Strategy

EHR: Why the rush?

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The following is a comment I wrote to the healthcareitnews.com post, “BLUMENTHAL: EHRS WILL BECOME ‘AN ABSOLUTE REQUISITE’ FOR DOCS”.

“The time has come,” the Walrus said, “To talk of many things: Of shoes and ships and sealing-wax, of cabbages and kings– …

The time has also come to ask the question, “Why the rush?”  Is the pronouncement that within the next ten years we will see widespread adoption of EHR in conflict with the timing of the Meaningful Use incentives?  It seems that way to me.

Whereas we may see an “upward slope in the adoption curve” within the next year or two as hospitals begin the process of selecting and implementing an EHR, we will not see so much as a hiccup in the slope of the Meaningful Use curve.

Why?  I think there are several explanations.

  • Not enough providers are far enough along to even attempt to pass a Meaningful Use audit.
    • Will they complete the requirements
    • If yes, will they pass the audit
    • Of those who have attempted to do the heavy lifting of EHR and CPOE, they do not know the Stage 2 & 3 requirements.  Those requirements may be enough to ensure nobody passes the audit.
    • To those providers just underway, whose board insists that they complete the installation in time to qualify for the incentives—good luck.  Many will make poor selection decisions which they will support with even worse implementations.
    • To those who have yet to start, there is no chance they will meet the target dates.

So what’s next?  What would you do if you were having a party and learned nobody could come that night?  You’d change the date.  Washington will do the same.

What does that mean if you are a provider?  I think it means you have enough time to do it right, even when the conventional wisdom is pushing you to hurry.

Jihad Joe EHR selection

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When competing hypotheses are equal in other respects, the principle recommends selection of the hypothesis that introduces the fewest assumptions and postulates the fewest entities while still sufficiently answering the question. It is in this sense that Occam’s razor is usually understood.  There is no corollary that works with EHR vendors.

What if we look at HIT vendor selection logically?  Have you ever noticed at the grocery store how often you find yourself in the longest checkout line, or when you’re on the highway how often you find yourself in the slowest lane?  Why is that?  Because those are the lines and lanes with the most people, which is why they move the slowest.

If you are asked in which line is Mr. Jones, you would not be able to know for certain, but you would know that the most probable option is the one with the most people in it.  You are not being delusional when you think you are in the slowest lane, you probably are, you and all the people in front of you.  The explanation uses simple logic.  It’s called the anthropic principle– observations of our physical universe must be compatible with the life observed in it.

It can be argued that the business driver which shapes the software selection process of some is the aesthetics of efficiency, a Jihad Joe approach to expediency.  Buy the same system the hospital down the street bought, the one recommended by your golfing buddy, or the one that had the largest booth at the convention.  Or, one can apply the anthropic principle, rely on the reliability of large numbers and simply follow the market leader.

Might work, might not.  My money is on might not.  There’s still plenty of time to do it right.  If that fails, there will always be time to do it wrong later.  Of course, you can always play vendor darts.  If you do, you should sharpen them so they’ll stick better.

What exactly is healthcare 2.0?

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I tend to take a slightly different bent on Healthcare 2.0, a bent which does not intentionally tie to the notion of Internet 2.0, but rather to the notion of an industry desperately needing to reinvent itself.

A few definitions may bring some sense to the discussion. I find it helpful to distinguish the business of healthcare from the healthcare business. I think of the healthcare business as the clinical side, and the business of healthcare as what it takes to make dollars and sense of it all.

Although the healthcare business in the United States is world class in many areas, in many hospitals the business of healthcare is mired in a 0.2 business model. It is often run like a franchised fiefdom of duplicative and ineffective cost and revenue silos—I’m going to duck for a moment in case anyone disagrees strongly with me.

I’m back. This 0.2 business model is being forced into a 2.0 model whether it wants to go there or not. Whether it is capable of making the journey is debatable. The model is regulated, and is about to be reregulated—to what—nobody knows. What national leadership there is is busy waving the magic IT wand thinking that will facilitate the transition from the dark ages and support the business model of National Healthcare—which, by the way, has little if anything to do with the model providers need to run their business.

