EHR: A billion for your thoughts

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’.

Health IT: magical thinking?

Below are a few thoughts I submitted to the WSJ Healthblog at


Interesting to note that they refer to the IT as it.  That’s because healthcare IT is being approached as a solution looking for a problem.  In may respects, the problem providers are trying to solve is the one created by Washington (the city, not the 1st president) mandating EHR.
If that’s the problem a provider is trying to solve, all solutions look good.  Healthcare providers need to approach HIT and EHR as real business problems, problems that require adult supervision, thoughtful analysis, and program officers with a track record of implementing big, hairy IT projects.
What’s your take on it?



Patient Relationship Management-there are some easy answers

MANUALSThere’s a reason penguins don’t play the viola—maybe that’s why they don’t have a home page. I used to try to approach things with an open mind, but people kept trying to put things like that in it. Did you ever notice that it’s difficult to encourage people to think outside the box especially if you haven’t seen evidence that the people inside the box are thinking? I’m sure there are those who think these ideas are mere snake oil, but who among you has ever seen a rusty snake?

There is often an inverse relation between the relevance of a document and its brevity. Roemer’s Law 17: the value of a patient user manual used in your call centers is approximately equal to the square root of the number of chapters. (That bit of insight is the equivalent of 4.6 raiments, where one raiment has been universally established as the amount of consulting insight needed to awe a frog for one hour.)

How many different patient user manuals are there in your patient call center? How many pages do those manuals occupy? I think user manuals are so long because call center managers believe busy people are effective people. People who aren’t busy all the time might start to think, and what good has ever come from that?

The United States Constitution is about 9,000 words—that’s about thirty pages. What is it about the interactions between patients and call center reps that requires more verbiage than the amount needed to keep 350,000,000 people living in prosperity and at peace with one another for more than 220 years?

For some people, work takes place in the fast lane. For me, it often takes place in oncoming traffic. To conclude, let’s agree to quit viewing things from the dark side of the sun. Sometimes instead of complaining about the darkness, it’s better to ignite a flame. The next time you are at your desk, open the user manuals, take out all the pages, and replace them with this one rule:


I guarantee that will improve performance. Some executives argue that the chances of something so patently absurd actually being true are a million to one. But consultants have calculated that million-to-one chances crop up nine times out of ten. It’s also fair to state that all mushrooms are edible, however it’s equally fair to state that some mushrooms aren’t edible more than once.

To those who want to prove me wrong, go ahead. Destroy the fabric of the universe, then call me.


Patient Relationship Management, start at the top

The customer in this news article wrote a letter to Sir Richard Branson, Chairman of Virgin Atlantic. His letter is a must read for anyone who is in need of a smile. The text below is from Fox News. Paste the link-the photos are critical to the story.

A passenger who wrote a letter of complaint to Virgin Atlantic expressing his dissatisfaction with the in-flight food is now being offered the chance to be a food tester for the airline, the Daily Telegraph reported.

The passenger’s complaint to Virgin chief executive Sir Richard Branson was written after a flight from Mumbai to Heathrow on Dec. 7 last year and has been widely praised for its humor.



Some EHRs are better than others

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.


Patient Relationship Management–why patients and hospitals collide






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.


Pigeon Project Management Office (PMO)


I just finished stacking two cords of wood, much like a squirrel getting ready for a long cold winter. My feet were doing the “Boy is it cold dance” in an effort to keep the blood circulating.  As I was picking up the scraps, my eldest picked up a piece and placed it in his backpack. When I asked him what he would do with it he told me he was going to carve it after school. His statement brought back boyhood memories of hours of whittling, an activity done if for no other reason than to get from one minute to the next. Grab a stick and whittle it away until there was nothing left.  What next? Grab another. The weight of the pocketknife felt equally good in my hand as it did in my pocket.
When is the last time the thought of whittling crossed your mind? Probably been a long time. It’s an activity meant for idle minds and hands, or minds that should be idle. There are times I find myself questioning what value so and so brings to the party. Do you do that?  “Why is she in this meeting?”  You know who I mean.  You’re sitting there trying to get your work done and all of a sudden, some Mensa wannabe with more idle time on their hands than a Lipitor salesman at a BBQ cook-off, makes an aerial assault on your cubicle like a pigeon on a Rodin bronze.  Drops in and changes the rules of the universe, at least your universe.

