Time Capsule: If EMR Vendors Designed Cars, the Steering Wheel Could Be Anywhere: Why a Universal Physician Interface Makes Sense (and will never happen)

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in November 2008.

If EMR Vendors Designed Cars, the Steering Wheel Could Be Anywhere: Why a Universal Physician Interface Makes Sense (and will never happen)
By Mr. HIStalk

I used to work in a two-IDN town. In fact, I had worked in the IT department of both of them (not at the same time, unfortunately, since that would have been a sweet paycheck).

Both IDNs bought big-ticket inpatient clinical systems within a few months of each other. Those who have worked in a two-hospital town or remember the Cold War understand this instinctively.

As inevitable as it was that rumors of one of us buying a system sent the other scurrying to draft an RFI, it was preordained that we would not consider the same vendor. Whichever IDN bought last would look like an unimaginative lemming, so there was no doubt that two vendors would be shuttling people into town for years.

I was shocked that the local newspaper not only cared about our respective deals, they took both IDNs to task in a rather scathing editorial for going our separate ways. In their minds, we had blown a golden opportunity to finally agree on something other than the fact that one of us was a plainly second-tier system (which one was another thing we didn’t agree on).

From a community perspective, they were probably right. Both places served mostly community-based physicians who practiced in hospitals of both IDNs. Our ruggedly individualistic decisions meant that most of the doctors in town would not only have to learn to use an EMR to keep in our smothering good graces (since ROI was dependent on massive, yet unlikely voluntary physician usage). They would have to learn TWO systems with nothing much in common except they both had a screen and a keyboard.

(That allowed us both to argue that we had chosen a better system than our cross-town loser competitors. In addition, there were only three real vendors that would have been acceptable and one of those was a little shaky at the time, so we went out of our way to avoid consensus).

Vendors would never object to this, of course. Software that looks and works alike has a name: “commodity.” In that respect, vendors had as much interest as we IDNs did in bucking the trend set by our competitor or vice versa.

Here’s an interesting idea, though. Why couldn’t CPOE and EMR systems have the same common user interface? They provide and accept the same basic information. Are screens really so highly proprietary and ingenious that they can’t be the same on all systems? Couldn’t they put their high-margin secret sauce somewhere else, like in clinical decision support, scalability, cost, or maintenance quality?

(You could almost make this happen in the old character-based days by using screen-scraping applications to redesign the front end, like Attachmate or programmable fake Windows front ends).

Everybody always says, “You can use a browser without reading a manual first.” As annoying as that statement is, everybody is right. Browsers, cars, TVs, and credit cards all look and work pretty much alike to the user. That increases adoption, yet still allows plenty of criteria on which vendors can compete and differentiate.

Physician systems operate under the most bizarre paradigm of any software application. The organization that buys them isn’t the one using them, for the most part, since doctors are self-employed (unlike pharmacists, rad techs, nurses, etc. who practice in just one place using just one system). Usage is voluntary and therefore sporadic. Those voluntary users (who are really our customers) are supposed to deal with it, show up for training, and read ongoing messages about bugs, upgrades, and downtime (times two or three, depending on the town).

If I were HIT King for a Day, my second decree (after putting a spending cap on HIMSS exhibits) would be this: every system intended for physician use will employ a common user interface whose visible appearance, terminology, and user interaction is fixed. Vendors who fail to comply will have their kneecaps broken by CCHIT.

What vendors do behind the scenes is their own business, but when you’re selling cars, no matter how clever your designers are, the steering wheels and pedals need to be in the same place if you want to move iron.

Time Capsule: Dirty Geeks and They’re Done Dirt Cheap: How Wall Street’s Huddled Masses Could Reshape Healthcare IT If We Just Asked Them

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in October 2008.

Dirty Geeks and They’re Done Dirt Cheap: How Wall Street’s Huddled Masses Could Reshape Healthcare IT If We Just Asked Them
By Mr. HIStalk

Healthcare IT has always been inbred. The same folks just keep moving between provider and vendor, hospital operations and IT, and Organization A and Organization B. The name tags change, but the faces stay the same. Most of the value of the HIMSS conference is in reconnecting with all those folks who scattered like billiard balls since you saw them last.

HIT is an esoteric discipline, at least according to those who are in it. We’ve kept it that way by demanding healthcare experience for most jobs, ensuring that few strangers and their highfalutin’ new ideas enter our comfortable midst (it also helps that healthcare pays less and uses bizarre technologies that the rest of the techie world has never heard of, like MUMPS and Magic).

Nobody knows whether healthcare will dodge the economic bullet this time around. If it does, lots of non-HIT techies will be pressing their noses to our glass, seeking a chance to start earning a paycheck again. It will look like that Twilight Zone episode where the guy is holding a gun on his neighbors to keep them out of his bomb shelter.

