informatics

EHR: Is your scope wrong? I bet it is.

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The hand-written note, scrawled in the best penmanship of my nine-year-old daughter, lay next to the plate of sugar cookies and the warm glass of milk.  It was eleven PM.  Three kids lay in their sleeping bags, asleep on the floor of the play room—cameras ready to capture images of the annual intruder.

Illuminated by the glimmering lights from the tree, I scanned her note.  Two pages.  Itemized.  Fifty-three lines, fifty-three items.  Requests.  The letter begins, “Dear Santa.  I wrote this list today.  I know you already got my letter.  These are other things you could give me.  Please leave them under the tree with the rest of my presents.”

There are a number of ways to view her letter.  It certainly is cute—it’s probably cuter if you’re not her parents.  You know what occurred to me at 11 PM as I stood there in my slippers eating the cookies and drinking the warm milk to reinforce the message to my children that Santa exists?  Two words.  Scope Change.  Plain and simple.

Weeks of thoughtful planning, buying, and wrapping possibly shattered by the scratchings of a number 2 pencil.

Make no mistake; this will happen to you on your EHR project.  Scope change.  Where will it come from?  Users, vendors, the CFO, reform.  Most projects fear change.  Change is feared because the project team never quite got their arms around the original scope.  Most change means more dollars and more time.

Scope change can be healthy.  Why?  I bet most EHR projects are under-scoped.  Did you read that correctly?  Yes.  I bet if an independent party assessed your scope document and work-plan you will find you are under scope in these three areas:

  • Change management
  • Work flow improvement
  • Training

If that’s the case, you will have spent tens of millions of dollars building something slightly more functional than a rather intricate Xerox machine.

“We need to talk about your TSP reports”

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If you recognize the stapler, you know the movie.  “Office Space”—Possibly the best movie ever made. Ever worked for a boss like Lumbergh? Here’s a smart bit of dialog for your Friday.

Peter Gibbons: I work in a small cubicle. I uh, I don’t like my job, and, uh, I don’t think I’m gonna go anymore.

Joanna: You’re just not gonna go?

Peter Gibbons: Yeah.

Joanna: Won’t you get fired?

Peter Gibbons: I don’t know, but I really don’t like it, and, uh, I’m not gonna go.

Joanna: So you’re gonna quit?

Peter Gibbons: Nuh-uh. Not really. Uh… I’m just gonna stop going.

Joanna: When did you decide all that?

Peter Gibbons: About an hour ago.

Joanna: Oh, really? About an hour ago… so you’re gonna get another job?

Peter Gibbons: I don’t think I’d like another job.

Joanna: Well, what are you going to do about money and bills and…

Peter Gibbons: You know, I’ve never really liked paying bills. I don’t think I’m gonna do that, either.

One more tidbit:

Peter Gibbons: Well, I generally come in at least fifteen minutes late, ah, I use the side door – that way

Lumbergh can’t see me, heh heh – and, uh, after that I just sorta space out for about an hour.

Bob Porter: Da-uh? Space out?

Peter Gibbons: Yeah, I just stare at my desk; but it looks like I’m working. I do that for probably another hour after lunch, too. I’d say in a given week I probably only do about fifteen minutes of real, actual, work.

I like to think of Peter as my alter-ego.

When I’m playing me in a parallel universe, I’m reading about a surfer dude cum freelance physicist, Garrett Lisi. Even the title of his theory, “An exceptionally simple theory of everything,” seems oxymoronic. He surfs Hawaii and does physics things—physicates—in Tahoe. (I just invented that word; it’s the verb form of doing physics, physicates.)

Ignoring that I can’t surf, and know very little physics, I like to think that Garrett and I have a lot in common. I already know Peter Gibbons and I do. So, where does this take us?

It may be apparent that I look at healthcare IT and reform from a different perspective than most; I’m the guy who doesn’t mind yelling ‘fire’ in a crowded theater. The guy who will never be invited to speak at the AMA convention unless they need a heretic to burn for the evening entertainment. I can live with that.

