Strategy

The change keeps changing

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Hello to those whom I’ve yet to meet.  This is rather long, so you may wish to grab a sandwich.

I write to share a few thoughts.  I reside in the small place where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s where those who place principle over fees dare to tread.

Where to begin? How to build your provider executive team? (Those who wish to throw cabbages should move closer to their laptops so as not to be denied a decent launching point.)

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time your project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing a healthcare organization, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon, external influences—the implications of reform and Stages 2 and 3 of Meaningful Use, and a national roll out of EHR with no viable plan to get there.  Staffing only to execute today’s perceived demands will get people shot and will fail to meet the needs of hospital. To succeed we need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare implications of reform and IT.  They’ve also indicated—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform.  I somewhat disagree with that perspective.

Here’s a simplified version of the targets I think most of today’s hospital CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them.  Here’s what I think. You don’t have to accept this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since this is my piece, I used it.

Before we go there, may I share my reasoning? From a business perspective, many would say the business of healthcare must move from a 0.2 to a 2.0 business model. (This is not the same as the healthcare business—the clinical side.)  The carrot?  The ARRA incentives—an amount that for many providers will prove to be more of a rounding error than a substantive rebate.

Large healthcare providers are being asked to hit complex, undefined, and moving targets, and they are planning on adapting to reform and reforming their own business model while they implement systems which will change how everyone works.  Hospitals are making eight and nine figure purchase decisions based in part on solving business problems they have not articulated. If success is measured as being on-time, in-budget, and fully functional and accepted, for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

Their overriding business driver seems to be that the government told them to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on an EHR system than they would to build a new hospital wing.  Many don’t know what the EHR should cost, yet they have a budget. Many don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff to help ensure my success—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot.  I’d staff with a heavy emphasis on the following subject matter experts:

• PMO
• Planning & Innovation
• Flexibility
• Change Management
• PR & Marketing

Contrary to popular belief, not all of these high-level people need to have great understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years for now the government would like us to believe there will be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of RHIOs, and mapped to a N-HIN.  Under the proposed model, standardization will not occur if only for the fact that there is no monetary value to those vendors whose standards are not standard.

Interoperability, cost, and the lack of standardization will force a different solution—one which is portable.  I think the solution will have to be something along the lines of a single, national, open, browser-based EHR.  It will be driven by consumers.  Consumers will purchase the next generation of super-smart portable devices that offer a combination of iPad/iPhone functionality.

The Personal Health (PRH) will have evolved to become the EMR.  How is this possible?  What do smart devices do?  They do one thing, billions of times each day, and they do it perfectly—they send and receive ones and zeros.  That is what today’s EMR are—ones and zeroes.  Those next-gen devices will be EMR-capable.  Why?  Because there are more than a hundred million customers who will keep buying these devices.

The so-called N-HIN will be the new Super Internet—not some cobbled together network of RHIOs.

Firms like Apple, Google, and Microsoft will drive this change.  We already buy everything they offer, in fact, we line up at midnight to do so.  By then, those firms will care less about selling the devices than they will about transporting the ones and zeroes that comprise the data.  Their current PHRs are their way of introducing themselves to consumers as players in healthcare.

The point I am trying to drive home is that from being able to adapt to change and reform, lean towards staffing the unknown.  Staff with leaders, innovators, and people who can turn on a dime. Build your organization like turning on a dime is your number one requirement. Don’t waste time and money worrying about Certification or Meaningful Use. If anyone asks you why, you can blame me.

If you want a real reason, I have two. First, they won’t mean a thing five years from now. Second, if I am the person writing an incentive check, I want to know one and only one thing—will your system connect with the other system for which I am also writing a check?  That is the government’s home run.

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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The Wildebeest Postulate

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

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

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

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

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

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

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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What is the future of the EHR/N-HIN landscape?

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One may argue it is possible to build the real Brooklyn Bridge with nothing but toothpicks, and a lake filled with Elmer’s Glue.  Difficult yes; prudent, no.   Urban legend is when the United States first started sending astronauts into space, they quickly discovered that ballpoint pens would not work in zero gravity.  To combat the problem, NASA scientists spent a decade and $12 million to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300C.

The Russians used a pencil.

The ability to do something is not justification for doing it.  Nor is that fact that someone has put it forth as an idea.  The willingness to do something merely because everyone is doing it or because someone instructed it be done probably has nothing to do with a business strategy, or if it does, it shouldn’t.

In the next five to seven years the business of healthcare at the provider level will have the opportunity to change markedly—the unanswered question is, will it have the ability?  To answer that at the provider level—primarily hospitals and clinics—I believe one must distinguish between the business of healthcare (how the business is run) and the healthcare business (how the care is delivered).

