PMO

The Wildebeest Postulate

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The Kalahari; vast, silent, deadly. The end of the rainy season, the mid-day heat surpasses a hundred and twenty. One of the varieties of waterfowl, most notably the flame red flamingo that nested in the great salt pans in Botswana, has begun its annual migration. In the muck of one of the fresh-water pools that had almost completely evaporated, writhes a squirming black mass of underdeveloped tadpoles. A lone Baobab tree pokes skyward from the middle of the barren savanna. In its shade, standing shoulder to shoulder and facing out, a herd of wildebeest surveys the landscape for predators.  Sir David Attenborough and PBS can’t be far away.

Some things never change. I make my way across the freshly laid macadam to meet the school bus. Fifty feet in front of me is a young silver maple tree, the buds of its green leaves yielding only the slightest hint of spring hidden deep within. The late afternoon sun casts a slender shadow across the sodded common area. One by one they come—soccer moms; big moms, little moms, moms who climb on rocks; fat moms, skinny moms, even moms with chicken pox—sorry, I couldn’t stop myself—as they will every day at this same time, seeking protection in its shade. My neighbors.  It’s only sixty-five today, yet they seek protection from the nonexistent heat, a habit born no doubt from bygone sweltering summer days. A ritual. An inability to change. In a few weeks the leaves will be in their full glory, and the moms will remain in the shadow of what once was, standing shoulder to shoulder facing outward, scanning the horizon for the bus. A herd. Just like wildebeest.

The children debus–I invented the word.  Mine hand me their backpacks, lunch boxes, and musical instruments.  I look like a Sherpa making my way home from K-2.

I shared this analogy with the neighborhood moms—the bruises will fade gradually. I can state with some degree of certainty they were not impressed with being compared to wildebeest. So here we go, buckle up. By now you’re thinking, “There must be a pony in here somewhere.”

Some things never change; it’s not for lack of interest, but for lack of a changer.  For real change to occur someone needs to be the changer, otherwise it’s just a bunch of people standing shoulder to shoulder looking busy. How are you addressing the change that must occur for EHR to be of any value?  EHR is not about the EHR.  It’s not about ARRA money, and it is not about IT.  It is about moving from a 0.2 business model to 2.0.  You need someone who sees the vision of what is is—sorry, too Clintonian—must lead.  Be change.

One of the great traits of wildebeest is that they are great followers.

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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Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

The User’s Role in EHR–a PowerPoint presentation

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This link will take you to a slideshare,net presentation that defines how healthcare providers can take control of the EHR project.  I welcome your comments.

http://www.slideshare.net/paulroemer/the-users-role-in-ehr

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

What do you tell the Steering Committee about EHR?

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Success and failure are often separated by the slimmest of margins. To succeed, sometimes you have to be prepared to think on your feet.  You have to outthink unfavorable circumstances. Often, success or failure hinges on how you present an idea.

Permit me to illustrate with frozen chicken. Several hours before dinner I threw some frozen chicken breasts into the sink, choosing to thaw them with water instead of the microwave. Some twenty minutes later while checking emails I wondered what we were having for dinner. Not to be outdone by own inadequacies, I remembered we were having chicken. I remembered that we were having chicken because I remembered turning on the hot water. The only thing I couldn’t remember was turning off the hot water.

I raced to the kitchen. My memory was correct. Noah would already have been building an ark.  Grabbing every towel I could find, I sopped the puddles from the hardwood floor.  While mopping I thought about how I might answer my wife if she returned to a kitchen that looked like Water World.  My first instinct, admittedly poor, was to tell her I thought the countertop wasn’t level and that the only way to know for sure was to see which direction the water ran. Telling her the truth never entered my mind.

Once the major puddles were removed, and believing the major threat from her had passed, my wits slowly returned.  I worked on version two of the story—how do I explain all the wet towels.  I arrived quickly at a more believable version of the truth—I would tell her I decided to wash the towels—all of them.  Why not get bonus points instead of getting in trouble?

