Health 2.0

EHR: Is your plan aiming far enough out?

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Can being an early adopter save your hospital millions of dollars?  We both know the answer depends on what one happens to adopt.  Suppose we are discussing the adoption of an idea?  Can that be analogous to not adopting another idea?  I think it can.  Allow me to explain.

Many providers are in the process of making a very expensive, highly complex, and wide-ranging decision regarding their healthcare information technology strategy (HIT) for their electronic healthcare records system (EHR).

A non-trivial moment.  Careers will be made and lost as a result—I’m betting more will be lost.  Why?  By making a bad choice on the EHR, on how to implement it, and on how to modify your organization.

I think the choices will be bad not from lack of effort but from lack of understanding of the complete issue.  What is the part of the issue that is lacking?  It’s the part which requires clairvoyance.  Whew, that was easy.

Defining your requirements does not pass the test of necessity and sufficiency.   It’s like playing darts while blindfolded.  The plan to select, implement, and deploy an EHR must account for a number of risky unknowns, including:

  • How will healthcare reform impact my organization
    • What constraints will it produce
    • What demand will it create for new HIT systems
    • What new major operating processes will result
    • When will reform really be implemented
    • How will reform be reformed
    • How will payors, suppliers, and people react to reform
    • How will you offset a resource shortage of fifty percent
    • What will change as a result of
      • Interoperability
      • Certification
      • Meaningful Use
      • Mergers and acquisitions

We don’t know what we don’t know.  That is not a throw-away line.  By definition, we never know what we don’t know.   However, the downstream success of your EHR will be highly dependent on these unknowns.

So, where does your need to be clairvoyant come into play?  One word—flexibility.  Every part of the plan must be built with that requirement in mind.  What will the system need to do in three years?  How will the landscape have changed?

If you aren’t convinced your EHR is either flexible or disposable, you’d benefit by rethinking your plan.  The idea for which I think we need early adopters is to spend time building to what will be, not what is.

EHR: A billion for your thoughts

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Every wonder how it is that all the billions in healthcare IT money came about?  I imagine it went something like this.

DC 1: Email those fellows over at HHS and tell them we should just make the doctors install Electronic Health Records (EHR).

DC 2: While we’re at it, how about we pay them a bonus to do it…

DC 1: …and we penalize them if they don’t.  Give them money with one hand and take it back with the other.

DC 2: How do we get EHRs to communicate?

DC 1: Make the states do figure it out.  They are looking for more money.

DC 2: I’ll email the governors and tell them we’ve got more billions to pass around.  Let them build some sort of Information Exchange.  They can set up committees and staff them with appointees.

DC 1: Then we can glue those together in some kind of national network.  Where are we going to get one of those?  Figure another ten billion for that.

DC 2: I’ll email the DOD, they are supposed to know something about building national networks.

DC 1: Just to get things kick-started, let’s email the troops and tell them we’ll sweeten the state pots a little more.  Get them to build these extension centers on a region by region basis.

All these dollars, so little value.  Most of it focused on trying to figure out how to get millions of somethings from point A to point B.

How did all those millions of emails get securely from point A to point B?  For a lot less than forty billion dollars isn’t it possible to figure out  how to get my health information to whomever needs it?  Email me, maybe we can come up with an idea for a network.

If you’re still puzzled, we can play hangman.  It has eight letters, starts with an ‘I’, and ends with ‘ternet’.

EHR-a doctor/CMIO’s perspective

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Dirk Stanley wrote this in reply to a post on http://radar.oreilly.com/2009/11/converting-to-electronic-healt.html

I felt it needs to be heard.

I can only say that no matter what we do from a technical standpoint, a lot of medicine isn’t ready from the cultural standpoint.

