healthcare

Is wellness being overlooked?

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The following are my comments to Sue Schick’s blog, Are you ready to commit to a wellness program?

With all of the pronouncements coming from Washington about healthcare reform, it is easy to be waylaid by Gossamer eddies and side currents that pay little attention to one key area—health. There is plenty of discussion about insuring the uninsured, covering pre-existing conditions, and the rollout of a national healthcare model under the guise of healthcare information technology and facilitating the transport of electronic medical records.

I think Sue’s words are spot-on and timely. Even if nobody is going to pay for it, with so many Americans participating in the healthcare conversation, an entire industry being re-engineered, and a trillion dollars to fund the transformation, should not there be more attention paid to wellness, to proactively making one responsible for one’s own health?

Unfortunately, my perspective on this issue is shaped from having been there, done that, got the T-shirt—a heart attack at the age of forty-six. I’ve transformed myself from someone who took twenty-four years off between workouts to barely taking twenty-four hours off between workouts. I didn’t need an employer to sponsor a wellness program; all I needed was a ride in an ambulance.

There may be a lot of different ways to get someone’s attention around wellness, around being responsible. Those who want to be well will have to make that decision for themselves. No company can do it for you, but companies certainly can be supportive of your efforts to help yourself.

There has been a lot of conversation in the healthcare debate about what role the insurance companies have played in driving reform. Right or wrong, a number of stakeholders view payors as bad actors, as the raison d’être of reform.

Wellness seems to offer payors a way to put on the white hat, to be proactive. Patients understand that they do not pay their providers for their healthcare. In the event patients need a provider, patients pay the insurers, cross their fingers, and hope the insurers agree to cover the expense.

I am somewhat of a dilettante to the insurance side of the healthcare model, so I apologize in advance if I misspeak. Here’s my take as to the white hat opportunity, a way to take a leadership role in the matter of wellness. When you apply for insurance, you receive negative ratings for unhealthy and unsafe behaviors; smoking, health history, sky diving. However, if you run five days a week, maintain your weight, eat fish and refrain from drinking, you accrue no points for good behavior. In fact, you are rated as though you made no proactive attempts to manage your own health.

Auto insurance companies raise your rates for certain bad behaviors, and they lower them for certain good behaviors. No accidents for two years—the rate goes down. No traffic violations—the rate goes down. Behavior modification. I am aware of it and I manage my behavior to get lower rates.

Can a similar model work for health insurance? What would it take for payors to offer an incentive model for rewarding good behaviors?

Why let your EHR vendor run your hospital?

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Healthcare Failures Magazine (HFM)  “It is not everyone who can finish dead last in the CIO of the Year competition.  How do you account for your total lack of accomplishment?”

PR:  “It was not as easy as it may appear.  I think it had to do with believing that my EHR vendor knew more about running a hospital than did we.”

HFM “Why do you say that?”

PR:  “They told me their EHR it had been implemented “As Is” at a number of hospitals and was running fine.  I was convinced that all hospitals are basically the same; admissions, treatment, discharge.  Besides, it saved a lot of money not having to customize it and do all that stuff about workflows.”

HFM “What about the change management?”

PR:  “Yeah, well I guess you could say that part kind’a blew up on me.  It didn’t take long to learn that our hospital didn’t function at all like their software.  According to our doctors, they didn’t think this vendor had ever been in a hospital, let alone run one.”

Who defines your vision?  Who is your chief imaginist, the person responsible for defining the type of hospital you hope to operate five years from now?  Do you want it to be your EHR vendor?  Probably not?  Is it your vendor?  It may well be.  Why? Do you want to outsource your imagination and your future to your vendor?

Without a detailed and comprehensive work flow improvement and change management program the only thing you will implement is your EHR vendor’s vision of how a hospital should function.  You’ll be just like each of their other clients.  Is that what your business model calls for, is it satisfactory?

How Can Healthcare Technologies Help Revive Healthcare?

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The following well-delivered blog was written by Matthew Browning RN, MSN, APRN is CEO of YourNurseIsOn.com.   I hope you find it as insightful as I did.  Thank you Matthew for contributing.

