Strategy

Why I differ with Mr. Halamka’s EHR strategy

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Below is a comment I wrote September 30, 2009 to Government Health IT in response to an article written about a conversation the author had with John Halamka titled, “Halamka: How to build a long distance service for healthcare.” http://govhealthit.com/newsitem.aspx?nid=72152 Most people whose comments I’ve read regarding Mr. Halamka’s vision for how the national EHR roll out might work tend to be quite supportive.  I don’t think my comments fall into the supportive category.  That may account for why they have yet to appear in print.  So, in the spirit of full disclosure, here’s what I offered.

I wrote several weeks ago that we ought to look at the telecoms networks, ATMs, OnStar, or some existing platform. My argument for redoing the national roll out strategy along those lines is that it may provide a way to eliminate the middleman, the RHIOs and HIEs, whose only real role seems to be like a train station in the middle of going from NY to LA. If nobody ever gets on or off, why have it.

The critical success factor of the telecommunications networks is called an interconnect, it’s what gets the call from A to B and provides redundant carriage. It’s also what eliminates the need for a middleman.

The AP wrote today that the current EHR national roll out plan will not work http://ow.ly/rPOH. With all respect to those working so hard on the current roll out plan, I think we need a serious rethink about what type of plan is required for the EHR roll out to work instead of pushing water uphill trying to make the current plan work. Here’s some thoughts I had about how it might be approached.

https://healthcareitstrategy.com/2009/09/27/how-can-ehr-be-made-to-work/

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How can EHR be made to work?

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I’ve never been mistaken as one who is subtle.  Gray is not in my patois.  I am guilty of seeing things as right and left and right and wrong.  Sometimes I stand alone, sometimes with others, but rarely am I undecided, indecisive, or caught straddling the fence.  When I think about the expression, ‘lead, follow, or get out of the way,’ I see three choices, two of which aren’t worth getting me out of bed.

I do it not of arrogance but to stimulate me, to make a point, to force a dialog, or to cause action.  Some prefer dialectic reasoning to try to resolve contradictions, that’s a subtlety I don’t have.  Like the time I left the vacuum in the middle of the living room for two weeks hoping my roommates would get the hint.  That was subtle and a failure.  I hired a housekeeper and billed them for it.

Take healthcare information technology, HIT.  One way or another I have become the polemic poster child of dissent, HIT’s eristical heretic.  I’ve been consulting for quite a while—twenty-five plus years worth of while.  Sometimes I see something that is so different from everything else I’ve seen that it causes me to pause and have a think.  Most times, the ball rattles around in my head like it’s auditioning for River Dance, and when it settles down, the concept which had led to my confusion begins to make sense to me.

This is not most times.  No matter how hard I try, I am not able to convince myself that the national EHR rollout strategy has even the slightest chance of working as designed.  Don’t tell me you haven’t had the same concern—many of you have shared similar thoughts with me.  The question is, what are we going to do about it?

Here’s my take on the matter, no subtlety whatsoever.  Are you familiar with the children’s game Mousetrap?  It’s an overly designed machined designed to perform a simple task.

Were it simply a question of how to view the current national EHR roll out strategy I would label it a Rube Goldberg strategy.  Rube’s the fellow noted for devising complex machines to perform simple tasks.  No matter how I diagram it, the present EHR approach comes out looking like multiple implementations of the same Rube Goldberg strategy.  It is over designed, overly complex.  For it to work the design requires that the national EHR system must complete as many steps as possible, through untold possible permutations, without a single failure.

Have you ever been a part of a successful launch of a national IT system that:

  • required a hundred thousand or so implementations of a parochial system
  • has been designed by 400 vendors
  • has 400 applications based on their own standards
  • has to transport different versions of health records in and out of hundreds of different regional health information networks
  • has to be interoperable
  • may result in someone’s death if it fails

Me either.

Worse yet, for there to be much of a return on investment from the reform effort, the national EHR roll out must work.  If the planning behind the national ERH strategy is indicative of the planning that has gone into reform, we should all have a long think.

I hate when people throw stones without proposing any ideas.  I offer the following—untested and unproven.  Ideas.  Ideas which either are or aren’t worthy of a further look.  I think they may be; you may prove me wrong.

For EHR to interoperate nationally, some things have to be decided.  Somebody has to be the decider.  This feel good, let the market sort this out approach is not working.  As you read these ideas, please focus on the whether the concept could be made to work, and whether doing so would increase the likelihood of a successful national EHR roll out.

