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Time Capsule: Community Physicians and Technology: Think Convenience Store Owner, Not Society-Minded Scientist

December 14, 2012 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 2008.

Community Physicians and Technology: Think Convenience Store Owner, Not Society-Minded Scientist
By Mr. HIStalk

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I have had the magic revelation. I know now why we healthcare IT people can’t figure out the seemingly puzzling behavior of small-practice doctors when it comes to technology adoption.

Here it is. Once they hang out a shingle, they’re no longer society-minded scientists. They’re small business owners.

The next time someone talks about physician practices, replace that term with “convenience store owner.” They’re on every corner, they compete vigorously for business, they watch expenses with an eagle eye, and they pay themselves only after everybody else gets paid. And unlike convenience store owners, they have to deal with insurance companies who tell them what they’ll get paid and hammer them with a mass of ever-changing regulations.

They’re also going to look at IT a lot differently than doctors in hospitals. Or especially, than hospitals themselves. Any money they spend on IT comes out of their own pockets. Any help they need doesn’t come from the friendly IT department — they have to find someone and pay high rates for even simple tasks, like installing a PC or figuring out connectivity problems.

Technology cheerleaders get frustrated that docs don’t just buy systems and get with the program so everybody can benefit. The problem is that everybody doesn’t benefit. Doc has just made a donation to insurance companies, patients, and hospitals who all appreciate the boost in their well-being from his or her investment. That doesn’t even include the extra time required to maintain electronic documentation, which always takes longer than scribbling. Physicians have just one thing to sell: time. They protect it strenuously, as they should.

We hospital types forget that 90 percent of a general practitioner’s time and even more of his or her income comes from their small business. Seeing patients in the hospital is a cost of doing business, not the day’s focus. While the hospital folks are going to meetings and delivering care as part of a big team, Doc’s out there on the front lines taking all comers, armed only with a few minimally trained assistants and whatever’s in his or her head, trying to improve health and provide a positive customer experience in an average of six minutes per visit.

The people they deal with in hospitals have, for the most part, never run a small business. They’ve always worked for someone else. The world looks a lot different when the only employer who’ll take care of you is you.

From an economic standpoint, doctors are paid to work. If we’ve got some kind of beef about excessive use of diagnostic procedures or esoteric treatments, we need to stop paying for them. That convenience store owner will sell you cigarettes and beer that are bad for you because (a) you want them, and (b) it adds to their bottom line. There’s a word for those civic-minded C-stores that stop selling them on principal: defunct.

Doctors are pretty much stuck in the small business model. The problem is that we’re expecting them to hold hands and join the choir even though they’re struggling to keep the doors open given rampant competition, reduced payments, and a fickle market.

I’m making a point to think twice before ripping doctors for not jumping all over e-prescribing, pay for performance, or interoperability. Unless you’ve got a rock-solid argument that would convince a convenience store owner, you’re wasting your time.

Time Capsule: Sun Was Right: The Promise of Healthcare Applications Requires a Grid, Not a Data Center Full of Servers

December 7, 2012 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 February 2008.

Sun Was Right: The Promise of Healthcare Applications Requires a Grid, Not a Data Center Full of Servers
By Mr. HIStalk

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Sun Microsystems has been saying for years that “the network is the computer.” I hooted when I first heard that because it seemed so transparently self-serving, but I actually think the company was right all along. Sometime, maybe sooner than later, your data center won’t need servers. In fact, you probably won’t need a data center or IT staff at all (so in an ironic twist, you can use that space to store paper medical records).

I came to this conclusion after realizing that those Sun thin client blowhards were right, too. All the software that’s important or cool these days runs over the Web, not on a desktop PC. I’ve traded Office bloatware and piggish e-mail clients for free, stripped down versions that run on the ubiquitous information grid known as the Internet. Tastes great, less filling. I can get my job done, derive and create greater value, and let somebody else worry about what’s under the hood.

In other words, I don’t need a loaded PC any more than I need a gas generator, a TV antenna, or an outhouse. The grid is better, cheaper, and more reliable to meet those needs. All I need is a connected appliance. But more importantly, the network adds tremendous value. You contribute a little by joining, but you get a lot in return (well, hopefully not in the outhouse part of my labored analogy, but you know what I mean).

That’s how physician billing vendor athenahealth works. It applies the collective knowledge of thousands of customers to instantly update reimbursement rules for all the practices on its grid. Doctors’ offices don’t need a roomful of souped-up computers or an expert on arcane billing practices. They just need a connection to the grid.

Back in the hospital, we’re still using the same old (literally) applications, monolithic piles of esoteric and proprietary hardware that require skilled care and feeding, connected by a fragile spider web of interfaces and middleware that often causes problems with response time, downtime, and botched upgrades. Even when they’re up and running, those systems have plenty of functionality but zero intelligence, obediently regurgitating stored data in a format that’s little different than how it was entered.

The Holy Grail is to pull data back out in a way that lets hospitals learn something actionable, like which antibiotics work best or which lab values correlate with genomic profiles. Few hospitals have the capability to even get that kind of information from their own locally stored data. Fewer still can tap into the collective knowledge of their fellow IDN members. And nearly none can focus the accumulated intelligence of hundreds of peers when making important clinical and business decisions.

New technologies such as Software as a Service will allow hospitals to move to the next level of collaboration – actually pooling their collective expertise with that of their fellow grid users. The applications themselves could be expertly managed by experts and paid for as a service instead of buying racks of servers and installing patches.

Organizations centralized IT in the first place to gain leverage, reduce costs, and reduce risk. Hosted applications are the next step up the food (and value) chain. Capital requirements should be less, space and people requirements minimized, and they’d get the best IT talent money can buy, not just the best that’s willing to move to International Falls, Minnesota.

Hospitals are uniquely positioned to share knowledge compared to nearly every other industry. Most of them are non-profits, those more than 50 miles a way aren’t competitors, and few disagree that healthcare costs are sucking the wind out of our economic sails. For that reason, it will soon make good sense to shut down the endlessly duplicated silos of locally maintained hospital IT and get on the grid instead.

Time Capsule: I’ll Alert the Media: Why Not Use Cheap, Easy Multimedia to Store Patient Information?

November 30, 2012 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 2008.

I’ll Alert the Media: Why Not Use Cheap, Easy Multimedia to Store Patient Information?
By Mr. HIStalk

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Clinical systems vendors don’t seem to have noticed that it’s now easy and cheap to record and store photos, audio, and video on computers. Everybody’s snapping a digital photo, recording MP3 audio, or using a cheap camcorder, camera, or cell phone to make a video recording that, while not exactly “Lawrence of Arabia” quality, is plenty good for nearly every other purpose. Storage isn’t a problem, either, now that you can dash into Best Buy and leave with a terabyte of external disk under your arm for $229.99, according this week’s ad.

