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Readers Write 6/22/11

June 22, 2011 Readers Write 22 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Epic Ponderings
By Cam O’Flage

Epic is a marvelous marketing machine, from initially establishing themselves as a boutique firm with a certain mystique since they were able to tell clients whether they were the right customer (rather than the customer telling Epic that they were the right vendor).  And it continues to be a superlative marketing machine.  They tell a good story, present a great vision, and manage customer expectations nonpareil.  They’re superb business people.

Epic doesn’t do everything right, but who does?

Epic makes many good decisions, but they make some bad ones.

Epic releases aren’t always so bug free.

Now, I know that I speak from a biased perspective since I currently am involved with provision of implementation consulting (staff augmentation) services.  But I’ve been around a long time and seen lots of successes and failures across multiple delivery systems using multiple vendor applications.

Epic’s current implementation methodology, however, is circumspect.  While it’s partially in response to ONC’s mandated MU timetable (another source of discussion), Epic does believe that it knows the best way to install its product.  But a tight timetable with little time to consider workflow needs or optimizations or deferral of vital function simply to make a deadline is so wrong.

We’re told time after time, plan and engineer correctly in advance to maximize return on investment and minimize production problems.  It’s in our business school case studies.  It’s in our re-engineering process improvement literature.  It’s in our quality theories.  Yet, Epic – and ONC – have embraced a slam dunk implementation methodology.  Get it in, optimize later.

There are so many choices.  So many informatics considerations (one of my biggest fears since so many of Epic’s designers and installers simply don’t have a good basis in understanding clinical informatics needs – or revenue cycle considerations, for that matter).  So many process issues.  So many opportunities to improve, to ensure that clinical documentation is complete, that patient safety is maximized, that budget is truly aligned with needs and expectations, that appropriate governance has been put into place, that risks are adequately mitigated, that expectations are properly established, that work/life balance is dealt with, etc.

There are too many customers that go apoplectic when there are budget overruns, even if scope has changed.  While that’s not an Epic problem per se, the perception that their plan is comprehensive and constitutes the safest way to attain MU is contributory.  CIOs and COOs and CFOs and VPs simply need to get real.  An EHR implementation is an immensely complex organizational change, fraught with unknowns and potential failure points.

There are too many customers who wish that they had done their implementation differently. There are too many times that customers realize that optimization entails rebuilding the foundation.  There are too many customers who find themselves a year later not where they wanted to be. HIStalk pages certainly document such things.

However, all of that said, I can’t say enough good things about Epic.  Epic truly focuses on improving the patient experience. Their culture is one of excellence, of passion, of dedication and commitment.  Their employees are smart and industrious.  And they continue to deliver what they promise.  I can’t say that about many IT vendors.

Why Are We Still Struggling with CPOE?
By Daniela Mahoney

6-22-2011 7-00-14 PM

I often ask CIOs a simple question: what keeps you awake at night? Over the years I have received many different answers. Lately I have been thinking about my work and my experiences from previous days and could not stop asking myself, “Why, after more than 30 years, are we still struggling with getting CPOE going?” What other industry has tried implementing technologies and three decades later they are still in their infancies with the results?

I was excited about the idea of writing an article each month for HIStalk to share some of my insights about what to do with this entire CPOE business and how to best prepare for its challenges. Then I was wondering about our colleagues in the industry, and who wants to keep reading about CPOE? Mine would be just one more article of something you read somewhere, else because “theoretically,” we know what we need to do and there is already a lot of information about it. And that is the exactly the key — we know the “whats” but we oftentimes miss the “hows”.

But, one would ask, why should anyone listen to Daniela? Well, you don’t have to. I am only going to share what I have learned by doing CPOE for over 20 years. I am going to keep it simple because I find that we can achieve much more when we present information in a way that we can relate to and it makes sense to most of us. It is like baking a molten chocolate cake –  it has only six basic ingredients, but the outcome is divine! You can add the raspberries on top if you wish. Simple is good, and we can achieve exceptional results.

