Time Capsule: The Bandwagon Effect and Healthcare IT Purchases

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 2006.

The Bandwagon Effect and Healthcare IT Purchases
By Mr. HIStalk

TV networks don’t announce election winners until the polls close. Why? Because those people who haven’t yet voted will be more likely to vote for the projected winner instead of whomever they really want to see in office.

It’s the same phenomenon that makes the Super Bowl or World Series winner everyone’s sudden favorite team. Everyone likes to be associated with a winner. Or, more precisely, no one wants to be associated with a loser.

Big healthcare IT vendors and consultants use that tendency to their advantage. Big Vendor A pretends to be genuinely puzzled as to why you’d risk your reputation and your career on smaller Vendor B. After all, everyone whose organization is as good and well-known as yours is buying Vendor A’s products, they say. Those customers are not only deliriously happy, they’ve formed a high school-like clique that makes fun of Vendor B losers and dates cheerleaders after football practice instead of attending chess club meetings. So you’re told, anyway.

Hospital IT people ought to know better. Unhappy Vendor A customers aren’t hard to find, although in some cases you must evade their marketing people and their cease-and-desisting attorneys threatening unhappy users to keep their gripes to themselves.

Healthcare IT also tends to follow polls run by HIMSS and vendors. What technologies are hot? What are other CIOs planning to implement? What IT projects do hospital CEOs see as strategic? Never mind the methodology of the survey or its applicability to an individual hospital. If everyone else is buying CPOE, single sign-on, or business intelligence applications, then who wants to be a contrarian loser?

Those in charge of technology decisions could make a brave stand for a product or vendor that their gut tells them is right. Or, more importantly, to provide the voice of reason for a purchase that makes little sense. They usually don’t. The fear of being fired if it doesn’t work out usually wins. Even if you’re right, you won’t get much reward for it, so why take the risk? Surely the popular product is at least “good enough.”

It’s ironic, though, that by making the “safe” decision, executives are often rewarding the behaviors opposite those they supposedly admire: innovation, entrepreneurship, customer support, and honest sales and marketing. If the market votes one way with its mouth but another with its dollars, those unrewarded traits everyone admires will become extinct.

CIOs gripe endlessly about Microsoft, but Linux on the desktop or even using open source office suites is too much trouble. They fuss about consulting fees, but don’t bother to make the case for bringing expertise in-house instead of contracting for it. They want the best PACS system, but not if it involves a low-profile company unwilling to fund travel junkets or make donations to the hospital’s foundation.

Bigger is not necessarily better. Best marketed, most widely sold, most written about, highest stock market capitalization, most money spent sponsoring industry events and organizations: none are necessarily better.

When all the lemmings are heading in one direction, the path of least resistance is to follow them. On the other hand, once you’ve seen where they’re going, that extra effort to break rank seems worth it.

Time Capsule: Economics 101 and the Healthcare IT Market

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 2006.

Economics 101 and the Healthcare IT Market
By Mr. HIStalk

You’ll remember this example from your MBA economics class. If sports tickets are priced perfectly, the venue will sell out precisely, leaving neither disappointed fans nor empty seats. Since the tickets aren’t priced perfectly, scalpers provide a valid economic function by ensuring that seats are available to those who value them more than others. The intersection of supply and demand is the correct price, which as scalpers know, is sometimes higher than the face value of tickets. That arbitrage goes right into their pockets.

Software isn’t a perfect model for supply and demand. Its incremental cost to the seller is nearly zero and those sellers work hard to dispel the “commodity’ notion that all products are equally acceptable.

Still, signs seem to point at some rationalization of supply and demand in the PM and EMR business in physician offices. Pricey vendors are getting squeezed hard by new entrants with cheaper products. Doctors aren’t as easily enamored with “Cadillac” offerings as hospitals seem to be. Another economic principle is working there, too – when companies make excess profits, newcomers will come in and undercut them, thereby shaking out inefficient players.

Hospital system vendors haven’t felt that pressure yet. The choice of enterprise systems is limited. Marketing-issued smoke and mirrors have kept hospital prospects thinking that Product A is far superior and/or acceptable than Product B, thereby keeping prices high. The cheapest vendor doesn’t always win and neither does the most expensive one. Neither does the “best” one, for that matter.

One explanation is that maybe hospitals aren’t a price-sensitive market. There’s some evidence of that: expensive drugs and medical equipment sell just fine even when cheaper alternatives are available. Hospitals can be convinced by questionable claims of product superiority or patient risk, and even more so by seeking vendors just as prestigious as they fancy themselves (no Walmart shopping for big academic medical centers, even though patients are the ones paying.) CIOs trying to keep their jobs and to develop a marketable resume are suckers for the “bigger is better” approach, even when the bigger vendor has a horrendous failure rate in hospitals just like theirs.

Hardware and services costs also skew the market. Even free software comes with a high price tag because hardware costs are similar for all products and hospitals demand lots of fixed-cost, on-site help. A vendor that can develop a turnkey product with low hardware costs should theoretically do very well, at least if they can overcome the marketing spin of the big boys.

Yet another anomaly is that the HIT market isn’t perfect. Hospitals don’t necessarily know what everyone else is buying, how it worked for them, and what they paid.

I’ve advanced my “Big Three” theory of broad-line systems vendors. Could the also-rans move more product if they cut software prices? Should they give their systems away just to start earning maintenance fees? Hospitals area always starved for capital, so maybe a monthly fee paid out of operational funds would be appealing.

We’ll learn by watching companies like Medsphere, which has a heavy R&D product that costs them nothing since Uncle Sam already paid for it. They can succeed only if they can find price-sensitive hospitals who believe that information systems are a commodity. They’ll also have to compete with Meditech, whose products are already relatively low in cost and whose huge customer base throws off recurring revenue that will let it meet any price threat.

It’s interesting to review the healthcare IT market using what you learned in economics and marketing. Vendors and upstart competitors should be doing that. HIT 2.0, anyone?

Time Capsule: Leapfrog’s Leap into Irrelevance

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 2006.

Leapfrog’s Leap into Irrelevance
By Mr. HIStalk

I sat in a hotel ballroom back in 2001 or 2002, hearing about The Leapfrog Group for the first time as an IT director in a large IDN. Like most people in the room, I was both energized and concerned. I liked the idea of a short list of evidence-based hospital quality standards. However, I worried that my hospital might have a tough time meeting them, thereby raising the ire of the big-employer healthcare dollars that were supposedly backing Leapfrog to the hilt.

