Strategy

Why is EHR not the right answer?

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The reason I chose to share this story is my belief that it is de rigueur among practitioners.  I have been spending some of my time working on behalf of a small clinic.  Four doctors, two offices, small lab, x-rays, some surgeries.

Great people, great mission.  Every physician spends several weeks each year doing unpaid missionary work in Africa and South America.  Their focus is caring, not dollars.  It is not my job to change their focus.  They do not turn away anyone who cannot pay.  Staff at the front desk help patients pay for their meds.  The four physicians routinely offer services and perform procedures for which they know they will not be paid.  I feel a real sense of pride helping them, and have slashed my rates to make sure they get the help they need without taking money unnecessarily from their coffers.  Their patients love them, and they add about a hundred new patients a month.

The business side of their practice could have been designed by Rube Goldberg.  As I interview the doctors, the nurses, the lab, and the front desk about the practice, I try to do so with a straight face, try not to betray the part of me that wants to say, “You’re kidding, right?”

They meet with about fourteen-hundred pharmaceutical reps each year.  I tried to pin down why they do it, but could not come up with an answer to support a business reason.  Since the pharma reps can no longer offer trinkets equivalent to those needed to purchase Manhattan, they give away lunch.  Enough lunches to ensure that everyone in the practice should weigh eight-hundred pounds.

They use the F-word a lot—faxes.  Two fax machines running often enough that without proper cooling they would melt through the floor.  The average fax is handled eight times before it is placed in the patient’s chart.

There is no email, no web site.  There is no triage—docs and nurses do not screen patient phone calls to determine who needs to be seen.  Seventy-five patients a day, two and a half people are full time on billing.  Three people man—actually, it should be “woman”, the front desk.  (Is that an intransitive verb, or simply poor writing on my part?)  The staff wants more staff.

I have been hired to help them with the selection and implementation of their EHR.  I can solve the EHR problem in five minutes, but I won’t.  Having an EHR will solve none of their problems, at least not until they turn what they do into a business.

Realigning their business processes will do more for their mission than any EHR.  Processes are inefficient and ineffective.  I cannot figure out how they collect money or pay bills.

I am willing to bet they are not alone in having these issues.  I’d bet that these problems can be extrapolated to hospitals.  Is Practice Management more important to physicians than EHR?  My guess is that the right answer is yes.

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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What if GM were involved in EHR?

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Goodness knows, the whole car thing did not work our too well for them

Do you ever think about the origination of some of your ideas?  For me, the good and the bad just seem to materialize.  Like the time a friend and I were hiking a peak in the Sangre de Cristo range in Colorado.  It had taken the better part of six hours of circuitous climbing to reach the summit.  It was late in the fall, and the temperatures were around freezing.  Roiling storm clouds were racing towards us from the west.

If we returned by the same route we knew we’d be caught up in a storm that we were neither prepared nor dressed to handle.  I spotted our car about six thousand feet below us.  If we headed straight to it, I thought we could cut our descent time by about an hour.  To do this though required that we make our own trail via a hunt and peck route of whatever the terrain permitted.  We dropped the first fifteen hundred feet in a matter of twenty minutes using a glissade.  This technique allows you to moonwalk and slide down a scree field, using your ice ax as a break.

After an hour we reached a point about two thousand feet above our car.  It was sleeting, and the wind was whipping around the face of the mountain.  There in the middle of nowhere stood a sign from the sheriff that read, “Devil’s Gulch, turn back.”  Our choice was to reclimb the mountain or to ignore the sign and press on.  I hate do-overs.  How tough can this be, I goaded him?  Be smart, kick it into high gear, and we’ll be done.

We pressed forward.  Fifteen minutes later, we reached a four hundred foot limestone cliff.  Between us and the next semi-reasonable terrain was a rather deadly looking wall of rock and scrub pine.  My pack made me feel like it was forcing me forward, so I removed it and tossed it over, thinking I’d retrieve it later.  Watching my pack bound from rock to rock for what seemed like more than a minute did nothing for putting me at ease.

We spent more time discussing each step than we spent taking it.  Those four hundred feet took us two hours.  Not my best idea, but it didn’t kill us.

So, during my run today, I had another idea.  This one is about OnStar, the GM tracking system.  I typed in to Google, “How does OnStar Work?”  Lots of hits.  The more I read, the more I began to feel like if one ignored the technology and focused on the concept a real argument could be made for pairing the idea, and a few others, and seeing what type of EHR network might be possible using a similar set of tools.

The OnStar concept is termed telematics, a combination of telecommunications and informatics.  Telematics is the integration of computing, wireless communications, and GPS.  It provides information to a mobile service like a phone, PDA, or laptop.  It is used for sending, receiving, and storing information over very large networks.  So, why is nobody having the conversation that says what if we image a similar network with added security that works from a healthcare provider’s office rather than a car.