As Paul has so poignantly illustrated in his recent articles on EHRs, Meaningful Use, CPOE, etc., the reality and the practicality of many of these systems, with their constantly moving goalposts and expectations, does not live up to the dreams and the promises being made. Millions of dollars are being wasted on the pursuit of a nebulous standard that is being corrupted by various factions, some fighting for openness, transparency and patient portability versus those wanting the control, ownership and monitoring of our personal medical records and data. If you are betting millions of dollars on these systems prudence dictates that you must be sure they are market ready and will meet regulatory approval. Besides, their are cutting-edge health 2.0 companies that will give you EHR systems for free.

While this drama has been forefront in the public eye, many new, easy to implement solutions have entered the marketplace to help get the daily business of healthcare done in ways never before possible. There are patient reminder services, staff communications tools, inventory control systems, waste management technologies and social media sites to connect facilities and their communities. Even without the spotlight, without government involvement, without the millions in promised taxpayer dollars and without the traditional healthcare company heavyweights, real change is being effected in healthcare delivery today.

What are some of the expectations we have of these types of real solutions in the healthcare environment? Well, as a nurse, I expect these technologies to make my life ‘easier’ if you will. They should help increase the amount of hours I spend at a patient’s bedside because every study shows that is the number one indicator of patient outcomes. The technology should make me more efficient in delivering the care my patients need: save steps when looking for supplies; decrease repetitive procedures; encourage efficient workflow and decrease the amount of time I must spend on non-nursing duties. Technology should enable collaborative, real-time communications with my employers, colleagues and even patients where we communicate at our best- from work, home, or on mobile devices and computers. Technologies can monitor patient status and notify caregivers when extra attention is needed, or can allow me to change my status from available to occupied or unavailable for care flow management.

As a business owner or investor, these technologies must be present and functioning today, must make the things we currently do every day more efficient and less costly, and should increase our abilities to communicate, manage, market, sell and make a profit or remain sustainable. We would like to increase our customer’s satisfaction with our services, increase their word of mouth and serve their needs while they are here. Since our customers are patients we would like technologies that help us decrease patient recidivism, infections rate, injuries and mortalities while improving patient outcomes. Since our staff is healthcare providers we would like technologies that increase employee moral, retention, satisfaction and productivity while decreasing turnover, absenteeism, vacancy rates, overtime costs and agency usage.

As a patient we expect to have these technologies make us feel well cared for, valued and respected. We do not want to fill out the same form multiple times, we want our complete, accurate, legible medical record available on demand- where ever we may be. We want scheduling software that eliminates waiting room ‘lay overs’ or technology that let’s US bill THEM when we have to wait 😉 We need to be able to research our hospitals and providers effectiveness, complaints, pricing and availability- or we will go to those who allow us to see this info. We want technologies that allow us  to age in place at home, or to help make our nursing homes better staffed and safer.           Technologies can keep us in touch with loved ones and families when separated by distance or circumstance and can connect us with providers from around the world or world renowned experts. It can be deployed cheaply, widely and quickly. It doesn’t have to do everything but it must do something well…and keep learning to do it better. Technology cannot be allowed to become an obstacle to doing business and continuing progress. We must harness its power to effectively achieve our healthcare objectives while faced with a seemingly insurmountable combination of increasing patient population contrasted with our shrinking supply of healthcare professionals. That is both the promise and the reality of technology in healthcare today. Your thoughts and comments are essential to continue the discussion and guide the adoption of technologies today in the healthcare arena. What are YOUR thoughts, wishes, needs and concerns about the state of technology in healthcare today??

About the author:

Matthew Browning RN, MSN, APRN is CEO of YourNurseIsOn.com a healthcare staff communications company. Mr. Browning is a frequent speaker, contributing author, tireless change agent and fierce advocate for Health 2.0, Patient’s Rights, Healthcare Technology, Aging at Home and Nursing. Matthew lives in New Haven, CT with his wonderful wife, Phoebe, and their energetic son, AJ. He can be contacted by email at Matthew@YourNurseIsOn.com , on Twitter @MatthewBrowning or feel free connect on LinkedIn at http://www.linkedin.com/in/matthewbrowning .