Medical culture is a weird creature, that not a lot of people understand. (I’m sure Glenn above can attest to this.) Docs, historically, have been used to people “compensating for them”, for example :

1. A doc writing a script for Percocet (1) tab PO QID PRN instead of Percocet (1) tab PO q6h PRN pain.
2. A doc writing for “regular diet” instead of “Regular diet, dysphagia level I, nectar thickened liquids.”
3. A doc having weeks to co-sign their verbal orders.
4. A doc writing “Vanco 1gram IV x1 STAT” instead of “Vancomycin 1 gram in 250mL 0.9% NS run over 2 hours at a rate of 125mL/hour”
5. A doc writing “Heparin protocol” in the pre-EMR world, versus an electronic order for “Heparin protocol” where *all of the teammembers know what to do*.
6. A doc choosing an EMR because “It’s the best for me” versus “It’s the best thing for my patient”.

These are the hidden implementation costs. Training docs to think along these lines is important, but nobody has a clear training plan on how to change this medical culture.

This is why, some people look at OpenVista as the solution – IMHO, putting OpenVista into a private hospital will not produce the results it does in a VA hospital. Docs need to understand there will be compromises, and they need to buy-in to those compromises, before any migration to EMR will work.

Technology only works if the culture supports it.
I can tell you there are still a LOT of cynical docs out there who are quick to try a solution, and if it doesn’t work the first time, they lose faith.

Again, I wish things were different, but as a practicing physician who sees a lot of different medical computing environments (ICU to private office), I’m really concerned about the implementation plan here.

Finally, I agree, we do need an EMR Czar, or a “rockstar” who will talk about these things openly to help change the culture to be more supportive of technology. The problem is that to talk about it openly would mean having frank discussions that a lot of people don’t want to hear yet…

– Dirk 😉

Patient Equity Management; Rome wasn’t burnt in a day

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marty_brain5_76

 

 

 

 

 

There’s the scene in Young Frankenstein when the character states, Could be worse, could be raining. The line is followed immediately the by sound of thunder and pouring rain. Lately, I’m reminded of that each time I ready the industry news and blogs. The message is that it is raining. Forty days and forty nights worth. Wet. Getting wetter. No towels in sight.

How’d we get there? We worked hard at it. What surprises me is how many providers are surprised by the situations in which they find themselves. During times like this patients discard marginal providers, the providers who never got around to valuing them. This is when it comes down to patient equity management (PEM)–providers who continue to manage by reacting to social media are going to continue to get wet.

It took years of mismanagement and lip service to make patients feel like they weren’t valued. Without a concentrated program of PEM it may take just as long to get them back. Rome wasn’t burnt in a day.

saint

Some EHRs are better than others

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The health club offers a boot camp course—see how this ties into healthcare?  I used to make fun of it until I decided to try it.  The spandex factor is about 9.8 on the spandex/Richter scale.  Thirty-something women whose color coordinated apparel makes it worth the sweat.  (Permit me a brief segue.  Some fashionista recently discovered that it was possible to convince women that instead of wearing one shirt, that it would be more fashionable to wear multiple shirts with coordinated colors.  So, the women in the boot camp course wear an array of clothes such that their headbands match their fingernail polish.)

On most days I am the lone male in the class.  I’ve summited 50 (years, for those wondering the use of the word).  Most of the women in the class are unable to have an intelligent conversation over a latte about Viet Nam.  Trying to be gentle, I attribute that to their age rather than the fact that they were waitlisted on the most recent Mensa membership drive.  Despite their inability to go mano y mano with the former secretary of defense, Robert McNamara, they look darn good in spandex.

I try not to look like I covet their fawning, but as a seven year survivor of the White Male RCA Stent Award, I accept it with a degree of grace.  (For the male readers who wish to make light of Boot Camp, try it before you tease.)

So, there I am, I am there.  It’s my Green Eggs and Ham moment.  Prior to the class I’d run five miles, and completed 33 pull-ups without stopping.  Did I mention I like being the lone male in the class?   There’s a certain adulation that goes with the title.  Some would covet the position, but as an adult, I take it in stride.

However…today another male comes to the class.  I do not mind having another male.  I do however look unfavorably having another male in the class who looks like he trains navy SEALS in his spare time.  The class had the usual amount of male gawking, albeit at the wrong person.

