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Time Capsule: Can’t We All Just Get Along? Why IT and Clinical Jobs are Different

April 4, 2014 Time Capsule 5 Comments

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 April 2010.


Can’t We All Just Get Along? Why IT and Clinical Jobs are Different
By Mr. HIStalk

125x125_2nd_Circle

I worked several years in hospitals before I went over to the IT dark side, spending time in both frontline patient care and operational management. It’s a lot different than working in IT. For those who’ve spent their entire healthcare careers sitting at a desk in front of a monitor, I thought I’d point out some of those differences as I see them.

The most dramatic difference is the timeline. IT people are the Pentagon generals fretting over long-term plans and organizational structure. Clinicians are the ground troops who are under siege by an enemy of superior number, hoping only to survive until the end of their shifts. Picture the soldiers in “Platoon” sitting in on a Pentagon press briefing — that’s how IT project meetings go down when clinicians are invited. Fragging is inevitable.

The biggest divide between IT people and patient care employees is that those people on the front lines don’t get to eat lunch out. Ask a surgery nurse about good restaurants and they’ll only know about close-by Chinese buffets willing to box up group order takeout clamshell boxes for 20 co-workers. Meanwhile, the IT people know all the fancy places with great appetizers and patio dining, although they don’t always know the prices since vendors often pick up the tab and even drive (anyone who knows anything about hospital parking will see the value in being picked up and dropped off curbside).

Team relationships are different for the front-liners. Clinical job skills are theoretically interchangeable, so the biggest difference between one nurse and another doing similar work is their attitude and work ethic. They don’t get to coast because they’re the only Oracle DBA or the last surviving in-house COBOL programmer. Out on the floors, nothing matters except what you got done during your last shift and how well you supported those around you. 

In my experience, IT’ers stab each other in the back a lot more. It’s an organizational behaviorist’s dream to put a bunch of Type A IT management people in a conference room and watch them skillfully undercut each other, lobby for suck-up points with the ranking person in the room, and dodge ugly assignments, all without being obvious.

Non-IT’ers are not nearly as subtle in the art of war. If they get mad, there will definitely be shouting, scowling, and storming out of the room. Their blow-ups are more spectacular, but are over almost immediately and everybody makes up, most likely with immediate hugs all around and a cake brought from home the next day (frontline workers eat on the job a lot). Come to think of it, that matches the timeline above — IT people are playing an intricate, involved chess game while the frontline workers go right for the boxing gloves.

Clinical people are blunt compared to their reserved and polished IT counterparts. If an application sucks, they’ll tell the CIO directly. They don’t mind ripping the "helpless” desk in front of the people who manage it or to complain that all the IT’ers are fast asleep in their beds when the network crashes at 2 a.m. Out on the floors, communication is urgent and potentially life-saving, so the ability to be soothing and politically correct is not valued. IT skin toughens a little after dealing with crusty night shift nurses who call people by their last names or that 25-year OR veteran who can make cardiac surgeons cry. You might as well expect eye-rolling and watch-glancing if you drag out a 45-minute PowerPoint that’s more propaganda than useful information.

Floor people don’t know or care about C-level management. To 90 percent of hospital employees, "management" means a nurse manager, supervisor, or ancillary department manager, not the $500K suits sitting in the really nice offices. They have probably never seen a hospital office that had good furniture, secretaries, and carpet on the floor. They also question (probably rightfully so) whether those suits really understand what it’s like to actually deliver the services that hospitals are paid to deliver. To the frontline worker (and, truth be told, probably to patients as well), nobody is vital to the mission if they aren’t working weekends and holidays. That’s why IT executives make a big show out of bringing in donuts at 6 a.m. during go-lives.

The biggest dividing line is salary, of course. IT pays better than actually delivering patient care, so IT is always stealing clinicians away from the bedside. That doesn’t win friends and influence people.

I can’t say one job is better than the other. Working on the floor is great because you can go home on time tired, but knowing exactly what you accomplished and you get to start over the next day with a clean slate. IT is a slog because it’s just the same old thing day after day, with little feeling of progress or individual accomplishment.

All things considered, though, I’d take the higher salary. Plus, eating lunch out whenever you want is undeniably cool.

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April 4, 2014 Time Capsule 5 Comments

Time Capsule: Certification: Third-Party Validation for People Who Are Lazy, Insecure, or Stupid

February 14, 2014 Time Capsule 3 Comments

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 March 2010.


Certification: Third-Party Validation for People Who Are Lazy, Insecure, or Stupid
By Mr. HIStalk

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I admit that I don’t understand why everything and everybody has to be certified these days. EMRs, CIOs, healthcare IT professionals, and nurses all can – for the right price – earn a third party’s validation of their existence (CCHIT, CHCIO, CPHIMS, and RN-BC, respectively).

Even the word itself is comforting. Your new software, IT leader, project manager, or informatics nurse must clearly be less of a risk because they paid someone else to say so. They have become “certified,” and therefore those lesser unwashed options with fewer letters after their name suddenly seem like a fool’s gamble just because they passed a cookie cutter test.

I don’t get it. Who would turf that suitability decision off on someone else, especially when it’s the incumbent themselves who paid for their seal of approval? Does it really help make a better choice?

(Someone told me once that a prospective CIO employer asked them to leave their CPHIMS credential off their application. The reason: HR’s policy was to validate every claimed credential, which would take time and therefore money, but IT didn’t care a bit whether candidates had CPHIMS or not.)

CCHIT certification hasn’t seemed to reduce the risk of adopting EMRs. Or, for that matter, the adoption rate itself. The government likes the comfort of having a third party preventing dangerously rogue EMRs from finding a home in the hands of willing provider customers. CCHIT is from the government and they are here to help. Theoretical benefits aside, nothing seems to have improved from letting prospects themselves evaluate products they might want to buy, other than costs have increased, a new bureaucracy has been introduced, and vendors now develop what CCHIT requires instead of what customers want.

I really don’t get the certified CIO credential. CHIME says an individual so anointed “demonstrates the commitment, knowledge, and experience required to master the core skills inherent to successful CIOs and IT executives.” In other words, the certificate holder has passed some test of theoretical knowledge. The kicker is this: candidates must have already been working as a CIO for three years. Was there a widespread problem where hospitals were hiring dangerously unqualified CIOs, keeping them on the payroll for years, but then suddenly finding that they suffer from incompetence that a simple test would have detected upfront?

My conclusion: certification makes no sense at all unless the decision-maker is too lazy, too insecure, or too stupid to evaluate for themselves.

In fact, I might be skeptical of choosing something “certified.” Is someone trying to hide their unsuitability by waving a rubber stamp seal of approval around instead of standing on their own merits? Aren’t by definition those certified products or job candidates insecure about their track record? I’m thinking those “certified pre-owned cars” at the local buy here, pay here lot. Why not just have your own mechanic check it over?

The main beneficiary of certification is whoever is doing the certifying. In the case of CCHIT, they got to build up a nice grant-fueled bureaucracy doing government work, but still attached to the HIMSS apron strings. For CHIME and HIMSS, their carefully constructed continuing education renewal requirements for certificate holders create a recurring revenue stream of conference and workshop attendance.

I like the business model. Certification thrives on insecurity and everybody is loaded with that. Insecure candidates earn certifications to impress insecure decision-makers. It’s a certified hit.

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February 14, 2014 Time Capsule 3 Comments

Time Capsule: HIMSS10: Party Like It’s 1999

January 24, 2014 Time Capsule No Comments

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 March 2010.

HIMSS10: Party Like It’s 1999
By Mr. HIStalk

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Healthcare is different, everybody says, Well, it sure is when it comes to throwing the excessive bacchanal that is the HIMSS annual conference.