OnStar doesn’t need Rhios.  OnStar has a single set of standards.  Now, instead of arguing why something like this can’t work in healthcare, isn’t there argument is seeing if it can?

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

Is the C-suite fiddling while EHR burns?

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There is an adage in the military—different spanks for different ranks.  If speaks to a double standard, the less egregious their punishment for similar offenses, similar misjudgments.

We see that every day in business, and we see it a lot in healthcare, especially in hospitals.  Physicians are held accountable for medical errors.  Hospitals pay millions for malpractice insurance knowing that mistakes will be made and people will be held accountable for their mistakes.

But what about on the business side?  Who is held accountable for business mistakes?  An acquisition that failed to deliver.  An expensive new service offering that bled the company dry.  A decline in the number of patients. The failure of a major IT initiative to deliver results.

Take EHR.  Some of you are saying, “Yes, please take it.”

  • Around sixty percent of the large EHR projects have failed in one respect or another
  • Most will not receive ARRA incentives
  • A large number of hospitals are on their second implementation of EHR
  • Some have productivity losses of thirty percent

Who is going to be fired for the two hundred dollar misstep?  The board?  Never.  The CEO—no.  The COO or CFO?  Unlikely.  The CIO?  That is the safe bet.

Did the CIO authorize the expenditure?  Nope.  Did the CIO get all the dollars needed to be successful, all the user support?  Unlikely.

In most cases the CIO has all of the responsibility and only some of the authority.  There are a handful of people in each organization tasked with the oversight of the large project.  They are the ones who should be asking the right questions, the ones who should be demanding answers.

A failed project, a failed strategy should not come as a surprise.  The only people who will be wearing EHR 2.0 T-shirts are those who authorized EHR 1.0.  How come these individuals are not accountable?

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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Patient Experience (Mis)Management (PEM)

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Patient Experience (Mis)Management (PEM)–my new post for @healthststemCIOhttp://ow.ly/22uEj

EHR Czar posting

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One summer in college, I worked for the state roads commission in Maryland.  If you like being outdoors, getting a lot of exercise, driving around in the back of dump trucks drinking beer it was the perfect job.

The average day went like this.  Each morning we’d report to the facility at seven, and sit around for an hour as the supervisors received their assignments for the day.  It would take another hour to gather the tools needed to complete whatever project we were given.  On the road by nine, the two full-time employees inside the truck, my friend and I laying in the back on burlap bags..

By ten, we had unloaded the tools, and scoped the work.  Most days we’d forget one or two tools needed to complete the work, radio back to the facility to have someone deliver it to us, and practice sitting on our shovels until we were fully outfitted.  It didn’t make sense to start the work knowing lunch was only thirty minutes out, so on most days we would simply wait until after lunch.  By one o’clock, our bellies full, we began our assignment—fix a guardrail, shovel some gravel, install a road sign, scoop a dead deer of the road.

The foreman, Butch, knew the location of every liquor store in the county.  Happy hour in the dump truck usually began at three—one case of beer for the two men in the front, one case of beer for my friend and me in the back.  We’d lay there with our shirts off as the supervisor chauffeured us around the county trying to kill time until we could return to the service bay.

I wonder if they need any help this summer.

One of the things I remember about that summer was a job posting in the service shed.  The posting was for a supervisor/foreman.  The single qualification was the requirement of having completed education through grade five—the “Are you smarter than a fifth grader” test.

I have no segue.  I am wondering if there is a posting in the ONC service shed for an EHR Czar.  If there were, what would be the requirements?

WANTED: EHR Czar—Fourth graders need not apply.

Count me in.

Are hospitals making the the same mistake as BP?

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

A lot of the strategic issues in healthcare are not easily explained.  One issue can be explained to a fifth-grader.  So, get your crayons out and follow along.

Fifty-some days and counting.  Say it with me—BP.  In many respects healthcare’s approach to social media is analogous to BP’s—the major difference is that neither the payors, pharma, nor the providers has yet to wipe out an entire geography—but the week is not over yet.

BP is offering an MBA in how not to use social media.  Nobody is queuing up on Amazon to buy the book, “BP’s ten pointers on crisis management.”

The funny thing about disasters is being able to schedule them in Outlook.  There are no pop-ups fifteen minutes before the big bang reminding you to get ready—“pipeline blows up in 15 minutes.”

We both know, sooner or later you will have one.  While yours may not crater the shrimping industry, it may be enough to do some serious damage to your business.  Most hospitals have a risk management group.  BP has one.  The mission statement of risk management is to assess and mitigate risks.

BP’s group probably had a plan in place to address a number of risks—risks like OPEC, an expansive war in the middle east, a tanker collision.  Apparently, they overlooked the risk of having a blowout a mile under the ocean.  Who’da thunk it?

