Time Capsule: Is Your Hospital IT Department like the Soviet Union? If So, It’s Time for Glasnost

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.

Is Your Hospital IT Department like the Soviet Union? If So, It’s Time for Glasnost
By Mr. HIStalk

I’ve been on both sides of the hospital IT fence. More than once, in fact, and in more than one organization.

I was frustrated by illogical users when I was in IT management. I was frustrated by illogical IT management when I was a user.

I was thinking the other day that IT is like the old Soviet Union, at least in some of the hospitals I’ve worked. It’s no wonder that the proletariat and the ruling party can’t get along.

Stoic bureaucrats in unelected positions of authority lay out an immovable five-year plan that changes every year. That frustrates the average citizen, who only knows what they can see first-hand: IT systems haven’t made their jobs easier or better.

Projects are kicked off with a revisionist review of history: similar projects were successful because IT says they were, user experience notwithstanding (lofty benefit projections for big-ticket IT purchases are never discussed publicly after they invariably fail to materialize).

High-profile project failures require placing personal blame, so somebody gets fired (usually the person least responsible for failure, dismissed by the person most responsible). The “Ministry of Our Projects Are Going Great” cranks out endless propaganda. Any vocal dissenters are deported to Siberia, stripped of IT committee and liaison responsibilities before they can cause an ugly uprising, replaced by more loyal party members.

Well-intentioned IT inefficiency designed to ensure equal treatment for all creates bread lines, i.e. long waits for the help desk line and a bureaucratic approval process for big ticket IT purchases (like $10 keyboards and $20 DVD drives).

That inefficiency in supply and demand leads to black markets, where people go to Office Depot with their department’s procurement card to buy laptops or bring in their own unsecured $30 router because wireless coverage is poor in their area and nobody’s fixing it.

All the cheap Best Buy technology is infinitely cooler than the stripped down, beige box PCs that IT issues. They’re like ugly Russian automobiles of the 1970s, thrown together by tractor makers for purely utilitarian purposes.

State-ordered collectivization forces local technical resources like servers and programmers to be brought under IT’s control in an attempt to boost productivity. It rarely works except on paper.

The creative and intellectual classes may seek a less oppressive environment, preferring a workplace where they can load their own software, use Macs, or buy an unapproved PDA that they’ll have to support themselves anyway.

Leaders, in the mean time, live in a more privileged world. They get sexier IT equipment (that they rarely know how to use) and get VIP treatment when they need IT help. Instead of cruising around Moscow in limousines, they peck publicly on BlackBerries and fancy laptops that the peasants can’t have.

Soviet-inspired IT leaders sometimes end up like Czar Nicholas II, overthrown and executed by the oppressed Bolsheviks (Career Is Over indeed). Hopefully, though, they (or their predecessor) introduce glasnost, making IT more transparent and allowing more individual freedom for the creative class.

What I learned in IT is that technology management is expensive; that getting people to agree on a common course of IT action is nearly impossible; and that the strategic deployment of IT is not something the average user can understand or appreciate.

What I learned as a user is that IT is often steered on wild goose chases by out-of-touch senior management; that my individual skills and capabilities are unimportant when IT enforces restrictive technology rules made for the clueless masses; and that rigid IT tunnel vision stifles the organization in its attempts to mitigate tiny IT-related risk.

What I learned as both is that everybody wins when IT listens to its users and vice versa.

Time Capsule: Once You Sign the Contract, You’re Just Another Customer Who Used To Have Leverage

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.

Once You Sign the Contract, You’re Just Another Customer Who Used To Have Leverage
By Mr. HIStalk

The healthcare software vendor I used to work for geared up for our annual user group meeting like hospitals preparing for pre-announced Joint Commission inspections, i.e. we scrambled frantically for a couple of weeks to make it look like we had done a good job all year.

Those user group meetings were generally cordial. Rank-and-file users with personal bones to pick usually didn’t attend since their bosses used the travel money themselves. It was our suits against theirs, a wary face-off of capitalist warriors on a hotel carpet battlefield under an ominous cloud of expensive cologne.

A few vendor riffraff like me were in attendance to support specific low-level contingencies. We were told: (a) show up only for the events for which you’ve been assigned, then get back to work; (b) don’t admit to any claims of software bugs or unannounced changes in strategic direction; and (c) stay away from the food.

One popular session every year was a "grill the executives" event. Our highest-ranking suits stood on a humbly bare stage and took questions from the audience. Our execs played it close to the vest, so it ended up being a Charlie Brown-like hum of pleasant but indistinguishable MBA-level buzzwords. It passed for sincerity, but an hour later, customers were hungry for information all over again.

I remember when one guy zinged the reigning suit. He waited for his turn at the aisle microphone, smiling and nodding sympathetically, but then grabbing the mike like he was Mick Jagger. Instead of belting out Satisfaction, he proceed to rip us a new one, complaining loudly and bitterly about something we had botched (forgive me for not remembering what, but the list of possibilities is long).

Since I knew that executive better than the customer and, therefore, respected him even less, my fellow flunkies and I secretly cheered the guy on. (It would have been more impressive if he hadn’t reached for his notes mid-rant, but it was still a pretty good job for a guy who spent his days under data center fluorescent lights).

The executive on stage looked like he had just discovered that a miscreant had keyed his mahogany wall, but he quickly got back on track. He oozed sincerity in personally promising the angry guy that someone at a more appropriate level would look into it. I bet he was happy with himself: he had talked the guy down.

Even as an industry newbie, I knew the customer’s plight. He had no leverage, so his only remaining shot was to whine publicly. His hospital had already bought our stuff.

Partnership promises aside, signing the contract of some vendors changes the dynamic from "we’ll do anything you want and put it in the contract” to "we’ll think about it and let you know." Switching costs are high, so most customers aren’t going anywhere no matter how mad they are. Everyone knows this.

If the vendor’s choice is between "do a lot of work for a customer who will pay us no additional money” vs. "do some work and rack up big sales," most (but not all) vendors will go for B every time.

That one-sided vendor advantage is probably being chipped away. KLAS reports give unhappy customers a forum, forcing vendors have to pay at least some attention to them. The few pay-as-you-go software licenses (like subscription models and ASPs) reduce the switching costs and give customers earlier options to bail. Blogs (obvious disclaimer: I write one) level the information playing field and call BS in ways that advertiser-supported magazines traditionally hadn’t touched. Unresponsive vendors are finding it a little harder to hide.

Still, I don’t blame those vendors. They live and die by the big sale. It’s easy to forget that you are actually expected to work for those recurring revenues when everybody is talking about the sales pipeline.

