EHR’s Gordian Knot

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.

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 your hospital’s strategy like everybody’s?

In high school when my mother thought I needed to come down a peg or two she would call me, “Never Wrong Roemer.”  Today I prefer to go by, “Dr. Knowledge” or “The Voice of Reason.”  You can just call me Paul.

During my senior year of track I competed in the pole vault and I anchored the mile relay.  In the interest of transparency, I think it more appropriate to say I ran the fourth leg of the mile relay—anchoring implies more speed than I actually possessed. On good days, we fielded a mediocre team.

I never enjoyed running the 440.  It is for sprinters, and I am a distance runner.  One day however I unwittingly became a sprinter.  We were in a dual meet against Wilde Lake High School.  As always, the mile relay is the last event.  If we won the relay we would win the meet.

The fourth runner from Wilde Lake received the baton several seconds before me and had me by twenty yards.  I made up the distance between us midway through the first turn.  One inconsequential factor I did not know at the time is that two years later he would be participating in the Olympic trials in the 440.

It turned out not to be so inconsequential.  What happened after I pulled alongside of him remains a bit of a blur; the same kind of blur the Wile E. Coyote saw each time he thought he had caught the Road Runner.  Turns out I had outsmarted myself.  I was caught up in the moment which is nothing like being caught up in the reality of the situation.  I was in a competition I couldn’t win and I did not know it until it was too late.

Business is a lot like that.  Leaders get caught up in the ferocity of what is going on around them.  You’ve seen them; you work with them.  These are the same people who don’t have an opening on their calendar for six weeks, the same people who are busy putting out last month’s fires, who are hurriedly building defenses for whatever may be around the next corner.

Some of those intelligent and well meaning leaders are so focused on catching the runner in front of them that they lose sight of the race, lose sight of their role as leaders.  Some leaders approach healthcare strategy as a series of directionless sprints while others view it as a marathon in a pack of lemmings.  If everyone is running in the same direction, how wrong can their strategy be if they stay with the pack?

I think we will discover in the next several years many of those marathoners will drop out or be disqualified.  They are approaching a poorly marked turn, and if they fail to take it they will be overcome by one or more of a multitude of factors that will eventually lead to their demise.

While it is impossible to disprove a negative, time will tell.  My advice—next time you see a fork in the road, take it.

Then there was the time I asked my mother to drop me off a half mile away from my girlfriend’s house so she would think I ran the full eight miles to come see her.  But, we will leave that story for another time.

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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Firing Winston

I was reporting to the board—or bored—sometimes it is the same.  The mission: figure out what was wrong, and then fix it.

I spent weeks talking to everyone from the executives to the receptionist.  I interviewed patients and physicians.  The doctors were not happy, the patients less so.  Costs were up, charges were down, and quality was down.

Of all the gin joints in all the towns…

The problem was easy to decipher.  I presented my findings.

“What do you recommend?” asked the chair of the audit committee.

I tried to look lost in thought.  “I fired Winston,” I replied.

“Why Winston?”

“Winston was where it all led; quality, cost, satisfaction.  Winston was responsible for the failures.”

Several members of the board nodded, and spoke among themselves.

After several minutes I jumped back into the fray.  “The more I think about it, the more I think Winston may be salvageable—not in the same role but somewhere else in the organization.  The employees really like him.  Besides, it’s the holidays.  Do you really want to be the reason Winston is not able to buy presents for the kids?”

The board held an in camera discussion.  “Agreed.”

I knew they would.  I started with my actual presentation.  “There is no Winston.”  The Winstons scattered around the table looked perplexed.  They were looking for the easy answer to the problems in their organization, they were looking for themselves.

Who are your Winstons?

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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Microsoft EMR: It’s Not Just a Matter of When, It’s a Matter of Who

This guest post ties nicely to some of what I have been writing about regarding why I think firms like Apple, Microsoft, and Google will be the real N-HIN, why PHRs will become EMRs on super smart next gen devices.

Its author is Austin Merritt of softwareadvice.com, a web site that provides advice on selecting EHR software.  I think the strategic reason for Microsoft’s entry into EMR would not be because there are big bucks to be made from a limited number of physicians but because it gives them a foothold into two of the key stakeholders; doctors and patients, one via an EMR and the other through its PHR.  If that is where they intend to stop, they’ve wasted everyone’s time.  I think they have bigger plans, and those plans include having patients walk in to the doctor’s office, both having the same EMR on the same or compatible devices.  The rest of this post is Austin’s.