This Mariel boatlift of geeks could be great news for healthcare. Banks and investment companies were (note the past tense) full of experts in online transaction processing, security, project management, and forecasting. What will we tell those folks when they drop by?

Traditionally, it would be a slightly more polite variant of “hit the road.” No healthcare experience means we don’t want you, no matter how skilled and experienced you are at the same kinds of technology that we’re planning to use. We’re healthcare and we’re different.

That’s a mistake. The industry could use some new, baggage-free ideas from people who have spent their lives doing what healthcare is just now learning about: running large-scale, mission-critical systems and conducting business innovatively over the Web. And right now, especially if your hospital or company is anywhere near New York, Boston, Chicago, Hartford, Charlotte, or other cities that revolved (note past tense) around the financial services industry, I bet you could hire them for about the same money you pay those same old retreads.

This could be the most exciting HIT development in decades. Many of our bread-and-butter applications are old, poorly secured, and Web-indifferent. Developing portals and RHIO connectivity is a snap compared to keep tracking of some of those bizarre investment instruments their former finance bosses just choked on.

Interested in patient payment systems, real-time adjudication, Web-based customer service, or throughput modeling? Those are the folks who could knock that out right now, already used to skipping lunch and working long hours.

Healthcare has always been jealous of banking IT people, visibly grinding their jaw when innocent outsiders make the inevitable comparisons of their cutting edge work vs. healthcare’s 1980s-era challenges still being solved. Deep down, we knew they were right. Former hospital staff turned self-taught analysts couldn’t hold a candle to the best and brightest techies who headed to Wall Street in droves and moved that industry from staid old storefronts to cutting edge electronic commerce. Hey, their stuff works – it’s not their fault that their big-dollar bosses were a lot dumber than everybody thought.

Now we get even. Pay them a lot less, squeeze them into cubicles, and make them take orders from clinicians turned semi-programmers. The tortoise won this race. We don’t care about your international arbitrage software – just write an EMR system that doctors will actually use.

Think of this as your own Wall Street bailout, with benefits.

Time Capsule: Every Time I Say It’s About Patient Care, You Tell Me It’s a Business: Healthcare IT Lessons Learned from “North Dallas Forty”

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in October 2008.

Every Time I Say It’s About Patient Care, You Tell Me It’s a Business: Healthcare IT Lessons Learned from “North Dallas Forty”
By Mr. HIStalk

One of my favorite and most insightful lines from any movie comes from “North Dallas Forty,” a cynical and dark football film from 1979. In a key scene, fictional football player O.W. Shaddock, masterfully played by former Oakland Raider John Matuszak, explodes his rage and frustration onto the team’s coaches, who constantly resort to using fear and ridicule to get tired and injured players to keep performing even when they shouldn’t. "Every time I say it’s a game, you tell me it’s a business. Every time I say it’s a business, you tell me it’s a game."

The quote may have been about sports, but it’s relevant to healthcare as well.

I’ve worked for both vendors and hospitals. There were plenty of times on both sides where I wanted to scream at management, “Every time I say it’s about patient care, you tell me it’s a business. Every time I say it’s a business, you tell me it’s about patient care.”

Our unusually capitalist approach to healthcare delivery is schizophrenic. Everybody understands giving massages or tummy tucks for the biggest fee the market will bear, but there’s something inherently distasteful in performing life-saving surgery or seeing patients through their final days of cancer while a business guy taps his calculator every now and then to remind everybody — including the patient — to keep the cost down.

IT is usually smack in the middle of that rift between clinicians and executives, the bearer of bad news about something one group wants that the other is loathe to deliver. Clinicians resent being told how to deliver care by $1 million hospital CEOs and their business-savvy underlings. The people in the mahogany offices can’t talk slowly enough about cost control to get the message across the financially naïve white coats who would bankrupt the place if someone wasn’t watching the till. Somebody wants a CPOE system or a tool to run a balanced scorecard and the IT person knows exactly which part of the organization will be calling for his or her head.

Clinical people working for vendors have the same struggle. They’re supervised by executives who not only have never delivered care, but who most often drifted into healthcare by accident and will probably drift right back out again someday. Every undelivered system enhancement or overstated capability make the clinicians want to scream like O.W. Shaddock, physically threatening an overconfident MBA vendor suit whose last service to others was whispering the Black-Scholes equation to a B-school classmate during a tough finance test.

We’re in a confounding business whose mission is frustratingly mixed. Deliver the best care or the best clinical software possible – as long as it’s profitable. If it’s not, the MBAs are ready to rush in and whip the widgets into shape. That’s a threat and a promise.