  • Government redirects REC funds plus whatever else is needed to quickly mandate, force, cajole, a national set of EHR standards
    • EHR vendors who account for 90%–pick a number of you don’t like mine—use federal funds to adapt their software to the new standard
    • What happens to the other vendors—I have no idea.  Might they go out of business?  Yup.
    • EHR vendors modify their installed base to the standard
  • Some organization or multiple organizations—how many is a tactic so let’s not get caught up in who, how many, or what platform (let’s focus on whether the idea can be tweaked to make sense)—will create, staff, train its employees to roll out an EHR shrink-wrapped SaaS solution for thousands and thousands of small and solo practice
    • What package—needs to be determined
    • What cost—needs to be determined
    • How will specialists and outliers be handled—let’s figure it out
  • Study existing national networks—do not limit to the US—which permit the secure transfer of records up and down a network.  This could include businesses like airline reservations, telecommunications, OnStar, ATM/finance, Amazon, Gmail—feel free to add to the list.  It does no good to reply with why any given network won’t work.  Anyone can come up with reasons why this won’t work or why it will be difficult or costly to build or deploy.  I want to hear from people who are willing to think about how to do it.  The objective of the exercise is to see if something can be cobbled together from an existing network.  Can a national EHR system steal a group of ideas that will allow the secure transport of health records and thereby eliminate all the non-value-added middle steps (HIEs and RHIOs)?  Can a national EHR system piggyback carriage over an existing network?

We have reached the point of lead, follow, or get out of the way, and two of these are no good.

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Is it time to rethink your approach?

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goatSo I’m making dinner the other night and I’m reminded of a story I heard a while back on NPR. The narrator and his wife were telling stories about their 50 year marriage, some of the funny memories they shared which helped keep them together. One of the stories the husband related was about his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf. She’d mix the ingredients in a large wooden bowl; 1 pound each of ground beef and ground pork, breadcrumbs, two eggs, some milk, salt, pepper, oregano, and a small can of tomato paste. She’d knead the mixture together, shape into loaves, and place the loaves into the two one-and-a-half pound pan, discarding the leftover mixture. She would then pour a mixture of tomato paste and water, along with diced carrots and onions on top of the two loaf, and then garnish it with strips of bacon.

He went on to say that meatloaf night at home was one of his favorite dinners. His wife always prepared the dish exactly as she had learned from her mother. One day he asked her why she threw away the extra instead of cooking it all. She replied that she was simply following her mother’s recipe.  The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”

Therein lays the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing. Several of you have inquired as to how to incorporate some of the EHR strategy ideas in your organization, how to get out of the trap of continuing to do something the same way it’s been done, simply because that’s the way things are done. It’s difficult to be the iconoclast, someone who attacks the cherished beliefs of the organization. It is especially difficult without a methodology and an approach. Without a decent methodology, and some experience to shake things up, we’re no better off than a kitchen table amateur (KTA). A KTA, no matter how well-intentioned, won’t be able to affect change. The end results would be no better than sacrificing three goats and a chicken.

So, we’ll talk about how to define the problem, how to find a champion, and how to put together a plan to enable you to move the focus to developing a proper strategy, one that will be flexible enough to adapt to the changing requirements. But keep the goats and the chicken handy just in case this doesn’t work.

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How do I know if we’re in trouble?

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FunnyCheckDoes anyone remember how many of each type of animal God told Moses to put on the ark? Are you sure? For those who missed it, Noah built the Ark, Charlton Heston built the stone tablets.

One word can make the difference between right and wrong, especially if the question is big enough. Who is asking the questions that are shaping your firm’s EHR strategy? Are they asking the right ones?  What are the right questions?  If your the person responsible for the money that will be spent on EHR, any of these deserve an answer;

  • If the ARRA money went away tomorrow, would we still be doing EHR?
  • May I see a copy of our EHR plan?
  • Who vetted the plan?
  • If so, would we still be doing it the same way?
  • Would we still have selected this vendor?
  • Did we issue an RFP?
  • How did we choose who received the RFP?
  • What criteria did we use to select the vendor?
  • Who in our shop had any experience writing an RFP of this nature?
  • Who has ever evaluated an RFP like this?
  • What commitments do we have from the vendor about meaningful use?
  • What commitments do we have from the vendor if meaningful use changes?