Here’s what our Mick Jagger would have advised. Don’t buy futures. If it’s important, get it in writing before the sale. Get visibility in the industry, which vendors respect because it gives you a platform. Put the vendor at risk by scaling payments to performance. Cheerlead for your vendor so they’ll want to work to keep you happily chirping. And if you have to use public shame to get them to listen, it’s probably a lost cause. It’s likely that (You Won’t Get No) Satisfaction.

Time Capsule: Best Buy’s “You, happier™” Slogan Says a Lot About Unhappiness (Both American and Healthcare IT)

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

I wrote this piece in September 2008.

Best Buy’s “You, happier™” Slogan Says a Lot About Unhappiness (Both American and Healthcare IT)
By Mr. HIStalk

To me, the most important part of the Sunday newspaper is the Best Buy ad. I don’t really need what’s in there (nothing they sell is essential, like food or clothing). I’m doing my patriotic duty, which calls for irresponsible consumer spending to keep the shaky economic wheels turning. I usually grab a computer gadget (who can resist yet another USB drive?) or a sure-to-be-unopened DVD boxed set of a TV show that I never watched when it was on.

This week’s ad had a new slogan under the Best Buy logo (right above the must-have LCD TVs). It said, “You, happier™.” They put that little TM in there, daring competitors to even think about appropriating such an ingeniously alluring come-on.

(TV may be nothing but trashy reality shows and endless commercials, but those can apparently masquerade as satisfying entertainment when beamed into a 52” plasma HDTV with surround sound. Insanity is watching Adam Sandler movies over and over on Blu-Ray and expecting different results).

Not that I don’t trust Best Buy’s motives, but I’m beginning to think that “You, happier™” isn’t working. According to a recent survey, US citizens are #16 in the list of countries when it comes to overall happiness. Everybody’s broke, so maybe we’re as happy as we’re going to get racking up credit card debt to fuel the pointless accumulation of consumer goods.

I was also thinking about the parallel with US healthcare. We’re mid-pack there, too, coming in at #37 as WHO sees it (edging Slovenia but trailing healthcare juggernauts Costa Rica and Dominica).

Providers waste a lot of money on poorly conceived IT purchases. That alphabet soup of ERP, CPOE, and BI looked appealing. So did all those juicers that late-night TV watchers ordered in a depressing quest for happiness (does anyone other than the 165-year-old Jack LaLanne really pulverize $3 worth of raw carrots to get a skimpy glass of awful-looking juice that still tastes like raw carrots?)

I love going into Best Buy. I’m happy roaming the HIMSS exhibit hall. I’m uplifted at the idea that I can trade money for, in the immortal words of Carl Spackler in Caddyshack, total consciousness. No fuss, no muss, just plug and play, or at least that’s the message. Don’t even think about trying to sell customers self-sacrifice and focused diligence when the guy next booth over is promising immediate gratification and a sweeping “vision.”

When healthcare IT enables great things, it’s because vendor and customer did a ton of work. That 10 percent of the iceberg that’s visible, the pretty screens and shiny servers, doesn’t begin to tell the story, although it often makes the sale. Home Depot’s hammer display doesn’t show bashed thumbs and blisters, I’ve noticed.

Conspicuous consumption of IT is highly unlikely to make “You, happier™” any more than passively buying self-help books or hanging on Oprah’s every word. What you get is a false sense of accomplishment that’s easily disproved by unchanged outcomes or efficiency. An hour later, you’re hungry again.

The industry doesn’t benefit long-term if customers are dissatisfied with vendors because they bought products naively, unwilling to contribute the sweat equity required for success. Maybe it would help if magazines and trade shows stopped trying to foist their breezy equivalent of Best Buy’s slogan on the industry: “You, Most Wired™.”

Time Capsule: The Olympics as a Project Management Lesson: Those Chinese Would Have Had Your Clinical Systems Live By Now

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

I wrote this piece in August 2008.

The Olympics as a Project Management Lesson: Those Chinese Would Have Had Your Clinical Systems Live By Now
By Mr. HIStalk

I don’t follow sports much. In fact, I might be the only American who didn’t watch any of the Olympics, other than a little of the women’s nude … uhh, beach … volleyball (I think the US beat some other teams, but I’m not really sure since they kept running back and forth under the net while I was distracted).

Actually, I did watch the closing ceremonies, having little choice because I had bartered away my evening TV rights to Mrs. HIStalk in return for being allowed to watch an Andy Griffith Show mini-marathon that preceded it (“The Pickle Story” episode was a key bargaining point in the protracted negotiations).

I’m glad I tuned in to watch the torch get snuffed. It held a valuable lesson (beyond the inevitability of aging, as evidenced by Jimmy Page’s frightful-looking gray hair).

The lesson is this: given resources and strictly followed project management principles, human achievement is nearly limitless.

Evidence was everywhere. China spent $40 billion on everything from infrastructure to costumes. The closing ceremony was so tightly scheduled and scripted that the elaborate equipment and cast of thousands could not be assembled until right before the show, with no time for on-site practice. Clips of memorable performances (all of victorious Americans, given the homer TV coverage) were a reminder of the incredible logistics of transportation, construction, lodging, computing, scheduling, media support, and preparation that rivaled and maybe even exceeded the obviously impressive human performance of the competitors.

If there was a project management Olympics, this Olympics would have brought home the gold. Everything was finished on time, it worked, and there was little evidence of what must have been hundreds of backstage arguments, compromises, and last-minute changes over several years. There were no excuses, extensions, or exclusions.

I bet you wish your last big project went that well. Me, too. In fact, I jotted down some thoughts about why China can orchestrate a picture-perfect Olympics while the average hospital can’t get its IT projects finished:

• Ruthless project management. Chinese leaders aren’t generally known as laid back cut-ups, so I’m assuming the pressure to deliver was excruciating.
• Unlimited budget. There’s no way costs could have been estimated accurately, so it must have boiled down to “whatever it takes.”
• Tons of dedicated employees and volunteers. China has over a billion people to choose from, none of whom have the “no, thanks” option.
• Individual and national pride was on the line.
• Would-be naysayers who were too scared to whine about the impossibility of it all, which left just shutting up and doing what they were told.
• A hard-stop, no-excuses, immovable deadline with the highly visible result beamed to the entire civilized world.

IT leaders probably shouldn’t rush out and declare themselves supreme ruler or demand billions of dollars just to get a project finished. Still, the Olympics would have failed if the goals were unclear, the money tight, or people stretched.

The lesson is that CIOs can do anything if given the right resources, requirements, and control. That is, if they bring highly polished expertise in planning, communication, and project management to the table. Anything less isn’t the Olympics; it’s more like professional wrestling.

My beach volleyball game would have suffered without these things. It might have been played on asphalt instead of sand because someone forgot to order it. It might have resulted in a tie because inexperienced scorers forgot to write down the points. And, it might have featured players wearing track suits because incompetent security guards allowed the team’s uniforms to be stolen from the coach’s wallet.

