EHR

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

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‘Twas the night before reform when all in the House

Were Tweeting and blogging and squawking like grouse

Their bill filled with zeroes and commas and flair

In hopes that the Senate would soon be there

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

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

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

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

With Pelosi and her Botox and while Reid took his nap

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

The docs sat on the sidelines, bemoaning their fate,

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

On the lawn of the White House there arose such disdain

As the public fought reform from ‘Frisco to Maine.

MSNBC, neigh now Comcast, buttressed their base,

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

The words on the pages of the newly printed bill,

Hid nuance, erudition, obfuscation, and skill,

Do not read the details, adjectives and signs,

Do not worry how it impacts your bottom line.

We are here to pretend we did that of import,

To Hell with Medicare, Medicaid and the sort

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

And this year silly people, this year WE are Santa

On Boxer, on Biden on Fienstein they came,

And we chortled, berated, and chided by name.

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

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

“This is about people you meet on the street.

People who must choose between their meds and to eat

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

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

And then in a twinkling I heard in my head,

The gnawing and chiding of Congress, who said,

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

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

Festooned all in new regs from NHS to VA

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

HITECH and ARRA are not making it fun,

RHIOs and RECs will soon come undone,

We’re paying the hospitals to do EHR

We know it seems silly, like we lowered the bar

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

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

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

Buying Canada would be cheaper and easier but wow

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

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

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

Make us more European, make our rich people skittish,

The tall socialist exclaimed as the dems shifted right,

Will Obamacare fail, have I lost all my might?

Why is EHR too much for normal brains?

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So, I’m watching the Alabama Auburn game and it suddenly strikes me, there are probably a lot of people trying to understand what it is a consultant does that we can’t do for ourselves.

For those who have a life, those who missed the game, Alabama entered the game undefeated and had a good chance to play for the national title.  Auburn opens the game with the best scripted opening plays I’ve ever witnessed—touchdown, onside kick, trick plays, touchdown.  14-0.

Their first however many offensive plays were brilliant.  They were planned perfectly.  The next time they had the ball it was apparent that they had not planned the however many and first play.  The plan failed to go beyond what they’d already accomplished.

How does that apply to what you do, what I do, and why I think I can help you?  It is best described by comparing your brain to a consultant’s brain.  Your work brain functions exactly as it should.  It’s comprised of little boxes of integrated work activities, one for admissions and registration, one for diagnosis, another for care.  There’s probably another box for whatever it is that the newsletter stated IT was doing three months ago and how that impacts what you do.  That’s your job.

Your boxes interface in some form or fashion with the boxes of the person next to you in the hospital’s basement cafeteria who is paying for her chicken, broccoli, and rice dish that reminds you of what you ate at crazy Uncle Bob’s wedding reception.  That interface is the glue that makes the hospital work.  It’s also the synapse, the connective tissue—I know it’s a weak metaphor, but it’s a holiday weekend—give me some slack—that tries to keep healthcare functioning in an 0.2 business model.

There are names for the connective tissue, you know it and I know it.  It’s called politics.  It’s derived from antiquated notions like, “this is how we’ve always done it”, “that’s radiology’s problem”, “nobody asked me”,

At some point over the next week or two the inevitable happens; the need arises for you to add some tidbit of information.  Do you add it to an existing box, put it in an empty box, or ignore it?  This is where you must separate the wheat from the albumen—just checking to see how closely you’re following.

Your personal warehouse of boxes looks like the final scene in Raiders of the Lost Ark—acre after acre of dusty, full boxes, no Dewy-decimal filing system, and no empty box.  There are two rules at the hospital; one, bits of information must go somewhere, and two, nobody can change rule one.

The difference, and it’s a big one, is that consultants have an empty box.  It’s our Al Gore lockbox.  We were born that way.  It’s like having a cleft chin.  We also have no connective tissue to your organization.  No groupthink.  No Stepford Wives. No Invasion of the Body Snatchers to turn us into mindless pods moments.  Consultants may be the only people who don’t care.  Let me rephrase that.  We don’t care about the politics.  We don’t care that the reason the hospital has four IT departments is because the hospital’s leadership was afraid to tell the siloed docs that they couldn’t buy or build whatever they wanted.