My 1st post on HealthsystemCIO.com

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The following is my first guest post on Anthony Guerra’s new site, HealthsystemCIO.com.

If you haven’t begun the process of selecting and implementing an EHR, Meaningful Use may not be something with which to concern yourself. The reason, you probably will not be done in time to collect the incentive money. How can I state that with such assurance? One of my clients has already implemented EHR and CPOE—already done the heavy lifting—and they will have to divert most of their resources just to meet the Stage 1 requirements.

If you haven’t begun, there may be no rush to acquire a vendor, although the vendors will not tell you that. Rushing may lead to a bad selection. Don’t cost yourself tens of millions get to have a chance at a few. By the way, did any of the vendors with whom you are speaking mention that they have no clue if their system will meet any of the Stage 2 and 3 requirements? Right now, it’s like the vendors are selling cars without knowing whether it will need to run on gas or Hydrogen.

I think the Meaningful Use dates will be pushed back. Why? Because few if any of the providers will be in a position to apply for the incentive money. Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.

Now for those whose EHR implementation is well underway or up and running — should you try for the incentive money? That’s a valid question. Just because someone is offering you a check doesn’t mean you have to take the money. Here are some questions you ought to be able to answer prior to deciding if Meaningful Use is meaningful to you.

  • Meeting MU requires a shift in your direction; you take on the MU tasks and sacrifice some of what you were going to do
  • What are those tasks, what resources will they consume
  • What year is the best year for you to meet MU; 2011-2015?
  • Did you know you can still maximize incentive dollars if you pass MU in 2013?
    • That gives you very little time to react to Stage 2 & 3 requirements

Meaningful Use is a binary contest — you make it or you don’t. The decision to meet Meaningful Use does not have to be binary. There is no way to collect for meeting 90 percent of the requirements. How might you financially calculate the probability of obtaining the incentives? Let’s begin with Stage 1—the easy one.

  • Calculate the maximum incentive you could receive
  • Multiply that figure by the degree of certainty you have that your plan will be completed on time — a number less than 1
  • Then multiply it by the probability you think exists for passing the audit, another number less than 1
  • Calculate your cost to complete Stage 1, then figure out your ROI — not much is it?I’ve seen one provider whose ROI is negative.
  • This makes evaluating Stage 2 & 3 calculations seem rather superficial. Want my advice for calculating an ROI out of requirements that don’t exist? I’d use a placeholder of six zeros preceded by a number greater than five for each Stage.

So take time to evaluate your options. The only people who will look foolish are those who don’t know what questions to ask.

How will reform impact Payors?

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I have developed quite a fondness for children’s books, particularly those with a well disguised allegory.  Long favorites of mine include the short stories, Uncle Remus, written by Joel Chandler Harris.  Br’er Rabbit (“Brother Rabbit”) is the main character in each of the stories, a likable troublemaker and prone to tricks.

His opposition is usually Br’er Fox Br’er Bear. In one tale, Br’er Fox and Br’er Bear hope to capture Br’er Rabbit.  Fox constructs a lump of tar and puts clothing on it. When Br’er Rabbit comes along he addresses the “tar baby” amiably, but receives no response.  Br’er Rabbit becomes offended by what he perceives as Tar Baby’s lack of manners, punches it, and becomes stuck. Now that Br’er Rabbit is stuck, Fox and Bear ponder how to dispose of Br’er Rabbit.

With each idea suggested for his demise, Rabbit has no complaints, however the helpless, but cunning, Br’er Rabbit always pleads, “Do with me what you will, but please don’t throw me in to that briar patch.”  Finally catching on to how “frightened” Br’er Rabbit is if the briar patch, Fox, believing he has the upper hand, throws Rabbit into the briars.  As rabbits are at home in thickets, the resourceful Br’er Rabbit convinces his enemies to do what he wanted them to do all along.

Sound familiar?  It should.  Br’er President and Br’er Congress.  The contest is how do they capture Br’er Payor and get Payor to play nicely.

“Let’s put caps on Br’er Payor’s rates,” suggested Br’er Congress.

“Do with me what you will,” pleads Br’er Payor.  “Cap my rates, but please don’t make us cover the uninsured.”