EHR, if done wrong will be nothing more than a multi-multi-million dollar scanner. Providers will indeed be paperless. However, paper is not the problem. The goal should not be the elimination of paper as though paper is a bad thing. If efficiency equates to speed, to doing something faster, the goal should not be efficiency. It is possible to streamline bad processes and do them faster.

To get to Healthcare 2.0 using my definition, to redefine the business of healthcare, providers must move towards being effective, towards solving business problems, eliminating waste and duplication, retaining doctors and patients, and running it like a real business.

My best – Paul

Why let your EHR vendor run your hospital?

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Healthcare Failures Magazine (HFM)  “It is not everyone who can finish dead last in the CIO of the Year competition.  How do you account for your total lack of accomplishment?”

PR:  “It was not as easy as it may appear.  I think it had to do with believing that my EHR vendor knew more about running a hospital than did we.”

HFM “Why do you say that?”

PR:  “They told me their EHR it had been implemented “As Is” at a number of hospitals and was running fine.  I was convinced that all hospitals are basically the same; admissions, treatment, discharge.  Besides, it saved a lot of money not having to customize it and do all that stuff about workflows.”

HFM “What about the change management?”

PR:  “Yeah, well I guess you could say that part kind’a blew up on me.  It didn’t take long to learn that our hospital didn’t function at all like their software.  According to our doctors, they didn’t think this vendor had ever been in a hospital, let alone run one.”

Who defines your vision?  Who is your chief imaginist, the person responsible for defining the type of hospital you hope to operate five years from now?  Do you want it to be your EHR vendor?  Probably not?  Is it your vendor?  It may well be.  Why? Do you want to outsource your imagination and your future to your vendor?

Without a detailed and comprehensive work flow improvement and change management program the only thing you will implement is your EHR vendor’s vision of how a hospital should function.  You’ll be just like each of their other clients.  Is that what your business model calls for, is it satisfactory?

How hospitals should deploy EHR to attract Docs

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This is a response I wrote to Brian Ahier’s post on HealthsystemCIO.com

Here’s an idea I raised a few months ago which discusses how to use EHR to your advantage in retaining ambulatory physicians. What prompted the idea was knowing of a hospital which spent nine figures on their EHR, only to find out that its functionality essentially ended inside its four walls. At the time nobody wrote that it wouldn’t pass muster. This idea may die before anyone finishes reading the comment; if not perhaps it merits at least a look-see.

From the perspective of the business model of the hospital, what do we know?

• Hospitals work at attracting and retaining good physicians
• In many markets, ambulatory physicians may choose to send their patients to any one of a number of hospitals
• The competition to attract patients and physicians is building
• The hospital and physicians both benefit if they are:

o On the same EHR
o On an EHR which interfaces easily

What if we change the question being asked, or at least change what constitutes a desirable answer from the perspective of the hospital? Let us go back to what we know.

• Non-hospital based doctors will not be part of the calculation to determine if the hospital meets Meaningful Use.
• Each of those doctors benefit from implementing and EHR system, and they will either qualify for stimulus money or be fined.
• Those same doctors and their patients benefit from having a seamless relationship with a hospital.
• None of those doctors has anything close to what can be considered an actual IT department.

o If 400 providers who practice at your hospital have to select an EHR, how many dozens of different EHRs will they select
o Not only do the providers lack the skills to select a good system, they lack the skills to implement it successfully.
o Most IPAs are not even offering a recommendation

What happens if we rephrase the question and ask, “What steps can a hospital take to:”

• Make ambulatory doctors want to send their patients to them
• Make it easy for the patient/physician/hospital relationship to appear seamless
• Possibly be paid for facilitating the EHR for their ambulatory physicians

If it were my hospital, here’s what I would do:

• Pull together a plan to figure out how a hospital could offer an EHR solution for each of the ambulatory doctors. This EHR solution could:

o Be the same EHR or one which can integrate with their EHR
o Be offered as a managed services solution
o Be offered as an outsourced solution

• Figure out what information is needed to determine the viability of offering its ambulatory doctors an EHR solution:

o Staffing
o Marketing
o Incentives
o Cost
o Roll-out
o Training

• Determine if the ambulatory doctors can somehow sign-over their incentive payments to the hospital.

o If yes, the incentive payment from 400 ambulatory doctors could fund about $18 million of the roll-out cost
o If not, there are still a number of great business reasons to think about helping the doctors get on the hospital’s EHR.