Predictions were dire back then in the post dot-bomb nuclear winter. Hospitals would be wildly overbedded. Savvy baby boomers, emboldened by buying books and dog food online, would be calling the shots, making shrewd healthcare decisions and choosing providers based on stringent quality measures that would be plastered all over the Web. Unfocused, change-resistant hospitals, which included all the ones I’d ever worked for or heard of, would be road kill.

If the IOM’s “To Err is Human” was embarrassing to hospitals, Leapfrog was threatening. Their mandates were prescriptive, concentrating on “just do it” guidelines. If you didn’t like their requirements, that was just too bad. Cisco and GM and other big employers had already decided you’d have to play ball their way for a change. Medical experts in fields that were covered by the Leaps howled, demanding to see the evidence supporting them, but it was not forthcoming. Leapfrog wasn’t looking for a debate.

Somewhere along the line, Leapfrog fizzled, surprisingly but decisively. Nowadays, they’re a quaint anachronism. The “news” on their site is mostly press releases applauding the accomplishments of other groups. Their 2004 website listed 152 members; now it has just 44. Among those that bailed were most of the HIT vendors: Allscripts, Cerner, Eclipsys, McKesson, Misys, and Siemens. I hope no one got hurt in the stampede for the exits.

I hadn’t even thought of Leapfrog for months until they issued a press release last week. Instead of containing major announcements of accomplishments or new guidelines, it described their self-commissioned survey that, ironically, laid bare their astounding lack of clout. Hospital compliance with their much-feared CPOE mandate was less than 10%. Over 90% of hospitals don’t meet Leapfrog standards for two surgical procedures. Intensivists in the ICU are used by only 30%. Apparently the risk of retaliation from the tiny band of surviving Leapfrog members isn’t much of a threat.

Maybe the timing wasn’t so good to name Methodist Hospital of Indianapolis as one of their Top Hospitals of 2006, sharing headlines with a string of medication errors that occurred there, some of which killed three newborns. Got CPOE? Check.

CPOE prevents errors, but rarely prevents significant patient harm, making it a bottom-feeder in the “bang for the buck” category of patient safety technologies. Documented successes are nearly non-existent. Still, Leapfrog pushed it as a must-have above all else, undoubtedly with few objections from its HIT vendor members who were happy to move some low-demand product, even if customers signed up out of fear alone.

It’s ironic that hospitals are stuck with white elephant CPOE systems because Leapfrog insisted on them. It’s sad that hard-won capital was diverted from better, cheaper, easier technologies that might have saved some patients instead of just keeping a now-irrelevant trade group happy. I think of those dead babies a lot, trying to decide if just maybe Leapfrog’s CPOE tunnel vision did more harm than good.

Time Capsule: Misys Lesson: Mama, Don’t Let Your Vendors Grow Up to Be Conglomerates

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 2006.

Misys Lesson: Mama, Don’t Let Your Vendors Grow Up to Be Conglomerates
By Mr. HIStalk

I doubt most Misys Healthcare customers are following the company’s corporate drama as it plays out in England. They want to go private. Wait – no, they just want to sell it to someone! The CEO will lead a takeover group. Hold on, he just resigned! Their board chair is optimistic about their prospects. Shhh … did I just hear him say the company’s software was old and non-competitive? What’s that smell? Shareholder torches burning outside the castle door!

Healthcare makes up about a third of the Misys portfolio. Within that, the lineup is a salad bar of old, mixed-heritage applications from Per-Se, Medic, Amicore, Payerpath, and Sunquest. Sometimes the blended family gets along, but often they don’t (and I’m speaking both technically and culturally.) If you know of any healthcare IT conglomerates in which any of the above isn’t true, that makes one of us.

Why did a British financial software company get into the US healthcare IT market in the first place? Well, let’s just say it wasn’t a noble desire to better humankind. From their Web site, “The main objectives were to reduce the Group’s exposure to a single market (insurance) and to increase its size in an already consolidating software sector.” That’s about as unemotional as an accountant’s nimble calculator fingers determining the net present value of three dinners with Myra the secretary vs. the potential passion-filled payout. At least they were honest.

With just two software sectors, Misys is focused, at least compared to bigger conglomerates that dip 1% of their corporate body (a toe) into the healthcare waters. Since Misys is the only company actively considering deconstructing healthcare IT out of the soup, what are we learning from their troubles?

• The best way to make money as a conglomerate is to break it up into parts that are usually worth more than the whole and are more affordable to more prospective bidders.
• Conglomerates often reduce corporate value unless they can harness some elusive benefit in supply chain management, reproducible management excellence, or marketing, which few can.
• Conglomerates are fine until you want to sell to someone else who doesn’t share your unconditional love for some of the uglier corporate children.
• Product investment matters more than that impressive brand name. You may be getting free milk every day, but at some point, you better start saving up for a new cow.
• In most cases, button-down corporate management saps out the innovation that made formerly independent companies interesting and successful in the first place.
• Healthcare IT divisions of big companies live and die by the quarterly (or twice-yearly) numbers. Ambitious division executives will sell their souls to avoid being called out as company laggards among their peers. Long-term planning goes out the corporate window.
• Healthcare IT customers carry little weight with toe-dippers. Are GE brass more worried about the flatlining former CareCast or sagging toaster sales at Wal-Mart? Does patient safety come up in Siemens corporate meetings as often as power generators?

Just about every outcome suggests that Misys Healthcare will be carved off and sold. If you’re a foot soldier, hang in there at least long enough to see if the change benefits you. If you’re a suit, Misys publicly labeled its healthcare unit as underperforming, which isn’t a highly valued resume bullet for the new owners, so you might want to beat the traffic out. If you’re a customer, anything or nothing could happen, but you’re stuck either way. If you’re a prospect, there’s a lot of uncertainty ahead, so act accordingly.

And if you’re a vendor focused only on healthcare IT, especially if you’ve resisted the urge to cash out by going public, I say thank you.

Time Capsule: GM and Intel are Right: Healthcare Is Too Expensive, but Technology Alone Can’t Fix It

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

I wrote this piece in October 2006.

