Strategy

What do you tell the Steering Committee about EHR?

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Success and failure are often separated by the slimmest of margins. To succeed, sometimes you have to be prepared to think on your feet.  You have to outthink unfavorable circumstances. Often, success or failure hinges on how you present an idea.

Permit me to illustrate with frozen chicken. Several hours before dinner I threw some frozen chicken breasts into the sink, choosing to thaw them with water instead of the microwave. Some twenty minutes later while checking emails I wondered what we were having for dinner. Not to be outdone by own inadequacies, I remembered we were having chicken. I remembered that we were having chicken because I remembered turning on the hot water. The only thing I couldn’t remember was turning off the hot water.

I raced to the kitchen. My memory was correct. Noah would already have been building an ark.  Grabbing every towel I could find, I sopped the puddles from the hardwood floor.  While mopping I thought about how I might answer my wife if she returned to a kitchen that looked like Water World.  My first instinct, admittedly poor, was to tell her I thought the countertop wasn’t level and that the only way to know for sure was to see which direction the water ran. Telling her the truth never entered my mind.

Once the major puddles were removed, and believing the major threat from her had passed, my wits slowly returned.  I worked on version two of the story—how do I explain all the wet towels.  I arrived quickly at a more believable version of the truth—I would tell her I decided to wash the towels—all of them.  Why not get bonus points instead of getting in trouble?

Version three sounded even better. Since I’d wiped the floor with the towels, instead of simply telling her I washed the towels, why not double the bonus points? I’d tell her I washed the floor, and washed the towels. Husband of the year can’t be far off.

A few hours have passed since the indoor flood. The floor is dry—and clean, the towels are neatly folded and back in the linen closet, and the chicken is on the grill. All the bases covered. A difficult and embarrassing situation turned into a positive by quick thinking and deft presentation.

Back to healthcare.  A few of you have written and asked, how do you propose we turn around our EHR implementation, turn the focus to solving business problems, not simply implementing an unwieldy system simply to collect the ARRA ransom money?

All kidding aside, it comes down to presentation. Clearly you can’t walk into a steering committee meeting with a just a slide deck showing that the current EHR implementation strategy will decrease productivity.  If there are problems with what you are doing, or the support you are receiving, or the immediacy with which the committee wants to the project to end, present the consequences of the action.  Then present what could be accomplished and what you need to make it happen.  EHR is not done just because the vendor is no longer in the building.  All you can conclude from that is that there are a few freed up parking spaces.  Your goose may be cooked.

So, what happened with my chicken dinner? I was confident I had sidestepped to worst of the threat. Overconfident, as it turned out.  My son hollered from the basement, “Dad, why is all this water down here?”

Parallel universes–replacing one EHR for another

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Some providers are changing their EHR system.  Why?

Why indeed?  What precipitates the need to change?  I bet if you take the top five or seven EHRs, and compare them to a rigorous set of requirements you will find they all score within one standard deviation of the norm.  You won’t hear that from the vendors, but they are the same with regard to the major functionality.

There is no single vendor who scores head over heels above the others.

I bet if you interviewed their customers you will not find a customer which thinks their vendor is the be-all end-all of healthcare.  In fact, you will learn at best most clients will score their satisfaction with their vendor mediocre. Depending on what numbers you read, you will see failure rates in excess of fifty percent.  Failure, by my metric, has more to do with what someone did or did not do to the application than it has to do with the application itself.  This is a “Do these pants make me look fat?” issue.  Guess what, it’s not the pants.

Is there a single vendor who can state that none of their clients has ever replaced them with one of their competitors? That means if you are thinking of replacing EHR A with EHR B, another hospital is thinking of replacing EHR B with EHR A.  Parallel universes, or is it universi?

The grass will not be greener.  Here is what will.  A lot of hospitals operate with what can best be described as anything but best processes–worst processes.  No EHR can handle those.  Before you begin again, evaluate your processes. Weed out the bad ones, do away with the duplicates.

Are you willing to spend another hundred million or two hundred million dollars to get marginally higher satisfaction? Instead, how much would you have to spend to change your processes, implement a change process, retrain your people, and devise a system to bring in your ambulatory doctors?  It would certainly not exceed nine figures.

