What should you budget for change management and work flows?

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They came in waves from just over the horizon, each wave approaching from different elevations, and different points on the compass. They were legion; too many to count, too many for which to be able to set a winning defense. We marshaled our forces, knowing we were helpless. As I sat there awaiting the final assault I was reminded of some of the great World War II black and white movies; Midway, Twelve O’clock High, Tora, Tora, Tora. Wave after wave of Japanese and German fighters attacking the apparently helpless US forces.


Our defense perimeter established, we waited and watched. The first wave circled twice above the cellophane covered bowl. Tiny holes were cut into the cellophane allowing the fumes from the apple cider vinegar to waft upwards. The lead fruit-fly banked left and made his assault on the target. He bounced off the cellophane, as did most of the initial flight. One by one, they recovered and made their way through the pin-prick holes. The second and third waves approached the half-covered Tupperware that held the pineapple slices. After several minutes passed we slapped the lid onto the container, trapping scores of them.

“It’s those Concord grapes,” my wife asserted, implicating the helpless grapes.

“Don’t blame the fruit,” I replied. “They’re just fruit.”  Here’s the segue, try to stay with me.

If you’ve ever flown into Chicago’s O’Hare airport you may have witnessed scores of planes stacked in the air space awaiting permission to land.  I recently made reservations for a trip to Chicago. I used Southwest’s web site to make my flight to Midway—they don’t fly into O’Hare but the illustration still works. I’m the type of person who is more suited to using a well-functioning online service to complete my business. Even so, it would not be unusual for me to be having an animated one-way conversation with my computer. I started talking to the website after having to enter the same data time after time. Don’t get me wrong; I got a great deal on the airfare—three tickets for less than I paid for one last time. The site’s design allowed me to book a hotel. I entered data to reserve three rooms to coincide with the dates of my flights. A nanosecond later, I had a confirmation code for one non-refundable, no cancellation allowed room for the night before my plane even went to Chicago. By now I was speaking to my computer in tongues.

Like with the fruit, don’t blame the computer. The software did as it was programmed.  A lot of healthcare providers are going to be amazed by what they do and don’t see from their EHR system.  The system will do exactly what it programmed to do.  That’s great news if your organization’s work flows are an exact match for those built into the code.  We both know they aren’t.  That when it becomes necessary to build work arounds.  Unfortunately, you’re building them to match your work flows to their code.  For those new to the process, you are now designing your organization to move even further away from how it presently runs.  The further away you move, the more you will require change management.  Unless you budgeted correctly months earlier, you have probably already run out of funds for work arounds and change management.  If that’s the case, your EHR system is approaching its do-over point.   For each dollar of IT spend, it probably makes sense to budget at least two dollars for these tasks.  I guess you can budget those dollars for EHR 2.0, but it may be someone else whose running the implementation.

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What are the voices telling you?

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My favorite thing about healthcare is having witnessed it up close and personal both as a cancer patient in the 80’s and as the survivor of a heart attack seven years ago.

I was fortunate enough to have testicular cancer before Lance Armstrong made it seem kind of stylish.  Caught early, it’s one of the most curable cancers.  As those who’ve undergone the chemo will attest, the cure is almost potent enough to kill you.

I self-diagnosed while watching a local news cast in Amarillo where I was stationed on one of my consulting engagements.  As we were having dinner, my fellow consultants voted to change the channel—I however had lost my appetite.  I went to my room, looked in Yellow Pages—see how times have changed—and called the first doctor I found.  This is one of those times when Never Wrong Roemer hated being right.

So, yada, yada, yada; my hair falls out in less time than it took to shower.  A few more rounds of chemo, the cancer’s gone and I start my see America recovery Tour, my wig and I visiting friends throughout the southeast.  If I had it to do over, I would go without the wig, but at twenty-seven the wig was my security blanket.  I don’t think it ever fooled anyone or anything—even my house plants snickered when I wore it around them.

I owned a TR-7 convertible—apparently it never lived up to its billing as the shape of things to come, more like the shape of things that never were.  My wig blew out of the convertible as I made my way through Smokey Mountain National Park.  I spent twenty minutes walking along the highway until I spotted what looked like a squirrel laying lifelessly on the shoulder—my wig.

The last stop on my tour was at a friend’s apartment in Raleigh.  Overheated from the long drive and the August sun, I decided to take a few laps in her pool.  I dove in the shallow end, swam the length of the pool, performed a near-flawless kick-turn and eased in to the Australian Crawl.  As I turned to gasp for air, I noticed I was about to lap my hair.  I also noticed a small boy, his legs dangling in the water, with a look of astonishment on his face.