Maybe it would help to see how the other half lives. Clinicians should sit through the meetings in which life-or-death decisions are made that concern the health of the entire organization, not that of individual patients. Executives should have to face real patients and caregivers regularly just to remind themselves of a mission more important than fancy new buildings and slick marketing.

And IT folks working for both providers and vendors … well, there’s really nothing you can do except wait for the dust to settle and support and enable whatever strategic plan results. Those other folks are playing tug-of-war and you’re the rope.

Time Capsule: This Is No Time for Timidity: Contrarians Who Take Bold Steps Instead of Moaning About Poor Financial Conditions Will Win

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in September 2008.

This Is No Time for Timidity: Contrarians Who Take Bold Steps Instead of Moaning About Poor Financial Conditions Will Win
By Mr. HIStalk

I bet every healthcare IT vendor wishes they were a mortgage lender. You make enormous profits for generations, pay gunslinging financial cutthroats salaries of up to hundreds of millions of dollars, and when the music stops on all those illogical investments that racked up obscene profits for years, you cry "Uncle." Uncle Sam, that is. Help, I’ve fallen and I can’t get up … come quick and bring your checkbook.

Unlike those investment clowns, healthcare IT companies die quietly when their time comes. Maybe they run out of cash, exceed the abilities of their founders, or learn the hard way how little they really know about their business. Those who can’t cut it slink off to the Great Vision Center in the Sky. Tough old world.

I’m not only a free marketer, I’m a Darwinist contrarian. You cannot succeed just doing what everyone else is doing. Sheep happily follow each other to the slaughter. The time to take bold action is when everybody else is too scared to, like now.

I have no data to back it up, but here’s what I believe. You hit your financial home runs when times are bleak, not when the exuberance is irrational. Buy when everyone else is selling. Expand when your competitors are cutting back. When the pendulum inevitably swings back, you’ll look like a genius. Those with the big brass ones will win.

There’s no doubt that credit will be hard to get, and rightfully so. But think about this: investors looking for stock market alternatives weren’t raised on plunking cash into unsexy bonds or gold funds. Companies with a track record and a good story will find investors. Maybe it isn’t the best time to run an IPO since stock prices follow the market down, but private investment should be ripe for some smart deals. Buy a competitor, replace unproductive employees, and make unpopular decisions while everyone is preoccupied with the Dow’s latest drop.

Vendors may see the customer pipeline start to dry up. Fear, rational or otherwise, makes people hunker down. That’s not the ideal situation, but it’s a good time to take a breath, look hard at product lines and strategies, and figure out a strategy for 5-10 years down the road. Sharpen the saw in preparation for the spring that inevitably follows winter.

It would be great if economic conditions sucked less, but you play the cards you’re dealt. Down markets eliminate weaklings. Survivors come back stronger than ever. The decisions you make today may well lock in a future (good or bad) that will persist for decades.

While all the timid MBA suits are whining, stuffing their money into mattresses, and telling everybody how well they could have done if the bad old market hadn’t betrayed them, real businesspeople will be quietly making moves to take advantage of current conditions. It’s a zero-sum game. You get to pick: on your feet or on your knees.

Time Capsule: Is Your Hospital IT Department like the Soviet Union? If So, It’s Time for Glasnost

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in September 2008.

Is Your Hospital IT Department like the Soviet Union? If So, It’s Time for Glasnost
By Mr. HIStalk

I’ve been on both sides of the hospital IT fence. More than once, in fact, and in more than one organization.

I was frustrated by illogical users when I was in IT management. I was frustrated by illogical IT management when I was a user.

I was thinking the other day that IT is like the old Soviet Union, at least in some of the hospitals I’ve worked. It’s no wonder that the proletariat and the ruling party can’t get along.

Stoic bureaucrats in unelected positions of authority lay out an immovable five-year plan that changes every year. That frustrates the average citizen, who only knows what they can see first-hand: IT systems haven’t made their jobs easier or better.

Projects are kicked off with a revisionist review of history: similar projects were successful because IT says they were, user experience notwithstanding (lofty benefit projections for big-ticket IT purchases are never discussed publicly after they invariably fail to materialize).

High-profile project failures require placing personal blame, so somebody gets fired (usually the person least responsible for failure, dismissed by the person most responsible). The “Ministry of Our Projects Are Going Great” cranks out endless propaganda. Any vocal dissenters are deported to Siberia, stripped of IT committee and liaison responsibilities before they can cause an ugly uprising, replaced by more loyal party members.

Well-intentioned IT inefficiency designed to ensure equal treatment for all creates bread lines, i.e. long waits for the help desk line and a bureaucratic approval process for big ticket IT purchases (like $10 keyboards and $20 DVD drives).

