EHR

How to calculate Meaningful Use’s ROI

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Just to make sure we are all turned to the same page in our Cliff Notes on Meaningful Use, today’s conversation is, “There is no “R” in ROI.”

Are you familiar with the Abilene paradox?  It is a paradox in which a group of people collectively decide on a course of action that is counter to the preferences of any of the individuals in the group.  It involves a common breakdown of group communication in which each member mistakenly believes that their own preferences are counter to the group’s and, therefore, does not raise objections.

I think it occurs more often than we think.  Try to recall the last meeting you attended in which you really disagreed with something that was said.  Chances are you knew some of the others in the meeting well enough to know they also disagreed.  The reason you know they also disagreed is because you had discussed the topic.  However, none of you raised your disagreement during the meeting.  Why?  Because you did not want to rock the boat.

It is similar to a pseudoconsensus.  Pluralistic ignorance.  These create a bystander effect—people are more likely to speak out about an issue when they are alone with someone than when others are present.

After further consideration I think we must consider the very real possibility that there is no ROI for Meaningful Use.  I write this in all sincerity.  Healthcare executives march in lock-step or group think to achieve the myth of finding an ROI for Meaningful Use.  The ROI is healthcare’s quest for the Holy Grail, albeit without the Monty Python sound track.  They cannot proceed without one, so they set the target, figure out what data will demonstrate that they have hit it, and disregard the reams of data that does not support the ROI.

What if the government came out with a standard stating all hospitals ought to buy, install, and use a fifty million dollar transplant device that also flosses the patient’s teeth?  This initiative is “optional”, but the government will pay the hospital a two hundred thousand dollar rebate.  There are several types of transplant flossers—the ones that deliver that fresh mint taste cost extra.

If we were having a business discussion about the ROI for the transplant device, healthcare executives would be foaming at the mouth about how impossible it would be to calculate an ROI, and rightly so.  They would argue all hospitals are different, they have different cost structures, the devices are all different.

The standards for Meaningful Use are arbitrary.  The standards were developed by people who do not need to meet an ROI.  There was no mandate in the development of those standards to create standards which when met would yield an ROI.  Any attempt to force an ROI will naturally differ in a number of ways:

  • by provider—size, structure, offering, geography
  • by their interpretation of Meaningful Use
  • by which EHR they implemented
  • when they began the implementation
  • how well they implemented the EHR

Somebody somewhere may hit a positive ROI on Meaningful Use, just like somebody playing darts may hit a bull’s eye.  Any positive ROI will be accomplished more out of chance, and from having fit the data to a predetermined ROI rather than measuring the ROI against its true impact.

Implementing an EHR can be very good for a hospital.  However, it should be a business decision for the hospital based on the same set of business rules the hospital would use to justify any other large expenditure.  If the hospital achieves an ROI it will not be because of having followed an arbitrary set of standards.  Any ROI for an EHR will come from having done it correctly.  Hitting the figure any other way means two things; it was a coincidence, or you are in for trouble down the road.

saint 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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If you come to a fork in the restaurant…

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In Greek mythology, there was a not so nice man, Procrustes.  He had an iron bed in which he invited wayfaring strangers to spend the night.  Some of the strangers were too long for the bed and others were too short.

Apparently Procrustes liked things orderly and could be a tad anal when learning his guests did not fit.  He would set on them with his smith’s hammer, to stretch the shorter ones to fit.  If the guest proved too tall, Procrustes would amputate the excess length.  Truth be told, nobody ever fit the bed exactly because Procrustes had two beds.

In contemporary terms, a Procrustean Bed is an arbitrary standard to which compliance is forced.  A Procrustean Solution involves fitting a business problem to a preconceived set of strictures.

Raise your hand if you have already figured out where this is headed.  Preconceived.  Arbitrary.  Compliance.  Strictures.

Do you spell Meaningful Use with an upper case Procrustean or one in lower case?  I prefer the upper case.  The business problem being fitted is the implementation of EHR.  The preconceived sets of strictures are the Meaningful Use standards.