Time Capsule: Why IT-Led Change Projects are a Bad Idea: We Aren’t Charming Enough to Convince or Scary Enough to Threaten

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

I wrote this piece in July 2008.

Why IT-Led Change Projects are a Bad Idea: We Aren’t Charming Enough to Convince or Scary Enough to Threaten
By Mr. HIStalk

I was e-mailing a colleague the other day and spouted off an off-the-cuff remark that I kind of like in retrospect (that’s not just vanity talking because sometimes I say something really stupid and I realize it right away.) It was this:

“Executives buy IT because they want to crack the whip but aren’t willing to, so they use IT to force conformance without confrontation.”

I’ve been the poor IT guy who became the lightning rod for some executive’s grand plan for change. The IT project was where the rubber met the road, so we became the bearer of bad news for the masses: “You have to change your ways — your boss told me to tell you.”

(Please excuse those arrows sticking out of my back. We IT messengers get a lot of those, so they don’t really bother us all that much.)

For that and other reasons, I don’t even like the idea of calling anything an “IT project” unless it involves user-invisible infrastructure. “Buying IT” really means “demanding change,” so the expected result isn’t a “go-live” — it’s a “be-different.” Only a little of that involves computer stuff.

Anointing IT people as change agents is like enlisting the CFO to redesign care (i.e., asking for trouble). Computer-loving pessimistic perfectionists don’t make good charismatic visionaries who can get people to fall in line behind a radical change like a Pied Piper. Three seconds after the wary masses start complaining and rolling their eyes, we’re commiserating with them and casting conspiratorial glances as we say quietly, “I don’t think it will work either, but that’s what I was told to do.” That’s realistic, but not so inspirational (it’s not surprising that CIOs rarely seek political office).

The IT department doesn’t carry a lot of weight. We’re always overloaded with somebody’s great ideas from last year that still aren’t finished. We zeroes-and-ones types have minimal user credibility (insert obligatory user help desk scorn here). Most importantly, we carry no explicit or implicit authority outside of our own little domain, so we can’t impose our will on mutineers. We aren’t charming enough to convince or scary enough to threaten.

I think of IT as a subspecialty of change, right up there with communications, metrics, and process design. There’s no shame in doing any of those subspecialties well without actually running the show, even when the most visible part of a project is a computer.

This is so obvious that I’m hesitant to risk my shaky reputation by even saying it out loud, but here we go. Projects with user visibility are change projects, not IT projects. Change projects should have real objectives, not just IT objectives. Attaining real objectives requires the leadership of people who have influence and skin in the game, not IT people whose expertise involves the tools. Ergo, IT should always be supporting cast, not limelight-hogging stars.

When it comes to big change projects that happen to involve the computer, the worst idea in the world is letting the IT department run the show. It’s no accident that big projects at Kaiser and Allina were run by project teams that were completely separate from IT and staffed by people with operational expertise and credibility instead of IT managers and technicians. They recognized that their project wasn’t CPOE, it was changing the behavior of clinicians. Not coincidentally, those projects succeeded where IT-led ones elsewhere went down in flames.

Time Capsule: Conduct a Survey, Game the Results: If the Results are Important, Somebody’s Cheating

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

I wrote this piece in July 2008.

Conduct a Survey, Game the Results: If the Results are Important, Somebody’s Cheating
By Mr. HIStalk

My doctor is part of a big medical center’s group practice. I noticed a big poster on the wall last week. It explains to patients in great detail how to fill out a patient satisfaction survey. It is helpful, especially if you want to give the office a perfect score (that’s the only option shown).

It’s about as heavy-handed as those car dealers whose signs urge, “See the manager if we didn’t earn all fives on your satisfaction survey.” Sometimes they even offer a free oil change if you agree to give them a perfect score. Strange: it’s their own survey, but they’re still encouraging customers to lie about being satisfied. Why bother to conduct a survey if you’re going to tamper with the results, especially if you’re only fooling yourself?

Places I’ve worked did employee satisfaction or communication surveys. Sounds great in the HR office, but in the trenches, executives were begging and threatening to get good marks.

All that led me to think about seemingly objective healthcare IT information sources that really aren’t. If the results are important, you can bet someone is cheating.

I went on a site visit for clinical systems awhile back. I knew the hospital was threatening to kick the vendor out and sue them, but everybody seemed manically happy. For good reason, it turned out: at least one of them was a vendor’s employee wearing a hospital badge. I also accidentally discovered that the hospital CEO had sent a threatening letter to the key contact, warning him not to say anything negative that would make the vendor mad (I saw it on his desk).

I’ve stopped reading free industry magazines. My IT world is a lot uglier, less conclusive, and more frustrating than the one they claim to live in. The stories are about as hard-hitting as a vendor’s press release. If you can’t find even one negative in a case study article, you’re reading propaganda.

I believe KLAS rankings in general, but I’ve heard that vendors work hard to get their best customers interviewed.

I’ve known some Most Wired survey respondents who either exaggerated or lied outright, depending on how charitable you might be at the moment. Looks good on the resume, you know, and the CEO will finally notice the IT department.

Most recently, I was excited that some healthcare-related organizations made Computerworld’s list of best places to work. Alas, employees from one of them e-mailed me to say that their employer had strong-armed employees to turn in happy surveys (think of the irony: those in the trenches were threatened to act happy or else).

My conclusion is this: caveat emptor. Nobody has an incentive to warn prospects about questionable vendors, products, or employers. Folks who wouldn’t lie to friends might exaggerate to strangers.

There’s an informal collusion among vendors, trade magazines, and member organizations to keep prospects buying by putting on a phony happy face. That’s their job. Yours is to seek the truth. And if the publisher of this newsletter sends you a reader survey, I’ll give you a free oil change if you say I’m the best thing about it.

Time Capsule: Want Doctors to Use EMRs? Find a More Effective Strategy than Shame

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 2008.

Want Doctors to Use EMRs? Find a More Effective Strategy than Shame
By Mr. HIStalk

Doctors are generally pretty smart. We agree on that, right? So why does the healthcare IT industry keep treating them like idiots?

A new, ultra-expensive study found that doctors aren’t exactly flocking to EMRs (it took an expensive study to determine that?) The hidden message: somebody has to do something to get those dummies to buy EMRs.

EMRs are, in other words, so darned compelling that prospects should be shamed or maybe even forced into buying them for the public good, kind of like seat belts (imagine some models of seat belts that cost $50,000 and require 30 minutes extra every time you start your car.)

In America, doctors are business owners, even though some people think that’s a distasteful concept. They have customers, employees, overhead, and equipment. They make good business decisions or they go broke. You can’t help patients if your practice tanks.

Many of those smart business owners don’t see the value of EMRs. They understand that EMRs might improve patient care in some cases, but the practical and immediate considerations of their cost, support, and time requirements win every time.

