meaningful use

How to calculate Meaningful Use’s ROI

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Just to make sure we are all turned to the same page in our Cliff Notes on Meaningful Use, today’s conversation is, “There is no “R” in ROI.”

Are you familiar with the Abilene paradox?  It is a paradox in which a group of people collectively decide on a course of action that is counter to the preferences of any of the individuals in the group.  It involves a common breakdown of group communication in which each member mistakenly believes that their own preferences are counter to the group’s and, therefore, does not raise objections.

I think it occurs more often than we think.  Try to recall the last meeting you attended in which you really disagreed with something that was said.  Chances are you knew some of the others in the meeting well enough to know they also disagreed.  The reason you know they also disagreed is because you had discussed the topic.  However, none of you raised your disagreement during the meeting.  Why?  Because you did not want to rock the boat.

It is similar to a pseudoconsensus.  Pluralistic ignorance.  These create a bystander effect—people are more likely to speak out about an issue when they are alone with someone than when others are present.

After further consideration I think we must consider the very real possibility that there is no ROI for Meaningful Use.  I write this in all sincerity.  Healthcare executives march in lock-step or group think to achieve the myth of finding an ROI for Meaningful Use.  The ROI is healthcare’s quest for the Holy Grail, albeit without the Monty Python sound track.  They cannot proceed without one, so they set the target, figure out what data will demonstrate that they have hit it, and disregard the reams of data that does not support the ROI.

What if the government came out with a standard stating all hospitals ought to buy, install, and use a fifty million dollar transplant device that also flosses the patient’s teeth?  This initiative is “optional”, but the government will pay the hospital a two hundred thousand dollar rebate.  There are several types of transplant flossers—the ones that deliver that fresh mint taste cost extra.

If we were having a business discussion about the ROI for the transplant device, healthcare executives would be foaming at the mouth about how impossible it would be to calculate an ROI, and rightly so.  They would argue all hospitals are different, they have different cost structures, the devices are all different.

The standards for Meaningful Use are arbitrary.  The standards were developed by people who do not need to meet an ROI.  There was no mandate in the development of those standards to create standards which when met would yield an ROI.  Any attempt to force an ROI will naturally differ in a number of ways:

  • by provider—size, structure, offering, geography
  • by their interpretation of Meaningful Use
  • by which EHR they implemented
  • when they began the implementation
  • how well they implemented the EHR

Somebody somewhere may hit a positive ROI on Meaningful Use, just like somebody playing darts may hit a bull’s eye.  Any positive ROI will be accomplished more out of chance, and from having fit the data to a predetermined ROI rather than measuring the ROI against its true impact.

Implementing an EHR can be very good for a hospital.  However, it should be a business decision for the hospital based on the same set of business rules the hospital would use to justify any other large expenditure.  If the hospital achieves an ROI it will not be because of having followed an arbitrary set of standards.  Any ROI for an EHR will come from having done it correctly.  Hitting the figure any other way means two things; it was a coincidence, or you are in for trouble down the road.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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If you come to a fork in the restaurant…

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In Greek mythology, there was a not so nice man, Procrustes.  He had an iron bed in which he invited wayfaring strangers to spend the night.  Some of the strangers were too long for the bed and others were too short.

Apparently Procrustes liked things orderly and could be a tad anal when learning his guests did not fit.  He would set on them with his smith’s hammer, to stretch the shorter ones to fit.  If the guest proved too tall, Procrustes would amputate the excess length.  Truth be told, nobody ever fit the bed exactly because Procrustes had two beds.

In contemporary terms, a Procrustean Bed is an arbitrary standard to which compliance is forced.  A Procrustean Solution involves fitting a business problem to a preconceived set of strictures.

Raise your hand if you have already figured out where this is headed.  Preconceived.  Arbitrary.  Compliance.  Strictures.

Do you spell Meaningful Use with an upper case Procrustean or one in lower case?  I prefer the upper case.  The business problem being fitted is the implementation of EHR.  The preconceived sets of strictures are the Meaningful Use standards.

