meaningful use

Who is responsible for your hospital’s HIT strategy, you or the ONC?

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Who is responsible for your hospital’s HIT strategy, you or the ONC?  Here are my thoughts regarding “What’s Next” and the “Gap Analysis”  with regard to the ONC’s interim final rule.  Remember, you don’t have to follow the IFR.

What’s Next:

  • Most if not all of the current HIT was built prior to government constraints
  • The ONC changed the rules after many hospitals already spent millions on EHR and CPOE
  • Nobody knows the staying power of the Meaningful Use rules or the impact of reform
    • Will the implementation be pushed back?  Quite possibly
    • Will the requirements be toughened?  Very likely
    • What if reform reduces revenue and increases demand?
    • What if existing doctor and nurse shortages grow worse?
    • What if some of the most vulnerable and expensive patients continue to have no coverage?
    • What if the ONC changes the rules?
    • What if reform cuts costs by eliminating “disproportionate share” payments?
    • What if there is a reduction in Medicare reimbursements?
    • More is unknown than is known about the impact on hospitals and physicians
    • There are two business models in play;
      • The ONC’s and reform’s nationalization and interoperability of healthcare
      • The mission of your organization
      • Do you build your HIT strategy to align with your hospital’s strategy or with the ONC’s strategy
      • Your pre-Meaningful Use HIT goals likely included:
        • Supporting your strategy
        • Consolidation for shared services
        • Clinical integration
        • Operational excellence
        • Reducing functional duplication between departments
        • Process improvement
        • EHR and CPOE implementation
        • Which of those goals would have to be altered because of Meaningful Use
        • What would your HIT strategy have been if there was no Meaningful Use

What’s the GAP between what you had planned and what your now have to consider?

  • How many millions will it take to meet Meaningful Use
  • What planned HIT projects must be delayed because of timing or resources
  • How do those millions compare to what you will receive from the ARRA funds
  • Even if the funds exceed the cost to get them, how do the changed systems impact your business model
  • You have a number of options to analyze regarding Meaningful Use:
    • Meet Meaningful Use later
      • A wait and see approach buys you time for the uncertainty to settle and for the impact of reform on HIT to become clearer
      • There is no requirement to be first
      • You have five years before Meaningful Use penalties begin
      • If the requirements expand as expected it will likely cost more to modify systems than to wait for a complete set of requirements
  • Do not meet Meaningful Use
  • Meet all of the Meaningful Use opportunities
  • Meet portions of Meaningful Use
  • What projects must be undertaken to achieve each option
  • Will those projects have long-term value for you, or is their only value meeting Meaningful Use
  • What process and change management implications are built into meeting Meaningful Use

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.

Should you consider disregarding Meaningful Use?

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Here’s a reply I wrote to a FierceHealthIT on some of Dr. B’s comments on Meaningful Use.

I know of a hospital who has already implemented a top tier EHR costing millions.  This organization ‘gets it’.  They are currently building a work-plan to see what additional work they must do to meet Meaningful use in time to qualify for 100% of the ARRA money.  First blush—it will take tremendous amount of work for them to do it, but they will get there—if they choose to do so.  They have a choice and the fact that they know that is their trump card.

If a hospital hasn’t even begun the EHR process, as more than 80% have not, coupled with the more than fifty percent failure rates, I’d estimate their chances their chances of making the deadline at less than 1/3.

So, what to do?  Stop and think.  Ask the right questions.  You have a choice of two strategies.  Let ARRA money drive your decision, possibly implement it wrong, and probably miss the deadline.  Then what do you have?  Not much.  Strategy number two; define your requirements, figure out what business problems you need the EHR to help solve, and buy the best one for you.  Confused?  Map out two work-plans for yourself.  One work-plan that shows what you would have to do and what you would have to spend to meet the ARRA requirements.  Draft a second work-plan that shows what you would have to do to implement what you really want.  Compare the two plans and determine your deltas, your gaps.