Maybe doctors haven’t noticed either. Otherwise, why wouldn’t they be retooling their practices to take advantage of cheap media? A picture is easily worth a thousand words, especially at today’s transcription rates. Doctors will peer endlessly and intently at diagnostic images and try to describe them in great detail with words, but are happy to read another doctor’s description of a wound or surgical procedure instead of demanding to see the actual photo or video of it.

Having something more than a mountainous chart (most likely paper, but possibly either electronic or an ugly hybrid of both) would sure be an advantage in trying to remember what the patient said two visits ago, what their infected eye really looked like, or what their exact words were in describing their chest pain.

Instead, doctors jot down a few illegible notes, taking time away from the patient to perform that secretarial work they complain bitterly about when it’s CPOE or e-prescribing.

Medical schools must be training them wrong. They’re documenting care and interventions like it was 1908. If this was Playboy, there would be no centerfold, just a wordy description to go along with the World Peace interview.

It would sure be nice to have the patient’s information captured in the EMR in something other than black letters on a white background. “Nice” is being too kind. It’s just ridiculous that our supposedly savvy move from paper to computer means only that the screen looks just like the paper.

I could rattle off hundreds of clinical benefits, but instead, I’ll play my most convincing trump card first and save us both the time: lawsuits.

Lawsuits are always “he said, she said.” The patient claims they weren’t warned, or the doctor says they weren’t told, or the surgeon swears he removed the sponge that somehow stayed inside the patient. Healthcare volumes are so high that no one remembers accurately, if they even remember at all.

That guy with the infected toe that the ED doc saw for 90 seconds comes back without the toe, but with a lawyer. There’s just no way for the doctor to look good trying to decipher a ratty pile of badly written paper in front of a puzzled jury and a mad-dog ambulance chaser.

Imagine if every exam room had a constantly running camera recording audio and video. Everything the patient says, everything they are told, every action that was performed – all recorded perfectly. At the patient’s next visit, it would take seconds to call up a fast-forward version, prepping the doc to impress the patient by noticing that her hair has been attractively cut or his wedding ring is now an untanned finger line.

If the lawyer is in tow (no pun intended), there is no gray area. Every scrap of information is right there in low-res video and audio, plenty good to stop most lawsuits cold (unless the doc is a quack, in which case the cameras and microphones should be avoided like the plague).

It’s as easy and cheap as having multiple security cameras in an office building or a Nanny-Cam. Privacy issues would need to be worked out, but those relating to technology and cost are done deals.

Today’s media can capture every nuance of physical fact, verbal cues, and the dynamics of a particular interaction, all permanently, cheaply, and easily retrievable. For that reason, it seems ideal for the practice of medicine, nursing, and other healthcare delivery, not to mention the educational and performance aspects. Maybe everybody’s just too busy to have noticed.

Time Capsule: Fiction Writers, Get Ready: The “Most Wired” Bandwagon is Leaving the Station

November 16, 2012 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 2008.

Fiction Writers, Get Ready: The “Most Wired” Bandwagon is Leaving the Station
By Mr. HIStalk

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It’s “Most Wired” time again and I’m excited! Just like those folks who find themselves overdue for a teeth cleaning or an annual prostate exam.

Actually, it’s worse. Hygienists and rubber gloved doctors work quickly. Those magazines, companies, and consultants with a vested interest in the Most Wired nonsense yammer incessantly about it for months, wasting free magazine space on how insightful it is, how much the results correlate directly to everything that’s good in the world, and how inferior you should feel if your hospital isn’t participating (and winning, preferably, since this is America and everything is competitive).

I once worked in a fairly sophisticated IDN’s IT shop. Lo and behold, right there on the newly announced Most Wired list was one of our tiny hospitals, a 100-bed rural facility with zero IT staff, remotely hosted green screen apps, and no IT budget.

We never found out who completed the application, but it was an impressive work of fiction. For example, it claimed a really high CPOE utilization, which was especially amazing because they didn’t even have a CPOE application (maybe they thought it stood for Clipboard Physician Order Entry). Same with nursing documentation – they were purely paper-based, but claimed to be electronic. Those reading the hallowed roster of winners probably thought that our little hospital was an enviably progressive IT hotbed.

People often make interpretational errors on the Most Wired survey form (often to their advantage, I know you’ll be shocked to hear) and sometimes lie outright. I’ve read down the list of winners some years and laughed out loud at their audacity. All it takes is some competitive pressure and a CIO or CEO who’s looking for bragging rights and suddenly the submitted numbers are as opportunistically flexible as a vendor completing a prospect’s RFP. If in doubt, just say you’re doing it and feign misunderstanding if caught.

Most Wired wouldn’t be so bad if only CIOs read it, bragging about their big W like a pimply teenaged boy excitedly describing his prowess in a purely fictitious romantic liaison. What’s the harm? It’s this: non-IT executives may actually think it’s a useful yardstick. The magazine loads up with impressive graphs and makes enormous logical leaps to connect IT spending with quality, cost, and the salvation of mankind. The gloss increases the danger that someone might take it seriously and leap vigorously onto the ill-advised bandwagon as a result.

I asked one of my employees to complete our Most Wired application one year. He was struggling with its ambiguity and the knowledge that many applicants were most likely fictionalizing to some unknown degree. Finally, he summarized: “How I answer depends on how badly you want to win.” We had won in the past and he knew the pressure was on for a repeat.

Just about everyone pushing Most Wired makes money on IT sales, implementations, or advertising. They have a vested interested in shaming people into buying and implementing, even when it’s a bad idea. The message is clear: winners buy IT while Luddite losers cower in the corner.

You can’t stop your peers from entering and maybe even winning Most Wired. You should, however, let your executives know what categories it measures, what you’re doing in those areas, and how your IT efforts support organizational goals in ways that go far beyond a simple survey.

If enough people do what they should be doing instead of what the survey pushes, maybe the foolishness will stop. It would be nice if organizations focused on their own strategic IT needs instead of worrying about how they rank on a vendor-sponsored survey that encourages one-size-fits-all conspicuous consumption.

Time Capsule: Some Hospitals Make System Decisions Based on What the CIO’s Buddy Thinks, So Aim Marketing Accordingly

November 9, 2012 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 2008.

Some Hospitals Make System Decisions Based on What the CIO’s Buddy Thinks, So Aim Marketing Accordingly
By Mr. HIStalk

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HIMSS and marketing agency O’Keeffe & Company, Inc. just released the results of their “Healthcare IT Marketing Sanity Check Study.” The announcement says their report reveals “significant disconnects” between vendor marketing strategies and provider decision makers.

Here’s where I start making stuff up since I’m not $995 worth of interested.

The report’s teaser says that peers are the strongest influence on provider IT executives. That’s obvious, don’t you think? Hospitals are highly local and generally non-competitive with each other (like schools and government agencies), so there’s no reason not to call up a peer to get a first-hand report.