Did you know that CPOE has been talked about since the 70s? In June 1971, the National Center for Health Services selected El Camino Hospital, CA, to evaluate and implement the Technicon Medical Information Management System (TDS) to be used by nurses, physicians, and others. The main goal was to expedite the overall patient care processes.

By 1974, 45% of all orders were entered directly by physicians into their CPOE system. Yes, we had it then, and unfortunately at that time in the 70s and 80s, some of the institutions and vendors who attempted had varying degrees of failures, with some limited successes. It was not until the late 80s and early 90s that we experienced a renewed effort and interest in CPOE. I started my journey on this path in 1990, so I can say that we have learned a lot. Or did we?

I am going to begin with the end in mind, assuming that we are not just doing CPOE to meet the political timelines, but also to do the right thing for the patients and give our clinicians a tool they can appreciate and incorporate into their everyday workflow. Based on this assumption, we will work backwards and talk about the right things to do as we prepare for this CPOE journey. Almost three decades later, it is about time that we get it right the first time around! Here is the roadmap we will talk about in the next 12 months:

  1. Is it only CPOE, or there is more? We have to think about what is ahead of us more holistically because CPOE is no longer a standalone project.
  2. What support we need from our leaders to pave the road for us and why?
  3. Why should I (physician) use it? What’s in it for me? How do we create a value proposition?
  4. How much will it cost?
  5. How do we create the teams (who steers the wheel vs. who shifts the gears)?
  6. Don’t let perfection get in the way of good. Setting the scope of what CPOE is and what it is not.
  7. Clinical process transformation. How to manage and not get crushed by the magnitude of change.
  8. How about the vendor? Where do they fit into this?
  9. Did we get it right? How do you know? (aka, success factors).
  10. What is going to make us fail? If 30% of CPOE installs have historically failed, how do we rise above this? (aka, risk factors).
  11. Large or small hospital, we need to roll out somehow. What are the options and their respective pros and cons?
  12. No, I did not forget about training and support. I will address this as well.

And if there are any other readers who enjoy cooking as much as I do, here is the link to the molten chocolate cake. 30 minutes to prepare, six minutes to cook, and 10 minutes to savor your work of art. And while you are enjoying this superbly rich chocolate delicacy, please try not to think of CPOE!

Daniela Mahoney RN is president and CEO of Healthcare Innovative Solutions of Seville, OH.

Thoughts on Lazar Greenfield Stepping Down
By Tiffany Carroca

On Sunday April 17, renowned surgeon Lazar Greenfield MD resigned from his position as president-elect of the American College of Surgeons (ACS). The resignation came just over two months after he had written a controversial article that caught the attention of nearly everyone in the healthcare community, including those in medical coding, and has achieved a level of infamy nationwide as the Valentine’s Day editorial. The controversy of the article stems from a statement made in which Dr. Greenfield suggests giving women semen for Valentine’s Day instead of chocolates.

The editorial was originally published in the February 2011 issue of the American College of Surgeons affiliated newspaper, Surgery News. The paper, made available free to the public online, was pulled from the Web site when the controversy erupted soon after the story ran. Interestingly, Dr. Greenfield was also editor-in-chief of the publication, but was subsequently removed from the position due to the content of his article.

Although Dr. Greenfield apologized for the editorial and reaffirmed his belief in the rights of women in health care, these actions did not end the controversy. Besides offending many female surgeons who have had to put up with sexual harassment for decades in this male-dominated field, Dr. Greenfield managed to dig himself in deeper when he sent an e-mail to several media outlets defending his claims. However, Dr. Greenfield did ultimately determine that resigning would be the best way to put an end to the uproar over his article. In a statement given to ABC News, Dr. Greenfield said, “My personal and written apologies were ignored, and my suggestion to use my experience to educate others rejected. Therefore, rather than have this remain a disruptive issue, I resigned.”

The comments made by Dr. Greenfield on Valentine’s Day seemed like a joke to some and the crass opinion of a womanizer to others. However, the statement does have a basis in scientific and medical fact. Dr. Greenfield was referring to a study published in the Archives of Sexual Behavior in 2002. The study was performed by psychologist Gordon G. Gallup, PhD at the State University of New York in Albany, and gained widespread attention when it was reported in the article Crying Over Spilled Semen by Tiffany Kary for Psychology Today.