Are you going to chase this for ARRA money?  Because someone in Washington thinks you should do this?

Answer this question first.  Is every hospital the same?  Are you as good as the best, better than the worst?  The EHR vendors think the answer is yes.  Keep you processes the same, skip change management, and the implementation will be a breeze.  We make every hospital look and operate the same.  When did the EHR vendors become the best practice savants?   The government thinks the answer is yes—that is why they are holding everyone to the same Meaningful Use standard.

One standard does not fit all hospitals—nor should it.  Set your own standards and decide for yourself if you fit your version of Meaningful Use.  ARRA money will end—then what?  You’re stuck with your EHR.  Get one you need.

Call me a cock-eyed nihilist

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I offered the following comment to Kent Bottles post,

My New Year’s Resolution: To See the World Clearly (Not as I Fear or Wish It to Be).

http://icsihealthcareblog.wordpress.com/2010/01/04/kent-bottles-my-new-year’s-resolution-to-see-the-world-clearly-not-as-i-fear-or-wish-it-to-be/#comment-131

As this is the first Monday of the New Year, I had not planned on thinking, at least not to the extent necessary to offer comment on your blog.  I distilled it to three points—perhaps not the three about which you wrote, but three that tweaked my interest—happiness, counterfeit, and healthcare clarity.

Suppose one argues that happiness lives in the short-term.  It is something that one spends more time chasing than enjoying, something immeasurable, and once attained has the half-life of a fruit fly.  I do not think it is worthy of the chase if for no other reason that it cannot be caught.  As such, I choose to operate in the realm of contentment.  Unlike happiness, I think one can choose contentment.

There are those who would have us believe that contentment, with regard to healthcare, comes about through clarity, and that clarity comes from contentment—the chicken and the roaders.  Those are the ones who argue that reform, any reform, is good.  Where does the idea of counterfeit come into play?  I think it is the same argument, the one which states that any reform, even something counterfeit, is good.  The healthcare reform disciples argue that reform in itself is good; be it without objective meaning,purpose, or intrinsic value.  Therein lays the clarity, even if the clarity is counterfeit.

Call me a cock-eyed nihilist, the abnegator.  I am not content.  My lack of contentment comes not from what is or isn’t in the reform bill.  It stems from the fact that reform, poorly implemented, yields an industry strapped to change, an industry that may require greater reform just to get back to where it was.

Healthcare IT reform, HIT, will have to play a key role in measuring to what degree reform yields benefit.  Without a feasible plan, HIT’s role will be negative.  There are those who feel such a plan exists.  Many of those are the same people who believe the sun rises and sets with each announcement put forth by the ONC.

I think the plan, one with no standards, one that will not yield a national roll out of EHR, is fatally flawed.  I think that is known, and rather than correcting the flaws, the ONC has taken a “monkey off the back” approach by placing the onus on third parties, and offering costly counterfeit solutions like Meaningful Use, Certification, Health Information Exchanges, and Regional Exchange Centers.  If the plan had merit, providers would be leapfrogging one another to implement EHR, rather than forcing the government to pay them to do it.

What may be driving the Meaningful Use announcement

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I often write not because I have something that needs to be said, but to try to explain something to myself.  If I get to a point where I think I understand an issue, I’ll make it public to see if the comments reflect my understanding, or to see if I need to have another go at my own thought process.  Which leads me to this—

Let’s back up the horses for a minute and return from whence we came.  EHR.  The idea was simple.  Two groups; patients and doctors.  Create a way to transport securely the medical records of any patient (P) to any doctor (D).

For the time being, let’s keep this at the level that can be understood by a third grader.  What two things do I need to satisfy this P:D relationship?  Data standards and a method of transport.

Do we have them?  We do not.  That being the case, what fury hath the ONC wrought?  (1 Roemer 9:17)  if you don’t have what you need, and you don’t have either the authority or a plan to get what you need, you must facilitate (fund) the creation of workarounds to fill the void.