What does this have to do with healthcare information technology?  Not much other than it goes to show you that there are those whose efforts may have superseded your own.  It doesn’t mean much when the item in question is pushups, it means a lot more when you’re trying to determine who did the best job spending one hundred million dollars on an electronic records system.

sainttop5

Patient Relationship Management–why patients and hospitals collide

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Rod

 

 

 

 

When universes collide, or is universi the plural? Not that is matters. I was watching NOVA.  The show focused on the lead singer of the Indie group The Eels.  The show walked through the singer’s attempt to understand was his father had done for a living.  His father was a physicist, in fact he was the person who came up with the notion of colliding universes. Colliding universes has something to do with quantum mechanics and cosmology—did you also wonder what makeup had to do with particle physics? In its rawest meaning, parallel universes have something to do with the notion of identical worlds living side-by-side, with no notion of each other, with differing outcomes from similar events. Got it?  Me either.

I’ll try to illustrate if for nothing else than my own attempt to understand. Let’s say I’m concurrently teaching my two sons to play two different card games, Poker and War. Poker, albeit a game of chance, is heavily rules-based—when to bet, when to fold, when to raise. On the other hand, War is purely a game of chance. The poker player likes rules and order. The one playing war—he’s seven—likes to win, and will do what is required to bring about that outcome. Each one plays independent of the other, using the tools at their disposal to direct the outcome of the game in their favor. They are oblivious to the goals and tactics employed by the person sitting beside them. Parallel universes.

What if we allowed these two universes to collide, to come into conflict with one another? For example, let’s say I have them play each other and I re-deal the cards, giving one the cards he needs for a poker hand, and the other the cards to play war. I then instruct them to play one another. The poker player becomes focused on the rules, and the one playing war has a laser focus on one thing—winning. The poker player quickly caves, knowing that he is engaged in a futile endeavor. This does not bother the other one whose only focus was to win.

Imagine if you will—sort of Rod Serlingish—two other games going on simultaneously, one team whose sole focus is winning, the other whose focus is on the rules. For the rules-based team there is no winning. The best they can ever hope to do is to measure up to the rules by which they are judged. Millions have been spent on technology to help ensure that adherence. Adherence to the rules will be monitored, recorded, reported, and measured. The rules-based team’s ability to continue to play the game will be based solely on how well they follow the rules. Now imagine that the universes in which these two teams are playing collide and these two teams play their separate games but against each other. One team having never been told how to win, never been instructed to win, never even given permission to win. The other team’s only purpose is to win.

This is a nonsense game. One we play every day.  One team is the hospital’s patients the other team is the employees who are tasked with patient customer care, patient relationship management (PRM).  The patients are focused on winning, those tasked with customer care or PRM are not permitted or equipped to win.

It’s possible for these two groups to change the outcome, to take away the nonsense.  To make that happen, the rules must change.  PRM can be very effective provided that it is designed to help the patients “win”, designed to facilitate favorable outcomes for patients.  The trick to changing the outcome is that the hospital must understand that a win for the patients in most cases is also a win for the hospital.

saint

Patient Relationship Management (PRM)-why men can’t boil water

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poker_head_pic

There was a meeting last week of the scions of the Philadelphia business community. The business leaders began to arrive at the suburban enclave at the appointed hour. The industries they represented included medical devices, automotive, retail, pharmaceutical, chemicals, and management consulting. No one at their respective organizations was aware of the clandestine meeting. These men were responsible for managing millions of dollars of assets, overseeing thousands of employees, and the fiduciary responsibility of international conglomerates. Within their ranks they had managed mergers and acquisitions and divestitures. They were group with which to be reckoned and their skills were the envy of many.

They arrived singularly, each bearing gifts. Keenly aware of the etiquette, they removed their shoes and placed them neatly by the door.

The pharmaceutical executive was escorted to the kitchen.

“Did your wife make you bring that?” I asked.

He glanced quickly at the cellophane wrapped cheese ball, and sheepishly nodded. “What are we supposed to do with those?” He asked as he eyeballed the brightly wrapped toothpicks that looked banderillas, the short barbed sticks a matador would use..

“My wife made me put them out,” I replied. “She said we should use these with the hors d’oeuvres.”