Microsoft Dynamics is largely present in just about every software market but medical. And they’re missing out big time. The United States healthcare IT market is growing at about 13% per year and is expected to reach $35 billion in 20111. The biggest opportunity for growth in the industry is among ambulatory care physician practices, partly due to the Stimulus Bill requiring the use of electronic health records (EHR) systems by 2015.

You would think Microsoft would be in such a promising industry, but you won’t find a Microsoft EHR available. The primary reason why is that EHRs are highly specialized, and Microsoft’s main products (Dynamics, CRM, and SharePoint) don’t come anywhere near the needs of physician practices. It would be very difficult for Microsoft to build an EHR from scratch and introduce it to the market. So what should Microsoft do to enter the industry? Acquire a current player.

Such an entry into the medical market would mimic the acquisition spree that Microsoft conducted between 2000 and 2002, when it acquired Great PlainsNavision, Damgaard, and several related vendors. These systems were re-branded and offered as Microsoft Dynamics. Before these acquisitions, Microsoft was not present in the enterprise resource planning (ERP) application market. Its only ERP presence was as an infrastructure vendor, licensing SQL Server databases and related platforms to support application rollouts. However, this lack of application presence gave competitors such as Oracle and SAP the opportunity to squeeze Microsoft out of the ERP infrastructure market by pushing Unix, Oracle databases and IBM DB2. By acquiring several applications, Microsoft was able to drive sales of its SQL Server and Windows Servers directly, in addition to the Dynamics applications themselves. This strategy proved effective in giving Microsoft a multi-billion dollar share of the lucrative ERP market.

Setting its sights on the medical market, Microsoft is starting to squeeze its way in with a few smaller acquisitions and developments of its own, mainly Amalga and HealthVault. However, these current medical offerings are on the periphery of the market and do not really target the sweet spot: electronic health records for physician practices. An intelligent acquisition of a large EHR player would provide a key piece of the puzzle for Microsoft’s entry into the medical market.

Acquired by Microsoft in 2006, Amalga provides information connectivity and interoperability to large healthcare networks. It is the primary Microsoft healthcare offering in the industry at this point, although it is not available in the United States. Microsoft may be planning to offer it domestically, as it did with Navision Damgaard, or may be looking to acquire a domestic vendor to complement it. Regardless of Microsoft’s strategy, Amalga still would not address the physician practice EHR market.

On the other end of the spectrum, HealthVault is a patient-managed, centralized health records solution. It is essentially designed to be a reference point for consumers, not a substitute for medical records. If Microsoft were able to introduce an EHR to the market and enable its users to make records accessible to patients, labs, specialists and pharmacies via HealthVault, then they would really be on to something. This synergy with its other products would just be an added bonus to having its own EHR.

So what would Microsoft prioritize as its key acquisition criteria when evaluating EHR targets? They would certainly want target vendors who possess the following:

  1. Large market share and name brand recognition. Microsoft usually likes to be the largest name in the business, so they would definitely want to sell a “big-name” system with which most buyers are already familiar.
  2. A scalable product for small and large practices. Microsoft would need to be able to cover a wide range of medical customers. While its bread and butter is always in the small and mid-size market, they would want scalability into the largest organizations.
  3. A .Net architecture to drag along infrastructure sales. Reinforcing the position of .Net in the medical software marketplace would be important because it would drive further sales of Microsoft infrastructure while squeezing out Unix, Oracle and IBM.
  4. An established, indirect sales channel. Microsoft historically favors selling through partners, including the existing Dynamics dealer network. An EHR vendor with a large dealer network would provide Microsoft an easily transferable sales channel and process.

So which EHR vendor should Microsoft acquire? This is where it starts to get interesting. We decided to examine Microsoft’s ten most logical targets in detail. Two very popular products, GE Healthcare’s Centricity and McKesson’s Practice Partner, did not make the top ten list. While these systems meet many criteria, the parent companies – General Electric and McKesson – are not really acquirable by Microsoft. The remaining ten are outlined below.

