healthcare 2.0

Who should be able to answer these business questions?

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I wrote this piece for Hospital Impact, published April 22, 2010.  (Not the title I would have chosen.)

http://www.hospitalimpact.org/index.php/2010/04/22/planting_the_seed_why_assembly_line_medi?blog=1&c=1&page=1&more=1&title=planting_the_seed_why_assembly_line_medi&tb=1&pb=1&disp=posts

Now that spring is in full bloom, I’ve been doing a little gardening. My dogs are the anti-gardeners. No sooner do I turn my back after planting something, there they are, happily digging away and ceremoniously digging it up. I don’t know if that’s because they don’t like the particular plant, or just happen to disagree with where I planted it.

Today I discovered the youngest dog uprooted a plant and replaced it with a Reece’s Peanut Butter Cup. Perhaps she wanted to grow a candy tree.

One thing that always confuses me about gardening is this: When I plant a one-gallon shrub, I dig a two-gallon hole. I place the gallon shrub in the two-gallon hole and proceed to fill the remaining one gallon hole with the two gallons of dirt lying next to it. Without fail, there is never enough dirt to fill the hole. Perhaps you can tell me what I am doing wrong.

Here is another area of confusion for me: When you walk or are wheeled into a hospital, neither you nor anyone else knows the answer to anything.

That is astonishing. Nobody can tell you:

* With whom you will interact.
* How long you will stay.
* What will happen to you.
* How it will happen to you.
* When it will happen to you.
* Who will be doing the happening.
* Exactly when it will happen.
* Whether it will need to happen again.
* What it will cost.
* What you will be charged.
* What will be covered.
* How much you will owe.

I am stupefied. How can anyone run a business like this? My daughter knows what her lemonade stand costs per cup. Wendy’s knows the cost of a bag of fries and a large Frosty. Porsche knows the cost of a Cabriolet, the cost of the shift knob, when the wheels will arrive at the factory, when they will be placed on the car, who will build it, who will inspect it, and who will sell it. They can tell you exactly who will touch the car, when they will touch it, and what those people will do to it.

The only thing anyone at a hospital may be able to tell you is whether HBO is billed separately. If I wanted to fly into space with the Russians, I would know the answer to each of those questions. The cost, for example: $50 million.

Why can’t a hospital do this? Because it doesn’t know the answers. It is not because anyone is keeping this information a secret–it’s because they really don’t know. The truly strange thing is that they seem to be okay with not knowing.

Recently, I reconnected with a good friend whom I haven’t seen in years. He is the vice president of finance for a large hospital. He used to be an accountant–a very detailed and precise profession, unless you’re one of the guys who used to do Enron’s books. (The only thing I remember about accounting is that debits are by the window and credits are by the door–if I’m in the wrong room, I’m at a total loss.) This business must drive him nuts!

And so I’ve been wondering; would hospitals be more profitable if:

* They had a P&L by patient?
* They had a P&L per procedure?
* The steps for the same procedure, say a hip replacement, were identical each time?
* They had answers to any of the questions you read above?

Of course they would!

Some areas of healthcare already discovered this tautology–Lasik, endoscopy, the Minute Clinic. Assembly-line medicine. Some people say those words with an expression on their face as though they’d just found a hair in their pasta. The office of my Lasik surgeon looked more impressive than the lobby of my Hyde Park hotel. It may leave a bad taste in the mouth of some, but for others, they are laughing all the way to the bank.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

We’re losing money, but making it up in volume.

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I wrote this in response to an article in modernhealthcare.com titled New doc payment system needed
I posted this question on a dozen healthcare Linked in groups; How Can Doctors and Hospitals Make Money in a Post-Reform, Health 2.0 World?  The reason for the question was to probe for ideas for a speech I am giving in May at ICSI.
My takeaway of the responses is that every approach seems to be triage.  I see the business of healthcare, as juxtaposed to the healthcare business (the clinical side) as a 0.2 business model.  Plus or minus variants of IT, the business continues to run in much the same manner it has for the last fifty years.

