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Readers Write 1/15/09

January 14, 2009 Readers Write 8 Comments

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Comments on the National Research Council’s Report
By Peter Basch, MD, Medical Director of Ambulatory Clinical Systems
MedStar Health 

Kudos to the National Research Council for their comprehensive and sober analysis of the state of health information technology as it exists today, and for their thoughtful recommendations. These recommendations reflect not just their research and editorial advice, but the current conventional wisdom and implementation approach of nearly all clinical informatics leaders. These recommendations call for continued federal financial support for:

  • Improved care enabled by HIT (and not for HIT adoption per se);
  • Innovation on workflow and process improvement;
  • Development of enhanced and highly functional clinical decision support for providers and patients;
  • Health care institutions and communities that appropriately aggregate data for quality improvement;
  • Continued education and training; and
  • Interdisciplinary research.

However, in spite of this clear support for funding and continued development of HIT, some media headlines have painted this report as harshly critical of the potential of HIT in general and EHRs in particular. This media misinterpretation resulted primarily from two faults inherent to the report : (1) the NRC’s mislabeling of their recommendations as a change from what health IT leaders are advocating for; and (2) the NRC’s inappropriate assignment of blame to EHRs as being the cause of dysfunction rather than their understanding that EHR functionality and implementation deficits are a result of a dysfunctional reimbursement system, which is based on volume of episodic care and verbosity of documentation.

pbasch While it is true many early adopter systems believed (at the time) that merely switching off paper medical records to EHRs would lead to improved and safer care, nobody has believed that, or has advocated that position in years. The current conventional wisdom is that HIT is quality and safety agnostic, and that its role is to serve as enabling infrastructure (toward whatever ends it is pushed to support). And as long as providers are incented primarily for procedures and volume, it is a surprise to no one (including the health systems studied), that their implementations have resulted thus far in only modest care improvements.

That said, there is a much clearer understanding in 2009 of where potential value lies in HIT implementations, and most health systems implement very differently now than even a few years ago — focusing on custom clinical content and targeted decision support — which can lead to further care improvements even within a dysfunctional health care system.

The NRC faults current EHR build as not supporting the cognitive support necessary to optimize care. This deficiency is obvious and abundantly clear to veteran EHR and HIT users – many of whom work on their own or with vendors on new and better functioning clinical decision support. However, let’s be fair as to the root cause of this deficiency. It is neither lack of vendor vision nor limitation of IT technology; it is lack of a market. 

EHR vendors must build applications that will sell, and the advanced clinical decision support that the NRC appropriately calls for does not and will not have a market — until health care is less fragmented, efficiency goals are aligned, and payment policy moves away from procedures and volume to information and quality outcomes. In our current fragmented and dysfunctional system, EHR purchasers are looking for a toolset that helps their practice to function more efficiently (and pay off the HIT investment) — which equals coding and documentation support. This is not the fault of EHRs, but squarely the fault of our healthcare system.

The NRC also makes the point that EHR technology needs to change because many providers find that they spend more of their time on using the EHR to document care rather than spending sufficient time on providing care. While it is certainly true that EHRs could make documentation easier, let’s not forget that providers using paper records voice the same complaints. Documentation changed from a medical art to a burdensome chore, not with the advent of the EHR, but with the Evaluation and Management (E/M) payment system changes of the mid 1990s.

This payment schema effectively eliminated the possibility of concise and relevant documentation, replacing it with a “pay-for-verbosity” system. These payment requirements (along with the very real threat of fines and prosecution for billing fraud) have unfortunately also served as the basis for many EHR sales to physician practices, as there was and still is a clear market for documentation and coding support. Again, the fix is not technologic; it is health system and payment reform.

In spite of these criticisms, the NRC offers good advice on improving HIT and EHRs and sound recommendations for federal support. However, the key to getting it right is combining support for HIT with health system process and payment reform. Without alignment of efficiencies and defragmenting healthcare and healthcare delivery processes, even better HIT will not be consistently and optimally used. And without a concomitant commitment to a sustainable business case for health information management and quality, even universal adoption of optimized HIT will be a disappointment. The time for change coupled with wise investments is now.

Just Watching FnC and Not FnC
By Duuude

Can we have a cat fight? Just what we need to spice up my Wednesdays – watching Fish and Chips and Not Fish and Chips!

