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What I Wish I’d Known Before … Taking College Courses While Still Working Full Time

That taking classes when you’re over 40 is pointless. Few, if any, employers believe that those over 40 have anything left to offer, regardless of one’s interest in continuing their education and staying current.

Nothing. I was glad I earned my MBA while working when I was 24-25 years old. At the time I knew it would be a short-term sacrifice for long-term gain and it was. I started the program part time in the evenings while I worked full time and concluded full time while working part time for eight months. To those of you in your mid-20s thinking about earning an advanced degree, get practical work experience for a few years first. It will make the degree more valuable as you will apply professional experience to course work and learnings from the program immediately in your work setting.

I wish I had known just how little sleep I would get! I went back to school after a divorce. I was a single parent working full time, carrying a full load of at least 12 credit hours, and it was a huge test of my stamina. However, it was the most rewarding experience. I wish there were online programs when I did it, I had to physically go to school.

I encourage all of my employees to follow their dreams and go to school as well. One finished her MBA, another just graduated with a BA, another is in school now. They all found programs that are online and that seems to be more manageable.

It’s worth doing. Time management, prioritizing and letting the unnecessary stuff go are the keys to sanity. And remember, there is a light at the end of the tunnel. Just get through one class at a time and eventually you’ll be done.

Engage with your full-time college student peers sooner — they can help you through. I worked full-time nights as a nurse, taking graduate-level business classes in the morning. I was so tired I didn’t sense how curious the ‘regular’ students were and how much they wanted to get to know me. Once I made the effort, they became a great support system.

I tried to do it 20 years ago with young kids, a more than full-time job, and travelling. Not surprisingly, I could not sustain the effort and was unprepared for the amount of non-class time I would have to commit, so that effort ended. Fast-forward to 2016, and tried again, this time with a completely online program. The coursework was still extremely challenging (more so than I remember from my brick-and-mortar experience), but the flexibility made all the difference in the world. Bottom line: be ready to commit the time and be realistic about your current life situation before jumping back in.

The course that seemed so valuable to gain new expertise ends up being little more than a high-level theoretical overview of the area. After a day of professional work with software, a computer science course seems like a step backwards, learning old techniques and theory. I find myself questioning the expertise of the professor compared to my professional colleagues. After a week of full-time work, I rarely have much energy to spend on deep learning, so I find myself doing the bare minimum to get by. I’m surprised at the low-quality work that is acceptable to get a decent grade.

I wish I’d had the foresight to schedule time for social activities when I first went back for my master’s. If I don’t look for opportunities to meet up with friends early, I either end up becoming a hermit or accepting last-minute invitations too close to class deadlines.

I wish I’d known how helpful programs like Khan Academy and even YouTube channels can be for brushing up on the basics. My advice for anyone going back for another degree after a long time out of academics would be to put pride aside and find a way to test how much you may have forgotten.

That I would immediately want to quit my job and go to school full time, forever.

It’s 100 percent worth it when you’re done. MBA.

You will be forced into TOUGH choices. After a while, it becomes hard to juggle school, work, and family. Additionally, I had travel related to school and for work. I ended up quitting work midway through the degree because my employer didn’t care about my MBA and I felt that I had reached my ceiling there. That helped me regain sanity.

I wish I’d known how much effort it would be. I knew college courses were hard, but I signed up, waxing nostalgic over going to college full time. Working then going to class after was totally different. It was basically paying a ton of money to do extra work. It feels especially hollow when you realize there are a dozen courses online where you could learn the same things for free.

That as time-consuming as it was, it wasn’t as bad as I thought it would be. I had put off getting my master’s degree for years because I thought I wouldn’t be able to handle all the extra hours. Once I got into my new routines, it was challenging but doable.

That success in school meant getting up early before work to read, staying up late to complete assignments, eating lunch at my desk at work while reading, and basically using every free moment to pull out my tablet and/or phone and chip away at assignments. Oh, and doing schoolwork on every vacation for four years, including on cruise ships.

Even though it was hard, it was worth it.

Academia is very different then real world and professors have a book perspective on leading business. Look for a school that has professors who have worked in your field and can provide real-world perspective.

There were three things I wanted to do well: work, family, and school. I found that one of these always suffered, and since family had the least-noticeable short-term consequences, that’s usually what I sacrificed. In the long term, however, the family impact was significant and I ultimately stopped taking classes. For anyone who is married or has a family, I would ask them to seriously consider whether a lack of degree is truly what is holding them back in their career. For me, it was not, and school was not worth sacrificing family time. If you’re single, go for it!

I wish I had known that my academic medical center’s (!!) implementation of software and a third-party vendor was done to suppress the usage of their highly-touted education benefits. I stopped taking classes after it became too much of an exhausting chore to utilize the “XX credits per year free!” benefit. (The “Benefits” [sic] department kept insisting I needed to pay for classes and fees that should have been covered by the education benefit.)

That it is well worth it – should have started sooner! Don’t be afraid to take more than one course at a time so you can finish your degree.

That I would be giving up my personal time completely for three years to complete my graduate degree. Online and flexible sounded wonderful when I started, but on top of a 50-hour work week, it didn’t take long for me to be on the computer every waking hour just to keep up.

The struggle was worth the effort. It took me five years to complete what would have been a full year on campus, but having that BS degree allowed me to move on. Without it, I would have not been eligible for most of the positions around the country that I have enjoyed and friends I made along the way. Now getting ready to retire from this life in HIS-land after 41 years.

That it was going to take five years for a master’s. I would still do it; it was the best thing I did for my career.

That work levels are exponential with more classes when you have a full time job. One class seems like a class load of work, two seems like four, and three seems like eight. I suspect with so much time taken up with your real job, being a full-time student makes the impact on limited free time more forcefully felt.

If there was an option to move the registration of the course to incomplete, audit, or pass/fail when work falls apart. Time allowed for completion of incomplete.

I had a very positive experience in completing a master’s degree while working full time. But it could have been a very different experience and outcome if it weren’t for the following factors:

  • The program was an asynchronous distance learning program, so I could do the work at night regardless of when I finally got home.
  • There was a lot of flexibility in the time for completion of the degree, so I could limit myself to one course at a time.
  • The faculty were excellent. I was impressed by the other students in the program. The topics, even in the required courses, were interesting, all of which kept my motivation high.
  • I had some flexibility in juggling my work responsibilities as I wasn’t doing full time patient care and my work deadlines tended to have some advance notice.
  • I had very minimal travel requirements for my job and for the degree.
  • My spouse was supportive in every possible respect

Taking two+ courses while working full time is incredibly difficult, especially if you come home from a day at work mentally exhausted. My tip: wake up early and get schoolwork done before you go to work. It’s tough, but it can be done! I would not recommend taking more than two courses at a time.