The study was conducted on 293 college women who were sexually active. The results showed that women experienced less depression after having unprotected sex, and the depression slowly returned as the time progressed after their last sexual encounter. Women who used condoms did not experience any reduced or heightened rates of depression.

The conclusion reached by Dr. Gallup was that the hormones contained in semen are absorbed through the walls of the vagina and elevate the mood of the woman after intercourse. Other variables that could have caused the reduced depression, such as birth control and behavior patterns, were also taken into account.

The group most outraged by the editorial was women in the healthcare field, most notably women surgeons. Colleen Brophy MD, a prominent professor of surgery at Vanderbilt University School of Medicine and chairwoman of the ACS’s surgical research, explained to Pauline W. Chen MD who reported on the story that she was “aghast” at the editorial. However, when the ACS refused to stand by her response, Brophy resigned from the College in response, claiming, “The editorial was just a symptom of a much larger problem. The way the College is set up right now is for the sake of the leadership instead of the patients.”

Many women in the healthcare field voiced their outrage over Dr. Greenfield’s editorial, but he was not without his supporters. Dr. Greenfield, a professor emeritus at the University of Michigan, had always been highly regarded and was presented with the Jacobson Innovation Award just last year, according to NPR’s Health blog.

A colleague at the University of Michigan, Diane M. Simeone MD, came out in his defense, saying that she has witnessed several accounts of gender bias among surgeons, but never from Dr. Greenfield. Similarly, Dr. Gallup, who conducted the initial study, also came to the defense of Greenfield, noting that what he said may not have been tasteful, but does have “some basis in available science.”

Undoubtedly, Dr. Greenfield’s remarks caused a public outrage even though they were based on science. However, a lewd and womanizing comment based on science is no less offensive that one based on fiction. If Dr. Greenfield was trying to be humorous or otherwise non-offensive with his comments, he failed miserably, as public opinion has shown. Even an esteemed doctor and scientist can fall from grace when injecting personal opinions into the science. As most scientists will agree, it is best to keep the science pure.

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Currently there are "22 comments" on this Article:

  1. Is the article about Epic supposed to be a joke? The article calls Epic a “superlative marketing machine”. Having never produced even a single press release, Epic is certainly not known for its marketing efforts. Perhaps the author thinks that the absence of a major marketing effort is actually a devious ploy that somehow causes hospitals to purchase systems. If so, I wish other vendors would copy Epic’s marketing genius.

  2. Cam O’Flage – you make some good points but they are meaningless b/c you haven’t revealed your name, position, or experience. Just something to think about

  3. Time for the kneejerk defensiveness from Epic supporters. @Cam, thanks for the honest assessment. Many knowledgeable, impartial people in the industry would reaffirm nearly everything you wrote.

    @NotQuite – you might have failed Marketing 101, but press releases are not the only form of marketing. Epic engages in the same marketing tactics that hospitals have for years – no direct press releases or ads, just make sure to feed a couple of feel-good articles to the local media outlets and highlight anything positive relating to your company’s products…kinda like linking news and journal articles and interviews to your website’s front page. But of course that’s only high school-level marketing. It gets much more complex from there. Epic is a marketing machine first and foremost, with an average software offering and good customer service.

    @Bryan – Cam mentions that he/she is an implementation consultant who works on Epic installs. It’s sort of obvious why he/she chose to remain anonymous. It’s not as if you stated your full name, title, employer, email, home address and social security number in your post.

  4. Believe it or not…Epic really does great marketing. In fact they do it so well you never see it coming until it’s too late.

    Comes under the heading – People want most what they believe they can’t have!

    I just wish our politicians would follow their lead. No press releases, no ads, no slamming the competitions, no blaring commercials, just stand quietly at a trade show and watch the booth fill.

    Oh, and as for Dr. Greenfield, as they said in the 60’s if it feels good..

  5. Daniela – I look forward to your articles. All of your topics/questions I have pondered and tried to answer. The first topic is a great one because I don’t think that it can stand alone. As a matter of fact, I think treating it as stand alone has a negative impact on its success. Can’t wait to hear your thoughts.