This in turn leaves the healthcare provider in what is best described as a Morton’s Fork scenario.  Shall I explain?  A Morton’s Fork is a choice between two equally unattractive alternatives—a dilemma.  The concept originated in 1487 under the rule of Henry the VII as a result of tax policy to ensure everyone paid taxes.  The argument was because the rich had enough money to buy things they must have enough money to pay taxes, and the poor who had bought nothing had saved their money, and thus had money with which to pay taxes.  The two prongs of the fork—back then forks only had two prongs.  Q. E. D.

The healthcare provider must choose between—as one may not choose among—two alternatives.  Attempt to meet Meaningful Use—a Procrustean Solution—turn their business model inside out to meet the government’s Gossamer standards.

Attempting to meet the standards does not ensure they will in fact meet the standards.  Should they only meet ninety-nine percent of the standards, they lose.  The Pareto principle does not apply.  There is no 80:20 rule.  They will not receive any incentive money as Meaningful Use is an all or nothing game.

The second alternative is to not meet Meaningful Use.  This choice may be voluntary, or involuntary—trying to meet Meaningful Use and failing.  Alternative Two—it is said—will result in reimbursement penalties from Medicaid and Medicare.

I do not think those penalties will be implemented, or at least they will not be implemented in the documented timeframe.

I also do not think there is a Morton’s Fork, because I think Meaningful Use will disappear because it is so arbitrary and capricious—and because the number of large providers who will meet it could all drive to lunch at Morton’s in a Yugo, at which time they could dine with a fork from Morton’s.

We have now come full circle.  My work here is through.

saint 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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My latest post to healthsystemCIO.com

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I think there is plenty of merit to quit chasing Meaningful Use and get on with your business.

http://healthsystemcio.com/2010/05/28/ten-catechisms-of-meaningful-use/

saint 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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Is there a business argument for Meaningful Use?

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I remember the first time I entered their home I was taken aback by the clutter. Spent and wet leaves and small branches were strewn across the floors and furniture. Black Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The windows.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.

And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

“Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives. Sort of like all the scurrying around Meaningful Use.  The normal has been subsumed by the abnormal, and in doing so has created an entire entity which is slowing devouring the resources of the organization.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid on a daily basis. When I talk with hospital executives they are marching headstrong into the Meaningful Use abyss.

It makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about it they always have an answer. It all boils down to something like, “We simply can’t turn down the money.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid.  It’s gotten to the point where no matter how goofy things get, as long as they are consistently goofy, there not goofy at all.

This is the mindset that enables leaders to be fooled by their own activity. Busy replaces thinking.

saint 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 wildebeest postulate

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The Kalahari; vast, silent, deadly. The end of the rainy season, the mid-day heat surpasses a hundred and twenty. One of the varieties of waterfowl, most notably the flame red flamingo that nested in the great salt pans in Botswana, has begun its annual migration. In the muck of one of the fresh-water pools that had almost completely evaporated, writhes a squirming black mass of underdeveloped tadpoles. A lone Baobab tree pokes skyward from the middle of the barren savanna. In its shade, standing shoulder to shoulder and facing out, a herd of wildebeest surveys the landscape for predators.  Sir David Attenborough and PBS can’t be far away.

Some things never change. I make my way across the freshly laid macadam to meet the school bus. Fifty feet in front of me is a young silver maple tree, the tips of its green leaves yielding only the slightest hint of the fall colors that are hidden deep within. The late afternoon sun casts a slender shadow across the sodded common area. One by one they come—soccer moms; big moms, little moms, moms who climb on rocks, fat moms, skinny moms, even moms with chicken pox—sorry, I couldn’t stop myself—as they will every day at this same time, seeking protection in its shade. My neighbors.  It’s only seventy-five today, yet they seek protection from the nonexistent heat, a habit born no doubt from bygone sweltering summer days. A ritual. An inability to change. In a few weeks the leaves will fall, yet they will remain in the shadow of what once was, standing shoulder to shoulder facing out, looking for the bus. A herd. Just like wildebeest.

The kids debus–I just made that word, hand me their backpacks, lunch boxes, and hundreds of forms for me to complete.  I look like a Sherpa making my way home from K-2.

I shared this perspective with the moms, and have halted most of my bleeding. I can state with some degree of certainty that they were not impressed with being compared to wildebeest. So here we go, buckle up. By now you’re thinking, “There must be a pony in here somewhere.”