(That’s a nice way of saying that hospitals aren’t good at methodically evaluating their needs vs. system capabilities. Some CIOs would rather base multi-million dollar systems decisions on gut reaction to the off-the-cuff comments of a complete stranger at a similar-sounding hospital, overlooking the fact that it’s often not lack of product knowledge that causes bad outcomes, it’s a lack of knowledge about their own organization. Also, that those helpful peers are sometimes paid or threatened by their vendors to be positive even when there’s little reason to be).

Another conclusion is that advertising is ineffective. That’s also obvious. Few decision-makers read the free rags that go straight from inbox to trash can. Fewer still read the ads and even fewer remember them when making selections. Would we forget that Cerner, GE, and McKesson are out there plugging away if they stopped running multi-page glossy ads tomorrow?

MBA marketing class starts with this underappreciated fact: marketing and advertising aren’t the same. Advertising is a tiny part of marketing, especially for anything other than low-priced consumer products. Marketing is choosing the right product, place, price, and promotion (years after the class, I’m still proudly reciting the 4Ps of marketing like an obnoxious child who can and will spell “Mississippi” at the slightest provocation).

The best hospital marketing is relationship based. I’m not happy to admit that because it brings up mental pictures of glad-handing sales schmoozers sucking up to ego-driven CIOs who are easy marks for shallow flattery (the “ashamed” part is because I’ve seen that work in places whose people should have known better, with the unimpressive results that you might expect).

I’m betting that your $995 would tell you to establish a peer relationship with hospital decision-makers. Help them with their need to be educated, to solve problems, and to look smart back home. Work through your existing customers, not around them. Provide opportunities for CIO and user collaboration, offer video tours of hospitals using your solutions, integrate process change education into demonstrations, and don’t ignore blogs, newsletters, and independent consultants in your marketing strategy.

(All of this presumes that your product really works. If not, you’re in big trouble anyway, so spend your money on product improvement or maybe bribing decision-makers to pick you.)

There is nothing inherently dishonorable about marketing. It’s true that dishonorable companies often use it in a scam-like fashion, but even honorable ones need to carefully craft and deliver their messages. The nearly universal availability of information, however, will change the methods that will accomplish that. In healthcare, it’s about relationships and the total package, not glossy ads or sprawling HIMSS booths.

Time Capsule: Cerner Layoffs In Review: Why Marching People Out Makes Sense, But Sickouts Don’t

November 2, 2012 Time Capsule 2 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 2008.

Cerner Layoffs In Review: Why Marching People Out Makes Sense, But Sickouts Don’t
By Mr. HIStalk

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Cerner laid off a bunch of people last week. Since I’m a typical 401K investor (not in Cerner stock) but also a wage slave, I can’t decide whether I’m a bourgeois capitalist pig or an oppressed member of the unpropertied proletariat. So, I’m waffling on how I feel about it.

It was only 97 people out of 7,800 employees worldwide (sorry, “associates” as Cerner calls them, although that feel-good term rings a bit hollow after hearing them admit to canning a bunch). That’s just over one percent of the workforce, probably a few weeks’ worth of resignations. Rumors put the real number much higher, and I believe them since I’m a conspiracy theorist when it comes to big corporations.

On the other hand, Cerner came clean by announcing it voluntarily. Antsy investors smelling “growth slowdown” leapt from their Google Alerts to their online brokerage accounts to dump the stock, sending share prices down eight percent. It wasn’t quite as bad as the aftermath of Neal Patterson’s infamous “tick, tock” e-mail of 2001, which dropped CERN nearly 25 percent, but was the opposite reaction than you might have expected given that shareholders usually love cost-cutting announcements.

Here are the gripes I’ve heard from current and former associates:

  • Cerner marched the former employees out after giving them news. Of course they did, and rightly so. How many workplace killings involve separated employees who seemed normal until they cracked? There’s no way to forcefully end the employer-employee relationship that doesn’t involve loss of dignity. March them out while they’re still in the first stage (denial) before they hit the second (anger). It’s cold, but responsible.
  • Cerner targeted management and older workers. Layoffs are about bang for the buck, which means going after expensive and often marginally value-adding middle management. Lots of those folks are mid- to late-career. Voluntary demotions take too much time and energy. It’s easier to cut the cord. Cerner is smart enough to have had HR test the list to make sure federal discrimination laws weren’t broken.
  • The Chief People Officer betrayed employees. Only the hopelessly naïve would mistake an HR person to be an employee advocate. Cerner is guilty of using the trendy, stupid, and overly chummy Chief People Officer title that may have misled some slow learners, but make no mistake: the CPO is a top-ranking company executive, not a friend of the working man or woman. Workers, by definition, are oppressed to some degree.
  • Management kept people who were well-connected, including obvious incompetents, while marching out good employees. Painting targets on backs is an inexact science. Managers are told how many casualties to create and then quickly make a list. Fairness isn’t guaranteed, even when it’s sought.
  • The company was hiring at the same time it was marching people out. Companies want quick contributors, which means hiring for very specific experience (which is probably how most employees got their jobs in the first place). That’s sad, but reality. The door revolves.
  • Unaffected employees should have a protest sickout to bring Cerner to its senses. That seems rather stupid given that the company just axed a bunch of people. Those paper tigers are just as terrified of losing their Cerner paychecks as those laid off were. An effective protest would be to leave Cerner and go to work for a competitor.
  • Clueless VPs who are exactly like Dilbert’s point-haired boss are the problem. No news there.
  • Customers will rise in protest at the cuts. That’s a comforting myth often expressed by those canned as they huddle in awkward and temporary support groups. It never happens, but the thought keeps people sane until they finally realize that they aren’t going to be returning to Cerner and should instead look for wonderful opportunities that will make them glad they got axed (which for some strange reason is often exactly what happens.)

Personally, I’m blaming Meditech. They’ve dominated the industry for 40 years by hiring cheap, obedient new grads and giving them skills with minimal market value elsewhere. More directly related to Cerner, Epic Systems does the same thing. Cerner is getting heavy competition from both, so that strategy appears to be working.

Perhaps Cerner is simply rebalancing its people portfolio to allow it to compete effectively, shooting for some predetermined kids-to-gray-hairs ratio that seems to work elsewhere. As a bourgeois capitalist pig, I don’t blame them, as painful as it unfortunately is to those affected.

Time Capsule: RHIOs 2.0 Dying Uglier Deaths than 1.0, but Hardy Survivors Guarantee Another Round

October 28, 2012 Time Capsule 2 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 2008.

RHIOs 2.0 Dying Uglier Deaths than 1.0, but Hardy Survivors Guarantee Another Round
By Mr. HIStalk

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I’m a contrarian. When everybody ignored reality and jumped on the RHIO bandwagon, I enjoyed being the bubble-bursting cynic who loudly predicted that they would all go up in flames. Yet another dumb idea, I said, slyly orchestrated by stake-in-the-game consultants, member organizations, and ad-happy magazines instead of market realities.

Some folks wanted to argue with me. I bet a few wanted to punch me. I was a real buzz-kill, raining rational thinking onto the frenetic, obedient parade of RHIO trough-lappers.