That inefficiency in supply and demand leads to black markets, where people go to Office Depot with their department’s procurement card to buy laptops or bring in their own unsecured $30 router because wireless coverage is poor in their area and nobody’s fixing it.

All the cheap Best Buy technology is infinitely cooler than the stripped down, beige box PCs that IT issues. They’re like ugly Russian automobiles of the 1970s, thrown together by tractor makers for purely utilitarian purposes.

State-ordered collectivization forces local technical resources like servers and programmers to be brought under IT’s control in an attempt to boost productivity. It rarely works except on paper.

The creative and intellectual classes may seek a less oppressive environment, preferring a workplace where they can load their own software, use Macs, or buy an unapproved PDA that they’ll have to support themselves anyway.

Leaders, in the mean time, live in a more privileged world. They get sexier IT equipment (that they rarely know how to use) and get VIP treatment when they need IT help. Instead of cruising around Moscow in limousines, they peck publicly on BlackBerries and fancy laptops that the peasants can’t have.

Soviet-inspired IT leaders sometimes end up like Czar Nicholas II, overthrown and executed by the oppressed Bolsheviks (Career Is Over indeed). Hopefully, though, they (or their predecessor) introduce glasnost, making IT more transparent and allowing more individual freedom for the creative class.

What I learned in IT is that technology management is expensive; that getting people to agree on a common course of IT action is nearly impossible; and that the strategic deployment of IT is not something the average user can understand or appreciate.

What I learned as a user is that IT is often steered on wild goose chases by out-of-touch senior management; that my individual skills and capabilities are unimportant when IT enforces restrictive technology rules made for the clueless masses; and that rigid IT tunnel vision stifles the organization in its attempts to mitigate tiny IT-related risk.

What I learned as both is that everybody wins when IT listens to its users and vice versa.

Time Capsule: Once You Sign the Contract, You’re Just Another Customer Who Used To Have Leverage

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in September 2008.

Once You Sign the Contract, You’re Just Another Customer Who Used To Have Leverage
By Mr. HIStalk

The healthcare software vendor I used to work for geared up for our annual user group meeting like hospitals preparing for pre-announced Joint Commission inspections, i.e. we scrambled frantically for a couple of weeks to make it look like we had done a good job all year.

Those user group meetings were generally cordial. Rank-and-file users with personal bones to pick usually didn’t attend since their bosses used the travel money themselves. It was our suits against theirs, a wary face-off of capitalist warriors on a hotel carpet battlefield under an ominous cloud of expensive cologne.

A few vendor riffraff like me were in attendance to support specific low-level contingencies. We were told: (a) show up only for the events for which you’ve been assigned, then get back to work; (b) don’t admit to any claims of software bugs or unannounced changes in strategic direction; and (c) stay away from the food.

One popular session every year was a "grill the executives" event. Our highest-ranking suits stood on a humbly bare stage and took questions from the audience. Our execs played it close to the vest, so it ended up being a Charlie Brown-like hum of pleasant but indistinguishable MBA-level buzzwords. It passed for sincerity, but an hour later, customers were hungry for information all over again.

I remember when one guy zinged the reigning suit. He waited for his turn at the aisle microphone, smiling and nodding sympathetically, but then grabbing the mike like he was Mick Jagger. Instead of belting out Satisfaction, he proceed to rip us a new one, complaining loudly and bitterly about something we had botched (forgive me for not remembering what, but the list of possibilities is long).

Since I knew that executive better than the customer and, therefore, respected him even less, my fellow flunkies and I secretly cheered the guy on. (It would have been more impressive if he hadn’t reached for his notes mid-rant, but it was still a pretty good job for a guy who spent his days under data center fluorescent lights).

The executive on stage looked like he had just discovered that a miscreant had keyed his mahogany wall, but he quickly got back on track. He oozed sincerity in personally promising the angry guy that someone at a more appropriate level would look into it. I bet he was happy with himself: he had talked the guy down.

Even as an industry newbie, I knew the customer’s plight. He had no leverage, so his only remaining shot was to whine publicly. His hospital had already bought our stuff.

Partnership promises aside, signing the contract of some vendors changes the dynamic from "we’ll do anything you want and put it in the contract” to "we’ll think about it and let you know." Switching costs are high, so most customers aren’t going anywhere no matter how mad they are. Everyone knows this.

If the vendor’s choice is between "do a lot of work for a customer who will pay us no additional money” vs. "do some work and rack up big sales," most (but not all) vendors will go for B every time.