Most citizens are shell-shocked from economic devastation. Most industries are reeling. But at HIMSS, it was 1999 all over again.

Sprawling exhibitor booths are burning electricity like a third-world country! Bring on the big-name entertainment! (OK, I admit that I hadn’t heard of Colbie Caillat and singing in a building full of fish tanks is new to me, but her Grammy Award seemed to get people’s attention). Cocktail hour in the exhibit hall are just what stressed hospital executives need to make informed, responsible IT decisions!

The most common phrase I heard in the exhibit hall other than Meaningful Use was Ruth’s Chris.

It was a Las Vegas time warp in Atlanta. Everybody slept in expensive hotel rooms and wore pricy clothes and screwed around with party schedules on expensive smart phones and fretted over dinner reservations and wine lists at expensive restaurants. The neon and booth babes were out in force, everybody loaded up on overpriced Starbuck’s coffee, and hired cars and limos lined up to transport captains of the HIT industry and their minions to and from the convention center.

In the back of my mind, though, was my hospital’s ED. I was thinking of the people patiently waiting there, those using it as their primary care provider because they can’t afford insurance. If I randomly chose one of those patients and took them to HIMSS, what would they think of the free-wheeling technology funfest?

I worry that hospital executives have decided that they are far superior in every way to the average patient they supposedly serve. They have more education, make more money, and enjoy life benefits that the randomly chosen ED patient cannot comprehend. When they travel, they travel in style, and thus supposedly struggling community hospitals will reimburse executives for $250 hotel rooms. And when they go to HIMSS, self-sacrifice is hard to find. In fact, so is any mention of real, live patients, many of whom would probably cause the suit-wearing crowd to physically recoil because they don’t look or act like them.

The other irony is that the key element of discussion, the topic that packed the conference rooms, was getting hands on taxpayer money. All those highly paid and highly expense accounted people were getting together to talk about hitting those economically shell-shocked people and companies a little harder in the pocketbook, making the choice on their behalf that their personal income would be better used to fund EMRs through higher taxes.

Maybe the local TV stations should send video reporters to conferences like HIMSS, just to show the folks back home who make it all possible how their healthcare and tax dollars are being spent.

I could be naïve. Maybe the HIMSS spectacle is so over the top that everybody gets the irony. In fact, I bet they were discussing it at Ruth’s Chris.

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January 24, 2014 Time Capsule No Comments

Time Capsule: Dark Side on Line One: If Cash Really is King, Now’s the Time to Leave That Hospital Job

January 17, 2014 Time Capsule No Comments

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 February 2010.

Dark Side on Line One: If Cash Really is King, Now’s the Time to Leave That Hospital Job
By Mr. HIStalk

125x125_2nd_Circle 

These days, more and more industry people are using Willie Sutton’s famous answer to why he robbed banks. “Because that’s where the money is,” they say. The current form of the question is this: “Why are you leaving your hospital job to work for a vendor or consulting company?”

I’ll be honest … I thought self-serving university people were full of it when they predicted big shortages of healthcare IT people. The sky is falling, they cried, but it sounded like a lame pitch to boost enrollment in their informatics degree programs. ARRA or not, it just didn’t seem likely that implementers and project people would suddenly be in big demand.

The anecdotal evidence I used to support that belief was this: many of the best people who work for the vendors my hospital uses have been laid off. Experience = higher salary = first to go, at least in the minds of dimwitted vendor VPs whose own ill-informed revenue projections fail to pan out, meaning he or she gets the elevator while the worker bees get the shaft.

I figured there must be lots of talent available, considering vendors are still cutting people loose. Plus, I didn’t (and still don’t) think federal handouts are going to provide enough lipstick for the pig that most doctors visualize EMRs as being (it’s not EMRs they are resisting – it’s USING the EMRs. Sounds the same, but isn’t.)

I guess my lesson learned is to never bet against the money. Cash will presumably get doctors to use EMRs they don’t really want. It’s also working to pull several hospital CIOs and other IT people to (or back to) the vendor dark side.

One non-profit CEO asked me if I thought he should continue working in his current role, which is good for society but not necessarily so great for his wallet. As altruistic as I can sometimes be, I gave him the classic answer from MBA economics: take the better-paying job and donate more to charity. Buy carbon credits for selling out. The window is wide open and this opportunity may never repeat.

Vendors and consulting companies are loading up. The talent they can most easily afford comes from hospitals. From there come the fresh troops, getting their call like a minor league baseball player being offered the chance to move up to The Show.

For those with short memories, though, vendors are just as quick (quicker, actually) to unload FTEs when conditions slip. If you have a loving, loyal hospital spouse who makes you happy and puts up with your idiosyncrasies, then think carefully before running off with the tarted up, drug-seeking vendor stripper who is whispering in your ear to throw it all away to run off to Las Vegas with her to gamble. It’s not nearly as fun as it looks.

The hospital IT people I know are in two camps. Some have worked for a vendor and wouldn’t go back at gunpoint, or have enough roots and loyalty to resist the siren song. You’ll see the second group at HIMSS – former colleagues who suddenly show up in a vendor both wearing shiny new Koolaid-stained suits, so flush with newfound enthusiasm that you would be jealous if you didn’t know the odds of eventual disappointment.

It’s like when low-paid civil service employees quit public service to work for fat cat contractors. It’s a shame, but nobody can really blame you for taking advantage of the cards you were dealt. There’s no unattractive scar even if you did just sell your soul.

I’m not even slightly tempted. I don’t like suits, travel, lumbering bureaucracy, and strategies developed by bean counters who don’t understand healthcare. The second happiest day of my work life was when I was hired by a vendor; the happiest was the day I quit. The years in between are a vaguely unpleasant blur.

But if your hospital job isn’t so great, if the economy has killed the hope retirement, or if you just want a change of scenery, the time is now to do something strictly for the money. The great thing about hospitals is that they won’t hold a grudge if you have to come crawling back in a couple of years.

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January 17, 2014 Time Capsule No Comments

Time Capsule: Meaningful Use in the ED: Get Outta My Emergency Room

January 11, 2014 Time Capsule 1 Comment

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 February 2010.

Meaningful Use in the ED: Get Outta My Emergency Room
By Mr. HIStalk

125x125_2nd_Circle

At my hospital, we worry a lot about ED satisfaction scores. No matter how well we do in areas such as OB or surgery, the ED scores always drag everybody else down. It always seems that the best and the worst aspects of our hospital’s care happen there.

We can only do so much to raise those scores. It’s not a democracy in ED, even though patients think it should be. You might have arrived first, but if the guy sitting across from you has a butcher knife sticking out of his neck, your abscessed tooth is just going to have to wait.

The ED is aptly named since it exists to serve patients with emergent medical issues. If you aren’t one, feel free to enjoy that second half-hour of “The Price is Right” on the “please don’t change the channel” TV because, as Samuel Shem said in The House of God, you are a GOMER – get outta my emergency room.

I’m not really sure why we want our ED satisfaction scores to be high, anyway. We tell everybody how much money we lose there. We use it to park patients who need beds that we don’t have. It doesn’t seem like a good idea to make patients so happy about their ED experience that they keep using our services and recommend them to others. The last thing we need is for them to return with their next ingrown toenail.

I also wonder about the fad of plastering emergency department wait times on highway billboards. It would seem that we are encouraging patients who might be tempted to drop by on a whim. I would interpret thusly: if you aren’t sure if you are sick enough to be willing to wait an hour, come on over because, at this moment, we can see you in 15 minutes.

I’m as much of a hard-driving entrepreneur as anybody who has always worked as a non-profit hospital wage slave. That’s why I’m sure my latest idea is a winner:  modifying ED software to show wait times that are multiples of the real number.