If you Google “oil spill” there are fifty million hits.  Add “BP” to the search and the results narrow to a mere forty million.  That toothpaste is never going back in the tube.  People who can’t find the Gulf of Mexico on a map know that BP ruined it.  Thirty years from now people will still know the name of the firm that poisoned the Gulf, destroyed businesses, ruined vacations, made people sick, and cratered home sales along hundreds of miles of shoreline.

No matter what type of disaster BP could have faced, they demonstrated they were not prepared.  Even if it is proven that the disaster was not BP’s fault, it is too late to change their ownership of it.  Nobody is ever going to delete those forty million Google pieces linking BP to failure.  If BP hired a thousand workers whose only job was to try to counter each piece of negative media it would take them decades.

What is the one word to describe BP’s social media strategy?  LATE.

There is no useful social media strategy worth anything that begins after a disaster, none worth anything that begins after a misstep, after a faux pas.  Dictionary.com defines a faux pas as a social error—a boo-boo.

Unlike Meaningful Use, a good social media strategy can have an almost infinite ROI.  A good social media strategy, in addition to adding revenues and capturing patients, can help assuage the bleeding.  A good social media strategy played out in advance creates allies.

Let us look at this from the perspective of large healthcare providers.  What types of unfavorable events could negatively affect a hospital?

  • A medical disaster
  • Fraud
  • Medical errors
  • Reform
  • Scandal
  • Medical malpractice
  • Natural disasters
  • A data breech

While all negative events are not the same, many aspects of a good social media strategy apply regardless of the type of problem.

There are two major components of a good healthcare social media strategy:

  1. It should be pro-active.  Your social media strategy should be building goodwill each day.  Google the name of your hospital and see how many hits you get.  Next, see how many thousands of those hits are attributable to people outside your organization—too many to count.  You are already late.  People are already posting videos and writing about you.
  2. It should be reactive.  Make sure your “What are we going to do now?” account has a positive balance.  At the very least make sure you can push a button and unleash a plague of social media “I feel your pain” initiatives.

I’d wager a hospital could develop an outstanding social media strategy for less than one-tenth of what it pays in legal fees.

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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How the C-suite sees the CIO

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This link is to my latest post for healthsystemCIO.com.  http://healthsystemcio.com/2010/06/10/how-the-c-suite-sees-the-cio/

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

A Perfect Metaphor

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Few things are perfect, and when you find something that is, it is worth examining.  One thing that is perfect is baseball, at least some aspects of it.

Think with me for a minute. 1845.  How much has changed since then?  Just about everything.  Do you know what has not changed—the distance between the bases—90 feet?  This distance may seem insignificant or inconsequential.

In the last 165 years the distance between the bases remained unchanged.  Equipment changed, improved.  The players got bigger, faster, and stronger.  It never dropped to eighty-nine feet; it never jumped to ninety-one feet.

To those who follow baseball, have you noticed how close many of the plays are at first base, or the closeness of the steals of second base?  Can you imagine what would happen to the game of baseball if the distance was shortened to eighty-nine feet?  Almost everyone stealing second base would be safe.  If the distance was ninety-one feet they would all be out.

Somehow, 165 years ago those people got it right, got it absolutely right.  Something as simple as a measurement along a dirt path has stood the test of time.  There are not even any discussions about trying to improve it.

Remember the Titanic?  If one measured all the time spent in its design, and all of the time it sailed before it sank, if you were a betting person you would have bet on the boat.  Reasonable people would have bet on the boat.  You would have been a fool to have bet it would have sunk.

You know what; the Titanic’s sinking was not a fluke. The laws of physics and ship design did not suddenly cease to work.  Do not blame the iceberg.  The Titanic was designed to sink—otherwise it would not have sunk.

What is often misjudged in business is the ill-informed notion that just because something has not collapsed it is not broken.  Hospitals are starting to collapse.  The business model of most of them almost ensures that left unchanged, many, many more will collapse.  They have been designed to collapse.  Just because they have yet to collapse does not mean they won’t, all it means is that they have not—yet.

Few things are perfect.  What discussions there are about the business model are not about improving the model, they are about cutting costs.  What do you have when there are no more costs to cut?  You have a less costly dysfunctional model.

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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Planning an EHR?

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You’ve probably figured out that I am never going to be asked to substitute host any of the home improvement shows.  I wasn’t blessed with a mechanical mind, and I have the attention span bordering on the half-life of a gnat.

I’ve noticed that projects involving me and the house have a way of taking on a life of their own.  It’s not the big projects that get me in over my head—that’s why God invented phones, so we can outsource—it’s the little ones, those fifteen minute jobs meant to be accomplished during half-time, between pizza slices.