That one-sided vendor advantage is probably being chipped away. KLAS reports give unhappy customers a forum, forcing vendors have to pay at least some attention to them. The few pay-as-you-go software licenses (like subscription models and ASPs) reduce the switching costs and give customers earlier options to bail. Blogs (obvious disclaimer: I write one) level the information playing field and call BS in ways that advertiser-supported magazines traditionally hadn’t touched. Unresponsive vendors are finding it a little harder to hide.

Still, I don’t blame those vendors. They live and die by the big sale. It’s easy to forget that you are actually expected to work for those recurring revenues when everybody is talking about the sales pipeline.

Here’s what our Mick Jagger would have advised. Don’t buy futures. If it’s important, get it in writing before the sale. Get visibility in the industry, which vendors respect because it gives you a platform. Put the vendor at risk by scaling payments to performance. Cheerlead for your vendor so they’ll want to work to keep you happily chirping. And if you have to use public shame to get them to listen, it’s probably a lost cause. It’s likely that (You Won’t Get No) Satisfaction.

Time Capsule: Best Buy’s “You, happier™” Slogan Says a Lot About Unhappiness (Both American and Healthcare IT)

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in September 2008.

Best Buy’s “You, happier™” Slogan Says a Lot About Unhappiness (Both American and Healthcare IT)
By Mr. HIStalk

To me, the most important part of the Sunday newspaper is the Best Buy ad. I don’t really need what’s in there (nothing they sell is essential, like food or clothing). I’m doing my patriotic duty, which calls for irresponsible consumer spending to keep the shaky economic wheels turning. I usually grab a computer gadget (who can resist yet another USB drive?) or a sure-to-be-unopened DVD boxed set of a TV show that I never watched when it was on.

This week’s ad had a new slogan under the Best Buy logo (right above the must-have LCD TVs). It said, “You, happier™.” They put that little TM in there, daring competitors to even think about appropriating such an ingeniously alluring come-on.

(TV may be nothing but trashy reality shows and endless commercials, but those can apparently masquerade as satisfying entertainment when beamed into a 52” plasma HDTV with surround sound. Insanity is watching Adam Sandler movies over and over on Blu-Ray and expecting different results).

Not that I don’t trust Best Buy’s motives, but I’m beginning to think that “You, happier™” isn’t working. According to a recent survey, US citizens are #16 in the list of countries when it comes to overall happiness. Everybody’s broke, so maybe we’re as happy as we’re going to get racking up credit card debt to fuel the pointless accumulation of consumer goods.

I was also thinking about the parallel with US healthcare. We’re mid-pack there, too, coming in at #37 as WHO sees it (edging Slovenia but trailing healthcare juggernauts Costa Rica and Dominica).

Providers waste a lot of money on poorly conceived IT purchases. That alphabet soup of ERP, CPOE, and BI looked appealing. So did all those juicers that late-night TV watchers ordered in a depressing quest for happiness (does anyone other than the 165-year-old Jack LaLanne really pulverize $3 worth of raw carrots to get a skimpy glass of awful-looking juice that still tastes like raw carrots?)

I love going into Best Buy. I’m happy roaming the HIMSS exhibit hall. I’m uplifted at the idea that I can trade money for, in the immortal words of Carl Spackler in Caddyshack, total consciousness. No fuss, no muss, just plug and play, or at least that’s the message. Don’t even think about trying to sell customers self-sacrifice and focused diligence when the guy next booth over is promising immediate gratification and a sweeping “vision.”

When healthcare IT enables great things, it’s because vendor and customer did a ton of work. That 10 percent of the iceberg that’s visible, the pretty screens and shiny servers, doesn’t begin to tell the story, although it often makes the sale. Home Depot’s hammer display doesn’t show bashed thumbs and blisters, I’ve noticed.

Conspicuous consumption of IT is highly unlikely to make “You, happier™” any more than passively buying self-help books or hanging on Oprah’s every word. What you get is a false sense of accomplishment that’s easily disproved by unchanged outcomes or efficiency. An hour later, you’re hungry again.

The industry doesn’t benefit long-term if customers are dissatisfied with vendors because they bought products naively, unwilling to contribute the sweat equity required for success. Maybe it would help if magazines and trade shows stopped trying to foist their breezy equivalent of Best Buy’s slogan on the industry: “You, Most Wired™.”

Time Capsule: The Olympics as a Project Management Lesson: Those Chinese Would Have Had Your Clinical Systems Live By Now

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in August 2008.

The Olympics as a Project Management Lesson: Those Chinese Would Have Had Your Clinical Systems Live By Now
By Mr. HIStalk

I don’t follow sports much. In fact, I might be the only American who didn’t watch any of the Olympics, other than a little of the women’s nude … uhh, beach … volleyball (I think the US beat some other teams, but I’m not really sure since they kept running back and forth under the net while I was distracted).