In many respects, the business of healthcare and the strategy surrounding it is pinned to a 0.2 business model.  Certainly there are exceptions to any aphorism, but taken as a whole, there is plenty of room for improvement.  As one hospital CEO told me, “What we really lack is adult supervision.”

So, how exactly does the toothpick bridge apply to healthcare?   Here’s my take on the situation.

  1. It may be possible to build and roll out a national network of EMRs through EHRs connected by HIEs to an N-HIN—I don’t think will happen in the next five to seven years, especially if to be effective the network requires a minimal participation of somewhere between 70 to 80 percent of healthcare providers.
  2. Even if I am wrong, why would anyone build a national EHR network out of toothpicks?  Could they possibly have devised a more complex and costly approach?
  3. The government arrived late for the party, has only limited authority, and chose to provide cash incentives instead of direction or leadership.  They passed the responsibility of the success of the national EHR roll out to hundreds of thousands of healthcare providers.
  4. The providers are burdened by having no experience in the sector, hundreds of EHR systems from which to select, no standards, hundreds of HIEs, no viable plan, no one with singular authority, a timeline that cannot be meet, and an unwritten set of Meaningful Use requirements.

The plan sounds like something designed by Rube Goldberg.  Could it be done this way?  I do not think we will ever know.  Not necessarily because it will fail, but because I think the plan will be supplanted by a more realistic one from the private sector.

The government’s plan relies on a top-down approach—albeit with a missing top; from the government, to the providers, to the patients.

The private sector plan will come from firms like Apple, Google, and Microsoft.  It will work because it will be built from the bottom up; from the patients, to the providers, and back.  Personal Health Records (PHRs) will become EMRs.  This approach will allow them to flip their PHR users to EMR users, and will be adopted quickly by millions of customers (patients).  Their approach will have a small handful of decision makers calling the shots instead of hundreds.

This model’s other component will be driven from another direction, by large hospitals and clinics that connect to small hospitals, small practices, and ambulatory physicians via a SAAS model.  Something like this is underway today at the Cleveland Clinic using their offering, DrConnect.

I believe the approach will be refined even further as the distinction between PHRs and EMRs erodes.  Instead of requiring remote care providers to have their own mini-EHR integrated with their practice management system, they will be able to use the EHR of a large hospital.  I anticipate that they will be able to log on to the system to access their patients’ EMRs as though they were actually resident in the large hospital.  This will all but eliminate the role of Health Information Exchanges (HIEs).  It will also extend the reach of those large hospitals, and aid in the retention and recruiting of physicians.

Why is this important?  Because the federal plan, which won’t be viable for several years, is designed to use software solutions which address a current business issue.  By the time their networked solution is fully functional it will be well on its way to obsolescence.  The government is forcing the expenditure of more than a hundred billion dollars on a static offering to address a non-static issue.  Their approach will not be able to keep pace with the changes demanded by market forces.  It reminds me off building a plan to go to the moon based on where the moon was instead of where it will be.  
[digg=http://digg.com/business_finance/What_is_the_future_of_the_EHR_N_HIN_landscape]

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The User’s Role in EHR–a PowerPoint presentation

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

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

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

Puppy Training Your Vendor

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Carrie Vaughan, a senior editor of HealthLeaders Magazine published an article in the December 8, 2009 issue titled, “Tips to Build a Successful Vendor-Provider Partnership.”  The link to her article is http://www.healthleadersmedia.com/page-2/MAG-243167/Avoid-the-Vendor-Upsell.

The points about which Carrie wrote are spot on.  I asked Carrie if she would permit me to use those same points as a foundation for this posting, to which she was kind enough to agree.  The four points come from her article.  I encourage you to read her piece, as any points with which you may take umbrage are mine, not hers.

To ensure we take an accurate look at the provider-vendor relationship, we must be willing to acknowledge that healthcare providers are from Mercury and the EHR vendors are from Pluto.  They exist in different orbits, and their business models are very far apart—they never intersect; not in space, and not on your project.

1. Have your own inside expert. Don’t rely on the vendor to tell you what you should be doing.  Never.  Ever.  Unless of course you think the vendor knows more about how you want to run your hospital than you do.  Remember, you select them—not the other way around.

Bringing a vendor into your hospital is a lot like bringing home a new puppy. Both need to know who runs the show. Don’t roll over.  They may not be looking to be led, but if you don’t lead them they will lead you.

You should have the expert on board at the outset, before you select the EHR vendor.  The expert should be your advocate.