Analyzing the model, it appears appears to me to be similar to the pattern created by dropping a pebble into a pond–ever expanding circles, but circles none-the-less.  Sort of a fractal business model, each fractal differing only by size.

The business of healthcare could not be facing more fundamental changes–most of which are external, most of which are unknown.  This is especially troubling for an industry whose P&Ls more closely resemble those of GM than of Apple.
It is time to stop relying on the adages, “We don’t know where we are going but we are making really good time,” and, “We’re losing money but we are making it up in volume.”
Rule number one for change–executives must admit they have a busted business model.  Rule number two–executives cannot change Rule number one.”
saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

What exactly is healthcare 2.0?

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I tend to take a slightly different bent on Healthcare 2.0, a bent which does not intentionally tie to the notion of Internet 2.0, but rather to the notion of an industry desperately needing to reinvent itself.

A few definitions may bring some sense to the discussion. I find it helpful to distinguish the business of healthcare from the healthcare business. I think of the healthcare business as the clinical side, and the business of healthcare as what it takes to make dollars and sense of it all.

Although the healthcare business in the United States is world class in many areas, in many hospitals the business of healthcare is mired in a 0.2 business model. It is often run like a franchised fiefdom of duplicative and ineffective cost and revenue silos—I’m going to duck for a moment in case anyone disagrees strongly with me.

I’m back. This 0.2 business model is being forced into a 2.0 model whether it wants to go there or not. Whether it is capable of making the journey is debatable. The model is regulated, and is about to be reregulated—to what—nobody knows. What national leadership there is is busy waving the magic IT wand thinking that will facilitate the transition from the dark ages and support the business model of National Healthcare—which, by the way, has little if anything to do with the model providers need to run their business.

EHR, if done wrong will be nothing more than a multi-multi-million dollar scanner. Providers will indeed be paperless. However, paper is not the problem. The goal should not be the elimination of paper as though paper is a bad thing. If efficiency equates to speed, to doing something faster, the goal should not be efficiency. It is possible to streamline bad processes and do them faster.

To get to Healthcare 2.0 using my definition, to redefine the business of healthcare, providers must move towards being effective, towards solving business problems, eliminating waste and duplication, retaining doctors and patients, and running it like a real business.

My best – Paul

Why doctors fail to embrace healthcare 2.0

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This is a reply I wrote to Kevin MD’s blog to a post written by Gwenn Schurgin O’Keeffe, MD, FAAP.

I view healthcare 2.0 with a bit of a twist from the Wikipedia definition, less from the perspective of social media and more from the vantage point of moving the business of healthcare from Version 1.0 to version 2.0.  I should note that I distinguish the business of healthcare (how it is run) from the healthcare business (the clinical side).

Having worked with executives in a number of industries, I think that for healthcare reform to be truly effective, the business of healthcare needs to evolve from an 0.2 model to a 2.0 model.  I think the same issues you raise still come into play; sheer panic, loss of control, loss of connection with patients, and blinders.

Going from an in-house business model to one being transformed by reform and Meaningful Use to a national healthcare model will exacerbate further those issues.  The in-house business of healthcare (how healthcare is run) was never built to handle a business model that will require every patient to be able to be connected to any doctor.  The system advances over the past few years—EHR, CPOE, and ePrescribing were implemented without any idea that the rules would change after the fact.

Will healthcare 2.0 offer huge advantages to how healthcare is run?  Absolutely.  The first question to answer before aiming for 2.0 is whose 2.0 model should you follow; yours or the government’s.  Are they the same?  No, and they are diverging even further as you read this.  The good news is that I think they will converge several years down the road.  What you need to decide is which model do you pursue before that happens.

Do EHR vendors have a built-in bias?

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I write from the perspective of hospitals and physicians who are required to pass tests of certifiable, meaningful use, and interoperability. As would be expected, comments made by EHR vendors are quite different from miine.   Forgive me for stating the obvious–their job is to get you to buy what their firm sells, to make you a believer.