This happens more often than is documented on large healthcare IT projects.  People set new courses and define programs rules that may have nothing whatsoever to do with the project’s charter or scope.  You do have a written charter and scope in the project office, don’t you?  If not, it’s easy to see how new directions and rules can be given a certain specious authority.

What’s the best way to handle this situation? Often these management Mensas are nervous about a lack of visible results and they need to report on something.  They may feel the need to be doing something, something resembling leading.  They don’t mean to interfere, and they believe that their little forays into the world of super PMO (Program Management Officer) will actually add value. You tell me, are they adding value, or are they preventing the team from sticking to the scope? There’s that irritating scope word again.  The next time you see one wandering aimlessly through the rows of cubicles, hand that person a pocketknife and a nice piece of balsa wood.  Although their efforts won’t add any value to what you’re trying to accomplish, at least it will get them out of the way for a little while.


Who was that woman who put in our first EHR system?


The first home I bought was in Denver.  Built in 1898, it lacked so many amenities that it seemed better suited as a log cabin.  There was not a single closet, perhaps because that was a time when Americans were more focused on hunting than gathering.  Compared to today’s McMansions, it was doll-house sized.

It needed work—things like electricity, water—did I mention closets?  I stripped seven costs of paint from the stairs.  Hand-built a fireplace mantel and a deck.  I arrived home to find my dog had eaten through the lathe and plaster wall of the space which served as my foyer/family room/ living room-cum-hallway.  I discovered the plaster and lathe hid a fabulous brick wall.

My choice was to patch the small hole, or remove the rest of the plaster.  Within an hour I had purchased man-tools; two mauls, chisels, and a sledge hammer.  I worked through dinner and through the night.  The only scary moment came as the steel chisel I was using connected to the wiring of two sconces which were embedded in the plaster.  On cold nights I can still feel the tingling in my left shoulder.

As the first rays of dawn carved their way through the frosted beveled glass of the front door, I wondered why I never before had noticed that the glass was frosted.  I wiped two fingers along the frost.  A fine coating of white powder came off the glass leaving two parallel tracks resembling a cross-country ski trail.  I surveyed the room only to see that the air made it look like I was standing inside of a cloud.  The fine white powder was everywhere—my Salvation Army sofa and semi-matching machine-loomed Oriental rug from the Far East (of Nebraska), a two-ton Sony television, and a component stereo system that had consumed most of much earnings.

Bachelor living can be entertaining.  One of my climbing buddies moved in with me.  The idea was I’d keep the rent low, and he’d help me by maintaining the house.  He didn’t help.  I made a list of duties; he didn’t help.  I left the vacuum in the middle of the floor, for two weeks; he didn’t help.  I made him move out, and advertised for a female roommate—an idea I now wish I’d marketed.  A girl from church came over to see the place.  I turned my back on her, only to find when I returned that she was on her hands and knees cleaning the bathroom.  I was in love.  It was like having a big sister and mother.  She even asked if it was okay if since she was doing her laundry if she did mine at the same time.  Life was oh so good.

Sometimes when one approach isn’t working it’s real easy to try something else.  And sometimes the something else gives you a solution in the form of a water-walker.  Healthcare IT and EHR aren’t ever going to be one of those sometimes.  There will be no water-walkers, no easy do-overs.  There won’t be anyone walking your hallways talking about their first wildly unsuccessful EHR implementation.  Nobody gets to wear an EHR 2.0 team hat.  Those who fail will become the detritus of holiday party conversations.  Who will be the topic of future holiday parties?  I’m just guessing, but I’m betting it will be those who failed to develop a viable Healthcare IT plan, whoever selected the EHR without developing an RFP, the persons who decided Patient Relationship Management (PRM) was a waste of money.  The good news is that with all of those people leaving your organization, it costs less to have the party.

