# How does Heisenberg’s Uncertainty Principle affect EHR?

One of the great things about social media is its ability to infer attributes of both the readers and the writer.  When you finally meet your virtual pen pal the mind wanders—I thought he sounded taller.

There are those among us who when they picture me writing, see me sitting at my desk, wearing my baby seal-skin slippers, and supping on a bowl of loggerhead turtle soup.

Segue.

According to Heisenberg’s Uncertainty Principle (used in physics) certain pairs of physical properties cannot both be determined simultaneously.  That is, the more precisely one property is known, the less precisely the other can be measured. For instance, the next time you are standing by the side of the road, and cars are whizzing by you, try to decipher the speed of the car, and its exact location.  If I remember my math correctly, the first derivative is its velocity, the second, its acceleration.  To know exactly where the car is at a precise moment in time, the car must be stationary—as in not moving.  Thus, to ascertain its position, the position must be fixed.  The Heisenberg Uncertainty Principle requires that for someone to determine B, A must cease to be a variable.

The Uncertainty Principle can be represented as something like this:

One can see that as additional properties are tossed into the mix the probability of predicting any particular outcome goes to zero.

Thus follows Roemer’s EHR Uncertainty Principle—if you don’t know where you are going, you arrived a long time ago (A little like Pink Floyd’s, “How can you have any pudding if you don’t eat your meat?”).

The conflicting principles include;

·         Implementation date

·         Completion date

·         Final cost

·         The vendor’s capabilities

·         Acceptance testing

·         What should the EHR do

·         How do you know when you are done

·         Should you meet Meaningful Use

·         Will you receive the ARRA money

Here is the point of the allegory.  The chances of a physician group or hospital knowing the answer to all but one of the above principles are zero.

Permit me to throw a wrench into the loggerhead soup and let you know that not having the answers to all but one of the variables is okay.  That is the way projects work.

Since most of you implementing EHR have not ‘been-there, done-that’ with respect to implementing EHR, it is reasonable to expect there are more unknowns than knowns (spell-check indicates that it is not a word, but I know you are keeping up with me).

So, how can you use Heisenberg’s Uncertainty Principle to your advantage?  It is actually rather simple.  Do not allow your implementation to be guided by the unknowns.

·         Do not set an arbitrary budget for something you have never purchased

·         Do not set an arbitrary implementation deadline

Do what you must to make sure you implement an ERH that does what you need it to do.  Do not let yourself be constrained by principles whose only possible effect will be to derail your project.

If you are willing to take that risk, the other principles become moot (the correct terms is moot, not mute—look it up—sorry about the preposition).

If all else fails, consider getting a pair of the seal-skin slippers.

Paul M. Roemer

Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335

+1 (484) 885-6942

paulroemer@healthcareitstrategy.com

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My blog: Healthcare IT Strategy How to Revive a Failed EHR Implementation

# Have I erred on the side of stupidity?

Twice in the span of twelve hours, I received unsolicited and honest feedback from two individuals whose opinion I value, about my attempt to share with you my thoughts about a range of issues concerning the business of healthcare.  One came from my father; since he holds that role he is allowed to offer unsolicited advice any time he wants, and I am entitled to listen to his advice.  The other bit of advice came in response to an email I wrote.  He is one of you, and he wrote the following:

I agree with many of your points and disagree with a few of them, and regardless, it’s a compelling, buzz-worthy angle that gets a lot of re-tweets and what have you, but I think it’s worth considering how these positions are affecting your ability to land consulting gigs in HIT. People want to hire consultants that they think will help them succeed, that think positively and pragmatically, and that are problem solvers (as opposed to problem recognizers): “we can do this together…I’ve had success before and if you let me, I will help you succeed…” that kind of thing. Just my 2 cents. It’s a trade-off, I know. You want to be honest and forthcoming, so I see the dilemma.

This was like being hit by lightening twice in the same day, so I thought I should take time to consider their input.  The feedback led me to ask if there are others who share the same opinion.  Is it possible my ramblings are about as well received, as I would be if I were to walk the streets of Tehran wearing a Star-of-David t-shirt?  What portion of readers drag my postings to their email folder entitled, “Kill him Later”?

Some believe a more effective use of consultants would be to compost them and use the energy generated to power a weed-eater.

Please permit me a few lines to try to explain my thought process for writing in my particular style and tone.  Before I began expressing my opinions on healthcare, I began reading what I considered the best healthcare blogs and editorials.  The first thing I learned is that I had nothing to offer of value on the clinical side of healthcare, so I focused my efforts on discovering what business issues providers dealt with, and which ones might benefit from receiving professional help—a consultant’s twelve-step program for problem solving.

I did a lot of homework; in addition to reading, I interviewed more than a hundred healthcare executives.  What was my takeaway?  One CEO told me the most needed skill on the business side of healthcare was “adult supervision”.  I did not charge in with uncorroborated opinions.  I used LinkedIn discussion groups to pose hundreds of questions about possible problems, studied the responses, and used them as a basis to formulate ideas about what was broken and what needed to be done to fix it.