This in turn leaves the healthcare provider in what is best described as a Morton’s Fork scenario.  Shall I explain?  A Morton’s Fork is a choice between two equally unattractive alternatives—a dilemma.  The concept originated in 1487 under the rule of Henry the VII as a result of tax policy to ensure everyone paid taxes.  The argument was because the rich had enough money to buy things they must have enough money to pay taxes, and the poor who had bought nothing had saved their money, and thus had money with which to pay taxes.  The two prongs of the fork—back then forks only had two prongs.  Q. E. D.

The healthcare provider must choose between—as one may not choose among—two alternatives.  Attempt to meet Meaningful Use—a Procrustean Solution—turn their business model inside out to meet the government’s Gossamer standards.

Attempting to meet the standards does not ensure they will in fact meet the standards.  Should they only meet ninety-nine percent of the standards, they lose.  The Pareto principle does not apply.  There is no 80:20 rule.  They will not receive any incentive money as Meaningful Use is an all or nothing game.

The second alternative is to not meet Meaningful Use.  This choice may be voluntary, or involuntary—trying to meet Meaningful Use and failing.  Alternative Two—it is said—will result in reimbursement penalties from Medicaid and Medicare.

I do not think those penalties will be implemented, or at least they will not be implemented in the documented timeframe.

I also do not think there is a Morton’s Fork, because I think Meaningful Use will disappear because it is so arbitrary and capricious—and because the number of large providers who will meet it could all drive to lunch at Morton’s in a Yugo, at which time they could dine with a fork from Morton’s.

We have now come full circle.  My work here is through.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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My latest post to healthsystemCIO.com

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I think there is plenty of merit to quit chasing Meaningful Use and get on with your business.

http://healthsystemcio.com/2010/05/28/ten-catechisms-of-meaningful-use/

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

Is there a business argument for Meaningful Use?

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I remember the first time I entered their home I was taken aback by the clutter. Spent and wet leaves and small branches were strewn across the floors and furniture. Black Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The windows.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.

And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

“Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives. Sort of like all the scurrying around Meaningful Use.  The normal has been subsumed by the abnormal, and in doing so has created an entire entity which is slowing devouring the resources of the organization.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid on a daily basis. When I talk with hospital executives they are marching headstrong into the Meaningful Use abyss.

It makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about it they always have an answer. It all boils down to something like, “We simply can’t turn down the money.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid.  It’s gotten to the point where no matter how goofy things get, as long as they are consistently goofy, there not goofy at all.

This is the mindset that enables leaders to be fooled by their own activity. Busy replaces thinking.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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My remarks to Brian Ahier’s insightful interview of Dr. Blumenthal

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I encourage those who have not read Brian’s interview of Dr. Blumenthal on HealthSystemCIO.com to make time to read it.  http://healthsystemcio.com/2010/03/27/chatting-with-the-national-coordinator-for-health-it/#comments

Brian also has a link to the audio.

Brian asked me to comment, and I was pleased to do so.  Here is what I wrote.

I enjoyed reading your interview with Dr. Blumenthal. Clearly he and the members of his team are working very hard on a number of difficult and rather diverse issues.

I have been wondering, how does one tell the story of EHR to someone who has no understanding of EHR? Not the story about the EHR system in a physician’s office, or the ungainly one in a hospital. The story to which I refer is the story of the national rollout of EHR and the drive for interoperability.

For me, the question of how to tell the story in a way to make it understandable raises a number of other questions. Is there a story, or is it a collection of short stories written by different people, guided by different principles and goals? Is there a plot? Does the story come together in a natural manner?

Sticking with the story theme for a moment—who are the main characters, do they relate to one another? Does it come to a meaningful conclusion, in fact, does it conclude?

Look at the various antagonists—EMR, EHR, PRH, Meaningful Use, Certification, HIEs, RECs, the N-HIN, interoperability, the ONC, CMS, ARRA, standards, vendors, and PR. I am sure I missed several.

Imagine if Random House allocated millions of dollars to publish and market a book which had yet to be put to paper. No plot, no outline. What if they hired a dozen writers, each with their own areas of expertise—and lack of expertise—and crossed their fingers.