2. Establish a specific executive liaison with your vendor.  This is not your new tennis partner.  This should be the person who has the authority to ensure your quantifiable wishes are being met, and whose responsibility it is to deliver the message to his troops, and marshal the resources necessary to get the job done.

3. Specify your contractual objectives. Ensure that the contract is aligned with the clinical and business objectives of the healthcare organization, not the vendor.  Before you can accomplish this, you have a lot of work to do with your team.  You must define your clinical and business objectives.  Often these two groups also have a Mercury and Pluto relationship.  Once you have these, your next task is to deliver these objectives to the vendor and have the vendor tell you in writing what they will meet, what they might meet, and what they can’t meet.  It would be nice to know these before you sign their contract.

4. Involve more people than just the IT staff. Need a rule of thumb, involve as many users as IT people—Mercury and Pluto.  You will need new processes, not just to squeeze an ROI from the EHR, but because many of your old ones have probably been around since the invention Band-Aid.

Each of these recommendations will actually help you and help your vendor be successful.  It will not be an adversarial relationship as long as you manage it.  If you don’t manage the relationship, you won’t have to worry about meeting Meaningful Use—you’ll be too busy selecting a replacement vendor.

One final thought, don’t let the vendor loose unsupervised on the oriental rugs.

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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Published on HealthSystemCIO.com–vendor darts

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Below is the full article I submitted to HealthsystemCIO.com, Anthony Guerra’s outstanding site for healthcare leaders.  As always, I am flattered that he finds my contributions worthwhile.

Is there a best Electronic Health Records system? Perhaps Cerner, EPIC, GE, or McKesson?  For those who have followed my writing, you’re probably thinking my answer is “None of the above.”

I’ll do one better, and I write this with the utmost sincerity—it does not really matter which vendor you select.  As the EHR vendors reading this pull themselves off the floor, permit me to explain why.  Researching the question this is very little information to support the notion that any of the major hospital EHR systems quantitatively stands out from the others.

There are a few sites that offer user assessments across a range of functions, but those have at most three opinions—not enough to consider statically significant.  There are plenty of EHR scorecards and comparison tools, just not many scores.  The vendors’ sites do a poor job of differentiating themselves from their competitors.  Vendors use superlatives and qualifiers in an attempt to differentiate themselves.  When one considers the basic functions that make an EHR an EHR, the top vendors all have them.  No vendor highlights major clinical or business problems that their solution solves that another vendor does not solve.  Instead, they state they do something better, easier, more flexibly—none of which can be measured by prospective clients.

Imagine, if you were an EHR vendor, and you knew that your product did things to benefit a hospital better than the other vendors, wouldn’t you have an independent competitive assessment, some sort of “Consumer Report” chart and evidence to support why you are better?  Of course you would.  You would highlight your superlatives.  I have not seen one that would be very helpful.  The only information I found that might be worth a read comes from Klas Research, http://www.klasresearch.com/.  However, the names of the modules rated are vendor specific, and none of the vendors use the same names.  It will give you a feel for how a small sample rated features within a given vendor, but there is no data to suggest how those ratings compare among vendors.

Even if there was a good comparison, the other thing to learn from this is all the areas that aren’t listed imply that the vendor is either no better or perhaps worse than the competition.  Cream rises to the top—we are left to choose among brands of milk.

One vendor may have a better medical dictionary than another, yet that same vendor will lack rigor in decision support.  No single vendor seems to have their customers doing back flips in their testimonials.  Some score high in their ability to deliver a complete inpatient solution and fail in their ability to integrate with other vendors.  Others hurt themselves during the implementation, user support, response time, and the amount of navigation required to input data.  Some EHR vendors posit their systems as being better at meeting Meaningful Use or passing all of the Certification requirements.  Ask them to name a single installed client for which they have met these.

Why doesn’t matter which vendor a hospital selects?  The reasoning holds not because all hospitals are the same, rather, it holds because were one to perform a very detailed comparison of the leading EHR vendors with a Request for Proposal (RFP), they would prove to be quite similar.  You might find significant separation if you only compared ten functional requirements.  You would expect to find less separation by comparing several hundred, and quite a similarity if you compare a thousand or more requirements.  The more you look, the more they seem the same.

Although the vendors will differ with respect to individual requirements, when evaluated on their entire offering across a broad range of requirements I would expect each to score within one standard deviation of the other.

Reason 2.  It is possible to find hospitals who will give outstanding references for each of the leading vendors.  It is equally possible to find users in hospitals who have implemented one of the “leading” vendors’ systems who will readily tell you that the purchasing the system is the worst business decision they ever seen.  More to the point, every vendor A has probably had at least one of its implementations uprooted and replaced by vendors B, C, or D.  The same can be said for vendors B, C, and D.