EHR need not be a do-over.  For those just getting started, do process prior to implementation, not after.

It’s not the pants.

How should a provider approach Meaningful Use?

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New Headquarters?

The following is my reply to a post in HealthcareITNews from March 8.  The title of the post is, CONSUMERS WEIGH IN ON TOP 10 MEANINGFUL USE ARGUMENTS.  The link is, http://www.healthcareitnews.com/news/consumers-weigh-top-10-meaningful-use-arguments#comment-574

Of cabbages—and kings—

And why the sea is boiling hot—and whether pigs have wings. Lewis Carroll, Out of the Looking Glass. It is a nonsense story, one which cannot be argued.

As are Electronic Health Records (EHR) and Meaningful Use (MU)—at least to date. Measured against any reasonable set of standards, except on a one-off basis, the national rollouts of EHR and MU have failed. I expect it will be even more so next year.
You, the public, have the right to comment, and we have the right to tell you why your comments hold no water. I think it is the inverse of you have the right to remain silent, you just don’t have the ability. I am writing about the ONC and the bone they tossed calling for public comment. They are required to provide for public comment in order to remove the N and the P from the NPRM.

Who among us believes the rule making will markedly shift direction as a result of any of the public comments? That is unfortunate for if they were to shift direction they might find a direction. We don’t know where we are going, but we are making good time getting there. Figures suggest a failure rate of EHR implementations of somewhere between fifty and seventy percent. As healthcare IT resources become scarcer, I expect the failure rate to increase. As providers rush into EHR without a detailed strategy simply to grab the incentive money, there will be more expensive failures. More failed EHRs is not a way to measure progress.
The current cover of Government Health HIT magazine depicts a foot race to meet MU. There is no race if there are no entrants. There may be more people on the cover than will actually qualify for the race, even fewer who will reach the end.

We would be better served if the plan for national rollout of EHR were not written on an Etch-A-Sketch. We don’t know what will be included in Stages 2 and 3 of MU. When will fifty percent of providers have an EHR, not just the software, but one that actually boosts productivity? How about 70% or 80%? Ten years? I ask the same question of the Health Information Exchanges (HIEs). Without unilateral adoption there will be large gaps. Will the national network function with these gaps? To what extent? Will the records only make it part of the way from Patient A to Doctor X?

Having not solved the EHR program on their own, and having no viable plan, the government laid the burden of making EHR successful on the backs of the providers. The government tries to offset the burden by offering financial gratuities—and penalties—to the providers. Not exactly the second coming of the Three Wise Men. Trying to hit the ONC’s targets is a little like playing the confidence game, the shell game. Under which shell will providers find the rules, the plan?
What to do?

It is easy to criticize. Permit me to offer a few suggestions. To the hospitals, if you are not well along the EHR path, do not make a difficult effort more difficult by chasing Gossamer incentive dollars. Stick to your plan. You have multiple failure points which three years from now will make chasing those dollars look like a pipe dream. The failure points? Your plan, the implementation, meeting the MU requirements, passing the MU audit. It does not look very promising to me.

To those hospitals which haven’t started their EHR initiative, or are less than halfway through the passing the failure points, don’t cancel your summer vacation. You have a lot more time to get it right then you have to get it wrong. Pay no attention to the man—or woman; even I can have a moment—handing out the Monopoly money. You won’t be receiving any. From where I sit, that is good news. It will cost a lot more to perform disaster recovery on a poor implementation than the funds you would have received by meeting MU.

How long does a hospital spend planning to build a new hospital wing? For large hospitals, the cost of your EHR will likely exceed the cost of the new wing. Plan accordingly. Invest six or nine months building a plan that might succeed.

For medium and small practices and solo providers you have nothing to lose by waiting a year months other than the resource problem. By then you will find very viable ASP and shrink-wrapped solutions.

Those who follow my blog, healthcareitstrategy.com, know I don’t write to garner favorable replies from those who think they’ve already got it figured out. I write for those who because of EHR have difficulty sleeping. Thanks for reading. As always, I appreciate your comments and disagreements.  