Sometimes it comes down to your WWOD (what would Oprah do) moment.  Not, what do they want me to do, not what would they do, not what is the least disruptive, not what goes best with what the other hospital did.

At some point it comes down to, what is the right thing to do; what should we do.

Big, hairy healthcare IT projects come out of the shoot looking like Auburn did against Alabama.  The first however many moves are scripted perfectly.  Heck, you can download them off Google.  Worse yet, you can get your EHR vendor to print them for you.

The wheat from the albumen moment comes when you have to come up with an answer to the question, “What do we do next?”

That’s why consultants have an open box.  You know what we are doing when our brain takes us to the open box?  Thinking.  No company politics to sidetrack us.  Everybody knows the expected answers, but often the expected answer is not the best answer.  Almost everybody knows what comes after A, B, C, and D.

Sometimes…E is not the right answer or the best answer.

At some point you’re no longer twenty

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There is a first time for everything.  Yesterday was the first time it occurred to me that there is a difference between being twenty and not being twenty.  A few days ago one of the women at the gym was bemoaning the fact that being forty wasn’t at all like being thirty–puhleeaasse.

There are those who would have you believe that there is no single muscle that is connected to every other muscle, a muscle which if pulled will make every other muscle hurt.  I beg to differ.  I think I found it—I call it a my groinal—it’s connected to my adverse and inverse bent-egotudinals, the small transflexors located behind the mind’s eye.  I found the muscle while running back a kickoff during a Thanksgiving morning game of flag football.

Call it homage to the Kennedys.  Sort of made me feel like one of them—I think it was Ethyl.  Old guys versus new guys—I know it’s a poor word choice but you know what I mean which after all is why we’re both here.  Did I mention that everything aches, so much so that I tried dipping myself in Tylenol?

There are two types of people who play football, those who like to hit people and those who don’t like being hit.  I am clearly a member of the latter camp.  I used to be able to avoid being hit by being faster than the other guy.  This day I avoided getting hit by running away from the other guy.

The weird part is that my mind still pictures my body doing things just like the college kids on the field, and it feels the same, it just isn’t.  Two kids just ran past me at the speed of light, and my only reaction was feeling like I wanted to ground the two of them.  Half the guys are moving at half the speed of the other guys.  At the end of each play, we find our side doubled over, our hands on our knees, our eyes scanning the sidelines for oxygen and wondering why the ground appears to be swaying.

As the game progresses, instead of running a deep curl pattern, I find myself saying things like, “I’ll take two steps across the line of scrimmage, hit me if I’m open.”  Thirty minutes later I’m trying to cut a deal with their safety, telling him, “I’m not in this play, I didn’t even go to the huddle.”  After that I’m telling the quarterback, “If you throw it to me, I’m not going to catch it, no matter what.”

All the parts are the same ones I’ve always had, but they aren’t functioning the way they should.  It’s a lot like assembling a gas grill and having a few pieces remaining—I speak from experience.  Unfortunately, implementing complex healthcare information technology systems can often result in things not functioning the way they should, even if you have all the pieces.  It helps to have a plan, have a better one than you thought you needed, have one written by people who plan nasty HIT systems, then have someone manage the plan, someone who can walk into the room and say, “This is what we are going to do on Tuesday, because this is what you should do on Tuesday on big hairy projects.”.

Then, if you still happen to lose your EHR bearings, remember it grows best on the north-facing wall of the hospital.

Why the N-HIN will be owned by public firms

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Here are a few more thoughts just to Emerilize the discussion—to kick it up a notch.  Not only do I think the national EHR market is ripe for the taking by a big three like Microsoft, Google, and Oracle, I’ll go so far to suggest that when the dust settles in 5-7 years, the N-HIN, the National Health Information Network, will be a regulated combination of a handful of those firms.

As for the other firms offering or planning to offer PHRs, permit me to suggest the following scenario.  Let’s say I am in charge of Google’s so far somewhat nonexistent healthcare line of business.  One of my goals would be to have more users of my PHR than any other firm.

Why does this model make sense?  Two ways, both of which come from the cable/telco business model.  Rule number one, content is king.  In cable, it is shows like HBO and Discovery.  In healthcare it is data; patient data, effectiveness data, disease data.