Would they be more successful if they offered penalties and incentives to the writers—a garrote and stick approach? What if they changed the rules after the writers started? What if they left undefined numerous areas of rules, rules which will impact the story, and told the writers to keep pushing ahead?

I do not see how the national EHR rollout story comes together. Now or some distant tomorrow—at least not under this approach. Is the approach viable? Having a few disparate successes does not make me a believer. Call me a cock-eyed nihilist.
Once every so often, an announcement is made that another single hospital reached Stage 7. One among thousands. Why do I view this from the vantage point of a glass half-empty? For me, the existing approach is one of guidance and facilitation. There are no long lines of providers trying to beat the others to the front of the EHR line. There have been several hundred million dollar do-overs.

If we circle back to the providers for a second, three of the largest causes of failure include the arbitrary setting of go-live dates without knowing what needs to be done or can be done in that time frame; second, letting IT and the vendor drive and manage the project; third, not getting users to define what they need and then having IT replicate those needs. IT does not need an EHR.

As I look at the government’s national rollout of EHR I see the same three problems. Who are the government’s users? Doctors, clinicians, and hospitals. There are fixed dates, many having undefined requirements. These are causing some providers to dash for the cash. Who is driving the rollout—the government’s users, or the government. They way the rollout is structured, the users have all of the responsibility and little of the authority. This is a government led IT project. Where are their users? They are running their practices and hospitals. They have one ear open towards, reform, another to the garrote and stick project rollout approach, another to EHR, and yet another to their business model. They have run out of ears.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

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How should a provider approach Meaningful Use?

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New Headquarters?

The following is my reply to a post in HealthcareITNews from March 8.  The title of the post is, CONSUMERS WEIGH IN ON TOP 10 MEANINGFUL USE ARGUMENTS.  The link is, http://www.healthcareitnews.com/news/consumers-weigh-top-10-meaningful-use-arguments#comment-574

Of cabbages—and kings—

And why the sea is boiling hot—and whether pigs have wings. Lewis Carroll, Out of the Looking Glass. It is a nonsense story, one which cannot be argued.

As are Electronic Health Records (EHR) and Meaningful Use (MU)—at least to date. Measured against any reasonable set of standards, except on a one-off basis, the national rollouts of EHR and MU have failed. I expect it will be even more so next year.
You, the public, have the right to comment, and we have the right to tell you why your comments hold no water. I think it is the inverse of you have the right to remain silent, you just don’t have the ability. I am writing about the ONC and the bone they tossed calling for public comment. They are required to provide for public comment in order to remove the N and the P from the NPRM.

Who among us believes the rule making will markedly shift direction as a result of any of the public comments? That is unfortunate for if they were to shift direction they might find a direction. We don’t know where we are going, but we are making good time getting there. Figures suggest a failure rate of EHR implementations of somewhere between fifty and seventy percent. As healthcare IT resources become scarcer, I expect the failure rate to increase. As providers rush into EHR without a detailed strategy simply to grab the incentive money, there will be more expensive failures. More failed EHRs is not a way to measure progress.
The current cover of Government Health HIT magazine depicts a foot race to meet MU. There is no race if there are no entrants. There may be more people on the cover than will actually qualify for the race, even fewer who will reach the end.

We would be better served if the plan for national rollout of EHR were not written on an Etch-A-Sketch. We don’t know what will be included in Stages 2 and 3 of MU. When will fifty percent of providers have an EHR, not just the software, but one that actually boosts productivity? How about 70% or 80%? Ten years? I ask the same question of the Health Information Exchanges (HIEs). Without unilateral adoption there will be large gaps. Will the national network function with these gaps? To what extent? Will the records only make it part of the way from Patient A to Doctor X?

Having not solved the EHR program on their own, and having no viable plan, the government laid the burden of making EHR successful on the backs of the providers. The government tries to offset the burden by offering financial gratuities—and penalties—to the providers. Not exactly the second coming of the Three Wise Men. Trying to hit the ONC’s targets is a little like playing the confidence game, the shell game. Under which shell will providers find the rules, the plan?
What to do?

