Time Capsule: WWJD: What Would (Steve) Jobs Do If He Worked in Healthcare IT Instead of Apple?

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

I wrote this piece in June 2009.

WWJD: What Would (Steve) Jobs Do If He Worked in Healthcare IT Instead of Apple?
By Mr. HIStalk

I’m having an identity crisis. After working exclusively with Windows PCs for decades, I bought a Mac for a family member.

The MacBook is easy to use, sleek, and full of eye candy. Its lit-up Apple logo exudes barely contained and self-aware hipness. I’m not fully convinced that it’s not just “different” instead of “way better” than the usual PC clones running Windoze, but I admire Apple for using its advantage as a proprietary hardware/software vendor to package cool design, thoughtful engineering, and a boffo user experience into a machine that ends up doing pretty much the same stuff you can do on a PC, only making you feel smug while doing it.

All the Mac people I’ve known were artsy types. I figured them to be right-brainers who were too preoccupied with social protests and making vegan brownies to handle manly computer tasks like using Regedit or spending a pleasant afternoon reinstalling WinXP after running out of options to fix one corruption or another. And, Steve Jobs in his jeans and turtleneck was one beret short of being a full-on artiste, while Microsoft gave us the hyper-annoying loudmouth Steve Ballmer as the cartoonish, kill-our-enemies capitalist pig who was ideally cast for the political climate of that time.

I’m convinced there’s a fortune to be made for someone to create the healthcare IT equivalent of Apple.

The industry is a lot more like Windows than Mac. Systems were clearly designed with user experience and brilliant design way down on the list, which is pathetic given that busy doctors and nurses are supposed to use them happily and constantly while not killing patients. Instead of Apple-like control over the entire ecosystem, customers just buy whatever systems they want, throw them in the same data center, and then fuss when the end result isn’t exactly seamless.

Systems break a lot, they disappoint their owners, and they are a long way from being cool. Fanatic loyalty to a product or company is unheard of, not too surprising considering that vendors titrate their effort (and quarterly expense) to a customer satisfaction level that’s only very slightly above the “let’s kick these guys out and start over” level.

Epic is kind of Apple-like. They have a quirky CEO who has an unwavering agenda, a funky campus, products that carry a premium price and never get de-installed, and tight control over their ecosystem. They hire easily influenced kids instead of other vendor’s retreads. Their customer list is relatively small but cult-like, jostling for space at the annual Verona gathering like Apple-heads annually migrating to California.

Epic does shun one of Apple’s core competencies, however: slick marketing that intentionally creates a world-against-us mystique. People still talk today about that shocking and downright arrogant 1984 Super Bowl commercial that declared war between an Macintosh-empowered creative class and oppressive Big Brother mainframers portrayed as storm troopers (which was really more of a minor skirmish since Apple wasn’t exactly a force to be reckoned with back then).

On the physician EMR side, you’ve got companies that have some Apple characteristics as brash giant-killers: eClinicalWorks, athenahealth, e-MDs, and a few others. Big companies have bought some of the potential Apples, although it’s hard to simultaneously bring them into the corporate fold while not screwing up what made them interesting in the first place. (What would you get if GE bought Apple? GE.)

So here’s my business advice (understandably highly valued and sought after since I’m a wage slave in a non-profit hospital who knows nothing about business): now’s the time to start up a physician systems company using Apple as the model. The market is fragmented, some of the major players and their technologies are stuck in the 1980s, Uncle Sam is throwing money around like only someone with a currency printing press can, and the number of doctors doing “none of the above” on an electronic system is 80 percent. Getting even 5 percent of that market would be a fantastic business.

And here’s my highly secret strategy that nobody would think of: hire a few people from Apple to show you how to do it. The reason HIT products and companies look alike is because the same people were involved, floating from one job to another and bringing their same preconceived notions along for the ride.

You’ll know when you’ve succeeded: users will clamor to have your lit-up logo on their laptops to show everyone how cool they are.

Time Capsule: Think Today’s Healthcare System is Bad? Imagine if Doctors Followed Only Their Own Best Interests

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 May 2009.

Think Today’s Healthcare System is Bad? Imagine if Doctors Followed Only Their Own Best Interests
By Mr. HIStalk

Everybody gripes about the US healthcare system’s high cost and low value. Rightly so, but it could be a lot worse. Here’s a thought I had today:

Imagine how bad it would be if doctors weren’t willing to follow the Hippocratic Oath.

I see doctors as falling into two camps. Some went to state medical schools at taxpayer expense. I figure those docs owe the rest of us, kind of like military academy students who have to repay their debt by serving in uniform once they graduate.

However, bunches of new MDs and DOs went to private med schools. They don’t owe us a thing.

Imagine the strain that doctors could place on the healthcare system if they took the course of action that benefits them the most, no different than a lawyer or accountant would do. They might refuse to:

• Treat patients who can’t pay cash upfront.
• Work for free serving on hospital committees or taking ED call.
• Work nights and weekends.
• Use someone else’s information systems, like CPOE.
• Use EMRs and interoperability technologies just because someone else wishes they would.

Doctors should be able to do whatever they damn well please and not feel guilty about it. If a doctor doesn’t want to take Medicare because it’s a money-losing pain, then blame Medicare, not doctor. If they shun using an EMR because it cuts their productivity, blame the vendor. If a hospital can’t survive without free doctor labor, then maybe it should fail or maybe the system is flawed.

If I were a cynical doctor watching my income drop, I would ditch the niceties and do whatever benefits me the most. I wouldn’t hurt patients, but I would focus on the activities that provided the most income or satisfaction, no different than most other professionals. Why not take advantage of the system that everyone plays in?

I’d start a boutique practice, cherry-pick the cash patients, and tell the insurance companies to stick it. I’d work 9 to 5 and tell patients to call the ED if they have an off-hours problem. I would get some humorless MBA to figure out how to run my practice like a factory, identifying those particular widgets that are the most profitable, then crank those out efficiently and soullessly. In any other field, this would be considered admirable and efficient.

Most importantly to this discussion, I would look at technology the same way a big company looks like plant equipment: it better pay for itself fast. Why else would I want it?

That sounds crass and cold, doesn’t it? So what? Doctors shouldn’t be expected to make sacrifices that other professionals don’t. Rightly or wrongly, we don’t have a charity-based healthcare system – it’s a business. Companies in business choose their means of production carefully. That’s why there’s a free market (or at least was until EMRs were mandated).

Doctors are soon going to be punished for using the technologies that provide them benefit if they’re not the ones Uncle Sam says are best. Next thing you know, professors will be fired for using overhead projectors instead of PowerPoint, accountants will be fined for doing calculations by hand, and lawyers will have to select only government-certified suits.

Thank goodness doctors haven’t wised up to the fact that they hold astonishing power over whether the healthcare system fails or keeps limping dysfunctionally along. Better hope the labor unions don’t whisper in their ear.

Time Capsule: Time Won’t Let Me: Everybody Hates Filling Out Timesheets, But It Beats Being Laid Off

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 May 2009.

Time Won’t Let Me: Everybody Hates Filling Out Timesheets, But It Beats Being Laid Off
By Mr. HIStalk

One of the least-popular yet most useful things I’ve done in IT management was to implement an electronic timesheet system. I thought it would add a defensible layer of transparency and accountability to our otherwise black hole of IT projects and maintenance activities (it did), but I didn’t expect the staff to resist (they did).