MARKET SHARE SCALABLE PRODUCT .NET ARCHITECTURE INDIRECT CHANNEL
NextGen
Greenway
Pulse
Aprima
Allscripts/Misys
eClinicalWorks
Eclipsys
athenaHealth
Epic
Cerner
  • NextGen – One of the “biggest names” in EHRs, NextGen focuses on medium to large enterprises. However, its system is certainly able to scale down to smaller practices. While it is often too expensive for groups with less than ten physicians, it has a strong position in the sweet spot of the market. Its .Net-based system is sold both directly and through a channel network, so NextGen is a good fit for Microsoft.
  • GreenWay – GreenWay has a nice product, but is toward the smaller end of the companies on this list. It sells primarily directly and has some channel partners. PrimeSuite 2008, its EHR and practice management sytem, is .Net-based and is popular among small and mid-sized groups. Microsoft could leverage its resources and Greenway’s technology to become a major force in the industry. Moreover, Greenway doesn’t come with any legacy of old architecture or acquired customers.
  • Pulse – Pulse has quickly climbed its way into the ranks of bigger EHR vendors and will likely stay here for some time. They were one of the first vendors to achieve 2011 CCHIT certification and are receiving a lot of buzz as a result. While the system is scalable and .Net based, Microsoft would likely want to pursue bigger fish for now.
  • Aprima – Aprima (formerly known as iMedica) has focused on its .Net framework and N-tier architecture from the beginning. As a result, its modern platform and interface make it widely received among physicians across a broad range of specialties. While Microsoft would likely focus on larger companies first, Aprima could be a nice additional partner to champion .Net.
  • AllScripts/Misys – A large brand and a publicly-traded company, it is a logical first place to look. After all, the company claims to have 160,000 physicians using its products. However, the 2008 merger between AllScripts and Misys presents the usual integration challenge, which might keep this firm busy for quite a while. Although we think the future of AllScripts/Misys is very promising, Microsoft probably wouldn’t get involved at this point.
  • eClinicalWorks – This system is probably the most ubiquitous of the list, especially among smaller practices. The recent deal to sell eClinicalWorks through WalMart will definitely increase its brand recognition and share of the market. However, the system is built in Java, an open programming language that is the traditional enterprise alternative to Microsoft .Net. Microsoft would most likely rather acquire a pure .Net system or one that is at least close to it, especially with Oracle, IBM and SAP all embracing Java.
  • Eclipsys – Eclipsys acquired MediNotes in 2009 in an attempt to move users to its Peak Practice EHR. While Eclipsys is fairly popular among hospitals, Peak Practice has not achieved similar success among small to mid-size outpatient practices. Existing MediNotes users are not thrilled about being forced to purchase Peak Practice and we’ve seen quite a few seeking a new solution from a new vendor. We think the success of the MediNotes deal is unclear and Microsoft would steer clear for now.
  • Athena – The youngest company on this list, Athena’s product offering is slightly different from the others. Its system is offered via software as a service (SaaS) and is combined with outsourced billing and revenue cycle management services. This offering is indeed unique, but not a suitable target for Microsoft due to its SaaS offering and labor-intensive service component.
  • Epic – This company possesses an interesting niche in the market. It has only 190 clients, but 150,000 physicians using its products. This is due to its focus on only the largest healthcare organizations in the United States. While this focus is great for Epic, it wouldn’t be effective for Microsoft. Epic will never be able to achieve the ubiquity in the small to mid-sized market where Microsoft dominates. It also sells direct, contrary to Microsoft’s traditional indirect sales mode.
  • Cerner – Cerner’s cash cow is Millenium, a product designed primarily for hospitals. PowerWorks, its outpatient EHR, does not possess the market share among physician practices that Millenium enjoys among hospitals. While Cerner is a recognized name, few practices consider PowerWorks. It is also an older system. Cerner would need to improve its PowerWorks offering before becoming a suitable target for Microsoft.

Although NextGen is not currently dominant amongst small practices, Microsoft could bring them downmarket. NextGen is unable to serve these smaller buyers for two reasons: 1) small practices cannot afford an enterprise expenditure; and, 2) NextGen does not want to (and maybe cannot) devote resources to chasing smaller deals. If Microsoft owned NextGen, they could double down on pursuing smaller practices, perhaps through their channel partners. They may even lower prices to buy market share and make up the difference with revenue from services, SQL licenses, and maintenance.

Which EHR do you think Microsoft should acquire?

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

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The McDonald’s healthcare business model

Sarah Palin continues to receive national media coverage.  Many hospitals continue to implement EHR without any measurable goals.  (One of those is bad.)

The year is 2014.  I had this dream the other night of having dropped my IQ when I was at the hospital, but I couldn’t remember which hospital, so off I went, hospital by hospital looking for my IQ—I realize there are those of you who believe this isn’t a great loss.

In the first hospital I visited, a photo of the new president hung behind the registration desk.  Next to her photo—surprised some of you with that I bet—hung the photo of the Secretary of Hospital Sameness.  For a while I wondered what someone in that position did day to day.  The more hospitals I visited, the more apparent it became.  The hospitals all looked very much alike, right down to dust on the fake Fichus tree next to the water fountain.  For a while I thought that maybe I was driving in circles until I noticed that even though receptionists were all named Gladys, they wore different clothes.  It was almost like visiting Stepford.