My ego had reached rock bottom and had started to dig.  I had one of those “know when to hold ‘em, know when to fold ‘em moments” and never again wore the wig after learning it was such a poor swimmer.

Do you get those moments, or get the little voice telling you that your EHR strategy isn’t fooling anyone?  It’s okay to acknowledge the voices as long as you don’t audibly reply to them during meetings—I Twitter mine.

Sometimes the voices ask why we didn’t evaluate the EHR vendors with a detailed RFP.  Other times they want to know how that correspondence course in project management is coming along.  It’s okay.  As long as you’re hearing the voices you still have a shot at recovery.  It’s only when they quit talking that you should start to worry.  Either that, or try wearing a wig.

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The effect of poor planning

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I’ve always considered myself to be rather athletic, although I must have been on break when they handed out the coordination genes.  Perhaps that is why I tended towards individual efforts like running.

As it was, I was fairly good at ice skating as long as I was moving forward, the straighter the better.  Turning and stopping required an abundance of room, and an absence of other skaters.

Whoever came up with the notion that if you can ice skate you can roller skate was either lying through his teeth, or I became skating’s anti-matter.  At the time of my first attempt at roller skating I was unaware that ice and roller skills weren’t transferable.  Have I mentioned I like having an audience?  I decided to audition my roller skating skills at a public skating rink while on a first date.

The night was proceeding swimmingly.  I learned quickly that it I stayed to the edge and leaned towards the center of the rink, centrifugal force would keep me from falling.  My confidence in my abilities began to build.  Music boomed from the overhead speakers.  Several couples held hands, the more skilled ones crossed their arms in front of them and held hands.  I tried it and eased us into the first turn.  The song switched to Barry Manilow’s “I write the songs.”  To my misfortune, I knew the words, and began to serenade my date.  When I guy sings Barry Manilow in front of anyone but his own shadow, only two things can happen and they’re both bad.

We hit the second turn and I began to accelerate.  We sped past a number of couples.  I sang louder, concentrating more on the words than on the task of keeping us both upright.

For those unfamiliar with the design of roller skates I should explain what I perceive to be a flaw design flaw—one which you will note has been eliminated in roller blades.  The flaw?  On the front of each roller skate about an inch from the bottom is a round rubber device that resembles a stunted hockey puck.  It serves no known purpose other than to sucker punch novice skaters.  If you mistakenly try to build speed by pushing off with the toe of your roller skate—as you do in ice skating—you are actually hitting the emergency brake.  And because the brake is at the front of the skate, the physics is such that once your feet stop, the only direction the rest of your body can go is head over heels.

I looked like I had purposefully launched myself over a pommel horse.  During the first few seconds of my flight I was reluctant to let go of my date’s hands.  I thought that if we fell together that there was some small chance that I could shift the blame for the crash to her.  We separated at speed and created sort of a demolition derby for those around us, bodies piling up like logs awaiting entrance to a saw mill.  For the rest of the evening it felt like people were pointing at me as if to say, “Steer clear of him, he’s the one who took us all out.”

My one mistake caused a chain reaction of bad events and a severely hematomaed ego.  Bad things rarely happen in a vacuum.  There’s cause and effect, and the effect can be disastrous.  For those of you whose EHR program is underway who may have scrimped on the planning process—you know who you are—you may as well be the captain of the Titanic throwing refrigerant in the water.  There is no recovery from bad planning.

No matter what the shape of your EHR implementation, if you find yourself humming a few bars of “I write the songs”, only two things can happen and they’re both bad.

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How’s the EHR vendor performing?

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Many organizations have a Program Management Office and a Program Steering Committee to oversee all aspects of the EHR.  Typically these include broad objectives like defining the functional and technical requirements, process redesign, change management, software selection, training, and implementation.  Chances are that neither the PMO or the steering committee has ever selected or implemented an EHR.  As such, it can be difficult to know how well the effort is proceeding.  Simply matching deliverables to milestones may be of little value if the deliverables and milestones are wrong.  The program can quickly take on the look and feel of the scene from the movie City Slickers when the guys on horseback are tyring to determine where they are.  One of the riders replies, “We don’t know where we’re going, but we’re making really good time.”