What is the long-term ROI, say five years and beyond, of having an ambulatory doctor send its patients to a given hospital? I bet it exceeds the cost of installing an ambulatory EHR.

What are the risks of HIT and EHR?

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It is refreshing to know that the voices I am hearing need not be my own.  When I try to summarize the issues for my own edification, I always circle back to the same few issues.

• No single person is both responsible and in authority regarding HIT and EHR. Provider-world pauses with each new pronouncement from Washington as though the missing EHR Dead Sea Scrolls had just been discovered in the reflecting pool.
• Those who implemented EHR did so without any idea that rules would be imposed after the fact.
• EHR is expected to serve two business models:

o Washington’s N x M patient/doctor connectivity effort
o A provider’s unique business objectives, none of which have anything to do with a patient in Atlanta being able to connect to a doctor in Anchorage.
• What model would providers be following if there were no Meaningful Use
• If the current EHR national rollout model was any good, providers would be racing to the front of the line to implement EHR instead of having to be offered rebates.
• The national rollout plan lacks viability for several reasons:

o No standards
o HIEs are each being developed in their own vacuum
o A horde of vendors whose mission does not tie to the national rollout or the providers’ business model and who have no incentive to adopt standards
o The requirements and dates for Meaningful Use will probably change once providers have tailored their systems to meet Stage 1
o The requirements for Stages 2 & 3, which may cost providers six zeroes preceded by some number greater than five, don’t exist.
o An ROI can’t be calculated on meeting Meaningful Use
o Both the likelihood and the impact of healthcare reform on HIT and EHR, just got vaguer by some order of magnitude.

I firmly believe the right EHR and CPOE will be great for hospitals. Providers will be better served by finding answers to the question, “What’s in it for me,” rather than, “What do they want me to do?” Unless of course, providers want them running their business.

What are the success factors for EHR?

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I just arrived in-country—I was in Wisconsin for two weeks.  I’ve been to forty-seven states, and Wisconsin has to be one of the friendliest.

Anyway, let us begin.  Not long after graduating with an MBA from Vanderbilt, I returned to Vandy to interview job candidates.  With me, was my adult supervisor, the VP of human resources—a stunning older woman; about thirty-five.  At dinner, she invited me to select the wine.  Not wanting to appear the fool, and trying to control my fawning, I pretended to study carefully the wine list.  Not having a clue, I based my selection entirely on price.  I had little or no knowledge of the subject; nonetheless, I placed the order with all the cock-sureness of a third-grader reciting the alphabet.

A few moments later Wine-man returned with a bottle, angled it towards me, and stood as rigid as a lawn statue.  After a few seconds my adult paused and motioned my attention towards Wine-man.  I remained nonplussed.  “You are supposed to tell him that the bottle he is holding is the one you ordered.”

“He knows it is what I ordered, that is why he brought it.”  I thought they were toying with me.

A few seconds later there was a slight popping sound and then Wine-man placed the cork before me on my napkin in a manner similar to how Faberge must have delivered his fabled egg to Tsar Alexander III for his wife Empress Fedorovna.  They were both staring at me, not the Tsar and the Empress—Wine-man and my adult.  “You are supposed to smell the cork.”  And so I did.

“Now what?”

“If it smells bad, it means the wine may be bad.”

To which I replied, “This is the Opryland Hotel—have you seen the wine prices?  They don’t sell bad wine.”  She nudged me with her elbow.  I could tell I was wowing her.  I smelled the cork.  “It smells like a cork,” I whispered to Wine-man.  He smiled and poured a half inch of wine in my glass.  I thought he was still pulling my lariat.

I looked bemusedly at the mostly empty glass, held it out to him, and asked him if I could have some more—I was thirsty.  Rather than embarrass me further, with a slight nod of her head my adult instructed the Wine-man that my sommelier class was over—any further proof of my inadequacies would be of limited marginal value.  Any chance that we would have gone dancing later that evening was about as flat as the wine.  I should have ordered a beer.  I was good at beer.

For those who are still reading, if you are wondering if I am actually going to make a point, here it comes.  I’m not fond of segues, so don’t blink.

