EHR: Got a few minutes?

Before we get started…I am on the plane yesterday, sitting in a middle seat.  An attractive woman fights her way down the aisle and sits next to me.  Five minutes later it happens again.  I felt like I had just won the USAir lottery.  The man who sits directly in front of me looks like the Taliban’s Mullah Omar, including the black turban.  Across the aisle is a screaming four-year-old.  For a second, I thought about executing a Jet-Blue exit strategy and deploying the emergency exit slide.

At a business dinner last night, we got into a conversation about driving habits.  The young woman across from me was explaining an incident for which she was pulled over for driving 94 miles an hour in her convertible Mercedes.  When the police officer asked her why she was driving so fast she told the officer she was trying to dry her hair.

Let’s roll back a few hours.  Got the time?

I am sitting at the airport holding my two two-dollar bottles of water scanning my options from among the array of shops.  Fast food.  The guy sitting across from me looked like he was eating Jell-O made from kelp.

Sundries.   Clothing, MSNBC—when did they get into retail?  Shoes, laptop devices, every possible cell phone accessory.  A nifty collection of watches at some kiosk.

A few years back I bought a Polar watch to help me track my running.  It measures heart rate, altitude, temperature, distance, rate, laps, and tracks and calculates my average pace.  What do I use it for when I run—the time—never took the time to learn how to use the other functions?

I also have a few antique watches—the kind you have to wind.  The only thing they do is keep time.  Then there is my Tag Heuer—a name I am not able to pronounce.  It is waterproof down to 300 meters.  I quit diving four years before I even found the watch—but it seems to work well in the shower.  It appears to have more Jewels in the back than the crown of a dictator from a third-world country.

The next time you are in a meeting, or sitting across from someone, look at their watch and see if you can read the time.  You may be able to estimate how much they paid for it by how much exposure it has on their wrist.  Some watches look like they have enough gadgetry to have been a prop in a Bond movie.  Altimeter, lunar phases, time zones in countries to which they have never traveled.  The face of the watch is so decked-out with features and functions that have nothing to do with keeping time that you may as well settle for knowing the moon is waxing.

My Polar watch is an allegory for EHRs that are failing and underperforming.  Lots of features, very little utility.  EHR implementations that do well seem to be those designed to go shallow on functionality and cut a wide swath utility.  Those that go deep into the functionality and narrow on utility are gathering dust.

Is there any good news?  Sure—when you turn on the computer monitor, you’ll notice a little digital clock in the lower right corner.  You may have wasted $200 million on the EHR, but you’ll always know the right time.

Kind Regards,

Paul

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

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How’s the national EHR roll-out going?


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

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

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

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

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

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

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

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

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

Kind Regards,
Paul

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

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EHR: What’s in it for me?

Field of Dreams.  Best guy movie of all times?  Forgive me, but I don’t usually start my day being PC.  (I don’t end it that way either.)  Pardon me as I wipe a tear.  Want to have a catch Dad?  For those of you whose minds don’t immediately shift to the shooting of Old Yellar, you’re on the wrong blog.

First there’s the field.  It’s green.  The same green God made when he made green.  There’s a cross-hatched pattern to the cut, the white lines brilliantly juxtaposed.  The air smells of peanuts and dogs.

Baseball, as spoken by James Earl Jones:

“Ray. People will come, Ray. They’ll come to Iowa for reasons they can’t even fathom. They’ll turn into your driveway, not knowing for sure why they’re doing it. They’ll arrive at your door, as innocent as children, longing for the past. Of course, we won’t mind if you look around, you’ll say. It’s only $20 per person. They’ll pass over the money without even thinking about it: for it is money they have and peace they lack…And they’ll walk off to the bleachers and sit in their short sleeves on a perfect afternoon. They’ll find they have reserved seats somewhere along one of the baselines where they sat when they were children, and cheered their heroes. And they’ll watch the game, and it’ll be as if they’d dipped themselves in magic waters. The memories will be so thick, they’ll have to brush them away from their faces… People will come, Ray…The one constant through all the years, Ray, has been baseball. America has rolled by like an army of steamrollers; it has been erased like a blackboard, rebuilt, and erased again. But baseball has marked the time. This field, this game, is a part of our past, Ray. It reminds us of all that once was good, and it could be again. Ohhhh, people will come, Ray. People will most definitely come…”