Instead of basking, I’ll continue my contrarian ways with another shocking, out-of-the-box prediction: some RHIOs will succeed, thereby embarrassing everyone.

RHIOs typified what is most wrong with healthcare IT: money and energy wasted by naïve providers easily led astray by slick salespeople touting an illogical but personally profitable pipe dream. I’m not proud of predicting the demise of RHIOs because it was just too easy, like shooting fish in a barrel or observing that most doctors won’t use CPOE unless you pay them or require it by law.

Not all RHIOs are created equal, though. Funding and governance differ. So does architecture. National trends aside, RHIOs are a purely local effort, connected to national trends only to the extent that they followed their simultaneous, ill-conceived creation.

If you’ve seen one RHIO, you’ve seen about 90 percent of them. That still leaves 10 percent that could mutate into a survivable form.

It stands to reason that some RHIOs will eventually exchange data, find ongoing operational funds, settle bitter turf disputes, and actually improve patient outcomes. It won’t be many of them, but even if it’s just one, we’ll finally have a living laboratory.

A living, breathing RHIO? That’s quite a leap from what started this whole mess: worshipful jawing about how wonderful David Brailer’s Santa Barbara project was, right up until the time it self-destructed without benefiting anybody at all except David Brailer.

Once we have a working RHIO, then what do we do? The bar will have been raised, making it obvious that the RHIO concept itself wasn’t the problem — it was the shortcomings of those running them.

Who wouldn’t want interoperability? The technical challenges are demonstrably solvable. Insurance companies want data sharing. Government wants it. Patients want it. Having one working example means everybody else needs to come back to the table and try again, no matter how embarrassing the whole RHIO 2.0 thing has been (I consider CHINs to be RHIOs 1.0).

Healthcare IT often chases fleeting dreams, then moves on to something else and never looks back once the going gets tough. There’s always low-hanging fruit elsewhere that needs picking, especially if you’re scared of heights.

Lack of real, working interoperability is inexcusable. For that reason, it’s a given — there will be a Round 3. Maybe it’s a Nationwide Health Information Network or a takeover of the RHIO concept by insurance companies. Regardless of what form it takes, you haven’t heard the last of interoperability.

Somewhere out there, right now, some HIMSS committee or consultant is trying to come up with a new name that will distance Round 3 from those embarrassing first two, mostly by calling it something different and hoping for new operating concepts driven by experience and Darwinism. Better technology, smarter governance, more clearcut operating parameters. Mark my words: RHIO Redux is coming soon.

Time Capsule: How the Layoff Grinch Stole Christmas: Clueless Management 101

October 19, 2012 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 2008.

How the Layoff Grinch Stole Christmas: Clueless Management 101
By Mr. HIStalk

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You had a pretty good holiday, I bet. Lots to eat, good company, and that slow, post-Christmas week to revitalize (even if you were “working” … wink).

Some industry folks didn’t enjoy it. They found lumps of coal in their stockings. Actually, it was pink slips, courtesy of Scrooges in suits who laid them off right before Christmas.

I’ve both given and received the “your position has unavoidably been eliminated” speech. Neither was enjoyable. Losing a job (and taking one from someone, for that matter) is shameful and energy-sapping. You head home in a nauseating haze, pitiful work belongings in the trunk, trying to find the right words to tell your significant other and maybe your kids and your parents. Imagine doing that right before Christmas. False cheer and optimism abounds, at least until the stark winter sun goes down early and the panic sets in all over again.

Companies hand-pick employees to march out, of course. The official excuse is that the outstanding managers have skillfully discovered duplication and cancellable projects, leaving nothing but good times ahead once the unfortunate smoke has cleared.

Here’s how it really works. Some manager’s budget or sales projection proves to be wildly inaccurate. Nobody can come up with anything better than payroll cuts. The suits draw up a list of employees who appear to be unproductive, whiny, or rebellious, using the chance to make up for previously unaddressed problems. Extra points are assigned if the victim doesn’t seem like the sort to argue, sue for discrimination, or return with armament (the worst part of being laid off is realizing that management put you in the same league as those losers who got axed with you.)

Only shareholders and competitors love layoffs. Great management and sound strategic planning seldom involves headcount-cutting your way to profitability. Before you know it, quality slips a notch, cheaper but less experienced workers are hired, and management hunkers down to desperately manage one quarter to the next.

I’d buy a toaster from a company like that. Maybe toothpaste. Probably not multi-million dollar enterprise software where the future value of support and R&D has been built into the large upfront cost.

How a company handles layoffs tells you a lot about its competence and humanity. To do it right:

  • Don’t use layoffs instead of setting and managing performance expectations.
  • Cut the use of contractors and consultants first.
  • Do it quickly, fairly, humanely, and not during November or December (duh).
  • Don’t hide on Mahogany Row before, during, or after.
  • Explain to the survivors how you’ll avoid doing it again.
  • Sacrifice management’s bonuses and perks since they’re the ones who failed.
  • If you have to lay people off more often than once every two years, lay yourself off and bring in better management.

For employees, layoffs are the new reality. We’re all contractors. Sometimes you get insurance and a badge with your name on it, but nobody’s getting the gold watch. So, think like a contractor:

  • Immediately start looking for another job if your company violates any of the rules above.
  • Keep your skills current, on your own time if necessary.
  • Keep up with the industry, make contacts, and market yourself to find the next gig.
  • Invest your money and try to develop secondary income stream so you aren’t one employer’s paycheck away from a financial crisis.
  • Don’t neglect any of the above to work massive hours thinking that your loyalty will be reciprocated.

I worked the bluest of blue collar jobs during summers in college (I wore a hard hat and a uniform with my name on the pocket). The militant union ran the show, but one of its bigwigs told me in confidence, “Workin’ man don’t need no union.” I’d like to update his wise words with this century’s version: “Workin’ man or woman don’t need no permanent employer.” Defer your gratification at your own risk … there are lots more coal-bearing Grinches out there, but lots of opportunities as well.

Time Capsule: Enterprise IT Projects Are Like Corvettes: Keep Hotheaded and Unskilled Drivers from Behind the Wheel

October 13, 2012 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 December 2007.

Enterprise IT Projects Are Like Corvettes: Keep Hotheaded and Unskilled Drivers from Behind the Wheel
By Mr. HIStalk

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Big IT projects are a lot more fun to talk about than little ones, aren’t they? Transformational! Visionary! Strategic!

Hospital executives love those adjectives. Big projects make them look like decisive leaders and doers, bold swashbucklers in gray pinstripe who will throw well-placed caution to the wind to get an exhilarating ride to the IT stars.

That those projects nearly always fail doesn’t deter them. CPOE, ERP, and RHIO projects are launched with great fanfare and unrestrained executive enthusiasm. They almost always die an ugly, quiet, and protracted death, sad little pockets of unrealized objectives and defeated naiveté. The executives find other pressing obligations at the first smell of death, leaving the CIO and team to ride the flaming plane into the ground.