I should note many of the blogs I read shared two traits; they often stated the same facts available on other blogs, and they rarely seemed to question the efficacy of the impact many of the Healthcare IT initiatives would have on operating healthcare’s business model—ours is not to wonder why, ours is but to do or die.

Not wanting to be superfluous, when I came to the fork in the road, I chose not to take a me-too position.  Instead, I threw metaphorical tomatoes and tried to get people interested in looking at the business model in a more disruptive manner.  Often, I did this by taking extreme positions on issues in the hope I might hit a hot button, and someone would think, “Perhaps we ought to talk to the tomato thrower and see if he can help us”.

My approach may prove to be less than brilliant.  What’s your take?

# The definitive EHR Buying Guide

So, here’s the thing with what a lot of EHR vendors seem to view as the lower end of the food chain, chum worthy customers—Hospitals, IPAs, group and individual practices.

Vendor darts.  I can’t tell you the number of providers with whom I’ve spoke who’ve had to navigate the chum-filled water of vendors trolling for dollars.  Unfortunately, when they come to your door, most of you are ill equipped and ill prepared to know whether you need what they’re selling.

It’s like playing EHR vendor darts—by the way—you’re practice is the dartboard.  Vendors fling their offering at you and hope they stick—the other way to play is to use the vendors as the darts, but you have to sharpen them or they’ll simply bounce off.

Just between you and me, or among us—if you’re a stickler about English—I’ve played vendor darts for years, and it’s always difficult for the dartboard to win.  (I am speaking parenthetically so they can’t hear us.)  We both know this is meant to be somewhat tongue-in-cheek.  The EHR vendors are professionals, and they have the utmost belief in their product, just as they will if they change firms and have to sell another product—this is the unspoken dirty linen of software.

There are a few hundred purported EHR solutions.  Each is a little different.  Which one is best for you?  Do they know which one?  If we are honest, the answer is, no, they don’t.  They do not know, they cannot know what features their competitors offer.

For those of you with any background in selecting software, any kind of software,I want you to do something for me.  Go to Google Search and enter “EHR RFP” and see what you find.  You won’t find anything helpful, anything that will help you select an application.  Big hint–if you cannot find something on Google, it does not exist.  That begs the question, what have providers been using to select an EHR vendor–rock, paper, scissors?

Vendors want you to stay focused on features.  Guess what?  Almost all of the leading products have just about the same features.  I want you to stay focused on business problems.  What business problems of your do their features solve?  It’s a fair question.  They should be able to answer it, and you should be able to answer it.

Rule number 1:  Any time a vendor tells you, “This is how we get our system to do that”, means their system doesn’t do it.  Those words signal a workaround, not a workflow.  It means they want your business to adapt to their way of manipulating how your business runs.  Have they ever run your practice; don’t think so.

Rule number 2: Vendors hope you don’t know about Rule 1.

What can you do?

1. Work with someone who can spell out your requirements in detail.
2. Work with someone who can navigate the chum field on your behalf.
3. Assess some of the free EHR systems

Or, without meaning to be too gauche, contact me.

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-Shift Happens

When my youngest daughter, who is also my oldest daughter was two, we had her straight-jacketed in her car seat as we headed off to run a few errands.  Cute as a button and immobile—just like the book says.  My wife had nicely fixed what was left of her hair—to our surprise, her four-year-old brother had given her a haircut the day before—with a pink beret.  As she had nothing else to do in the back seat, she toyed with the beret, eventually removing it.

After a few miles, checking on her via the rear-view mirror I noticed the beret was nowhere to be seen.  Ninety-nine times out of a hundred, that would mean she had dropped it out of reach, or tossed it to one of her invisible friends in a one-way game of catch.  I asked her where the beret was—sorry for ending in a preposition, but I have a call with a client in a few minutes and do not have the time to ensure I am writing this with the proper King’s English.

Her reply was to simply point to her mouth and giggle.  I repeated the question and she repeated her response.  Being the Super Dad; my son’s term for me, I eased to the side of the road.  We checked the floor of the car, check her car seat, and under her blankets—no beret.  We replayed the question for the third time and received the same response.  We checked her mouth—no beret.  We were hesitant to believe the charade-like communications of a two-year-old.  Nobody in their right mind would swallow a beret.  Then we started to think about the situation.  Bright, shiny, colorful things probably all look like candy to a two-year-old.

We called my sister-in-law, a pediatric nurse practitioner, and an executive at Children’s Hospital of Philadelphia.  She made it clear that we needed to head to the hospital, do not pass Go; do not collect two hundred dollars.

We drove to the ER.  They did their magic, and we were soon looking at her image of her tummy—that’s the most clinical term I know to describe the situation.  There was the beret—we could not tell if it was pink, but we were hopeful that this had to be the same one about which I am writing.

As it turns out, the problem did not lay with her ability to communicate, it lay with our inability to believe that someone without an MBA—feel free to substitute MD or PhD—could define the situation accurately.

I do not have time for a segue, so let us jump into this.  It is easy to ignore what others are saying when a bunch of acronyms a printed on a business card after the presentation of your name.  Been there, done that, too well educated for whatever opinion you may care to offer on the topic.