These are very basic questions, but I bet if you ask them of your team, you will not be pleased with several of the answers.  If they can answer all of them to your satisfaction, they may proceed to step two.  If not, send them back for another try.draft_lens5971462module46826602photo_1247932409Creative_Loafing_-_Hanging_out_-_GBowen

EHR Strategy, a call to action

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EHR Strategy, What I Do & How I Can Improve Your Efforts

Several people have told me that I need to come right out and state the role I play in the Electronic Healthcare Records (EHR) space, and how my consulting firm will add value to your efforts.  Spell out your services, and state a call to action.  This writing will address that topic, and will be the only time I use your time to try to sell you on me.  If you’ll bear with me for a few minutes, I will explain why I write with such self-assurance that most organizations (Hospitals, clinics, IPAs, and providers) have the wrong EHR Strategy—or no recognizable strategy—and my equally self-assured belief that working together we will mitigate that problem.

Here are the facts around EHR:

  • Most large EHR projects have a high probability of failing—the larger the project, the higher the probability
  • Large EHRs may cost more than a new hospital wing—a number of people know of one truly outstanding hospital who spent more than $300,000,000 on their EHR
  • Hospitals are much more knowledgeable about the requirements of a hospital wing and what it will do for them than they are about their EHR strategy
  • All healthcare providers who have entered the EHR space have done so trying to hit the trifecta of moving Gossamer targets;
    • Certification
    • Meaningful use
    • Interoperability
    • Hundreds of vendors who have their own agenda at heart
    • So many individual, disparate, committees are working on standards…do we need to even go there?  Doesn’t each committee create its own standards—if so, where is the standardization?
    • If one removes DC from the loop, many providers can’t articulate the business problem they want the EHR to solve, nor can they articulate an ROI
    • Providers have budgets without requirements, budgets without any knowledge of what an EHR system should cost
    • An EHR should have a greater impact on patients, providers, and payors than any other single program, yet who is in charge?  What skill set to they have to do this?
    • Most providers do not have a plan, a qualified planner, a decider.  Who is reviewing and approving the plan?  What makes them credible?

Those are the reasons we are here.  Our job is to reposition those facts such that they improve your chances of being successful with your EHR selection and implementation.

You know what?  It’s not about the EHR.  It never should be.  The EHR system only accounts for about 20% of the projects success or failure.  It’s code.  The other 80% comes down to planning, conversion, change management, training, user acceptance (patient, doctors, nurses, and administrators), and workflow improvement.

You know what?  It’s about breaking down kingdoms between intra-hospital departments.

It’s about knowing that you can walk into the EHR war room and know that somebody is the decider.  That somebody is able to say, “This is what we are going to do first, second, and third, because that’s the only way we can improve your chances of having a successful EHR program.

That’s what we do.  Most people, given the opportunity, will fail 100% of the time performing open-heart surgery.  A mere handful will avert failing.  Most people will fail 100% of the time who are leading an EHR program will fail.  A mere handful will not.

We are the ERHPMO (Program Management Office).  We are your advocate in managing the EHR vendor to benefit you.  Needless to say, most vendors do not like having us on board.  We are vendor neutral, provider advocates.

We are the anti-Accenture business model.  We do not back up the bus and drop off the children.  We will not try to put 30 people on your project.  You do that—clinicians, and IT.  We pull up in a Prius, drop off a few grownups who’ve been there, done that, got the T-shirt.

We work hand in hand with Hospitals, IPAs, clinical providers, and doctors to help you successfully address some or all of the following;

  • understand the EHR landscape
  • create your EHR strategy, in-house versus SaaS
  • eliminate wasteful redundant costs via shared services analyses
  • define your requirements
  • issue an RFP
  • evaluate vendors
  • negotiate contracts with the vendors
  • plan and execute the change management
  • rationalize your EHR with other which may exist within your walls
  • define and rebuild workflows
  • develop and execute a training program for user acceptance

This is not the time to experiment, or hope you get it right.  To minimize the probability of failure, this is the time to bring in the adults.

That’s what we do.  Sorry for the sales pitch.  Please let me know how we can help.

paulroemer@healthcareitstrategy.com

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Cast, Blast, and Gin Rummy

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duckSeveral years ago I was invited to go on the ultimate boys’ toys, weekend getaway. A dozen of us flew from Denver to Utah, and then drove to a point somewhere west of Bozeman Montana. It was to be a weekend of sport, a weekend of competition, and a more than occasional libation. To say that the people who organized the trip came from money would be a major understatement. They were in the oil bid’ ness. The father of one of the guys was the CEO of the second or third largest petroleum company in North America. We stayed at his ranch, a 12 bedroom log cabin in the middle of Nowhere, Montana, which is about 20 miles west of Next to Nowhere, Montana.