If this is a fair assessment, what accounts for the difference?  How can we account for why one hospital loves a given EHR system and another one hates the same system?  Chances are they both needed about the same solution.  Chances are they received about the same solution.

Here’s the difference.  The hospital who thinks they made a good choice:

  • Had a detailed strategy and implementation plan
  • Paid as much or more attention to process alignment, change management, and training as they did to the implementation
  • Managed the vendor instead of being managed by the vendor.

Simply put—the problem is not the EHR system.

One other thought.  “Pay no attention to the man behind the curtain—the Great Oz.”  Do not put your scarce capital into a solution just because it offers or promises either Certification or Meaningful Use.  Yes, there is much discussion about both of these.  The industry stops and holds its collective breath each time a new set of stone tablets are brought forth from the ONC or CMS.  You can meet Meaningful Use with a Certified system and still wind up with a system the users hate and that does not support your business model.

Here is something else I cannot explain.  For those hospitals replacing a one hundred million dollar EHR with another hundred million dollar EHR, why do they think the second system will be any better?  If the systems are not materially different, the only way to get a different result is by changing behavior, not changing systems.  Why make the same mistake twice?  What could be so wrong with the first implementation that an expenditure of far less than another hundred million could not solve?

What is the cost of EHR 2.0 not working?

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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Users are from Mercury, IT is from Pluto

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The two groups are often far apart.

I learned an interesting word which led to some very interesting reading on the topic.  The word and topic are qualia (pl).  There are several wordy explanations with which I won’t waste your time.

Daniel Dennett identified four properties that are commonly ascribed to qualia. According to him, qualia are:

  1. ineffable—they cannot be communicated, or apprehended by any other means than direct experience—see, touch, taste, hear, smell.
  2. intrinsic—they are what they are independent of anything else.
  3. private—interpersonal comparisons of qualia are impossible.
  4. directly or immediately apprehensible in consciousness—to experience a quale is to know one and to know all there is to know about that quale.

Got it?  That didn’t do it for me either.  Here are a few examples that helped me understand it.

  • How does wet feel?
  • What does blue look like?
  • What is the smell of mowed grass?
  • How does salt taste?
  • What is the sound of a whisper?

Common things.  Our brain knows what they are, yet to describe them to someone who has not experienced them, almost indescribable.  Your brain processes it one way, your mind processes it another.  Take a look at these pictures.

Now let’s look at healthcare IT projects, to be more particular, implementing an electronic health records system, an EHR system.  When you pictured the implementation in your mind, when you studied the implementation plan it painted a nice picture.  All the pieces made sense—sort of like the picture on the left.

At some point after most EHR implementations, the IT department still sees a pony.  The users can’t see the pretty picture.  Trying to explain what went wrong to the steering committee is like trying to describe to them the color blue.

IT people are able to look at the picture on the left and visualize the picture on the right.  When IT people talk to users, to the users it sounds like the picture on the left…

…and it feels like this.

It matters what the users think, and see, and feel.  If IT waits until the end to involve the users, the users will never see a pretty picture.  I’ll let you in on a secret.  In many hospitals the users (doctors and nurses) do not think IT has any understanding of their business.  Why prove them correct by keeping them out of the loop.  Their input is at least as important as IT’s and the vendor’s—probably more so.

“Look what we built for you” is not what the users need to hear.  “Look what we did together” has a much better chance of succeeding.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 85-6942
paulroemer@healthcareitstrategy.com

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How to handicap selecting your EHR

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Several 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 were not 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.

There are two ways to handicap your EHR.  One way is to look at the program from the perspective of risk assessment and assess–handicap–the risks.  The other way to to be a detriment to the program’s success.  One of these is bad.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 85-6942
paulroemer@healthcareitstrategy.com

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

Patient Relationship Management (PRM): Left Brainers, Right Brainers, and No Brainers

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Sometimes I feel a little like the ambassador from the planet Common Sense, and unfortunately very few of us speak the same language. Let’s see if we can segment the Patient Relationship Management (PRM) population into left brainers, and right brainers. I am wrestling with an issue that I believe is a no-brainer.

One point, upon which both sides seem to agree, is that without the patients, PRM would be superfluous. The breakdown is that for a hospital to flourish in the long term, hospitals should re-engineer their business processes to facilitate the dissolution or substantive reduction of traditional customer service.  This extends beyond the cordial relationship of a nurse or a doctor and their patients in hospital beds.

In many, if not most instances, the very existence of traditional customer service provides a vehicle which acts as an enabler for failure. It gives hospitals permission to be mediocre in dealing with their interactions with their patients and physicians. In effect, traditional customer service is a tacit admission to the employees and the patients, “We don’t always get it right. We don’t always do our best.