GM and Intel are Right: Healthcare Is Too Expensive, but Technology Alone Can’t Fix It
By Mr. HIStalk

Big-company CEOs have healthcare on their minds. I know that because they keep insulting us in the national media. We’re too expensive and we underutilize technology, they say. In fact, it’s our fault that jobs are moving offshore, not their own corporate greed or inefficiency.

My first reaction: who do they think they are? We’re getting lectures on innovation, productivity, and cost control from GM? If I wanted that kind of advice, I’d go to Toyota.

Quibbles aside, they’re right. Healthcare cost increases have to stop eventually. Most US job growth since 2001 was in healthcare, and that’s not something to be proud of. We’re leaving an expensive mess for our children to clean up just as Baby Boomers suck the system dry with healthcare demands. If GM doesn’t like it today, they’ll hate it tomorrow, unless they’re watching from China or India.

Businesses want to force computers on us, dragging us kicking and screaming out of the dark ages. Unfortunately, software doesn’t automatically bring increased productivity and lower cost. If it did, we’d be using it already. Think of all of those hospital dollars spent on Microsoft Office and Windows, which were supposed to have made us stunningly more effective, but instead gave employees something to screw around with instead of working.

I’d like to think that computerization can really reduce costs, but I haven’t seen that happen anywhere so far. Showcase sites keep buying the latest and greatest, but the correlation to bottom line and quality outcomes is murky at best. Where’s the average 100-300 bed hospital that has seen its overall costs drop 30% because of software? You’d know them, because every other hospital in their town would be out of business.

Hospitals can cut expenses in three ways, all of them at their local level. They can manage labor, which is by far their largest expense. They can go after the utilization and the cost of drugs and supplies. They can control physician practice variation. I’m glad I said “can” instead of “do” because, for various reasons, these things don’t happen. Software can only do so much.

I’m glad much of our recent IT investment relates to patient safety and outcomes. I hope electronic medical records really do become a standard, with all the information sharing that the RHIO people keep yapping about.

But when it comes to drastic cost reductions driven solely by buying and implementing software, I’d say that’s wishful thinking. There’s a lot of work to be done fixing the system and its underlying misaligned incentives before we try to automate it. No business became a world-beater just by installing SAP, even if they weren’t one of those that went bankrupt trying.

I do see a ray of hope in being called out by big-company CEOs. As hard as it is to have change forced on you, that’s the only way it will happen. I work in a hospital, but I’m also the occasional patient and medical and insurance bill-payer. When wearing those hats, I’m just as mad and frustrated with the system as those CEOs and I bet you are, too.

Healthcare is too expensive, too bureaucratic, and too unimpressive in benefits delivered compared to its horrendous cost. I’m pretty sure fixing it will require more talents than a software guy like me can offer, even if GM and Intel believe otherwise.

Time Capsule: Don’t Look Now, Your Loop is Open

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

I wrote this piece in September 2006.

Don’t Look Now, Your Loop is Open
By Mr. HIStalk

Three babies dead in Indiana, overdosed with the wrong heparin product in a hospital not using bedside barcode verification of meds. Technology failed them, plan and simple.

Ten years ago, nursing and pharmacy systems didn’t talk to each other (pharmacists and nurses didn’t either, but that’s another story.) Finally, everyone agreed that was pretty stupid, so vendors did a little bit of integration to make their systems look like they did. The electronic Medication Administration Record (MAR) was born, although most hospitals stuck with once-a-day printed versions for a several reasons, most of them illogical.

Along came CPOE, usually awkwardly bolted up to those same nursing and pharmacy systems. It was (and is) expensive, rarely used, and inefficiently designed for physicians, but it caught the eye of well-intentioned hospital executives who were blissfully unaware that all those CPOE-preventable errors weren’t the ones harming patients anyway. I like to think of it as the Job Security Act for Chief Medical Informatics Officers.

Don’t buy the ubiquitous vendor buzzword “closed loop,” which implies we’ve got meds under control. We don’t. The dent in harmful medication errors has been slight. Why? Because nurses still walk a tightrope without a net, armed only with limited drug knowledge, too much work, paper records updated with pens, and a wide-open candy machine of increasingly dangerous drugs … uhhh, I mean decentralized medication distribution cabinets.

We bought the technology least likely to be used, that addresses errors least likely to be harmful, that doesn’t help the user who needs it most, and deployed it in patient care areas where serious errors are least likely to occur.

But let’s look on the positive side. Technology is the only hope of improving the situation, so there’s opportunity galore.

If you’re a vendor with an integrated bedside verification system, get those sales guys on the road because I guarantee you’ll sell a bunch of them in the next year if yours is any good. Guarantee, I said. The Indiana errors are the pin that will pop the CPOE balloon, making even the big-picture types comprehend that they’ve been chasing the wrong solution. Board members will find the money, given the extreme embarrassment and financial exposure likely to follow a high-profile screw-up.

If you sell add-on tools for electronic MARs or have the expertise to consult in that or any other patient safety area, polish up your shingle. Plenty of organizations need your help. They haven’t fixed their own problems, so a well-dressed stranger who flies into town and has PowerPoints seems like the next thing to try.

If your company is one of the few that sells medication distribution cabinets, get some real informatics people designing improvements instead of those engineers who are more concerned with servo motors and drawer design instead of intelligent software. You could definitely do better and the market will reward you for it.

And if you’re Cerner, congratulations! You bought Bridge Medical and their bedside verification technology just at the right time and announced plans for your own line of medication distribution cabinets. You’ve got a widely installed customer base that wanted closed loop meds. If you don’t mess it up, you could build a huge business on the other half of the loop, the one that isn’t closed. I guarantee that, too.

But for goodness sake, let’s all agree not to dawdle. Too many parents will already know the sorrow of celebrating their baby’s first birthday in a cemetery.

Time Capsule: Drug Rep Gifts Banned – What About IT Reps?

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

I wrote this piece in September 2006.

Drug Rep Gifts Banned – What About IT Reps?
By Mr. HIStalk

Stanford Hospital last week joined the growing number of academic medical centers that prohibit their physicians from accepting gifts from drug company salespeople. The reps aren’t even allowed on campus, except by appointment to conduct product inservices.