Doctors won’t use EMRs just because non-doctors preach at them. They will not be shamed for sticking with paper when it makes personal economic sense. Societal benefit aside, they have to protect their income and their time (which are synonymous).

EMRs, in other words, are no different than any other piece of medical equipment that the doc/business owner might buy. It’s a logical decision made by a smart person. If I’m a doctor, my decision tree might look like this.

First, can it make me money? Doctors buy fancy imaging equipment because they can bill the heck out of it under current reimbursement rules. EMR assembly lines would have to run night shifts to crank enough of them if docs could bill for their use. They can’t, which means payors (including patients) aren’t convinced about EMR benefits, either.

Second, would having an EMR give me competitive advantage? Here’s a question that gives you the answer: would you go find a new doctor just because your old one, who just happens to be the greatest doctor you’ve ever known, doesn’t use an EMR? Neither would all those Joe Sixpacks who are prodded by industry polls into saying that EMRs are essential, but who in reality don’t care whether their own doctor uses one or not.

Third, will using an EMR get me sued less? You’ll know that’s true when medical malpractice insurers give significant discounts to EMR-using doctors.

Fourth, when it breaks, who do I call? Doctors are not hospitals, with their separate department of nerds anxious to tackle the latest problem due to operating system quirks, software upgrades, driver incompatibility, and user errors. The Geek Squad guy is not only expensive and not found in most American towns, he also doesn’t know much about EMRs.

Sticking with the “how we do things here in America” theme, here’s how you get doctors to use EMRs. Make them faster, easier to use, and better supported to the point they provide inarguable business and clinical value, no different than a fax machine or an office PC. In other words, don’t just complain about paper — beat it in a fair fight.

And once you figure out how valuable EMRs are, make the person who gets that value pay for them.

Time Capsule: If Uncle Sam Doesn’t Like Healthcare Administrative Costs, Why Did He Create 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 June 2008.

If Uncle Sam Doesn’t Like Healthcare Administrative Costs, Why Did He Create Them?
By Mr. HIStalk

Want to defraud Medicare? Apparently it isn’t very hard. A recent high school dropout started punching in fraudulent claims from a kitchen table laptop and didn’t stop until she hit $100 million worth, many of them paid without question. Another news story talked about hospitals that have been charged with overbilling the government, insinuating they did it intentionally.

Certainly there are plenty of crooks in healthcare and I hope they’re all locked up. On the other hand, the payment system is extraordinarily convoluted and complex. Put a microscope to the high volume of transactions submitted by the average hospital and a sharp auditor could no doubt find a few inaccurate ones. It’s just electronic claims Nintendo, moving imaginary paper back and forth with little added value, so it’s not perfect.

It’s like the tax system. Magazines used to take fictitious family situations and ask big-name accountants to figure their tax liability. The results were all over the place, with each accountant defending his or her interpretation of the tax code. Nobody could say for sure what the right answer was. You can bet, though, that if you’re audited, that low-ranking civil servant who’s making you sweat will pick a big number and it’s up to you to argue otherwise. They don’t see it as your money at all.

The common element is the federal government and its entourage of special interest groups, lobbyists, and consultants. They don’t have an incentive to make anything simple, especially if that would result in claims getting paid more generously or quickly.

Besides, the government is going broke, mired in national debt that would take generations to pay off even if the federal budget were balanced today. Paying less than providers bill or deserve buys the politicians a little more time before the economy goes up in flames.

Old-timers remember that hospitals first bought computers to support complicated Medicare reimbursement. It was like an arms buildup, though. Once Uncle Sam got computers of its own, we were back to square one. The government demands the most tedious, obscure, and hard-to-capture information from providers, even though nothing useful ever seems to come from it.

They created the nightmare that is healthcare billing, a nasty by-product of what a lot of folks back then called a socialist experiment in which politicians inserted themselves between providers and patients. With that came insurance companies and a never-ending increase in costs.

Think about that the next time a gasbag politician starts whining about the administrative costs of healthcare and the huge chunk of GDP they consume. Uncle Sam, as the biggest payor, is the also most demanding, bureaucratic, and arrogant. On top of that, it blames providers for being inefficient. Can you imagine?

I’m glad the government is occasionally and uncharacteristically prudent. Sometimes it seems it has gone beyond that in healthcare. You get the feeling that it can’t afford the care that politicians have promised to voters and the only way to hide that fact is to intentionally pay providers less than they are entitled.

On the other hand, be careful not to make a mistake. Once you hit $100 million or so, somebody might start asking questions.

Time Capsule: Doctors Mostly Ignore Primitive Clinical Decision Support: Help Them Do Right Instead of Warning Them They Might Be Wrong

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 2008.

Doctors Mostly Ignore Primitive Clinical Decision Support: Help Them Do Right Instead of Warning Them They Might Be Wrong
By Mr. HIStalk

Anyone who has worked with hospital clinical systems knows that so-called “clinical decision support” for physicians has been a bust in many (most?) cases. You turn on all those high-falutin’ warnings that were the primary reason you bought CPOE. The doctors scream bloody murder at the interruptions. You dial it back, they still gripe. C’mon, Doc, we bought this to help you practice good medicine.

Finally, you learn an expensive lesson. From the doctor’s perspective, the optimal decision support setting for your CPOE system is to shut off everything except (a) dose range alerts at the “you’re about to kill this patient” level, and (b) allergy warnings, which they will still ignore 95 percent of the time. (The docs would have told you that upfront, but clinical systems arousal means not asking questions whose answers reflect imperfect reality).

Your shiny new system might (if you’re lucky) save a patient once or twice a year who would have been in big trouble pre-CPOE. Otherwise, the average patient isn’t getting much benefit. Check your stats – an ignored warning is a useless one.

Today’s clinical decision support is mostly old-school, mainframe stuff, simple lookups and algorithms like “do these two drugs interact” and “this test is not recommended, please use this one instead.” It was designed from the paradigm of finding something the physician might have missed and providing a pesky error message, no different from crude screen edits that catch keystroke errors.

In other words, the computer just tells doctors when they might be wrong instead of helping them be right in the first place. May I repeat? The computer just tells doctors when they might be wrong instead of helping them be right in the first place.

The more useful paradigm might have been, “Let me give you some carefully and intelligently mined information that might help you diagnose or treat, not scold you afterward.”

Today’s hospital systems contain a heck of a lot more useful information than they did back in the 1980s when allergy alerts were hot stuff. The challenge now is separating the good stuff from the noise. What subtle trends are occurring with this patient? What correlations exist that humans might miss? What information from the patient’s longitudinal record could help make the right decision now? Can anything be gleaned from the hospital’s vast database of past therapies and outcomes that would improve this particular patient’s care?