I did this in my late twenties while earning my MBA and enjoyed it thoroughly. Having context for the classwork in my daily life kept my engagement level high and helped to develop my time management skills. I would not necessarily recommend approaching undergraduate work this way, as there are important social aspects to a college education.

What I Wish I’d Known Before … Selecting a Consulting Firm for EHR Implementation or Optimization

Make sure consultants have a basic orientation to your organization, especially around acceptable use policies, communication, security.

They don’t know everything — trust, but verify.

Don’t let them burn billable hours with your vendor or other consultants without your participation or approval.

The #1 job of consultants is to create fear, uncertainty, and doubt (FUD) that you can survive without them.

Don’t be fooled by the sample resumes. In most cases, it is unlikely those will be the resources on your project. Bait and switch is common.

Don’t forget to factor in travel expenses — the more distance, the more $$$. Make sure they find your travel guidelines acceptable.

Call lots of references. Not the ones they gave you, but others on their “we’ve worked for every health system in country “ logo slide. Find out who is on their A team and get them.

Check their quoted number of employees (many firms are 70 percent temporary people). Go to LinkedIn and see how many people actually list them as an employer. Find out their turnover rate (both senior management and staff consultants) — again, LinkedIn is useful for this.

Unless they’re sharing financial and other risks with you, they’re not your “partner.” Let them do something small successfully, then sign them up for something larger. Interview their consultants and ask hard technical questions.

Always remember that they know more about you than you know about them. Consulting firms are notorious at being opaque. Beyond them really screwing something up and you spreading the word, they have very little accountability.

That they’d then try to get me fired so they could put their replacement in as interim leadership and bill for it.

How they vet their consultants.

I wish we’d had more perspective on the specific skill sets those working with us would have to ensure they fit the roles as we’d defined them.

What I Wish I’d Known Before … Serving on the Board of a Company or Non-Profit

That the Robert’s Rules of Order my Dad had occasionally instigated at the dinner table would be so yearned for when pandemonium decimated meetings run by the unaware.

How critical it is to have goals and milestones. We are over a year into a new non-profit and just now getting a board of directors in place. If I had it to do over again, I would sit down at a organizational meeting and put 4-5 big goals on a sheet of paper or electronically with a timeline.

How few of the non-profit board members read the written materials sent before the meeting.

I wish I had known more about the company’s ability to actually focus on, and be accountable to, their strategic mission. This relates to the balance of operational needs, strategic directives/promises, and monitored deliverables.

After being on the executive team of a large hospital and taking up a board spot on a non-profit, I wish I had remembered how little impact (rightfully) the board has on operations. It’s frustrating to offer suggestions and get ignored.

That I would quickly come to hate the comment “we’re all volunteers” as an excuse for why people couldn’t get things done and no one was held accountable.

How complex the interpersonal relationships can be and how much of an impact those interpersonal relationships can have of the function or dysfunction of a board.

How much I would have enjoyed it and how much I learned from a management / leadership standpoint. No kidding. Maybe it’s the non-profit organization itself or the fact that my fellow board members are easy to work with and for the most part share similar goals for the organization. I am going on 12 years serving for this organization in some capacity (eight years on the board) and I love every minute of it. One day I will have to step aside and let another person get as much out of it as I have.

I joined the board of a non-for-profit charity to give back. I didn’t realize just how much giving I’d be doing and what the annual give/get really meant.

I wish I’d known that I’d be working with some other board members who were only on the board because they were busybodies and had no intention of reading relevant documents, including legal depositions, that we needed to make decisions on and vote. Ugh. Never again!

The backstory on infrastructure acquisitions and their political import. Local politics are horrific.

What I Wish I’d Known Before … Retiring or Career Downsizing

Clearly the hit on the paycheck is the first thing that comes to mind. But honestly, when I look at ROI between continuing to work and no longer working, it makes it all worthwhile. Which is to say, the incremental difference in the paycheck to continue to work does NOT offset the pain and retiring and giving up that paycheck was the right thing to do. As much as I enjoyed my job in the latter years, it was not so much because of my managers, but because I figured out how to make it work. I’m glad to be retired honestly. And don’t even miss the paycheck!

Wish I had known devastating effect of having your life and ego wrapped so tightly around the work you’ve done or who you do it for. Working for a prestigious company gives you an identity to colleagues, friends, and family. When that goes away, part of you goes with it. You quickly realize that you no longer have a big name attached to big resources.

How much I would miss the daily interactions and problem-solving. The sense of trying to accomplish something as part of a team is difficult (impossible?) to recreate sitting at home. Also, my failure to create a meaningful alternative hobby during my (limited) spare time while working. Be sure to get an engaging interest outside of the office and family.

Perfect time to pick up a new hobby such as programming, web / app development. If you already know a computer language, learn a new one. There are some amazing new tools to play with out there: Python, SQL, Angular, MongoDB, Web2Py, etc. All free, open source. Pure fun. Expanding your mind to new levels, not to mention acquiring some needed skills as well. As the song goes:

“Go ask Alice
I think she’ll know
Remember what the dormouse said
Feed your head
Feed your head”


I went from working full-time to retirement in two days. Wish I would have / could have worked part-time for a while to ease myself into it. I also should have tried harder to find another job before I retired. Biggest reason I decided to go when I did (which was about three years before what Social Security considers full retirement age) was because of an insufferable department director and an incompetent CIO, both of whom were gone roughly a year after I retired. But it’s all good now. I love retirement.

Although the finances are OK, I think I’d like to have built up a little bit more reserve and know how busy I’d be. It has been nearly 10 years since leaving the workforce. Time is spent on things that I never even thought about doing (genealogy research is a huge time-suck), and at the same time, being more “available” for whatever short- or long-term project needs to be done among friends and family versus trying to squeeze it into weekends. Some of these (house fix-up) projects span a few weeks, others a few years. Have not been bored at all, but also have not had time to take a nap, which was a weekly thing after a 65-hour work week.

I wish I’d known how much I would enjoy downsizing my career from being a large system CIO. The quality of life improvement made me realize how much I was missing, and not having to constantly play politics was a huge relief. Having said that, I do miss a lot of the people that I worked with, truly some dedicated professionals who are really trying to make a difference in healthcare.