In looking at Not FnC’s comments, the first thought I had was the lyrics from These Things by She Wants Revenge:

There is nothing to see here people keep moving on
Slowly their necks turn and then they’re gone
No one cares when the show is done

OK, back to the serious stuff. Fish and Chips is off on how long the Sutter implementation has gone on. Not two years –I believe it’s been going on for five or six years. If a Sutter resource can confirm that timeline, feel free to confirm or correct. 

In defending Sutter, even though there were questions concerning the selection process of their Electronic Health Record (was there a bona fide selection process?), whether Sutter realized what it actually would take to implement across the enterprise as well as the whole standardization processes, to achieve said Electronic Health Record, they figured out their strategy in rolling out to their acute care affiliates. Note, they already have Epic ambulatory up and running at several ambulatory sites. Most notably, PAMF. Just ask Stanford (wasn’t that their primary business reason to ditch Carecast?)

FnC, do you realize how many disparate hospital information systems Sutter had across their enterprise? It literally spans across the vendor community! While they have a physician portal, that’s not the same. Also, supporting these disparate systems in Sac-town is a huge challenge! They needed to change and consolidate systems, standardize workflow, etc.

Now, can you raise a question about their selection process? Absolutely! In fact Mr. H can probably dig up previous discussions. Project planning methodology, cost realization, ROI, whether the Citrix farm will work across Sutter? Heck yeah! But remember, if you stack up Epic, Cerner, McKesson, Siemens, etc. and you’re looking for a good, integrated HIS, who do you think people will pick? The market is saying Epic, and from what I’ve seen, it’s a solid choice.

Now having said that, here’s my beef with what I’ve seen over the past few years. There are a lot of health systems that implemented one costly solution and decided a couple of years later to throw more money around at another solution when really the two different systems are hardly different. In a homogenous environment, if I have Cerner Millennium and I’ve been running it for four years, why would I then go and say, “Well, let me ask the Board to toss out a few hundred million more and get Epic because my competitor has it.”

Is Epic better than Cerner? Yes it is! Is tens or hundreds of millions dollars better? Not by a long shot. It looks like for the past year or so, the bandwagon-hopping system selection methodology has slowed quite a bit, but there are hospitals still looking for solutions and if they’re big or an academic setting, more likely than not, they’re implementing Epic.

Being Ricky Roma,
… Or, Tales From the Dark Side – Episode IV 

As a long-time reader who has enjoyed the high quality of the Mr HIStalk and HERtalk musings, I would like to share some personal thoughts, observations, and recommendations in the area of healthcare IT sales; aka, "the Dark Side". I have lived in both the hospital IT management world and the vendor world and have learned that most of you who work in hospitals ‘don’t know the power of the Dark Side’.

Sales is often called the "Dark Side" of our industry because of the perception of having to forfeit one’s ethics, morals, ruth (as in the opposite of ruthless), and all other goodness remaining in one’s soul in order to be successful. Plus you generally have to wear a suit and fancy shoes all of the time.

In many cases, an attempt to characterize any large group defaults to the actions of a few tainting the image of the many. However, in sales, this is usually not the case. Most sales people in nice suits in fact should be treated like Sith and duly avoided.

Even in this current economic climate, you may have an occasional desire to purchase new, or possibly even better, technology; and sometimes must engage with those who are specifically compensated to separate you from as much as your hard-budgeted money as possible. In this mini-ecosystem, all sales people and sales organizations plot to favorably position their wares. Some, will occasionally misrepresent their goods and/or services. To help you fight the Good fight, here are a few simple tips from the Dark Side

NEVER believe the demo
ANYTHING can be made to work in a PowerPoint/Web/canned environment. Please say this out loud, right now, in your best Senator Stuart Smalley affirmation voice. Anything, even an enterprise EMR that connects rromaseamlessly with any and all other applications, can be shown to work on a laptop. There are plenty of companies that put more resources into building demos than the product itself. The vendor product demonstration is a fair way to baseline what the product or service is supposed to do, but should always be viewed with suspended belief. Don’t believe the demo.

A good plan to ensure reality meets expectations is to write out the functionality you are looking for (some people use categories such as "Must Have" and Like to Have" for this) and then ask at least two vendors to see this functionality working in several actual installed customer sites (Web conference is a good way to do this logistically). Do this at the very start of your process. If the vendor balks at this, you should either run away as fast as possible or be fully cognizant that you will be signing a development deal.