This is the twelve step nightmare for anyone who had a father.  At the end of the movie there is a dialog between Ray Kinsella and Shoeless Joe Jackson:

Ray Kinsella: I did it all. I listened to the voices, I did what they told me, and not once did I ask what’s in it for me.
Shoeless Joe Jackson: What are you saying, Ray?
Ray Kinsella: I’m saying? What’s in it for me?

Amidst all the confusion, amidst all the regulation, where does that leave you?  Ask, “What’s in it for me?”  What’s in it is whatever you put into it.  Drive this process to your benefit.  Build an EHR because it benefits you, not because it’s forced upon you.

EHR Short Cuts

How able are you to conjure up your most brainless moment—don’t worry, we aren’t on the EHR part yet.

As I was running in San Diego I was passed by a harem of seals—Navy Seals.  Some of them were in better shape than me, I couldn’t judge the fitness of the others as they ran by me too fast.  That got me thinking.  For those who having been regular readers, you’ll know this is where I have a tendency to drive myself over a cliff.

Seeing the Seals took me back to my wistful days as a cadet at the US Air Force Academy.  Coincidentally, my hair looked then a lot like it looks now.  One of the many pastimes they tossed our way for their amusement and our survival was orienteering; sort of map reading on steroids.  One night they took us to the foothills of the Colorado Rockies, paired off the doolies, gave us a set of map coordinates, a compass, map, and flashlight.  The way training worked, those who proved to be the fastest at mastering skills fared better than those who weren’t.  Hence, there was plenty of incentive to outperform everyone; including getting yourself to believe you could do things better than you could, sort of a confidence building program.

We were deposited in a large copse—I’ve always liked that word—of trees—I don’t know, but it seems adding trees to the phrase is somewhat redundant.  We had to orient ourselves and then figure out how to get to five consecutive locations.  The sun had long since set as we made our way through the treed canyon and back up a steep ravine.  After some moments of searching we found the marker indicating we were at point Able.  The group started to examine the information that would direct our journey to point Bravo.

While they honed their skills, I was examining the map, taking some bearings with the compass, and trying to judge the terrain via the moonlight.  My roommate, a tall lanky kid from Dothan, Alabama asked why I didn’t appear to be helping.

“Look at this,” I replied.  “Do you see that light over there, just to the right of that bluff?  I think I’ve found us a shortcut.”

“What about it?”  Asked Dothan.

“If my calculations are correct, that light is about here,” I said and showed them on my map.  “It can’t be more than a hundred yards from point Delta.”

“So?”

“So why go from Alpha to Bravo to Charlie to Delta, if we can go right to Delta from here?  That will knock off at least an hour.”  I had to show my calculations a few times to turn them into believers, but one by one they came aboard.  The moon disappeared behind an entire bank of thunderheads.  We were uniformly upbeat as we made our way in the growing blackness through the national forest.  Unlike the way most rains begin, that night the sky seemed to open upon us like a burst paper bag.

“Get our bearing,” I instructed Dothan.  As it was my idea, I was now the de facto leader.  As we were in a gully, getting our bearings required Dothan to climb a large evergreen.

“I don’t see it,” he hollered over the wind-swept rain squalls.  I scurried up, certain that he was either an idiot or blind.

“Do you see the light?”  They asked me.  I looked again.  Checked my map.  Checked my compass.  “It has to be there,” I yelled.

A voice floated up to me.  To me I thought it probably sounded a lot like the voice Moses heard from God as he was building the Ark.  (Just checking to see if you’re paying attention.)  “What if they turned off the light?”

I almost fell out of the tree like an apple testing the laws of gravity.  What if someone had turned off the light?  There was no ‘what if’ to consider.  That is exactly what happened.  Some inconsiderate homeowner had turned off their porch light and left us stranded.