Bravo to Stanford. Physicians think they’re too savvy to be influenced by free lunches, rounds of golf, or drug samples, but drug companies know better – subtle bribery works. A $100 staff lunch influences even a $500K a year doctor whose prescriptions for one medical condition might generate thousands of dollars a week of business for the drug company.

I’ve taken my share of IT vendor goodies: junkets, executive dinners, trips on private jets, and one memorable evening spent in an internationally known billionaire’s back yard. Having thereby flouted the rules of propriety myself, I’m qualified to issue my first-ever standards of conduct for CIOs and other provider-side executives.

The most important fact is this: it doesn’t matter whether your acceptance of vendor swag is improper; it matters only that it might appear improper to an outsider, like the attorney of a bid-losing vendor who’s suing you for tortuous interference or the “60 Minutes” camera crew accosting you on your way to drop the kids off at school.

It’s obvious, but if your organization is sending out RFIs or RFPs or is otherwise involved in system selection, accepting anything is unwise. Even speaking to vendor reps is not smart. Don’t let vendors provide free lunches or giveaways to employees attending demos. Vendors shouldn’t pay for your site visits – if you can afford their product, you can spend your organization’s own money on flights and hotels. Spurned vendors aren’t nearly as chummy, I’ve found.

Otherwise, lunches are always OK, whether one-on-one or group. Stuff for the IT department is OK, like shirts, food brought in, or sports tickets. This is the IT version of the unrestricted grants that drug companies offer, where you accept small items without reciprocating and the chance of undue influence is minimal. Corporate ethics people are usually OK with this, as long as the gifts aren’t for the specific benefit of an individual.

On the other hand, it’s never OK to solicit stuff from a vendor: free software from the Microsoft rep, donations for a pet cause, money for a department party, or entry fees for a fundraiser. Vendor strong-arming is tacky.

I also don’t like the idea that vendors buy access to prospects by sponsoring conferences and giveaways for HIMSS and CHIME, but that’s apparently a hopeless cause. It looks like Halloween, except the trick-or-treaters are wearing suits or conscientiously casual golf apparel.

Spouse trips are out. So are ridiculously transparent junkets, phony advisory board conferences, honoraria, or a visit to the German countryside to see your future PACS system being assembled. It’s tempting when all your cross-town colleagues are lining up at the feed trough, but it’s still wrong, don’t you think?

Having decision-making authority means vendor reps will try to soften you up like gangsters wooing supermodels — with flattery, rapt listening, and a shower of baubles. You know what they really want. Surely your integrity is worth enough that you won’t sell it that cheaply, especially knowing that they won’t respect you in the morning.

Time Capsule: For Employees in Uncarpeted Areas, Hide Technology Complexity Like McDonald’s Does

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

I wrote this piece in September 2006

For Employees in Uncarpeted Areas, Hide Technology Complexity Like McDonald’s Does
By Mr. HIStalk

A recent state survey found that El Camino Hospital’s medication error rate nearly tripled after implementation of a supposedly safer, closed-loop type of information technology for medication orders. El Camino, widely recognized as a hospital technology pioneer going back to the 1970s, suffered an embarrassing setback as onsite investigators found actively occurring medication errors that were unknown to the hospital.

Major implementations like CPOE expose serious flaws in an organization’s ability to manage change, to communicate, and to educate — those soft skills often scorned by take-charge caregivers and logical IT types. If El Camino can have problems like these, so can just about any other hospital.

Medical errors, including technology-induced ones, have gotten so bad that some hospitals are actually advising patients to bring along a friend to protect them from staff mistakes. I can’t imagine any other business throwing in the towel and admitting defeat to customers. I’d have just two words for a restaurant waiter who suggests I watch the cook to make sure he doesn’t poison me: “Check, please.“

Walk the uncarpeted areas of the hospital on night shift, where clinicians get dumped because they’re new, working multiple jobs, or desperate to earn shift differential. The variation in practice is shocking to anyone who assumes that policies are consistently followed or that nurse executives speak knowledgably for those folks who toil in the appropriately named “graveyard shift,” where some of the most horrific mistakes are made by tired, under-supported clinicians left to their own devices by the A-team nine-to-fivers. Sometimes they don’t even get computer training because no one wants to come in at 3 in the morning.

Software and medical equipment isn’t designed with these people in mind. Our mental picture of a user is an intelligent, thoughtful person who sits in a quiet room and carefully reads all the screens, labels, and warnings we put in front of them. This paradigm works well in those hospital departments where knowledge management is the key responsibility: laboratory, radiology, and pharmacy, for example. Their employees embrace technology and use it willingly to boost productivity in performing repetitive tasks. The IT track record in those departments is outstanding.

Nurses and doctors don’t work in that world, however, so our efforts and computerizing their work has been spotty. They didn’t go into their professions because they love computers. Much of their work isn’t even all that logical, no easier to computerize than that of a teacher, artist, or mechanic. Rightly or wrongly, how they do things varies by individual or by area, making it highly unlikely that non-personalizable off-the-rack software, as a rigid enforcer of business rules, will ever be fully accepted by those who don’t follow the rules anyway.

For vendors, maybe simpler is better, hiding the complexity like a McDonald’s cash register, where pushing a button with a hamburger picture on it rings up a hamburger. For hospital leaders involved in IT, maybe it’s time to venture out “where the sun don’t shine” – the night shift, uncarpeted underworld of patient care where all of our IT horsepower often fails to protect our patients.

Time Capsule: The VA Outperforms Private Hospitals in IT Vision and Resolve

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

I wrote this piece in September 2006.

The VA Outperforms Private Hospitals in IT Vision and Resolve
By Mr. HIStalk

If you work in a non-government hospital, here’s what your patients are reading in this week’s Time magazine: Veterans Affairs (VA) hospitals are better than yours in satisfaction, quality, and technology. Their costs are going down while yours are skyrocketing. Elderly males treated in the VA system have a 40% less risk of death. You can only hope your ED patients don’t run out screaming to enlist in the military.

The article credits the VA’s advanced and fully-deployed information technologies, but commercial software vendors can’t gloat or take credit. The VA built the VistA system itself. It isn’t slick or technically impressive, but it works.