The weekend’s activities included fly fishing, duck hunting, and Gin Rummy. Each participant was given a handicap rating in each event. The idea behind the rating was that if you are weak in one event, you were paired with an individual who is skilled in that event. In theory, that would level the playing field among the teams. Since I have never fly-fished or hunted I was odd man out. But I was game, and it’s amazing how good one can become at something when one has to fight their way through it.

Let the games begin. We started the competition with a full day of fly-fishing. Our destination was the Madison River, an impressive, fast running, expanse of snow melt. The stretch we would finish was about 150 feet wide, and its average depth was somewhere between waist and chest high. As I would soon learn the bottom was covered with what appeared to be the equivalent of moss covered bowling balls. I was instructed by one of the more experienced fishermen to tie a nymph to the end of the tippet. For those of you who are as novice to the sport as I was, a nymph is an artificial lure which mimics an insect larva. It is designed to lure fish who feed along the bottom, not the nubile young woman referenced in Greek mythology.

We fished for several hours. My legs ached from trying to maintain my balance in the strong current. I was about ready to admit defeat when the tip of my rod bent sharply into the water. Standing perpendicular to the current, I could see as the brightly speckled back of a large rainbow trout turned upstream. Naturally, I turned upstream with it and began to try to reel him in. First mistake. It was at that point that I first realized that the height of the water was now about level with my chest waders. Second mistake. The guys on the other part of the river and along the bank were yelling at me. I thought it was words of encouragement. Final mistake. As it turns out, they were trying to convince me not to turn upstream. At the exact moment that I faced stream head on, was the exact moment my feet lost purchase with those moss covered bowling balls of which I wrote. Turning yet again to my physics, I quickly recalled the equation; force equals mass times acceleration. Instantaneously, I was swept downstream, still clutching my fly rod in my right hand.

Wayne Newton’s first law of fluid mechanics took over; waders, no matter how good they are, if positioned in a plane that is horizontal to the river will fill rapidly with water, just as mine did. The choice with which I was faced was do I save myself and lose the fish, or do I try and land the fish? One of the shortcomings of maleness—I was going to use maledom until I Googled it—is that we rarely have actual choices, especially when we are around other males or for that matter, females. Naturally, I opted to land the fish. My reel had become dislocated from my rod. I remember grabbing the reel and stuffing it down my waders, and as I tried to float my body as though it was a raft without a rudder towards the river’s nearest bank, I began to reel in the monofilament with a hand over hand motion. After several minutes I was standing dripping wet and proudly displaying a 19 inch rainbow trout.

We cooked the fish and played Rummy until about three in the morning, awoke at four, grabbed our shotguns and headed out into the darkness without so much as a cup of coffee. Round three of the competition was to be duck hunting. To this day I’m still unclear as to why we had to hunt ducks while it was still dark. Weren’t there any ducks who needed shooting at brunch time, I inquired? Twelve guys, who collectively smelled like a distillery, and who are operating on an hour of sleep, armed with loaded shotguns, trod through a willow thicket as dawn approached. As I neared the river bank, a startled duck shot skyward. I raised my over and under twelve-gauge shotgun, sort of took aim, and fired a volley. The duck seemed to pause in midair, and then fell like a rock into the racing water. I watched helplessly as my quarry floated away from me. I looked downstream and was pleased to see two men fishing from a rowboat. The duck floated right towards them. A man reached down, retrieved my duck, and dropped it in his boat. He then waved to me. Thinking he was being friendly I returned his wave. He then rowed away with my duck.

It was a great three days. Part of what made the weekend fun with not having to excel at each event. It helped knowing that in areas where my skills weren’t as good, I could count on the skills of others and vice versa. The idea behind this approach was to build competitive and level teams. That approach works well in mano y mano events like those I described. It works much less well in EHR, HIT and healthcare reform in general.  I’m trying to recall if I wrote previsouly about a meeting I attended with a former hospital CEO.  His take on EHR was the total inability of his peers to have any precience regarding their approach to EHR.  According to him, very intelligent people were making very unintelligent decisions, committing their entire institution to strategies made with almost no data.  Some people can give a better explanation for why they bought their car than they can for why they selected their EHR.   That’s the wrong way to handicap this event.

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