  6. I think that camouflage had some interesting points.

    In regards to marketing what’s interesting is that I interact with many epic customers in my degree program and they all talk about how unique epic’s implementation is without ever having experienced a different methodology. Having seen both Epic and Eclipsys(before allscripts) I realized that they are all using the same methodologys (Why else does every hospital want PMP certification?) the only significant difference is the software (Smaller differences every day) and the employees.

    I was recently chastised by a CMIO for making the statement that hospitals are different from vendors. He said that they are all in it for the bottom line and that hospitals are not patient focused any longer except in terms of that being their target business market. If a CMIO can say that about our current hospital environment (Which admittedly is trying to survive and thrive on very thin margins) what does that say about the rest of the healthcare system EHRs included.

  7. Cam O’Flage does make some accurate points, except for the marketing piece I agree with NotQuite. As for not revealing his/her name and position, you must be careful not to get on the Epic “bad” or “banned” list. Comments made by Cam O’Flage could easily get you on “the list”.

  8. Epic does plenty of marketing. They works HARD to ensure that they’re viewed as different, better…more “pure of heart” than their competitors. They also work HARD to control the message – threats, draconian non-competes, naive employees, “good” and “bad” lists, etc.

    The fact that Epic is able to maintain the facade that they’re truly exceptional reflects the sorry state of technology, acquisition and implementation of the EHR industry more than their greatness..

  9. Why would a vendor do their own press releases when another market research firm, everybody knows who it is, is steadily doing it for them? How does the saying go “Crazy like a fox”?

  10. EPIC makes a decent product that is inflexible, and they refuse to be interoperable, or play with others………that will be the their downfall….they started off well intended, and then greed and avarice put the best interests of the patient to the wayside……yet, Institutional Boards, Dean’s, Sr. Administrators, aren’t knowledgable in the healthcare IT world, they look around and say “let’s do what everyone else seems to be doing”, and they ignore the warning sings…..A hospital in Tuscon that has to lay off 10-15% of their stafff because fo the costs of the EPIC install; the $6billion and 8 years it took Kaiser to implement EPIC, the countless numbers of CIO’s that have been released into the general community because the EPIC install went more than $20-60million over budget and 6months to a year past their milestones……..the 100 consultants that had to be hired when a Florida Hosptial wanted to go live with EPIC…….(If you’re paying $100 – $160 million, shouldn’t the vendor be knowledgable enough to install and implement the product in everyday healthcare workflows)? Yet, EPIC keeps “winning” Charlie Sheen style……perhaps Judy has Tiger Blood in her Kool-Aide………Ultimately, however, the other vendors need to find a way to beat her back, and they haven’t done so…..so, to the Cerner’s, GE’s, AthenaHealth’s, Mckesson’s of the world, I say to you……it’s time to get in the game, act like the Big Boys you are (GE) or aspire to be (AthenaHealth) …..there is always an angle, you’d better find it, or you will become irrelevant, and there’s not much time left

  11. Having done two very successful soup-to-nuts Epic implementations as a provider, and as a current non-Epic customer, I am pretty sure I have as much credence as any one when I say that Cam’s observations regarding Epic are misguided. Though not without their failings, they are far and away the best vendor and best product I have ever worked with. I also spent 18 years in the consulting/vendor space doing implementations for all the major vendors out there and that experience confirms this observation as well.

    The anonymous observations that have been made want to put the blame on Epic for any bad implementation outcomes, but the fact of the matter is that failed or flawed implementations are usually due to poor project management, lack of leadership, and a lack of organizational political acumen.

    If you want to respond to me, at least have the courage to identify yourself. You can contact me directly at:

    David L. Miller, MHSA, FHIMSS, CHCIO
    Vice Chancellor and Chief Information Officer
    University of Arkansas for Medical Sciences
    4301 W. Markham St., # 633-1
    Little Rock, AR 72205-7199

  12. I think the Epic model hospital has made the installs too easy. The hospital analysts don’t get experience building, so they are shy about optimizing. When you built all the Master Files and Category Lists yourself , then you know how to build and optimize. Model has made the analysts lazy. It was intended to be a model, not the build forever.

