How does Heisenberg’s Uncertainty Principle affect EHR?

One of the great things about social media is its ability to infer attributes of both the readers and the writer.  When you finally meet your virtual pen pal the mind wanders—I thought he sounded taller.

There are those among us who when they picture me writing, see me sitting at my desk, wearing my baby seal-skin slippers, and supping on a bowl of loggerhead turtle soup.

Segue.

According to Heisenberg’s Uncertainty Principle (used in physics) certain pairs of physical properties cannot both be determined simultaneously.  That is, the more precisely one property is known, the less precisely the other can be measured. For instance, the next time you are standing by the side of the road, and cars are whizzing by you, try to decipher the speed of the car, and its exact location.  If I remember my math correctly, the first derivative is its velocity, the second, its acceleration.  To know exactly where the car is at a precise moment in time, the car must be stationary—as in not moving.  Thus, to ascertain its position, the position must be fixed.  The Heisenberg Uncertainty Principle requires that for someone to determine B, A must cease to be a variable.

The Uncertainty Principle can be represented as something like this:

One can see that as additional properties are tossed into the mix the probability of predicting any particular outcome goes to zero.

Thus follows Roemer’s EHR Uncertainty Principle—if you don’t know where you are going, you arrived a long time ago (A little like Pink Floyd’s, “How can you have any pudding if you don’t eat your meat?”).

The conflicting principles include;

·         Implementation date

·         Completion date

·         Final cost

·         Your functional requirements

·         The vendor’s capabilities

·         Acceptance testing

·         What should the EHR do

·         How do you know when you are done

·         Should you meet Meaningful Use

·         Will you receive the ARRA money

Here is the point of the allegory.  The chances of a physician group or hospital knowing the answer to all but one of the above principles are zero.

Permit me to throw a wrench into the loggerhead soup and let you know that not having the answers to all but one of the variables is okay.  That is the way projects work.

Since most of you implementing EHR have not ‘been-there, done-that’ with respect to implementing EHR, it is reasonable to expect there are more unknowns than knowns (spell-check indicates that it is not a word, but I know you are keeping up with me).

So, how can you use Heisenberg’s Uncertainty Principle to your advantage?  It is actually rather simple.  Do not allow your implementation to be guided by the unknowns.

·         Do not set an arbitrary budget for something you have never purchased

·         Do not set an arbitrary implementation deadline

Do what you must to make sure you implement an ERH that does what you need it to do.  Do not let yourself be constrained by principles whose only possible effect will be to derail your project.

If you are willing to take that risk, the other principles become moot (the correct terms is moot, not mute—look it up—sorry about the preposition).

If all else fails, consider getting a pair of the seal-skin slippers.

Paul M. Roemer

Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335

+1 (484) 885-6942

paulroemer@healthcareitstrategy.com

My profiles: 

My blog: Healthcare IT Strategy How to Revive a Failed EHR Implementation

Finally, an EMR worthy of a T-shirt

Those who are regular readers know I’ve commented on more than one occasion that you never see anyone at the HIMSS convention walking around wearing a T-shirt imprinted with the slogan, “I love my EPIC”, or one stating, “McKesson forever”–unless they were talking about the implementation plan.

Today, my perspective changed–I’m going to start selling T-shirts printed with the phrase, “SRS-Soft Rocks my Docs.”

You may ask, ‘Who is SRSSoft’?  Fair question.  I could not have given an adequate response to that question prior to today.

I spent some time with them, ran their demo–I played doctor but they stopped me before I was able to insert a chest tube.  I ran the demo.  Why is that important?  It went like this.

“So, if you were a doctor, what would you do?”

With enthusiastic anticipation, I searched for my scalpel–that wasn’t what he meant.  “I’d see who my next patient is.”

“Do it.”  (Mind you, all of what I am doing happens on one screen faster than a sneeze.)  I clicked the schedule and up popped all the patient’s information.

“Next?”

“I’d probably want to review their chart.”

“Do it.”  (Don’t try this at home unless you are a devotee of Scrubs or other medical training.

Same screen, up pops the chart.

“Next?”

I click on the notes from their last visit, compare their labs by pulling up a comparison chart–new versus old; scan the X-RAY, and review their list of medications.  I did this all on one page and figured out in less time than it took you to read this.  We did the demo using two screens.  That way, if I am describing what I am seeing to the patient on their X-RAY, instead of holding the film up at the ceiling and hoping my patient understand what I am talking about, I point to it with my mouse and let the patient see it one their screen.