Remember, the demo is an illusion. A lunch demo, doubly so.

Think carefully about the site visit
If it isn’t obvious to you, the site visit is the most one-sided event since the war in the Falklands. In my vendor career, I have only ever lost one deal out of many, many, many where we did a site visit. And that was my own fault for mismanaging cultural personality differences. We on the Dark Side love the site visit since we get to stack the deck and script 99.44% of the event. In my hospital career (pre-Dark Side), I usually felt like I was the mark in a shell game on these visits. How about you?

In the same amount of time that it takes to travel to TX, NY, CA, FL, WI, PA, KS, TN or anywhere else from that Johnny Cash song, you could do at least ten reference calls or Web meetings, while at the same time saving some of that hard-budgeted money. The bottom line is that ALL vendors have their one or two showcase sites in their proverbial back pocket. Getting beyond these "set-ups" and talking to regular customers will mean the difference between purchasing a solution that will bring value to you and your hospital and explaining the failure at next year’s capital budgeting committee meetings or at a job interview.

If you do decide upon doing a site visit, be sure to ask if the organization you are visiting receives any compensation (such as maintenance credits, discounts on past or future purchases, paid-for trips, etc) from the vendor for their hospitality.

The variety of individual and organizational negotiating styles never ceases to amaze me. Zillions of books, ranging from achieving win-wins to subconsciously hypnotizing your opponent, have been written on negotiating, so I won’t belabor this point except to provide two snippets of inside information from the other side of the table.

The first is to not agree to terms until you have had at least one "walk-away" from the deal. Even if you are the most soft-ball negotiator in America, you can get more of what you want (lower price, better terms, better support, etc) in this fashion. A week or two of delay in your buying process generally won’t harm a well-planned project, but it is just murder on a sales person who thinks he/she is close to signing a deal with you, especially when their sales manager/VP is breathing down their back to close it before the end of the month/quarter/fiscal year or pink slip.

The second point is to ALWAYS maintain a line of discussion with your back-up vendor, and tell your chosen vendor that you are still also in discussions with their closest competitor. I have often seen some hospitals take this a little too far literally undertake dual contract negotiations. My personal belief is that this is a waste of time. Lawyers, (who mostly live in an even Darker World ) may recommend this, but just keeping a back-up solution in the wings is generally sufficient.

The Good, the Bad, and the Ugly
My final recommendation from the Dark Side is to proactively do your best to work with good sales people. This may sound like the ultimate in oxymoronism to you. But, in my experience in interviewing more than a few sales candidates over the years is that Pareto Principle rules. Almost all sales organizations are made up of roughly 20% standouts (Good); 60% who are OK and can do the job (Bad); and 20% who should cause you to demand a replacement (Fugly). So, before you condemn all sales people back to the used car lot, there are several upsides to working with that top 20% sales person that you should know about:

  • They are a good litmus test for the quality of the company. They won’t stay at bad companies because they cannot earn the type of money they know they can command. Like the Canary in a Coal Mine, they will not be around if the company’s oxygen is depleting.
  • They carry a lot of clout in their organization, much like your hospital’s surgeons. If you need to ask a favor, they can almost always get something done for you.
  • They are almost always well connected in the industry and can make connections for you, for things like back door references on other projects, quality IT personnel you may want to poach from other healthcare organizations, pulled pork recipes, etc.
  • They can actually add value in helping you with your process and end goals. This may sound like heresy to those who think all sales people are predatory scum, but the Good’s history of success generally means that they have observed many best practices which can ultimately help make you more successful.
  • Show your sales person the door if they over-rely upon their number of years in healthcare to try to win credibility; or if they "name drop" more than four or five people in your meeting. If industry longevity is their only way of winning your trust, then you are not dealing with someone who can help you.
  • To test the credibility of your sales person, try asking a ridiculous question. Ask if their product will do something that is technically impossible or that you know cannot be done. Ask if the service can be customized to do something outside the bounds of reality. This may sound a little silly, but some sales people will say just about anything to try to win your business, especially if they are struggling or had their nest egg  invested in Fannie Mae. I guarantee you will be surprised and amused by the variety of responses you get to these character tests.
  • Finally, if do you get stuck with a Fugly, someone who is in that bottom 20% or even in the bottom 80% for that matter, but you think you might like the product or service they are selling; you should e-mail the company’s CEO to let her/him know that you were a underwhelmed by the quality of the sales effort. Tell them that you would like to either work directly with said CEO or be reassigned to the company’s top sales person. Either way, you are going to be guaranteed a high level of service going forward. Also, you are more likely to get a really good deal. If you didn’t already know this, a selling CEO is the bane of any VP Sales’ existence. We all know that the CEO will give away the farm to close the deal. As the top dog, he/she simply cannot allow himself or herself to fail at closing the deal.