Here’s what my company will offer. We will erect huge, blinding electric wait time signs over the ED entrance, out on the street, and right beside your blue hospital sign on the highway. We inflate the actual ED wait time ridiculously (in fact, we can probably just use a randomization routine instead of measuring anything since we’re just making it up anyway). Our artificially enhanced wait times will discourage people to stay the heck out of our ED unless they are truly sick enough to not mind the wait.

This should be an easy sell to the ED doctors, who didn’t take an emergency residency to perform primary care. The really ill patients will appreciate not having to grimace in pain while the seemingly healthy extended family in the next row over settles in for a loud, impromptu gin rummy game and sends out for fast food.

Best of all, hospital executives could tout their high number widely, eliciting sympathy and support from taxpayers who otherwise resent their million-dollar salaries. Who would feel sorry for a hospital that manages to see ED patients in 20 minutes?

For a slight additional fee, I would modify the garish signs to proudly display an inflated number of patients who have left against medical advice. Those are the kinds of patients who need to be gently pushed back into less-expensive medical venues – the ones who found it inconvenient to wait their turn. This is not a metric of inefficiency, but rather a measure of triage success.

I have another flavor of my business model that I think will be quite attractive. I will hack the billboard system of the other hospital in town in what I’m calling my patient flow maximization solution. If your ED gets backed up, you push a secret button that drops the wait times on the other guy’s billboard to five minutes. I am naming that enhancement the Elective Diversion Module.

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January 11, 2014 Time Capsule 1 Comment

Time Capsule: Notice of Proposed Rulemaking: Everybody Must Watch Jay Leno at 11:35 Eastern

January 3, 2014 Time Capsule No Comments

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 January 2010.

Notice of Proposed Rulemaking: Everybody Must Watch Jay Leno at 11:35 Eastern
By Mr. HIStalk

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I’m excited about the government’s encouragement (or mandate, depending on your perspective) that doctors use electronic medical records. Mandatory progress must go on despite the gripes of a few malcontents (i.e., the majority of doctors, patients, and taxpayers).

It is a travesty that more healthcare providers don’t use computers. Software can make healthcare as transparent, efficient, and consumer-driven as other organizations that have spent billions of taxpayer dollars on technology (such as the IRS, the military, and Medicare). The federal government must intervene when minimally educated and technologically illiterate doctors refuse to adopt EMRs voluntarily in their private businesses.

(It worked for TVs. The government decided that Americans should enjoy the benefit of watching cultural programming such as “Judge Judy” and “America’s Next Top Model, in visually stunning high-definition glory. The FCC ordered broadcasters to switch exclusively to HDTV, thus stimulating the economy by selling tons of imported flat panel TVs, enriching lenders as financially strapped citizens let the balance ride on their high-interest credit cards, and increasing landfill employment to bulldoze now-useless tube models.)

In fact, I believe that this “cure all ills” administration needs to take a step further. It’s time to support the most visible employee of the biggest EMR vendor company – Jay Leno.

Jay’s audience, like that of EMRs, has been pathetic in number and more indifferent than loyal. Hype and gimmicks weren’t enough to entice viewers (even the large number of unemployed ones with nothing better to do) to sit through an hour of his cheaply produced and repetitive nightly show.

Jay is a national treasure, too important to be left to the whims of fickle TV viewers. It is therefore essential to mandate, for the economic good and the image of America worldwide, that every one of those new LCD TVs must be tuned to NBC’s “Tonight Show” every night once Jay comes back.

(NBC’s owner GE bought back Jay’s 11:35 slot with $40 million of its own cash. Admirably, it did not ask for a federal Conan bailout.)

To encourage the development of cultural refinement in appreciating Jay’s hilarity and keen interviewing skills, it will be necessary to equip cable and satellite receivers with sensors that will detect households that are not compliant at least four of five consecutive weeknights. Those tuning in will receive a rebate on their bills that non-watchers will forego. After a few years, those non-adapters will have a “Jay support surcharge” included on their bills.

Each viewer must also be a Meaningful Viewer, jotting down Jay’s bon mots for repeating later, paying attention to the commercials, and laughing with significant amplitude at Jay’s latest carefully constructed John Edwards quip (rim shot!) This, too will be monitored electronically.

Jay is an experienced late-nighter, so it would not be prudent to spent taxpayer money on untested hosts such as Conan O’Brien. Therefore, Jay alone has been certified for the 11:35 slot. All other programs, such as the Magic Jack infomercial or “Cake Boss” marathons, are not permitted even when Jay has on dull guests such as Paris Hilton or Larry the Cable Guy.

Lastly, it is imperative that Jay receive feedback about which of his jokes and sketches are working. Technology will be added to the set-top box to solicit constant feedback about the quality of Jay’s humor, which will be de-identified and aggregated quarterly for analysis by the same crack NBC executives who couldn’t make his show work before. With this information, Jay can develop monologue templates that the government will mandate for use by up-and-coming comics, thereby protecting viewers from edgy humor from fresh newcomers.

All of this government spending will actually prove profitable to taxpayers, according to bailout expert Timothy Geithner. While Jay’s show will probably never make money, it will provide an effective advertising platform for the upcoming Chevrolet Volt. What’s good for GM is good for the country, given that the country now owns 61 percent of GM.

Does Jay think this bold, essential plan will work? You bet! His new sidekick Triumph the Insult Comic Dog (merged from a previously retired product line) says you can “bank” on it (rim shot!)

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January 3, 2014 Time Capsule No Comments

Time Capsule: Marry in Haste, Repent at Leisure: Choose your EMR Soul Mate Carefully

December 14, 2013 Time Capsule No Comments

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 January 2010.

Marry in Haste, Repent at Leisure: Choose your EMR Soul Mate Carefully
By Mr. HIStalk

125x125_2nd_Circle

Too much Meaningful Use has led me to Meaningless Musing. Here’s where it took me: the same handful of wrong reasons that convince people to marry unwisely also convince them to buy EMRs that will make them unhappy.

Let’s start with lust. A good-looking partner often leads to hasty and ill-advised EMR marriages. Providers swoon over the slick, sexy sales demo of an EMR that seems cool and popular. They can’t wait to get legally hitched and embark on a lifetime of what they expect to be never-ending passion and soul-mating, flinging themselves at each other several times a day.

Once the vows are said and the papers signed, the romantically foggy lens they’ve been looking through clears shockingly. In the unforgiving harsh light of day, the sultry enigma turns into an endlessly argumentative pest, or maybe a hot mess looking for company in their downward slide. Your new EMR is Bobby Brown to your Whitney Houston.

The most in vogue reason to marry an EMR is cold, hard cash. Certified EMRs come with a taxpayer-funded dowry. Golddiggers rationalize that it’s just as easy to marry someone rich as it is someone poor. You are Anna Nicole-Smith, trying to work up lustful yearnings for a billionaire who is 63 years your senior. And like Anna, EMR users may not live long enough to enjoy the fruits of their connubial labors. Once your $44,000 has been spent, you still have to enter orders and pay larcenous tech support rates for hardware maintenance.

There’s also the shotgun wedding, although that’s a hopelessly dated concept now that society’s moral linkage between parenthood and marriage has been fully disengaged. Still, HITECH-seeking hospitals and practices are sure to push doctors and EMRs together despite their inherent incompatibilities, unwilling to take no for an answer when ARRA money is on the line.

My college roommate’s mom had wise advice, triggered by his ill-disguised lust for all things female and fearing he would sully the family home by marrying the pregnant, drug-using dropout that he found endlessly fascinating (she even had a tattoo, unheard of back then). His mom told him to picture a person who is horribly disfigured and wheelchair-bound after being burned in a fire, requiring his constant care and attention. Would he still be happy to spend the rest of his days with that person? If not, she isn’t the one. She wasn’t, apparently.