If you’re a vendor looking to gain an edge in next generation’s sales wars, look no further. This is stuff that doctors would actually use. This is information that would decrease clinical variation and help apply cutting edge knowledge to individual cases. Information saves money and lives, so hospitals would pay for that result.

This is not simple programming work or a subscription to some expensive third-party drug database. In fact, making something like this work with yesterday’s architectures would be a big pain. It would require a lot of information about a particular patient, including some not readily available today (like an easy way to specify, “What do you think’s wrong with this guy, doc?”)

That level of guidance would also require customization capability since doctors aren’t interchangeable. Urologists don’t focus on the same information as cardiologists. Doctor A might pay a lot of attention to respiratory data points, while Doctor B might be a blood sugar man. Let each flag suggestions as “helpful” or “not helpful” so the system can learn what to offer next time (yes, computers can learn.)

Once vendors figure all that out, the next logical step would be to tie literature to practice. Journal knowledge shouldn’t be hidden away in libraries and online subscriptions. Specialty content vendors are already evaluating and grading that new information into decision support applications for immediate, routine patient use. That’s pretty cool and would be even cooler if undertaken under the open source banner to encourage broad participation and to minimize financial barriers to adoption.

The industry’s efforts to create electronic clinical decision support have largely misfired, as evidenced by its half-hearted use and unimpressive impact on outcomes. Surely some smart folks out there can come up with a better plan that will help make all these systems worth their cost.

Time Capsule: Hello, NAHIT? Wanna Buy My Dictionary for $29 Billion?

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 2008.

Hello, NAHIT? Wanna Buy My Dictionary for $29 Billion?
By Mr. HIStalk

The New Oxford American Dictionary costs $48 and contains definitions of 350,000 words. What a deal! HHS just paid consultants $500,000 of taxpayer money to make up five healthcare IT definitions (being overachievers trolling for future engagements, the consultants threw in an extra one). At that rate, that $48 dictionary is actually worth just over $29 billion (shipping extra).

Furthermore, NAHIT (sorry, they apparently prefer the authoritarian-sounding “The Alliance,” according to the Web site) didn’t even get real definitions for its (your) money. Your sixth grade English teacher would be horrified to see, for instance, that the definition for electronic medical record starts out with “An electronic record …” That’s not a real definition, even if it did cost $83,000. If it were, the dictionary entry for civil war would be, “A war that is civil.”

Consultants can’t say, “Have a nice day” without gravely presenting a PowerPoint and an executive summary, so the handful of one-sentence definitions is buried in a 40-page report that no one will ever read.

Note: it is law that every healthcare IT article written by dull reporters or unimaginative academics must start with one of two opening lines, either, (a) “In 2004, President George Bush called for every American to have electronic health records by 2014” or, (b) “In its landmark 1999 report To Err is Human, the Institute of Medicine said that medical errors kill 98,000 Americans each year.” Spoiler: this one goes with (a).

The report implies that the appalling lack of consultant-produced definitions was a matter of national importance, suggesting that the pesky term Health Information Exchange threw the entire United States government into a near-standstill by causing poor EMR adoption and public indifference to healthcare IT. Its conclusion is that, despite war and economic woes, all is again right in the federal world and the HIT pipelines are flowing. The definition deficit has been eliminated.

Give the criticality of the situation, what methodology did BearingPoint use to create the definitions? Since they’re consultants, duh, they “conducted a literature review” and then asked a few people, “Say, what do you think these terms mean?” and packaged it all up with a big invoice. Ca-ching!

Here’s a polite assessment of their work: at least the definitions won’t be contentious. Nobody would read them and argue (except non-CCHIT certified EMR vendors since the report says, in essence, that their CCHIT-certified brethren are EHRs and everybody else’s are EMRs, giving a nice, parochial nod to another ONCHIT pet project). The definitions, in other words, were plainly obvious, thereby throwing the whole “why did they spend all that taxpayer money” question right out into the open.

Here’s another negative beyond $500K of irretrievably lost funds. The cash went to perennial trough-lapper BearingPoint, which some lawmakers tried to ban from government work after its $472 million debacle, the CoreFLS ERP system at the Bay Pines VA in Florida. That project nearly shut down the hospital before it was mothballed for good in August 2004, having never advanced beyond disastrous beta testing. All has been forgiven, apparently, except for those VA folks who were fired or reassigned because of it.

Optimists would say that taxpayers usually fare much worse when Washington bureaucrats meet big consulting firms, so blowing only $500,000 is actually not a bad outcome. Here’s another: if you order in the next 30 minutes, I’ll sell you that dictionary for just $1 billion. Act now and, like BearingPoint, I’ll throw in a bonus definition: boondoggle.

Time Capsule: Put Down That Computer and Listen: Why Filling Out and Reading EMR Data Screens May Cause Doctors to Shortchange Patients

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 2008.

Put Down That Computer and Listen: Why Filling Out and Reading EMR Data Screens May Cause Doctors to Shortchange Patients
By Mr. HIStalk

I’m a fan of an interesting learning concept called the Illusion of Knowing. Here’s what it says: you’ve read something carefully, sometimes more than once, so you’re confident you’ve mastered whatever it says. Later, however, when hard-pressed to put the information to good use, you blank out. You didn’t know it after all – you just thought you did because you had passively read it.

(Cue sweat-inducing college final exam dream. You couldn’t find the exam room, and when you finally did, you realized you hadn’t attended any of the classes … you know the rest).

Anyway, some Harvard doctors made me think of that with their recent NEJM report on EMRs. They question whether EMRs really improve care given their emphasis on creating reams of bland and predefined information, but with no capability to encourage fresh, individualized thinking to diagnose and treat patients.

(Note: I’m reading between the lines since the actual lines themselves require a NEJM subscription, which I don’t have because I’m cheap and they use a lot of big words when little ones would do fine).

The authors cite a doctor colleague who said that hunting for useful information in an EMR is like the Where’s Waldo? games of a few years ago. The kicker is this: that colleague is so frustrated with all the meaningless junk in EMRs that he makes index cards to track what’s important.

That’s where I thought of the Illusion of Knowing. A doctor could read all the EMR screens and figure, “Everything I need to know is right there, so if I study it long enough, I’ll figure out how to improve this patient’s life.” That’s EMR Nintendo: recognize and react to some event, which may seem like practicing medicine to a programmer since that’s how logically programming works.

Here’s a problem: doctors don’t have the time to conduct scavenger hunts for vital facts in the handful of minutes per encounter that the benevolent insurance companies and practice managers allow them.

Second problem: EMRs aren’t set up to allow automatic or manual grading of individual factoids, so everything looks potentially important.

Third problem: EMRs try to turn freeform and sometimes tentative thoughts into dropdowns and template-driven generic verbiage that may destroy their original context (that’s what programmers do: impose order and create retrievable database information, so it’s not really their fault).

