CIOs, Others React To Meaningful Use Final Rule

CIOs, Others React To Meaningful Use Final Rule. InformationWeek Healthcare–my comments http://ow.ly/2bS4D

EHR–where do you place the emphasis?

You said I stole the money. Sometimes it all depends on what you emphasize. For example, say the sentence aloud to a friend, and each time place the emphasis on a new word. You said I stole the money. You said I stole the money. You said I stole the money. You said I stole the money. You said I stole the money. The meaning changes as you change your emphasis. You said I stole the money? You can even change it so that it reads like a question.

The same is true with providers and the level of success a firm has working with EHR. Where is your emphasis? If you believe there is a correlation between emphasis and spending, I bet we can prove your firm’s is much more closely aligned to technology than it is to process. What does technology address? Let’s list how deploying technology makes your firm better, or does it? Millions followed by millions more. Redesign the patient portal. Add EHR. Mine the data—heck, strip mine it. Show me the ROI. Isn’t that a lot of money to spend without a corresponding business justification?

The technology that is tossed at the problem reminds me of the scene from the “Wizard of Oz” when the Wizard instructs Dorothy and the others, “Pay no attention to the man behind the curtain.” When Toto pulls the curtain aside, we see a nibblet—I love that word—of a man standing in front of a technological marvel. What’s he doing? He’s trying to make an impression with smoke and mirrors, and he’s hoping nobody notices that the Great Oz is a phony, that his technology brings nothing to help them complete their mission.

From whose budget do these technology dollars usually come? IT. From the office of the CIO. What did you get for those millions? Just asking.

Part of the problem with doing something worth doing on the EHR front is that it requires something you can’t touch, there’s no brochure for it, and you can’t plug it in. It’s process. It requires soft skills and the courage to change your firm’s emphasis. They won’t like doing it, but they will love the results.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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Why buy an EHR system?

Posted by Paul Roemer

Do you ever wonder why people buy drills? Because they need a drill? No.

They buy drills because they don’t sell holes.

Why buy an EHR system? Because you need an EHR?

I hope you have a better reason than that. If you’re interested, I sell holes.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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Where workflow goes to die

Posted by Paul Roemer

There are two types of business processes; easily repeatable processes (ERP), and Barely repeatable processes. Most of the real work that needs to be done in EHR workflow improvement happens in the blank white space between the boxes on the org chart. That’s where you’ll find a lot of the BRPs–Barely Repeatable Processes.

It is easy to automate the ERPs, and nearly impossible to automate the BRPs. If you can’t reform either set of processes with your EHR all you have implemented is a very expensive chart scanner.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
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EHR’s Gordian Knot

Posted by Paul Roemer

There were four of us, each wearing dark suits and sunglasses, uniformly walking down the street, pausing at a cross-walk labeled “consultants only”—I think it’s a trick because a lot of drivers seem to speed up when they see us. We looked like a bad outtake from the movie Reservoir Dogs. We look like that a lot.

Why do you consult, some ask? It beats sitting home listening to Michael Bolton or practicing my moves for, So You Think You Can Dance, I tell them.

Listening to the BBC World News on NPR whilst driving, there’s one thing I always come away with—they’re always so…so British. No matter the subject—war or recession—I feel like I should be having a proper pot of tea and little cucumber sandwiches with the crusts removed; no small feat while navigating the road.

Today’s conversation included a little homily about the Gordian knot with which the company Timberland is wrestling, questioning whether as a company Timberland should do well, or do good. (Alexander the Great attempted to untie such a knot, and discovered it had no end (sort of like a Möbius strip, a one-sided piece of paper–pictured above. (For the truly obtuse, among which I count myself, the piece of paper can be given a half twist in two directions; clockwise and counter-clockwise, thereby giving it handedness, making it chiral—when the narrative gets goofy enough, sooner or later the Word dictionary surrenders as it did with chiral.))) I’m done speaking in parentheses.

Should they do well or good? Knowing what little command some people have of the English language, those listeners must have wondered, why ask a redundant question. Why indeed? That’s why I love the English, no matter the circumstances they, they refuse to stoop to speaking American.

Back to Gordo and his knot. That was the point of the knot. One could not have both—sorry for the homonym. Alexander knew that since the knot had no end, the only way to untie it was to cut it. The Gordian knot is often used as a metaphor for an intractable problem, and the solution is called the “Alexandrian solution”.