It was for their benefit, after all. Executives were complaining about IT costs because they had no idea what we were working on (coddling those same PC-illiterate honchos armed with the highest-powered laptops and cool PDAs that never got used except to mess them up was a lot of what we did). They couldn’t figure out why we kept needing more people (forgetting all the cool new applications they went out and bought without allocating operating funds to keep them running). They figured we must be screwing around since we rarely emerged from our IT hole to encroach on the rarefied air of their windowed, couched, and conference tabled offices (because we were trying to keep outdated servers and applications running on a shoestring instead of chatting on our couches).

I pictured the day when, under snotty cost pressure from the bean counters, I would triumphantly wave a slickly printed labor allocation pie chart and proclaim, “Sure, we can cut IT costs. Which of your financial applications would you like to shut down?” (it actually did kind of work out that way).
Employees still resented the “getting into my business” aspect of accounting for their time. They made it clear with eye-rolling and begrudged compliance that the whole timesheet thing was invading their personal, company-paid space.

I’ve done this twice. The arguments are always the same:

• I’m too busy to track everything I do (suck-ups)
• I multi-task, so it’s impossible to record time accurately (excuse-makers)
• I don’t want to have to drop everything just to record a two-minute phone call (whiners)
• I would need at least 200 time codes to fully represent my broad contributions to the enterprise (opportunistic night shift computer operators)

Here’s a given. At the meeting where the timesheet idea is first floated (carefully masked under the working title “effort tracking,” which fools no one) and employee resistance first rears its ugly head, someone who considers themselves a master of cynical wit will invariably say, “How do I record the time it takes to record my time?” Ha ha, that never ceases to amuse even after hearing it 100 times.

Everybody hates recording their time. Software is often old and clunky (I see somebody has modified Twitter into a timekeeping system – you Tweet when you change activities and it records the elapsed time. That must really tear at the soul of Twittering geeks who still hate having their time tracked).

But the thing is, it works beautifully. Even given the inevitable fudging and one-upmanship involved (did you really work 112 hours this week?), it’s amazing to find out where employees really spend their time. You find out how long it takes to upgrade the payroll system, develop a new CPOE order set, and apply the latest server patches. You can then plan for next time.

The faint Big Brother overtones help, too. Folks who don’t mind goofing off but are too honest to lie on a timesheet might work a little harder rather than perjuring themselves.

And at least it’s not the Soviet-inspired problem tracking system, which forces employees to stop co-workers mid-sentence to announce, “I can’t talk to you until you open a ticket.”

Time Capsule: Despite What Vendors Say, Offering a Payment Plan Doesn’t Make Their Product SaaS or You Their Partner

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

I wrote this piece in April 2009.

Despite What Vendors Say, Offering a Payment Plan Doesn’t Make Their Product SaaS or You Their Partner
By Mr. HIStalk

There was a time, before software vendors and consultants, when the word “partner” was pretty clearly defined. Partners signed a contract to be in business together, sharing profits and losses. They worked side by side, using their respective strengths to meet agreed-on goals. Their interests were aligned.

(Partnerships as business entities are usually a bad idea, even though they sound civil and synergistic. You don’t get any tax breaks, nearly all partners end up fighting much of the time, the actions of one partner legally bind the other, and ownership is illiquid. Just so you know.)

Vendors and consultants always want to “partner” with you, at least by their definition of the word (“sell you stuff under the pretext of being a trusted associate looking out for your best interests instead of our own, which is clearly a bald-faced lie.) The word itself is uttered with such phony conviction and heartfelt emotion that you just might believe it anyway, just like when a frat boy whispers “I love you” into the ear of a drunken sorority queen hoping equally fervently to consummate a transaction that is beneficial to at least one of the parties involved.

As a thought leader and futurist (I’ve decided to call myself those vague terms and you should anoint yourself with them, too – the people I’ve seen using them without embarrassment don’t seem all that insightful), I’ve observed permutations of the already-bastardized “partner” moniker. Here are the flavors I just saw at HIMSS, for example.

• When talking to the IT geeks, vendors trot out the “Software as a Service” buzzword, even though they’re often selling the same old products that are priced the same old way. Despite the buzzword, I saw no evidence that most of those Johnny-come-lately vendors are offering the theoretical advantages of SaaS: lower prices, an open market for plug-in functional components, or a scalable and highly reliable/recoverable hosting model requiring nothing more than a browser-equipped PC. (If SaaS sounds familiar, that’s because you’ve heard it before under the then-cool buzzwords of Application Service Providers, hosted services, or if there’s a little snow on your chimney, time-sharing systems. It was and often still is a pretty good deal from some of those non-Johnny-come-lately companies).
• Some vendors, wanting to ride the buzzword gravy train but hamstrung by old technology and inadequate hosting infrastructure, turned SaaS into a financial concept. Subscription pricing is a way to sell the same application to the same user, only in a no-money-down pay scheme. You sign a contract and pay either a fixed amount or a fee that varies by usage. Most vendors, sweating nightly over revenue recognition, don’t give customers one of the key benefits, though: the option to cancel at any time. You might be paying monthly rent, but the lease is ironclad. (The best thing about subscription pricing is that what you pay is based on your level of usage. The worst thing about subscription pricing is that what you pay is based on your level of usage. You get in the door cheaper, but if you’re your project beats the odds and enjoys significant use, you’ll probably pay more than if you’d just bought it upfront. So, you’re betting against yourself.)
• The third (and for the customer, the best by far, which also makes it the least common) option is the “We Make Money When You Make Money” model. This is where the vendor puts their money where their mouth is, actually going at risk with you instead of just cooing sweet words into your ear, drop-shipping their wares, and then starting the hunt for the next sorority girl. Now you’re partners – you either sink or swim together. Interests are aligned. Most vendors wouldn’t dare offer that deal to hospitals. Hospitals aren’t very good at implementing products, mandating their use, and getting serious about reaping their ROI. No wonder vendors want to take their money and run.

So, let’s just drop this laughable pretense that hospitals and vendors are partners. Partnerships don’t involve one partner writing a check to the other. You might have a partner on the golf course, on the dance floor, or in bed, but when it comes to healthcare IT, there are only sellers and buyers.

Time Capsule: Here’s President Obama’s Mandatory EMR Feature List: Firing GM’s CEO Makes it Clear That Federal Money Has Strings Attached

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

I wrote this piece in April 2009.

Here’s President Obama’s Mandatory EMR Feature List: Firing GM’s CEO Makes it Clear That Federal Money Has Strings Attached
By Mr. HIStalk

Was anyone but me surprised when President Obama decided it was time for GM’s CEO to quit and that Chrysler had no choice but to merge with Fiat? Man, I guess you really give up day-to-day control when a big lender (like Uncle Sam or the mafia) puts up the cash to keep you in business. Even Nixon wasn’t so bold as to say that what’s good for the country damned better be good for GM or else.

Say, wait a minute … healthcare is getting a lot of government money. Surely the feds wouldn’t start telling us how to run our shop, right?

I wouldn’t count on it. We might be selling our souls here.

This particular government, faced with a dismal economy and an ambition to make major changes in American society, doesn’t seem to be shy about crossing that previously sacred line between government and private industry. It’s surprising that a Democratic government would be as hard-nosed as private equity firms in putting their people in key positions of responsibility, demanding equity in return for financial support, and mandating changes in product development and sales despite the market’s sometimes differing interest (car makers made a ton of profit on gas-guzzling SUVs that consumers apparently wanted, at least until gas got temporarily expensive and financing became unavailable).