Tactical IT projects, on the other hand, nearly always succeed. You want to put in a lab system, HR suite, medication automation, PACS, or portal? They’ll work as planned, delivering pretty much exactly those reasonable benefits projected by the less-lofty suits who are usually involved. Sexy or not, most hospitals have the aptitude to make these projects work.

Unfortunately, enterprise-wide failures suck up a lot of the available capital, organizational energy, and IT resources of hospitals whose reach has exceeded their grasp. Failure is hard work.

The bigger the project, the more likely it will flop. It’s more than a linear relationship. Projects twice the size have four times the chance of failing. (Note: I just made that number up, which is shameful for an objective publication, but then again, I’m just an obnoxious guest here).

Where that failure point lies depends on an organization’s readiness. An assessment tool for warning signs might be useful. Score low enough and your project is doomed before the Rolex-wearing salesperson has headed off for the Caribbean.

Your organization should steer clear of big-vision projects and stick with the tactical stuff if:

  • Organizational politics are ugly and widespread.
  • Everybody in the trenches likes things the way they are and management doesn’t have the skill to convince them otherwise.
  • Strategies always seem to involve copycatting the ideas of smarter or better-known organizations.
  • Conditions are never stable enough for long-range planning and consistent execution.
  • Stakeholders are too busy to attend project meetings.
  • Everybody secretly hopes software will start enforcing all the rules that nobody follows now.
  • Managers rely on intuition instead of objective tools like productivity management, process redesign, and a consistent reward system.
  • Non-IT projects that cross disputed organizational territories (physicians vs. administration, pharmacists vs. nurses, finance vs. everybody else) fail every time they are attempted.
  • Funding never seems to be available for post-project assessment and improvement.

Hospitals don’t see themselves in the flattering mirror held in front of them. Vendors and consultants don’t say a word. The healthcare IT industry would shrink to half its size if somebody created a tool that could unerringly conclude, “Don’t waste your money – you can’t handle this project.”

Rich parents have no business giving their 16-year-old a new Corvette, even though the salesperson is deliriously reassuring. That car is for people with years of experience and cooler heads.

If only the healthcare IT industry could figure out how to keep its overconfident and unskilled drivers from behind the wheel, maybe fewer of them would wrap themselves around trees at 100 miles per hour.

Time Capsule: E-prescribing is Simple, Except That Most Physicians Don’t Use EMRs

October 5, 2012 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 December 2007.

E-prescribing is Simple, Except That Most Physicians Don’t Use EMRs
By Mr. HIStalk

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The push for electronic prescribing by physicians is accelerating. Mike Leavitt of HHS thinks doctors should get a bonus for doing it (actually, a chance to earn their money back from a planned reimbursement cut). Intel Chairman Craig Barrett, in his role as a member of the American Health Information Community, recently told CMS to use its purchasing power to lay down the law to its doctor vendors. He’s often a simplistic blowhard, but he’s probably right that the customer gets to make rules that suit them.

E-prescribing is theoretically efficient, easy, and secure. Why, then, is the industry still 95 percent based on wadded up, illegible, and easily altered paper prescriptions that are free of any context that could reduce errors, improve formulary compliance, and save time for patients?

I can think of several reasons.

E-prescribing, like almost all aspects of healthcare automation, doesn’t benefit the doctors who have to change their work patterns to use it.

Patients don’t benefit directly, so they don’t really care enough to push their doctors. With paper, they can (as many patients do) not get the prescription filled, save up money to pay for it, or try to order a cheaper supply from Canada or overseas. Paper gives them that control.

Existing e-prescribing systems are generally unsophisticated and lot less functional than you might expect (like not being able to handle pharmacy verification that the prescriptions were accepted and/or filled).

DEA and state regulations vary on what kinds of prescriptions can be issued electronically.

The chicken-and-egg dilemma. Pharmacies aren’t excited about processing prescriptions electronically because physicians aren’t sending them. Physicians don’t send them because, in many cases, the pharmacy is still stuck in yesterday’s world of telephone and fax.

Efficient electronic prescribing requires an electronic medical records system in the doctor’s practice, which is still a tiny minority of them.

That last item is the big one, of course. E-prescribing should be a by-product of documenting a patient visit. It’s just not reasonable to expect a physician to leave the treatment room, fiddle with a standalone e-prescribing system, and re-key duplicate information.

Scrawling out a paper prescription takes a fraction of that time. The act of writing it gives the doctor time to look away from the patient, collect his or her thoughts, and make notes on the ever-present paper chart. The ritual of handing it over offers a chance to counsel the patient and to add finality to the visit. It’s a rule: you put your pants back on while he or she is writing, you take the prescriptions with one hand and shake with the other, and then you beat it so the doc can make their patient quota for the day.

Everybody rolls their eyes at how backward healthcare is, but we’re not alone. It’s very likely that your visit to an attorney, accountant, or mechanic is computer-free, except for your final bill. In fact, here’s a challenge: name any professional other than a physician who is expected to peck clerical work into a computer while consulting with their customer.

That’s why the only answer is to reward doctors (or punish them less, under Leavitt’s proposal) for e-prescribing. If we truly believe that the benefit is significant (do we?) then somebody needs to cover its cost and maybe help out with EMR expenses too. Without either a carrot or a stick, neither electronic prescriptions nor EMRs will ever gain critical mass.

Time Capsule: If Nurse Shortages Require a 50 Percent Labor Reduction, What Technology Will You Install (or De-Install)?

September 30, 2012 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 December 2007.

If Nurse Shortages Require a 50 Percent Labor Reduction, What Technology Will You Install (or De-Install)?
By Mr. HIStalk

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The recent CDW Healthcare nurse survey about IT is both fascinating and sobering. Nurses are too busy with patient care to get application training or participate in IT projects. They continue to believe that IT can improve their jobs, even though current systems involve frustrating duplication. They also think that applications bought on their behalf are ineffective and unreliable.

“Nursing systems” really aren’t that at all. They are really “systems to get nursing to do stuff that someone else wants.” Electronic charting, medication administration, order entry, bedside barcoding, and patient assessment: none of these save nurse time. They may have an impact on quality (slight or otherwise) and they may create an impressive-looking electronic record for other people to read. What they don’t do is make it easier for nurses to finish their work by shift’s end.

Here’s an exercise to ponder. The hospital CEO comes to you and says, “Mr. or Ms. CIO, our RN shortage is serious this time. There’s no solution in sight. We have no choice but to use just half the nursing hours we have available today. You heard me right — I said half. Quality cannot suffer. You have an unlimited budget to implement whatever technology you can find that will deliver that result. Do that and you’ll get a nice bonus — I’ll let you keep your job.”

Let’s say you receive that ultimatum. Would you recommend clinical documentation systems or bedside barcoding as a way to survive on 50 percent fewer nursing hours? I’m pretty sure you wouldn’t. So what would you recommend?

You’d first need to find out how nurses spend their time. That’s a simple observation study, easily done by data-driven IT types, engineers, or quality experts.