Like a tailor-made suit, VistA was developed to meet the VA’s needs, not those of a vendor’s “average” hospital customer. Just as hospitals talked themselves into buying instead of building (helped along by vendors and risk-averse CIOs,) the industry’s darling turns out to be a homebrew job.

The article pointed out the obvious: every hospital should match the VA in enterprise-wide longitudinal patient records and bedside bar-coding. Beyond that, though, is the implicit message that technology is a change enabler that requires significant process redesign to accomplish anything meaningful. Everybody hates to hear that because it moves the argument from “expensive” to “impossible in our culture.”

The VA didn’t go out and say, “Hey, let’s replace a couple of old systems with these we saw at HIMSS.” It didn’t hire a superstar CIO loaded with prejudices (positive or negative) formed by time spent elsewhere. It didn’t pander to making the “Most Wired” list. Earlier versions of VistA had been around for years before the VA mandated its full utilization. It took a strong, non-IT leader to drive home the mission to 200,000 employees. Information systems were involved, but it wasn’t an IT department project — not by a long sight.

Patients don’t care what tools you use. They care only about results. If your hospital is a good one, you’re probably already delivering fine care using whatever systems you have.

The bad news is for not-so-great hospitals — your IT checkbook can’t bail you out. Bad chefs don’t get better just by spending more on knives. Obvious, yes, but we seem to keep re-learning those lessons with big IT purchases that turn out to be a giant leap –sideways.

Technology’s failure to deliver isn’t usually a vendor or CIO problem, although it’s easy to make them targets. Once the software is up and running, it’s an organizational challenge, one often unfortunately dumped into the wrong laps. You can buy software as good or better than the VA’s, but your mileage will definitely vary.

Let’s give the VA its due. Against improbable odds, it managed to turn an underperforming government agency into an industry-beater, using a little bit of technology and a lot of vision and resolve. Miraculously, the VA did it while making both its patients and government bureaucrats happy. The VA has definitely raised the now-public bar for the rest of us.

Time Capsule: Few Threats Seen to Healthcare IT’s ‘Big Three’

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 2006.

Few Threats Seen to Healthcare IT’s ‘Big Three’
By Mr. HIStalk

Neither Phamis nor IDX sold very many LastWord / CareCast systems. Its mid-80s architecture wasn’t sexy. Only big hospitals scared to death of hardware-induced downtime could afford its Tandem hardware.

When GE bought IDX last year, the renamed Centricity Enterprise was to be its first-string offering, at least until co-development with Intermountain Healthcare yields a commercially viable product.

So far, GE’s luck seems to be all bad. I haven’t heard much about new sales. It was booted from the UK and shown the door at Stanford. And now, high-profile customer Sharp HealthCare is replacing it with an unnamed vendor’s system.

The industry has obviously consolidated dramatically over the past few years. I wouldn’t have guessed back in 1996 that the high flyers would be the little-known ambulatory system vendor Epic Systems, ambitious lab system vendor Cerner, and small-hospital dominator Meditech.

I don’t see anyone catching up to these Big Three, with the possible exception of dark horse McKesson. GE Healthcare, Siemens, Eclipsys, Misys, and others may get an occasional full-system sale, but they’re mostly fighting over crumbs.

With the benefit of 20-20 hindsight, I looked back to see what clues I might have picked up about these Big Three 10 years ago:

• They built their own products instead of acquiring someone else’s.
• They had a single product line and architecture (although both Cerner and Meditech were porting theirs to new platforms).
• They touted integration over everything else.
• They had broad offerings that could replace best-of-breed systems.
• They sold benefits, not cutting edge technology.
• They had competent clinical systems, not just administrative applications.
• They kept their product functionally current.
• They were led by their founder and, as a result, had a consistent company culture.
• They stuck with their game plan, unswayed by trends or even customer demands.
• They had only one business: healthcare IT.

Maybe the Big Three moniker is appropriate, reminiscent of the early Detroit days when Ford, GM, and Chrysler rose to dominance over a plethora of now-forgotten competitors. If someone like American Motors tried to horn in, the Big Three either waited for them to fail or just bought and buried them. The high barrier to entry protected them from competition, at least until they got lazy and let overseas companies eat their lunch.

I don’t see many threats to healthcare IT’s Big Three. Open source gets a lot of press, but little adoption so far. Self-development is all but dead in most hospitals. Few foreign competitors exist, as evidenced by the United Kingdom’s reliance on American vendors for Connecting for Health. The big-system vendor pool is shrinking, not growing.

Perhaps the biggest threat is a mature market, in which hospitals have little incentive to switch from one commoditized product to another, especially given limited funds. Even in that scenario, that’s when companies make big profits, milking a locked-in recurring revenue stream while spending little on research and development. Growth is replaced by high profits.

Perhaps the biggest loser in a Big Three scenario is hospitals, who will have few competitive choices with even less innovation than today. Car buying became a passionless checklist process once everything from Detroit started looking alike. Maybe those heart-pumping days of picking from an array of wildly different products offered by 10 potential vendors are over.

Time Capsule: CCHIT’s First Certification List is Unsatisfying

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 2006.

CCHIT’s First Certification List is Unsatisfying
By Mr. HIStalk

The Certification Commission for Healthcare Information Technology’s long-awaited announcement of the initial class of 20 certified ambulatory electronic medical records products this week was oddly unsatisfying. Rather than being an exclusive club, most big-name vendors made the list.

As I’ve said previously, certification has little value if most products earn it. Prospects considering the usual vendors won’t find their job any easier: everybody scored 100%. No one likes a game that ends in a tie.

CCHIT may ramp up the standards for future years. Maybe this initial pass was made intentionally easy (or, maybe vendors put a lot of resources into enhancements – we don’t know). That’s how certification usually works. You make it easy enough to be attractive initially and then toughen it up once it catches on.

The biggest companies dominate the list. Not coincidentally, they market the most expensive products to the largest physician practices. For them, the cost was inconsequential. On the other hand, they were already facing each other in system selections. Their prospects didn’t need much encouragement to consider EMRs. For those reasons, certification doesn’t really change anything for anybody in this category.

The winners were those newly certified products whose sweet spot is smaller practices. They have tons of competitors and CCHIT’s endorsement may help them rise above the crowd. They just have to figure out how to effectively market their new credential.