One way to provide oversight is to constantly ask the PMO “why.”  Why did we miss that date?  Why are we doing it this way?  Tell me again, why did we select that vendor?  Why didn’t we evaluate more options?  As members of the steering committee you are responsible for being able to provide correct answers to those questions, just as the PMO is responsible for being able to provide them to you.  The PMO will either have substantiated answers, or he or she won’t.  If the PMO isn’t forthcoming with those answers, in effect you have your answer to a more important question, “Is the project in trouble?”  If the steering committe is a rubber stamp, everyone loses.  To be of value, the committee should serve as a board of inquiry.  Use your instincts to judge how the PMO responds.  Is the PMO forthcoming?  Does the PMO have command of the material?  Can the PMO explain the status in plain English?

So, how can you tell how the EHR effort is progressing?  Perhaps this is one way to tell.

A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick the cat up. The brother hesitated, then said, “I’m so sorry, but while you were away, the cat died.”

The man was very upset and yelled, “You know, you could have broken the news to me better than that. When I called today, you could have said the cat was on the roof and wouldn’t come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said he had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and won’t come down.”

If you ask the PMO how the project is going and he responds by saying, “The vendor’s on the roof and won’t come down,” it may be time to get a new vendor.

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EHR: add three cups of technology and stir

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According to my neighbor, who is a woman, next week is the season premier for “Desperate Hot-wives”—her words, not mine. My wife refers to my little brain hiccups as Roemer-minutes, a little hitch in my git-along where the thinking part of my brain briefly vacations in the fifth dimension. Speaking of the fifth dimension, the dimension, not the sixties rock group, I was reading up on it the other day. There’s this professor of theoretical physics from Harvard, Lisa Randall, who happens to look a little like Marcia Cross who portrays Bree Van De kamp—actually she looks more like Jodi Foster. See how quickly this all ties together? Anyway, Dr. Randall has developed a theory about how the universe is warped—something many of us expected. According to her model, the reason gravity appears so weak is that the universe is actually warped by a hidden fifth dimension—must be why we haven’t seen it, because it’s hidden—and our gravity is just the leftovers from the dark side.

For the inherently curious, in mathematical terms her equation is, ds2=dr2+e-kr(dxm dxn hmn). That was helpful, wasn’t it? Here’s where it gets complicated. People in Europe will are testing the Large Hadron Collider to look for gravitons, theoretical particles of gravity. The collider smashes protons into one another, and if these theoretical particles appear then disappear that somehow proves the theory. However, and depending whether you’re a glass half-full or a glass half-empty kind of person, this is a rather big however, we could all die. This is where the distinctions between the meanings of the words possible and probable become rather important.


According to this whole other branch of physics, something quite unpleasant could happen, the creation of doomsday phenomena, including microscopic black holes that would grow instantaneously and swallow the earth, and strangelets that could transform the earth into a dead dense lump. Could it happen? Yes. Will it? Probably not. So there you have it.

Where does that leave us? Assuming that it does, leave us, that is, alive, it makes the notion of implementing EHR seem just a tad more simplistic. At least we won’t be creating any black holes. So, set your phasers for stun and let us begin again. To implement EHR in your organization you need a champion, a sponsor. Someone who isn’t afraid to say, ‘follow me’. As we said before, this type of project does not lend well to the notion of ‘add three cups of technology and stir’. The champion is needed not so much for figuring out the shape of things to come, but for their ability to cause those things to be implemented within the organization. This person should have ready access to resources, dollars, and the ear of someone very senior in your firm. Next time we’ll begin to take a look at the champion’s role.

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Cast, Blast, and Gin Rummy

duckSeveral years ago I was invited to go on the ultimate boys’ toys, weekend getaway. A dozen of us flew from Denver to Utah, and then drove to a point somewhere west of Bozeman Montana. It was to be a weekend of sport, a weekend of competition, and a more than occasional libation. To say that the people who organized the trip came from money would be a major understatement. They were in the oil bid’ ness. The father of one of the guys was the CEO of the second or third largest petroleum company in North America. We stayed at his ranch, a 12 bedroom log cabin in the middle of Nowhere, Montana, which is about 20 miles west of Next to Nowhere, Montana.

The weekend’s activities included fly fishing, duck hunting, and Gin Rummy. Each participant was given a handicap rating in each event. The idea behind the rating was that if you are weak in one event, you were paired with an individual who is skilled in that event. In theory, that would level the playing field among the teams. Since I have never fly-fished or hunted I was odd man out. But I was game, and it’s amazing how good one can become at something when one has to fight their way through it.

Let the games begin. We started the competition with a full day of fly-fishing. Our destination was the Madison River, an impressive, fast running, expanse of snow melt. The stretch we would finish was about 150 feet wide, and its average depth was somewhere between waist and chest high. As I would soon learn the bottom was covered with what appeared to be the equivalent of moss covered bowling balls. I was instructed by one of the more experienced fishermen to tie a nymph to the end of the tippet. For those of you who are as novice to the sport as I was, a nymph is an artificial lure which mimics an insect larva. It is designed to lure fish who feed along the bottom, not the nubile young woman referenced in Greek mythology.