Everybody’s clinking their glasses and high-fiving over the gravy train headed healthcare IT’s way. Fear the person from the government who’s here to help: there may be a hidden price.

It’s clear that CCHIT (or something like it) will enjoy unprecedented power to set mandatory product requirements. “Effective use” will do the same for providers, spelling out exactly how they must use their technology. As Uncle Sam becomes an even more dominant buyer of healthcare services, the ratchet may be turned on reducing costs and following somebody’s medical cookbook. Viewer discretion is not advised.

It was flattering when Obama and company got interested in our little world of healthcare IT. Now it’s scary.

There’s not much question that government is now driving the HIT industry. The question is: to what? Will it be just like today, only bigger? Or is the real agenda to use government clout to finally whip private industry around a little, making businesses behave in some unspecified way that runs contrary to the free market?

I’m as shell-shocked about the economy as everybody else, so I get tired of reading headlines of mind-boggling historical significance that still sound like just more bad news. Somehow, Obama’s giving GM and Chrysler marching orders got my attention, even after watching the financial industry basically disappear overnight. The CEO of every company right now, right or wrong, is the former junior senator from Illinois who has never held a real job (I don’t count being a professor or lawyer) or run a business.

All I will say is this: be careful out there. It’s becoming clearer that government gifts, like private equity investments, come with strings attached. I’m really confused at this point whether I should feel proud or disgusted.

Time Capsule: Please Excuse My Rear In Your Face, But I Have To Leave This Presentation: How HIMSS Presenters Can Suck Less

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

I wrote this piece in March 2009.

Please Excuse My Rear In Your Face, But I Have To Leave This Presentation: How HIMSS Presenters Can Suck Less
By Mr. HIStalk

Here’s my theory: HIMSS knows that most of its annual conference presenters aren’t nearly as interesting as the jaunty and trumped-up descriptions in the program, so they intentionally arrange the chairs in long rows so audience members can’t bail out discreetly. Even the doors are guarded – by throngs of standing attendees not quite sure they’re ready to make a commitment by actually sitting down, but thereby blocking your access to the cool, energizing air of the hallway that smells like … freedom.

(It would be cool if conferences would legitimize buyer’s remorse by leaving the session doors open and encouraging people to drift in and out based on their real-time interest level. The immediate feedback to presenters — both good and bad — would be priceless).

It would be so much easier if speakers did a good job in the first place. Having spent a shocking percentage of my adult life sitting in the dark on bad seats in convention center rooms, I believe I can offer some valuable speaker suggestions.

• Everybody dresses up to deliver their presentation, so suits don’t really make much of a positive impression. Try wearing shorts, an Insane Clown Posse tee shirt, or a kilt. Somebody may mistake your attire as a sign of inherent coolness or quirky genius, at least until you start talking.
• Unless you’re the CEO who’s actually in charge of the whole hospital, don’t lead off with a boring slide full of proud-as-a-peacock statistics about your employer’s ED admissions and annual budget. Audience members immediately drift off trying to determine whether your place is bigger or smaller than theirs.
• Nobody traveled to Chicago in the dead of winter to watch you recite a memorized speech. Add a little excitement by going off-script, under-preparing, or actually interacting with the audience instead of droning to them. Most of the HIMSS presentations are about as spontaneous as a press release and are delivered with a similar lack of enthusiasm (I truly believe presentations would be better if someone was chosen at random from the audience to go onstage cold and just wing it).
• Do not use PowerPoint as a TelePrompter. It’s fairly safe to assume that most of the people going to HIMSS can read. Avoid the Shakey’s Pizza sing-a-long moment (Note: actually, adding the bouncing ball might be kind of fun if you aren’t otherwise entertaining).
• Never put up a slide that requires you to say, “I know you can’t read this.” If our reading it isn’t important enough for you to fix your slide, leave it out.
• Be daring: don’t use PowerPoint, or if you can’t speak without it, use only graphics. A picture is worth a thousand words, so put in the right ones and you won’t have to say anything.
• If there’s any possible way can make your point without a slide, please do. This will shock the audience, however, who have never seen a non-keynote speaker actually speak without using on-screen bullet lists (you could even leave the house lights up, cutting into the sleep of those who stayed out too late the night before). If this seems too radical, you can pretend the AV isn’t working (“darned laptop …”), forcing you to reluctantly go off-script.
• Just because PowerPoint conveniently provides a bulleting function for creativity-impaired speakers doesn’t mean everything should be bulletized. Given the choice between being subject to a dozen PowerPoint bullets vs. .22 caliber ones, I might have to think about it.
• We know you have lots of facts, but we don’t want or need to see them all. Pruning your presentation takes you longer, but your time is inconsequential compared to that of the roomful of people forced to endure flabby prattling. Everybody loves a speaker who finishes early.
• Get out from behind the podium and create some energy for the giant room full of people drowsy from their $12 union-produced Caesar salad. If you can’t hold the attention of 500 or more people, maybe you should be writing articles instead of giving speeches.
• Do not look at the screen, point at it, or wave a laser pointer at it. It’s ours, not yours.
• Use photos in your presentation to remind us about the real life that we are anxious to rejoin once you stop talking. Pictures of people are perfect since everybody looks at those, especially if you slip in ones of celebrities or hotties. Pictures of your kids or pets always buy you at least a few minutes of goodwill (you can sneak those in by making them your desktop background).
• Don’t fiddle with your water or slurp it into the microphone. Attendees resent your having a nice, icy pitcher and a glass all your own, so it will make them thirsty. Or, it will make them have to pee.
• No clipart, no stock photos. One obligatory Dilbert or Far Side cartoon at the beginning and end is acceptable.
• Don’t use time at the end for questions. 99 percent of people in the room just want to head for the bathroom, coffee line, or most importantly, the Middle Eastern bazaar known as the exhibit hall. People charging the question microphone just want to prattle on with non-questions, showing off their knowledge instead of their lack of it. Their punishment is near-trampling as they try to swim upstream to the microphone as everybody else heads the other way toward the doors.
• Don’t mistake the post-presentation charge of business card-waving people to mean you were an outstanding presenter. Some people are natural suck-ups.

Time Capsule: Healthcare Transparency 2.0: Using RHIOs to Rate, Criticize, and Publicly Rat Out Idiot Patients Wasting Everybody Else’s Healthcare Money

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

I wrote this piece in February 2009.

Healthcare Transparency 2.0: Using RHIOs to Rate, Criticize, and Publicly Rat Out Idiot Patients Wasting Everybody Else’s Healthcare Money
By Mr. HIStalk

I’ve always made fun of those “Get a Free Medical (wink, wink) Scooter” commercials that run during the fake judge TV shows that are watched religiously by homebound, unemployed, and intentionally deadbeat people while the rest of us are at work. I see them occasionally while getting my oil changed, waiting to have labs drawn, or getting a haircut. I feel like I’m peering into a sociology experiment gone horribly wrong.