That once you have a “5” in front of your age, you suddenly become the least desirable applicant for any job in your profession. It seems employers think that once you hit 50, all your knowledge disappears. I would never have downsized had I known that I could never go back.

I retired “early” primarily because I was on the verge of burning out, both professionally and personally. So it’s more what I did know before retiring and that I had prepared myself for the transition. Best move I ever made. I am a recovered workaholic and quite content.

I haven’t done it yet, but an planning on getting off the corporate (software vendor) rat race as soon as my youngest graduates high school in three years. I’ve been through countless acquisitions, layoffs, VC, PE, and makeovers over my entire career. It takes its toll. Career downsizing will be a sacrifice, but selling the house, not buying a new car, and moving back to Florida and living out on the slow lane near the beach is my dream. My advice to the young up and comers: the price is not worth the prize.

I wish I had known before retiring that retirement REALLY would be one more of life’s major change experiences, similar to entering kindergarten, going away to college, beginning the first job, getting married, having a baby, getting a divorce, losing a loved one through death, etc. No matter how much I planned or expected certain events to occur, it was (and is) challenging.

Even though I had prepared myself before retiring, I was surprised at how quickly I became irrelevant.

What I Wish I’d Known Before … Being Admitted to a Hospital or Being Seen in the ED

How much my ambulance / ED / hospital bill would be for a three-day emergency admission at an academic medical center in Tokyo. Being an American, I spent much of that time stressing about how much it would cost me, assuming I’d be presented with the usual five-digits-or-worse sums we get slammed with in the US. Turns out I didn’t need to stress out so much The ambulance ride was free, courtesy of Japan’s taxpayers. The ED workup, including tons of labs and imaging orders plus the three-day stay, ended up being about $2,000. I expected at least one more digit on that number. The standard of care and facilities was actually better than what I’ve seen at most US hospitals. A good reminder of just how absurdly out of hand healthcare costs in America are by comparison. In related good news, my employer’s surprisingly generous health insurance plan reimbursed the full cost, no questions asked, probably because it was way cheaper than paying for a comparable situation here at home.

1. In the Emergency Department, even though I confirmed with the reception-triage nurse that my physician earlier had called into the ED to discuss my condition and to refer me to the ED and hospital, my medical record, under referring physician, listed SELF-REFERRED.

2. For the next 5 1/2 hours, while I was waiting for a decision to be made about my painful condition and hopeful admission to the hospital, two or three of my “neighbors” in the Emergency Department room were seen and admitted to the hospital. In addition, an Emergency Department staff nurse who complained of flu onset was immediately admitted to the hospital in an available pediatric bed.

3. After another three hours, finally a call was made to the gastroenterologist on call, a Fellow. She never came to see me. I was told by the attending Emergency Department physician 1) that GF did not think I needed to be admitted; 2) that except for requiring a blood transfusion, which would be risky, I was “healthy” and I should be discharged home.

4. Three days later (after the weekend), when I appeared for a rescheduled Clinic appointment, I was immediately admitted to the hospital with intractable diarrhea, failure to thrive, iron deficiency anemia, and a urinary tract infection. I remained in the hospital for TEN days.

5. After discharge, ONLY one day later, the home health nurse, my referring physician, and the on-call hospital physician advised me to return to the ED so I could be readmitted to the hospital.

6. This time in the ED, an NG tube was placed down my throat. From the time I received the NG tube to the time I was finally re-admitted to the hospital, eight and a half hours transpired! I was told that the reason for this intolerable delay was that the Medicine and Surgery Department physicians could not determine what was really wrong with me, and so they argued back and forth about which service should admit me!

Information about your condition and treatment will be verbally communicated to you regardless of your ability to comprehend or retain it due to pain and medication. And your care is overseen by a series of non-employee hospitalists that come and go, leaving nothing but a bill and an 800 number where you can leave a message but never hear back.

Upon discharge, you will be given a paper prescription for three days of medication and instructions to contact your PCP that wont be able to see you for a week.

Within three weeks, the bills for out-of network providers that you don’t remember seeing begin to arrive and will continue to arrive over the next year.

The only coordination of care that exists is what you personally enforce so take notes as best as you can keep copies of what little information is shared with you.

I took my wife to the ED late at night one time. After a thorough examination of her condition (ectopic pregnancy / ruptured fallopian) and in consultation with her OB practice’s on-call physician, the ER team decided to wait for my wife’s personal OB to come in for his morning rounds to see her. So they admitted her, without really consulting us and considering any alternative options, for the few hours until he came in and could get prepped for emergency surgery. She had a private room for all of about four hours, but of course that resulted in a significantly larger bill. I wish we had known more about this plan and had an opportunity to weigh in on the admission decision.

My wife was admitted following a skating fall and a early evening broken wrist. The ED did not tell us that a doctor would not be available to set the break until the morning, when we could have gone to a nearby hospital and had it done right away.

Admitted after about twelve hours in the ER bay (not too much of a complaint, they’re a busy hospital) to a room shared with a women with an altered mental state who rang the nurse call button about once every half hour.

I was brought a hospital gown and trousers, which were left folded on a chair that was past the end of my bed. I was hooked up to an IV on one side, and a heart monitor on the other, so I couldn’t even crawl to the end of my bed to try and reach for them.

The main light in the room was a bright overhead fluorescent light that spanned the width of the room, directly over the head of both patient beds, meaning that every time they checked on her in the middle of the night, they turned on a light that shone through my eyelids.

Eventually they stopped turning it off altogether, so I had to try and sleep with a pillow over my eyes, while hooked up to a drip and a heart monitor.

Similar experience with meals: I was moved to a new room that was “private” (until the next patient moved in) and when dinner came around it was a fruit cup and nothing else.

  • “That’s what you ordered.”
  • “I didn’t order anything, I just got here.”
  • “That’s what the last person in this bed ordered.”
  • “They were discharged, they aren’t here to eat their dinner. I am.”

The nurse felt really bad for me and rustled up something a little more substantial, but the total lack of coordination and apparently awareness that beds turn over was startling. I made sure to order a nice full meal before I was discharged so that whoever came after me got at least something they could eat.

Being provided instructions by the nurse on how to make my own bed with new linens. I don’t know what to make of that. On the one hand, nurses aren’t maids, so it seems weird to be churlish that the nurse wouldn’t be making a bed, but on the other hand it definitely seems weird to ask a patient (who is still hooked up to a heparin drip with a heart monitor in the gown pocket) to do it.