To the question; Well or good. Good or evil. Are the two choices mutually exclusive? For an EHR? They need not be. The question raised by the BBC was revenue-focused (doing well) versus community or green-focused (doing good). My question to the reader is what happens if we view EHR with this issue as an implication, a la p→q.Let’s review a truth table:

if P equals	if Q equals	p→q is
define requirements	increase revenues	TRUE
play vendor darts	increase revenues	FALSE
ignore change management	increase revenues	FALSE
no connectivuty	increase revenues	FALSE
new EHR software	increase revenues	FALSE
change processes	increase revenues	TRUE
eliminate waste	increase revenues	TRUE
decrease redundancy	increase revenues	TRUE
Strong PMO	increase revenues	TRUE

From a healthcare provider’s perspective the answers can be surprising; EHR can be well and good, or not well and not good. The Alexandrian solution for EHR is a Alexandrian PMO.

Have your people call my people–we’ll do lunch.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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The EHR Certification Myth

Posted by Paul Roemer

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial–like Kojak without the warmth.

Why is this a part of the overall plan? Is this planned failure? Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Let’s describe two failure types; certification and Full test. The certification test, by definition, is necessary. The Full test is both necessary and sufficient. It is possible to pass certification without passing the Full test. Therefore, the Full test is a stricter test. Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test? Same as always. Fully functional, on time, within budget, and user accepted. Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact: One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion: The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations. Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification. (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact: Most large, complex, expensive IT projects fail—they just do. This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed. Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion: Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak? You bet. Insurmountable? Doesn’t have to be.

What can you do to improve your chances of success? Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points. EHR Fail Safe Points? The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test. The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD. They need not have a slew of EHR implementation merit badges. The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built. They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR. Those skills are needed—in spades—and you need to budget for them. The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre. They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

What do you think?

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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Why is EHR not the right answer?

Posted by Paul Roemer

The reason I chose to share this story is my belief that it is de rigueur among practitioners. I have been spending some of my time working on behalf of a small clinic. Four doctors, two offices, small lab, x-rays, some surgeries.

Great people, great mission. Every physician spends several weeks each year doing unpaid missionary work in Africa and South America. Their focus is caring, not dollars. It is not my job to change their focus. They do not turn away anyone who cannot pay. Staff at the front desk help patients pay for their meds. The four physicians routinely offer services and perform procedures for which they know they will not be paid. I feel a real sense of pride helping them, and have slashed my rates to make sure they get the help they need without taking money unnecessarily from their coffers. Their patients love them, and they add about a hundred new patients a month.

The business side of their practice could have been designed by Rube Goldberg. As I interview the doctors, the nurses, the lab, and the front desk about the practice, I try to do so with a straight face, try not to betray the part of me that wants to say, “You’re kidding, right?”

They meet with about fourteen-hundred pharmaceutical reps each year. I tried to pin down why they do it, but could not come up with an answer to support a business reason. Since the pharma reps can no longer offer trinkets equivalent to those needed to purchase Manhattan, they give away lunch. Enough lunches to ensure that everyone in the practice should weigh eight-hundred pounds.

They use the F-word a lot—faxes. Two fax machines running often enough that without proper cooling they would melt through the floor. The average fax is handled eight times before it is placed in the patient’s chart.

There is no email, no web site. There is no triage—docs and nurses do not screen patient phone calls to determine who needs to be seen. Seventy-five patients a day, two and a half people are full time on billing. Three people man—actually, it should be “woman”, the front desk. (Is that an intransitive verb, or simply poor writing on my part?) The staff wants more staff.

I have been hired to help them with the selection and implementation of their EHR. I can solve the EHR problem in five minutes, but I won’t. Having an EHR will solve none of their problems, at least not until they turn what they do into a business.

Realigning their business processes will do more for their mission than any EHR. Processes are inefficient and ineffective. I cannot figure out how they collect money or pay bills.

I am willing to bet they are not alone in having these issues. I’d bet that these problems can be extrapolated to hospitals. Is Practice Management more important to physicians than EHR? My guess is that the right answer is yes.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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EHR, where’s my hammer?

Posted by Paul Roemer

Those of you who’ve visited previously may have caught on to the fact that my wife likes to keep me away from bright shiny objects such as tools. Let me tell you about my first house, a two-story stucco building in Denver, built in 1902. My favorite part of the home was the brick wall. That is had a brick wall was not apparent when I purchased it.

I came home from work to find that my dog had eaten through the lath and plaster in the living room and there was the brick. I had to decide what to do. I knew nothing about lathing—I know that’s not really a word—or plastering. What to do. My only tool was a hammer, so I began to hammer. For those who haven’t done this, hundred year old plaster being pounded with a hammer makes a lot of dust. This process proved to be very slow.