The scooters don’t really look all that fun, but apparently “free” makes them a blast, at least to that latter category of people (since so many of us are joining the “unemployed” category involuntarily, I’ll focus on the intentional deadbeats). “When did you realize your mobility was impaired, Mr. Jones?” “Why, when I saw that sweet scooter model that looked like an ATV with a beer can holder and a ‘Free with Medicare’ sign on it, sir.”) I suspect it’s the same people who borrow someone else’s handicapped sticker to get the best parking place.

Apparently that “intentionally deadbeat” demographic is a rich vein to be mined by semi-scrupulous companies who know that “Jerry Springer” moves some medical iron while “Meet the Press” doesn’t. Now comes mesothelioma time, valiant ambulance chasers channeling Robin Hood by taking money away from anyone who has it and redistributing it (minus the 90 percent legal fees) to the daytime TV audience not quite up to the subtle nuances of General Hospital.

My solution is either simply brilliant or brilliantly simple (I can’t decide). Use RHIOs to turn healthcare professionals into a constantly communicating network of fraud- and sleaze-sniffers and pay them for turning people in (the government is terrible at detecting Medicare fraud, yet is puzzlingly world class at snooping on citizens). Everybody wants transparency, so let’s make it work both ways. Patients ought to have some skin in the game.

Anybody can rate doctors and hospitals anonymously, even to the point of adding vicious, unsubstantiated comments. If Mr. Smith rips Dr. Jones on a public doctor rating site, Dr. Jones should be able to, as on eBay, add a blistering response, such as, “This lard-butt patient smokes, ignores my advice, has sued three doctors so far, and has never paid a dime of what he owes me.”

RHIOs could be the interoperability platform for exchanging information about those crackpots who ruin the system. Doctors, nurses, pharmacists, and dentists could flag patients who stiff them on co-pays even though they drive Jags, who use someone else’s insurance card, or who are just plain nasty. Let the doctor check their credit report, criminal record, IQ, and work history while they’re at it. They’re the ones who will be facing them naked (the patient, not the doctor) in an exam room, so it shouldn’t be Mystery Date in there. Like the stockbrokers say, “Know your customer.”

Patients who have filed more than one malpractice suit would get tagged so other doctors can avoid them. It would be like the NFL: patients get one medical challenge with no hard feelings, but frequent malpractice flyers get marked as trouble, as do drug-seekers and scooter-wanters.

Forget evidence-based medicine. If you really want to save healthcare dollars, give doctors the tools to identify and avoid those who seek to use them dishonestly and irresponsibly. That fruit is abundant and low-hanging. Plus, it’s not like the RHIOs are really doing anything anyway.

Post the information publicly and let’s put some shame back into dishonesty, criminal behavior, and irresponsibility. It could even be made cost-neutral by charging the public to peek at the postings. I bet people who make “Cops” or “Dog the Bounty Hunter” could figure out how to monetize it.

Now if you’ll excuse me, I think I’m coming down with a touch of mesothelioma, so I’ve got a scooter to order while they’re still free.

Time Capsule: My Lifelong Clock-Puncher’s Entrepreneurial Brainstorm: How the HIStalk Home Shopping Channel Will Make Me Rich

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

I wrote this piece in February 2009.

My Lifelong Clock-Puncher’s Entrepreneurial Brainstorm: How the HIStalk Home Shopping Channel Will Make Me Rich
By Mr. HIStalk

I’m a veritable font of business ideas. That might surprise you since I’ve worked my entire career as someone else’s employee (I’m pretty sure my puzzling lack of distinction there is because they haven’t properly motivated me.) Still, one of these days, I’m going to start a company and reap a massive windfall from my pent-up entrepreneurial ability. I may be on Social Security by then, but I know it will happen and I’ll be a great yet humble CEO.

So here’s my latest and greatest idea (you are hereby non-disclosed): the HIStalk Home Shopping Channel.

I’m turning a liability into an asset. Everyone knows that conference speakers and site visit hosts nearly always have a hidden agenda — to say good things about their vendors and get something in return. Maybe they want extra-special support, or free registration to the user conference, or an eventual vendor job. Maybe they just want to convince themselves that they made a smart decision (even if they didn’t.) I’ll make that the foundation of my fledgling enterprise.

I’ll start out with a genial, eternally curious host. They’ll need to be disturbingly cheery and clueless, the on-screen empty vessel who can bond with the equally clueless audience, shrieking with unrestrained delight like the QVC crowd when Wolfgang Puck performs expert chef tasks like frying onions or whisking eggs. I’m sure some vendor marketing person can handle the role admirably, beaming with obvious delight as the celebrity physician effortlessly works the EMR system that’s on sale while dropping the occasional bon mot.

The EMR they demo won’t be the same as the one they actually use in real life, of course. Surely no one believes that Wolfgang’s restaurants use his 28-piece, $249.90 Bistro Elite Stainless Cookware Set, which would withstand about five minutes of heat from a real restaurant stove before melting into a sad, molten, Puck-endorsed puddle.

We’ll have theme shows for clinical disciplines. Blowout sales of slow-moving systems. Huge discounts on previous software versions. Maybe we’ll even cash your federal stimulus check like those sleazy "buy here, pay here" car lots.

Here’s where you come in. What moves the goods on shopping channels is ringing, hysterical endorsements of the product by telephone callers who have been carefully screened and coached to keep it positive. They’ll say anything that gets them on TV with Wolfgang since most of them sound like they watch TV all day. Plus, who wants to admit that the Bistro Elite set looks much better when Wolfgang is sautéing shallots in it instead of burning store brand tomato soup in it after getting too engrossed in Oprah to whisk?

So we’ve got a clueless host, a product-pimping celebrity, and some questionably knowledgeable and objective endorsers. All we need is some flattering camera angles, some "order now because they’re flying out of here" on-screen graphics, and offshore order-takers.

HIStalk Home Shopping would generate entirely new buyer motivations. Mobility through consumption! Picture yourself improving care with cool PowerPoint-ware! Call our Demo-Doc any time as long as you say great things – he will be your pal and you will have all kinds of fun and hijinks together!

I don’t know, maybe it isn’t such a great idea. It sounds too much like the HIMSS annual conference

OK, how about this: paid product placements in popular TV shows. Say, isn’t that a Cerner CPOE system Dr. McDreamy is using? You know you want one!

Time Capsule: The Obama-HIStalk Digital Stimulus Grants: Why Letting Me Hand Out the Freshly Printed HIT Cash Makes Sense

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

I wrote this piece in January 2009.

The Obama-HIStalk Digital Stimulus Grants: Why Letting Me Hand Out the Freshly Printed HIT Cash Makes Sense
By Mr. HIStalk

This government stimulus thing is new to everyone. It’s no wonder all of us (Uncle Sam included) are bumbling around cluelessly, flitting from one hare-brained idea to another on how we’ll improve healthcare by throwing new money at old products used by uncommitted providers who have had minimal impact so far.

Hospitals and vendors are used to being poor, so the pressure is excruciating. Without the excuse of perpetual poverty, people are going to want results. Duh!

(It’s ironic. We got into this mess by living beyond our means. Now Uncle Sam is going to do the same to buy our way out of the recession. If it fails, we’ll be like Zimbabwe printing $100 trillion notes that won’t buy a loaf of bread.)

Nobody can quite figure out what to stimulate with the hundreds of billions. What people are missing is this: it doesn’t matter. The goal is to just blast a lot of freshly printed cash out there. It only has to exchange hands enough times to create the illusion of restored prosperity. Nothing really has to be fixed in return. You might as well kick $100,000 cash bundles out of airplanes. Just get the money into circulation and hope for the best.