At some point, the conversation must have quickly shifted from, “We need standards and transport”, to, “Since we don’t have standards and a means of transport, we must come up with other ways to try to make this work.”  Now, I don’t believe this is literally what happened, but I think one could see how it might have evolved.

Other ways.  What other ways?  The ONC loves me; it loves me not.  HITECH.  ARRA.  Take the monkey off our back and put it on the backs of the providers.  Pay doctors to implement EHR.  Smote them if they don’t.  Write checks.  Big checks.  Lots of big checks.  Instead of coming up with a single transport plan and one set of standards, provide guidelines.  Make pronouncements.  Fund RHIOs and make them responsible for creating hundreds of unique transport plans and ask the RHIOs what progress they are making towards a single set of standards.  Get the monkey off your back.

Create artificial goalposts that get the HIT world all a twitter every time the ONC makes a proclamation.  What goalposts?  Meaningful Use and Certification.  Just so there is no misinterpretation of what I think the issue is permit me to spell it out—Meaningful Use and Certification exist because there are no standards and there is no means of transport.  Conversely, had the ONC developed standards and transport, there would be no discussion of Meaningful Use and no Certification.  Standards would have forced vendors to self-certify.

The other activity could be viewed as a feint.  Not one developed out of malice, rather one that came about from the void that resulted from the lack of a viable plan.  Meaningful Use and Certification are expensive workarounds for a failed or nonexistent national EHR rollout plan.  As are RHIOs and RECs, the six million dollars, and the forty billion dollars.

The HIT world grinds to a halt at the very mention of an announcement from the ONC.  Their missives are available in PDF or stone tablets.  Imagine someone robs a bank, and as they exit the bank, they jaywalk on their way to their getaway car.  The police missed the robbery, and focus all their efforts on the secondary issue, the jaywalking.

The chain of events has caused the focus to move away from the primary issues of no standards and no plan, and towards a plethora of secondary issues, issues for which hundreds of people are responsible and no single person has authority.

I think that by the end of 2013 pronouncements on Meaningful Use and Certification won’t be able to buy time on MTV.

If any of this is close to being correct, what are the implications for a hospital looking to select and implement an EHR?  Find the EHR that is best for your hospital.  Not the one most likely to earn ARRA money.  Not the one which will pass today’s Meaningful Use test.  Define your requirements.  What requirements?  The ones you believe will most closely align with how the healthcare industry will look in 2015 and beyond.  Meaningful Use will change.  Reform will change.  Funds will change.  Reform will change again.  Will your EHR be able to change?

The ONC’s recent Meaningful Use proclamation required 556 pages.  If you occupy the C-suite of your hospital, I hope you don’t let those pages define your selection of an EHR.  Some would argue that with so many pages that there must be a pony in there somewhere.  From what I read, I’m in no hurry to rush out and buy a saddle.

What is wrong with the ONC’s 2010 budget?

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Some comments I wrote to ahier.blogspot.com’s posting of the ONC’s 2010 budget.

Their mission, “ONC leads, coordinates, and stimulates public and private sector activities that promote the development, adoption, and use of health information technologies to achieve a healthier Nation” although offering nice sentiments, for $61 million, ought there not be a way to measure whether or not they achieved the mission? How does one know if they led, coordinated, and stimulated, and if so to what degree?

Who certifies their work? Who determines if their work resulted in Meaningful Use? Before anyone gets excited by what they plan to do in 2010, let’s look at what they did in 2009.

1. What did the ONC accomplish, complete, put to bed?

2. What did they complete that facilitated the HIT work required of the providers?

There are no standards. There is no believable plan to obtain standards anytime soon. There is no viable national roll-out plan for EHR.

Instead of HIT/ARRA handouts, and HIE’s designed by hundreds of independent groups, and RECs designed by inexperienced appointed committees, why not use the $61 million to state that by such-and-such a date there will be a written and executable plan stating when we will have standards and a workable and believable roll-out plan?