Reason number two, the cable/telco model values the businesses based on the number of assets.  What are the assets?  Subscribers.  You and me.  Each body adds somewhere between five and ten thousand dollars to the valuation model of a Comcast or Verizon.  Downstream, some valuation will be placed on each PHR subscriber.

So, back to the example of me running Google’s healthcare offering—if you don’t like Google as an example, insert your favorite firm.  If I’m Google, am I troubled by the fact that other firms are building their own solutions?  No, and here’s why.  The difficult part of the business model is adding users, adding subscribers.  Why not let a bunch of firms do the business development work for me, do the dirty work to get the users, and then just devour those firms?  Once I own them, I convert them to my platform.  Do I then get some ‘ownership’ or right to use the data?  That would certainly be the business goal.

One million users valued at five thousand dollars adds five billion in valuation.  Ten million adds fifty billion.  Ten billion is about 2.5% of the US market.  Do I stop at the border?  Of course not.

By the way, while all this is going on, Google, MS, or whoever will also be creating standards and be building or buying up EHR firms.

HIT/EHR: A little adult supervision can’t hurt

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Among other things, EHR requires adult supervision like parenting.  My morning was moving along swimmingly.  Kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—I guess we could call them evergreens—to make them look snow-covered.  (I just em-dashed and em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  I may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things are other things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctor’s.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.

EHR-a doctor/CMIO’s perspective

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Dirk Stanley wrote this in reply to a post on http://radar.oreilly.com/2009/11/converting-to-electronic-healt.html

I felt it needs to be heard.

I can only say that no matter what we do from a technical standpoint, a lot of medicine isn’t ready from the cultural standpoint.

Medical culture is a weird creature, that not a lot of people understand. (I’m sure Glenn above can attest to this.) Docs, historically, have been used to people “compensating for them”, for example :

1. A doc writing a script for Percocet (1) tab PO QID PRN instead of Percocet (1) tab PO q6h PRN pain.
2. A doc writing for “regular diet” instead of “Regular diet, dysphagia level I, nectar thickened liquids.”
3. A doc having weeks to co-sign their verbal orders.
4. A doc writing “Vanco 1gram IV x1 STAT” instead of “Vancomycin 1 gram in 250mL 0.9% NS run over 2 hours at a rate of 125mL/hour”
5. A doc writing “Heparin protocol” in the pre-EMR world, versus an electronic order for “Heparin protocol” where *all of the teammembers know what to do*.
6. A doc choosing an EMR because “It’s the best for me” versus “It’s the best thing for my patient”.

These are the hidden implementation costs. Training docs to think along these lines is important, but nobody has a clear training plan on how to change this medical culture.

This is why, some people look at OpenVista as the solution – IMHO, putting OpenVista into a private hospital will not produce the results it does in a VA hospital. Docs need to understand there will be compromises, and they need to buy-in to those compromises, before any migration to EMR will work.

Technology only works if the culture supports it.
I can tell you there are still a LOT of cynical docs out there who are quick to try a solution, and if it doesn’t work the first time, they lose faith.

Again, I wish things were different, but as a practicing physician who sees a lot of different medical computing environments (ICU to private office), I’m really concerned about the implementation plan here.

Finally, I agree, we do need an EMR Czar, or a “rockstar” who will talk about these things openly to help change the culture to be more supportive of technology. The problem is that to talk about it openly would mean having frank discussions that a lot of people don’t want to hear yet…

– Dirk 😉

EHR: work plans are necessary but not sufficient

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I wonder about things, little things, things I see on Nova or on Bizarre Foods.  Take water, more specifically, ice.  It floats.  The only solid that floats in its liquid state.  Most solids sink, not ice.  For those of you thinking boats float, they’re not considered to be solids—does that make them liquids?

It turns out that as water goes from four degrees centigrade, its densest point, and towards freezing, it becomes less dense and floats.  It’s volume increases by 9%, and part of that 9% is trapped air.  That air, even though you can’t see it, exists between the two H’s and the O.  which takes us to the following.

Have you spent much time studying work plans?  While there are more interesting ways to spend your time, there are times meant for writing them, and times meant for studying them.