Tomorrow I was going to issue an EHR RFP for a small clinic.  Not any more.  No point in having them pay me to hunt down a solution when I’ve already found one.  Did I mention you can also get it with a world-class practice management system?

So what makes me think this EMR can handle a practice size of up to a few hundred doctors?  Let me try to summarize its benefits with the following.  If we separate healthcare into two arenas–the business of healthcare (the business side) and the healthcare business (the clinical side)–this EMR is so well designed, it makes the mundane business tasks almost invisible to the doctor.  Instead of spending twenty percent of each day moving charts, filling out forms, sending faxes, dictating and transcribing notes, the clinical team can either spend more time with their patients or see more patients.

Now, let me tell you about their secret sauce, part of what makes it so special.  You are going to think I’ve lost my mind when you read this.

One of the first questions most doctors are going to ask a vendor is whether or not the system is certified.  (Do not repeat this to anyone–that is why I am writing in parentheses–this system is not certified.  They have no plans to get it certified.)  Why?  Because certification is as relevant to the value of an EMR as agriculture is to bull fighting.  Certification will not improve care, will not enhance the doctor patient relationship, it will not improve the patient experience, it will not increase productivity.  Certification does one thing.  It enables you to get a check provided that your EMR implementation does not fail, provided that you pass the Meaningful Use audit, and provided you are willing to upgrade your existing system to your vendor’s new and improved certifiable version.  That certifiably makes little to no business sense.

Anyway, if you want a system that makes the stuff you hate doing go away, take a look at this.

I’ve also written about way hospital EHRs fail.  A big reason for their failure is the drop in productivity they experience, and a lack of acceptance from the doctors.  Sort of makes me wonder if they could use this tool as a front-end for those big pricey EHRs.

Me, I printing T-shirts.  PayPal accepted.

How can you solve the EHR puzzle?

Seth Godin wrote about the “Perfect Problem.”

A perfect problem, in its existing state, is unsolvable.  The way most of us handle it is to click our heels together three times and hope it goes away.  We tend to work on imperfect problems, those that can be solved.

What is the difference between the two?  The first step is the ability to understand what makes the perfect problem uniquely unfixable.  Perhaps a few examples would help.

  • The CEO imposed a deadline for the implementation of EHR.
  • CMS Meaningful Use rules do not fit with our operational strategy.
  • If we do not implement EHR by this date, we do not get the money.
  • We must meet Meaningful Use
  • We do not have enough resources from the EHR users to understand their processes.
  • We cannot continue to support these low-margin services
  • We do not have enough time to define our requirements
  • We cannot afford to spend the time required to assess our processes before we bring in the EHR vendor.

What can be done?  The easy answer is to plan for failure and do your best to minimize it.

What is another way to describe the above examples?  They are constraints.  They can all be rewritten using the word “can’t”.  Rewritten, we might say, “We had a chance to succeed, but because of X, Y, and Z we can’t.”  If that assessment is correct, you will fail, or at least under-deliver at a level that will be remembered for years to come.  That’s a legacy none of us wants.

There are a few solutions to this scenario.  You can eliminate the seemingly intractable constraints; the organization can determine to re-implement EHR and hope for different results; or they can simply find someone else to solve the perfect problem.

Experience teaches good leaders really want reasoned advice.  They want the members of the C-suite to tell them what must be done to be successful.  Good leaders do not accept “can’t”—not on the receiving end, not on the delivering end.

Some will argue, “This is the way our organization works.”  Even if that is true one must consider what is needed to make an exception to the constraint.  Would you accept this logic from a subordinate?  Of course not.  You’d demand a viable solution.  If you are being constrained in your efforts to solve a perfect problem, perhaps it is time to restate the constraints.

One of my college professors—way back when we still had inkwells on our desks—told me that if you cannot solve the problem the way it is stated, it is to your advantage to restate the problem.  Maybe the solution to the perfect problem is to restate it in a manner that makes it imperfect—solvable.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

“How many days ago was Sunday?”

The photo comes from my Robert Redford look alike period.

Do you ever awaken wishing you were all you used to think you were before you figured out you weren’t?  Me either.  I’m someone who has these kind of days when it’s best to keep me away from shiny objects.

During college, I spent several summers volunteering for a group called Young Life at their camps throughout the US.  Silver Cliff was one of their camps in the mountains of Colorado.  Each week we’d take in a few hundred high school kids from throughout the US, and give them the opportunity to do things and challenge themselves in new ways; everything from riding horses to rappelling.

The prior summer I was the head wrangler at one of their camps—I had never ridden a horse prior to being placed in charge of the riding program.  This summer is was the person running the rappelling program.  Needless to say, I had never done that before either.