Version three sounded even better. Since I’d wiped the floor with the towels, instead of simply telling her I washed the towels, why not double the bonus points? I’d tell her I washed the floor, and washed the towels. Husband of the year can’t be far off.

A few hours have passed since the indoor flood. The floor is dry—and clean, the towels are neatly folded and back in the linen closet, and the chicken is on the grill. All the bases covered. A difficult and embarrassing situation turned into a positive by quick thinking and deft presentation.

Back to healthcare.  A few of you have written and asked, how do you propose we turn around our EHR implementation, turn the focus to solving business problems, not simply implementing an unwieldy system simply to collect the ARRA ransom money?

All kidding aside, it comes down to presentation. Clearly you can’t walk into a steering committee meeting with a just a slide deck showing that the current EHR implementation strategy will decrease productivity.  If there are problems with what you are doing, or the support you are receiving, or the immediacy with which the committee wants to the project to end, present the consequences of the action.  Then present what could be accomplished and what you need to make it happen.  EHR is not done just because the vendor is no longer in the building.  All you can conclude from that is that there are a few freed up parking spaces.  Your goose may be cooked.

So, what happened with my chicken dinner? I was confident I had sidestepped to worst of the threat. Overconfident, as it turned out.  My son hollered from the basement, “Dad, why is all this water down here?”

Parallel universes–replacing one EHR for another

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Some providers are changing their EHR system.  Why?

Why indeed?  What precipitates the need to change?  I bet if you take the top five or seven EHRs, and compare them to a rigorous set of requirements you will find they all score within one standard deviation of the norm.  You won’t hear that from the vendors, but they are the same with regard to the major functionality.

There is no single vendor who scores head over heels above the others.

I bet if you interviewed their customers you will not find a customer which thinks their vendor is the be-all end-all of healthcare.  In fact, you will learn at best most clients will score their satisfaction with their vendor mediocre. Depending on what numbers you read, you will see failure rates in excess of fifty percent.  Failure, by my metric, has more to do with what someone did or did not do to the application than it has to do with the application itself.  This is a “Do these pants make me look fat?” issue.  Guess what, it’s not the pants.

Is there a single vendor who can state that none of their clients has ever replaced them with one of their competitors? That means if you are thinking of replacing EHR A with EHR B, another hospital is thinking of replacing EHR B with EHR A.  Parallel universes, or is it universi?

The grass will not be greener.  Here is what will.  A lot of hospitals operate with what can best be described as anything but best processes–worst processes.  No EHR can handle those.  Before you begin again, evaluate your processes. Weed out the bad ones, do away with the duplicates.

Are you willing to spend another hundred million or two hundred million dollars to get marginally higher satisfaction? Instead, how much would you have to spend to change your processes, implement a change process, retrain your people, and devise a system to bring in your ambulatory doctors?  It would certainly not exceed nine figures.

EHR need not be a do-over.  For those just getting started, do process prior to implementation, not after.

It’s not the pants.

EHR–the five stages of grief

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The Kübler-Ross model, commonly known as the five stages of grief, was first introduced by Elisabeth Kübler-Ross in her 1969 book, On Death and Dying.  I heard a story about this on NPR, and it made me think about other scenarios where these stages might apply.

My first powered form of transport was a green Suzuki 250cc motorcycle.  My girlfriend knitted me a green scarf to match the bike.  One afternoon my mother walked into the family room, saw me, and burst into tears.  When I asked her what was wrong, she told me that one her way home she saw a green motorcycle lying on the road surrounded by police cars and an ambulance—she thought I had crashed.  I asked her why, if she thought that was me lying on the road, she did not stop.

My girlfriend’s mother, didn’t like my motorcycle—nor did she like me.  Hence, my first car; a 1969 Corvair.  Three hundred and fifty dollars.  Bench seats, AM radio.  Maroon—ish.  It reminded me a lot of Fred Flintstone’s car in that in several places one could view the street through the floor.  Twenty miles per gallon of gas, fifty miles per quart of oil.