He nodded sympathetically; he too had seen it too many times. I went to the front door to admit the next guest. He stood there holding two boxes of wafer thin, whole wheat crackers. Our eyes met, knowingly, as if to say, “Et Tu Brutus”. The gentleman following him was a senior executive in the automotive industry. He carried a plate of freshly baked chocolate chip cookies. And so it went for the next 15 to 20 minutes, industry giants made to look small by the gifts they were forced to carry.

The granite countertop was lined with the accoutrements for the party. “It’s just poker,” I had tried to explain. My explanation had fallen on deaf ears. There is a right way and a wrong way to entertain, I had been informed. Plates, utensils, and napkins were lined up at one end of the counter, followed in quick succession by the crock pot of chili that had been brewing for some eight hours, the cheese tray, a nicely arrayed platter of crackers, assorted fruits, a selection of anti-pastas, cups, ice, and a selection of beverages. In their mind, independent of what we did for a living and the amount of power and responsibility we each wielded, we were incapable of making it through a four hour card game without their intervention.

I deftly stabbed a gherkin with my tooth pick. “Hey,” I hollered “put a coaster under that glass. Are you trying to get us all in trouble? And you,” I said to Pharmacy Boy, “Get a napkin and wipe up the chili you spilled. She’ll be back here in four hours, and we have to have this place looking just as good as when she left.”  I thought I was having the neighborhood guys over for poker; I was wrong. So was each of the other guys. We had been outwitted by our controllers, our spouses. Nothing is ever as simple as it first appears. We didn’t even recognize we were being managed until they made themselves known.
Who’s managing the show at your shop, you or the patients?  The answer to that question depends on who owns the relationship, who controls the dialog.  If most of the conversation about your organization originates with them, the best you are doing is reacting to them as they initiate the social media spin, or try to respond once the phone started ringing.  It’s a pretty ineffective way of managing.  It’s as though they dealt the cards, and they know ahead of time that your holding nothing.
There are times when my manager isn’t home, times when I wear my shoes inside the house—however, I wear little cloth booties over them to make certain I don’t mar the floor.  One time when I decided to push the envelope, I didn’t even separate the darks from the whites when I did the laundry.  We got in an hour of poker before I broke out the mop and vacuum.  One friend tried to light a cigar—he will be out of the cast in a few weeks.

Be afraid. Be very, very afraid.

saint

Work Flows–learn to color outside the lines

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munch_scream

Somewhere out there is the person or persons who invented Chuck e Cheese. I am convinced that whoever deserves the credit either does not have children, or if they do, does not take their children to Chuck e Cheese under any circumstances. If you’ve never been, it’s one of those places whose true cacophony must be experienced first-hand. The FDA should conduct clinical trials of blood pressure medicines there. The formula is simple; machines that make noise plus kids that make noise equals happy kids. Some parents are immune to the noise. I’m not some parents–never have been, don’t see it happening any time soon. I could feel the pressure build, the parents around me were coping the best they could. One father whose eyes looked like those in Edvard Munch’s painting “The Scream” was popping Xanax like they were jellybeans.

I collected a group of parents and we sequestered ourselves behind the skeet-ball. “We’ve got to come up with something to ensure we never have to do this again,” I whispered, trying to rally my charges.

“I can’t do this anymore,” replied a frail-looking man who had developed a nervous tick.

I paused and pondered as an idea flittered past my id. Then I started a smile which soon covered my face.

“What?” asked Tick man.

“Yes, tell us,” implored The Scream.

It was a coloring outside the lines idea if there ever was one. “WebEx,” I barked as the idea began to take shape. “We do virtual birthday parties on WebEx. We each login our children from the comfort of our home. No screaming kids, no cold pizza, no spilled soda. It’s perfect. While they’re doing that, we can be in another room watching football.”

The idea had legs right up until the point where my wife overheard it. “You old Grinch. Get back over here with your son.” I caved, but I’m holding the idea in reserve.

Thinking outside the box. In creating the vision for re-engineering your work flows, why start there? That’s where everyone starts. Remember, if everyone’s thinking outside the box, all that means is that the box has moved and everyone is back in it. Why not create a vision that includes something like re-engineering all non-clinical patient-facing activities? A stretch goal is not trying to reduce billing calling by fifty percent. That’s what world class providers are trying to do. Other stretch goals might be asking questions like;

1. What would have to happen to the practice to be able eliminate eighty percent of all patient complaints?
2. What would it take to move half of all patient contacts to the web?
3. What would happen to first patient satisfaction if you set a goal to use social media to explain how to resolve claims problems?