Sometimes, a little guidance is helpful—even if it has to come in the form of being led around like camel with a ring through its nose.  One of my on-line friends, a nurse who teaches nursing—seems like a good fit–asked me what are the success factors for EHR.

Often, what is important in a leader is having the knowledge and temerity to ask the right question.  In healthcare it appears that the number of executives with answers may exceed the number asking questions.  Value is often measured by scarcity.   Good questions, especially around EHR and Meaningful Use, seem to be in short supply.

Here’s my take on some of the critical success factors:

  • Adult supervision—this is not defined by the age on your driver’s license
  • Invest time to plan your EHR plan; 6-9 months for a fair sized hospital
  • Actual written requirements (an RFP) that comes from your business strategy
  • A written healthcare information technology plan
  • Invest more than half of your time and effort in work flow alignment, change management, and training.
  • Should your plan seek to meet Meaningful Use
    • By when
    • How
    • What drives your strategy—Washington or your business model

Pretty simple things.  The right things usually are—like knowing what to do with the wine cork.

What is the value of perfection?

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Here’s another great post by another great person I met online, Maryanne Colter, of MMColter Ltd.   She’s on Twitter @mmcolter.  What I love about this post is her emphasis on hitting a target worth hitting.  Aim for the moon on quality or defects and you may hit it.  Perfect ought not be a stretch goal, as a target it should be de rigeur.  Thanks Maryanne–the rest is hers.

Treating people like shoes…

On January 19th Senator Grassley issued an open letter to medical software vendors and hospitals, chastising them for slamming in EMR software, giving higher regard to being on time and on budget than making sure the software was performing flawlessly.  After all, we are dealing with people’s lives. I got the impression from the Senator’s letter that the passive “mistakes were made” is not going to be an acceptable answer; 100% accuracy should be the only acceptable answer.

And yet it happens. A few weeks ago I spoke to a charge nurse at an Academic Medical Center  (one that was cited in a 2006 study as being exemplary in high quality care) who told me they had around 100 fixes to their system in the first few weeks after go-live.  He also recounted an incident where they lost an entire day of a patient’s nursing documentation somewhere in the transfer between the PACU and the patient’s room.

Strange as this may sound, the solution may be to treat people like shoes.   I once consulted at a company that’s known for its shoes.  Not a tiny company, but one where probably half the world owns a pair of their shoes.  A team of highly trained employees and consultants streamlined processes and put in the technology that increased the overall efficiency of the supply chain by 34%.

Imagine if we had done a shoddy job with their data and said 98% accuracy was ‘good enough’?   We would have transferred data from design to manufacturing, but maybe the shoelaces were a little short, but that hit the 98% mark and would have been ‘good enough’.  When we started manufacturing the shoes, who would have cared if the sole were a little cockeyed?  It still would have been within our 98% mark.  Two percent of the customer orders for the faulty shoes would have contained 2% wrong products or the wrong sizes. Two percent of all orders would have been shipped to the wrong stores. Invoices that were 98% accurate would have been ‘good enough’.  And all of those mistakes would have been done 34% faster.

How about if we treat the delivery of medicine with the same regard as a carton of shoes? We supplied shoes to a major retailer who demanded 100% accuracy of carton labels.  If any one of the hundreds of characters on the carton label were misplaced, the carton would be automatically rerouted, photographed, and emailed back to the supplier with the message of “get this 100% accurate, or else…”.  Think of all the places in medicine where a “get it 100% accurate, or else” rejection message might save a life.

There is no single analogous situation from business to medicine and there are certainly enormous differences, not the least of which is we are dealing with biological systems and the things that can go wrong increase by a thousand-fold.  But instead of looking at what works and adapting it to healthcare, most of healthcare patently rejects ‘outsiders’ with ‘outside ideas’ and throws the baby out with the bathwater.

Whenever using analogies it is imperative to do a thorough analysis of the differences, but the answer to the question “what is different?” is not “everything”! Data is either accurate or not.  Software testing results are either thorough or not. The only answer to the question, “Did you get enough training to flawlessly perform you job?” should be yes, or else more training is needed. Period. These are not unique notions. The healthcare industry has the worst case of ‘not invented here’ refusal to adapt quality improvement measures from ‘outside sources’ since JIT had to be renamed Lean because the US could not get over its WWII bigotry of anything remotely Japanese.