Buyer’s remorse.  We’ve all had it.  There is a lot of buyer’s remorse going around with EHR, a lot of the five stages of grief.  I see it something like this:

  • Denial—the inability to grasp that you spent a hundred million dollars or more on EHR the wrong EHR, one that will never meet your needs
  • Anger—the EHR sales person received a six-figure bonus, and you got a commemorative coffee mug.  The vendor’s VP of Ruin MY life, took you off his speed dial, unfriended you in Facebook, and has blocked your Tweets. You phone calls to the vendor executive go unanswered, and are returned by a junior sales rep who thinks the issue may be that you need to purchase additional training.
  • Bargaining—when you have to answer to your boss, likely the same person who told you which system to purchase, as to why productivity is below what it was when the physicians charted in crayon.
  • Depression—you come in at least fifteen minutes late, and use the side door, taking the stairs so you won’t see anyone.  You just stare at your desk; but it looks like you are working. You do that for probably another hour after lunch, too. You estimate that in a given week you probably only do about fifteen minutes of real, actual, work. (Borrowed from the movie, Office Space.)
  • Acceptance—the EHR does not work, it will never work, you won’t be around to see it if it ever does.  Your hospital won’t see a nickel of the ARRA money.  You realize the lake house you were building will never be yours, but the mortgage will be.

The five stages of EHR grief.  Where are you in the grieving process?

True, there are a handful of EHR successes.  Not nearly as many as the vendors would have you believe.  More than half of hospital EHR implementations are considered to have failed.

If you are just starting the process, or are knee-deep in vendor apathy you have two options.  You can bring in the A-team, people who know how to run big ugly projects, or you prepare to grieve.

If it was me, I’d be checking my list of friends on Facebook to see if I was still on my vendor’s list of friends.

“Are the best intentions of EHR Half-Full or Half Empty?”

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Doublethink. Functioning simultaneously on two contradictory beliefs and accepting both as true. By definition, one must be false, unless of course you are living in a parallel universe, in which case you’re in need of more help than I can deliver. George Orwell defined it as, “A vast system of mental cheating”—on yourself, I might add.

What does doublethink accomplish and why does it exist with varying degrees within each of us? First, it allows us to overcome our own competence. I think that’s worth repeating, overcoming our own competence. We know better and yet we talk ourselves out of accepting what we know, creating an equal and offsetting false belief.

Second, it acts as a safety net. How? Let’s say we are one hundred percent confident in Belief A. Well, almost. There’s always that little nagging disbelief, that little devil on the shoulder trying to convince you otherwise. Sort of like ‘buyer’s remorse’—only we’ll call it believer’s remorse. Just in case Belief A is wrong, maybe I should have a backup belied, Belief B. Jeckyll and Hyde.

How does that impact one in the EHR problem?  Buckle up. Most people with whom I’ve worked are very passionate about what they do and are paladins of their methods.  Sort of EHR young Turks.  Belief A. They do everything they can for the program.

While sincerely believing in the importance of EHRs, here’s what else I’ve observed.  Much of that belief envelopes the limited notion of believing that nothing lays outside of their skill set. They often recognize it more as a desire than a belief.  They know fully that they will face challenges which are new to them.  They know fully that many implementations have failed and that they need to spend more effort on change management and work flow alignment than was budgeted.  The list of challenges for which they lack the expertise never empties.  They know the light at the end of the tunnel is just a train. They know fully that solving the current problem only seems to reveal the next one.  Belief B.

So, we’ve come full circle. We outwardly profess we can do what others have failed to do, yet in our heart of hearts we believe that you may never see an ROI. Doublethink.

Which gets us back to our original question, “Are the best intentions Half-Full or Half Empty?”