Then, you’d push tasks that add minimal value down the food chain to cheaper and more readily available employees. That assumes you have those, of course. Many hospitals inexplicably got rid of LPNs and nurse aides years ago, using expensive and hard-to-find RNs to pass meal trays and give baths. Didn’t all those hospital suits learn anything about labor management in their MBA programs?

Then, you’d automate where you could to improve efficiency. Buy more PCs and Pyxis machines so nurses don’t wait in line. Provide portable communications devices. Have all drugs and supplies delivered to an in-room cabinet for each patient. Let someone else reconcile narcotics counts and give report. Integrate nurse call systems with other communications.

Maybe you’d even de-install some of those applications that quietly eat up nurse time because of poor design. Watch the kid at McDonald’s ring up your hamburger. Now imagine what the screen would look like if your current clinical systems vendor designed it. Real estate sales would skyrocket because every McDonald’s would need another mile of drive-through lane to hold the angrily waiting customers.

Maybe the RN shortage isn’t that severe at your place (so far, anyway). Still, you should make sure that IT systems aren’t contributing to it. When installing new systems, practice “first do no harm”: will they require more nurse time? Any answer other than “no” is unacceptable. And if you’re convinced that technology saves time, this is a great opportunity to prove it.

Time Capsule: Sutter’s $150 Million Turned $500 Million Clinical Systems Project: Where Seldom was Heard a Discouraging Word, Apparently

September 22, 2012 Time Capsule 2 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 2007.

Sutter’s $150 Million Turned $500 Million Clinical Systems Project: Where Seldom was Heard a Discouraging Word, Apparently
By Mr. HIStalk

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Sutter Health didn’t seem embarrassed when the local newspaper recently reported that its 26-hospital Epic clinical systems project will end up costing around $500 million. In fact, Sutter’s COO even hinted that the tab could run higher, saying that EMR projects rarely meet budget and timeline projections. He didn’t sound concerned.

Or, maybe it was gallows humor. Sutter’s original project budget was $150 million. Being off by over 230 percent is scandalous, at least when someone other than Uncle Sam is involved. Luckily, Sutter can afford a gaffe of a few hundred million.

Wildly faulty project budgets and timelines are not uncommon. Project complexity goes up much faster than being simply linearly related to bed size or headcount. It’s closer to geometric: doubling the bed size quadruples the effort (and therefore the cost). It’s anti-economy of scale. Little hospitals have it easy, other than they’re broke.

That’s no excuse for a bad estimate. Complex projects demand sophisticated planning and risk mitigation. Socking a lot of cash in a contingency fund is poor substitute for planning well in the first place.

The main reason for underestimation may be more psychological than numeric. Project costs are often underestimated and riddled with unlikely assumptions because that’s what people want to hear. This is similar to groupthink, in which members of a group are so reluctant to disrupt group harmony that they avoid viewpoints that are contradictory or critical.

Those executives who collectively decide to plunk down hundreds of millions of dollars for software may not be all that enthusiastic about the idea individually and off the record. Everybody else seems to like the idea, so it’s easiest to avoid arguing with peers by just going along as a passive rubber-stamper, especially if the boss clearly favors doing it.

After all, everybody else is hot to get going, too. Consultants urge action, especially when they smell an opportunity to get new engagements. Affected departments love anything new and fun, at least initially, so their appointed representatives can’t wait to get started. Journals, HIMSS conferences, and vendor salespeople encourage action because the industry (and therefore their place in it) depends on churn.

The CIO, being nurtured in an IT advocacy mindset, often naively believes that IT fixes problems, even when available solutions are dysfunctional and collective experiences suggest otherwise. If the other VPs are willing to do it, the reasoning goes, why not get a chance to shine, beef up the resume a little, and move up on the staff-and-budget yardstick they measure each other against?

Many of these big-ticket projects will never even come close to being worth what they cost. Does anybody go back to the people who made the “go/no go” decision and either ask for an explanation or fire them for bad judgment? Not usually. The project’s once-broad circle shrinks to a grim core of IT people stuck with the unenviable task of trying to reconcile unreasonable expectations with the ugly product limitations and internal processes at hand. What started out as a noble collective mission becomes a never-ending IT ground war that no one wants to talk about.

It goes without saying that IT people shouldn’t be initiating or leading projects other than those involving IT infrastructure. What may need to be said, however, is that the process and choice of people involved in making huge IT project decisions may be flawed as well. Seldom is heard a discouraging word when project-friendly allies sit around a conference room table breathing each other’s air.

If hospitals really wanted to make an informed decision, they’d bring in patient advocates, safety experts, physicians, risk managers, finance experts, and process engineers. That’s pointless if the pre-ordained executive answer to the “should we do this” question is already “yes.”

Time Capsule: Two Economic Theories That Explain Why Epic’s Competitors Had Better Improve Fast

September 14, 2012 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 November 2007.

Two Economic Theories That Explain Why Epic’s Competitors Had Better Improve Fast
By Mr. HIStalk

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Let’s say you own a hot sports team. Your tickets are more expensive than those of any other team in the league. Your venue sells out for every game with no group discounts, $8 concession stand beer, and an indifference to customer requests to change the uniforms, get better-looking cheerleaders, and add more women’s restrooms. You as the team owner know what’s best, and if the fans don’t like it, there are thousands more eagerly willing to take their seats.

Welcome to Team Epic Systems.

Arch-competitor Cerner embarrassed itself last week by complaining that a big provider in its back yard, University of Kansas Hospital, chose Epic over lower bidder Cerner in a $50 million deal. According to a spokesperson, the Epic choice was “a disappointment to Kansas City.” Cerner, she said, would have spent a ton of research money at KU, but will have to look elsewhere because KU’s doctors vastly preferred Epic’s product (the unpatriotic nitpickers).

Make no mistake, Epic has changed the industry, at least when it comes to high-end academic medical centers. Back in the late 1990s, economists might have characterized the healthcare systems market as an oligopoly. That’s when four or fewer sellers own at least 40 percent of the market. SMS, HBOC, Cerner, Meditech … yep, sounds like one to me.

Epic’s remarkable record of big-provider wins moves the high-end HIT market closer to a monopoly, a market with no substitute goods or economic competition.

Epic is quirky. They don’t negotiate pricing. They share the “we know better than our customers” business model as Meditech, but from the opposite end of the pricing spectrum. Complain and it’s the Soup Nazi – no system for you. They’ve got all the customers they need, so they aren’t about to put up with foolishness.

Some of the Epic craze is surely due to the bandwagon effect (buying what everyone else like you or better buys), but most of the credit goes to its only real competitors in the high-end market – Cerner, Eclipsys and McKesson. What does it say about the products and services of those companies when customers like KU buy from high bidder Epic even though it costs far more and VIP coddling is highly improbable?