(See: Wall Street bailouts. And note: while I enjoyed MBA macroeconomics, I really never understood the whole money supply thing, so I could be slightly off base).

That’s why I humbly nominate myself to personally manage the process for healthcare IT’s $20 billion lottery winnings.

Everybody agrees that the deficit-enhancing stimulus needs to be a shock-and-awe carpet bomb of currency to put out the recessionary fires, kind of like John Wayne in “The Hellfighters” bombing burning oil wells to snuff out the flames. Here’s how I’ll get all that money into circulation and working by April.

I’m going to take all $20 billion to the HIMSS conference (note to self: I’ll need a suite rather than a room, hopefully one with a large in-room safe). When the show opens in the inevitable Chicago snowstorm, I’m going to quietly observe the action and decide in a unilateral but entirely trustworthy manner who I’m going to hand it out to, kind of like Oprah giving away cars or that ‘50s TV show “The Millionaire.” There’s no committee and no paperwork – you just have to impress me while I’m undercover, and I tend to like non-conformists.

Unlike Uncle Sam, I don’t care about your previous track record. Given the state of healthcare IT, the folks with a long industry history aren’t the ones you would want leading a revolution. It’s time to identify some new blood.

I’ll start with the Venture Fair, giving some CEO-wannabe armed with his idea for an EMR written in Excel $50 million. Then on to the opening reception, where anyone willing to publicly say that interoperability is a cruel hoax will find wads of cash in their pockets afterward. CIOs of hospitals under 200 beds doing CPOE get $10 million, no questions asked.

Got a cool booth design that catches my eye? Here’s $25 million – thanks for the chuckle. A session presenter who actually has something interesting to say without any obvious bias? Take this $50 million, my friend, and do good deeds. A bored hooker forced by economically challenged Johns to moonlight as a booth babe? This million will get you through an informatics training program. A replacement for the cheesy HIMSS opening theme, “Now Is Our Time?” AC/DC live right there in the hall, doing “ Information Highway to Hell.”

I’m going to seek out the industry’s downtrodden, the non-suit wearing, non-badge ribboned rank and file who have been rowing hard in the galleys while the millionaire captains were steering the ship aground. As long as you’re passionate, poor, and fun, you get one of the thousands of Obama-HIStalk Digital Stimulus grants (extra points if you’ve been laid off or forced to move to Kansas City).

You might scoff at the frivolous nature of my self-nomination, but I will get the job done better than any HIMSS committee or federal agency. The money will trickle down like nobody’s business. I will make sure only interesting people and not soul-sucking corporations get it and I won’t siphon off 20 percent as my administrative costs. It might work and it might not, but that’s no different than any of the fancy-pants suggestions that are on the table. Everybody’s making it up as they go.

All I ask in return is adoration and maybe an Obama fist-bump. And, the thanks of a grateful nation.

Time Capsule: Software Usability: A Great Idea Whose Time (At Least in Healthcare) Will Never Come

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

I wrote this piece in April 2009.

Software Usability: A Great Idea Whose Time (At Least in Healthcare) Will Never Come
By Mr. HIStalk

It seems that everyone (other than software vendors) is talking about software usability these days. A long-delayed light bulb finally went off somewhere that suggested, “Say, these systems we have are cryptic, ill-suited to match real-life work flows, and maybe should have had some human factors review before they were shipped prematurely as usual.”

Usability is a hot topic mostly for ambulatory EMRs. It’s a logical (or, some would say, convenient) reason that doctors don’t use them. The problem vendors have is that those private doctors actually have a choice, unlike their hospital counterparts who have IT people making EMR decisions without their input (except maybe the rubber stamp approval of the gadget-happy, CIO-reporting, doc-turned-CMIO who hasn’t practiced in years.)

Hospitals are willing EMR buyers (although inconsistent EMR users.) Vendors in that market sell to the C-level who are wowed by a “cue the music, the future is now” video, a visit or two from top vendor suits, and maybe a promise of extra-special hospital representation on vendor committees or to provide allegedly welcome input on how to make the marginally useful product marginally better (meaning: sign here and we’re out of this hick burg for good.)

That’s the dilemma of PM/EMR vendors. Doctors who are mostly an annoyance in hospital sales (critical, interrupting know-it-alls who check their watches constantly) are the people who actually make the “buy” decision in practices. They have to actually use the product, so they are as critical as anybody would be when it comes to the tools of their trade. Poor design can’t be glossed over. There’s no big-picture visionary willing to ignore product realities and make a decision based on a futuristic video.

Hospitals are so intent to buy that they’ll just pick the best of the worst and live with it. Doctors in practice will hold their ground and buy nothing (which they have, in droves.)

Government payola will probably get a bunch of those unwanted systems sold, but not necessarily used beyond the “minimum necessary” to get a check. The government subsidy will be long spent, but the product will live on and be cursed frequently. Users will get used to the irrational design like they do in hospitals, although their productivity may never recover to the level it was using paper.

The problem with usability is that you can’t just bolt it on after the fact. It’s part of design, not last-minute touchup. The ARRA gold rush will be a faint memory by the time a system launched today would ever reach the market.

None of that matters anyway. When’s the last time you saw a new, built-from-scratch clinical or practice EMR system? You don’t take a 1985 MUMPS-based system and suddenly embrace modern usability concepts. It’s not an iPhone that will not only steal market share but create its own market. Healthcare software has a limited market, limited competition, and product lifecycles that span generations.

Here’s what will happen with software usability discussions. People will gripe about how bad current products are. Vendors will do a little bit of pig-lipsticking so that products at least look more usable in demos, even when they aren’t. Private doctors will, like their hospital counterparts, be enticed or forced by higher authorities to use the admittedly non-usability centered products and they will learn to work around their quirks.

Usability, for all the passionate discourse, is a lost cause that will have minimal impact on the stodgy healthcare IT market.

Time Capsule: Buying Doctors Systems They Don’t Want: Why Even Detroit’s Bailout is More Progressive than the HIMSS EMR Welfare Program

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

I wrote this piece in January 2009.

Buying Doctors Systems They Don’t Want: Why Even Detroit’s Bailout is More Progressive than the HIMSS EMR Welfare Program
By Mr. HIStalk 

I must be getting old. I can actually remember when the most-feared words you could hear were, "I’m from the federal government and I’m here to help."

That has recently changed to, "We’re such terrible businesspeople that we desperately need Uncle Sam as a business partner to survive."

HIMSS is right there in the bread line, begging for $25 billion of taxpayer dollars to help loosen up prospects that haven’t shown much interest in buying the EMRs that its vendor members sell. That’s not too surprising; as a trade association (its words), the #1 job of HIMSS is to help its big-paying vendor members make money, of which Uncle Sam’s is as good as anyone else’s (which isn’t saying much these days since the overheated currency printing presses will probably deflate the dollar’s value as quickly as they’re printed.)

That’s what "advocacy" is all about (don’t you DARE call it "special interest lobbying" because that doesn’t sound as noble, just like the annual conference is an "educational event" rather than drawing in captive provider prospects for the vendor members to woo.) Obama’s got lollipops for everybody, even justifiably failed dinosaurs like venture capital owned Chrysler, proud purveyor of bad cars that even rental car companies avoid. So, why not a nice, round $25 billion to move a few EMRs?