If the sweet young thing of an EMR that’s catching your eye becomes old, cranky, or unreliable, would it still be attractive once the money is gone?

Doctors should not be shamed into EMR marriage because of societal pressure (all the other doctors are getting hitched), age (being an EMR spinster isn’t all that shameful), or lust (you can get free milk without buying the cow by messing around with computers as a hobby instead of actually using them in practice, i.e., like informatics doctors do).

Ditto getting EMR betrothed because you want a big wedding (the vendor’s celebratory dinner) or to rebound from a bad previous marriage (the EMR you de-installed because the vendor was unresponsive).

Breakups are ugly. They involve a lot of ill will, money, and wasted time and energy. Like they say, marry in haste, repent at leisure.

The right reasons to get EMR nuptialized is that you’ve finally found that special lifetime companion with whom you want to spend every waking minute, the one you admire, that special person with whom you will grow together, and that soul mate with whom you will share intimate thoughts through good times and bad. For better or for worse, for rich or for poor, till death (or vendor insolvency) do you part.

I bet my roommate’s ever-practical mom would add one last item: just on the off-chance that you’ve chosen unwisely, get an ironclad pre-nup.

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December 14, 2013 Time Capsule No Comments

Time Capsule: Let the Government Giveth to Healthcare by Takething it Away from Healthcare Profiteers

November 15, 2013 Time Capsule 1 Comment

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 December 2009.

Let the Government Giveth to Healthcare by Takething it Away from Healthcare Profiteers
By Mr. HIStalk

125x125_2nd_Circle

It’s increasingly clear that nobody wants to pay for healthcare, especially those who receive lots of healthcare services. The lobbyists of every patient or provider group have the same recommendation: let someone else foot the bill because we can’t afford it.

Everybody is convinced that everyone else is profiting obscenely from healthcare. When healthcare reform is being debated (which sounds more civil than the “debate” really is), it looks like that old Clint Eastwood spaghetti western, where Clint and Lee van Cleef and some other guy are listening to a musical pocket watch playing down, grimacing and jaw-flexing and finger-twitching, ready to blast each other into oblivion once the last note plays.

(I never really believed that scene, even if there really were musical stopwatches that played that loud in the 1870s. Given that at least one gunplay participant is always a black hat-wearing oaf of a bad guy, you know in real life that guy’s not waiting until the other gunslinger draws his hogleg – he’s going to start shooting up the place before Clint even lights up his stogie).

Anyway, I have invented a healthcare financing model that is fair to all, requires minimal administrative cost, and is transparent. Here it is:

Heavily tax the personal incomes of individuals who make big bucks from delivering healthcare products and services.

Corporate finance is too complex for me. Money-losing companies seem to thrive, even when showing a paper loss. And don’t even get me started trying to cogitate the difference between “making a profit” and “having a positive cash flow” because I just can’t grasp it.
I do know this, however: at some point, organizations have to pay out profits to living, breathing individuals who file that income on an IRS tax form. That’s where my plan kicks in: when that person makes excessive healthcare income, I want them taxed heavily.

(How do I define “excessive healthcare income”? Easy: it’s anyone who makes more than me.)

Uncle Sam then takes the proceeds and plows them back into covering healthcare costs. That neatly closes the loop so that those profiting heavily from healthcare have to help pay for it. I’m fuzzy on my MBA economics, but I think there’s some kind of economic multiplier effect in there, too, and God knows we could use that right about now.

Scumbag drug company shareholders, shady device manufacturer executives, glad-handing EMR vendor sales directors, wildly overpriced nurse staffing agency owners, million-dollar hospital VPs, and gazillion-dollar plastic surgeons from El Lay: it doesn’t matter. Uncle Sam knows how much of your income comes from healthcare-related salary, dividends, capital gains, and business income. Sorry pal, you’re getting socked with a 50% tax rate on that money.

You know that Joe Sixpack will love the idea of sticking it to million-dollar non-profit hospital executives or Ferrari-driving doctors. There aren’t enough of those caviar-eaters to outvote the masses no matter how much whining comes from AHA or AMA.

This confiscatory tax plan sends a message: it’s OK to make a nice living off the backs of sick people, but you don’t get to make more than a year than the average patient makes in a lifetime. Sorry, John Hammergren and Neal Patterson, we aren’t paying you to become multi-centimillionaires just because you sell supplies and equipment that sick people need.

Other countries use the Value Added Tax. It’s easy to collect, it’s consistent, and it’s hard for cheaters to avoid. Therefore, I advocate the Healthcare Unjustifiably Rich Tax. Don’t just tax the healthcare rich, HURT ‘em.

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November 15, 2013 Time Capsule 1 Comment

Time Capsule: My Simple Solution to Privacy and Security: Publish Everybody’s Electronic Medical Records on the Internet

November 8, 2013 Time Capsule 3 Comments

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 December 2009.


My Simple Solution to Privacy and Security: Publish Everybody’s Electronic Medical Records on the Internet
By Mr. HIStalk

125x125_2nd_Circle

Before I knew better, I worked for a crappy and perpetually money-losing hospital software vendor. A key to our non-competitiveness was an unbroken string of clueless executives (is that redundant?) who were either first-time managers or bottom-feeders.

One of those manglers (as we wittily and privately called them in pathetically insignificant resistance to their tyranny) decided that it made perfect sense that we support center people would pick up each other’s voice mails.

That particular mangler’s underdeveloped brain had reasoned thusly: customers might call an analyst’s extension directly (despite company rules specifically forbidding that practice) and leave an important message (like, “Our entire system just crashed and patients are dying as a result, so I thought I’d leave this personal voice mail message on your unlisted extension rather than calling the 800 number”).

(Spoiler: weeks later, an equally uninspired analyst, in a rare burst of analytical skill, asked the obvious question: couldn’t we just change our voice mail message with instructions for clients to call the 800 number? The mangler furrowed her brow for several minutes and finally acknowledged that this innovative practice might indeed be worthy of a trial project.)

So the mangler decided each of us would pair up with a phone buddy (I wish I was making this up, but I’m not) and we would share our voice mail codes and listen to each other’s messages, thereby helping customers who were loathe to follow our rules about not leaving them in the first place.

It would have happened except for the strenuous objections of one analyst, who was agitated that those messages might include medically related ones (probably depression-related since all of us were on shaky employment ground with our nose-diving employer).

I still think about that ridiculous episode today, primarily trying to answer this question: why are we so protective of our medical records? We’re all subject to the same human frailties, so anything you have that’s dysfunctional, too big, too little, oozing, or wrinkled makes you one of a large number of people having that same characteristic.

In 30 seconds of hard analysis, I drew this conclusion: it’s an animal reflex to hide weaknesses from predators (such as company back-stabbers, stalkers, and insurance companies).

Because of those fears, privacy and security concerns threaten to derail EMR adoption and data exchange. It costs a bundle to encrypt, decrypt, lock, track, and manage electronic health information. Hackers rise to the challenge regularly.

I have a solution. It draws inspiration from those cold-weather socialists in Norway who recently decided to place all tax records online. Anybody can look up anybody else’s income and net worth (“tax porn,” the wags call it). The Norwegians believe that universal access to that knowledge will apply constructive pressure for equality.

My can’t-miss proposal is this: we declare that all medical records and insurance files are immediately and forever placed in the public domain.