Before deciding not to read further, ask yourself a few questions. The purpose of the questions is to try and articulate a quantifiable business goal for customer service, PRM.

1. Does customer service have planned revenue targets
2. Does it have its own P&L?
3. Does it have a measurable ROI?
4. What is the loaded cost for each patient and doctor interaction?
5. Could the costs of those interactions be eliminated by fixing something in operations?

If the answers to 1-3 are no, the answer to 4 is unknown, and the answer to 5 is yes, your hospital inadvertently made the decision to ignore revenues and to incur expenses that provide no value to your organization. I believe this premise can be proved easily.

The careers of many people are directly tied to the need to have customer service and call centers. Big is good. Bigger is better. Software, hardware, telecommunications, networks—more is better. Calls are the lifeblood of every call center. Without those calls, the call center dies. Calls are good, more calls are better.

When was the last time you were in a meeting when someone said something like, “In the last three years our patient call volume has continued to increase,” or, “Calls have gone up by forty percent.” That part may sound familiar. The phrase nobody has heard is, “We can’t continue to add that many calls.” Tenure and capital. That part of the business is managed with the expectation that the number of calls will continue to grow. And guess what? It does. How prophetic is that? Or is it pathetic? You decide.

Given that, how does the typical healthcare provider manage their customer service investment? Play with the numbers. In many organizations, if customer service management can show that patient satisfaction is holding steady, no matter how bad it is, and they can use the numbers to show that some indicator has moved in a favorable direction, other areas of the business are led to believe that customer service is performing well.

Memo to those executives who are authorizing customer service expenditures—I want to make sure there is no mistaking how I view the issue. If that is what you are hearing from your customer service managers, they either don’t understand their responsibility, or they understand it and they don’t want you to understand it.

To be generous, if patient satisfaction with regard to customer service is below ninety-five percent, your customer service is in serious need of a re-think. Just because patient satisfaction is not tanking faster does not mean customer service is functional.

Most executives know how to get numbers to paint whatever picture they need to paint. Beware the sleight of hand. Any time the customer service manager comes to you and says he is improving operations by reducing the average amount of time someone spends on the phone talking to a patient (average handle time), don’t believe anything else he tells you. Allow me to translate. When the customer service budget is tight (too many interactions and too few people with which to interact) the way to make it fit the budget is to make your people end the call quicker. Shorter calls mean more calls per hour. Note—speed buys you nothing, except for more repeat calls, less resolution, less patient satisfaction. It’s a measure of speed—IT IS NOT A MEASURE OF ACCOMPLISHMNET.

I’d be willing to bet that somewhere between twenty-five and fifty percent of calls from your patients and physicians can be addressed better via a combination of social media and the Internet.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 85-6942
paulroemer@healthcareitstrategy.com

My profiles: LinkedInWordPressTwitterMeetupBlog RSS

I hate to be a pest…

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…but I inadvertently just proved my own point, albeit to myself. I have been fooling around–with my old MP3 player, and I couldn’t get it to turn off or on–that’s why my wife hides the power tools.

I ducked into a nearby phone booth and put on my SSCC (self-service customer care shirt)–do you realize most kids under the age of ten have never seen a phone booth? Sorry.

Off to Google. I never even considered going to the manufacturer’s web site. I typed, “Remove battery from Creative Vision:M.” Up pop several YouTube videos, each done by one of Creative’s customers, showing step-by-step with voice instructions explaining how to correctly remove the battery. I place a lot more faith in what a customer tells me than I do in what they firm tells me.  Your customers (patients and doctors) do the same thing.

The user manual that came with the device never mentions how to remove the battery.

And this is my point. Your patients know what your other patients need, and in what form it will be most useful. And, they are providing it. Now, how difficult would it be for a hospital, say your hospital, to start thinking about your patients as though you were a patient? Not very.

Of the few hospitals which have a Patient Relationship Management (PRM) strategy or social media (SM) strategy, not too many are effective.  I’ve only seen one which uses those to increase revenues.  Most hospitals use PRM and SM to manage spin, to try to counteract what their patients are saying about them.  One can only imagine the impact a hospital could have by starting the spin, starting conversations about itself using these tools.

You know what?  You don’t have to imagine it.  It is probably the easiest project you will undertake.

Here’s a link to a PowerPoint deck on the subject of PRM.

http://www.slideshare.net/paulroemer/good-CEM-deck

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

paulroemer@healthcareitstrategy.com

My profiles: LinkedInWordPressTwitterMeetupBlog RSS