Project Management lessons from Alice and Wonderland

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During my career I’ve been involved with hundreds of project teams, some quite gifted, others whose collective intellect was rivaled only by simple garden tools.  I’ve been asked often if I can define what distinguishes the two types of teams.  For me it always comes down to leadership.  It doesn’t matter how hard the people work, it matters how well they are lead.  Does the leader know what to do tomorrow?

That got me to thinking.  Are there some leadership secrets, some project management gems that may have been overlooked?  Rather than offering traditional mish-mash consulting jargon, I thought it would be helpful to find a common ground by which we can form a basis for this discussion.  Hence the following narrative: Everything I learned about project management I learned from Alice in Wonderland.

So, you have spent tens of millions on an electronic health records system.  Some did so without even defining their requirements.  The project is chugging along, new regulations and penalties are appearing through the diaphanous mist like the Cheshire Cat’s toothy grin.

“Well! I’ve often seen a cat without a grin,” thought Alice.  “But a grin without a cat! It’s the most curious thing I ever saw in my life!”


How fast must you run so as not to lose ground?  How many milestones do you have to meet, how many due dates do you have to check?  What can be learned from the Red Queen in Alice in Wonderland?  She told Alice, “It takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast.”




For the EHR project to progress it requires extraordinary effort.  This begs a question of the project leader, where does the project need to go?  In a conversation with the Cheshire Cat Alice asks,

“Would you tell me, please which way I ought to go from here?” “That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where,” she said.
“Then, it doesn’t matter which way you go.” “So long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

If you only walk long enough.  What is enough for a three year project?  When are you done?  When the money runs out; when there are no more tasks in the work plan.  It seems many EHR projects are much bigger than allowed for by the plan.  They get big, impossibly big.  A lot of that size comes from underestimating the effort to support workflow improvement, change management, and user acceptance.

“Sorry, you’re much too big.  Simply impassible,” said the Doorknob to Alice.   “You mean impossible?” “No, impassible.  Nothing’s impossible.”

We don’t have the benefit of getting advice from talking doorknobs which is why we get so stymied when confronted with having to do the impossible. What is impassible or impossible for your project?  It might be deciding or knowing when to stop.

Alice laughed. “There’s no use trying,” she said: “one can’t believe impossible things.”
“I daresay you haven’t had much practice,” said the Queen. “When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”

Believing it does not make it so.  Never has, never will.  Belief does not beget success.  Planning does.  Defining your requirements may.  There is no shortage of ex-CIOs who believed their EHR vendor.

Then there’s the skill of managing your EHR vendor.  Perhaps Eaglet said it best, “Speak English! I don’t know the meaning of half those long words, and I don’t believe you do either!”

There will always be those select members of every project team who are so dense that light bends around them; those who have not learned that it is better to keep their mouth shut and appear unintelligent than to open it and remove any doubt; those who have the right to remain silent, who just don’t have the ability.

“You couldn’t deny that, even if you tried with both hands.”

“I don’t deny things with my hands,” Alice objected.

“Nobody said you did,” said the Red Queen. “I said you couldn’t if you tried.”

Do you find yourself sitting through a status meeting unable to tell if the project is moving backwards or forwards, unable to tell what is hiding around the bend?  You think so hard your head feels like your ears are trying to switch places with your eyes.  When all else fails, try this bit if advice.

“Fan her head!” the Red Queen anxiously interrupted. “She’ll be feverish after so much thinking.”  A little thinking won’t hurt, who knows; in small doses it might even be beneficial.

Now, let’s assume you’ve got yourself all worked up.  You and your team are pouring over your work plan, trying to decide what’s left to accomplish, or what can’t be accomplished.  How do you know what’s what and which is which?

“Begin at the beginning,” the King said, very gravely.  “And go on till you come to the end: then stop.”

I’ll take the King’s advice and do the same.

Donuts and plants, project management 101

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(I sometimes find it helpful to recite my blogs using different voices like Neil Diamond.  You?)