Now that we have certified products, we’ll find out if the marketplace values that status. If so, cautious vendors who sat out the first round will jump in line quickly. If not, even those who earned certification this week may opt out of future rounds. Vendor flaunting of the credential is the only way word will get out to the masses, although it wouldn’t be surprising if CCHIT forged relationships with physician and practice management groups to co-brand their certification efforts in some way.

What about customers? I’ve talked to several CEOs of ambulatory EMR companies and they don’t agree on the benefit of certification to physician practices. It may increase EMR adoption, but that’s a guess. It may reduce buyer risk, but only in the limited areas it measures. It may shake out vendors perceived as weak, but it may also provide a misleading stamp of approval to immature products with unproven support and longevity. It may improve reimbursement, but no one’s quite sure how. Customers still need to consider many factors in deciding when or what to buy.

I think the federal government will encourage the use of certified EMR products by sweetening reimbursement or making it a requirement for government-related purchases. We know the government is encouraging adoption of electronic records, so why wouldn’t it show a preference for certified ones? You might see the same nudging from insurers or regulators. It all depends on how well certification catches on.

Impatient people like me may have expected too much of an immediate product differentiator in this first round of certification. Still, CCHIT has done a good job defining the process, sticking to its timetable, and communicating its progress. Perhaps its most important work is yet to come.

Time Capsule: Hospitals Want Software to Do The Dirty Work of Changing Physician Behavior

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 2006.

Hospitals Want Software to Do The Dirty Work of Changing Physician Behavior
By Mr. HIStalk

An editorial in the latest American Journal of Managed Care titled “Defending Computerized Physician Order Entry From Its Supporters” stresses that physician order entry (CPOE) and clinical decision support systems (DSS) are separate entities, despite popular perception. Ross Koppel, a sociologist and Penn professor, says that sloppy terminology has confused the respective benefits and shortcomings of CPOE and DSS.

Ross’s sociologist view is interesting. We’re expecting a lot from immature CPOE and DSS systems that most hospital executives can’t define, even when they’re plunking down hard-earned capital dollars to purchase them.

CPOE is a smart typewriter that, standing alone, has little ability to improve patient outcomes. It prevents transcription errors, although those seldom harm patients because they’re usually caught anyway. CPOE makes it easy to choose common order defaults instead of “winging it.”

Beyond that, the benefits (both clinical and financial) come from DSS, not CPOE. (I’ve often joked that hospitals could use e-mail as a poor man’s CPOE system – just let the doc free-text whatever he or she wants and send it to the appropriate department, thereby eliminating transcription and turnaround time errors for free.)

Commercially available DSS systems are, unfortunately, mostly frightfully immature, even more so than CPOE. Early adopters share war stories of nagging alerting, inflexible third-party rules, the inability to customize and personalize, and problems with performance-sapping rules engines incapable of delivering alerts of any more sophistication than the old hard-coded screen edits. No wonder doctors have been underwhelmed.

Still, the real problem is right down Ross’s alley. Hospitals usually buy CPOE and DSS because they’ve failed to control physician behavior otherwise — often euphemized as “reducing practice variation” or “practicing evidence-based medicine.” They want software to do the dirty work that they can’t or won’t: telling physicians that they’re wrong and demanding that they change. When docs don’t follow the electronic cookbook’s rules any better than the paper ones it replaced, systems and vendors are blamed.

I’ve been involved in two CPOE/DSS implementations, both involving large IDNs and well-known vendors. In both cases, hospital administrators ill-advisedly shot their patient safety technology wad on CPOE, confident that it would improve patient care better than any other investment (despite ample contradicting studies). Physician adoption was universal in one, minimal in the other, but one element was common: 90% of the expected DSS benefit never materialized. Pre-implementation enthusiasm gave way to the grim reality that the system wasn’t going to be much help in changing practice patterns. We purchased DSS, but implemented a smart typewriter.

No software contains a switch that turns resistant physicians into docile, rule-following sheep who make better decisions under the watchful eye of Big Brother’s can’t-miss medical guidelines. Displaying a few dumbed-down alerts won’t convince them they need to change. But if your hospital has already spent a few million on CPOE and DSS thinking that was the case, you’ve learned that already.

Maybe physicians will recognize the next generation of systems as their ally, not their enemy. After all, they want the best outcomes for their patients, too. Where they disagree is that we have the answer right now with these first-generation CPOE and DSS applications that we can’t even define.

Time Capsule: Public Trading Leads to Trouble for Merge and Misys

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 2006.

Public Trading Leads to Trouble for Merge and Misys
By Mr. HIStalk

In this week’s Merge Healthcare saga, three top executives stepped down, the company’s previous financial reports and audits were declared unreliable, and Nasdaq de-listing appears imminent. Talk about your memorable holiday!

Merge’s nemesis was that least-exciting of corporate swashbucklers, the unseen accountant, whose pressured blessing of questionable bookkeeping practices ticked like a time bomb — buying desperate executives time to avoid the torch-waving mob of unhappy shareholders, but eventually blowing up in the faces of anyone unfortunate enough to be in the vicinity at the time.

Publicly-traded firms do everything they can, sometimes including cheating, to show a paper profit. Stock price trumps everything. The shareholder is the most important customer and they demand not just profit, but profit growth. Every quarter’s end is another spin of the Russian Roulette revolver.

Privately-held companies do the opposite. Profits mean paying taxes, so those are deferred as long as possible. Companies have little reason to juice the books unless they are borrowing money or trying to go public. Owner-operators are motivated by their long-term equity in the business, so what’s good for them is probably good for me as their customer. We’re both in for the long haul.

The Misys situation provides an interesting backdrop. The rash of activity seems to point to one outcome: Misys will likely cease to exist as a publicly-traded firm. Prospective purchasers, including the company’s current and prior management, see more value than the share price suggests, leading to talk of taking the company private. That won’t come cheap, so there’s a good chance that the healthcare division would be auctioned off to pay down some of the cost.

Neither Merge nor Misys would be in trouble if they weren’t publicly traded. The lure of shareholder cash came with an unpleasant ride on a merry-go-round that didn’t agree with them or their customers. In Misys’s case, they’re willing to pay to get off. They are disillusioned with the pot of gold that most privately-held companies secretly seek.