There are more than four hundred firms who have something to sell you, something they believe will make your life better. How do you know which one of them is offering something that may work for you? How can you tell? Heck, how can you tell which product will still be viable in three years?

A question worth considering.  As passionate as the vdenors’ sales reps are, when a sales rep moves from Vendor A to Vendor B, does their passion remain with Vandor A?  Of course not.  The new “best thing since slided bread” is the thing offered by Vendor B.

Where does that leave you?  For starters, don’t buy it on faith.  Don’t buy it just because somebody else bought it–is their judgement better than yours?  You need a way to make an objective decision about some very subjective information.  One way to do that is to turn the subjective issues into quantifiable business requirements.

What do you think?

How the Grinch stole healthcare

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(n.b. Pelosi, Reid, and the term Payor may be changed to the names of your favorite vilans without materially altering the story.)

Every Congressman
Down in Congress-ville
Liked Health reform a lot…

But the Payors,
Who lived just North of Congress-ville,
Did NOT!

The Payors hated Health Reform! The Congressional reform season!
And as everyone’s heard there is more than one reason.
Was it the fear of losing their monopoly right.
Worried, perhaps, that Congress might indict.
But I think that the most likely reason of all
May have been that the uninsured took them all to the wall.

Staring down from their man-caves with indemnifier frowns
At the warm lighted windows below in the town.
For they knew every Congressman down in Congress-ville beneath,
Canted an ear to hear them gnashing their teeth.

“If this passes, they’ll kill our careers!”
“Healthcare reform! It’s practically here!”
Then they growled, the ideologues nervously drumming,
“We MUST find a way to keep Reform from coming!”
For, tomorrow, they knew…

…Stumbling home from the tavern at a quarter past two                                                                                                                 What each Congressman, intern, and page might just do

And then all the milieu. Oh the milieu, the milieu
The thing the Payor hated more than mom’s Mulligan stew.

Then all the Congressmen, the left and the right, would sit down and meet.
And they’d meet! And they’d meet!
And they’d MEET! MEET! MEET! MEET!
Implement full provision; cover pre-existing…how sweet
Which was something the Payors couldn’t stand in the least!

And THEN
They’d do something Payors liked least of all!
Every Congressman down in Congress-ville, the tall and the small,
Would stand close together, their Healthcare bells ringing.
With Blackberrys-in-hand, the Congress would start pinging!

They’d ping! And they’d ping!
AND they’d PING! PING! PING! PING!
And the more the Obligators thought of the Congressman-Health-Ping
The more they each thought, “I must stop reform-ing!
“Why for all of these years we’ve put up with it now!
We MUST stop health Reform from coming!
…But HOW?”

Then they got an idea!
An awful idea!
THE Indemnifiers
GOT A WONDERFULLY, AWFUL IDEA!

“I know what to do!” The CEO Payor laughed in his throat.
And he made a quick Congressional hat and a coat.
And he chuckled, and clucked, “What a great Payor raucous!
“With this coat and this hat, I’ll look just like Saint Bacchus!”

“All I need is a pass…”
The Payor looked around.
Since Congressional passes are scarce, there was none to be found.
Did that stop the old Payor…?
No! The Payor simply said,
“If I can’t find a pass, I’ll make one instead!”
So he called his aide Max. Then he took some red paper
And he dummied up the pass and he started this caper.

THEN
He loaded some bags
And some old empty sacks
On a Benz 550
And he rode with old Max.

Then the Payor called, “Dude!”
And the Benz started down
To the offices where the Congressmen
Lay a-snooze in their town.

All their windows were dark. Quiet snow filled the air.
All the Congressmen were dreaming sweet dreams of healthcare
When the Payor came to the first office in the square.
“This is stop number one,” The old Warrantist – a winner
And he slipped passed the guard, like sneaking to a State Dinner.