Do you ever look back with amazement on how naïve you were in your first job?  You walk in, your head so full of knowledge it feels like it should explode.  You’re just waiting for that first opportunity to release the pearls of wisdom accumulated during all those years of schooling.  I was pretty sure I knew almost everything that needed knowing.

I worked as the assistant to the CFO of a large petroleum services firm in Fort Worth, Texas.  Lot’s of visibility, lot’s of people watching my every move.

My first day on the job, I was expected to attend a meeting at 7:30 AM.  Overtime.  I brought donuts, knowing how hungry everyone must be because they hadn’t had time to eat breakfast.  As I soon learned, the others in the room had been there since 6 AM for another meeting—they were not impressed by my offer of donuts.  My boss walked me over to an east-facing window an pointed at the orange ball of light floating above the horizon.

“That’s the sun,” he said.  “It’s been up two hours—so have we.  It comes up this time every morning.  Get used to it.”

That went well.  I noted that five o’clock had come and gone and nobody made any attempt to rush the doors.  I decided to leave around seven.  As I waited for the elevator I noticed that two very large plants in very attractive pots were being thrown away.  They’d be perfect for my barren apartment.  It took me several trips to get the plants and pots situated in my TR-7 convertible.  Over the next several days I noticed that next to the elevator bays on the other floors were identical plants in identical pots.  What was the likelihood that these were all being thrown away?  Probably zero I surmised.

So, my first day on the job I unknowingly stole the company’s plants.  What would day two offer, a walnut credenza, brass lamps?  Gonna’ need a bigger car.

Do you know people like that on your project, those who portend to know everything that don’t?  Plant thieves.  Sometimes they masquerade as program managers, sometimes as analysts.  They hide what they don’t know behind a flurry of meetings, a full calendar, reams of emails.

It’s easier to spot the plant thieves than it is to stop them from adversely affecting your project.  It’s easy to observe, easier to complain about.  What to do about it?  Why are you asking me?  That’s why they pay you the big bucks.

EHR: work plans are necessary but not sufficient

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I wonder about things, little things, things I see on Nova or on Bizarre Foods.  Take water, more specifically, ice.  It floats.  The only solid that floats in its liquid state.  Most solids sink, not ice.  For those of you thinking boats float, they’re not considered to be solids—does that make them liquids?

It turns out that as water goes from four degrees centigrade, its densest point, and towards freezing, it becomes less dense and floats.  It’s volume increases by 9%, and part of that 9% is trapped air.  That air, even though you can’t see it, exists between the two H’s and the O.  which takes us to the following.

Have you spent much time studying work plans?  While there are more interesting ways to spend your time, there are times meant for writing them, and times meant for studying them.

Having a work plan can be a little like having a bike; nice, practical for some things, impractical for others.  Like with most things, there are work plans and there are work plans.  Some may not be worth the paper on which they are written.

Just like not everyone can write a book worth reading, not everyone can write a work plan worth implementing.  Lines on paper don’t necessarily yield a project of much value.  Remember how with the ice there are things between the H’s and O’s?  Well, with a lot of healthcare IT and EHR work plans, there are things between the tasks on the work plan, or at least there should be.  Can’t see them either.  Those things?  The missing tasks, the tasks that should have been in the plan, the tasks that would have given the plan a fighting chance to succeed.

Some gaps are good, like with ice.  Others can leave you hanging.

saint

Why we don’t allow horses do medical procedures or EHRs

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There are three or four basic rules those of us who write should use, unfortunately I do not know them. For those of my ramblings that seem long, it’s only because I have not had the time that is required to make them shorter. This I fear is one of those. I write to find out what I am thinking; if and why you read remains uncertain. All of us learned to write in elementary school—most then moved on to greater things—I remained trapped with the notion that being able to spell words more than one way may one day be regarded as a talent.