So, where are we? We need a project champion, who has executive sponsorship, and who is willing to create a vision that has some legs.

Oh, I forgot to mention that after we left Chuck e Cheese we had all the seven year-olds over to our house for a sleep over.  I should have stayed at Chuck e Cheese; it was quieter.

sainttop5

EHR-step away from the scalpel

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So, I lunched today with a friend who is an executive at a healthcare consultancy.  She recently spent four days in a hospital, entering via the trauma center.  The purists among us would think, “If she only had a personal health record (PHR).”

As it turns out, she did.  From what I understood form our chat, the people in the hospital did not welcome her understanding of healthcare.  She handed someone on the trauma team her PHR from Google Health Vault.  According to her, she had downloaded enough data on her jump drive to where MRI’s were dripping from the USB.

At some point they determined she needed to have surgery because of something that appeared on her CAT scan.  Moments before seeing how well she could count backwards from 100, she was able to convince the surgeon that she did not require an operation because what they saw was a pre-existing condition which was documented on her PHR.  Step away from the scalpels.

I think the scalpel thing only served to spur her on.  After leaving the hospital, she requested a copy of her bill—all forty-three pages.  She read it, line by line.  They hate it when patients do that.  Her insurance covered everything, so it’s not like she was minding her pennies.  She was minding her sanity.  Seven hundred and some dollars for Tylenol.  She never took any Tylenol.  Somehow the billing system was tied to the fact that Tylenol was prescribed, independent of whether she actually took it.

Seventy-nine hundred dollars for a CT-scan.  Only ten times higher than the national average.

Where were the failure points?  People.  IT.  Process.  It’s a good thing she knew what she was doing or right now she’d be missing a thing-a-ma-jig—and they would have billed her for another Tylenol to manage that pain.

Without change management and work flow improvement, EHR will only make things worse.  There is a term of art for the intersection of work flows, people, and data—it’s called a mess.  To minimize the mess, to have any shot at an ROI, the sooner you employ adults to run the Program Management Office (PMO) for your EHR, the better your chances.

sainttop5

Reform: Congress must answer, “What’s in it form me?”

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If reform fails to pass, what’s the reason?

Is it because Congress ignored that ninety-eight percent of healthcare is local; Hyperlocal?  I think the answer is a resounding yes.  What is hyperlocal?  You know the saying, “All politics is local?”  Well, hyperlocal is local on steroids.  It’s moms and dads making choices about who will care for their family.  It’s the doctor down the street, not the doctor chosen by some system.

I think individuals see the bill as “What’s in it for them—them is defined as anyone other than me” and “What will it do to me?”  HR 3200 isn’t viewed as improving my healthcare, nobody sees it as meCare.  That is why when viewed nationally so few are behind it.

It’s not that nobody is interested in providing healthcare to those who don’t have it.  What concerns people who do have healthcare is their belief—which may have nothing to do with reality—is that to provide healthcare to those who don’t have it requires that those who have it to give up some of their benefits.  Those with healthcare see reform as a zero sum game.

What has people trying to kill the bill is that nobody who currently has healthcare believes they will see any net gain benefit from the bill—they will see a net loss.  If any benefit will accrue to those who presently have healthcare, they certainly can’t articulate the benefit.

To gain support for HR3200, Reform 3.0, or whatever it comes to be called the bill must address first person interests, not second or third.  Does that sound selfish?  It may be.  However, they are toying with reforming a fifth of the economy and a service of which eighty percent of the people are generally pleased.

For reform to pass, Congress must learn to conjugate the care verb: First person—iCare, meCare Second and third person—heCare, sheCare, theyCare, youCare. That about covers all the various forms of caring.

What Congress hasn’t come to grips with is that there is no meCare in heCare, sheCare, or theyCare—hence, people don’t care to support reform.

What do you think?

black saint 2