(Prospects don’t have the money for these desperately needed systems, HIMSS intones, yet it rails against free EMRs, whether open source or government created. So, HIMSS is apparently pro- EMR only when its vendor members profit.)

At least Detroit is keeping a straight face when it says it will make much-needed product and efficiency changes with our money. The HIMSS program doesn’t say that the EMR vendors who get the money will change anything at all. To them, the dust-gathering EMR products aren’t the problem, it’s those darned chintzy doctors who won’t buy them. And unlike Detroit, nobody’s offering taxpayers any equity or oversight in the companies that will rake in all the freshly printed money. It’s the EMR version of George Bush’s "everybody go shopping" stimulus package all over again, which did — well, nothing at all except run up the federal debt.

What’s also lacking is any kind of context in the recommendation. With all of healthcare’s problems, is $25 billion for the same old systems really the best investment? If healthcare needs dramatic reform (of which there are few doubters except those who profit from it today), then is this the right time to automate? Are EMR trailblazers having such great success and positive ROI that massive rollout is sure to be worth it?

That last item is the biggest bugaboo in the HIMSS EMR welfare program. Without provider skin in the game, there’s no assurance that we’ll see anywhere near $25 billion worth of patient benefit. "Having" is a long way from "using optimally," especially when one vital fact is brought back by cynics like me: these are systems that most doctors have already assessed as not being worth it. And, in Cynicism Round II: free isn’t cheap enough for systems that take more doctor time to use without giving them any benefit. How about a show of hands of all of you willing to stick around at work for a couple of extra hours each day to use a new computer system that doesn’t benefit you or your employer?

HIMSS has got politicians moistened up at the concept of interoperability as the big payoff for all of this acquisitive action. Sounds great, right? That’s what all those failing RHIOs said, too. "Interoperable" is a theoretical systems capability, quite a long way from overcoming the governance, privacy, and cost problems that stand in the way of actually interoperating. Instead of pushing "interoperable" systems, why not use the $25 billion jackpot to reward providers who actually exchange predefined data instead of just funding their technical capabilities and hoping it will somehow just happen?

That’s my pitch for Uncle Sam. Don’t use my money to fund stale tactics and failed market participants. Use it (if you must) to set the goals of what we really need (improved quality, outcomes, and efficiency), create rewards for meeting them, and let the market decide which tools are best suited for getting the job done. If your EMR can do that, it will fly off the shelf under its own power without requiring HIMSS to fling it at doctors like Cupid’s arrows.

Let’s hope the Detroit equivalent of HIMSS has less self-serving ideas than to simply hand out taxpayer dollars so people can buy Chrysler Sebrings.

Time Capsule: My Low-Tech Dentist Turns Out To Be a Closeted Techie: Why Nobody Cares What IT You Use, Only What Outcomes You Deliver

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

I wrote this piece in December 2008.

My Low-Tech Dentist Turns Out To Be a Closeted Techie: Why Nobody Cares What IT You Use, Only What Outcomes You Deliver
By Mr. HIStalk

My 2005 experience with an IT-savvy dentist was not good. My first (and last) visit to Dr. High-Tech took forever since he had to show me his PACS equipment, his electronic dental record, and his swing-arm TV monitor that would allow me to watch the Three Stooges while getting drilled and scraped.

Unfortunately, he was also a terrible dentist: slow, annoyingly educational, and prone to ill-concealed panic. Despite a flawless exam a year earlier, Dr. High-Tech somberly declared that my mouth was in imminent danger of total destruction, requiring a long list of heroic and expensive interventions that included $7,000 worth of work on one tooth alone.

I headed off for a second opinion, picking a dentist at random from the phone book (I’ll call him Dr. Low-Tech). His conclusion: I needed a filling and nothing more.

I’ve gone to Dr. Low-Tech for the three years since. His office has wood floors, real living room furniture, and no Judge Judy on the TV. He takes his time, talks my ear off, and sings loudly and off-key with the piped-in oldies station. He doesn’t need a dream team of ultra-specialist colleagues. He doesn’t hurt me, he’s never late, and he doesn’t overcharge.

Last visit, I saw something as shocking as Mommy kissing Santa Claus. I followed Dr. Low-Tech out from the treatment room and watched him pass through an unmarked door, getting a brief glance of a massive LCD monitor whiteboard showing every room’s occupant and status.

No wonder he can single-handedly juggle maybe 10-12 patients at a time, all in various stages of numbing, drilling, and swishing. He’s using online scheduling and resource management!

Suddenly everything became clear. I remembered that instead of getting appointment reminder calls, I’d been getting “click if you’re coming” e-mails. The hygienist always knew my history. The front office ladies could always give a perfect balance on my insurance.

Dr. Low-Tech was a closeted techie. He used IT, but didn’t want it to get in the way of taking care of his patients in a personal and caring way. That’s unlike Dr. High-Tech, who hoped patients would be impressed with his gadgets since that’s about all he had going for him.

Dr. Low-Tech has it right. Patients don’t need to know about IT any more than they needed to understand the old-school manila folder filing system. ‘Most Wired’ nonsense aside, nobody gets points for owning technology, whether it’s a doctor, a mechanic, or an accountant. Those professionals are free to use whatever tools they want, but they’ll be judged on outcomes, not on what they’re packing under the hood. Tools might make them a little bit better, but that’s about it.

Measuring the impact on the patient experience should be a part of every technology implementation review. Did patients notice? Was their impression of the overall experience (not the technology itself) better or worse? Did it enhance their experience, or did it get in the way and take away from the human interaction and caring that most people would agree is a vital part of a patient encounter? Did outcomes change?

Doctors always say “first, do no harm.” That’s as true of technology as anything else. Even bad golfers carry around the same expensive gear that Tiger Woods uses, hoping that owning it will make them better golfers. Unfortunately for them, scores don’t lie.

Time Capsule: Camping Out for a Cerner Black Friday Door-Buster Special: Mr. HIStalk’s Plan to Stimulate the HIT Economy By Encouraging Unrestrained Holiday Season Greed

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 2008.

Camping Out for a Cerner Black Friday Door-Buster Special: Mr. HIStalk’s Plan to Stimulate the HIT Economy By Encouraging Unrestrained Holiday Season Greed
By Mr. HIStalk

Capitalists and fans of pointless and unsatisfying consumerism, rejoice! Even in a tanking economy, America’s newest national holiday, Black Friday, brought out the greedy and sometimes violent masses last week, just like the good old (pre-recession) days.

I’m guessing that most of us in the industry weren’t standing in front of our local Wal-Mart on Thanksgiving evening, anxiously awaiting its 5:00 a.m. opening (picture a Soviet bread line made up of looters on a camping trip). No amount of civil irresponsibility is too much to score precious Caitlin a “Baby Alive Learns to Potty” doll.

Caitlin: “Mom, did Santa bring this?”

Role Model Mom: “No, Princess, I beat a woman in a wheelchair senseless and ripped it from her bleeding hands right in front of her kids at the checkouts to save $20 that day after we gave thanks for God’s bounteous riches. Now go away while I watch Desperate Housewives.”

All of that publicly displayed greed has stimulated my latest brainstorm: HIT Black Friday.