Another article that was published at about the same time extols the virtues of speech recognition systems. Those create more voluminous and anecdotal information, but the context is perfectly preserved. Unlike discrete data, doctors could re-read a narrative and glean new information after the fact. Programmers hate bunches of text that don’t lend themselves to convenient database structures (although natural language processing can reverse engineer some of it back into data fields).

We in the industry could debate the merits of templates vs. narrative, but that discussion is moot. The real problem is medicine itself. A table of dry patient facts can help support diagnosis and treatment decisions, but even fresh-faced doctors know that patient care isn’t a video game of spotting a symptom and blasting it with drugs or surgery. The first thing they learn in medical school is not how to read charts or write orders, but to go into the patient’s room and look and listen. Sometimes the least-obvious information is the most useful.

Perhaps a redesign of EMRs is in order that takes semantics and metadata into account to better reflect the physician’s thought process and judgment rather than just trying to force those thoughts into a convenient data structure that looks good in a table and uses classification tools that say in black and white what might be better expressed in not just shades of gray, but in rainbows of colors. Or, maybe a well-designed study (not financed by EMR vendors, most likely) would find that chatty paper records lead to better outcomes than terse and categorized electronic ones.

The bottom line is this. EMRs have affected patient outcomes only modestly, if at all. If doctors still have to make index cards, maybe legacy EMR design should be revisited.

Time Capsule: The Idealistic HR Rep Is Wrong: IT Success Means Treating Your Stars Better Than Everyone Else

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 2008.

The Idealistic HR Rep Is Wrong: IT Success Means Treating Your Stars Better Than Everyone Else
By Mr. HIStalk

Healthcare IT is an industry of experts. Folks with highly specific skills are the hardest to find and keep.

You know them. They’ve developed battle-hardened expertise in the quirks of a particular vendor’s product, often as technical experts (aka programmers, system analysts, or application specialists). You, some other hospital, or a vendor raised them from sapling to stout oak. Unfortunately, others covet and sometimes steal them. Losing one can kill your project or your reputation with users quickly.

Job #1 for an executive is to keep these stars. Here’s the biggest secret for doing that: don’t treat everyone equally. The idealistic, chipper HR rep is dead wrong. You keep your stars by identifying them and treating them better than everyone else, proudly and loudly.

(My motto is this: keep the top 10 percent of employees deliriously happy, the middle 80 percent comfortable, and the bottom 10 percent miserable).

Stars are like attractive women – they know it. That means having options, one of which is leaving for greener pastures. Insecure managers who try to beat down excellence by applying by-the-book principles of democratic, feel-good management in which everyone is treated alike will be left with plodding conformists. The geniuses will be long gone. Unfortunately, one genius can outperform a handful or more of plodders, especially when you’re talking about programmers, DBAs, and the like.

Most of those stars don’t want to be managers, so the promotion carrot doesn’t work. They aren’t starving, so throwing money at them won’t buy their loyalty. The best strategy is to identify that top 10 percent, then break the rules for them (who doesn’t feel special when someone breaks rules for them?)

Make them attend only that 10 percent of meetings that are important. Managers have long detuned their outrage threshold and will happily sit through time-wasting sessions where no conclusions are reached and no assignments made, but technical folks would rather be accomplishing something.

Give them whatever technical toys they need and then some. Your best analysts should have a huge monitor, a mobile device of their choosing, and whatever software they think will look cool on the shelf. These may or may not improve productivity, but they serve as a badge of honor visible to all that they’re special (that motivates others to seek stardom, too). Compare the cost to that required to find and train a replacement – it’s nothing.

Feed them. Surprise pizza or an off-campus lunch is cheap.

Put your best people in the best workspaces. Windows motivate. So do fancy chairs. Working from home on occasion is a real perk. Airless, institutional cubicles that scream interchangeable galley slave aren’t for stars. Brad Pitt doesn’t share a dressing room with the extras.

Send a note of thanks to their significant other after a long stretch of heads-down work.

Let them wear whatever they want as long as they’re not meeting with outsiders. People do their best work when they’re comfortable. Only managers wore ties as toddlers.

Respect stars, even if you can’t do the same for everyone else. Everyone, right up to the big boss, should know their background, hobbies, family members, and favorite vacation spots.

Send them off to training. It’s a badge of honor for an employer to invest in training-related travel. If the training budget is limited, spend it on the stars instead of dividing it equally.

Let them screw around on the clock with technologies you may never use. Hospital stuff is sometimes outdated, so exposure to cutting edge technologies is a motivator.

Allow them to interact with users and executives and users if they want. It’s insulting to have a middle manager boss steal the limelight when things are going great, but hide behind a closed door the rest of the time (I know because I’ve done it).

Make it clear to managers that their primary focus is to keep their stars happy and productive, which often means butting out and not trying to artificially add value. Not all managers are stars, either.

If an assignment is too trivial to make it sound crucial even by stretching the truth, give it to someone else, not a star. And if it’s critical but probably impossible, give it to a star and tell them so, feigning surprise when it gets done in a blinding flash of genius.

All of this sounds simple, but have you formally identified your stars and intentionally treated them better than the non-stars? If not, you’d better do it before someone else does.

Time Capsule: Process Anarchy: Why Hospitals Buy Off the Rack, But Expect a Tailor-Made Fit

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 2008.

Process Anarchy: Why Hospitals Buy Off the Rack, But Expect a Tailor-Made Fit
By Mr. HIStalk

I recently met with a group of employees from one department in a big medical center. So big, in fact, that many of that department’s couple of hundred employees didn’t know each other and had to be introduced. They’re assigned to odd locations, doing highly specialized work, and rarely poke their heads out to see what’s going on anywhere else, even within their own department.

We were talking a software rollout that affected them. That’s where the consensus thing comes into play – how they should use it, what changes they would see, and all the other painful change management stuff that wraps itself around a technology implementation.

Two of them were talking and animatedly gesticulating. It looked like an American tourist trying to get a Moscow local to understand that he’s looking for a restroom by just saying it slower and louder. Finally, one turned around and said (with some combination of wonderment and exasperation), “We work one floor apart, but it’s a completely different world.”

There’s an automation challenge for you. One information system, but two completely opposite groups trying to agree on how it should be configured. From the same department of the same hospital.

That’s a nightmare for healthcare idealists and software developers. In a perfect world, all hospitals would work the same. In a less-perfect world, hospitals might vary, but at least practices within a single hospital would be consistent. In a world that’s in disarray, everyone in a given department would at least follow a single set of rules. And in a world of madness, even small subgroups of individual departments do things their own way, a healthcare version of anarchy.

I’d say most hospitals are somewhere between disarray and madness. That doesn’t even account for IDNs with hospitals from 50 beds to 1,000 beds that face the daunting challenge of getting all of them to agree on a single software setup that reflects their intra-group disarray.