Having a work plan can be a little like having a bike; nice, practical for some things, impractical for others.  Like with most things, there are work plans and there are work plans.  Some may not be worth the paper on which they are written.

Just like not everyone can write a book worth reading, not everyone can write a work plan worth implementing.  Lines on paper don’t necessarily yield a project of much value.  Remember how with the ice there are things between the H’s and O’s?  Well, with a lot of healthcare IT and EHR work plans, there are things between the tasks on the work plan, or at least there should be.  Can’t see them either.  Those things?  The missing tasks, the tasks that should have been in the plan, the tasks that would have given the plan a fighting chance to succeed.

Some gaps are good, like with ice.  Others can leave you hanging.

saint

EHR: shift happens

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After several years of therapy, I’d begun to accept that I might not be the “Voice of Reason” for all things, maybe just for the important things.  Laugh all you want—most of you have been here, you just don’t blog about it.  To fully grasp the import of what I’m about to write, for the newbies, there’s benefit in reading https://healthcareitstrategy.com/2009/09/19/ehr-how-to-recover-from-poor-planning/.  If there was ever déjà-vu all over again, this is it.  It takes an idiot to be this stupid once.  I’ve managed to refine the process.

At some point, there may be benefit to society as whole for someone to do the math and holler above the fray, “he doesn’t get it and he never will.”  This is not a discussion about what is PC, it’s about my ineptitude.  I have become my own euthanasia moment.

The chicken breasts are moved from the freezer to the sink to be thawed by water because the energy used to heat water is cheaper than energy used to run the microwave.  Forgive me for tearing.  (I am at an impasse between tear and tear.)

This is twice in fewer months than it takes not to approve healthcare reform.

I am watching, “Trauma in the ER”.  It’s part of my MD correspondence course.  I’d just about learned to insert a chest tube when something reminded me of running water.  I ran to the kitchen.  The water is running. The chicken breasts are floating. Hawaiians are surfing the curl in my kitchen.  We have so been there done, that.  I am stupefied.  The last time I did this, I was able to hide it from my wife.  The oak floor boards are now warped to the point where they now look more like bread bowls from the Plymouth colonies than boards.

I wish I spent my days inventing this material.  It’s difficult to understand, but in spite of my ineptitude, I am allowed to vote to determine who will be the next president.  I have become a Mensa wanna-be gone amuck.

Where does this leave us?  There are no second chances with healthcare reform, EHR, or HIT.  We are talking about gazillions of dollars and people whose lives depend on the outcome.  This is an economy shifting moment.  This is our paradigm shift.  ess it up and we will all be saying, “shift happens”

saint

The real role of the C-suite in selecting an EHR vendor

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Cool Hand Luke.  Great guy film, not on Oprah’s chick flick list.  “What we have here is a failure to communicate.” That’s the line spoken by the captain of the prison pronouncing his summary judgment of the problem between he and Luke—Paul Newman: the line refers to Luke failing to understand the one-way nature of the communication between the chain gang prison captain and Luke. The line is an opening for a second speech directed to the other prisoners who are watching the abuse. The captain goes on to say “Some men you just can’t reach.”

A failure to communicate. Indeed. It’s not always obvious where to place the blame. For example. I had pulled together a pile of my clothes to donate to Goodwill; suits, blazers, pants—the usual mélange. Next to them, several feet away, on top of the ironing board, were two of my new suits, a taupe, double-breasted Jones of New York, and an Ungaro Uomo Parisian pinstripe—they were destined for the cleaners. Stop me if you’ve heard this one before. Seeing the pile on the floor, my wife offered to drop my donated items at the Goodwill.

It wasn’t until later that same day that I thanked her for dropping my suits at the dry cleaner, at which point the quisling replied with a look that told me she did not know that of which I spoke. A failure to communicate. All of my suits, those destined for Goodwill, and the two destined for the drycleaner had done an Elvis and left the building.  Poof, nada, nothing.  Disappeared into the fashion catwalk abyss.  Never mind that I was planning to wear the pinstripe to a rather important meeting.  Wave goodbye to the suits.

Two intelligent people separated by a common language.  Dictionary dot calm defines that as marriage.  Mars and Venus.  In our case it was Goodwill versus Chin’s drycleaner—that’s not racist, just the name of the business.