I’m picturing a Friday morning line of rental cars filled with hospital IT people sitting in Epic’s frosty driveway, hoping to score a 20 percent break on software license fees (if they’re one of the first five hospitals to sign a contract and if Judy likes them). Turkey-tryptophan groggy CIOs rushing Cerner’s HQ to score a pre-sunrise BOGO deal on Millennium applications. RSNA attendees taking indirect Chicago flights to first get rolled-back pricing on a clinical transformation door-buster special ($200 an hour a twenty-something consultant) from one of the big consulting firms.

Like those consultants, I’m projecting big benefits. Big PR all around. Low vendor costs. Desperate competition since nobody’s selling anything anyway. The chance to upsell (“Say, know what’d go great with that LIS? A matching CPOE application and an extended warranty at 20 percent annual maintenance. Want it wrapped?”)

Print publications would love the revenue from full-page ad inserts. Muckraking blogs like mine would leap at the chance to leak the Black Friday deals. The HIMSS opening session could feature videos of big-name CIOs out-sprinting each other in Friday’s pre-dawn hours at the HIMSS bookstore to get discounts on the latest Marion Ball bestseller or chic HIMSS hoodies for all the homeys in the HIT ‘hood. Nothing creates demand better than the illusion of widespread demand.

In fact, instead of having its virtual conference during the shopping season, HIMSS should stage a Midyear Conference in December that eliminates all the usual boring parts (educational sessions) and focuses entirely on a big-budget, sprawling spectacle of Vegas-like exhibits, self-important attendees jostling to fill their vendor trick-or-treat bags, and the Marrakesh Bazaar-like scent of aroused technology capitalists getting their HIT hunt on during the industry’s annual bacchanalia of commerce (OK, smartass, it is NOT the same as the annual conference – I said December).

Now don’t get all high-horsey on me. HIT is about moving iron. Closing the deal. Getting, not using. To paraphrase that Brillat-Savarin quote shown at the beginning of Iron Chef America, “Tell me what you buy, and I will tell you what you are.”

Like Black Friday, during all the hustle and bustle of enjoying family and reflecting on one’s good fortune and place in the universe, let’s take a moment to remember what’s really important: buying a lot of soon-to-be junk like an ancient Egyptian boy king loading up his tomb with Blu-Ray players and GPSs since an afterlife without them would just plain suck.

So set your alarm for next November 27 at 3:00 a.m. for the first HIT Black Friday. Like the leader of the free world said, it’s your patriotic duty to get out there and go shopping.

Time Capsule: If EMR Vendors Designed Cars, the Steering Wheel Could Be Anywhere: Why a Universal Physician Interface Makes Sense (and will never happen)

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 2008.

If EMR Vendors Designed Cars, the Steering Wheel Could Be Anywhere: Why a Universal Physician Interface Makes Sense (and will never happen)
By Mr. HIStalk

I used to work in a two-IDN town. In fact, I had worked in the IT department of both of them (not at the same time, unfortunately, since that would have been a sweet paycheck).

Both IDNs bought big-ticket inpatient clinical systems within a few months of each other. Those who have worked in a two-hospital town or remember the Cold War understand this instinctively.

As inevitable as it was that rumors of one of us buying a system sent the other scurrying to draft an RFI, it was preordained that we would not consider the same vendor. Whichever IDN bought last would look like an unimaginative lemming, so there was no doubt that two vendors would be shuttling people into town for years.

I was shocked that the local newspaper not only cared about our respective deals, they took both IDNs to task in a rather scathing editorial for going our separate ways. In their minds, we had blown a golden opportunity to finally agree on something other than the fact that one of us was a plainly second-tier system (which one was another thing we didn’t agree on).

From a community perspective, they were probably right. Both places served mostly community-based physicians who practiced in hospitals of both IDNs. Our ruggedly individualistic decisions meant that most of the doctors in town would not only have to learn to use an EMR to keep in our smothering good graces (since ROI was dependent on massive, yet unlikely voluntary physician usage). They would have to learn TWO systems with nothing much in common except they both had a screen and a keyboard.

(That allowed us both to argue that we had chosen a better system than our cross-town loser competitors. In addition, there were only three real vendors that would have been acceptable and one of those was a little shaky at the time, so we went out of our way to avoid consensus).

Vendors would never object to this, of course. Software that looks and works alike has a name: “commodity.” In that respect, vendors had as much interest as we IDNs did in bucking the trend set by our competitor or vice versa.

Here’s an interesting idea, though. Why couldn’t CPOE and EMR systems have the same common user interface? They provide and accept the same basic information. Are screens really so highly proprietary and ingenious that they can’t be the same on all systems? Couldn’t they put their high-margin secret sauce somewhere else, like in clinical decision support, scalability, cost, or maintenance quality?

(You could almost make this happen in the old character-based days by using screen-scraping applications to redesign the front end, like Attachmate or programmable fake Windows front ends).

Everybody always says, “You can use a browser without reading a manual first.” As annoying as that statement is, everybody is right. Browsers, cars, TVs, and credit cards all look and work pretty much alike to the user. That increases adoption, yet still allows plenty of criteria on which vendors can compete and differentiate.

Physician systems operate under the most bizarre paradigm of any software application. The organization that buys them isn’t the one using them, for the most part, since doctors are self-employed (unlike pharmacists, rad techs, nurses, etc. who practice in just one place using just one system). Usage is voluntary and therefore sporadic. Those voluntary users (who are really our customers) are supposed to deal with it, show up for training, and read ongoing messages about bugs, upgrades, and downtime (times two or three, depending on the town).

If I were HIT King for a Day, my second decree (after putting a spending cap on HIMSS exhibits) would be this: every system intended for physician use will employ a common user interface whose visible appearance, terminology, and user interaction is fixed. Vendors who fail to comply will have their kneecaps broken by CCHIT.

What vendors do behind the scenes is their own business, but when you’re selling cars, no matter how clever your designers are, the steering wheels and pedals need to be in the same place if you want to move iron.

Time Capsule: Dirty Geeks and They’re Done Dirt Cheap: How Wall Street’s Huddled Masses Could Reshape Healthcare IT If We Just Asked Them

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 2008.

Dirty Geeks and They’re Done Dirt Cheap: How Wall Street’s Huddled Masses Could Reshape Healthcare IT If We Just Asked Them
By Mr. HIStalk

Healthcare IT has always been inbred. The same folks just keep moving between provider and vendor, hospital operations and IT, and Organization A and Organization B. The name tags change, but the faces stay the same. Most of the value of the HIMSS conference is in reconnecting with all those folks who scattered like billiard balls since you saw them last.

HIT is an esoteric discipline, at least according to those who are in it. We’ve kept it that way by demanding healthcare experience for most jobs, ensuring that few strangers and their highfalutin’ new ideas enter our comfortable midst (it also helps that healthcare pays less and uses bizarre technologies that the rest of the techie world has never heard of, like MUMPS and Magic).

Nobody knows whether healthcare will dodge the economic bullet this time around. If it does, lots of non-HIT techies will be pressing their noses to our glass, seeking a chance to start earning a paycheck again. It will look like that Twilight Zone episode where the guy is holding a gun on his neighbors to keep them out of his bomb shelter.

This Mariel boatlift of geeks could be great news for healthcare. Banks and investment companies were (note the past tense) full of experts in online transaction processing, security, project management, and forecasting. What will we tell those folks when they drop by?