Certain hospital areas are so ruggedly individualistic that nobody else understands them 90 percent of the time (peds, oncology, surgery, ED, and ICU). Experienced nurses who transfer in feel like new grads all over again because everything is different (that’s a big problem right there). They defiantly stick with puzzling practices and dare well-intentioned outsiders (like administrators) to understand what they do, much less change it.

Those practices mimic the medical education of the doctors who work there, which rewards specialization. Each specialty proudly creates its own lingo, methods, and forms. Sometimes they’re necessary extensions, sometimes plainly bizarre and illogical practices used like gang colors – to make sure outsiders know they’re outsiders.

That’s why best-of-breed systems designed for those specialty areas won’t go away in the foreseeable future. That’s also why systems that all areas use, like CPOE and clinical documentation, can turn into an unmanageable stew of configurability options that drive vendors crazy when they’re trying to program and test changes. Instead of delivering strategic new functionality, products keep moving laterally with new options to be chosen once, even though a given client will just set it and forget it without receiving any real benefit.

Vendors have it tough. The respective agendas of current customers vs. prospects are very different. Entire new functionality may interest only a few potential users. The most vocal users are the showcase accounts, like academic medical centers, who demand changes that make no sense to the average hospital. Any resemblance to consensus is accidental.

(And here’s a vendor kudo: what little standardization exists in hospitals can be attributed to three groups: software vendors, the Joint Commission, and professional organizations for specific disciplines.)

Maybe it’s asking too much for vendors to deliver off-the-shelf software that every hospital can not only use, but love. One size doesn’t fit all.

Lip service aside, most hospitals want it their way. Anything less makes them angry. Cost and complexity forces them to buy suits off the rack when, deep down, what they really want is to have a tailor to make them one that fits perfectly.

Time Capsule: The First Lesson I Learned Working for a Vendor: Products Don’t Need to Be Great, Just Good Enough

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 2008.

The First Lesson I Learned Working for a Vendor: Products Don’t Need to Be Great, Just Good Enough
By Mr. HIStalk

I took my first vendor job many years ago, moving over to the dark side after a short career in hospitals. It was a common vocational change then and still is today: learn an application as a hospital user, then hire on with the vendor who sells it. Ca-ching!

I was anxious to use my hard-won experience to address the application’s many shortcomings. I figured it would be a slam dunk since none of the vendor’s people seemed all that sharp. My dazzling insight, I reasoned, would not only make the vendor’s application the best on the market, it would sweep me to my inevitable destiny as a software genius.

In other words, I was delusional enough to think that the only thing standing between the vendor and greatness was bringing me on board to share my vast frontline knowledge. I expected awe-struck respect, endless gratitude, and … OK, I’ll say it … maybe an outpouring of publicly proclaimed vendor love from my new best friends that I’d have to smilingly shrug off in amused embarrassment.

Stop your snickering. I admit it – I was naïve (I lost most of that naiveté when the vendor eliminated my job just a few months later with no visible sign of reluctance or regret. I was, as it turned out, highly expendable).

Instead of teaching the vendor some lessons, I had learned a few myself.

Vendors don’t necessarily want their applications to be the best; they only want them to be good enough. In the secret vendor playbook, some applications are simply placeholders to keep them from losing profitable package deals. Anything more is a waste of resources better spent on something more strategic.

Knowing how hospitals work is useful to a vendor, but not essential. In my company, decisions were made by humorless corporate wannabes who were short on brilliance and hospital experience, but long on ambition and political skills. It was like high school, where jocks and bullies ran roughshod over the smart and sensitive kids, except that these particular jocks had MBAs didn’t mind lying to the faces of employees and customers alike and were constantly plotting their upward mobility and the people whose backs they’d happily climb to get it.

Vendors enhance software applications to make new sales, not necessarily to keep current users happy. Leverage drops enormously once a hospital progresses from prospect to signed customer.

It’s not a shortage of good ideas that makes a product mediocre, it’s the decisions executives make about allocating resources to it. Execution is the rate-limiting step, not brilliant planning and design.

Perhaps the most eye-opening lesson for me was to appreciate how disillusionment breeds contempt among product insiders nearly everywhere. They’re like hot dog factory workers – they’ve seen the unsavory manufacturing process and wouldn’t eat one on a dare. “Held together by spit and baling wire,” they’ll snort, “old code cobbled together to form a house of cards on a shaky foundation. It’s junk and needs to be rewritten.”

As a new hire fresh off the hospital front lines, I was uncomfortable hearing my beloved application sneered at by those who developed and supported it. Surely they realized how well it really worked.

Most companies don’t have a place for product lovers. There’s too much compromise and indifference required to work for vendors who sell a broad range of applications. A software application is the end result of years of compromise and mediocrity-seeking, the perfect tension between intentional underinvestment and outright customer revolt.

It’s no wonder that few customers really love their software applications. They were designed to be tolerated, not adored.

Time Capsule: EMR Vendor Starts Secretive, Lucrative Business: Pimping the Patient Data of its Provider Customers

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 2008.

EMR Vendor Starts Secretive, Lucrative Business: Pimping the Patient Data of its Provider Customers
By Mr. HIStalk

Genetic medicine company Perlegen Sciences probably never saw the controversy coming. Its March 18 press release innocently and proudly announced an exclusive collaboration agreement with an unnamed EMR vendor to mine that vendor’s database, which is said to hold medical information on four million patients. To egghead scientists who don’t get out much, that sounds like a victorious achievement for medical research.

Perlegen will sift through mountains of data to select patients who meet its research criteria. The company will then contact the providers of those patients, asking them to contact the patient on the company’s behalf and offering them cash for providing a DNA sample. (Everbody’s watched enough CSI to know about the Q-Tip cheek swab thing, of course).

Perlegen’s intentions sound noble, at least when they’re the ones reciting them. The company is hoping to find genetic markers that can predict the individual response of patients to specific drugs. That correlation could improve patient safety and drug efficacy. And boost drug company profits, of course, which is the real point (some of its investors are drug companies).

The fastidiously unnamed EMR vendor is being paid to provide massive amounts of supposedly de-identified patient data (that methodology wasn’t specified). They get a cut of the take. Perlegen gets an ownership stake in the EMR vendor. Everybody’s happy.

Except perhaps those patients whose information is being probed by a company they’ve never heard of. Generously provided by another company they’ve also never heard of. Do they really want a genetic research firm peeking into their medical records, obtained in an open-air bazaar?

You’ll be hearing more about this story. It opens up a number of legal and ethical questions that are sure to tickle the fancy of journalists, privacy advocates, and software vendors.

The document trail will be interesting. Did the providers’ Notice of Privacy Practices indicate to patients that their data would be marketed since this goes well beyond the usual treatment, payment, and operations? Did the EMR vendor’s contracts with its customers reserve the right to not just store their data, but to sell it?