Some things never change; it’s not for lack of interest, but for lack of a changer. For real change to occur someone needs to be the changer, otherwise it’s just a bunch of people standing shoulder to shoulder looking busy. How are you addressing the change that must occur for EHR to be of any value?  EHR is not about the EHR, it’s about moving from a 0.2 business model to 2.0.  Are you chasing ARRA incentive dollars simply because someone is writing a check?

Someone who sees the vision of what is is—sorry, too Clintonian—must lead.  Be change.

One of the great traits of wildebeest is that they are great followers.

saint 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 market share

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The link below takes you to a post written by Software Advice’s Chris Thorman regarding the market share for inpatient and outpatient EHRs.  It is designed to be a collaborative piece, and Chris is asking for feedback and correction.  I found it to be a well-written and helpful piece, perhaps you also will.

http://www.softwareadvice.com/articles/medical/ehr-software-market-share-analysis-1051410/

saint 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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If only doctors were meerly apathetic about EHR

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For those who remember the television show M.A.S.H., this brief bit of dialogue was from Henry Blake to Hawkeye after one of Hawkeye’s patients died.

“There’s two rules about war.  Rule 1–in war young men die.  Rule 2–doctors can’t change Rule 1.”

There’s a similar way to apply that logic when it comes to EHR, HIT, and new IT systems.

Rule 1.  If doctors don’t use them, the systems will die.

Rule 2. Simply having an EHR doesn’t change Rule 1.

A survey by Nuance Communications shows that 90% of doctors are concerned about the usability of EHR.  Those results underscore the importance of process and changemanagement and training.

As I wrote previously, it’s not about the EHR, it’s about what you can do with it.

My person struggle with usability–We have a piano in our home even though nobody plays it.  For some reason I’m not permitted to understand, we pay to have it tuned twice a year.

saint 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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Revising your work flows?

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revised work flowAs a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR? The reason is simple. The taxonomy of most, if not all EHR systems, is that they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

saint 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 Google, Apple & Microsoft will win the EMR battle

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In the next few years, brick and mortar, immobile physician-centric EMRs and EHRs—those large EHR systems implemented by healthcare providers residing on large systems will be supplanted by portable patient-centric EMRs residing on a next generation of super smart devices—we call them smart phones today.  The limited functionality of today’s Personal Health Records (PHRs) will be replaced by these portable patient-centric EMRs; EMRs that are cloud-based and accessed through super functional next generation smart devices—the grandchildren of the iPhone and the Droid.  Why do I think that is the case?  Please keep reading.

Five billion people voluntarily purchased cell phones.  Initially, consumers had to be convinced they needed cell phones.  The uptake was slow.  Something changed, compelling us to buy cell phones.  We initially bought cell phones not because we needed phones, but because we wanted convenience—we bought convenience.  What made it convenient?  Portability.

Not much changed for several years—not until Palm created a phone-sized portable device that could do other cool things.  Then Blackberry took it one step further—a device that could handle basic email and phone calls.

Very recently, piggybacking on the success of the iPod, Apple redefined the market for smart devices.  They did not set out to build a phone, or a web browser, or a MP3 player, or an email client, or a SMS device—or a device designed to do all of those specific tasks.  Instead they built a device capable of doing just one thing—securely and wirelessly sending and receiving ones and zeros.  Those ones and zeros became emails, faxes, internet interaction, downloading and playing music, videos, images, calls, text messages, and data.  Apple also paved the way for other firms to have customers download thousands of other ones and zeroes applications.  The iPhone device simply sends, receives, reads and writes ones and zeroes.

Phone calls on the smart device (the iPhone) are but a small subset of the device’s total usage.  This breakthrough is what I think of as the “Transport Phase,” moving ones and zeros from point A to point B, reassembling them, and recreating the same thing on the other end.

In the last two years, we have seen the maturing of the Transport Phase whereby the device is even smarter, faster, has more storage and actually performs tasks.  It appears to infer and learn.  It is capable of gaming and GPS functions.  It performs more tasks than the computer on the Saturn rocket.  Last year Google made its debut with the Droid.  It is open and operating in a cloud.  The smart device’s features and usage are so ubiquitous that the pricing model commoditized.

