet the ARRA requirements.  Draft a second work-plan that shows what you would have to do to implement what you really want.  Compare the two plans and determine your deltas, your gaps.

Are you going to chase this for ARRA money?  Because someone in Washington thinks you should do this?

Answer this question first.  Is every hospital the same?  Are you as good as the best, better than the worst?  The EHR vendors think the answer is yes.  Keep you processes the same, skip change management, and the implementation will be a breeze.  We make every hospital look and operate the same.  When did the EHR vendors become the best practice savants?   The government thinks the answer is yes—that is why they are holding everyone to the same Meaningful Use standard.

One standard does not fit all hospitals—nor should it.  Set your own standards and decide for yourself if you fit your version of Meaningful Use.  ARRA money will end—then what?  You’re stuck with your EHR.  Get one you need.