I think this flash of insight makes me a thought leader since nobody else has recommended it. Once the initial outrage wears off, we’ll get used to the concept that if society is taking care of everybody, then society gets to see the result. I see many advantages:

  • We could immediately stop worrying about breaches of privacy since there isn’t anything to breach. And since there will be no privacy, we also won’t need security.
  • Lame RHIOs and HIEs wouldn’t need to keep pretending they have any chance of success that doesn’t involve government welfare since providers can get clinical information directly.
  • Providers have no excuse for not checking allergies, meds, and past surgeries since it’s as easy as Googling “Tiger Woods mistress”.
  • It adds a much-needed layer of personal accountability to those having their healthcare costs paid for by someone else (which is almost everybody, since patients are appalled at the idea of spending their own money for their health and well-being). Say, neighbor, I happened to run across your medical records and maybe you want to drop a few pounds and cut back on the prescription narcotic use, eh?
  • It connects the life sciences industry to potential clinical trials subjects. I noticed that thing growing on your lung – do you want in on our multi-billion dollar drug study in return for a Chili’s gift certificate?
  • It would make everybody feel better about their medical condition since they can easily find people who are worse off than they are.

My plan, unlike all those stimulus-happy privacy projects, is revenue-positive. Google and Microsoft are failing miserably to convince people they need personal health records, so the federal government will offer them the chance to outbid each other for the right to host the records and charge for access (or and splatter context-aware text ads on every page). They can charge whatever they want, but Uncle Sam gets his 80 percent cut off the top.

Then we use that money to buy EMRs (which will improve since vendors won’t be wasting their time on privacy and security functions) and to start paying down the crushing national debt.

I couldn’t possibly accept any kind of recognition or compensation for this significant contribution to humankind. Well, maybe just one thing: I get to keep all the ad revenue generated from page views of medical information involving celebrities and politicians.

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November 8, 2013 Time Capsule 3 Comments

Time Capsule: Why Put Monitoring Cameras Only in the OR? Improving Your Career Outcome with an eCIO

November 1, 2013 Time Capsule 2 Comments

Why Put Monitoring Cameras Only in the OR? Improving Your Career Outcome with an eCIO
By Mr. HIStalk

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Rhode Island’s health department recently ordered an error-prone hospital to install video cameras in all of its ORs. They will be monitored by a non-surgery employee who will oversee all the cases to make sure the surgical teams do the mandatory time-outs and site marking.

(They didn’t do it before because they were they were too busy harming patients. Here’s a clue the situation was all fouled up: in one case, surgeons were supposed to repair two fingers, but instead operated on the same finger twice. Doh!)

I like this monitoring idea. It’s like having a guardian angel looking over your shoulder, ready to whisper into your ear when you’re about to do something unwise.

In fact, I’m proposing that this observational benefit not be limited to that one hospital’s OR. We IT people need help, too, because we sometimes make embarrassing mistakes. What about a CIO-cam?

I hereby lay claim to the eCIO business model, in which centrally staffed consultants (probably in India, although I haven’t worked that out yet) monitor the plush offices of hospital CIOs to prevent them from doing something stupid.

Imagine this. Contract negotiations are winding down. The final change-tracked document has been printed off, pens have been produced, and the vendor’s executive sales VP (your best pal today who won’t take your calls as soon as the ink dries on your signature) is back-slapping anything that moves, anticipating a tropical vacation and home remodeling courtesy of the elephant (you) he or she has just bagged.

Suddenly, the CIO (you) looks away, frowning and clearly troubled. Mahesh the eCIO has just whispered in your ear from the opposite side of the globe. "You are NUTS if you sign that deal without a penalty clause, change-of-control terms, and striking through the arbitration and jurisdiction clauses. Take a time out and think about it."

Just like in the Rhode Island OR, the observer may have just saved a life. Or a career, anyway.

Mahesh can ensure that the layoffs and promotions aren’t mixed up, urging you to mark an X on the head of the otherwise indistinguishable employees who are about to receive their final wishing of well in their future endeavors on their escorted stroll off-property. The eCIO can monitor your heart rate and respiration, making sure that calm prevails when the network is down and angry surgeons are lining up with scalpels and the intent to first do serious harm. The eCIO can even monitor dangerous conditions at the HIMSS conference, where a few too many reception drinks might invite disaster (like saying what you really think about your vendors or the opening speech read laboriously from the TelePrompter).

I’m pretty sure Mahesh can even cover your vacation, wiring up to the not-to-be trusted IT directors and sending them advice (or maybe a few punishing volts) if they get too full of themselves in your absence. ("No, Steve, you are not authorized to create new positions or to move to a nicer office. Put down that pen and step away.")

Best of all, the rock star CIOs who already dominate every conference and publication could extend their celebrity reach even further in an inshoring model variant. Instead of wiring up Mahesh from India, the eCIO company could strike a deal with John Halamka, Martin Harris, or other bigwig CIOs who never seem to be at work anyway. Pay them, say, $2 million a year (only a slight raise) and make them the CIO of everywhere!

Even poor and rural hospitals could then afford to get a timeshare piece of John Halamka’s satellite-borne emanations, strutting him proudly around town in his half-day visit once per year. The rest of the time, he’s sitting in his eCIO center, keeping a watchful eye on his far-flung underlings who do the real work with the confidence that he’ll warn them when they are about to screw up.

I need to cut this short. The publisher of Inside Healthcare Computing just whispered in my earpiece that, from what she’s seeing on my screen, I need to dial it back a little.

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November 1, 2013 Time Capsule 2 Comments

Time Capsule: The Latest Stimulus Package for Healthcare IT and a Wheezing Economy: H1N1 Reporting

October 25, 2013 Time Capsule No Comments

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 2009.

The Latest Stimulus Package for Healthcare IT and a Wheezing Economy: H1N1 Reporting
By Mr. HIStalk

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You are nobody as an HIT vendor unless you’re doing something fancy with H1N1 flu reporting, including spewing self-congratulatory press releases that brag about your civic contributions.

Cerner started it by sending customer ED data to Washington, supposedly giving Uncle Sam real-time H1N1 outbreak reports, even though H1N1-specific data elements are hard to come by, the vast majority of US hospitals don’t use Cerner, and the vast majority of flu sufferers don’t go to the ED. Not to mention that there’s nothing the government can do anyway except observe ("Man, Lockhart, Texas is really getting pounded.")

You would think H1N1 tracking is right up there with an actual H1N1 cure. Google has its own outbreak map generated from Web searches (they can also assess the prevalence of enlarged mammary glands and propofol overdoes, I’m guessing). Web sites loaded with AdSense ads are hoping for a quick buck from providing questionably useful maps and graphs.

Even Harvard Medical School and Children’s Boston have released their own competing iPhone H1N1 trackers ($2 and free, respectively). It’s not really clear what marginally coherent yet mobile consumers are supposed to do with their newfound information. Wear surgical masks? Do that point-and-wink thing instead of shaking hands? Head to their bomb shelters and fight off infected interlopers like the guy in “Night of the Living Dead?”

(Note to self: have my people contact Harvard to IPO a mash-up between their H1N1 tracker and traffic-enabled GPSs, allowing paranoid motorists to avoid entire swaths of geography where H1N1 is around).

H1N1 is a deadly, hand-wringing pandemic (according to TV people anxious for something somber to talk about between inane banter), even though only about 1,000 Americans have died of it so far compared to the 30,000 to 50,000 who die every single year from the plain old unsexy flu and its complications. Drug companies are licking their chops. Panicked citizens not typically known for following a healthy lifestyle or paying attention to seasonal flu vaccines are fighting each other to get the hyped H1N1 version, with the resulting shortages making them even more hysterical.

The government, meanwhile, is saying the one thing that’s guaranteed to send people into a full-fledged panic: "Don’t panic."