“Why not make Payor cover pre-existing conditions?”  Asked Br’er President.

“Do that,” chided Br’er Payor.  “We’ll even cover hangnails.  But please don’t make us cover the uninsured.”

“You know Br’er President,” said Br’er Congress, “Br’er Payor seems awfully afraid that we will make them cover all of the uninsured.   Let’s do that, let’s hit Payor where it will hurt the most.”

And so they did—made Br’er Payor cover the uninsured—threw them right into the briar patch.  Right where Br’er Payor wanted to be all along.  Thirty-one million new customers—how awful.  Smack dab in the middle of a recession, payor is handed a windfall of new customers.  Premiums.  Times twelve—twelve months.  Let’s estimate a hundred dollars a month.  That’s about thirty-seven billion in new revenues.  Billion with a B.  How is that for cutting healthcare costs.

Now suppose, just suppose that Br’er Payor has little motivation to be a good corporate citizen.  I know I am asking you to take a leap of faith.  Silly me, but I have this question that is gnawing at my craw.  What if Br’er Payor collected all these premiums and set the deductible so high that none of their new customers was ever able to file a claim?  The feds tossed the payors right into the briar patch, didn’t they?

What’s the probability around Meaningful Use?

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Below is a reply I wrote to a post on MU in Healthcare IT News
What’s the probability, that you complete the Stage 1 Meaningful Use requirements?  What’s the probability, after doing your best to meet the Stage 1 requirements that you actually pass the audit?  What’s the probability you’ll have the time needed to implement Stage 2 and 3 before the penalties begin? (That’s sort of like asking if you know the probability of seeing a bluebird on the third Tuesday of June.)
Now, go ahead and calculate an ROI based on everything you don’t know.  Not too easy is it?

The doctors’ thoughts on social media are probably correct

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Some more thoughts on the post on KevinMD’s site stemming from Dr. Gwenn’s blog.

Justifiable on-line road rage.  I run a consulting firm.  You know what?  I hate it—running the firm, that is.  The consulting is great fun.  I am guessing that being a physician is a lot like that.  Very few of you became doctors to run a business, let alone one that is front and center on the evening news, Twitter, and every other blog on the planet.  Add to that a government who is changing the business model without any thought to how it impacts your business.  They want a nationalized healthcare system whereby each patient can be accessed by any doctor—that has nothing to do with your effort to treat actual people.

Interesting discussion, and the comments are spot on, especially the, “Where’s the beef” comments.  It is silly to expect that overlaying a few technologies makes things better.  This reminds me a little of Dorothy running around in ruby slippers, and the magic answer was clicking her heels three times.  Unless K-mart had a big sale on ruby slippers, there is no quick win technology for doctors lining the shelves of Office Max.

To rub salt in the wound, the government is forcing more technology on physicians, namely EHR.  If the technology was as great as the prognosticators write, doctors would be scrambling to be first in line.  Has that happened?  Of course not.  Instead, the government is taking a Tony Soprano approach, offering rebates for doctors who take a course they don’t want to take, alternatively, burying bodies off the New Jersey Turnpike.

So, some tactical thoughts starting with EHR.  Don’t do anything yet.  You have at least a year.  Yeah, you won’t get the ARRA money—that’s according to what’s written.  Guess what?  Nobody else will get it either.  The ONC will have to change either the timing of Meaningful Use, or the rules, or both.  I think they will push it back.  Twelve to eighteen months from now, someone will offer a robust, shrink-wrapped solution that makes sense.  If you’re interested, here’s a link to an audio interview I did for doctors about an EHR strategy—it’s just ideas, I’m not pushing anything.  Go to EMRFIX.com and search for the link.

Other practical thoughts.  There are a few hundred thousand doctors, none of whose Hippocratic Oath said anything about healthcare 2.0, or offered any training on how to get there, or whether you should even try to get there.  Most of my physician friends set up their business model on a whim and a prayer, like all entrepreneurs do—like I did.  There are probably as many business models for doctors as there are doctors.  The good news is that some have done better figuring out the business side of healthcare than others.  It’s not an ego thing.  It’s not about being intellectually gifted and not being smart enough to figure out something as simple as running a business.  Why?  Smart has nothing to do with it.  There are things to be learned from the efforts of others, and there are ways that some of the technologies can help.