  13. As the vendor of a web based software that helps clinicians manage chronic conditions, all I have to say is that Epic may be great at some things, but they are not great or even adequate at listening to the needs of clinicians. Their implementations and unwillingness to ‘play with others’ has repeatedly forced clinicians using my software ( and the software of other vendors in my space) to stop using our software- which is more efficient in its workflow and more effective at helping the clinicians create safe, effective and measurable programs- and use their clunky, inadequate and ultimately time consuming module made up on the fly (and that certainly was paid for by the client). So, if an ‘improved patient experience’ means waiting longer on an inefficient clinician workflow, not getting their educational and instructional needs met, and putting their care givers in the position of not being able to track their or measure their patients results, then yes, Epic delivers. Sour grapes- you know, a little, but mainly incredulity and disappointment in the Hospital administrators who ignore their own clinicians, and disappointment in Epic’s arrogance in ignoring them as well.

  14. Go Razorbacks! Riddle me this, Big Dave……..how much have you talked Ol’ Arkansas into spending on The Big Red Machine, AKA, EPIC? I imagine it’s a pretty penny…..so you’d better say what you’re saying, or you may have just asked your board to write a check your A$$ can’t cover…….EPIC’s sad/bad implementations are due to an unimaginative non-intuitive software, and yes, sometimes combined with poor management………yet, once again for $160million, you should get better advice than from some kid not old enough to drink, and who is probably still on his/her parrents’ health insurance plan…….don’t you think?

  15. A – clearly spoken by one who can’t even spell Epic, much less have any experience in the space, which is why you continue to hide behind anonymity. You do a nice job of repeating what you have only heard, though. Your numbers clearly show that, as does your thought that any CIO worth his salt would rely upon the vendor for advice that needs to come from within his own organization.

    Last reply I’ll make to anyone who’s too inept to identify themselves.

  16. You’re right that’s why so many CIO’s runaround saying the word Model these days……..they’d never let a vendor tell them what to do………Why don’t all of you simply reply like the kool-aid guy from the commericals in the 1970’s:Ohhhhhhhhhhhhhhhhhhhhhhh Yeahhhhhhhhhhhhh

  17. The Buddha twice uses the simile of blind men led astray. In the Canki Sutta he describes a row of blind men holding on to each other as an example of those who follow an old text that has passed down from generation to generation, much like the Christian Gospel (Matthew 15.14) saying about the blind leading the blind.[2]

    In the Udana (68–69)[3] he uses the elephant parable to describe sectarian quarrels. A king has the blind men of the capital brought to the palace, where an elephant is brought in and they are asked to describe it.

    “When the blind men had each felt a part of the elephant, the king went to each of them and said to each: ‘Well, blind man, have you seen the elephant? Tell me, what sort of thing is an elephant?”

    The men assert the elephant is either like a pot (the blind man who felt the elephants’ head), a winnowing basket (ear), a plowshare (tusk), a plow (trunk), a granary (body), a pillar (foot), a mortar (back), a pestle (tail) or a brush (tip of the tail).

    The men cannot agree with one another and come to blows over the question of what it is like and their dispute delights the king. The Buddha ends the story by comparing the blind men to preachers and scholars who are blind and ignorant and hold to their own views: “Just so are these preachers and scholars holding various views blind and unseeing…. In their ignorance they are by nature quarrelsome, wrangling, and disputatious, each maintaining reality is thus and thus.” The Buddha then speaks the following verse:

    O how they cling and wrangle, some who claim
    For preacher and monk the honored name!
    For, quarreling, each to his view they cling.
    Such folk see only one side of a thing.[4]

  18. A-32…Now your quoting Buddha? You need to get back on your Lithium…better yet…Grape Kool-Aid…you would be surprised how much better you feel and the world looks after just one sip.

  19. Anon32 – man, you need a hobby or something. Self reflection through parables is nice, but the overall rants are tiresome.

  20. Certifiable has a point. My question though is will model systems force hospitals to standardize methods of care?

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