Does anyone have the sense that what reform will really accomplish is to reform away healthcare competition?  There appears to be a move afoot towards the efficiency that is created by sameness—what I call the McDonalds healthcare model.  Put one on every corner.  Make them identical.  Limit the options.  Everyone gets a burger.  Nobody gets a steak.

Eliminate waste.  Does that mean eliminate ways of operating that differ from how the government permits them to operate?  There is talk of pulling costs out of the system thereby making it more efficient.  You tell me.  Is the argument that there is so much inefficiency that by becoming efficient not only will we be able to cover everyone, but we will be able to do it at a cost below what it costs to care for far fewer people?

How do you understand it?  Are costs being removed, or simply moved?  If someone with no access to healthcare suddenly has healthcare—a good thing by almost anyone’s standards—the reasoned person knows costs have just increased.  (Healthcare theorem 1:  The cost to provide healthcare to 2 people is greater than or equal to the cost to provide it to one person.)  If costs have increased, how does one make a believable argument that the basis for reform is cost reduction?

I try hard not to be too cynical, but sometimes I think, why bother.  By the way, I found my IQ.  Thanks for asking.

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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Does it come in blue?

The store for audiophile wannabe’s. Denver, Colorado. The first store I hit after blowing an entire paycheck at REI when I moved to Colorado. 

The first thing I noticed was the lack of clutter, the lack of inventory. There were no amplifiers, because amplifiers were down market. There were a dozen or so each of the pre-amps, tuners, turntables, reel to reel tape decks, and these things called CD players. They also had dozens of speakers. At the back of the store was an enclosed 10 x 10 foot sound proof room with a leather chair positioned dead center.

When the ponytailed salesperson asked about my budget, like a rube I told him I didn’t have one. He beamed and took that to mean it was unlimited. It really meant I hadn’t thought of one. He asked me what I liked to listen to.

“Pink Floyd, Dark Side of the Moon.”

Within a few seconds I was seated in Captain Kirk’s chair, and Pink Floyd’s Brain Damage filled the room in pure digital quadraphonic sound. I was in love.

I lived a block and a half away. Since the equipment wouldn’t fit in my Triumph, I made several trips carrying home my new toys—gold plated monster cable, solid maple speakers that rested on nails so as to minimize distortion, a pre-amp, tuner, receiver, turntable, and stylus.

It wasn’t that I deliberately bought stuff I didn’t need. I walked in uneducated. I had never bought what I was looking at. I didn’t know how much to spend, nor what it would do for me. Looking back at that purchase decision, I bought specs I didn’t need. I didn’t realize it was possible to build audio technology that would meet performance specs beyond what I person could hear, heck beyond what anything could hear. Not understanding that possibility, I bought specs I couldn’t hear. I spent hundreds of dollars on features from which I would never receive value. You too?

It happens all the time. Stereos. Cars. Computers. Applications. Technology. Having bought it doesn’t mean it was needed, that it was the right thing to do, that it has an ROI, or that it meets the mission.

What if hospital business models weren’t so tribal?

I tend to look at it from the perspective of the business model of many hospitals.  How does one transform a 0.2 business model to function in today’s let alone tomorrow’s changing healthcare model?

The clinical side of healthcare, the healthcare business, in juxtaposition to the business of healthcare, would never quarter to the idea of buying millions of dollars of technology without first knowing how they were going to use it.

Plenty can be gained by applying what other industries have done to become more effective.  In some respects the inherent structure, cost duplication, and rigid departmental silos remind me a lot of how the various agencies under Homeland Security function, operating in isolation, performing much of the same work, and not sharing information.

Other industries operate with a much less tribal model than healthcare.  Hospitals have created tribes and tribal chiefs.  In some hospitals the tribes have names like radiology, general surgery, psychiatry, and OBG/YN.  Other hospitals have redundant tribes named admissions, human resources, IT, and payroll.  Each tribe is run by the tribe’s chief.  The chief’s dominant weapon is his or her budget which is lorded over its individual tribe, and a dispute vehicle of the other tribes.

The tribal organization is more a reflection of how the hospital evolved over the years, not a result of an inept business strategy.  Nobody set out to build an ineffective and internally competitive model, or one that duplicated support functions.  Acquisitions have reinforced and exacerbated the problem, duplicating and increasing costs without yielding a resultant increase in value.

Before the business of healthcare is prepared to cope with the unknowns of the myriad of external influences it will face in the next few years, it must first change how it functions under its current structure.  It might begin by revisiting its present structure and making sure that its performance and quality precede the application of technology.

I frown on using the term efficient.  To me, efficiency implies speed, and doing bad things faster is no solution.  Let us work at improving effectiveness and good things will happen.

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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