Like Garrett, I too see an exceptionally simple theory in everything, especially when it comes to improving the business of healthcare. It’s not rocket surgery, but then, it was never meant to be–before someone writes, I know it should be scientists.  It’s process, change management, leadership and foresight.

Sometimes I like to look at the problem from a different dementia—Word didn’t have a problem with my usage of that word.  I look at healthcare and ask myself three questions:

1. How did they ever get so siloed?

2. How did they ever get so so big without a cohesive IT strategy?

3. Is it possible to reverse both of those AND improve the business.

I am convinced the answer is yes.

The Dark Side versus the Blind Side

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My take on this is probably far-afield from the mainstream. I think the Dark-Side, firms like Google, Microsoft, and Oracle look at the confusion and lack of planning in terms of what the final EHR/PHR platform will look like and they simply drool. With hundreds of EHR vendors and RHIOs and RECs and standards groups all operating independently, all aiming at an undefined target, which group is best positioned to solve this platform problem, the Dark Side, or the Blind Side?

The Dark Side’s plans are underway and visible through their PHRs. Like the tip of an iceberg, I bet that most of what they are doing to own this space is presently unseen. Practice Fusion, if their product attracts enough customers will be devoured, or they will be ignored. RECs, RHIOs, Meaningful Use, Certification, a lack of standards, and no network are large red flags from the government saying “we don’t know where we’re going, but we’re making real good time.”

Here’s a reply I drafted at the request of Brian Ahier to his blog, http://radar.oreilly.com/2009/11/getting-personal-with-health-t.html

The Dark Side knows exactly where they’re going. They don’t need a network; they have one. The Internet. There are those who argue HIPAA and security. HIPAA and security can be more readily handled on a network that’s been up and running for twenty years and was built by the military than they would be under anything developed off the cuff under Washington’s leadership.

Now for the Deathstar issue–ownership of the data. The question is are ownership and possession one in the same? I bet they will not be. I’d also bet that five years from now somehow that Dark Side will have at least access to it. I can’t prove any of this, but I’d love to sit in on the strategic planning committees of the Dark Side. I bet some or all of this is underway. The Blind Side may be blind-sided.

EHR Tips for supplementing ARRA funding

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Patient Relationship Management–why patients and hospitals collide

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

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

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

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

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

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

saint

The importance of due diligence

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What was your first car?  Mine was a 60’ something Corvair–$300.  Four doors, black vinyl bench seating that required hours of hand-stitching to hide the slash marks made by the prior owner, an AM radio, push-button transmission located on the dash.  Maroon-ish.  Fifty miles to the—quart—I carried a case of oil in the trunk.

I am far from mechanically inclined.  In high school I failed the ASVAB, Armed Services Vocational Aptitude Battery—the put the round peg in the round hole test.  Just to understand how un-complex the Corvair was, I, who hardly knows how to work the radio in a new car, rebuilt the Corvair’s alternator—must not have had many working parts.  I could see the street from the driver’s side foot well.

However, it had one thing going for it, turning the key often made it go—at least for the first three or four months during which I owned it.  Serves me right.  A guy in school who I didn’t know who was selling it pitched it to me as his dream car.  Not wanting to look stupid, I bought into the sales pitch.  Pretty poor due diligence.  An impulse purchase to meet what I felt was a social imperative—a date-mobile.

The last time I made a good impulse purchase was an ice cream sandwich on a hundred degree day.  Most other decisions could have used some good data.  The lack of good data falls on one person, me.

How good is the data you have for deciding to implement and EHR?  In selecting an EHR?  Did you perform the necessary due diligence?  How do you know?  It’s tedious, it can lack intellectual stimulation?  You want to be seen as someone who made a wise choice.