We fished for several hours. My legs ached from trying to maintain my balance in the strong current. I was about ready to admit defeat when the tip of my rod bent sharply into the water. Standing perpendicular to the current, I could see as the brightly speckled back of a large rainbow trout turned upstream. Naturally, I turned upstream with it and began to try to reel him in. First mistake. It was at that point that I first realized that the height of the water was now about level with my chest waders. Second mistake. The guys on the other part of the river and along the bank were yelling at me. I thought it was words of encouragement. Final mistake. As it turns out, they were trying to convince me not to turn upstream. At the exact moment that I faced stream head on, was the exact moment my feet lost purchase with those moss covered bowling balls of which I wrote. Turning yet again to my physics, I quickly recalled the equation; force equals mass times acceleration. Instantaneously, I was swept downstream, still clutching my fly rod in my right hand.

Wayne Newton’s first law of fluid mechanics took over; waders, no matter how good they are, if positioned in a plane that is horizontal to the river will fill rapidly with water, just as mine did. The choice with which I was faced was do I save myself and lose the fish, or do I try and land the fish? One of the shortcomings of maleness—I was going to use maledom until I Googled it—is that we rarely have actual choices, especially when we are around other males or for that matter, females. Naturally, I opted to land the fish. My reel had become dislocated from my rod. I remember grabbing the reel and stuffing it down my waders, and as I tried to float my body as though it was a raft without a rudder towards the river’s nearest bank, I began to reel in the monofilament with a hand over hand motion. After several minutes I was standing dripping wet and proudly displaying a 19 inch rainbow trout.

We cooked the fish and played Rummy until about three in the morning, awoke at four, grabbed our shotguns and headed out into the darkness without so much as a cup of coffee. Round three of the competition was to be duck hunting. To this day I’m still unclear as to why we had to hunt ducks while it was still dark. Weren’t there any ducks who needed shooting at brunch time, I inquired? Twelve guys, who collectively smelled like a distillery, and who are operating on an hour of sleep, armed with loaded shotguns, trod through a willow thicket as dawn approached. As I neared the river bank, a startled duck shot skyward. I raised my over and under twelve-gauge shotgun, sort of took aim, and fired a volley. The duck seemed to pause in midair, and then fell like a rock into the racing water. I watched helplessly as my quarry floated away from me. I looked downstream and was pleased to see two men fishing from a rowboat. The duck floated right towards them. A man reached down, retrieved my duck, and dropped it in his boat. He then waved to me. Thinking he was being friendly I returned his wave. He then rowed away with my duck.

It was a great three days. Part of what made the weekend fun with not having to excel at each event. It helped knowing that in areas where my skills weren’t as good, I could count on the skills of others and vice versa. The idea behind this approach was to build competitive and level teams. That approach works well in mano y mano events like those I described. It works much less well in EHR, HIT and healthcare reform in general.  I’m trying to recall if I wrote previsouly about a meeting I attended with a former hospital CEO.  His take on EHR was the total inability of his peers to have any precience regarding their approach to EHR.  According to him, very intelligent people were making very unintelligent decisions, committing their entire institution to strategies made with almost no data.  Some people can give a better explanation for why they bought their car than they can for why they selected their EHR.   That’s the wrong way to handicap this event.

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Is EHR as difficult as everyone says it is?

Yes, and then some.  EHR is at the beginning of a national rollout .
• Studies suggest that 200,000 healthcare IT professionals are needed for EHR. The total number it healthcare IT professionals today is 100,000
• It’s not known which EHRs qualify for incentives under ARRA
• Less than 8% of non-VA hospitals have EHR in even a single department (this does not mean these pass meaningful use test)
• Only 1.5% have them in all departments
• Studies state that 1/3 to 2/3’s of implementations fail
• Implementation by small practices has been almost non-existent
• Small and individual practices will need a full service “wrap around” solution encompassing the following services:
o Project management
o Selection
o Implementation
o Adapting work flows
o Training
o Support
• Major reasons for not doing EHR are
o Up-front costs
o Lack of IT skills
o Ongoing support costs
• Hospitals and large providers usually use their own IT departments for EHR, none of which has ever implemented EHR. Hence for the most important project undertaken by a provider, they elect to do it with people with no experience, relying on the vendor
• Where will the EHR vendors find the IT expertise and project management resources to staff a national roll out?