Fast forward.  We were lost, real lost.  We didn’t finish last, but we did earn extra exercise the next day, penalized for being creative.  Who’da thunk it?

Short cuts.  When they work, you’re a headliner.  When they fail, chances are you’re also a headliner—writing the wrong kind of headlines.  I hate being redundant, but with EHR we may be dealing with the single largest expenditure in your organization.  It will cost twice as much to do it over as it will to do it right.  If you haven’t done this before—I won’t embarrass anyone by asking for a show of hands—every extra day you add to the planning process will come back to you several fold.  There may be short cuts you can take, but planning should not be one of them.  How much should we plan?  How long should it take?  Who should participate?  We will look at each of those questions in some detail.  For now, let’s answer those three questions with; more than you think, longer than you’ve planned for it to take, and different skills than you’re currently using.

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

My profiles: LinkedInTwitter
My blog: Healthcare IT Strategy My thoughts on “One EMR Vendor’s View of Meaningful Use”

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

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

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

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

  • Is it necessary?
  • Is it sufficient?

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

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

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

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

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

Some vendors are like a fine wine

Have a vendor for dinner tonight.

Fashion can be reinvented every 6 months, healthcare can’t.

That’s plenty of reason to try to get EHR/HIT right.  Remember this little principle; DIRT-FIT–Do It Right The First Time.  Don’t know how?  There are some who do.  There is even a larger group who think they do.  If you look pretenders in the eye, sometimes they blink.  Some vendors are like a fine wine—you have to stomp on them and keep them in the dark until they’re ready to have for dinner.  To be fair, they may feel the same way about me.

A vendor client of mine mentioned their customers told them the vendor did not understand their customer’s business. The vendor thought the customer’s comments were unfounded–their basis for believing this is that they had been in the business for years.  I told the CEO I would buy dinner for everyone in their firm who previously worked on the clinical side of a healthcare provider.

I ate by myself, no wine.  A nice Chianti served with a side of fava beans would have been nice.  Clarice?
Kind Regards,

Paul

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

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Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

EHR–One time at band camp…

Like many of you, I see two distinct groups who do not play well in the same sandbox—clinical and IT.  Having clinicians go to the HIT summer camp to pick up a few skills is not the same as pulling a few costly and hairy projects from the bowels of project hell any more than it would be to have an IT executive take an EMT course and then assume that person was qualified to perform surgery—this one time at band camp…

Before I get up on my stool and knock myself off, I know CMIOs and CIOs who have made HIT and EHR very successful.  To them I ask, do not rake me across the Twitter coals as I try to make a point.

There’s knowledge, and then there’s qualified.  Doctors do four years of medical school, they intern, and if they specialize, they throw in a few more years before they become the in-charge.  Years of training and practice before the doctor is allowed to run the show.  Why?  Because what they are about to undertake requires practice, tutelage, and expertise.  Most of the actual learning occurs outside the classroom.

There are those who suggest the skills needed to manage successfully something as foreboding as full-blown EHR can be picked up at HIT Camp.  This does a disservice to seasoned IT professionals.

Most large IT projects fail.  Large EHR projects fail at an even higher rate.  Most clinical procedures do not fail, even the risky ones.

What’s the spin line from this discussion?

  • Rule 1—large EHR projects fail at an alarming rate
  • Rule 2—sending a clinician to band camp probably won’t change rule one

Don’t believe me?  Ask friends in other industries how their implementation of an ERP or manufacturing system went.  There are consulting firms who make a bundle doing disaster recovery work on failed IT projects.  They line the halls like turkey vultures waiting for CIO or project manager carrion.

Back to Rule 1 for a moment.  How can I state that with such assurance?  Never before in the history of before—I know that’s not a proper phrase—has any single industry attempted to use IT to:

  • impart such radical charge (patients, doctors, employees)
  • impart it on a national basis
  • hit moving and poorly defined targets—interoperability, meaningful use, certification
  • take guidance from nobody—there is no EHR decider
  • implement a solution from amongst hundreds of vendors
  • implement a solution with no standards
  • move from an industry at 0.2 to 2.0 business practices
  • concurrently reform the entire industry

Just what should a CMIO be able to do?  What are the standards for a CMIO?  To me, they vary widely.  Is a CMIO considered an officer in the same sense as the other “O’s” in the organization, or is it simply a naming convention?  The answer to that question probably depends on the provider.