(This is actually Swine Flu II, of course. Gerald Ford got everybody excited about it as his presidential candidacy was flailing in 1976. The pandemic never happened, but 40 million people got the swine flu vaccine at a cost of $135 million, 30 died of its side effects, $3 billion in legal claims were filed, $50 million worth of vaccine was destroyed, Ford lost to Jimmy Carter, and Chevy Chase lost the subject of his only funny bit. It was the lowest point of the year, other than when "Convoy" went to #1 on the pop charts).

So what if you’re a small HIT player without the resources to accurately track (or even claim to track) H1N1? Here’s a plan: hire a bunch of unemployed telemarketers to just call up houses and ask whoever answers if they or anyone they know has H1N1. Put out press releases claiming it was your advanced technology, create a fancy Web page, and find yourself a politician to thank you publicly for your valuable services to a grateful nation.

Just be aware that people exaggerate their own illness for maximal sympathy or as justification for skipping work, so any kind of sniffles or tiredness will convince people to say they have H1N1 because they heard about it on Oprah ("headaches" become "migraines", "a cold" becomes "the flu", and "getting sick from too much Super Bowl beer, wings, and guacamole" becomes "food poisoning"). That’s actually a good thing, though — your H1N1 numbers will be higher than everybody else’s since most flu sufferers don’t need hospital treatment like Cerner is measuring, so you will be widely cited by people trying to prove that H1N1 is the next Black Death.

Those inflated H1N1 numbers are good. When it comes to healthcare IT and the economy in general, you just can’t have enough H1N1 stimulus. It’s what I call "viral marketing."

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October 25, 2013 Time Capsule No Comments

Time Capsule: My Can’t-Miss Entrepreneurial Brainstorm: Display Computer Data in the Handwriting of the Person Who Entered It

October 19, 2013 Time Capsule 1 Comment

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 2009.

My Can’t-Miss Entrepreneurial Brainstorm: Display Computer Data in the Handwriting of the Person Who Entered It
By Mr. HIStalk

125x125_2nd_Circle

I don’t want to brag, but I’m a business genius, one of your classic serial entrepreneurs who is so full of hot ideas that I haven’t found the time to stop working as a hospital wage slave. Each idea is so much better than the one before it that I can’t decide on the best one to pursue, so I’m continuing my decades-long preparation of reading Forbes and MSN from the catbird’s seat, located deep in the bowels of an academic medical center.

(One of these days, maybe when I retire, the world will be shocked and awed by the torrent of pent-up business expertise that I’ll unleash, even more so since I’ve never actually been in business except for a short stint as a paperboy back before Craigslist drove all the newspapers out of business.)

You will no doubt value my latest brainstorm appropriately – healthcare IT data elements displayed in a font created from the handwriting of the person who entered the data. Boo-yah and ca-ching!

Everything needs a serious-sounding name for the newly created genre, like “social networking” (or “social not-working.”) I like to call this “Reverse Handwriting Optical Recognition” (RHOR) or “Character Recognition and Proxy Personalization” (CRAPP). You are hereby non-disclosed.

They say every successful product has to solve a customer’s problem (I’ll believe that when someone explains what purpose the TV show “The Bachelor” serves). So, here’s the one I’ve targeted: clearly wrong information looks believable when you see it on a computer screen or printed report.

My inspiration is the news that Cedars-Sinai overdosed CT scan patients for 18 months because none of the techs noticed that the screen defaults were wrong.

Hospital people usually seem blithely unconcerned when presented with hilariously incorrect computer information, like a pregnant male patient or an ED bill for $12 million. The neat and orderly computer output throws off their radar in the absence of a visual cue that would identify the blithering idiot who entered the information in the first place.

Here’s my technical architecture design. Each user’s security profile will include a handwriting sample that has been scanned to a font. When the computer displays or prints something entered by that person, it does so in their own handwriting.

Brilliant, right? The bad information won’t be so reassuring if it’s displayed in a child-like scrawl or a breezy note punctuated with that smiley thing that tip-seeking waitresses draw on your check. Your radar would say, "I don’t trust a thing that fool says."

Skeptics or cynical venture capitalists might ask me, "What about information that the computer creates, like drug schedules or co-pay amount?" I smirk knowingly as only a world-weary entrepreneur can do. Computers, although good at idiot savant tasks like spitting out lists or calling up historical information, are the dumbest pseudo-people in the room. I’ll display their primitive conclusions in the sloppy scrawl of a 14-year-old who was raised with a keyboard instead of a pen, or maybe as indecipherable teen-like text messages saying something like UR PT IS DED ROTFL .

No longer will doctors and nurses place undue confidence in information just because it looks official. Those worthless clinical observations entered by a co-worker you wouldn’t trust with your drive-through order? Visual elimination made easy by Mr. CRAPP (send me that royalty payment, please, Cedars).

Darn, now I’m getting one of those serial entrepreneur brainstorms that may cause me to skip CRAPP and just go on to CRAPP 2.0. We write an add-on software application that lets users rate each data element for accuracy and usefulness. If someone’s a real bonehead, you answer "Did you find this data element useful?" with “no.” If someone enters an incorrect allergy or creates a duplicate medical record that has to be merged later, you rate them low. When enough people do the same, the user gets anonymous feedback of scorn and ridicule.

I don’t watch “The Bachelor” or other reality TV (except “Shark Tank” and my fellow high-flying capitalists), but I’ve heard of a concept that I might use in CRAPP 2.0. If you enter enough bad information, your co-workers might vote you out of a job.

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October 19, 2013 Time Capsule 1 Comment

Time Capsule: The Best Time to Build a Data Warehouse Was 20 Years Ago: Why Someone Should Create a Standard Clinical Data Warehouse for Providers to Populate

October 11, 2013 Time Capsule 1 Comment

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 2009.

The Best Time to Build a Data Warehouse Was 20 Years Ago: Why Someone Should Create a Standard Clinical Data Warehouse for Providers to Populate
By Mr. HIStalk

125x125_2nd_Circle

No matter what you do, it’s never enough. We healthcare IT geniuses have advanced the industry all the way into the early 1990s with our proprietary software applications, portals, and wireless infrastructure. Job well done, right?

Now all of a sudden, nobody’s happy with just capturing data electronically. They actually want to use that information for other stuff, moving the finish line right as we’re about to win the race.

All those state-of-the-art MUMPS and COBOL applications aren’t good enough for government work any longer. Automating for efficiency is yesterday’s news. It’s the information we’re capturing that’s important – for getting paid, for improving outcomes, or maybe even for keeping doctors and hospitals out of the red by selling data to those rich drug and device companies who need to conduct medical research or outcomes studies.

My hospital, for example, has a homegrown data warehouse. It’s useful (as it ought to be for what it costs to develop and maintain). It’s still only as good as the systems that feed it, though, and the analysts who work on those feeder systems always have a ton of "yes, but" cautions about the data they can provide, the kind of caveats that egghead data consumers hate to hear.

A common question: what bed was the patient in when a given item was ordered? Our answer: our systems don’t capture that. What’s their weight history? Same answer. Who ordered the treatment? Maybe we know, maybe not (it depends how far you want to go back in our CPOE journey). What time was the surgical incision made? Don’t know. What was the condition for which a drug was ordered? Only your doctor knows for sure.

The bottom line is that the information we have is pretty good, but we’re always running up against useful pieces of data that we don’t have. We can answer questions, but some only with an asterisk.

It is highly satisfying (not to mention enlightening) to be able to assemble complex electronic data elements into a reformatted database that will support some research project. It’s depressing, though, that our vendor systems simply don’t capture everything we need (and that the vendors, at least in our case, have zero interest in providing those capabilities).

My hospital’s IT resources and vendor are certainly average or better. If we have gaps and compromises in our data, I’m sure those are nearly universal (and even worse if you’re talking about physician practice EMRs).