Actually, I did watch the closing ceremonies, having little choice because I had bartered away my evening TV rights to Mrs. HIStalk in return for being allowed to watch an Andy Griffith Show mini-marathon that preceded it (“The Pickle Story” episode was a key bargaining point in the protracted negotiations).

I’m glad I tuned in to watch the torch get snuffed. It held a valuable lesson (beyond the inevitability of aging, as evidenced by Jimmy Page’s frightful-looking gray hair).

The lesson is this: given resources and strictly followed project management principles, human achievement is nearly limitless.

Evidence was everywhere. China spent $40 billion on everything from infrastructure to costumes. The closing ceremony was so tightly scheduled and scripted that the elaborate equipment and cast of thousands could not be assembled until right before the show, with no time for on-site practice. Clips of memorable performances (all of victorious Americans, given the homer TV coverage) were a reminder of the incredible logistics of transportation, construction, lodging, computing, scheduling, media support, and preparation that rivaled and maybe even exceeded the obviously impressive human performance of the competitors.

If there was a project management Olympics, this Olympics would have brought home the gold. Everything was finished on time, it worked, and there was little evidence of what must have been hundreds of backstage arguments, compromises, and last-minute changes over several years. There were no excuses, extensions, or exclusions.

I bet you wish your last big project went that well. Me, too. In fact, I jotted down some thoughts about why China can orchestrate a picture-perfect Olympics while the average hospital can’t get its IT projects finished:

• Ruthless project management. Chinese leaders aren’t generally known as laid back cut-ups, so I’m assuming the pressure to deliver was excruciating.
• Unlimited budget. There’s no way costs could have been estimated accurately, so it must have boiled down to “whatever it takes.”
• Tons of dedicated employees and volunteers. China has over a billion people to choose from, none of whom have the “no, thanks” option.
• Individual and national pride was on the line.
• Would-be naysayers who were too scared to whine about the impossibility of it all, which left just shutting up and doing what they were told.
• A hard-stop, no-excuses, immovable deadline with the highly visible result beamed to the entire civilized world.

IT leaders probably shouldn’t rush out and declare themselves supreme ruler or demand billions of dollars just to get a project finished. Still, the Olympics would have failed if the goals were unclear, the money tight, or people stretched.

The lesson is that CIOs can do anything if given the right resources, requirements, and control. That is, if they bring highly polished expertise in planning, communication, and project management to the table. Anything less isn’t the Olympics; it’s more like professional wrestling.

My beach volleyball game would have suffered without these things. It might have been played on asphalt instead of sand because someone forgot to order it. It might have resulted in a tie because inexperienced scorers forgot to write down the points. And, it might have featured players wearing track suits because incompetent security guards allowed the team’s uniforms to be stolen from the coach’s wallet.

Time Capsule: Why IT-Led Change Projects are a Bad Idea: We Aren’t Charming Enough to Convince or Scary Enough to Threaten

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in July 2008.

Why IT-Led Change Projects are a Bad Idea: We Aren’t Charming Enough to Convince or Scary Enough to Threaten
By Mr. HIStalk

I was e-mailing a colleague the other day and spouted off an off-the-cuff remark that I kind of like in retrospect (that’s not just vanity talking because sometimes I say something really stupid and I realize it right away.) It was this:

“Executives buy IT because they want to crack the whip but aren’t willing to, so they use IT to force conformance without confrontation.”

I’ve been the poor IT guy who became the lightning rod for some executive’s grand plan for change. The IT project was where the rubber met the road, so we became the bearer of bad news for the masses: “You have to change your ways — your boss told me to tell you.”

(Please excuse those arrows sticking out of my back. We IT messengers get a lot of those, so they don’t really bother us all that much.)

For that and other reasons, I don’t even like the idea of calling anything an “IT project” unless it involves user-invisible infrastructure. “Buying IT” really means “demanding change,” so the expected result isn’t a “go-live” — it’s a “be-different.” Only a little of that involves computer stuff.

Anointing IT people as change agents is like enlisting the CFO to redesign care (i.e., asking for trouble). Computer-loving pessimistic perfectionists don’t make good charismatic visionaries who can get people to fall in line behind a radical change like a Pied Piper. Three seconds after the wary masses start complaining and rolling their eyes, we’re commiserating with them and casting conspiratorial glances as we say quietly, “I don’t think it will work either, but that’s what I was told to do.” That’s realistic, but not so inspirational (it’s not surprising that CIOs rarely seek political office).

The IT department doesn’t carry a lot of weight. We’re always overloaded with somebody’s great ideas from last year that still aren’t finished. We zeroes-and-ones types have minimal user credibility (insert obligatory user help desk scorn here). Most importantly, we carry no explicit or implicit authority outside of our own little domain, so we can’t impose our will on mutineers. We aren’t charming enough to convince or scary enough to threaten.