It is easy to criticize. Permit me to offer a few suggestions. To the hospitals, if you are not well along the EHR path, do not make a difficult effort more difficult by chasing Gossamer incentive dollars. Stick to your plan. You have multiple failure points which three years from now will make chasing those dollars look like a pipe dream. The failure points? Your plan, the implementation, meeting the MU requirements, passing the MU audit. It does not look very promising to me.

To those hospitals which haven’t started their EHR initiative, or are less than halfway through the passing the failure points, don’t cancel your summer vacation. You have a lot more time to get it right then you have to get it wrong. Pay no attention to the man—or woman; even I can have a moment—handing out the Monopoly money. You won’t be receiving any. From where I sit, that is good news. It will cost a lot more to perform disaster recovery on a poor implementation than the funds you would have received by meeting MU.

How long does a hospital spend planning to build a new hospital wing? For large hospitals, the cost of your EHR will likely exceed the cost of the new wing. Plan accordingly. Invest six or nine months building a plan that might succeed.

For medium and small practices and solo providers you have nothing to lose by waiting a year months other than the resource problem. By then you will find very viable ASP and shrink-wrapped solutions.

Those who follow my blog, healthcareitstrategy.com, know I don’t write to garner favorable replies from those who think they’ve already got it figured out. I write for those who because of EHR have difficulty sleeping. Thanks for reading. As always, I appreciate your comments and disagreements.  

Some hospitals have more than one EHR–Why?

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I wrote this reply in response to a blog written by Jay Fischer titled,

Do Multi-EHR Hospitals fulfil Meaningful Use Compliance more Easily?

It is interesting that for such a “new” addition to the support systems and processes that support the business of healthcare, and for the relatively few of them that have been implemented in hospitals, we can have the discussion of whether there is enough merit in having more than one EHR.

Leading hospitals are discovering they do not need multiple departments to perform similar functions.  Some hospitals have more than one admissions department, payroll, human resources, information technology, and pharmacy.  The individual groups which “own” those functions argue strongly for why they need to maintain ownership.  I have yet to see an argument which is upheld under examination.

One HR department should be sufficient.  In a market where hospitals are scrambling to cut costs, we will see hospitals reducing the number of EHRs to a single EHR.  This will happen as other hospitals are implementing EHR on top of EHR.  Who knows, perhaps as hospitals work to get down to a single EHR, they will find a market for slightly used, previously owned EHR.

For sale, one EHR, used by a grandmother from Des Moines.  Make offer.  

Why should you reframe the EHR discussion?

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Are you one of the millions with recurring dreams of taking college exams?  I remain haunted by two, both which happen to be rebroadcasts of real events.

In the first, I had convinced my graduate school professor of operations management that since I took operations research in college that I could “audit” his class and be the teaching assistant.  I used the term auditing to mean I didn’t have to attend the class or do the home work.  From the school’s perspective, it did mean I had to take the final.  As I learned sitting at my desk, wishing I could think of any excuse to move my pencil across the pristine pages of the blue book, apparently there is a difference between operations research and operations management.  Whatever the difference was, it accounted for the blank pages staring up at me.

At the end of the exam the only marking in my book was the note I wrote to the professor, “I think we both know I know how to do this however, I froze.  If you need to fail me, I understand.”  He gave me a “C”.  I saw him when I visited Vanderbilt last year, and he recognized me and remembered the story—I like to keep my audience riveted.

The other dream has to do with my lone Poly-Sci class as an undergrad.  I am a proponent of the notion that I can answer almost any question provided I can reframe the question into one I can answer.  The exam instructed us to answer a question about a book I hadn’t read.  My only choice was to reframe the question, equating it to one from a book I had read.  I gave what I thought amounted to a fairly reasoned response to “my” version of the question.  The professor agreed that I had, and then wrote on the cover of the exam book that he too used the same device when he was in college.  It had not worked for him and he wasn’t going to allow it to work for me.

I think many of those grappling with EHR would benefit from reframing the question.  Many view the question as, “How do I accomplish what the folks in Washington want me to do?”  Sometimes that question might deserve an answer.  In the case of EHR I do not think it does.  In fact, I think answering the question, and then building a plan around your answer can make EHR more difficult, and it can move you away from your business goals.