Here’s how I think it should work—I realize nobody has asked for my opinion, but this way I’ll at least provide good fodder for those who are so bold as to put their disagreement in writing.

I love the concept of the CMIO and think it is essential to move the provider’s organization from the 0.2 model to the 2.0 model.  Same with the CIO.  However, getting them to pool their efforts on something like EHR is likely to fail as soon as one is placed in a position of authority over the other.  It’s sort of like getting the Americans and French to like one another.

I liken the CMIO’s value-add to that of the person providing the color commentary on ESPN—it adds meaning and relevancy.  The CMIO owns and answers a lot of the “what” and the CIO owns and answers a lot of the “How”.

Still unanswered are the “Why” and “When”.  A resource is needed who can state with assurance, “Follow me.  Tomorrow we will do this because this is what needs to be done tomorrow.”  That skill comes from an experienced Project Management Officer, the PMO.  It does not come from someone who “we think can handle the job.”  Nobody will respect a PMO’s  ability if they do not have the requisite expertise.  EHR needs someone who can state from their experience, “One time at band camp…”   If the EHR can’t lead, or the team is not willing to follow the PMO, you can plan on doing the project over.

How does Heisenberg’s Uncertainty Principle affect EHR?

One of the great things about social media is its ability to infer attributes of both the readers and the writer.  When you finally meet your virtual pen pal the mind wanders—I thought he sounded taller.

There are those among us who when they picture me writing, see me sitting at my desk, wearing my baby seal-skin slippers, and supping on a bowl of loggerhead turtle soup.

Segue.

According to Heisenberg’s Uncertainty Principle (used in physics) certain pairs of physical properties cannot both be determined simultaneously.  That is, the more precisely one property is known, the less precisely the other can be measured. For instance, the next time you are standing by the side of the road, and cars are whizzing by you, try to decipher the speed of the car, and its exact location.  If I remember my math correctly, the first derivative is its velocity, the second, its acceleration.  To know exactly where the car is at a precise moment in time, the car must be stationary—as in not moving.  Thus, to ascertain its position, the position must be fixed.  The Heisenberg Uncertainty Principle requires that for someone to determine B, A must cease to be a variable.

The Uncertainty Principle can be represented as something like this:

One can see that as additional properties are tossed into the mix the probability of predicting any particular outcome goes to zero.

Thus follows Roemer’s EHR Uncertainty Principle—if you don’t know where you are going, you arrived a long time ago (A little like Pink Floyd’s, “How can you have any pudding if you don’t eat your meat?”).

The conflicting principles include;

·         Implementation date

·         Completion date

·         Final cost

·         Your functional requirements

·         The vendor’s capabilities

·         Acceptance testing

·         What should the EHR do

·         How do you know when you are done

·         Should you meet Meaningful Use

·         Will you receive the ARRA money

Here is the point of the allegory.  The chances of a physician group or hospital knowing the answer to all but one of the above principles are zero.

Permit me to throw a wrench into the loggerhead soup and let you know that not having the answers to all but one of the variables is okay.  That is the way projects work.

Since most of you implementing EHR have not ‘been-there, done-that’ with respect to implementing EHR, it is reasonable to expect there are more unknowns than knowns (spell-check indicates that it is not a word, but I know you are keeping up with me).

So, how can you use Heisenberg’s Uncertainty Principle to your advantage?  It is actually rather simple.  Do not allow your implementation to be guided by the unknowns.

·         Do not set an arbitrary budget for something you have never purchased

·         Do not set an arbitrary implementation deadline

Do what you must to make sure you implement an ERH that does what you need it to do.  Do not let yourself be constrained by principles whose only possible effect will be to derail your project.