I wish I had known that just because nurses don’t get technology doesn’t mean they can’t give you excellent care. At the time I was doing desktop support at a hospital and went to the ED with a particularly virulent GI bug. Due to a combination of factors, they decided to admit me after six hours in the ED. I went to the floor where I felt the nurses were particularly incompetent based on the interactions I had had with them about their computers. The care I got was wonderful and I was incredibly grateful and humbled.

The difference between being admitted and being observed.

That the hospitalists may not be in my insurance plan and I don’t really get to choose the one that will see me.

That the doctor treating me while at an in-network hospital was actually out of network. Then that HDHP out-of-network charge single-handedly emptied my HSA for co-pay and co-insurance.

Even though the wait at the ED seemed shorter than at urgent care, by the time you add in waiting around for the doctor to get results and then actually share them with you, it ends up equaling out, except from a money perspective. ED is definitely more expensive.

As CIO, I was shocked at how folks taking care of me used the systems we had deployed. In discussion with them, it turned out their training was not adequate or they were told “this is how we do it.” What disappointed me most was that my staff was well aware of it and had done nothing to improve the situation, including giving management a heads up. Turning that around took a long time.

I’m probably not a very good person to answer this one, but I honestly felt very prepared for my inpatient surgery a few years ago. I owe this to a pre-op surgery instruction program I attended which was hosted at the hospital a month or so before the actual day of surgery. My doctor and his staff were also very organized and on top of their processes before the day. I had all my questions answered, fears allayed, and was pretty ready to go on D-Day. In fact, my care while at the hospital was so good, I almost didn’t want to come home. Yep, I know, this sounds like a paid advertisement. But I think it was my own initiative to educate myself and the the doctors’ / hospital’s efforts to plan how to educate patients to be ready.


What I Wish I’d Known Before … Taking my First Hospital IT Executive Job

That shifting organizational culture takes time and patience. When you actually succeed and the culture starts to change, your employees who were barriers to change will start to leave the organization.

That budgets are boring and the software in the space doesn’t help. Where’s the digital disruption in the budget planning space?

How political and backstabbing a faith-based healthcare system can be. And how adeptly a CFO can play the game.

Hospitals still may not value the role of IS leadership. Control of budgets can be limited to the point of requiring approval for PC purchases and everyone in the department is viewed as a help desk function. Strategic vision and focus on critical topics such as information security are lacking. In those cases, your role as an IS executive is to prove your department’s worth and role in the organization and drive cultural change. This effort takes many years with seemingly slow progress.

That even as a physician executive, my clinical credentials would be a point of debate among all the physicians with whom I had to interact. They challenged my authority constantly because I didn’t see as many patients as them, didn’t see as sick of patients as them, didn’t see patients in their specialty, etc. They had a host of excuses for why they shouldn’t listen to me and unfortunately our senior leadership wasn’t willing to tell them they were full of bull and needed to just get in line. I had the last laugh though when I led the (successful) initiative with the operations side of the organization to change their contracts to require compliance with EHR use and tied it to their bonuses. Surprisingly, they all got in line after seeing a drop in their bonuses once the new contract was in place.

Not much because I did a consulting project for them before they offered me the position. So I had a pretty good idea what I was up against and how long I would want to work in that type organization. I also made it clear that if they did not agree with the recommendations in my report, they shouldn’t hire me. I’d recommend that approach (if available) to others to minimize unknowns.

That the same projects I rolled out quickly and successfully (1-2 weeks) in the mid-sized physician office where I was the boss would take months to years to complete in a hospital-owned ambulatory setting. Change management is easier when everyone is on the same page, but much harder when duties are dispersed over multiple locations and individuals with varying skill levels. Partnering with a strong operations administrator with experience helps ensure success.

Healthcare IT is messy. Gaining physician cooperation in institutions where they are not employed (which is the majority) ranges from tough to nearly impossible. Healthcare economics are messy.

As a CIO, how much of my job would be pure politics, trying to placate high-production specialties practices and physicians whose productivity (and income) was negatively impacted by EMR implementations. That and the realization to whatever lip-service we received from the rest of the C-suite regarding “innovation” and “investing in technology to improve patient care,” IT was always viewed as a cost center, and when the inevitable cuts came, IT is at the front of the line. Having said all that, given all of the challenges, discovering how rewarding it could be when you accomplished despite the obstacles.

Most hospital CIOs are politicians, and as such, are reluctant to measure the value of their projects, like ROI.

Existing politics and relationships can be your death knell. When you arrive to your first C-suite job, be mindful about these two items. If you are not, it can put you in a very bad position. My advice is to use the two ears-one mouth ratio to listen and observe to figure out what is what. There are many reasons the team you just joined is there. They have most likely figured out how to keep their high-paying, high-perk jobs and they are not about to let the new person on the team mess that up.

Real power does not always lie with the obvious titles. Try to become aware of who is really running the show and who the CEO really relies on. Also, some CEOs promote politics more than perhaps they should. It then becomes high-stakes gaming where you, as the newbie, will lose if not careful. It is a harsh reality of many C suites, but it exists. I have worked in six organizations with various levels of C-suite politics. Four of them were fraught with really messed up, toxic behavior. Two were not.

Even with that said, I would not trade any of those experiences as it has helped prepare me for the job I have today. In my current role, while I have our office and company politics fairly figured out and know when to speak up and when to duck, it is a constant part of the job to help ensure I am not a casualty from an ill-timed or ill-placed remark or taking a stand when I could have just let it go. It is truly an art at this level and takes a lot of practice, observation, willingness to not die on every hill, and of course a bit of luck.

What I Wish I’d Known Before … I Quit My Job to Go to Work for Myself

How much you need to understand your strengths and weaknesses, and that just because you are great at a particular skill in your industry, it doesn’t you’ll be great a running a business in that industry.

That I would work harder and longer for myself than for any other boss or company. And that I would have more fun and freedom! Too bad healthcare insurance availability and costs for small businesses are pushing me back to working for an employer.

That I haven’t done it yet. “I don’t have an idea, what if I fail?” Fear is a shitty thing. For those who have, give those of us who haven’t hope, but don’t sugarcoat it!

I knew the cost of health insurance would be a large expense. However, I didn’t project that the cost would more than double from one year to the next.

I should have done it SOONER!