Those things?  Blocking and tackling.  Business processes.  Social media.  Eliminate the rework.  Eliminate whatever tasks that don’t add value to your business.  Are there activities you can outsource?  Payroll?  Can you have someone design a website that will answer questions for your patients so they don’t have to call you?  Can you collaborate with other doctors?

Just some ideas.  You are justified in your angst.

Should you consider avoiding Meaningful Use?

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Where were we?

There are a few things stuck in my craw—imagine that.  One is Meaningful Use.  The other is also Meaningful Use.  Permit me to address these one at a time.  I’ll start with Meaningful Use.

Are you kidding me?  Who are these people?  To disguise that of whom I write, let’s invent some aliases, Dr. B and Dr. H.  For all the meetings, all the pronouncements, you’d think sooner or later one of them would state, “There is no way any of this makes sense.”

Why do you say that Paul?  May I?   What if you threw a party and nobody came?  What if you held a $40 billion lottery and nobody won?  Here are the rules.  A handful of people less than seven feet tall decide to buy homes in a community.  All the homes have door openings that are seven feet high.  New people move into the community.  One day the homeowner’s association mandates that all homeowners must build homes with door openings that are seven feet high.  Most homeowners ignore the mandate.  The association then decides to offer the homeowners rebates if they comply with the mandate, and penalize them if they don’t.  Most of the homeowners ignore the mandate.

Indifferent to the fact that their mandate isn’t working, the association decides to add new rules, rules that affect the homeowners who already built homes with seven foot tall doors, and those who didn’t.  One of the rules is that the seven foot tall doors must now be eight feet tall; another mandates that all roofs must be in the basement.  Homeowners who comply will win the lottery.  Those who don’t won’t.

How does the lottery pay out?  It doesn’t.  They made it impossible for anyone to get the money.   Suppose you gave a lottery and nobody won?  Suppose you made it so obtuse that nobody cared if they won.

That’s where I think we are with EHR.  The smart healthcare providers are asking themselves the question, “What if we make a business decision not to meet the Meaningful Use requirements?”  “What if we decide what is and isn’t meaningful.”

There are 2 “business models” in play—the national healthcare model, and the model your firm follows—they have different goals.  I asked my client, “When you made your selection of EHR, did you have any hint that the government was going to create rules to manage what it does?”  I assume their answer is a lot like yours—“Not at all.  We were worried about FDA oversight, but nothing like the stimulus.  The PQRI was available as an incentive to use ePrescribing, but really small potatoes.”

The national healthcare model under development will create an infrastructure such that every patient can be connected to each physician via a series of HIEs and the N-HIN.  To get there, they need you—they can’t do it without you.  What do they need from you?  Participation.  Participation by having and EHR, ePrescribing, and CPOE.

Even if it were to work, what’s in it for you?  Very little.  They know that—that’s why there are payments and penalties.  Most hospitals like the idea of implementing EHR.  Given the choice those same hospital executives would choose to listen to an entire Celine Dion CD if it would allow them to skip implementing CPOE.

If there are not many good business reasons to meet Meaningful Use, why should you build an entire strategy around it?  You wouldn’t paint your hospital pink simply because Washington said you should, although given a choice between the two ideas, pink sounds pretty good.  Let’s say you take them up on meeting Meaningful Use.  You build your strategy, drop current initiatives, implement these systems, train your people—then what?  Indeed.  What happens if the government changes its mind?  Moves the dates, changes the requirements?

In order to go for Meaningful Use you must be able to suspend your ability to think rationally.  If you do not think the HIE and N-HIN model will work—I have not met anyone who thinks it will—why even give Meaningful Use another thought.

My client is a group of 14 hospitals—they could get millions of ARRA dollars.  If you don’t have more than one hospital, your ARRA rebate will be much less.  They have already installed EHR and CPOE.  To get the millions they have to spend millions.  What happens if they spend it and the feds change their direction?  What then?  What do they do with the eight or nine figures of systems they build to follow Washington’s lead?  Take them out?  Modify them?  What happens to their business model as a result of all of this “leadership” from the ONC?