They continue to promise funds to support an ill-conceived plan trying to get everyone on board, an approach that yields to the notion that “There must be a pony in there somewhere.” Ladies and gentlemen–there is no pony.

A reply to Government Health IT on Meaningful Use

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A response to a post in Government Health IT. http://www.govhealthit.com/newsitem.aspx?nid=72187#

Although I can’t prove it, I’ll bet by 2012 the meaningful use standards will have gone the way of the first reform bill. Hospitals should not be making buying decisions that involve hitting standards that have no meaningful use.

However, if hospitals fail to be able to deliver on what the system can do and how well they roll it out within their organization, they have no one to blame but themselves. This is why I place such a premium on planning and establishing detailed functional requirements. Involve the users, excel at change management, and plan like the success of your organization depended on it.

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The ambiguity & apathy of user acceptance

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ambiguity

Why write if you can cut and paste.  The comments listed below are extracted directly from a blog titled SmartBlogs Work Force, http://smartblogs.com/workforce/2009/10/05/why-well-miss-ambiguity/#comment-19170.  The blog attacks Generation Why (my term) for being ambiguous in the workforce.  It seems to me that they can just as well be applied to why EHR has a low acceptance level.

  • Animosity between workers and bosses in business will increase. Ambiguity often looks pretty darn black-and-white to the worker who doesn’t see the nuance. And when workers think management is overanalyzing/dragging its feet/fumbling a simple problem, they lose patience with, and lose faith in, management’s ability to perform.
  • Many younger employees will “opt out” of a corporate system they don’t fully understand. This will ultimately prolong their own learning curve as they try to re-create a “better” structure without realizing that a number of the problems with our current structure will exist in any system populated by humans because the problems stem from our human nature, not our system design.
  • Leadership will suffer. Take ambiguity away from leadership, and you take away tough decisions and responsibility. What you’re left with is overpaid administration. That’s the image many young professionals today seem to have of leadership, so that’s what they’ll create.
  • The Applization of design will get more expensive, as companies that try to build simple products with minimal learning curves find they lack employees who can accurately predict real-world user behavior.
  • Individuals will double down on what they are good at, which in this case is solving problems by working HARDER BETTER FASTER SMARTER. This will rob many companies of their “manager class,” as people who stay in the system opt for specialist roles rather than managerial roles that come with more — yep, you guessed it — ambiguity.
  • Career paths will become more fixed. Our ability to process ambiguity extends to our ability to assess other people. Already, resume readers look for specific patterns, jettisoning capable applicants with “non-conforming” histories. This trend will continue to amplify for awhile.
  • Companies will ruthlessly centralize their decision-making functions, concentrating power with a few select people who “get it.”
  • Individuals will become more system dependent, just as people who aren’t good at division become more dependent on their calculators. This will create feelings of frustration and resentment.
  • Stress levels will explode further. If you think it’s bad now, just wait. There is a lot of unresolved fear out there. Mix in a dash of helplessness (which is a often a synonym for “unable to handle ambiguity”) and you’ve got a potent mix.

black saint 2

A response to an ICMCC blog on Meaningful Use

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This reminds me of the old Wendy’s commercial, “Where’s the beef?”  The comment regards the posting, http://blog.icmcc.org/2009/10/02/meaningful-use-where-is-the-patient/comment-page-1/#comment-98522

I think three years from know we will see that meaningful use proved to be a smokescreen which demonstrated no meaningful use. I also think there is benefit in looking at why healthcare providers have to be offered money and subjected to potential fines to do something that is supposed to be good for them. In turn, why do they then need to be pushed into rolling it out according to someone’s timetable who’s not even a part of their organization.

1. Why are providers running from EHR instead of towards EHR?

2. Why do they have to be paid to implement EHR?

3. Why do they have to be cajoled to roll it out according to somebody else’s time table?

black saint 2

EHR: my 12-step program

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Sometimes I need to shift into neutral and allow myself the luxury to pause and reflect.  This afternoon I find myself reflecting on the past 35 years, coincidentally, the same number of years since I graduated from high school—it’s okay to fast forward to the end to see if I actually tie this into anything worth your time, I can’t guarantee anything as of yet.  If I don’t come through, I’ll owe you one.  Maybe I’ll write something so obtuse at the end about reform that you’ll feel as though the fault lies with you for not understanding me.