What did I do? I bought a bigger hammer—such a guy approach to a problem, isn’t it? It took three hammers to get down to just bare brick. What would you have done? When your only tool is a hammer every problem looks like a nail.

As you go through the EHR planning process in your war room—you do have a war room, don’t you? (Try Sam’s Club, after all, they sell EHRs.) Get out the really big piece of paper, the one with your EHR design—you do have a really big piece of paper, don’t you? (Back to Sam’s.)

Next to the box on the paper labeled “Shiny New EHR” should be lots of empty space so you can draw in all of the other systems with which your EHR will have to interface. One of the readers of this blog wrote recently that his EHR had more than 400 interfaces.

EHR, if done correctly, will do much for patients, doctors, and administrators. It’s not a panacea. It won’t reach its potential unless you also integrate it with those systems that unlock its potential. Improving your efficiency and effectiveness takes more than merely an EHR system.

When your only tool is a hammer, you’d better hope every problem is a nail. What other tools are you using? Please share your ideas about what works well.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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What if GM were involved in EHR?

Posted by Paul Roemer

Goodness knows, the whole car thing did not work our too well for them

Do you ever think about the origination of some of your ideas? For me, the good and the bad just seem to materialize. Like the time a friend and I were hiking a peak in the Sangre de Cristo range in Colorado. It had taken the better part of six hours of circuitous climbing to reach the summit. It was late in the fall, and the temperatures were around freezing. Roiling storm clouds were racing towards us from the west.

If we returned by the same route we knew we’d be caught up in a storm that we were neither prepared nor dressed to handle. I spotted our car about six thousand feet below us. If we headed straight to it, I thought we could cut our descent time by about an hour. To do this though required that we make our own trail via a hunt and peck route of whatever the terrain permitted. We dropped the first fifteen hundred feet in a matter of twenty minutes using a glissade. This technique allows you to moonwalk and slide down a scree field, using your ice ax as a break.

After an hour we reached a point about two thousand feet above our car. It was sleeting, and the wind was whipping around the face of the mountain. There in the middle of nowhere stood a sign from the sheriff that read, “Devil’s Gulch, turn back.” Our choice was to reclimb the mountain or to ignore the sign and press on. I hate do-overs. How tough can this be, I goaded him? Be smart, kick it into high gear, and we’ll be done.

We pressed forward. Fifteen minutes later, we reached a four hundred foot limestone cliff. Between us and the next semi-reasonable terrain was a rather deadly looking wall of rock and scrub pine. My pack made me feel like it was forcing me forward, so I removed it and tossed it over, thinking I’d retrieve it later. Watching my pack bound from rock to rock for what seemed like more than a minute did nothing for putting me at ease.

We spent more time discussing each step than we spent taking it. Those four hundred feet took us two hours. Not my best idea, but it didn’t kill us.

So, during my run today, I had another idea. This one is about OnStar, the GM tracking system. I typed in to Google, “How does OnStar Work?” Lots of hits. The more I read, the more I began to feel like if one ignored the technology and focused on the concept a real argument could be made for pairing the idea, and a few others, and seeing what type of EHR network might be possible using a similar set of tools.

The OnStar concept is termed telematics, a combination of telecommunications and informatics. Telematics is the integration of computing, wireless communications, and GPS. It provides information to a mobile service like a phone, PDA, or laptop. It is used for sending, receiving, and storing information over very large networks. So, why is nobody having the conversation that says what if we image a similar network with added security that works from a healthcare provider’s office rather than a car.

OnStar doesn’t need Rhios. OnStar has a single set of standards. Now, instead of arguing why something like this can’t work in healthcare, isn’t there argument is seeing if it can?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

The EHR Certification Myth

Posted by Paul Roemer

EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

Why is this a part of the overall plan? Is this planned failure? Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Here’s what can be concluded just based on the facts.

Fact: One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Bleak? You bet. Insurmountable? Doesn’t have to be.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

Pale Rhino Consulting

Thought Leadership With A side Order Of Wit: Disrupting Healthcare Consumerism

EHR

CIOs, Others React To Meaningful Use Final Rule

EHR–where do you place the emphasis?

Why buy an EHR system?

Where workflow goes to die

EHR’s Gordian Knot

The EHR Certification Myth

Why is EHR not the right answer?

EHR, where’s my hammer?

What if GM were involved in EHR?

The EHR Certification Myth

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