Perhaps the next market phase will follow a far more obscure economic theory called Hotelling’s Law. It postulates that sellers will make their products as similar as possible to maximize overall demand, even though customers would benefit from product differentiation (examples: drugstores and gas stations operate across the street from each other, airlines copy each other’s flight schedules and prices, both of which benefit the businesses at the expense of customer convenience in having a choice).

In other words, if I’m a vendor and Epic is beating me like a drum, maybe I’d better just copy what they do. For businesses, the best role model is the one making the most money.

Epic needs more competition than Cerner, Eclipsys, and McKesson are giving it. For those companies, Epic’s product is seen by prospects as so vastly superior (including in KLAS rankings) that they’re willing to pay more for it, quirks and all.

It would be good for the entire industry if those or other vendors could mount a credible challenge to the big dog. Unfortunately, operating in a publicly traded, quarter-by-quarter mindset, nothing suggests that such an invasion of Epic Stadium is imminent.

Time Capsule: Actual vs. IT-Measured Quality: Giving Data the Benefit of the Doubt When Money’s On the Line

September 7, 2012 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 October 2007.

Actual vs. IT-Measured Quality: Giving Data the Benefit of the Doubt When Money’s On the Line
By Mr. HIStalk

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It’s inevitable that hospitals and providers will someday get paid more or less based on how they perform on quality measures. Smart people will create a list of clinical actions that supposedly measure quality, or at least serve as a proxy for it. Follow those standards and you’ll get a bonus (or, for you fellow pessimists, avoid a penalty).

Coming up with standards is hard. Medicine keeps reminding us that it’s an art and not a science. Patient outcomes don’t always bow down obediently to even a well-designed medical cookbook (if they did, all doctors would already be treating patients the same). And if you start paying hospitals to give aspirin for heart attacks, you’d better make sure it adds value.

Still, at least for common chronic diseases, the standards are starting to become clearer and more defensible. Widespread use will prove or disprove their value. They can always be changed to reflect new knowledge.

Once the standards are in place, what’s left sounds easy: just sift through reams of electronic information to see how well providers have followed them. Then, write those checks. However, an editorial in the current issue of JAMA reminds us that data standards are poorly defined.

I don’t think providers will cheat, but I think they will err on the side of getting paid when the information is murky. For example, heart attack patients who smoke are supposed to get advice on stopping. Somewhere in the digital soup lives a data bit. It gets turned on when a nurse checks off a “smoking cessation education offered” item.

But, what does that check mean? (or as the geeks say, what is the metadata?) Does the nurse check the box only when she’s done a bang-up job of patient education, including having the patient demonstrate their understanding? Or, does a “smoking cessation” item pop up from an order set, which creates a task, which creates a “click here to make this item go away” entry on the flowsheet?

Reminder: you get paid for checking the box, not doing a wonderful job.

Hospitals are supposed to give clot-buster therapy to new heart attack patients with 30 minutes of their coming through the door. That means you need a super-accurate recording of the time they came in, plus the actual time the drug started coursing through their veins (not when the order was entered or when a nurse pulled the med from the Pyxis machine).

Reminder: conveniently retrievable data isn’t necessarily the same as clinically relevant data, even though it fits the loose definition of what’s being sought. It’s easier to rationalize that what you have is good enough than to go after something new.

Payers might want doctors to encourage patients to get flu shots. Do they pay them for actually giving it, or just for recommending it? Is it for all patients, or just those who happened to have an appointment at the time of year the flu shot inventory is available?

Reminder: physician payments may be based on a denominator of all patients under their care, not just those who have had an office visit.

I’ve looked at a lot of hospital data, particular that involving medications and treatments, and I wouldn’t trust it in many cases. There’s a lot of variability behind what looks deceivingly black and white to a programmer.

We IT people like the idea of pay-for-performance because we are logical and data-driven. It also provides the comforting illusion that providers who follow checklists will keep us from dying. Where we may get uncomfortable, however, is when we realize that our information systems will be taken as gospel by the check-writers. Deep down, I don’t think we really believe that our information is quite ready for that level of scrutiny.

Now’s the time to review your data and metadata. Most quality measures involve just a few data points: when something happened, what drugs were given or what tests were performed, and what was done when the patient was discharged. If you can comfortably produce that data without crossing your fingers behind your back as to its reliability, then you are ready for data-driven quality measurement.

Time Capsule: The Incentive Misalignment Between IT Leaders and IT Projects: Why CIOs Set Unreasonable Expectations

August 31, 2012 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 October 2007.

The Incentive Misalignment Between IT Leaders and IT Projects: Why CIOs Set Unreasonable Expectations
By Mr. HIStalk

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Spoiler: because projects would never get done otherwise.

A recent Canadian report provides a good overview of the how clinical information systems are (or more precisely, aren’t) improving patient safety. As simple as it sounds, one recommendation struck me as being profound: “Expectations for EHRs and patient safety must be realistic.”

Why that’s interesting: big clinical system projects would never get done unless the CIO takes an internal salesperson role, not much different than the salesperson who sold the hospital on the (unrealistic) system benefits in the first place. In other words, CIOs have to set false hopes to get projects going. If users knew what was coming, they’d opt out.

Users (played by Tom Cruise): “I want the truth.”

CIO (played by Jack Nicholson): “You can’t handle the truth!”

Maybe that’s why system users become disillusioned, vendors feel customer heat, and CIOs get fired. Everybody has an incentive to overstate the likely benefits, right down to the point where those benefits don’t materialize. Then, let the finger-pointing begin.

Systems have gaps of various sizes between what customers expect and what they actually get in the form of real, working software that they’ll use optimally. How big the gap is depends on two things: (a) the product, and (b) the customer. The money’s been spent, though, and the higher powers want to see the results that everyone agreed to in that innocent, long-ago moment of pre-purchase euphoria.

The result: disappointments and delays must be glossed over. IT types huddle behind closed doors with the same fervor as vendor marketing departments, carefully crafting the message, singling out project friends and enemies, and enlisting shills to vouch for inevitable wonderfulness of it all. The IT department knows the ugly underbelly of what’s ahead, but a grin-frozen face must be presented so users won’t panic. IT and its users have become uneasy enemies.

Beyond even that irrational exuberance, CIOs are sometimes create further damage. They push automation as a great way to implement organizational change because that’s what IT cheerleaders are supposed to do. They override popular voting for which system to buy. They overestimate the capabilities of their own stretched department to implement and support new applications. And worst of all, they sometimes unwisely let themselves be cast as project champion or owner.

You don’t want to own something you can’t control. You’ll be constantly begging everybody else to donate their resources to what has suddenly become your project. Executive supporters suddenly can’t spare their own folks to get it done. Before you know it, it’s CIO Giant Sucking Sound 2.0.

Hospital operational executives can’t control clinicians day to day. It’s CIO hubris to think that a tiny, stretched IT department can lead organizational change from the cheap seats. That’s never happened and it never will.