I wish someone would have hot me over the head making sure I comprehended the true cost to do business. Business registration at the state and local level, general liability insurance including automobile insurance, you’re your own technology shop, meaning you will have to buy and install all your software and hardware and configure it so it works. It is probably 25 percent more expensive than you think to start a new company.

Before I quit my job to go to work for myself, I wish I had known that 30+ years later I still would be happy having made that important decision.

That my finances were going to take a larger hit than I expected not because my business didn’t take off (always a known risk), but because it took me longer to get back into the job market than I had expected. Although I had very competitive job opportunities, my personal situation had changed while working for myself, precluding most travel or moving out of the metro area I was in.

That I had the skills, knowledge, expertise, and professional network to quit an established position and start our own firm. Wish that I’d had the confidence to do it a few years earlier.

That it doesn’t matter how successful you are right out of the gate — hire a salesperson. I didn’t because a series of old clients signed with me just after starting my new company and I became overconfident in my success. I know now that selling while you are successful sure beats trying to catch up when those early contracts start expiring. Also, as the owner, president, and chief guru, it takes a full time salesperson and you won’t have time to be that if you’re doing everything else, too.

Nothing. If I’d not been naive and ignorant, I probably wouldn’t have started the company. My ignorance allowed me to ignore the risks and take the leap.

Everything takes longer than you think. It is not easy for organizations to decide to work with small firms, even if the individuals at those firms have stellar resumes. The security blanket of a big brand name drives revenue, even if the quality of services from small firms is generally substantially better.

The sheer terror of the roller coaster ride of income and no income. It’s debilitating and drains every last ounce of downtime from what is already an oversubscribed schedule. Say goodbye to relaxing at the weekend or even on Sunday — you spend 24/7/365 working or thinking about work and where the next penny will come from. As for the clients and choices, it’s amazing how cheap companies can be when considering payment. They all seem to forget that at least 50 percent of any fees go directly to basic costs that are not covered when you are not an employee (billing rate vs. take-home rate).

Chasing after unpaid invoices is definitely one of the most unpleasant aspects of being self-employed. One positive impact I didn’t anticipate, however, is the way it makes you think about time and making every minute count, whether you’re working or not. Also, the sense of satisfaction gained from building your business and knowing you’re helping your clients is extremely gratifying.

You wind up being put in the tough position of actively having to sell your services simultaneous to having to wind down your existing assignment. That puts a strain on you, and for those of us who got into being solo to do more as opposed to sell more, it could be awkward to have to wear both those hats. It also reinforces the message that, as a solo practitioner, when you are not working, you are making zip. No PTO, nothing like that. A little extra pressure!

In a startup of one employee, I loved setting my own schedule, driving to my own goals, and working from home. But I realized I missed the interaction of other co-workers, being part of a team, and having my home be a home. If i was building a product, I would have stuck around longer to foster it, but I was doing consulting and contracting, which is hard to scale.

How much happier I’d be. I’ve observed two kinds of consultants – those doing it to stay in the flow (and make some money) while waiting for their next real job and those for whom it is their real job. No right answer, but it helps to know which you are. Today’s technology (Google Apps, Dropbox, VOIP, Upwork, and more) make it easier than ever before. A few pointers: Get a domain name – Gmail suggests you’re not committed. Consider forming an entity like an LLC or S-Corp. There are great retirement benefits available such as solo 401(k), if your revenues allow it — remember that any savings match comes from you, so need to take it seriously. If your business can support it, a virtual assistant can give you great leverage for scheduling, invoicing, and other routine tasks. Take advantage of the flexibility it provides in your life, though the flipside is you can always be on call.

The cost of being self-employed. There are direct costs, such as self-employment taxes and insurance benefits: life, health, disability, and professional liability insurance, and indirect costs, such as handling business development for the next assignment while executing the current assignment. And handling contracts is brutal. I once had a government organization ask me to sign an 80-page contract for a job that was worth a couple of thousand dollars. We eventually got it down to three pages because I refused to sign a document that would cost me more in legal advice than the job would pay for my services.

You will need an accountant. You will pay for an accountant. Even if you think you can do it yourself or fall victim to the “QuickBooks will do my taxes for me” idea, you will need an accountant.

What I Wish I’d Known Before … Taking a Travel-Heavy Job

I wish I’d been aware of the social isolation and pressure to get things done in my limited time at home. There are friends I used to see regularly that I haven’t been in touch with for years now. With weekends really being my only time at home, I spend the majority of that time doing things that need to get done around the house, running errands, going to the doctor. It doesn’t leave much time for a social life or even seeing family.

Whatever your lifestyle health-wise, it will just be amplified by the travel. Work out regularly now? You’ll have an even better schedule to accommodate it. Not great about getting to the gym? Don’t romanticize that travel is going to help with a gym in every hotel. It only makes it harder and you’re eating restaurant food more than ever.

Choose your credit cards wisely to maximize perks.

The importance of inflatable lumbar support pillows. And how difficult it is to do any meaningful work on flights — neither the environment nor the ergonomics are conducive to productivity.

How much I would miss my family.

I wish I’d known I wasn’t as adventurous as I thought I was. Turns out I don’t like exploring new cities by myself.

I wish I’d known how much of my weekend time would be spent playing catch-up: dry-cleaning, laundry, cleaning, friends, family. All the little stuff that gets spread out through a normal week is condensed into two far-too-brief days.

I wish I’d bought shoes that were more comfortable.

How much I would miss my son. I originally thought that early mornings to the airport, overnight stays, and getting home late at night would impact my ability to get things done, find time to exercise, eat well, etc. However, I was quickly able to adapt and those areas of my life were not impacted. The hours from my son was the toughest part. I no longer weighed the time traveling with the time or more productive time in the office. I now weighed that time with the time a way from him. I’ve since left that job and started my own company where I can control my time based on its REAL value.

How it can strain a marriage. After doing it for 5+ years, we had not much in common. Weekends were spent catching up on chores and then getting ready to leave on Sunday or early Monday. We have no children, so we made the decision for him to spend several weekends with me at my long-term location to give us a common talking point, which did help. I gave the job up after six years and the marriage is still going strong at 41 years. The good part about the travel was the friends I met and have kept across the country and the experiences I would have never otherwise have had. I’ve been sailing in Long Island Sound and also experienced Fleet Week on a house boat in San Francisco Bay.

That the clients were actually interested in applying best practices vs. creating more layers of status quo.