What should you do?  That’s up to you.  Here’s an idea or two.  First, ask yourself what your EHR/HIT strategy would be if there was no ARRA money.  (You do have a written HIT strategy, don’t you?)  Second, decide if you think that the current national roll out strategy will work.  Third, figure out what you won’t be able to do if you have to invest even more time and money meeting Meaningful Use.  Next, add up all the money it will cost you to meet their requirements and compare that to what they will pay you.  I bet the costs are more than the rebate.

I think Meaningful Use won’t exist in 3-5 years.  I think the N-HIN won’t be available by then either.

Here’s the real kicker for hospitals that have more than two beds.  If you have not yet selected your EHR vendor you shouldn’t even be thinking about meeting Meaningful Use for the first year because you can’t there in the time available to you.  That take’s the pressure off, doesn’t it.

The parabolic parable

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The bad thing about being a former mathematician in my case is that the emphasis is on the word former. Sometimes I’m convinced I’ve forgotten more than I ever learned.—sort of like the concept of negative numbers. It’s funny how the mind works, or in my case goes on little vacations without telling me. This whole parabola thing came to me while I was running, and over the next few miles of my run I tried to reconstruct the formula for a parabola. No luck.

My mind shut that down and went off on something that at least sounded somewhat similar, parables. That got me to thinking, and all of a sudden I was focused on the parable of the lost sheep, the one where a sheep wanders off and the shepherd leaves his flock to go find the lost one, which brings us to where we are today.

Sheep and effort.  Let’s rewind for a second. Permit me to put the patient lifecycle into physics for librarian style language—get the patient, keep the patient, lose the patient.  These are the three basic boxes where providers focus resources. How well do we do in managing that lifecycle to our advantage? We have marketing and sales to get the patient, we have patients care to keep the patient.  Can anyone tell me the name of the group whose job it is to lose the patient?  Sorry, I should have said to not lose the patient. Freudian—actually, we probably have our pet names for the department who we fault for patients leaving.

Where do most providers spend the majority of their intellectual capital and investment dollars? Hint—watch their commercials. It’s to get the patient. Out comes the red carpet. They get escorted in with the white glove treatment. Once they’re in, the gloves come off, to everyone’s detriment. Nobody ever sees the red carpet again. A high percentage of a firm’s budget is to get the patients, and another large chuck for existing patients. Almost nothing is spent to retain exiting patients.

Existing versus exiting. Winning providers roll out the red carpet when patients exit. They do this for two reasons. One, it may cause a patient to return. Two, it changes the conversation. Which conversation? The one your ex-patient is about to have with the rest of the world. How does your firm want that conversation to go?

You’re no Aristotle

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Everything is written with the idea of persuading the reader; either explicitly—what is written is true, or implicitly—what is written is informative or funny, thereby persuading you that the author is informative or funny. Aristotle employed three forms of rhetorical persuasion; pathos, ethos, and logos. For those of you thinking, “Yeah, but you’re no Aristotle,” you’ll get no argument from me, but you have to admit, it’s a good likeness.

I basically write from whatever stream of clatter happens to be knocking about at the time. For me, writing is a little like speaking in parenthesis, only a little quieter and with more ambiguity. So, what is lurking up there at the moment? Sure you want to know?

I’m trying to convince my son the futility of not doing something correctly the first time he does it, arguing that it takes twice as long to do it wrong as it does to do it correctly. I call it the DIRT-FIT Principle—Do It Right the FIrst Time. For instance—loading the dishwasher. It takes a certain amount of time after clearing the counter to place the dishes, glasses, and utensils in the dishwasher pell-mell. It takes twice as long to redo it.  The same principle applies to making his bed, putting away his shoes, and brushing his teeth.

The same principle applies to implementing an EHR system. It costs twice as much to put it in twice as it does to implement it correctly the first time. I bet you know a hospital who is busily implementing EHR 2.0.  There is the difference between EHR implementations and sons. Implementations have the right not to do it correctly the first time—my son doesn’t.