I think of IT as a subspecialty of change, right up there with communications, metrics, and process design. There’s no shame in doing any of those subspecialties well without actually running the show, even when the most visible part of a project is a computer.

This is so obvious that I’m hesitant to risk my shaky reputation by even saying it out loud, but here we go. Projects with user visibility are change projects, not IT projects. Change projects should have real objectives, not just IT objectives. Attaining real objectives requires the leadership of people who have influence and skin in the game, not IT people whose expertise involves the tools. Ergo, IT should always be supporting cast, not limelight-hogging stars.

When it comes to big change projects that happen to involve the computer, the worst idea in the world is letting the IT department run the show. It’s no accident that big projects at Kaiser and Allina were run by project teams that were completely separate from IT and staffed by people with operational expertise and credibility instead of IT managers and technicians. They recognized that their project wasn’t CPOE, it was changing the behavior of clinicians. Not coincidentally, those projects succeeded where IT-led ones elsewhere went down in flames.

Time Capsule: Conduct a Survey, Game the Results: If the Results are Important, Somebody’s Cheating

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in July 2008.

Conduct a Survey, Game the Results: If the Results are Important, Somebody’s Cheating
By Mr. HIStalk

My doctor is part of a big medical center’s group practice. I noticed a big poster on the wall last week. It explains to patients in great detail how to fill out a patient satisfaction survey. It is helpful, especially if you want to give the office a perfect score (that’s the only option shown).

It’s about as heavy-handed as those car dealers whose signs urge, “See the manager if we didn’t earn all fives on your satisfaction survey.” Sometimes they even offer a free oil change if you agree to give them a perfect score. Strange: it’s their own survey, but they’re still encouraging customers to lie about being satisfied. Why bother to conduct a survey if you’re going to tamper with the results, especially if you’re only fooling yourself?

Places I’ve worked did employee satisfaction or communication surveys. Sounds great in the HR office, but in the trenches, executives were begging and threatening to get good marks.

All that led me to think about seemingly objective healthcare IT information sources that really aren’t. If the results are important, you can bet someone is cheating.

I went on a site visit for clinical systems awhile back. I knew the hospital was threatening to kick the vendor out and sue them, but everybody seemed manically happy. For good reason, it turned out: at least one of them was a vendor’s employee wearing a hospital badge. I also accidentally discovered that the hospital CEO had sent a threatening letter to the key contact, warning him not to say anything negative that would make the vendor mad (I saw it on his desk).

I’ve stopped reading free industry magazines. My IT world is a lot uglier, less conclusive, and more frustrating than the one they claim to live in. The stories are about as hard-hitting as a vendor’s press release. If you can’t find even one negative in a case study article, you’re reading propaganda.

I believe KLAS rankings in general, but I’ve heard that vendors work hard to get their best customers interviewed.

I’ve known some Most Wired survey respondents who either exaggerated or lied outright, depending on how charitable you might be at the moment. Looks good on the resume, you know, and the CEO will finally notice the IT department.

Most recently, I was excited that some healthcare-related organizations made Computerworld’s list of best places to work. Alas, employees from one of them e-mailed me to say that their employer had strong-armed employees to turn in happy surveys (think of the irony: those in the trenches were threatened to act happy or else).

My conclusion is this: caveat emptor. Nobody has an incentive to warn prospects about questionable vendors, products, or employers. Folks who wouldn’t lie to friends might exaggerate to strangers.

There’s an informal collusion among vendors, trade magazines, and member organizations to keep prospects buying by putting on a phony happy face. That’s their job. Yours is to seek the truth. And if the publisher of this newsletter sends you a reader survey, I’ll give you a free oil change if you say I’m the best thing about it.

Time Capsule: Want Doctors to Use EMRs? Find a More Effective Strategy than Shame

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in June 2008.

Want Doctors to Use EMRs? Find a More Effective Strategy than Shame
By Mr. HIStalk

Doctors are generally pretty smart. We agree on that, right? So why does the healthcare IT industry keep treating them like idiots?

A new, ultra-expensive study found that doctors aren’t exactly flocking to EMRs (it took an expensive study to determine that?) The hidden message: somebody has to do something to get those dummies to buy EMRs.

EMRs are, in other words, so darned compelling that prospects should be shamed or maybe even forced into buying them for the public good, kind of like seat belts (imagine some models of seat belts that cost $50,000 and require 30 minutes extra every time you start your car.)

In America, doctors are business owners, even though some people think that’s a distasteful concept. They have customers, employees, overhead, and equipment. They make good business decisions or they go broke. You can’t help patients if your practice tanks.