EHR–the five stages of grief

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The Kübler-Ross model, commonly known as the five stages of grief, was first introduced by Elisabeth Kübler-Ross in her 1969 book, On Death and Dying.  I heard a story about this on NPR, and it made me think about other scenarios where these stages might apply.

My first powered form of transport was a green Suzuki 250cc motorcycle.  My girlfriend knitted me a green scarf to match the bike.  One afternoon my mother walked into the family room, saw me, and burst into tears.  When I asked her what was wrong, she told me that one her way home she saw a green motorcycle lying on the road surrounded by police cars and an ambulance—she thought I had crashed.  I asked her why, if she thought that was me lying on the road, she did not stop.

My girlfriend’s mother, didn’t like my motorcycle—nor did she like me.  Hence, my first car; a 1969 Corvair.  Three hundred and fifty dollars.  Bench seats, AM radio.  Maroon—ish.  It reminded me a lot of Fred Flintstone’s car in that in several places one could view the street through the floor.  Twenty miles per gallon of gas, fifty miles per quart of oil.

Buyer’s remorse.  We’ve all had it.  There is a lot of buyer’s remorse going around with EHR, a lot of the five stages of grief.  I see it something like this:

  • Denial—the inability to grasp that you spent a hundred million dollars or more on EHR the wrong EHR, one that will never meet your needs
  • Anger—the EHR sales person received a six-figure bonus, and you got a commemorative coffee mug.  The vendor’s VP of Ruin MY life, took you off his speed dial, unfriended you in Facebook, and has blocked your Tweets. You phone calls to the vendor executive go unanswered, and are returned by a junior sales rep who thinks the issue may be that you need to purchase additional training.
  • Bargaining—when you have to answer to your boss, likely the same person who told you which system to purchase, as to why productivity is below what it was when the physicians charted in crayon.
  • Depression—you come in at least fifteen minutes late, and use the side door, taking the stairs so you won’t see anyone.  You just stare at your desk; but it looks like you are working. You do that for probably another hour after lunch, too. You estimate that in a given week you probably only do about fifteen minutes of real, actual, work. (Borrowed from the movie, Office Space.)
  • Acceptance—the EHR does not work, it will never work, you won’t be around to see it if it ever does.  Your hospital won’t see a nickel of the ARRA money.  You realize the lake house you were building will never be yours, but the mortgage will be.

The five stages of EHR grief.  Where are you in the grieving process?

True, there are a handful of EHR successes.  Not nearly as many as the vendors would have you believe.  More than half of hospital EHR implementations are considered to have failed.

If you are just starting the process, or are knee-deep in vendor apathy you have two options.  You can bring in the A-team, people who know how to run big ugly projects, or you prepare to grieve.

If it was me, I’d be checking my list of friends on Facebook to see if I was still on my vendor’s list of friends.

Your EHR contract–Until death do us part?

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That’s a long time. There are those who suggest that statement sort of takes away any incentive they had to live forever. They wonder why it couldn’t be somewhat less restrictive like, “for the foreseeable future,” or “until one of us gets bored,” or “renewable every four years.”

Till death do you part. Sort of like you either just purchased or are about to share your future with. Once the figures get beyond two commas, you’re pretty much locked in—for better or for worse. It makes no difference if you’ve outgrown it, no longer need it, figure out you never needed it, found something better. Perhaps next time you can suggest more friendly language as you stroll arm in arm down the EHR contract aisle.

First, you must make the other party think that they need you more than you need them.
The best contract is an agreement that is binding on the weaker party—hopefully your EHR vendor. Here’s a little twist for the next contract negotiation with the EHR vendor.

Vendor: Will you manage my EHR with all your heart?

Manage it till death you part?

C-suite: Yes, I’ll manage with all my heart,

From now until death do us part,

And I will manage it when it breaks,

And when my boss over the coals me rakes,

And when it’s fit, and when it’s sick,

(Oh, CAN’T we finish this contract quick?)