We received a day’s worth of instruction before we were turned loose on the kids.  One of the first things we had to learn was that the ropes and harness, if properly secured to the carabineers and figure eight, would actually keep you from falling to your death.  The first test was jumping from a platform way up in a tree while on belay.  After a few moments of white-knuckle panic, I stepped over the edge and was belayed safely to the ground.

From there, we scouted a place for the rappel, and found two suitable cliffs, each with about a hundred foot vertical drop.  Watching my first rappel must have reminded others of what it would have been like watching a chimp learn how to use tools for the first time.  After several tentative descents, I was able to make it safely to the bottom in a single jump.

Each day we’d run a few dozen kids through the course, ninety-nine percent of whom had never rappelled, or ever wanted to rappel.  To convince them that it was safe and that they could complete it, I would instruct them in the technique as I hung backwards over the chalk face of the limestone cliff.

Each day we’d have one or two kids who wanted nothing to do with my little course.  Occasionally, while on belay, one of them would freeze half way down the cliff, and I’d have to belay down and rescue them.

Once or twice I’d have an attractive female counselor on belay, her knowing that I was the only thing keeping her from being a Rorschach stain on the rocks below.  Scared, and looking for a boost of confidence, “She’d ask, how long have you been doing this?” I’d look at my watch and ask her how many days ago was Sunday.  I viewed it as an opportunity to have a little fun with her—sort of like turning to your friend in the checkout line in 7-eleven and saying loud enough for others to hear, “I thought we agreed we weren’t going to use our guns.” I also hoped maybe even having to go on a heroic rescue.

How long have you been doing this?  That’s seems like a fair question to ask of anyone in a clinical situation.  It’s more easily answered when you are in someone’s office and are facing multiple framed and matted attestations of their skills.  Seen any good EHR or HIT certificates on the walls of the people entrusted with the execution of the EHR endowment?  Me either.  I have a cardiologist and he has all sorts of paper hanging from his wall.  Helps to convince me he knows his stuff.  Now, if I were to pretend to be a cardiologist—I’ve been thinking of going to night school—I’d expect people would expect to see my bona fides.

Shouldn’t the same logic apply to spending millions of EHR dollars?  Imagine this discussion.

“What do you do?”

“I’m buying something for the hospital I’ve never bought.”

“Why?”

“The feds say we’ve got to have it.”

“Oh.  What’s it do?”

“Nobody really knows.”

“How long have you been doing this?”

“How many days ago was Sunday?”

“What’s it cost?”

“Somewhere between this much,” he stretches out his arms, “And this much,” stretching them further.

“Do the doctors want this?”

“Some do.  A lot don’t.”

“How will you know when you’re done if you got it right?”

“Beats me.”

“Sounds like fun,” she said, trying to fetter a laugh.

Sounds like fun to me too.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

Do you need to fire Ferguson?

It may be time to fire Ferguson.

I was listening to Imus the other day as he was interviewing the famous promoter, Jerry Weintraub.  The promoter relayed a story about one of his clients, John Denver.  Mr. Denver was constantly complaining about a number of things on one of his European tours, and he demanded the promoter come speak with him.  Here’s a replay of the conversation.

“Yes. Well, he was in Europe, and he was on tour. And everything was wrong. He hated everything. He hated the venues. He hated – the airplanes were no good. The sound systems were no good. Everything was no good. And he said to me, you know, I’m going to fire you; everything is wrong here. I said, yeah, I know, I know.

I sat down with him; I said, John, everything is going to be fine. He said, why? Why? I said, because I fired Ferguson. He said, why did you fire Ferguson? Why? What does firing him – going to do? I said, he’s been responsible for all the things that you’re troubled by: the hotels, the sound system, the venues, da, da, da, da. And he said, it’s going to be OK now? I said, yes, I’m putting other people in. Great.

And that evening, Denver and I went out to have something to eat. At dinner, I said to him, John, you know, I feel really terrible about firing Ferguson. He said, why? I said, because it’s not like you and it’s not like me. And John Denver said to me, I agree with you; it’s not like us. What can we do to help the guy? It’s really not like me. I got to help him. I said, I’ll put him in another area in the company. He’ll be fine. We’ll take good care of him. He said, that’s great, I feel so much better. Of course, there never was a Ferguson.”

Sometimes you need to shake things up a bit.  Do you need to fire Ferguson?

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

Have I erred on the side of stupidity?