If you are willing to take that risk, the other principles become moot (the correct terms is moot, not mute—look it up—sorry about the preposition).

If all else fails, consider getting a pair of the seal-skin slippers.

Paul M. Roemer

Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335

+1 (484) 885-6942

paulroemer@healthcareitstrategy.com

My profiles: 

My blog: Healthcare IT Strategy How to Revive a Failed EHR Implementation

How to Revive a Failed EHR Implementation

My latest post on www.healthsystemCIO.com.  Here’s an idea I think merits consideration.

http://healthsystemcio.com/2010/07/30/how-to-revive-a-failed-ehr-implementation/

What do you think?

Finally, an EMR worthy of a T-shirt

Those who are regular readers know I’ve commented on more than one occasion that you never see anyone at the HIMSS convention walking around wearing a T-shirt imprinted with the slogan, “I love my EPIC”, or one stating, “McKesson forever”–unless they were talking about the implementation plan.

Today, my perspective changed–I’m going to start selling T-shirts printed with the phrase, “SRS-Soft Rocks my Docs.”

You may ask, ‘Who is SRSSoft’?  Fair question.  I could not have given an adequate response to that question prior to today.

I spent some time with them, ran their demo–I played doctor but they stopped me before I was able to insert a chest tube.  I ran the demo.  Why is that important?  It went like this.

“So, if you were a doctor, what would you do?”

With enthusiastic anticipation, I searched for my scalpel–that wasn’t what he meant.  “I’d see who my next patient is.”

“Do it.”  (Mind you, all of what I am doing happens on one screen faster than a sneeze.)  I clicked the schedule and up popped all the patient’s information.

“Next?”

“I’d probably want to review their chart.”

“Do it.”  (Don’t try this at home unless you are a devotee of Scrubs or other medical training.

Same screen, up pops the chart.

“Next?”

I click on the notes from their last visit, compare their labs by pulling up a comparison chart–new versus old; scan the X-RAY, and review their list of medications.  I did this all on one page and figured out in less time than it took you to read this.  We did the demo using two screens.  That way, if I am describing what I am seeing to the patient on their X-RAY, instead of holding the film up at the ceiling and hoping my patient understand what I am talking about, I point to it with my mouse and let the patient see it one their screen.

Tomorrow I was going to issue an EHR RFP for a small clinic.  Not any more.  No point in having them pay me to hunt down a solution when I’ve already found one.  Did I mention you can also get it with a world-class practice management system?

So what makes me think this EMR can handle a practice size of up to a few hundred doctors?  Let me try to summarize its benefits with the following.  If we separate healthcare into two arenas–the business of healthcare (the business side) and the healthcare business (the clinical side)–this EMR is so well designed, it makes the mundane business tasks almost invisible to the doctor.  Instead of spending twenty percent of each day moving charts, filling out forms, sending faxes, dictating and transcribing notes, the clinical team can either spend more time with their patients or see more patients.

Now, let me tell you about their secret sauce, part of what makes it so special.  You are going to think I’ve lost my mind when you read this.

One of the first questions most doctors are going to ask a vendor is whether or not the system is certified.  (Do not repeat this to anyone–that is why I am writing in parentheses–this system is not certified.  They have no plans to get it certified.)  Why?  Because certification is as relevant to the value of an EMR as agriculture is to bull fighting.  Certification will not improve care, will not enhance the doctor patient relationship, it will not improve the patient experience, it will not increase productivity.  Certification does one thing.  It enables you to get a check provided that your EMR implementation does not fail, provided that you pass the Meaningful Use audit, and provided you are willing to upgrade your existing system to your vendor’s new and improved certifiable version.  That certifiably makes little to no business sense.

Anyway, if you want a system that makes the stuff you hate doing go away, take a look at this.

I’ve also written about way hospital EHRs fail.  A big reason for their failure is the drop in productivity they experience, and a lack of acceptance from the doctors.  Sort of makes me wonder if they could use this tool as a front-end for those big pricey EHRs.

Me, I printing T-shirts.  PayPal accepted.