My docs, and goodness knows I have several of them, I trust with my life—and I have.  These same docs, I would not trust to manage the P&L of a lemonade stand.  This has nothing to do with their IQ, it has to do with their training.  They would not trust me to insert a chest-tube, even though I have watched several episodes of Life in the ER.

At some point, we need to take a hard look at who is best to do what for whom.  Acronyms, in and of themselves, do not qualify one to make business decisions, especially in a virulent environment like healthcare.  Reform, EHR, ONC, Meaningful Use, Certification.  Shift happens, and is happening.

Sometimes there is value in listening to the two-year-old.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

# EHR–where do you place the emphasis?

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

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

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

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

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

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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# The wildebeest postulate

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.

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 this a fair representation of the hospital business model?

I have been looking for a way to represent pictorially the hospital business model and the forces which act upon it.  The picture below came to me last night while playing this board game with my daughter.  It is from the children’s game, Boobytrap.  The way the game is played is that the players try to remove the red, blue, and green pieces without causing the trap to spring and displace all of the pieces.

If we represent patients as the individual playing pieces and make the assumption that each side of the game exerts pressure on the model, I think it represents fairly the external forces with which the large provider model has to battle.  As the forces increase from some combination of costs, regulation, procedure price ceilings, and payor reimbursements, the number of patients in the model will decrease and may do so in a catastrophic manner.  Without a concurrent decrease in those four forces it is unlikely that the model will support additional patients.  Clearly, without changing the size of the board it is impossible to grow the number of patients beyond the board’s capacity.

A couple rules come into play.

• The forces are all external.  They cannot be controlled or abated by the hospital.
• The strengths of the various forces change over time
• The forces result in some maximum number of patients which can be serviced under the hospital’s existing business model.
• As each patient is lost, the stability of the model weakens.

Does this way of depicting the large provider business model ring true?  Does this help illustrate why the model must change?

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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# Herman Melville’s take on healthcare’s business strategy

Someone once summed up one of Fred Astaire’s screen tests with the following; “Can’t sing.  Can’t act.  Balding.  Can dance a little.”  Probably the same guy who evaluated my Mensa application.  I’ve been accused of having a similar outlook.  I once accosted a guy who was walking on water, accusing him of not being able to swim—but that was a looonnngggg time ago.

The internet is full of opinions, but hopefully not full enough. One of the reasons I chose math over English as my major was the affection I held for getting the right answer, or barring that being able to know precisely where my errant efforts led me away from the answer.

In my narrow-minded view of the universe the downside of English, literature—the soft studies—was the notion held by those who taught that there was more to be divined by the story than just the story.  Those who can do; those who can’t teach.  They displayed a Stepford mentality in their obdurate ability to outthink both the author and their students, to bring forth nascent ideas of the author’s hidden meaning.

Herman Melville wrote Moby Dick.  I am willing to bet he wrote it just the way he intended to.  Nobody has uncovered a frayed notebook of Melville having penned his thoughts about the real meaning of life from a cannibal’s perspective, or suggesting Queequeg was a misunderstood cross-dressing sycophant who was never close to his mother.  We don’t come away from our reading of Moby Dick  with a more in-depth ability to understand anything except for perhaps what it felt like to live aboard a whaling ship.

These interpretations are poppycock.  Art critics do the same thing as they bloviate about the hidden meaning behind what the artist really intended to convey, meaning only they can see.  Ever notice how none of these popinjays, these opiners present their opinions as fact?  Pretentious fops.

I write and paint.  Those who’ve read my missives know there is no buried meaning.  If I had wanted to convey something else I would have written something else.  If I use dark colors and bold brush strokes when I paint it is because I feel they add to what I want to show; it is not a reflection of having missed two days of Zoloft.

Nobody will ever know what Shakespeare intended to convey with his addition of the three witches in Macbeth, or whether Joyce Kilmer had ever seen a tree.  That said, I do have a few strong opinions about where this whole business model of healthcare is headed.  I think these types of opinions; along with the opposite opinions differ from the type offered up as truths in an English Lit class.  They differ in that at some point they will be proven right or wrong—time will tell.

As I have written, I think the large provider model—the business model—is seriously flawed.  Moreover, I think it may prove fatal.  Providers will run out of costs to cut, will run out of processes to re-engineer, and will have no more Italian marble with which to line the foyer.  The good news is that they will still have the machine that goes “Ping” just in case somebody needs it.

I do wonder how Melville would have expressed his ideas about healthcare.

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.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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# What if in five years? Ten years?

As if we don’t have enough problems already.

Just curious to hear if you think any of these are viable. What happens to the hospital business model if we see this type of vertical or horizontal integration?  Primary care doctors outsource their up-market needs to hospitals, why can’t hospitals do that and move down-market?  What if:

* Payors buy hospitals then “outsource” the care back to the hospitals
* Hospitals also serve as payors
* Hospitals buy specialists way outside of their network and create a “branch healthcare” model similar to that of branch banking.

What do you think?

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

My profiles:
Contact me: paulroemer paulroemer paulroemer