The difference between you and me is that when I learned I’d made a poor decision I bought a different car.  You can’t do that with an EHR.  You’re stuck looking at the street through the hole in the floor for a long time.

saint

EHR: add three cups of technology and stir

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According to my neighbor, who is a woman, next week is the season premier for “Desperate Hot-wives”—her words, not mine. My wife refers to my little brain hiccups as Roemer-minutes, a little hitch in my git-along where the thinking part of my brain briefly vacations in the fifth dimension. Speaking of the fifth dimension, the dimension, not the sixties rock group, I was reading up on it the other day. There’s this professor of theoretical physics from Harvard, Lisa Randall, who happens to look a little like Marcia Cross who portrays Bree Van De kamp—actually she looks more like Jodi Foster. See how quickly this all ties together? Anyway, Dr. Randall has developed a theory about how the universe is warped—something many of us expected. According to her model, the reason gravity appears so weak is that the universe is actually warped by a hidden fifth dimension—must be why we haven’t seen it, because it’s hidden—and our gravity is just the leftovers from the dark side.

For the inherently curious, in mathematical terms her equation is, ds2=dr2+e-kr(dxm dxn hmn). That was helpful, wasn’t it? Here’s where it gets complicated. People in Europe will are testing the Large Hadron Collider to look for gravitons, theoretical particles of gravity. The collider smashes protons into one another, and if these theoretical particles appear then disappear that somehow proves the theory. However, and depending whether you’re a glass half-full or a glass half-empty kind of person, this is a rather big however, we could all die. This is where the distinctions between the meanings of the words possible and probable become rather important.


According to this whole other branch of physics, something quite unpleasant could happen, the creation of doomsday phenomena, including microscopic black holes that would grow instantaneously and swallow the earth, and strangelets that could transform the earth into a dead dense lump. Could it happen? Yes. Will it? Probably not. So there you have it.

Where does that leave us? Assuming that it does, leave us, that is, alive, it makes the notion of implementing EHR seem just a tad more simplistic. At least we won’t be creating any black holes. So, set your phasers for stun and let us begin again. To implement EHR in your organization you need a champion, a sponsor. Someone who isn’t afraid to say, ‘follow me’. As we said before, this type of project does not lend well to the notion of ‘add three cups of technology and stir’. The champion is needed not so much for figuring out the shape of things to come, but for their ability to cause those things to be implemented within the organization. This person should have ready access to resources, dollars, and the ear of someone very senior in your firm. Next time we’ll begin to take a look at the champion’s role.

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Healthcare Informatics: one time at band camp…

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Here’s a response I posted to a Healthcare Informatics article, by Mark Hagland, “Revenge of the Clinical Informaticists”.

The link is: http://healthcare-informatics.com/ME2/dirmod.asp?sid=349DF6BB879446A1886B65F332AC487F&nm=&type=Blog&mod=View+Topic&mid=67D6564029914AD3B204AD35D8F5F780&tier=7&id=5E2E36E45CB54ECA8D2B08DC3E4D679C

I wrote the following:

I wrote on this same topic yesterday, albeit with a slightly different bent.  Like you, I see two distinct groups who do not play well in the same sandbox—clinical and IT.  Having one group go to the other’s summer camp to pick up a few skills is not the same as pulling a few costly and hairy projects from the bowels of project hell any more than it would be to have an IT executive take an EMT course and then assume that person was qualified to perform surgery—this one time at band camp…

Before I get up on my stool and knock myself off, I know CMIOs and CIOs who have made HIT and EHR very successful.  To them I ask, do not rake me across the Twitter coals as I try to make a point.

There’s knowledge, and then there’s qualified.  Doctors do four years of medical school, they intern, and if they specialize, they throw in a few more years before they become the in-charge.  Years of training and practice before the doctor is allowed to run the show.  Why?  Because what they are about to undertake requires practice, tutelage, and expertise.  Most of the actual learning occurs outside the classroom.

There are those—not Mr. Hagland—who suggest that the skills needed to manage successfully something as foreboding as full-blown EHR can be picked up at IT Camp.  They do a disservice to seasoned IT professionals.

Most large IT projects fail.  I believe large EHR projects will fail at an even higher rate.  Most clinical procedures do not fail, even the risky ones.

What’s the spin line from this discussion?