Always bring workout clothing on a trip. You never know if you’ll get the chance to hit a great gym or run even if you’re not in the mood while packing. Always keep a charger, a pair of socks, and some cash in your briefcase or backpack.

You have to live on the road the same way you do at home, meaning that you must have the discipline to maintain your diet and exercise routines and not succumb to overeating and drinking.

That my employer mandates carry-ons (won’t pay for checked bags), requires adults who have never met to share rooms, believes that $45 per day will cover three square meals in major cities, and refuses to reimburse tipping of any kind.

Working a 12+ hour day. You pretty much need to be available to meet with the customers during THEIR 8-5 day job, but you also have to prepare for those meetings, etc. after the normal workday is over. I’ve seen this in both sales and implementation roles. Some companies are cheap and insist that you stay at low-end hotels (think Ramada Inn with outside doors) and have all kinds of budgetary constraints. It’s kind of hard to ask for the travel expenses policy during the interview, but somehow try to find those things out. 

Buy a second set of makeup and leave it in the suitcase for travel days. Get the back-office phone numbers for airlines and rental cars and call them as soon as you realize your plane is delayed and you need to book a hotel or car before the rest of the herd. I realized that there is an entirely other population of people on this earth who are “travel people” and they know a LOT of stuff. Talk to them as you wait to board your plane. They can save your hide some days.

When you do the math after you divide the number of real hours worked into the salary you accepted, you really only earn $2.50 an hour.

If I had one thing to do over, it would be to somehow add a day (on my own dime) and explore the city I had traveled to. Easier said than done, as most days I just wanted to get home, but sounds good anyway.

That regardless of travel schedules, colleagues still expect you to respond in a timely manner, which means working at night to catch up on all the day’s missed emails and phone calls.

How I would always be tired and spend my weekends doing expense reports, laundry, and sleeping.

While during my interview process I was asked if I would be willing to travel for my job, I didn’t think much of it, given the position description stated 5-15 percent of my time would be on the road. That’s not much, right? I should have known something was up when, on my first day, I was asked if I had a valid passport. Nineteen months later and more than 300K air miles logged from monthly trips to Europe, Asia, and plenty of domestic trips, I left after I couldn’t sleep for more than 90 minutes at a time. I could never get my body clock adjusted to all those changing time zones. Some people are cut out for it, but I learned I definitely was not one of those people.

Wish I’d known how agreeable it would be to the way I like to work. Depart, immerse, get it done, then go home. Rinse, repeat. And when I am home, I mean I am HOME.

Get a credit card that offers lounge access. Sure, it’s good to have a quiet place to work, but I also really need a place to get drunk after a flight delay at the end of a long work week.

You will lose all track of time and the seasons of life. I remember once sitting in a boarding lounge and a family was sitting in the row behind me and they were taking their son or daughter to college and it was an emotional discussion. I was touched by it, but was so consumed by my conference schedule that I didn’t even realize that the seasons of life was going on all around me while I was going from the Javits Center to the McCormick Place to Moscone Center and so on.

If you are single, your friends will stop inviting you to events because, well, you are just never home.

Flying sucks. It is exhausting for your wife who has to keep the family ship and the sailors (the kids) on course while you are gone. Eating out all the time is tough on trying to stay in good shape. As I have gotten older, the three-hour time change from West to East Coast has become a bigger impact on the sleep pattern. At least there is Uber and Lyft now so I don’t have to hassle with rental cars as often (those guys must be having a major negative impact in the revenues of Hertz, Avis, etc.)

How much weight I’d gain if I did anything other than maintaining a disciplined diet and exercise regimen.

That there is no benefit to letting the corporate office handle travel plans. Make sure to negotiate the ability to control your own travel, get a good travel-specific credit card, invoice for your expenses, and then reap the rewards. It took me a full year on a job (three weeks of travel a month) before someone let me know they asked and corporate agreed. Within the next six months of travel, I had upgraded status on all of my flights and hotels and had enough points to take my entire family on a vacation we’d normally never afford.

Unless you are going to or coming from a meeting in which specific attire is required, always fly in specific travel clothes. When you get to your destination, put all of the clothes in a bag (they are covered in whatever grossness wasn’t cleaned on your flight) and don’t touch them until it is time to fly home. This way you limit your (and your clothes’) exposure to travel-related disgustingness to just one outfit. I have sat on broken airplane seats and ruined suit pants, I have had people miss the emesis bag and get it all over a nice dress shirt, I have seen and smelt unthinkable things. But luckily I am now forever wearing clothes that I don’t worry about when it all happens. When you get home, toss them in the wash on “kill everything” cycle of the washer by themselves and you’ll feel like you are keeping germs and stink (relatively) at bay.

Try not to take travel-heavy jobs. Honestly, they are just not worth it. The novelty wears off, the lack of life balance is endemic to those you’ll meet, and in the end, you’ll be grateful you decided to find something closer to home. Unless it is a once-in-a-lifetime opportunity, keep looking instead of being a road warrior. Very few people who have retired from travel-heavy jobs have ever told me they really enjoyed it. If you can, try NOT to take the position.

Clinical depression is highly likely. You’ll become almost obsessed with maxing out loyalty programs. Wal-Mart becomes a source of “healthy” food in rural areas. Too many people have pre-check. Too few airports have dedicated pre-check lanes. Getting squishy/soft/fat is almost inevitable. Vented car seats are heavenly. Podcasts are your best friend.

How much time would be wasted from flight connections when your home airport isn’t a major one.

The impact to your family is huge. You have to have a good support structure, and if you have kids, you have to have backup plans in place for the inevitable sickness or childcare issue. You also need to really understand your company’s policy up front about scheduling your travel and the ability to dictate some home weeks when needed.

That US companies do not consider travel time as work (contrary to labour laws where I live).

The importance of willpower and honoring your commitments. It’s too easy to cheat, in every aspect, when you’re on the road.

I wish I’d  had access to a company handbook to verify printed policies. The manager I was hired under explained that we travel Monday and Friday and are on site with clients the rest of the week. If we needed to travel on a weekend, we’d receive comp time. He retired and was replaced by a manager who felt that as salaried employees, we didn’t deserve comp time, so there were many go-live weeks where we worked seven days or even back-to-back weeks that formed 14-day hits without a break and with no comp time. When we investigated, it turns out the company handbook is mute on the subject and it’s up to manager discretion. This would have been different if we were consultants or if we were bonused on billable hours, but we weren’t. Needless to say, there was a fair amount of turnover under the new manager (me included).