The project champion must be an operational leader who’s responsible for most of the affected areas and who can deliver the expected results. That person, along with a team of stakeholders, should define the need for automation, lead the selection process, oversee implementation, and set and measure benefits and outcomes. They should also weigh the inevitable (and often justified) objections of clinicians worried about patient safety.

It’s a shame that the only way to convince users and departments to change is to paint a falsely rosy picture of the likely result. If organizations had more willpower and focus, the need to deceive them to get projects done would be greatly reduced.

Time Capsule: Where Good Products Go to Die: The Elephant’s Graveyard of Conglomerate-Acquired Products

August 24, 2012 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 October 2007.

Where Good Products Go to Die: The Elephant’s Graveyard of Conglomerate-Acquired Products
By Mr. HIStalk

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Some people were surprised by last week’s announcement that GE Healthcare had acquired Dynamic Imaging, a well-regarded vendor of Web-based radiology and PACS systems. If you’ve ever been a customer of the clunky Centricity PACS product as I have, you might not be quite so shocked.

What happens next (at least if the past is a reasonable predictor of the future) is that Dynamic Imaging as a product and vendor will be quickly assimilated into GE. That’s a nice way of saying that the innovation and non-bureaucratic sales and support that attracted customers in the first place is about to be sucked out of it, much like an Army recruit who’s given a humbling crew cut to strip away his individuality.

The problem is more widespread than this example, even though GE has a disproportionate share of the elephant’s graveyard of formerly well-regarded products. The “first to worst in KLAS” phenomenon has struck before, nearly always at the hand of large conglomerates. The least-positive news you can get as the happy user of a focused, niche software application (short of company bankruptcy, anyway) is that its vendor has been bought out by some multi-national corporate behemoth.

Conspiracy theorists might blame the big company for executing a strategy of buying and burying its more nimble competitors. More often, though, I think it’s the big boys overestimating their capabilities. If they were that good, how did a little company beat them in the first place?

Another argument is that, if you have the money, you can let someone else blaze the trails, then just buy whomever’s left standing. Wall Street apparently loves the cheap nameplating of software instead of the R&D intensive building of it, although searing a once-proud application with the corporate branding iron often has the same effect as splashing holy water on a vampire.

If you’re a prospective customer of a recently acquired product, remember that KLAS is a lagging indicator. The damage won’t be obvious for years. What, then, are the danger signs?

  • The product’s name is quickly changed in a Soviet-like revisionism to provide the illusion of integration.
  • The new owner decides to keep selling overlapping products despite certain market confusion and cannibalization.
  • Full and synergistic integration is quickly proclaimed after a superficial bolting-on to other applications the vendor sells (at least enough to keep salespeople from giggling out loud when they talk about an integrated suite).
  • The people brought over from the old company leave, surprised to find that even a big paycheck isn’t enough to put up with endless corporate nonsense. They’re replaced by well-traveled and interchangeable corporate managers who thrive in such an environment, i.e. people that provider-siders are guaranteed to dislike and distrust intensely.
  • Development timelines are extended, functionality promises are increasingly vague, and technical innovation takes a back burner. The idea of having bought for the future seems hopelessly naïve.
  • Longstanding customers are bewildered when attending the first post-acquisition user conference and realizing that the main objective has changed to “keep them minimally happy so we don’t threaten the maintenance revenue stream until we can sell them something else.”

Companies with a “buy” instead of “build” strategy should succeed, at least on paper. Their financial and organizational strength should theoretically take a promising upstart and turn it into an industry leader. That sometimes happens with well-run technical companies like Microsoft, Cisco, and Google.

Unfortunately, that’s the exception rather than the rule in healthcare IT. The hot little company’s spirit is usually wrung out in the smothering embrace of the massive corporate bosom. Nobody’s left smiling except the founders who took the money and ran.

Time Capsule: Smoking the CIO-Doctor Peace Pipe: Let Practices Choose Their Own PM/EMR Gift

August 17, 2012 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 October 2007.

Smoking the CIO-Doctor Peace Pipe: Let Practices Choose Their Own PM/EMR Gift
By Mr. HIStalk

mrhmedium

Hospitals suddenly want to align themselves with private practice physicians. They don’t want to buy their practices in that fashionable and fabulously unsuccessful trend of a few years back, but they recognize the need to at least keep the war cold.

Much of the desired hand-holding is, by definition, electronic. RHIOs, referrals, integration of office systems with hospital systems — all require expertise beyond what doctors have available. It’s junior league IT in the doc’s office, hospitals figure — a cakewalk for the crackerjack IT team they’ve assembled.

What sometimes knocks the idea off the tracks is someone holding the CIO title who doesn’t really buy into the concept of enterprise computing, which includes connecting outside the organization.

CIOs are, by and large, reasonable and polite people. However, many of them know nothing about physician practices. They have their hands full already, falling further and woefully behind under a tsunami of unfunded IT demand from inside the hospital walls.

CIOs are trained to keep hospital department heads happy, and rightly so. Not doing so is a career-limiting strategy. Throwing a bunch of whiny and uncooperative doctors into the mix isn’t likely to increase the level of unrestrained joy among the technophiles.

Doctors have unreasonable demands, at least as observed from hospital IT departments. They abhor standards in any form, medical or technical. They don’t work in a polite business culture, so they are alarmingly prone to say exactly what they think, with an extra helping of sarcasm and contempt laid on top of what may well be a shaky intellectual platform. Anything that costs them money is an abhorrent attempt to pick their pockets, starve their children, and insult their intelligence.

Hospital executive leaders understand that doctors distrust hospitals and everyone who works in them. The feeling is generally mutual. However, the market is limited for doctors without hospital privileges and hospitals without admitting doctors, so cooler heads prevail and technology peace pipes must be smoked. That means turfing the whole thing off to the CIO to make it happen.

Some CIOs are as stubborn in their unwavering paradigms as their doctor counterparts. IT systems must be purchased from big, reputable vendors with publicly scrutinizable financials. Extra points are awarded if the company also sells hospital systems, runs on familiar hardware, is used by similarly unimaginative hospitals, is priced high enough to avoid suspicion, and has a cadre of glad-handing suited minions to soothe concerns that the product might be anything but the best.

That’s how CIOs buy hospital systems. Since the goal is getting access to doctor data and tying them to the hospital by giving them free systems, the CIO gets to pick the gift themselves since they have to support it afterward.

Physicians don’t use EMRs all that much, but consider this: utilization hasn’t improved much since hospitals got involved. Whatever they’re buying for doctors isn’t inflecting that magic tipping point. Free isn’t cheap enough if it’s something you don’t want (think “free kittens”).

Most physician practices are small. They want systems that are simple and that save them time (time is all they have to sell, after all). They aren’t about to use the CIO-friendly systems that hospitals want to provide them at no cost if those systems don’t fit their small business. If it takes more of their time, the “no cost” part of the pitch isn’t convincing.

The track record of CIOs in choosing systems that doctors will use in their offices isn’t any better than that of choosing systems they’ll use in the hospital. Lesson learned: let the doctors pick the systems you insist on giving them for free.

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