Then he slid down the hallway, Harry Reid was in sight.
Reid was chumming Pelosi, he planned quite a night.
He got nervous only once, for a moment or two.
Then he realized that the leadership hadn’t a clue
Then he found the Congressional stimuli all hung in a row.
“These Stimuli,” he grinned, “are the first things to go!”

The Payor slithered and slunk, with a smile somewhat mordant,
Around the old Cloakroom, and looking discordant!
There were copies of the bill stuffed in jackets and on chairs,  He even found a copy tucked under the stairs
And he stuffed them in bags. Then the Payor, very neatly,
Started humming a tune from Blue Cross rather Cheeky!

Then he slunk to the Senate Chamber, the one facing East
He took the Senators’-copies! … didn’t mind in the least!
He cleaned out that Chamber and almost slipped on the floor.
Saw an Internet router, and thought of Al Gore

Then he stuffed all the copies in the trunk of his Benz.
And he thought to himself, “Why don’t I have friends?”                                                                                                                    “There’s always TW,” he said with no jest                                                                                                                                                    But TW’s being chased by reporters, those pests.

The Payor spotted the Grinch having trouble with his sacks
And he lent him a hand—he offered him Max                                                                                                                                           Max was quite pleased, for he knew this December,
That the Grinch would become the Payor’s board member.

The Grinch was all smiles–he’d made quite a killing
Offering to help pillage if the Payor was willing.
He stared at the Payor and asked, “New glasses?”
The Payor simply smiled, saying “These people are such (You did that to yourself, not me.)

And, you know, that old Payor was so smart and so conniving
When he next saw Pelosi he found himself smiling!
“Why, my dear little Nanc’,” the Bacchus look-alike stiffened,
“Botox in this light makes you look like a Griffin.
“I’m taking these home,” he said pointing to the copies.
“There’s a comma on one page that looks way too sloppy.”

And his fib fooled the Griffin. Then he patted her head
And he gave her a wink, and he sent her to bed
And as Speaker Pelosi shuffled off to her army,
HE said to himself, “What a waste of Armani!”

Then the last thing he needed
Was to mess up HITECH.
Then he went to HHS, the DOD and the VA,
Stuffed mint jelly in their servers so that they would not play

And the one EHR
That still worked in the DC
Was the one bought from CostCo and tucked under the tree.


Then
He did some more damage
To HIEs, and the N-HIN

Leaving PHRs
Far too trashed
For a doctor who did knee-shins!

It was quarter past dawn…
None in Congress were his friends
All the Congressmen, still a-snooze
When he packed up his Benz,
Packed it up with their copies of reform in those bags! Stacked to the leather ceiling,
Manila envelopes with name tags!

Three miles away were the banks of the river,
He was poised with the bags all set to deliver!
“Pooh-pooh to the Congressmen!” he was Payor-ish-ly humming.
“They’re finding out now that no Reform is coming!
“They’re just waking up! I know just what they’ll do!
“Their mouths will hang open a minute or two
“The all the Congressman down in Congress-ville will all cry BOO-HOO!”

“That’s a noise,” grinned the Payor,
“That I simply must hear!”
So he paused and the Payor put a hand to his ear.
And he did hear a sound rising over the snow.
It started in low. Then it started to grow…

But the sound wasn’t sad!
Why, this sound sounded merry!
It couldn’t be so!
But it WAS merry! VERY!

He stared down at Congress-ville!
The Payor popped his eyes!
Then he shook!
What he saw was a shocking surprise!

Every Congressman down in Congress-ville, the tall and the small,
Was singing! Without any health reform at all!
The Congress didn’t care, a few were disgraces,
All they wanted, it seemed, was TV with their faces

And the Payor, with his Payor-feet knee deep in the muck,
Stood puzzling and puzzling: “Man, there goes my bucks.
It could be about healthcare! It could be global warming!
“It could be Al Qaeda, Afghanistan and desert storming”
And he puzzled three hours, `till his puzzler was sore.
Then the Payor thought of something he hadn’t before!
“Maybe Congress,” he thought, “simply needs a free ride.
“Maybe Congress…just needs to look like they tried.