So, we are to meet tonight—I have seen none of them since I departed for the Air Force Academy.  There is a reason I haven’t seen anyone.  The part I don’t get is why at this time we’ve mutually decided to end our hibernation.  It’s a little like the emergence of the seventeen year locusts times two.

We have only Facebook to blame for this folly.  I must admit it has been rather entertaining seeing pictures of them as adults, and reading how they describe themselves.

During my senior year I pulled my hair back when I ran.  My hair is no longer pullable.  I am some twenty pounds heavier than my playing weight.  I considered the drive-through face lift on the way down today, but thought the bandages would give it away.

Do most people go through this, wondering if you’ll impress those for which you held with such low regard, and they for you?  (That sentence was a bugger to piece together.)  At what point do we say this is stupid and move forward?  I’m guessing it must happen at year thirty-six or beyond.

I don’t understand my motivation in agreeing to come.  Is there an entertainment factor, some degree of closure, an in-your-face moment?  Is it because you get to look the high school bully in the eye and pretend he’s the parking attendant, tossing him the key to your Mercedes and ordering him not to scratch it?  What is it about those four years as opposed to any other four years that draws people back?  There is definitely something voyeuristic to it.  No other four year period in anyone’s life could exert that same pull.  Maybe that speaks to the transitory pattern of our lives after high school.

It’s the only time when we saw the same hundreds of people day in and day out for four straight years.  Maybe it had to do with having no responsibility, or maybe it had to do with bell bottoms, platform shoes, and long hair.  Relationships were built in the hallways next to our lockers—sort of a premature cohabitation—and lasted until the bell rung for home room.  New ones—upgrades—began to blossom on the school bus on the way home.  It was the best of times; it was the worst of times.  It was Nixon and Led Zeppelin, Peter Max and 3.2 beer.

These people with whom I am about to reunite, we are strangers once removed—by tomorrow I will know if it would have been better to have left it that way.  Some of them will never be mistaken for someone who knew how to calibrate ground-to-air missiles—perhaps they think that of me.  Some are poltergeists who  think of themselves as the Zeitgeists of my generation—I do not know what that means, but it looked like a good sentence as I was typing it.

There’s less than two hours until the foot lights come up and the actors have to move downstage to their positions.  I’m guessing that only the boringly secure have decided to play themselves.  The twelve-steppers are deciding which character to play on opening night and rehearsing their lines with their spouse or significant other—a term by the way which held no meaning in high school.  Costumes lay strewn across the hotel bed as the actors decide on the perfect, here’s how I turned out after thirty-five years look.  I find myself torn between the erstwhile bon vivant prepster and the Barry Sonnenfeld, Men in Black look.

Anyway, I’ve waxed and waned to the degree where I now feel completely marginalized.  I wrote in my year book that I wanted to be president.  A lot of these people are a few fries short of a Happy Meal, but I think even they will discern quickly that I fell short of that goal.  Nonetheless, I wake each day intent on slaying my personal dragons.  You?  Here comes the segue.

The time is coming where we will need to decide which character we will play in the roll out of our EHR systems.  Are there those who will break from the pack, eschew what others will say about their approach, toss aside the conventional wisdom of being in lock-step with the majority, and decide to approach this as a solution to a business problem?

I dare say that most will choose the path most traveled.  The path that says how wrong can I possibly be by doing what everyone else is doing.  Those who act on what they know is right, those who look for an EHR solution that rates future flexibility higher than the ability to conform to non-existing standards, higher than the gossamer guidelines of certification and meaningful use, will find that not only have they leapfrogged their peers, they will find that they have selected wisely.

Those who choose to follow the crowd may find themselves hibernating with the cicadas.

saint