A better question, at least for your hospital or practice is, “Does it make sense for me to accomplish what the folks in Washington want me to do?”  Has Washington demonstrated enough leadership over EHR, Meaningful Use, Interoperability, or reform to justify following?  Have they provided enough clarity, defined a set of business objectives, or justified their reasoning?  Does their reasoning fit your business model?

I bet it does not.

Why DC might be wrong on Meaningful Use

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I watched recently Barry Levinson’s movie Liberty Heights about a handful of people in Baltimore growing up in the fifties.  In one scene the high school practices a civil defense drill.  For those who have never seen a civil defense drill, a number slightly smaller than those who have never seen a dodo bird, permit me to explain.

From the fifties through the early eighties the fear of the US and the Soviets—if you have to look it up, it is better that you stop reading—engaging in nuclear war seemed so imminent that school children participated regularly in drills to protect them from nuclear attack, nuclear winter, nuclear annihilation.  The exercise was called duck and cover.  Stay with me now—those in charge were quite serious about this.

In duck and cover, once you saw the flash of the nuclear explosion—assuming your retinas weren’t fused—you were supposed to get under a table, most likely a wooden one that would have already turned to ash, and assume the fetal—or fecal position.  Educated adults came up with this idea as a solution, people with PhDs.

Generations of kids, millions of kids practiced this drill several times a year.  Someone puts forth a directive.  Instead of challenging it, other reasoned adults wallow in their folly.

Duck and cover.  Lemmings off cliff.

EHR and Meaningful Use.  Lemmings off cliff.

Question it before you leap.  EHR is a great opportunity.  EHR under the government’s direction—this is the same institution who developed duck and cover.  EHR and Meaningful Use—if you find it meaningful, you would probably benefit from speaking with someone who does not share your perspective.

Meaningful Use from EHR’s Meaningful Muse.

My latest piece on healthsystemCIO.com

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What Would You Do Without MU?

I was wondering how CIOs would approach the implementation of EMRs if they had never heard the term Meaningful Use. The more I thought about the question, the more I felt it merited discussion. If I were a CIO, I would not let these outside regulatory influences dictate my strategic decision making. As a member of the executive team, my responsibility is two-fold; to facilitate and improve patient care, and to contribute to the business as an advisor, someone whose actions positively impact the bottom line.

Some CIOs have been forced to abdicate their responsibility and to approach EHR as order takers. Sometimes the CEO/CFO/COO creates a directive mandating EHR. That said, their guidance may end. In other, more problematic cases, it doesn’t, and they also supply the name of the EHR vendor that must be used. The worst reaction to this pressure is to not challenge the issue of whether your organization will attempt to meet Meaningful Use. The concept is much more novel than it may appear.

What if Meaningful Use didn’t exist? Many hospitals undertook EHR without any hint of the fact that MU was coming — coming with money, penalties, and constraints. Many completed the implementation only to learn that to meet MU they are not done, far from it. In fact, they have just begun modifying their implementations, and paying big time for those changes.

Those who started EHR early did so under the notion that their efforts were working in concert with an established set of business goals. This is the right way to operate. Remember, EHR is voluntary — really. By default, that makes meeting MU voluntary. There is no hidden directive that states all those who implement an EHR must meet MU. Not meeting it may subject your organization to penalties, and these should be factored into your ROI calculation.

Let’s assume you have, or are going to implement, an EHR system. For large providers, it is difficult to develop a business argument for not having EHR. Now assume that MU does not exist. We already have seen examples of how having MU impacts HIT strategy, how would not having to plan around MU impact your EHR and HIT strategy? What other projects would be at the top of your list? What initiatives could you own if you did not shuffle resources away from your preferred strategy simply to chase MU? Instead, would you be addressing patient and physician churn? Implementing managed services opportunities? Aligning workflows? Developing a social media platform?

There is nothing wrong with assessing what you would be doing to support your hospital if there were no Meaningful Use. You can and should undertake that assessment and calculate its ROI. Then, instead of having a lone MU ROI, you have something else against which to compare it.