I’d better go.  Somebody left the vacuum in the middle of the floor so I need to get cracking before my wife advertises for a female roommate.


what’s your HIT group doing for you?


I love to cook and I belong to several internet food related sites. As an aside, one of my favorites is Maybe it’s my personality, or lack of one, but I’m not a fan of recipes, at least not the details like measuring, ingredients, cook time, and temperature. I think that this is where the fact that I function with equal vigor from both hemispheres of my brain causes conflict—probably also explains why I had such a difficult time completing my math degree. If I don’t like the details, what else is there, you may ask? It’s more than the pictures, if that was all there was I’d be satisfied just cutting pictures out of Better Homes and Gardens magazine. I like the ideas those sites generate, but I also can’t stand to be encumbered by some silly set of rules. I guess I figure that with a set of rules anyone can be successful making that particular recipe, so where’s the challenge in that.

So anyway, I decided to smoke a nice sized duck on my grill. I rinsed the bird, trussed it, pricked the skin with a fork, stuffed it with a few blood oranges, and applied my homemade rub to the skin. The apple-wood chips were smoking nicely as I placed the bird, breast-side up on the roasting rack I had placed inside the cast-iron skillet. After turning down the burners I closed the lid. The grill, I should point out, is a seven-burner, infrared, stainless steel monstrosity with which one could probably roast an entire pig or forge iron ore into ingots. Total roasting time, about two hours. I checked the thermometer on the grill’s hood; it displayed a temperature of three hundred and fifty degrees–perfect, more or less.

It turns out that it can take as long as five minutes for the grill’s thermometer to register the correct temperature. The temperature dial on this particular model redlines at seven hundred degrees, high enough to produce spontaneous combustion. After two hours at 700 degrees, interesting things begin to happen to the carcass of a duck. Upon raising the lid the entire bird looked as though it had been spray painted a matte black. The roasting rack had melted. The leg bones appeared to have been charred from the inside out—they disintegrated the moment I touched them. I felt like a helpless doctor in the ER, there was nothing I could do to save it.

Have you ever felt that way when you try to understand how any of the healthcare IT projects are progressing? How’s EHR?  What’s the impact of reform on EHR?  Why aren’t we doing more with social media?  How come we don’t have a patient relationship management (PRM) system?  According to the reports that come across your desk, everything seems to be humming along nicely. In the committee meetings, seats are filled.  The emails imply all is fine.  Looking fine and being fine are not the same.  Looks can be deceiving. Ask the duck.

By the way, the duck fat did a great job of seasoning the iron skillet, so if that ever happens to you simply explain that what you were really doing was seasoning the pan.


Why I differ with Mr. Halamka’s EHR strategy

Below is a comment I wrote September 30, 2009 to Government Health IT in response to an article written about a conversation the author had with John Halamka titled, “Halamka: How to build a long distance service for healthcare.” Most people whose comments I’ve read regarding Mr. Halamka’s vision for how the national EHR roll out might work tend to be quite supportive.  I don’t think my comments fall into the supportive category.  That may account for why they have yet to appear in print.  So, in the spirit of full disclosure, here’s what I offered.

I wrote several weeks ago that we ought to look at the telecoms networks, ATMs, OnStar, or some existing platform. My argument for redoing the national roll out strategy along those lines is that it may provide a way to eliminate the middleman, the RHIOs and HIEs, whose only real role seems to be like a train station in the middle of going from NY to LA. If nobody ever gets on or off, why have it.

The critical success factor of the telecommunications networks is called an interconnect, it’s what gets the call from A to B and provides redundant carriage. It’s also what eliminates the need for a middleman.

The AP wrote today that the current EHR national roll out plan will not work With all respect to those working so hard on the current roll out plan, I think we need a serious rethink about what type of plan is required for the EHR roll out to work instead of pushing water uphill trying to make the current plan work. Here’s some thoughts I had about how it might be approached.