The negative impact it would have on my health. Too much airport food and booze and not enough sleep or exercise.

How a travel-heavy job would negatively impact my health. The inability to exercise on a sustained and regular basis, sleep deprivation, constant exposure to sick people on airplanes and buses, and constantly being expected to lavishly entertain clients with lots of alcohol all contributed to a pretty rapid decline in overall health and fitness.

Join an airlines club like American Admiral. if your employer won’t pay for it, you can usually use miles. When your flights get scrambled, the club staff will get you re-routed faster and with preference.

It makes it very hard to have a normal social life in your home town. When you travel all week, you tend to want to stay home on the weekends. If you don’t have a strong local social circle, this can make it tough to meet local friends. It also makes it hard to participate in community events or take weeknight classes (i.e. personal enrichment classes). I left a strong social circle in my 30s and moved to a new town on the opposite coast just when I started traveling full time for work, and 10 years later, I have thousands of frequent flyer points (and some fabulous global travels) but not one new friend in my new town. Something to think about.

As a business traveler, the last thing I want to do on weekends is travel some more. It has affected my desire to do weekend getaways, camping trips, and weekends away with the guys way more than I would have ever expected.

A travel-heavy job really reduces your ability to be involved in the community, be it board involvement, local government, or coaching a kids’ sports team. Getting involved is a lot easier if you are home every night of the week.

Sometimes an existing job you took without much travel can later turn into a job with heavy travel expectations, so apparently flexibility is just expected if you want to keep your job.

The travel T&E policy, in detail. Preferred vendors. Expectations about traveling on Sundays and holidays. Coverage for airplane WiFi. Will I be carting executives around with me all the time? Can I get executives or experts to come with me when I need them?

How tough it is on your body as you age. Back problems waiting to happen.

When I was in my 20s and fresh out of graduate school, I took a travel-heavy IT healthcare job that was exciting, challenging, and fulfilling. It was at the inception of the healthcare IT industry in the 1970s and everything we did was new. This lifestyle did not promote the ability to carry out personal relationships in an ideal manner. I was focused on my career and did not consider the long-term ramifications of not having met “Mr. Right.” Eventually I did meet and marry the right person, but by this time I was in my 40s and not able to start a family. We have been happily together now for 25 years and I recently retired from the healthcare IT industry. During this entire time, I continued weekly travel with the exception of a few positions I held as a direct employee of a healthcare system. The travel takes its toll, but the chance to work with many different organizations and people throughout the USA and Canada was very rewarding. My husband used my weekly Monday through Thursday absences as an opportunity to complete his PhD and he continues to work as a professor for a well-known online university.

What I Wish I’d Known Before … Going to my First HIMSS Conference as an Exhibitor

I knew HIMSS was a big conference, but I didn’t realize that the impact would be that it is just hard to move around and accomplish a lot. You never really get to see the whole exhibit floor or do a lot of things because it just take so long to get there. Food lines are long, there’s no place to sit. It’s a complete workout. The startup pavilion has some of the more interesting companies and the big vendor booths are very impersonal. Then, when it is all over, you wonder what you really accomplished or learned and if it was worth all the trouble.

Wear really, truly comfortable shoes.

That my exhibitor badge gets me into educational sessions as well. Someone more experienced at these events helped guide me in finding helpful sessions for my area of expertise.

Very long hours on your feet. I have a pair of super supportive shoes I call “my HIMSS shoes” and I am never without them.

HIMSS is all about making and strengthening business relationships. But on the floor, you literally have about 30 seconds to get someone’s attention and earn the right to have a meaningful conversation.

As an exhibitor, it can devolve into a party atmosphere, quickly. Pace yourself.

Wear comfortable, not necessarily stylish, shoes.

Wear comfortable shoes!

The exhibit hall is like the Caribbean, full of ports (booths) and buyers are like cruise ship passengers. The enthusiasm doesn’t always stick once they get home and visitors will confuse ports/vendors. Give them something memorable (in good way) and be prepared to present again after HIMSS if you want them to truly remember anything you showed them.

Be careful about scheduling meetings first thing in the morning after the first day. Last day first or last are the worst times for any real business to happen.

Stop at two drinks. Period. It’s possible, even likely, that key people in the industry are around you at all times, even 1 a.m. in the hotel bar. Remember that this is your career and you’re making an impression even after exhibit hours are done.

Make reservations for every anticipated meal, even if for two people, as everything will be packed. And, if invited to a meal by a vendor, verify that that vendor has a reservation inclusive of all invited attendees. I attended a breakfast at a previous HIMSS with a vendor where the rep from the vendor did not make reservations for an intolerably crowded joint and eight executives huddled around a bar-height bistro table for two in the hallway of the casino discussing the strategic direction of our partnership.

How your message gets lost in the noise and the value proposition is questionable, unless you are one of the larger vendors.

The amount of time you will be on your feet. I have HIMSS shoes, comfortable, dressy shoes half a size too big with the most cushioning insoles I could find and hiking socks.

Establish scheduled meetings before or during HIMSS if you are looking to sell (vs. touch current customers, develop business development relationships, or perpetuate your brand). It is not worth pulling anyone off the floor to learn about your product anymore since, unlike in the early days, most of the folks walking the floor are fellow vendors.

HIMSS is in a conference that companies in the healthcare information technology industry must attend even, if the value for doing so is minimal. Pulling out is a public red flag that there is a problem or at least a big change in the company. So we go and represent with minimal expectation of value, but it can be fun for the team selected to the representing.

What I Wish I’d Known Before … Taking a Job Selling Software to Hospitals or Practices

I wish I would have known that the company had a policy of customizing the application to whatever they thought the prospect needed. Functionally what we wound up doing was demoing vaporware, and there was no way the clients would ever get that content without customizing. It’s entirely unethical. I was gone within a few months.

As someone who has started two small HIT software companies (both acquired by larger HIT companies) and was responsible for designing, selling, and implementing the systems and overall customer satisfaction, a couple things I would want to know:

What is the main value that customers get from the system?

What percent of the customers get that value? (Software companies love to highlight their reference sites, but what is more important is what benefit do the majority of the customers derive from the software. Reference sites are nice, but even a blind squirrel finds a nut once in a while.

Can you quantify the value?

How does the value stack up against the investment?

How long does it take to get the software installed and how long before the customer starts receiving the value?

How much work is it going to take by the customer to get the software running and keep it up and running and is that amount of work and cost part of the return on investment analysis?