Write this down: if your organization doesn’t already have a rich warehouse of query-capable data, it needs one. It’s a tough, expensive, and technically tedious effort to figure out all the what-ifs with your current transaction processing systems (What happens if you change a drug name? Can you handle merged patient records? How can erroneous information be fixed or deleted?)

It’s worth the effort for two reasons. First, it will help you get paid. Second, you’re sitting on a treasure trove of data that could be anonymized and licensed to big companies that have a lot more money than the average provider, some of which might even use it to conduct patient-benefiting research. Everybody wins.

Academic medical centers have blazed the trail. It’s time for community hospitals and physician practices (and their systems vendors) to follow.

It would be easier if someone would simply design an off-the-shelf data warehouse known to work well for clinical and population-based inquiries, and then simply give the input specs to the provider and their vendors. That’s great for interoperability. Maybe more importantly, it’s a clear target for providers to shoot for.

I know it’s annoying that everybody’s suddenly pontificating on the importance and economic value of encounter data. Trouble is, they’re right.

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October 11, 2013 Time Capsule 1 Comment

Time Capsule: Lessons from Shark Tank — Beware of Vendors Borrowing Money or Going Public

October 4, 2013 Time Capsule 1 Comment

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 2009.

Lessons from “Shark Tank” — Beware of Vendors Borrowing Money or Going Public
By Mr. HIStalk

125x125_2nd_Circle

I don’t watch a lot of TV, but lately I’ve been watching this show called “Shark Tank.” It’s a reality show from Mark Burnett, the Survivor guy who made TV 100 times more of a vast wasteland than anyone thought possible, killing lame dramas and comedies in favor of cheaper and even lamer junk shows that make Dead Billy Mays infomercials look like Shakespeare plays.

The premise of “Shark Tank” is this: small business owners who need funding pitch their business idea to a panel of private investors who critique it nastily (it’s reality TV, after all) and maybe begrudgingly offer to loan the owner money at quite unfavorable terms (such as demanding half of the company in return).

So, the businessperson has three ways to look stupid: they can be turned down cold, they can take the offered money at usurious rates, or they can voluntarily walk away as the investor panel agrees among themselves just how stupid the business owner is for not wanting to throw in with whiz kids like themselves.

The last show had a guy who had invented a folding guitar. He had sold a few hundred of them at $500 each and, by applying some questionable math, decided his company was worth $10 million (the expressions on the faces of the money lenders when they heard that figure were priceless).

One sympathetic money man (sympathetic on a greedy bloodsucker scale, anyway) asked him an excellent question, though: do you want to make really great guitars or do you want to make a lot of money?

His message was clear. Big profits and quality just don’t mix. The idea of actually making a great product was incomprehensible to the money man. The real money was to be made in licensing the folding neck idea to other guitar companies. Instead of being an engaged, driven entrepreneur making guitars he’d be proud to sell, the guy could just sit on the porch and cash checks.

This made me sad. The money man was right – people like him don’t care about quality, customer benefits, or long-term value. They don’t even care about the product or service. Everything they need to know is contained in the financial and marketing numbers. And if the visionary founder takes money from them, he or she will be elbowed aside as the business is pillaged to yield the biggest, quickest return possible. So, forget that great product – wouldn’t you rather get rich instead? All of the money people, it turned out, made their pile selling out to some bigger company (which often regretted it, I found out from Googling).

It makes you wonder how many great innovations have been pushed aside because a dollar-fixated money man didn’t see the point. It also makes me wonder how many dull, average companies got that way because they took someone’s cash, put the founders out to pasture, and set all the fun, smart ideas aside and turned themselves into a bad mutual fund run by second-tier MBA school graduates.

My hospital got burned once when the vendor we had just chosen went public and the obligatory new gunslinger corporate executives suddenly became more worried about the company’s quarterly numbers than my hospital or their products. I’ve had vendors that were bought by GE and were never heard of again. Others borrowed themselves to the hilt and had to put the money men in charge as collateral, which naturally meant the answer to every problem was to charge us more, give us less, and sell of chunks of the company to anyone interested.

I like to think the time for change is at hand. The financial industry melted down because of that kind of short-sighted greed. The government will either have to live within its new lesser means or keep selling the country off piecemeal to foreign debt-holders. People want to shop local, keep it simple, and live green. Rich people and monolith corporations suddenly don’t look so infallible any more.

So while you’re out their driving your Prius and eating organic apples, give this a try. Every now and then, buy an IT product or service from a low-debt, founder-led company that thinks creatively, has fun, and cares about its customers. The last thing we need is more faceless widget factories run by money-lending Sharks.

In fact, I kind of hope Shark Tank gets cancelled.

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October 4, 2013 Time Capsule 1 Comment

Time Capsule: A Harvard Vision of One-Stop Shopping: Why Someday You Might Buy a Michael Jackson Ringtone, a “Pull My Finger” Game, and CPOE from the Same Vendor

September 27, 2013 Time Capsule No Comments

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 2009.

A Harvard Vision of One-Stop Shopping: Why Someday You Might Buy a Michael Jackson Ringtone, a “Pull My Finger” Game, and CPOE from the Same Vendor
By Mr. HIStalk

125x125_2nd_Circle

The software my hospital uses is the same as everybody else’s – old. We still have musty mainframes running character-based applications. We use oddball servers running systems whose vendors have changed hands several times or closed up shop completely. Some of our systems, like the gray-haired employees who support them, haven’t changed their look since Reagan was in office.

So here’s my thought. The only significant, computing-related change I’ve seen in my hospital in several years came about because of infrastructure, not applications. The expensive and painfully implemented software applications had only modest impact on creating information and even less on its consumption.

Those ground-breaking technologies at my place were:

  • Wireless connectivity that made systems portable and therefore clinician-friendly.
  • PACS and related imaging technologies that changed the entire paradigm and workflow of managing and using patient images.
  • Physician portals that took information we already had (mostly in the largely ignored clinical data repository) and made it universally available and easier to use.

(I’ll eliminate the Crackberry since peon employees aren’t allowed to have them, but executives are fixated with them to the point I’m thinking about trademarking the name VPacifier).

You could argue that these weren’t new technologies at all. Years before we put them in, our employees had already been screwing around with WiFi, digital photography, and Internet pages at home. They didn’t have to be prodded to use their equivalent at work.

So, as my previous hospital employer’s chief medical officer always said after rambling pointlessly, where am I going with this?

The most promising innovation in physician systems won’t come from for-profit software vendors like Cerner and Epic, who aren’t thrilled at the prospect of rewriting their cash cows. Instead, it will come from the iPhone, and I’m not just talking about mobile applications, I’m talking about software architecture.

A couple of geeky Harvard professors are pushing the concept of “an iPhone-like platform for healthcare information technology.” They’ve written a journal article and are convening a tiny, invitation-only conference of non-vendor people to flesh out the concept later this year. If they can overcome the back-scratching CIO-vendor-consultant troika that keeps the status quo in place, their idea could be big.

What they’re saying isn’t new: monolithic, scripted applications sold by soup-to-nuts vendors don’t work well (can I get an amen?) A better architecture model for healthcare involves tightly focused, substitutable, turnkey, plug-and-play applications that run on the same basic platform. The customer can use whatever combination of mini-apps that works best for them, with one flip of the switch bringing one of them online (or offline in the case of buyer’s remorse — gee, I wonder why vendors would have a problem with that?)

Like the iPhone, in other words, with its ridiculously well-designed user interface, its App Store, and its portable form factor. People get the iPhone without going to class, studying a stack of manuals, or hiring a consultant to explain what they just bought. They also aren’t held hostage to the single vendor to which they’ve sold their souls.