Perlegen drops the words “HIPAA” and “IRB” to make everything sound on the up-and-up. They’re HIPAA-immune, however (they’re not providers) and it’s not clear whose IRB will oversee the project. In other words, it’s not illegal, but it sounds a bit loophole-ish. So much for HIPAA offering broad privacy protection.

The biggest villain here appears to be the EMR vendor. It has no contractual agreement with patients as far as we know, so what is it doing selling their information?

Don’t blame Perlegen – they should have been told ‘no’. Blame lax privacy protections, the unnamed EMR vendor, and poor IT market conditions for leading to such a desperate cash grab. When that vendor is named – and it will be – we’ll know how it worked out such a sneaky deal, how it’s de-identifying the data of its customers, and how it justifies being partially owned by drug company interests.

Time Capsule: In a Capitalist Society, Somebody Will Always Sell a Fat Man a Speedo or an Unprepared Hospital a Clinical System

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 2008.

In a Capitalist Society, Somebody Will Always Sell a Fat Man a Speedo or an Unprepared Hospital a Clinical System
By Mr. HIStalk

One great thing about capitalist America is that people will sell you anything you can afford, even if you’re likely to do something stupid with it. Klutzes can get chainsaws. Fat guys can buy Speedos. Elected officials can hire prostitutes.

And hospitals with minimal chance of success can buy clinical information systems.

Any IT system can be misused. It’s the clinical ones that usually create the most awe-inspiring mushroom clouds, however. They come with irrationally high hopes, require the unwavering participation of stressed clinical users, and push the competency limits of both vendors and hospital IT shops.

The hospital loses millions. The vendor loses reputation points. Patients lose the chance for better or less-expensive outcomes. Money talks, however, so the customer signs on the line which is dotted, gets one last handshake from the salespeople they’ll never see again, and eventually realizes the magnitude of what’s required to get value from their big-ticket purchase. Gulp.

Would-be clinical systems customers are like that crazy 16-year-old driver down the street, except no learner’s permit or exam is required, just cash. Hospitals perform endless vendor due diligence, but those vendors don’t return the favor by saying, "Our analysis tells us that you’re going to be an unsuccessful customer who will bad-mouth us for your own shortcomings, so we’ll pass."

Let’s stretch reality by pretending that vendors might actually turn down prospects that are sure to fail. What kind of questions should they ask?

• Can you provide a list of at least three big, successful change management projects you’ve done in the last five years?
• Do you monitor and publish IT metrics, including those that measure user satisfaction?
• Are your physicians compliant with rules involving the drug formulary and chart completion?
• How standardized are your order sets?
• How standardized are your forms and how do you manage them?
• Can you document participation and results of your clinical committees?
• When was the last time your executives communicated a big vision that inspired cultural change?
• How dissatisfied are your users with current manual and paper processes?
• Are you so desperate to keep nurses and other short-supply employees that you let them break all but the most serious rules?
• Are you willing to take a productivity hit while users are being trained?
• Where will this project fall on the "most important organizational project" pecking order?
• How often are operational VPs involved in big change projects?
• Who does or doesn’t agree that this solution is the best answer to the problem we’ve identified?
• Have you set aside money for ongoing support?
• How mature is your project management function?
• Do you maintain an IT strategic plan that aligns with the organization’s overall strategic plan?
• Have you identified who gains and who loses power and prestige with this change?

Smart consultants could develop an easy hospital self-assessment tool that would predict with 90 percent accuracy whether a hospital’s implementation of a given system is likely to be successful. Vendors won’t develop it, though, because it would discourage prospects. Hospitals won’t either, because if they were smart enough to ask that question, they would be smart enough to already know the answer.

The current environment is simple to comprehend. Vendors sell products, customers use them to deliver results. Unfortunately, we’re seeing lots of the former, but far less of the latter. Everybody blames vendors, but let’s be honest – a guy who buys an extra-large Speedo should know better.

Time Capsule: Everybody Hates Their IT Department: Where Alignment, Control, and Honesty Collide

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 2008.

Everybody Hates Their IT Department: Where Alignment, Control, and Honesty Collide
By Mr. HIStalk

I was talking to a colleague at HIMSS about IT departments. “Our users hate us,” he lamented. “We’re nice people trying to do the right thing, but they hate us. You wouldn’t believe some of the jokes and nasty comments we hear.”

The easy answer is that nobody likes being told they can’t do something. That’s a core competency of many IT departments: telling users they can’t install software on PCs, can’t buy systems without IT approval, and can’t blow the entire organization’s IT budget buying big-screen monitors and stylish laptops. Doing their job as laid out by leadership, in other words, as unpopular as that may be.

Implementation projects, however, probably encourage even more unlikable behavior. The marching orders are to get the system live, on time, and on budget. If that means steamrolling user objections for the good of the order, even valid ones, so be it.

In that respect, the interests of the IT department and its vendor are aligned. So, it’s not surprising that users regard them both with the same distrust and sometimes disgust, writing them off as fast-talking flimflammers trying to put something over on the people who have to live with their systems long after they’ve moved on to the next project.

IT is just another vendor. Vendors are unresponsive, clueless, and untrustworthy, users reason. Ergo, we hate them all. They get no credit for trying to do the right thing in moving the big-picture dial.

IT lives in the world of conference rooms, PowerPoints, and big teams. Clinicians thrive on making quick solo decisions with whatever information is available, changing the plan after seeing the result. It’s an honest world, though, and when IT people try to hard-sell the benefits of going live, changing processes, and accepting software inadequacies, the “us vs. them” atmosphere sets in quickly.

Clinicians are also quick to spot even well-intentioned dishonesty or heavy-handed enlightenment campaigns since they deal with human frailties all day long. When project people conspire offline to minimize or even hide major software problems, enlist secret allies to manipulate group thinking, or strategize with leadership to marginalize whiners, finely-tuned clinician noses immediately catch the unmistakable whiff of manure.

Sometimes those noses pick up the scent of condescension as well. IT folks fancy themselves as process experts and unbiased observer, which they very well may be. Users can’t make decisions, aren’t consistent in processes, and don’t understand the big picture, the logic goes. Using that knowledge to influence behavioral change, however, requires an incredible amount of finesse and ongoing respect. Those qualities don’t always run deep in IT-land.

It’s nearly impossible, in other words, for IT to be the much-loved middleman for policies made at the top but despised at the bottom: technology control, process change, and application imperatives. The IT department is often smack in the middle of clashes between what executive management wants and what the rank-and-file is willing to do with the resources they have.

It may be oversimplification to say that every IT department that’s doing its job will be scorned by users. In hospitals, however, the current state of leadership and IT alignment nearly assures it.