I hope this brief peek into the power of the Dark Side was helpful for you. Also, for the sake of my Good peers, I ask that you use any of this information for good, not evil purposes.


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Currently there are "8 comments" on this Article:

  1. Great recommendations from Dark Side. Might have saved some of my past EHR selection teams lots of time, money, and over-optimism. From now on, watch out you sales people!

  2. The Sutter implementation began far longer than 2 years ago. (Former recruiter, worked for several of the Sutter facilities). Give ’em a break though. They did (do?) have every system known to man across the enterprise. They also changed CIOs, and not too long ago brought in a director to move them to more of a PMO structure. A very impressive PM formerly of the treasury dept.

    I mention all this to make a suggestion to those execs considering one of Ricky Roma’s site visits or reference calls. (GGGR is the best)

    Who, besides your sales rep knows the users of whatever software you might be looking at? Your friendly neighborhood headhunter, of course! We know the companies, the names of everyone there, and the version of the product. If your headhunter (somebody good of course) doesn’t know that (or can’t look it up), he is of no use to you. Ask about other clients’ experiences. Don’t reply on your rep to introduce you to someone…

  3. Thank you Dark Side. So refreshing to read the truth. Let us remember that 75% of HIT implementations result in failure. Thank you for your candor and insights.

  4. I think Peter Basch really nailed the unspoken issue underlying the failure of HIT to deliver on the promises- that it’s aimed at satisfying a reimbursement scheme that is not aligned with delivering optimum, efficient healthcare. Having access to what the previous docs did is good for the patient, documenting 2 elements on each of 9 systems in the physical part of E&M coding (or 10 review of systems elements) is only good for helping my organization compete for ever scarcer 3rd party payor dollars.

    Oh, and great discussion of The Dark Side- been on both sides too, much truth was written. I don’t know how to get around one problem with site visits. Why would anyone waste their time offering to be a site visit without some incentive?

  5. A highly contractive hybrid term that my wife & I have come to use and chuckle every time is “fool-em-up.” Fool-em-up can be applied across the broad spectrum of demos, presentations, balance sheets, excuses, etc. Anytime you want to demonstrate your brand of truth, you simply apply the “fool-em-up” and make everyone happy and secure.

    I give credit to “fool-em-up” from a lovable and brilliant chief software architect that I worked with years ago and still around. Fool-em-up, you know who you are and I applaud your skill.

  6. @Ricky Roma-

    Great insight…we just finished a very lengthy EMR/PM selection process and most of your points hit very close to home (ouch!). Thanks for giving us sand people (or at least some of us who like to have our heads in the sand) a glimpse into how it is in your world.

  7. “Tales from the Dark Side” was an excellent commentary and full of truth. Perhaps, even thought they routinely get “beat up” in HIStalk, KLAS comments (not scores, although they, too, have some merit) should be referenced as an evaluation tool. With all the “magic” that takes place on site visits or demos, the client commentary is taken from KLAS interviews with real clients that are well past the site visits and demos and have to deal with the REAL product on a day to day basis. KLAS includes both positive and negative comments and the sheer volume as well as the tone of each section is a good indicator of what really works… or doesn’t!

  8. Re: Skeptical. For prove me wrong detail, I would recommend starting with this Journal of American Medical Informatics Association article published online on March 4, 2009: http://www.jamia.org/cgi/reprint/M2997v1 (warning, pdf). It is healthcare specific and neatly summarizes a large body of work in this area. Then for even more background, research the 78 additional studies which are cited.

    Is the 67% failure rate sacrosanct? No. Is an actual figure generally agreed to be an abysmal number? Yes.

    Does it really matter to, say a hospital’s board of directors, whether HIS projects fail because of staffing, lack of support, organizational roadblocks, or software not working? These failures are not necessarily always about Dark Side sales people lying or being sleazy, they are about HIS management not using their gold to set their own rules for being successful. Instead, they let us set these rules.

    For suggestions on setting your own rules, see my last note.

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