Twice in the span of twelve hours, I received unsolicited and honest feedback from two individuals whose opinion I value, about my attempt to share with you my thoughts about a range of issues concerning the business of healthcare.  One came from my father; since he holds that role he is allowed to offer unsolicited advice any time he wants, and I am entitled to listen to his advice.  The other bit of advice came in response to an email I wrote.  He is one of you, and he wrote the following:

I agree with many of your points and disagree with a few of them, and regardless, it’s a compelling, buzz-worthy angle that gets a lot of re-tweets and what have you, but I think it’s worth considering how these positions are affecting your ability to land consulting gigs in HIT. People want to hire consultants that they think will help them succeed, that think positively and pragmatically, and that are problem solvers (as opposed to problem recognizers): “we can do this together…I’ve had success before and if you let me, I will help you succeed…” that kind of thing. Just my 2 cents. It’s a trade-off, I know. You want to be honest and forthcoming, so I see the dilemma.

This was like being hit by lightening twice in the same day, so I thought I should take time to consider their input.  The feedback led me to ask if there are others who share the same opinion.  Is it possible my ramblings are about as well received, as I would be if I were to walk the streets of Tehran wearing a Star-of-David t-shirt?  What portion of readers drag my postings to their email folder entitled, “Kill him Later”?

Some believe a more effective use of consultants would be to compost them and use the energy generated to power a weed-eater.

Please permit me a few lines to try to explain my thought process for writing in my particular style and tone.  Before I began expressing my opinions on healthcare, I began reading what I considered the best healthcare blogs and editorials.  The first thing I learned is that I had nothing to offer of value on the clinical side of healthcare, so I focused my efforts on discovering what business issues providers dealt with, and which ones might benefit from receiving professional help—a consultant’s twelve-step program for problem solving.

I did a lot of homework; in addition to reading, I interviewed more than a hundred healthcare executives.  What was my takeaway?  One CEO told me the most needed skill on the business side of healthcare was “adult supervision”.  I did not charge in with uncorroborated opinions.  I used LinkedIn discussion groups to pose hundreds of questions about possible problems, studied the responses, and used them as a basis to formulate ideas about what was broken and what needed to be done to fix it.

I should note many of the blogs I read shared two traits; they often stated the same facts available on other blogs, and they rarely seemed to question the efficacy of the impact many of the Healthcare IT initiatives would have on operating healthcare’s business model—ours is not to wonder why, ours is but to do or die.

Not wanting to be superfluous, when I came to the fork in the road, I chose not to take a me-too position.  Instead, I threw metaphorical tomatoes and tried to get people interested in looking at the business model in a more disruptive manner.  Often, I did this by taking extreme positions on issues in the hope I might hit a hot button, and someone would think, “Perhaps we ought to talk to the tomato thrower and see if he can help us”.

My approach may prove to be less than brilliant.  What’s your take?

EHR 2 a-days

It’s hot and muggy; a hazy pall seems to levitate before me.  We call it Pennsylvania in summer.  Chest pain yesterday, nitro in gym bag.  Intervals today.  I hate running intervals as much now as I did in high school, but they’re better for the heart than just running distance.  Twenty-four 110’s.  Did I mention it was hot?

I am on the high school track.  The football team is/are—where are all the English majors when you need them—going through their drills.  Running and thinking.  That’s a good combination for me.  After two laps I’m glistening, after three I’m soaked through.  That’s when it hits me.

Practice.  Offensive and defensive drills.  Blocking and tackling.  Run the option.  Block the punt.  Come back tomorrow and do it again.  Do it until you get it right.  Do it until you can get it right in the game.  Pretty neat idea all this practicing.

Know where this is headed?  See, that wasn’t too difficult—remember, the desk is hard, the task is difficult. (My one takeaway from eighth grade English.)  Who doesn’t get to practice, doesn’t even have a coach?  Bingo, the EHR Project Management Executive.  It would be better if they did.  Imagine this conversation:

“Sorry Charlie, hit the showers.”

“Why Coach?”

“Your change management isn’t working for you today.  You’re leaving processes untouched.”

“It was the docs’ fault.  They just toy with me.  Treat me like a wonk and tell IT jokes behind my back.”

“Your game plan is coming apart.”

“But I didn’t get to practice, we didn’t even get to warm up.  I’ll do better next time.”

“Which next time is that Charlie?  With whose money?  These are The Bigs, Charlie.  Only grownups play here.  I’m afraid I’m going to have to send you back down to Single A.”

“Private practice.?”

“Sorry Charlie”—sounds like the tuna commercial.

You’ve got one shot at this, no warmups, no practices; there are no do-overs, and you are gambling millions.  DIRT-FIT  Do It Right The FIrst Time

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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