And we will own it when it’s bad,

And we will own it when I’m mad,

And I will still own it when it’s broke,

When all our patients want me to choke,

And when if fails Meaningful Use,

And when its failure cooks my goose,

And I will be none the dapper,

As my career goes in the (you fill in the blank),

While searching the bowels for our old charts,

Since productivity has fallen apart,

I will manage it as you like,

As all our doctors go on strike,

And I will eat green eggs and ham, and I will like them Sam I am.

Comparing EHRs–like measuring how wet is water

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The following is a reply I wrote to John’s post at emrandhipaa.com on

EMR Key Differentiators.  http://www.emrandhipaa.com/emr-and-hipaa/2010/03/07/emr-key-differentiators/comment-page-1/#comment-122817

You are spot-on with your comment about the requirement that they be measurable.  Otherwise everyone will be arguing something as nonsensical as how wet is the water.

Even on the second group of differentiators, one can argue that they are too easily qualified.  “Excellence” and “easier” are difficult terms to measure.  Stating that an EHR was designed for a specialty may be of no more value than stating a Yugo was designed for the sports car enthusiast.

I’d look for differentiators along the lines of the following, and then see if they result in business improvements:

  • Our system requires 25 % fewer clicks per process than systems A, B, and C
  • Our system uses 1/3 less screens to enter X than systems A, B, and C
  • Productivity at hospitals H1, H2, and H3, as measured by factors E, F, and G, is up 12%
  • We are able to see an average of 12% more patients since we started using XYZ
  • Rework and errors by our clerical staff is down 8% since we started using XYZ

These differentiators each translate to measurable increased revenues and decreased costs.

But, for how long will this matter?  The business driver towards EHR seems to be to ameliorate today’s problems.  I believe the future of healthcare is not the EHR, HIE & NHIN.  The future of healthcare is post-EHR, electronic medical records will be in a cloud, and will be here before the paint on the NHIN has dried.

Overcoming competency

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Which is more difficult—overcoming competency or incompetency, or is this another example of rhetorical nonsense? Experience has taught me that some firms are ambidextrous when it comes to overcoming competency—they can overcome being competent with either hand or with both hands tied behind their back.

Let’s see. Competency without value is what? I think that’s incompetency. That’s what I call the Competency Gap—not even knowing that what’s being done isn’t delivering the value. The Competency Trap is the silly belief that trying harder and implementing technology somehow improves the problem. It’s sort of like, “We don’t know where we’re going, but we’re making really good time.”

I’ll go out on a limb and guess there was a time in your hospital or clinic when you didn’t have to overcome the competency of those who claimed that EHR would make everything better, those who thought you needed help, thought they knew how to help, those who backed up the truck, dumped the EHR technology at your doorstep, and started you down healthcare’s Bataan death march.

Some EHR initiatives make me more paranoid than I already am.  How is it working out for you?  Are the clipboardists checking your every move to see how well the EHR is performing?  If in the midst of their competency they did not redesign all the processes affected by EHR, it is probably not working too well. It seems a little like planning a daisy and pulling it up every hour to check the roots and see how well it’s growing.

You tell me. Are the doctors and staff any happier? More satisfied? Has the EHR worked, has it improved productivity, or has it simply given the appearance of looking high-tech?  My guess is that everyone would be a lot more successful if people would leave the daisies alone.  

“Incompetency begets incompetency. The last thing a guy who isn’t sure of himself wants is a guy backing him up who is sure of himself.”

Lee Iacocca

Why should you reframe the EHR discussion?

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Are you one of the millions with recurring dreams of taking college exams?  I remain haunted by two, both which happen to be rebroadcasts of real events.

In the first, I had convinced my graduate school professor of operations management that since I took operations research in college that I could “audit” his class and be the teaching assistant.  I used the term auditing to mean I didn’t have to attend the class or do the home work.  From the school’s perspective, it did mean I had to take the final.  As I learned sitting at my desk, wishing I could think of any excuse to move my pencil across the pristine pages of the blue book, apparently there is a difference between operations research and operations management.  Whatever the difference was, it accounted for the blank pages staring up at me.

At the end of the exam the only marking in my book was the note I wrote to the professor, “I think we both know I know how to do this however, I froze.  If you need to fail me, I understand.”  He gave me a “C”.  I saw him when I visited Vanderbilt last year, and he recognized me and remembered the story—I like to keep my audience riveted.