I’ve watched several of my vendors go public or be acquired by public companies over the years. I can’t think of a single example where my organization was better served afterward. Once the sexier siren of shareholders stole their attention, I saw a decline in support, development, and customer communication. A revolving door of soothing suits tried to explain the publicly-proclaimed synergies that somehow never seemed to benefit my organization. I went to bed with Company A for logical reasons, but then woke up startled to find an uninvited Company B beside me instead.

I don’t consider it to be good news when my vendor announces plans to go public or to be acquired. As a customer, my experience suggests that I won’t be thrilled with the result. In a perverse way, the only safe strategy might be to just go ahead and buy from the big publicly-traded vendor upfront, whose large warts are at least fully developed. In other words, for the same reasons people eat at McDonald’s – to accept plainly obvious mediocrity for fear of being disappointed otherwise.

Time Capsule: Consider Funding Health IT Projects Like Bill Gates Would

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 2006.

Consider Funding Health IT Projects Like Bill Gates Would
by Mr. HIStalk

It’s no longer news when a big, non-profit integrated delivery network pays a CEO $1 million or a CIO makes $300K for running a small department. We’ve come a long way since the days when ministering to the sick was a calling, where selfless caregivers toiled for a subsistence wage in service to mankind. And why not, since a big IDN can make hundreds of millions of dollars in profit (sorry, “surplus”) in a good year? Once nuns got replaced by MBAs, hospitals became a big business, feeling quite unlike charities to those working inside them. The only surprise in the IRS’s questioning of whether hospitals deserve tax-exempt status is that it took them so long.

VP panic ensues when the local newspaper prints executive salaries, fiscal year results, or drawings of the latest vanity construction project. Nurses may be de-motivated. Unions might be called in. A bitter janitor might key all the luxury cars in reserved spots. Beaten-down doctors may get even crankier when they find out that even bottom-feeding HR and marketing VPs out-earn them.

I thought of this when I read that Bill Gates and Warren Buffet will turn over their billions to serve those in need. I’ve worked in hospitals and IDNs for many years. Are we good stewards of charitable dollars, efficiently funneling them directly to those in need with minimal administrative overhead and waste? That’s how you evaluate a charity, and on that basis, IDNs don’t seem to compete very well. We’re no Salvation Army, with tiny salaries and a focused mission.

Still, another headline gave me an idea. Studies are proving what we all knew: RHIOs can’t survive without charity. If RHIOs provide benefits to patients, yet offer no hope of financial self-sufficiency, then maybe that’s a good and direct use of charitable dollars. Put a few million long-term dollars into some well-organized RHIOs and see what happens.

I like this because Gates’s charity is notoriously efficient. You compete with other causes under rigorous conditions on how well your project will benefit society. RHIOs would have to prove themselves worthy of funding, which would be an interesting exercise in itself given their sketchy “let’s put on a show” origins.

What other health care IT projects deserve charitable consideration? I’d vote for a center for usability research to make health care software more user-friendly and less training-intensive. I like the idea of a free clearinghouse for clinical rules, knowledge, and content to be shared by non-profit hospitals. Maybe we need a patient safety organization just for IT, watching out for problems caused by poorly-designed software and medical technology. Perhaps a non-profit medical informatics consulting organization could help hospitals with an occasional need for that expertise..

If you’re involved in hospital IT, my advice is to review your projects like the Gates Foundation would. Are they ingenious, cost-effective, highly beneficial to patients, and highly likely to succeed? If so, put your resources into those.

In the meantime, here’s my challenge to you. Come up with a list of health care IT projects that are noble causes, benefiting a large population in a way that the free market and the government haven’t. What IT-related work would be ingenious, cost-effective, highly beneficial, and highly deliverable enough to pass scrutiny from the Gates Foundation? Send them my way and maybe we’ll talk about them in a future article.

Time Capsule: US Hospitals Can Learn a Lot From Richard Granger’s Approach

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 2006.

U.S. Hospitals Can Learn a Lot From Richard Granger’s Approach
By Mr. HIStalk

The British government’s audit report of its Connecting for Health project, released a few days ago, confirms the obvious. Richard Granger and company have put together a remarkable program for aggressively managing their software vendors.

Granger was tough from the beginning. He threatened, for example, to write his own PACS if high vendor pricing made that an attractive option. Complex contracting was wrapped up in less than a year. Vendors had to prove their ability to deliver through real-life simulations. Most importantly, contracts clearly state that no one gets paid until their stuff is working. All of this, unfortunately, is highly innovative in the back-scratching world of public sector IT.

The Achilles heel of Connecting for Health’s vendors has been the contractor-subcontractor relationship. Big consulting companies won the business, then promptly subbed out to application vendors. That was covered in the contracts, too: the bidder is liable if its subcontractors under-perform, which they largely have. Smart contracting protected the National Health Service against the failings of iSoft and IDX, hitting the consulting companies who chose them squarely in the wallet. That’s how it ought to work.

Granger holds firm and goes public when he has to, unafraid to rip recalcitrant vendors by name. I like to picture him as a Gordon Ramsay-type scrapper, happy to take someone down a notch when they need it.

Providers in the US can learn a lot from the auditor’s report. Vendors throw the ‘partnership’ buzzword around a lot to impress rubes, but it’s usually a marketing term instead of a true risk-sharing contract like Granger demands. Hospitals usually just moan about poor vendors instead of using their intelligently crafted contract to withhold payment or send them packing. The auditors lauded NHS for protecting the taxpayers’ money through smart IT management, and rightly so.

I compare it to road work, which most states do poorly. How many times do you drive by miles of orange barrels with no workers in sight, unless they’re standing around aimlessly, and even then only on weekdays from 8:00 until 4:00 when they’re not on break? Traffic is snarled around the clock for months as grass grows from piles of unmoved dirt amidst infrequent activity consisting mostly of sociable shovel-leaning. That’s how hospital IT projects and vendors sometimes work.

On the other hand, I lived in a state that ran roadwork like a private business. Contractors were given incentives to finish projects early while meeting quality standards, which unsurprisingly, they almost always did. Work could be done only at night, worker inconvenience notwithstanding. The difference to motorists was striking, the state saved money, and incompetent contractors were driven out. The only mystery is why other states aren’t smart enough to copy their success instead of having single-lane rush hour traffic cursing at orange barrels.