I found it is not a bad idea to get in the habit of writing down my thoughts–it saves me from having to verbally rake others with them. Some of my thoughts require little or no thought from those who read them, for the very simple reason, they made no such equivalent demand upon me when I wrote them. My goal in writing, other than to entertain myself is to create a somewhat humorous context to facilitate thinking. As one who enjoys the written word I understand that no urge is equal to the urge to edit someone else’s thoughts, as several of you have done with mine. It sometimes feels as though the best I can hope for in formulating a series of ideas about a topic is to borrow well from experts, those people whose have already made all the mistakes that can be made in a very narrow field. The need to write and share my opinions requires constantly trying to prove my opinion to an audience who may not be friendly, which is why silence may be better–silence is often the most difficult opinion to refute. Unfortunately, trapped inside every consultant is the urge to write; sometimes that urge is best left trapped inside.

Much of the project management office consulting I do comes from having listened respectfully to very good advice, and then going away and doing the exact opposite. In general there appears to be a lack of strategy concerning EHR, making it like trying to jump a chasm in two leaps—it can’t be done. Without knowing what outcome you want to achieve, any path will take you there. This isn’t because the people in charge don’t see the solution—it is because most people have no familiarity with the scope and magnitude of the problem.

Large information technology projects like EHR are often dominated by two types of people: those who understand what they do not manage, and those who manage what they do not understand. If we are being honest, the end product of project management is making it more and more difficult for people to work effectively. It’s sort of like why we don’t allow horses do medical procedures—it would probably take way too much training. I think that many EHR projects are ineffective because those leading the charge attempt to rely upon reason for answers, thinking, “If we know one then we know two since one and one are two”.

To make the EHR efforts more effective, I humbly suggest we need to learn much more about what constitutes the “and”.

EHR technology makes it easier to do a lot of things, but some of the things it makes easier ought not to be done. The only reason to have an EHR system is to to solve specific business problems within the organization. Getting EHR to do want you want it to is ninety percent mental–the other fifty percent involves voodoo. If you don’t make mistakes during the process, you’re not working hard enough on the problem—and that’s a big mistake. Need I say more? Any complex system that works almost always comes from a simple system that works. The corollary is also true, if the current paper and manual records system didn’t deliver best practices, how can the more evolved ones be expected yield best practices?  EHR alone won’t make you better, it will just make you automated.

Success is a much more likely outcome when one builds upon success. Most EHRs have enough technology to handle anything that comes up, unless a provider forgets that the EHR is just a tool.  It took human error to create the problems we have with our health records processing.  Why then are we so quick to think that technology will fix them?

Misery not only loves company, it insists on it. That is why having a competent project management office (PMO) plays such a dominant role in the success or failure of the EHR. When the circumstances turn extraordinary, as they are in today’s economy, extraordinary measures are required. Plan, take time to deliberate, and when the time for action has arrived, stop thinking and get after it. The important thing to remember in deciding what action to take is not to search for new data points but to discover new ways to think about the ones you have. The direction of am EHR strategy may have limits, but perhaps it says more about the limits of imagination and common sense instead of the limits of what is possible. And remember this basic rule, when assessing common sense and imagination, always round up.

I’m not always disgruntled about that which I write, but I’m often far from gruntled. As graduate student I aspired to a stable job, I craved factual certainty and the respect of my peers—so I became a consultant. I soon learned that this is like wanting to be a vegetarian so you can work with animals. The only job I was fit for was consulting. This notion rested on my belief that I was not suited to work nine to five, and that consulting wasn’t quite like working. One of the nice things about consulting is that putting forth absurd ideas is not always a handicap. The good news is that consultants, when addressing things outside of their expertise are just as dumb as the next guy. I’ve always believed that being honest with my clients is the best policy—does that mean that if I chose to be dishonest I would be using second best policy? Oscar Wilde said, “If you want to tell people the truth, make them laugh, otherwise they’ll kill you.” That’s my hope with these little musings. Remember, we’re all in this alone.

The preceding was a pilfering of quotations.

saint