And what happened then…?
Well…in Congress-ville they say
That the Payor’s small wallet
Grew three sizes that day!
And the minute his wallet didn’t feel quite so tight,
He whizzed in his Benz passing through a red light
And he brought back the copies of the bill for reform!
And he…

…HE HIMSELF…!
The Payor calmed the whole storm!

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

What is meant by Healthcare 0.2 and 2.0?

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eat_more_chickensized

Last night I was explaining to my sister-in-law my notion about healthcare 0.2 and the need to transform it to healthcare 2.0.  She had no idea what I meant.  That’s a problem—not because she’s my wife’s sister but because she an executive at one of the top children’s hospitals.

I figured that if she didn’t understand what I meant, I may have also confused others—sort of like typing with a keyboard full of marbles.

I’ve written that healthcare is a 0.2 business being forced towards 2.0—H2.0.  What exactly do I mean by Health 0.2?  It could just as easily be 0.5 or 0.7.  The idea behind the label is that there is a large gap between where the healthcare business is, H0.2, and the future of the healthcare business, H2.0.

Permit me to share how I distinguish between the business of healthcare and the healthcare business.

  • The business of healthcare—clinical, care, patients
  • The healthcare business is paper intensive and duplicative and includes support business functions like:
    • Human resources
    • IT
    • Payroll
    • Vendor relationship management (VRM)
    • Patient relationship management (PRM)
    • Registration…and so forth

Successfully bridging the 0.2 to 2.0 GAP replies equally on foresight and planning.  For the change brought about by the bridge to take hold, change needs to be an ongoing event.

To begin the assessment, healthcare leaders must undertake an honest assessment of the organization’s strengths and weaknesses.  Sounds simple.  It’s not.  Hospitals are noted for their fiefdoms, and the fiefs, run mostly by doctors, aren’t big on being told there’s a better way to do things, nor are they keen on giving away control.

To change how the business is run, to make it more effective, and thus more efficient, requires that the major business functions be retooled.

We’ll take a look at how a hospital might go about this.

sainttop5

Healthcare 2.0, can you get there from here?

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water2

From a business perspective, not clinical, the critical success factor for H2.0 relies on healthcare’s ability to move from being an 0.2 industry.

H0.2 is the “As-is” model.  H2.0 is the “To-be” model.  To reach H2.0 healthcare must bridge that functional, work flow, change management, user acceptance, and technical GAP.  The Gap will differ by provider.  There is no singular work plan to help providers know what they need to do to build a custom plan to bridge the gap.

None of this matters until the healthcare provider willingly acknowledges that they have a long way to go to get to anything that resembles H2.0.

H0.2 – H2.0 = GAP

If you don’t mind the gap,  H2.0 is just H2O–all wet

black saint 2

Health care hero

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I continue to struggle with you as to understanding the etiquette of the social web.  In spite of that, each day I become more impressed with those who have something to say and who are able to intelligently and gracefully articulate their positions on a range of issues.

Hero is such a disposable word.  I thought it might be of interest to share the meaning of the word from the eyes of a ten year old.

Forgive me for stealing a minute of your time for these few paragraphs.  Although I rant about the healthcare system, and independent of whether it needs changing and how to change it, I am quite a fan.

One year ago my 10-year-old son was given a writing assignment to draft a paragraph about his hero.  He wrote the following, an event that happened when he was 4,  which I subsequently framed and placed on my night stand—the spelling errors help authenticate the narrative:

“An amblence driver is my hero. He saved one of my familys members lives, My Dad. One late night my dad had a hart attack (I had a horrible ear ake.  We called the hospital and an ambulance came to take my dad.  The driver took him to the hospital (it takes 30 minutes to get there going 60 miles an hour.)

I love to read and write, and as you know, I can be critical of those who do and don’t, but this is the best thing I’ve ever read.

Thanks for indulging me.saint