I admire Richard Granger. What’s wrong with being tough when so much public expectation and money is at stake? Hospital IT departments may be smaller, but they can learn a lot from Connecting for Health’s experience in managing their vendors and their projects. Of all the blowhards on the health care IT speaking circuit, he’s one of few who I’d look forward to hearing.

Time Capsule: Vendors Seek to Diversify As the Hospital Systems Market Matures

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 2006.

Vendors Seek to Diversify As the Hospital Systems Market Matures
By Mr. HIStalk

Vendors of traditional hospital information systems are hedging their bets for future success, judging from recent announcements. McKesson said this week it is acquiring RelayHealth to move into consumer health care systems. A group of vendors said they would develop standards to make their home health devices interoperable. And Cerner’s announced growth areas are mostly outside of traditional hospital IT.

The message seems clear – business prospects are better elsewhere. Wall Street likes growth that big conglomerates and publicly-traded vendors can’t get from hospital-only sales, given a finite supply of prospects that are big enough to afford their wares. The recent spike in clinical systems deals may have been transitory, locking up all the laggard customers but leaving fewer for the years to come.

Perhaps we’re in the classic mature market, where the customer base is saturated, vendors are consolidating, product prices go down to reflect decreased demand, and emphasis moves from R&D to solid, user-friendly applications that are differentiated primarily on specific features (think Rubbermaid). Vendors can still make a lot of money, only instead of from product sales, profits come from selling high-margin services and maintenance to existing customers.

Under this scenario, and given high switching costs, hospitals may no longer command the undivided attention of vendors whose gaze is wandering to sexy new markets. Maybe there won’t be any successful hospital-only vendors left, except possibly for Meditech, which is ideally suited for success due to its dominant market penetration, near-universal customer retention, low cost through economies of scale, and private ownership.

Even if the hospital systems market is mature, just about every other health care IT sector isn’t. Business will sizzle in ambulatory systems, various forms of telemedicine, data analysis, payer intelligence, genomics, interoperability, consumer health, drug research, home health, and medical device connectivity. Products in the innovation and growth stages of the product life cycle require high development and sales costs. The aggregate market must be defined and created. Most companies will lose money, but winners will emerge from the turmoil to gain competitive advantage and profitability.

It will be interesting to see how the traditional players fare in these markets, where they’ll need seldom-used capabilities such as technical innovation, nimble execution, and delivery of their message to a much larger number of prospects who behave less cohesively and identifiably than hospitals. Having a good idea isn’t enough. If I were an investor, I’d buy strictly on the quality of company management, choosing vendors with visionary, focused leaders who can rise above a host of new market entrants that are likely to fail due to stumbles in execution.

The original HIT marketplace was first changed dramatically by the emergence of large, full-line hospital systems vendors that moved the industry away from small, innovative best-of-breed vendors and customer self-development. The second change was the absorption of most vendors into unfocused conglomerates or larger competitors. The third wave — obviously underway — is diversification of vendors into non-hospital health care IT.

It remains to be seen whether hospitals will be better or worse off with these changes. We struggled even when we had the undivided attention of our vendors, failing to manage change and gain ROI in an admittedly screwy and ever-changing health care non-system. We may not enjoy giving up the limelight. After many years as a hospital IT person, I’m a little jealous to see the excitement growing in those areas of health care I don’t yet know much about.

Time Capsule: When CIOs Are Under Pressure, “Man of Action Syndrome” Kicks In

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 2006.

When CIOs Are Under Pressure, “Man of Action Syndrome” Kicks In
By Mr. HIStalk

Hospitals and vendors don’t brag when their IT projects harm patients. Therefore, I’m not surprised that press releases haven’t announced several recent, disastrous examples where IT leaders overrode worried clinicians and continued with a flawed clinical system go-live to the detriment of patient care.

Being of a clinical background, I’m compelled to give this scenario a name and an acronym, even though I can’t diagnose or cure it. Man of Action Syndrome, or MAS, is the psychological need of someone in IT authority to veto those more knowledgeable clinicians who express well-founded patient safety concerns about clinical IT projects.

The name is not sexist since I’ve not yet seen a female CIO so afflicted. MAS also seems to spare CIOs with a clinical background.

Its victims are generally male, Type A, ego-driven MBAs with a history of programming or consulting. Anxious to add value by showing business savvy and decisiveness in an ill-suited environment of caring and empathy, they won’t allow budgets or dates to slip. It’s a quantitative thing.

A wise old project management saying is, “Good, fast, cheap — you can only pick two.” Unfortunately, those with MAS obsess on ‘fast’ and ‘cheap,’ knowing that it’s far easier to bury (no pun intended) qualitative project shortcomings that fall into the ‘good’ category. You can always blame users or the vendor.

I’ve been on both sides of the fence. IT people add value in formalizing system selection and planning. Those are repeatable processes where past experience may improve the chance of success. Unfortunately, that kind of management-by-control experience doesn’t work with clinical process change.

Ideally, an assembled group of clinicians would drive clinical system projects. However, it’s hard to engage them. That’s when MAS kicks in: “My neck’s on the line, so here’s what we’re going to do.”

From my limited experience, I would say that CIOs overrule the concerns of nurse informatics people nearly 100 percent of the time and IT-based physicians at least 50 percent of the time. Because those people represent a large number of their disenfranchised non-IT counterparts, the CIO has, in effect, dismissed the concerns of an entire discipline, often with reasoning such as, “They don’t see the big picture” or “They don’t know the pressure I’m under to deliver ROI and on-time implementation.”

Maybe practicing clinicians should be the ones making the go/no-go decision without IT people or other hospital management in the room. I’ve seen clinicians leave meetings shaking their heads, worn down from trying to get their message across to an IT team more comfortable hard-selling their own agenda instead of listening to what’s best for patients.

Perhaps the evolving role of the chief medical information officer will eventually balance the MBA approach. Maybe we’ll see more CIOs who have cared for patients instead of thriving in a Dilbert-esque world. Possibly the new wave of clinicians formally trained in informatics will provide credibility to concerns that the software doesn’t work, the users aren’t ready, or the communication has been poor. Non-IT hospital leadership may eventually understand that that silver bullet they paid for is just lead under the paint. Until then, if you’re a CIO with symptoms of Man of Action Syndrome, please contact your health care professional at once.