It does not take a Harvard person to tell you who would love this (customers) and who would hate it (the troika, although CIOs might surprise me and embrace the idea). Those who love it have additional ammunition: the cheap consumer gadget known as the iPhone will be rearranging healthcare IT priorities even if the Harvard guys flop, most likely soon taking the #4 spot on my list.

So can the Harvard guys succeed? Beats me. They have a fun idea that needs a ton of fleshing out to even be discussed publicly. Lots of ivory tower stuff fails. And, nobody’s paying much attention since the HITECH gold rush has them hypnotized.

Still, I’m cheering for them since it’s about the only radical platform change out there that could shake the HIT applications business back to life. Open source has elicited nothing but yawns. Vendors are consolidating without new entrants to threaten them. Hospitals haven’t shown any interest in manhandling their vendors into updating their last-millennium wares. Same old, same old.

I think it’s darned interesting, although being an industry pessimist, I’ll root for the Harvard guys while betting against them.

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September 27, 2013 Time Capsule No Comments

Time Capsule: A Day in the Life of IT-Visionary Hospital VPs: Laying Out CPOE Benefits to Luddite Doctors

September 20, 2013 Time Capsule 3 Comments

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 2009.

A Day in the Life of IT-Visionary Hospital VPs: Laying Out CPOE Benefits to Luddite Doctors
By Mr. HIStalk

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Doctors are such whiners when it comes to computers. Everyone can see that. Resisting the use of CPOE and EMRs is just silly in this day and age where everything is done on computers.

This recently came to a head at my hospital. The CEO got a voice mail from a peer at St. Roxy Hospital, left on his desk by his executive assistant, who transcribes all of his messages.

St. Roxy was mandating CPOE, he read, underlining the word “mandatory” since it was important. Doctors need to do all their work on computers instead of the paper chart. There were too many errors and too little opportunity to oversee their work by monitoring electronic databases.

My CEO responded decisively, leaving his executive assistant a Post-It note on her monitor right beside the one holding her current password, asking her to schedule a meeting with all his VPs about CPOE. She was asked to prepare a relevant PowerPoint presentation and attend the meeting to run the laptop.

The executive assistant e-mailed all the VPs to ask them when they would be free for an hour in the next two weeks. It took a week to get all their replies since some were out of town and hadn’t set their vacation alerts.

One was late in responding because her top-of-the-line hospital laptop had failed after her teenaged son had used it for several consecutive hours of doing Internet research for a school project in his locked room, necessitating a call to the VP-only IT support hotline so that a technician could be dispatched to her house on a Friday evening.

Once the meeting finally occurred, everyone agreed that it was time to take a hard line with CPOE-resistant doctors. The marketing VP took minutes, asking to have someone type them up because he doesn’t have a PC in his office since it clashes with his executive furniture.

The CPOE software vendor was the problem, the COO decided. He had his assistant arrange a Webex with the vendor after having her call the CIO to find out what vendor had provided the $20 million system. It started late because several of the VPs needed personal help getting connected. Once on, the vendor’s sales VP apologized that he would be not be able to see the PowerPoint because he was on the road, where he doesn’t like carrying a laptop.

The solution, it was decided, involved tablet PCs and speech recognition software. The CIO had never used either, but recommended that the CEO order some of both for doctors to try. Since the CEO was running late for his 5:30 tennis match, he asked his executive assistant to get on “The Google” and order some copies. She asked if it was OK to work an hour of overtime to get it done since she was responding to a Wackovea request to send in her account’s user name and password to avoid having access to her checking account frozen. He agreed, telling her to draw up a check request and leave it in his inbox to sign.

The CIO was tasked with putting some kind of graph on the executive dashboard to monitor the progress. He wasn’t too worried about it since executives rarely looked there anyway. He had asked them whether they found the Intranet useful, but all the VPs replied that as leaders, they relied on instinct and their skills at understanding people to make decisions rather than graphs.

Everyone felt good about the progress that had been made in helping doctors understand their vision of shifting their income-earning patient care activities to computers. So good, in fact, that the CEO decided to publish his thoughts on CPOE to his widely read blog, which will happen just as soon as his executive intern finds the time to write something up for him.

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September 20, 2013 Time Capsule 3 Comments

Time Capsule: Who Wants to Be a Healthcare Millionaire?

September 13, 2013 Time Capsule 4 Comments

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 2009.

Who Wants to Be a Healthcare Millionaire?
By Mr. HIStalk

I’m a conservative capitalist, but I’m inherently distrustful (jealous?) of anyone who is obscenely wealthy (like most people, I define that as anyone making more than me). For that reason, I can’t decide how I feel about the $30 million in compensation that McKesson paid CEO John Hammergren last year.

As a capitalist, I say more power to him. The board sets his compensation and they should know what he’s worth to the company. That’s how the free market system works (recent spectacular free market failures aside). Greed is good.

On the other hand, I’d be miffed I owned MCK shares, which dropped by a third during that same year. They’re still worth less than half of what they were when McKesson paid $14 billion for HBOC in 1998, only to find out its books were stored in the fiction section. Why is the CEO raking it in but shareholders and 401K employees are losing their nest eggs? (I can’t see from SEC filings that he evens owns any shares, which probably doesn’t inspire much confidence in those who do).

I might be upset as a customer, seeing where my McKesson products fall in the rankings and not getting much innovation for my investment. Heck, Steve Jobs only made $15 million in 2007 and the man invented the iPhone and changed the world, for goodness sake.

I’d be furious as a general critic of CEO compensation. Hammergren’s comp is something like 1,000 times that of the average employee, actually hitting a reported 5 percent of total company earnings last year when he supposedly took home $59 million. He’s also got what magazines have said is the largest going-away nest egg of any American CEO at $85 million (companies spend a fortune getting a CEO and then another one to get rid of them). Surely the financial and automotive industries taught us that companies have no backbone when it comes to paying their executives rationally.

I’m personally upset is as a healthcare purist working stiff. All we on the ground hear is how we have to sacrifice and put the brakes on endless healthcare price increases. No more generous 3 percent pay raises, cafeteria discounts, or travel budgets. The hospital CEOs telling us that are often making $1 million or more a year, as breathtakingly excessive for a non-profit as Hammergren’s $30 million. The people on the wrong end of the decision are wearing scrubs and actually delivering the only service the hospital is paid for – too bad they toil in the non-carpeted areas of the hospital.

Who should be most miffed, though, are consumers watching their medical insurance get more expensive even as it covers less. McKesson basically resells drugs, a manufacturer’s middleman holding and distributing inventory. Is that really such a valuable service? And is running a hospital really such hard work that nobody would to it for less? Is running a mid-sized IT department really worth $300K?

If we get serious about healthcare reform, we cannot avoid debate about who, personally, is making what. I don’t know if the average citizen wants to finance $30 million middleman CEOs, $2 million hospital CEOs, and $1 million doctors. Healthcare must not be much of a calling if nobody in it is willing to work cheaper.

But here’s where I really get confused. Equally debatable are $300K CIOs, $150K IT directors, and $100K programmers. The salary is less, but there are a lot of us. Who’s to say what value we IT types add to healthcare vs. what we’re paid to do it?

I’m no accountant, so I look at healthcare costs as a black box. Profits have to end up as some kind of payment or equity earned by individuals. Lots of people on that list are making more than they are worth, at least judged from the value they appear add to patient outcomes. Still, I don’t see any of them offering to give it back.

So who’s on that list of the massively overpaid people making healthcare so expensive that it threatens the future of the country? John Hammergren for sure, but maybe you and me, too.

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September 13, 2013 Time Capsule 4 Comments

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