Today’s devices can operate more than one hundred thousand apps—including hundreds of medical applications.  The vast majority of the healthcare applications are for doctors and clinicians.  Very few healthcare applications are available to customers (patients) and there is no PHR for any of the devices.

This will change, and change in a big way.  The smart device many call a phone can do things nobody envisioned ten years ago.  Those “experts” were wrong.  We have a new set of experts today.  They claim:

  • PHRs offer little value
  • PHRs have been slowly accepted by the mainstream
  • There are no good healthcare apps on smart devices for patients
  • There are no PHR apps on smart devices
  • There is no such thing as an EMR on a smart device

My take?  They are correct on all five claims—today.  What else of note is underway?  The launch of the iPad.  Bad name choice.  I would have called it the iGoogle, but neither firm would go for that.  Why the iGoogle?  Stick with me on this.  Google is in the process of transcribing every written word and digitizing the great works of art—ones and zeroes.

What did Apple do?  Apple did one thing—their new smart device made Google’s library potable.  Portable.  Ones and zeroes, colored text and images can now reside on a one and a half pound tablet one a device with a thickness of one half inch.  Complaints—it’s not a computer, it cannot take pictures, it cannot make calls.  Not yet.

Yesterday calls (ones and zeroes) were made portable, as were text messages, emails, videos, and GPS.  Tomorrow, today will be yesterday.  Look forward a thousand tomorrows.

What exactly are the electronic medical records flying around in ERHs costing hundreds of millions of dollars?  Ones and zeroes.  Nothing more.  Oh, did I mention these institutionalized EMRs are immobile.  The plan calls for them to be portable—a billion here and a billion there.  Maybe it comes down to what kind of portability you think Americans will adopt.

I think two things are in store for healthcare.  In the near-term, stationary hospital-centric EMRs and EHRs will begin to be replaced with portable patient-centric EMRs residing on super smart devices owned by individuals.  Point two; the limited functionality of today’s immobile Personal Health Records (PHRs) will be replaced by portable patient-centric EMRs, EMRs that are cloud-based and accessed through super functional next generation smart devices.  These devices will be the offspring of the iPhone, the Droid, and the iPad.  EMR functionality will be available, along with the existing functionality on these super smart devices.  Customers will not need to buy a separate device to make their EMRs portable.  They will simply gain access to that functionality when they purchase the next generation phone-camera-notebook-tablet-MP3-EMR.

Just because PHRs can’t do much today doesn’t mean PHRs won’t evolve to become tomorrow’s EMRs and EHRs.  PHRs will be replaced by EMRs in the same way mere voice applications have been supplemented by multitudes of additional powerful applications.

What business drivers will make this happen?  Apple, Google, and Microsoft are huge corporations, corporations with which almost everyone currently does business.  They are not healthcare companies.  They do not operate like the government.  They know how to build and market very high-tech, glitzy devices packed with the functionality their customers demand.  Customers line up outside of stores for days to be the first to have one.  Hospitals and physicians are not doing that to install EHRs.

Why do PHRs exist?  They exist as a way for these companies to establish a foothold in healthcare, to have their customers begin to associate their healthcare records with the likes of Apple and Google.  They know there is very little money to be made with PHRs.  The revenues will come to them as the functionality evolves the PHR into the EMR.

Measured in today’s dollars, the average US resident will spend about $650,000 on healthcare during their life, or about $8,000 a year.  Eight thousand a year doesn’t seem like much until you extrapolate it.  Eight thousand a year times three hundred and fifty million people comes out to an annual healthcare expenditure of about three trillion dollars.

Let’s compare that $8,000 a year figure to what we spend in other areas.  The average annual phone bill is around $700.  The average cable bill is $1,000; electric—$1,200.

What if these companies developed a way to build a secure, HIPAA compliant, portable EMR application that could be accessed using the next generation of the super smart device we get in line to purchase?  In addition to everything else it can do, the device will have secure access to clouds to access, update, and transport electronic medical records—combining the future functionality of the tablet and open architecture of smart devices like the Droid.