The other dream has to do with my lone Poly-Sci class as an undergrad.  I am a proponent of the notion that I can answer almost any question provided I can reframe the question into one I can answer.  The exam instructed us to answer a question about a book I hadn’t read.  My only choice was to reframe the question, equating it to one from a book I had read.  I gave what I thought amounted to a fairly reasoned response to “my” version of the question.  The professor agreed that I had, and then wrote on the cover of the exam book that he too used the same device when he was in college.  It had not worked for him and he wasn’t going to allow it to work for me.

I think many of those grappling with EHR would benefit from reframing the question.  Many view the question as, “How do I accomplish what the folks in Washington want me to do?”  Sometimes that question might deserve an answer.  In the case of EHR I do not think it does.  In fact, I think answering the question, and then building a plan around your answer can make EHR more difficult, and it can move you away from your business goals.

A better question, at least for your hospital or practice is, “Does it make sense for me to accomplish what the folks in Washington want me to do?”  Has Washington demonstrated enough leadership over EHR, Meaningful Use, Interoperability, or reform to justify following?  Have they provided enough clarity, defined a set of business objectives, or justified their reasoning?  Does their reasoning fit your business model?

I bet it does not.

Why DC might be wrong on Meaningful Use

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I watched recently Barry Levinson’s movie Liberty Heights about a handful of people in Baltimore growing up in the fifties.  In one scene the high school practices a civil defense drill.  For those who have never seen a civil defense drill, a number slightly smaller than those who have never seen a dodo bird, permit me to explain.

From the fifties through the early eighties the fear of the US and the Soviets—if you have to look it up, it is better that you stop reading—engaging in nuclear war seemed so imminent that school children participated regularly in drills to protect them from nuclear attack, nuclear winter, nuclear annihilation.  The exercise was called duck and cover.  Stay with me now—those in charge were quite serious about this.

In duck and cover, once you saw the flash of the nuclear explosion—assuming your retinas weren’t fused—you were supposed to get under a table, most likely a wooden one that would have already turned to ash, and assume the fetal—or fecal position.  Educated adults came up with this idea as a solution, people with PhDs.

Generations of kids, millions of kids practiced this drill several times a year.  Someone puts forth a directive.  Instead of challenging it, other reasoned adults wallow in their folly.

Duck and cover.  Lemmings off cliff.

EHR and Meaningful Use.  Lemmings off cliff.

Question it before you leap.  EHR is a great opportunity.  EHR under the government’s direction—this is the same institution who developed duck and cover.  EHR and Meaningful Use—if you find it meaningful, you would probably benefit from speaking with someone who does not share your perspective.

Meaningful Use from EHR’s Meaningful Muse.

When reform collides with EHR…

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If I remember my physics correctly, there’s no discernable difference between screaming in a vacuum and not screaming in a vacuum, unless of course someone turns it on while you’re in it, and then by default, you’re screaming. That seemed to make sense to me during my run, but seeing it on the screen isn’t doing much for me. Ever since I tore my Achilles I can’t run as far, and I’ve gained a few pounds. I feel like I’m in my first trimester-running for two of us, sort of a Shamu in Nikes.

Enough about me.  Here’s the deal. There seems to be a slight shifting of the winds in terms of those who now believe reform will work.  The winds are blowing more towards the skeptics.  Who among us can articulate what is included in the reform effort in a single PowerPoint slide?  (Can you picture Ross Perot with his slides and wooden pointer?)  If we can’t explain the reform effort to ourselves, how then can we explain the business problem we’re trying to solve with EHR?  Until you’re comfortable articulating the benefits to your organization—not the ones spelled out on a dot-gov web site, you’re better off holding on to your checkbook.

The current EHR/healthcare reform effort violates Keynes’ third law of shopaholics anonymous–just because something you can’t afford and don’t need goes on sale doesn’t mean you have to buy it. (Unless of course it impresses your friends.)  In addition to the trillion dollar stimulus, maybe the government was awarded discount coupons–20% off on EHR if redeemed before the payors own the providers.