“Outsiders” are not viewed as people who would take accuracy even more seriously when dealing with human beings. Instead, we are viewed with the assumption that because we have only dealt with shoes and cardboard boxes that our concern for accuracy and quality must somehow be cavalier.

The healthcare industry needs perfectionists and they can come from anywhere.  It needs people who when they hear “perfect is the enemy of the good” answer with “tell that to the patient whose medicine is one decimal point away from killing them.” Sometimes, perfect is the only option.

I have a dear friend who has a brain tumor.  Thankfully it is benign, but eventually he will need radiation or surgery.   When that day comes, one of the most brilliant, wise, and compassionate minds in the world will be one decimal point away from destruction or cure.  He is the only reason I keep pounding my head against the wall of “ideas from outsiders are not good enough here.”

One of my heroes once said about accidents, “I am of the opinion that zero is the right number…You cannot plan to kill three people a year because you killed four people last year and you want to get a little better…So the goal is zero…Zero injuries. Zero reportable incidents.”  That man was Paul O’Neill when he was the CEO of Alcoa.  Heaven forbid we should learn a lesson from people who make pop cans.

My 1st post on HealthsystemCIO.com

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The following is my first guest post on Anthony Guerra’s new site, HealthsystemCIO.com.

If you haven’t begun the process of selecting and implementing an EHR, Meaningful Use may not be something with which to concern yourself. The reason, you probably will not be done in time to collect the incentive money. How can I state that with such assurance? One of my clients has already implemented EHR and CPOE—already done the heavy lifting—and they will have to divert most of their resources just to meet the Stage 1 requirements.

If you haven’t begun, there may be no rush to acquire a vendor, although the vendors will not tell you that. Rushing may lead to a bad selection. Don’t cost yourself tens of millions get to have a chance at a few. By the way, did any of the vendors with whom you are speaking mention that they have no clue if their system will meet any of the Stage 2 and 3 requirements? Right now, it’s like the vendors are selling cars without knowing whether it will need to run on gas or Hydrogen.

I think the Meaningful Use dates will be pushed back. Why? Because few if any of the providers will be in a position to apply for the incentive money. Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.

Now for those whose EHR implementation is well underway or up and running — should you try for the incentive money? That’s a valid question. Just because someone is offering you a check doesn’t mean you have to take the money. Here are some questions you ought to be able to answer prior to deciding if Meaningful Use is meaningful to you.

  • Meeting MU requires a shift in your direction; you take on the MU tasks and sacrifice some of what you were going to do
  • What are those tasks, what resources will they consume
  • What year is the best year for you to meet MU; 2011-2015?
  • Did you know you can still maximize incentive dollars if you pass MU in 2013?
    • That gives you very little time to react to Stage 2 & 3 requirements

Meaningful Use is a binary contest — you make it or you don’t. The decision to meet Meaningful Use does not have to be binary. There is no way to collect for meeting 90 percent of the requirements. How might you financially calculate the probability of obtaining the incentives? Let’s begin with Stage 1—the easy one.

  • Calculate the maximum incentive you could receive
  • Multiply that figure by the degree of certainty you have that your plan will be completed on time — a number less than 1
  • Then multiply it by the probability you think exists for passing the audit, another number less than 1
  • Calculate your cost to complete Stage 1, then figure out your ROI — not much is it?I’ve seen one provider whose ROI is negative.
  • This makes evaluating Stage 2 & 3 calculations seem rather superficial. Want my advice for calculating an ROI out of requirements that don’t exist? I’d use a placeholder of six zeros preceded by a number greater than five for each Stage.

So take time to evaluate your options. The only people who will look foolish are those who don’t know what questions to ask.

What’s the probability around Meaningful Use?

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Below is a reply I wrote to a post on MU in Healthcare IT News
What’s the probability, that you complete the Stage 1 Meaningful Use requirements?  What’s the probability, after doing your best to meet the Stage 1 requirements that you actually pass the audit?  What’s the probability you’ll have the time needed to implement Stage 2 and 3 before the penalties begin? (That’s sort of like asking if you know the probability of seeing a bluebird on the third Tuesday of June.)
Now, go ahead and calculate an ROI based on everything you don’t know.  Not too easy is it?