Many of those smart business owners don’t see the value of EMRs. They understand that EMRs might improve patient care in some cases, but the practical and immediate considerations of their cost, support, and time requirements win every time.

Doctors won’t use EMRs just because non-doctors preach at them. They will not be shamed for sticking with paper when it makes personal economic sense. Societal benefit aside, they have to protect their income and their time (which are synonymous).

EMRs, in other words, are no different than any other piece of medical equipment that the doc/business owner might buy. It’s a logical decision made by a smart person. If I’m a doctor, my decision tree might look like this.

First, can it make me money? Doctors buy fancy imaging equipment because they can bill the heck out of it under current reimbursement rules. EMR assembly lines would have to run night shifts to crank enough of them if docs could bill for their use. They can’t, which means payors (including patients) aren’t convinced about EMR benefits, either.

Second, would having an EMR give me competitive advantage? Here’s a question that gives you the answer: would you go find a new doctor just because your old one, who just happens to be the greatest doctor you’ve ever known, doesn’t use an EMR? Neither would all those Joe Sixpacks who are prodded by industry polls into saying that EMRs are essential, but who in reality don’t care whether their own doctor uses one or not.

Third, will using an EMR get me sued less? You’ll know that’s true when medical malpractice insurers give significant discounts to EMR-using doctors.

Fourth, when it breaks, who do I call? Doctors are not hospitals, with their separate department of nerds anxious to tackle the latest problem due to operating system quirks, software upgrades, driver incompatibility, and user errors. The Geek Squad guy is not only expensive and not found in most American towns, he also doesn’t know much about EMRs.

Sticking with the “how we do things here in America” theme, here’s how you get doctors to use EMRs. Make them faster, easier to use, and better supported to the point they provide inarguable business and clinical value, no different than a fax machine or an office PC. In other words, don’t just complain about paper — beat it in a fair fight.

And once you figure out how valuable EMRs are, make the person who gets that value pay for them.

Time Capsule: If Uncle Sam Doesn’t Like Healthcare Administrative Costs, Why Did He Create Them?

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in June 2008.

If Uncle Sam Doesn’t Like Healthcare Administrative Costs, Why Did He Create Them?
By Mr. HIStalk

Want to defraud Medicare? Apparently it isn’t very hard. A recent high school dropout started punching in fraudulent claims from a kitchen table laptop and didn’t stop until she hit $100 million worth, many of them paid without question. Another news story talked about hospitals that have been charged with overbilling the government, insinuating they did it intentionally.

Certainly there are plenty of crooks in healthcare and I hope they’re all locked up. On the other hand, the payment system is extraordinarily convoluted and complex. Put a microscope to the high volume of transactions submitted by the average hospital and a sharp auditor could no doubt find a few inaccurate ones. It’s just electronic claims Nintendo, moving imaginary paper back and forth with little added value, so it’s not perfect.

It’s like the tax system. Magazines used to take fictitious family situations and ask big-name accountants to figure their tax liability. The results were all over the place, with each accountant defending his or her interpretation of the tax code. Nobody could say for sure what the right answer was. You can bet, though, that if you’re audited, that low-ranking civil servant who’s making you sweat will pick a big number and it’s up to you to argue otherwise. They don’t see it as your money at all.

The common element is the federal government and its entourage of special interest groups, lobbyists, and consultants. They don’t have an incentive to make anything simple, especially if that would result in claims getting paid more generously or quickly.

Besides, the government is going broke, mired in national debt that would take generations to pay off even if the federal budget were balanced today. Paying less than providers bill or deserve buys the politicians a little more time before the economy goes up in flames.

Old-timers remember that hospitals first bought computers to support complicated Medicare reimbursement. It was like an arms buildup, though. Once Uncle Sam got computers of its own, we were back to square one. The government demands the most tedious, obscure, and hard-to-capture information from providers, even though nothing useful ever seems to come from it.

They created the nightmare that is healthcare billing, a nasty by-product of what a lot of folks back then called a socialist experiment in which politicians inserted themselves between providers and patients. With that came insurance companies and a never-ending increase in costs.

Think about that the next time a gasbag politician starts whining about the administrative costs of healthcare and the huge chunk of GDP they consume. Uncle Sam, as the biggest payor, is the also most demanding, bureaucratic, and arrogant. On top of that, it blames providers for being inefficient. Can you imagine?

I’m glad the government is occasionally and uncharacteristically prudent. Sometimes it seems it has gone beyond that in healthcare. You get the feeling that it can’t afford the care that politicians have promised to voters and the only way to hide that fact is to intentionally pay providers less than they are entitled.

On the other hand, be careful not to make a mistake. Once you hit $100 million or so, somebody might start asking questions.