What if firms like Apple and Google made these next-gen super smart devices available for free?  This approach is almost identical to the current model of highly discounting smart phones to lock customers into service agreements.  Why would Apple and Google give away the super smart device?   The reason to give it away only makes sense if the real business opportunity is so large that the money they would have earned from the device is a drop in the bucket compared to the downstream revenues.

What if firms like Apple, Google, and Microsoft devise a way to earn a transaction fee of one percent for each dollar of healthcare services that either comes in through their device or goes out over it?  That is how phone usage is billed.  Companies bill for ones and zeroes sent and received.  They do not care what information those ones and zeroes contain.

The model of providing devices to consumers for free is no different than giving away toothbrushes to sell toothpaste.  The bulk of the revenues come not from the device; but from what consumers do with the device.  A one percent transaction fee applied to the three trillion dollar healthcare market is a thirty billion dollar business.  That’s a pretty good chunk of change for coming up with another service facilitated by moving around ones and zeroes.

Let’s suppose for a minute that as consumers adopt this model that these same corporations, using cloud computing, succeed in building an interoperable healthcare network, the same network the federal government plans to spend billions to develop.  The companies do not need to build it, it exists today—the internet—and it exists wirelessly.  The government just announced the development of a supercharged internet.

This makes Health Information Exchanges (HIEs) and the National Health Information Network (N-HIN) obsolete before they are even built.  As a result of having built the network, and having equipped customers with these EMR capable devices—next generation super smart devices—these firms then own the entire EMR food chain.  Might these firms then be able to garner some kind of usage rights to clean medical data, data that has been scrubbed so as to make it anonymous, data which they can sell to payors, providers, the government, and pharma?  It’s all about the healthcare data, or at least it will be.

The business opportunity is data usage, transporting ones and zeroes.  Data usage is what Apple and Google sell—the portable devices are simply a means to an end.  According to gigaom.com, Apple’s revenues just from its App Store exceeded $2.4 billion in 2009—pretty good money for a start up, a start up that uses a super smart device.

Microsoft doesn’t sell computers.  It sells ideas.  Microsoft is an enabler.  It sells the ability to allow people to do more and more things.  The idea about which I write is no different from Microsoft’s, Apple’s and Google’s current business models.  The smart devices, sell data, data transport, and data usage—ones and zeros.

The difficulty healthcare providers have with today’s approach to EMRs and EHRs is they are focused on now, on today.  They are costly, immobile, hurting productivity, and are driven from the top down—the government.

What if this idea comes to pass, or even something close to it?  What does that mean for physicians?  More than anything else it means physicians will face patients who will take more responsibility for their health, patients whose medical records are stored on the same smart device as their Rolling Stones records.  Physicians will be able to beam the patient’s EMR to their own EMR capable super smart device.  The demand for EMRs will shift from building immobile EHRs that may meet today’s business requirements—to a patient driven demand for portable EMR devices that will meet tomorrow’s requirements, devices which in addition to containing EMRs will meet there other smart device requirements.  It is those other requirements which will drive consumption, the EMR functionality will be a bonus.

I think in five years terms like Meaningful Use, Certification, HIEs, and incentives will be outdated.  The C-suite should be looking at what lies ahead, not at what will be outdated by the time a monolith EHR-NHIN has been implemented.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

paulroemer@healthcareitstrategy.com

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Key questions for CEOs and their Boards

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Been there, done that, got the T-shirt.  Everybody who thinks they have their arms around EHR and healthcare reform, take one step forward……whoa, where are you going Sparky?

The questions below resulted from a round-table discussion I recently had  with six healthcare executives about EHR and healthcare reform. The topic we discussed was what questions should C-Level executives be prepared to answer and what questions should boards be asking. What do you think? Are their others you’d add?

Are we taking adequate advantage of stimulus funding to improve our readiness?

How is health care reform going to impact our business and when?

Are we doing enough to be ready to succeed in an environment where we get paid for outcomes rather than inputs?

Are we ready to comply with Federal policies for Electronic Health Record reporting and sharing?

Are we achieving our own business improvement standards? Do we have the right standards?

Are we ready to use web 2.0 technologies to improve clinical outcomes for our clients?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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