Two intelligent people separated by a common language.  Like healthcare providers and vendors. Like the IT and the hospital’s C-suite. If A implies B, and B implies C, then maybe B is just intended to be a clever roadblock. Maybe the C-suite invented B so they didn’t have to deal with A—vendors. It sure seems like it sometimes. If the C-suite was really interested in selecting the best EHR, they should start by listening and learning to the clinicians and those in IT.

black saint 2

The effect of healthcare reform on others

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"Not a real boy"

"Not a real boy"

Somebody had to do this, so it may as well be me.  Sometimes to bring clarity to issues, it helps me if I dumb-it-down.  Which got me to wondering, how would the whole healthcare reform debate play out with Mother Goose?  Here’s what I was able to learn from my interviews.

Jack & Jill went up the hill, Jack fell down, and learned Mother Goose’s insurance wouldn’t cover him because he’s not a real boy.  Having recovered, Jack was soon found not so nimbly jumping over the candlestick.  His charred wooden body is being sanded in an effort to heal the burns.  Not only is Jack not a real boy, he’s also not a candidate for Mensa.

They sent the Little Old Woman who lived in the shoe home with a can of Desenex because her AARP insurance had expired and Medicare told her she already used her share of the money.  Afterwards, she was interviewed by Planned Parenthood for an episode of “I didn’t know I was pregnant.”

And remember that tuffet upon which Little Miss Muffet sat?  It wasn’t the spider who frightened her away, it was the deductible she’d hay to pay to cover the rash she got.  She tried sussing out her own treatment using social media on WebMd.

Jack Sprat could eat no fat, but he forgot to disclose that when he completed his insurance application.  He now suffers anemia anonymously as his not so lean wife left him.

How about Peter Peter Pumpkin eater?  All that fiber blocked his colon—a little personal prevention could have saved him a lot of time posed in the Thinker position.

Mary and Little Bo-Peep had a little mutton for dinner which after having sat on the counter all day produced various toxins which were absorbed into their bloodstream.  This resulted in them being rushed to the Mother Goose Clinic with a case of food poisoning.

Simple Simon met a pieman who knew nothing of pasteurization.  Simple is sitting three seats away from Mary in the waiting room.  The Clinic has been unable to locate either of their records on their EHR which cost in excess of one hundred million dollars.

Old King Cole called for his pipe even though he had a severe case of sinusitis.  CVS was out of Z-packs, and home he went with just a tin of Prince Albert.

All the king’s men tried to make a meal out of Mr. Dumpty.  Several were to learn later that one can get Salmonella from eating a raw egg that had been tromped on by horses.

Pat-a-cake.  The baker’s man, not one for washing his hands before pattying his cakes, caused Tommy to be seen by an internist.  Apparently neither real men nor cartoon men wash there hands.

The Butcher, the Baker, and the Candlestick-Maker, were being treated for nontuberculous mycobacterial disease for poor hygiene having been found bathing together.

It was reported that Georgie Porgie who’d been kissing girls had made them cry when they discovered they had contracted the herpes simplex virus.  Their mother, embarrassed by the turn of events, reported to the school that her twins were out with the H1N1 virus.

The Three Blind Mice were found to have stitched themselves together after unsuccessfully trying to sew back on each other’s tails.  It was later discovered that the tails had been cut off by the Farmer’s wife with the Butcher’s knife.  The mice are suffering from septicemia.  The Crooked Man and Yankee Doodle are trying to ascertain why the Farmer’s Wife and the Butcher were later found hiding in the barn.  The Farmer’s wife is being treated with Effexor on an out-patient basis for clinical depression.  The Farmer was not available for comment.

It’s believed that Willie Winkie is suffering from a plantar wart after running through the town in just his nightgown.  Uninsured, he tried removing the wart with the knife he’d borrowed from the Butcher, only learn the knife had been recently use to amputate the tails of some handicapped mice.

Old Mother Hubbard, a spinster of questionable repute, upon learning that there were no bones in the cupboard for her dog Hannibal, began to get hungry herself.  She settled for a meaty broth, and fava bean soup, and a nice Chianti.  Polly was seen putting on the kettle.  The SPCA continues to look for Ms. Hubbard’s dog.

saint