  • Rule 1—large EHR projects will fail at an alarming rate
  • Rule 2—sending a doctor to band camp probably won’t change rule one

Don’t believe me?  Ask friends in other industries how their implementation of an ERP or manufacturing system went.  There are consulting firms who make a bundle doing disaster recovery work on failed IT projects.  They circle the halls like turkey vultures waiting for CIO or project manager carrion.

Back to Rule 1 for a moment.  How can I state that with such assurance?  Never before in the history of before—I know that’s not a proper phrase—has any single industry attempted to use IT to:

  • impart such radical charge (patients, doctors, employees)
  • impart it on a national basis
  • hit moving and poorly defined targets—interoperability, meaningful use, certification
  • take guidance from nobody—there is no EHR decider
  • implement a solution from amongst hundreds of vendors
  • implement a solution with no standards
  • move from an industry at 0.2 to 2.0 business practices
  • concurrently reform the entire industry

Just what should a CMIO be able to do?  What are the standards for a CMIO?  To me, they vary widely.  Is a CMIO considered an officer in the same sense as the other “O’s” in the organization, or is it simply a naming convention?  The answer to that question probably depends on the provider.

Here’s how I think it should work—I realize nobody has asked for my opinion, but this way I’ll at least provide good fodder for those who are so bold as to put their disagreement in writing.

I love the concept of the CMIO and think it is essential to move the provider’s organization from the 0.2 model to the 2.0 model.  Same with the CIO.  However, getting them to pool their efforts on something like EHR is likely to fail as soon as one is placed in a position of authority over the other.  It’s sort of like getting the Americans and French to like one another.

I liken the CMIO’s value-add to that of the person providing the color commentary on ESPN—it adds meaning and relevancy.  The CMIO owns and answers a lot of the “what” and the CIO owns and answers a lot of the “How”.

Still unanswered are the “Why” and “When”.  A skill is needed that can state with assurance, “Follow me.  Tomorrow we will do this because this is what needs to be done tomorrow.”  That skill comes from an experienced Project Management Officer, the PMO.  It does not come from someone who “we think can handle the job.”  Nobody will respect that person’s ability, and if they can’t lead, yo can plan on doing the project over.

Oh, if anyone is still reading, here’s my original post; https://healthcareitstrategy.com/2009/09/28/what-should-be-the-role-of-the-cmio/

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Can you blame providers if they fail Meaningful Use?

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3Here’s what I wrote in reply to a post on Healthcare Informatics, http://bit.ly/LX8Jb

I don’t wake up each day planning to be at odds with ninety-eight percent—I’m probably being overly generous assuming two percent of the people are as jaded as me—of the HIT community, maybe I just come by it naturally.

The first time I heard of RECs (regional extension centers) the first thing that came to mind was playgrounds, something akin to what the Police Athletic League might find useful.  Five hundred and ninety-eight million dollars.  They tried 597 and determined it wouldn’t be enough and figured 599 would be too much, but 598 million was just right.  Then Goldilocks made her way over to the porridge—sorry for turning left at the fairy tale ramp.

A large part of the success or failure of reform hinges on the success or failure of EHR.  Accordingly, the government made the egregious decision to manage the process of building and rolling out a national EHR down at the molecular level.  They have involved themselves at the front-end, at the vendor level, and at the back-end.  The more anxious they become, the more money they waste, adding another guise to get the healthcare providers to take their eyes off the ball.  Five hundred ninety-eight million “we’re just here to help you” dollars.

This money could be spent to pay the top EHR vendors to create one set of standards and modify their systems to fit those standards.

Meaningful Use.  Don’t get me started.  How can I fault thee; let me count the ways.  Those tested early for Meaningful Use will be examined less rigorously than those tested later.  This is like the IRS saying that if you file your taxes in February, don’t worry about those silly little math errors.  Healthcare will be the only industry whose software quality assurance check occurs after they pass the fail-safe point, the point of no return.

With good leadership providers should know EHR will pass meaningful use before implementing the system. If they fail to pass Meaningful Use, shame on them.

saint