Case in point—trim touch ups.  Can, brush, paint can opener tool (screwdriver).  Head to the basement where all the leftover paint is stored.  You know exactly where I mean, yours is probably in the same place.  Directions:  grab the can with the dry white paint stuck to the side, open it, give a quick stir with the screwdriver, apply paint, and affix the lid using the other end of the screwdriver.  Back in the chair before the microwave beeps.

That’s how it should have worked.  It doesn’t, does it?  For some reason, you get extra motivated, figure you’ll go for the bonus points, and take a quick spin around the house, dabbing the trim paint on any damaged surface—window and doorframes, baseboards, stair spindles, and other white “things”.  Those of us who are innovators even go so far as to paint over finger prints, crayon marks, and things which otherwise simply needed a wipe down with 409.

This is when it happens, just as you reach for that slice of pizza.  “What are all of those white spots all over the house?”  She asks—you determine who your she is, or, I can let you borrow mine.  You explain that it looks like that simply because the paint is still wet—good response.  To which she tells you the paint is dry—a better response.

“Why is the other paint shiny, and the spots are flat?”

You pause.  I pause, like when I’m trying to come up with a good bluff in Trivial Pursuit.  She knows the look.  She sees my bluff and raises the ante.  Thirty minutes later the game I’m watching is a distant memory.  I’ve returned from the paint store.  I am moving furniture, placing drop cloths, raising ladders, filling paint trays, all under the supervision of my personal chimera.  My fifteen-minute exercise has resulted in a multi-weekend amercement.

This is what usually happens when the plan isn’t tested or isn’t validated.  My plan was to be done by the end of halftime.  Poor planning often results in a lot of rework.  There’s a saying something along the lines of it takes twice as long to do something over as it does to do it right the first time—the DIRT-FIT rule.  And costs twice as much.  Can you really afford either of those outcomes?  Can you really afford to scrimp on the planning part of EHR?  The exercise of obtaining EHR champions and believers is difficult.  If you don’t come out of the gate correctly, it will be impossible.

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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Strategy Millstones, should that read Milestones?

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If you like adventure, here’s a site to check, http://www.jfk50mile.org/.  This is an annual event whose origin came about during the cold war.  Fortunately for both of us, the entry date has already passed.  The thought behind the JFK fifty-mile hike/run was that because of the possibility of a nuclear attack, each American should be in good enough shape to cover fifty miles in a day.

I participated in the event twice—I wrote participated because to state that I ran the entire way would be misleading— and I can state with certainty that almost no Americans are close to being able to complete this.  The event is run in the fall starting in Boonsboro, Maryland.  It takes place along the Appalachian Trail and the C&O Canal and various other cold, rain soaked, and ice and leaf covered treacherous terrains.

We ran it in our late teens or early twenties, the time in your life when you are indestructible and too dumb to know any better.  One of my most vivid memories of the event was that on the dozen or so miles along the mountain trail, leaves covered the ground.  By default that meant they also covered the rocks along the trail, thus hiding them.  That we were running at elevation—isn’t everyone since you can’t not run at at least some elevation, (that may be the worst sentence every written) but you know what I mean—meant the prior night’s rain resulted in the leaf covered rocks being sheathed in black ice.  That provided a nice diversion, making us look like cows on roller skates—roller blades had yet to catch on outside of California.

There were several places along the trail where the trail seemed to fork—I’m not going to say and I took it—and it wasn’t clearly marked.  Runners could easily take the wrong fork (or should that be Tine?).  I think it would have been helpful had the race organizers installed signs like, “If you are here, you are lost.”  Hold on to that thought, as we may need it later.

Some number of hours after we began we reached the C&O Canal, twenty-six miles of flat terrain along the foot path.  It’s difficult to know how well I was doing in the fifty-mile race, in part because I had never run this distance and because there we no obvious mile markers, at least so I thought.  Then we noticed that about every five and a half to six minutes we would pass a numbered white marbled marker that was embedded along the towpath.  Mile stones.  At the pace we were running, we anticipated we would finish high in the rankings.  As fast as we were running, we were constantly being passed, something that made no sense.  That meant that a number of people were running five minute miles, which we knew they couldn’t do after running through the mountains, or…Or what?

The only thing we knew with any certainty at the end of the day was that the markers with which we used to determine our pace and measure how far we’d run were not mile markers.  We never figured out why they were there or how far apart they were, but we greatly underestimated their distance and hence our progress.

It doesn’t really matter whether you call them mile stones or milestones.  What matters is whether they serve a valid purpose.  If they don’t, milestones become millstones.  Milestones are only useful if they are valid, and if they are met.  Otherwise, they are should’ a, could’ a, would’ as—failure markers, cairns of missed goals and deliverables.

How are your milestones?  Are they valid?  What makes them valid?  Are they yours, or the vendors?  All things to think about as you move forward.

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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