Traditionally, it would be a slightly more polite variant of “hit the road.” No healthcare experience means we don’t want you, no matter how skilled and experienced you are at the same kinds of technology that we’re planning to use. We’re healthcare and we’re different.

That’s a mistake. The industry could use some new, baggage-free ideas from people who have spent their lives doing what healthcare is just now learning about: running large-scale, mission-critical systems and conducting business innovatively over the Web. And right now, especially if your hospital or company is anywhere near New York, Boston, Chicago, Hartford, Charlotte, or other cities that revolved (note past tense) around the financial services industry, I bet you could hire them for about the same money you pay those same old retreads.

This could be the most exciting HIT development in decades. Many of our bread-and-butter applications are old, poorly secured, and Web-indifferent. Developing portals and RHIO connectivity is a snap compared to keep tracking of some of those bizarre investment instruments their former finance bosses just choked on.

Interested in patient payment systems, real-time adjudication, Web-based customer service, or throughput modeling? Those are the folks who could knock that out right now, already used to skipping lunch and working long hours.

Healthcare has always been jealous of banking IT people, visibly grinding their jaw when innocent outsiders make the inevitable comparisons of their cutting edge work vs. healthcare’s 1980s-era challenges still being solved. Deep down, we knew they were right. Former hospital staff turned self-taught analysts couldn’t hold a candle to the best and brightest techies who headed to Wall Street in droves and moved that industry from staid old storefronts to cutting edge electronic commerce. Hey, their stuff works – it’s not their fault that their big-dollar bosses were a lot dumber than everybody thought.

Now we get even. Pay them a lot less, squeeze them into cubicles, and make them take orders from clinicians turned semi-programmers. The tortoise won this race. We don’t care about your international arbitrage software – just write an EMR system that doctors will actually use.

Think of this as your own Wall Street bailout, with benefits.

Time Capsule: Every Time I Say It’s About Patient Care, You Tell Me It’s a Business: Healthcare IT Lessons Learned from “North Dallas Forty”

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 2008.

Every Time I Say It’s About Patient Care, You Tell Me It’s a Business: Healthcare IT Lessons Learned from “North Dallas Forty”
By Mr. HIStalk

One of my favorite and most insightful lines from any movie comes from “North Dallas Forty,” a cynical and dark football film from 1979. In a key scene, fictional football player O.W. Shaddock, masterfully played by former Oakland Raider John Matuszak, explodes his rage and frustration onto the team’s coaches, who constantly resort to using fear and ridicule to get tired and injured players to keep performing even when they shouldn’t. "Every time I say it’s a game, you tell me it’s a business. Every time I say it’s a business, you tell me it’s a game."

The quote may have been about sports, but it’s relevant to healthcare as well.

I’ve worked for both vendors and hospitals. There were plenty of times on both sides where I wanted to scream at management, “Every time I say it’s about patient care, you tell me it’s a business. Every time I say it’s a business, you tell me it’s about patient care.”

Our unusually capitalist approach to healthcare delivery is schizophrenic. Everybody understands giving massages or tummy tucks for the biggest fee the market will bear, but there’s something inherently distasteful in performing life-saving surgery or seeing patients through their final days of cancer while a business guy taps his calculator every now and then to remind everybody — including the patient — to keep the cost down.

IT is usually smack in the middle of that rift between clinicians and executives, the bearer of bad news about something one group wants that the other is loathe to deliver. Clinicians resent being told how to deliver care by $1 million hospital CEOs and their business-savvy underlings. The people in the mahogany offices can’t talk slowly enough about cost control to get the message across the financially naïve white coats who would bankrupt the place if someone wasn’t watching the till. Somebody wants a CPOE system or a tool to run a balanced scorecard and the IT person knows exactly which part of the organization will be calling for his or her head.

Clinical people working for vendors have the same struggle. They’re supervised by executives who not only have never delivered care, but who most often drifted into healthcare by accident and will probably drift right back out again someday. Every undelivered system enhancement or overstated capability make the clinicians want to scream like O.W. Shaddock, physically threatening an overconfident MBA vendor suit whose last service to others was whispering the Black-Scholes equation to a B-school classmate during a tough finance test.

We’re in a confounding business whose mission is frustratingly mixed. Deliver the best care or the best clinical software possible – as long as it’s profitable. If it’s not, the MBAs are ready to rush in and whip the widgets into shape. That’s a threat and a promise.

Maybe it would help to see how the other half lives. Clinicians should sit through the meetings in which life-or-death decisions are made that concern the health of the entire organization, not that of individual patients. Executives should have to face real patients and caregivers regularly just to remind themselves of a mission more important than fancy new buildings and slick marketing.

And IT folks working for both providers and vendors … well, there’s really nothing you can do except wait for the dust to settle and support and enable whatever strategic plan results. Those other folks are playing tug-of-war and you’re the rope.

Time Capsule: This Is No Time for Timidity: Contrarians Who Take Bold Steps Instead of Moaning About Poor Financial Conditions Will Win

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 2008.

This Is No Time for Timidity: Contrarians Who Take Bold Steps Instead of Moaning About Poor Financial Conditions Will Win
By Mr. HIStalk

I bet every healthcare IT vendor wishes they were a mortgage lender. You make enormous profits for generations, pay gunslinging financial cutthroats salaries of up to hundreds of millions of dollars, and when the music stops on all those illogical investments that racked up obscene profits for years, you cry "Uncle." Uncle Sam, that is. Help, I’ve fallen and I can’t get up … come quick and bring your checkbook.

Unlike those investment clowns, healthcare IT companies die quietly when their time comes. Maybe they run out of cash, exceed the abilities of their founders, or learn the hard way how little they really know about their business. Those who can’t cut it slink off to the Great Vision Center in the Sky. Tough old world.

I’m not only a free marketer, I’m a Darwinist contrarian. You cannot succeed just doing what everyone else is doing. Sheep happily follow each other to the slaughter. The time to take bold action is when everybody else is too scared to, like now.

I have no data to back it up, but here’s what I believe. You hit your financial home runs when times are bleak, not when the exuberance is irrational. Buy when everyone else is selling. Expand when your competitors are cutting back. When the pendulum inevitably swings back, you’ll look like a genius. Those with the big brass ones will win.

There’s no doubt that credit will be hard to get, and rightfully so. But think about this: investors looking for stock market alternatives weren’t raised on plunking cash into unsexy bonds or gold funds. Companies with a track record and a good story will find investors. Maybe it isn’t the best time to run an IPO since stock prices follow the market down, but private investment should be ripe for some smart deals. Buy a competitor, replace unproductive employees, and make unpopular decisions while everyone is preoccupied with the Dow’s latest drop.

Vendors may see the customer pipeline start to dry up. Fear, rational or otherwise, makes people hunker down. That’s not the ideal situation, but it’s a good time to take a breath, look hard at product lines and strategies, and figure out a strategy for 5-10 years down the road. Sharpen the saw in preparation for the spring that inevitably follows winter.

It would be great if economic conditions sucked less, but you play the cards you’re dealt. Down markets eliminate weaklings. Survivors come back stronger than ever. The decisions you make today may well lock in a future (good or bad) that will persist for decades.

While all the timid MBA suits are whining, stuffing their money into mattresses, and telling everybody how well they could have done if the bad old market hadn’t betrayed them, real businesspeople will be quietly making moves to take advantage of current conditions. It’s a zero-sum game. You get to pick: on your feet or on your knees.