Why would a prospect buy the competitors’ products rather than the product we are selling?

What is the customer retention rate, and don’t include the customers that have to renew because they are in a multi-year agreement. I would want to know what percent of customers renewed the last 2-3 years that had the option to turn off the system.

Do Epic and Cerner have a similar offering?

What is my quota and how have the current sales team done with respect to that quota over the last two years?

What is the retention rate of the sale staff over the last 2-3 years?

How long has the sales leader been in the role?

Can I live in San Diego?

Do I have to wear a tie to client meetings?

Most of the people you talk to or not meaningfully involved in the decision-making process.

The people who are using your software are often not at all involved in the decision process, which injects hostility once purchase and deployment happens.

Don’t sell your software without the client having a strong change management plan in place. The sale is usually worth less money than having your name dragged through the mud later if adoption is poor.

You should aim to sell one client multiple things over the course of a long relationship more than trying to get clients.

Take your estimate of the sales cycle and double it.

Old-fashioned networking and being able to discuss specific use cases that resulted in success are the best methods for selling. Healthcare is not very impressionable by social media, content marketing, email campaigns, or other more modern marketing tactics.

How lonely the job can be.

For five years in my career, I sold an EMR to physician practices. Looking back, I wish I had understood better the degree to which physicians lacked the appreciation of the overall efficiency and throughput of their practices (which they usually owned) versus their role within the practice. Most thought only in terms of themselves and their own time, and these were the ones that struggled or refused to modernize their practices (also usually the ones with full waiting rooms of frustrated patients). Those I worked with that recognized that they were a part of a larger system embraced changes to their practices supported by EMR, they flourished, and tended to have happier patients with shorter waits for appointments.

How difficult it was going to be to accurately forecast when the sales would close.

My job is a hybrid, or at least it’s supposed to be. I have a half dozen clients that I am responsible for their satisfaction as well as a quota for each client. However much our company likes to say “It all comes down to satisfaction! Keep your clients happy!” and even with tying a portion of our compensation to client satisfaction surveys, it’s obviously all about selling. Leadership would rather you sell whatever you can, however you can, even if you piss off everyone in the process. It’s a very short-sighted model, but with how the direction this company is moving, I’m not very surprised. If you have any ounce of empathy, or like to forge client relationships that focus on more than dollars and cents, selling may not be for you. (If there are companies we can work for that actually give a hoot about clients beyond what they buy quarter to quarter, please share!)

That some of the “function and features” are pure vaporware. They haven’t been tested or met compliance in any setting other than the developer’s environment. This obviously causes major concerns from the client at go-live. I end up selling future versions that a user will not experience until 12-24 months later.

In no particular order or rank, here are a few of the things I wish I’d known before getting into the HIT sales field.

The training for salespeople is very limited and you’ll hear, “We don’t want you to train them, just sell it.” My product training for my first job included watching two demos of the application by my manager, one of which was provided while we waited for our plane at the airport. EHR software is complicated enough that vendors should either sufficiently train sales reps or use product specialists for all demos.

You’ll want to ask a lot of questions about your territory (how often does it change, how successful were previous sales reps, what is the turnover in this territory, are there any/many happy customers in my territory, etc.) to try and figure out if you really can make your numbers. Sales managers like to pretend that all sales territories are created equal, but they are not.

To truly provide a demo that shows a provider how your software works for their workflow, you will need to do a discovery with the provider or someone who truly understands the workflow. In the ambulatory physician space, it can be very difficult to get face time with the doctor and critical staff, so you know this beforehand and be able to prepare sufficiently to show them what they want/need to see. This discovery isn’t or shouldn’t be done to use smoke and mirrors and trick the staff. It’s no different than a doctor not being able to accurately diagnose a patient unless they’ve had sufficient time to do an assessment and evaluation before they prescribe the correct treatment. Salespeople should really refuse to do demos if they don’t get this time, but as long as they have quotas, they will do it.

Many physicians and their practice staff won’t bother to complete the requisite pre-work before their implementation, which further compromises their ability to optimize the expensive software they just bought. It is time-consuming, but it’s usually a question of “pay me now or pay me later.”

Not sales, but working in HIT for 16 years for companies that sell commercial software to doctors and nurses. I wish I’d known about the stress of being morally compromised on a daily basis as keeping my job (and thus my ability to pay my rent and buy food) requires either doing things I know are the wrong thing to do, or not doing things that are the right thing to do (way more of the latter than the former, fortunately). I’ve seen some very dark instincts on the business and technology “leadership” side of the house. If you ask why I stay, the only answer I have is: if I leave, that’s one less person banging the drum for what is right.

How often solutions aren’t fully baked before companies try to package them as GA.

Does the product actually work? Can the company actually implement and deliver it? Can they support it? Do they have any idea who will actually buy it? And who pays for it? Too many healthcare software companies I’ve worked for/with think that “if it treats patients better” or “makes the organization better” or “makes clinicians better” or “makes patients safer” (etc.) their product will fly off the shelves. All you, Mr. Salesperson, have to is bust your hump, get in front of the right people, and do your sales magic. Healthcare sales today is ALL about compliance or cash. C-Levels are only buying that which they HAVE to have, will save them money, or make them money (hard ROI).

Who are the competitors who are investing in the same product line?

While software is 100 percent margin, software companies in healthcare don’t want to pay as much as other technologies and their products are usually late.

I was in a sales support position, demonstrating application software. I suppose I was naïve to think that I would have to stretch the truth about the functionality of said software. Salespeople would provide me with what my response should be to certain questions. To which I stated, “That’s when I turn to you, because I won’t lie.” Ultimately, I transferred to another department within the vendor company to training so that the end user would find out how the system really worked. I would hear, “But they said [that being the salesperson] the system could do that.” To which I replied, “I know what they said, but I’m here to tell you the truth.”

What I Wish I’d Known Before … Bringing an Ambulatory EHR Live

That technical dress rehearsal issues would get ignored or not addressed before the go-live. Wasn’t that the point of the TDR?

I wish I knew ahead of time that the EHR vendor outsourced their support to a third party. This arrangement created speed bumps to getting real support answers relayed from the EHR vendor through the support vendor.

I wish I knew how effective running a mock clinic was for training providers, especially physicians. An EHR analysts plays the role of a mock patient and gets checked in, roomed by the MA or nurse, seen by the doctor, and checks out. Ideally, the provider completes common orders, does a note, and charges. Any system problems can be caught by the analyst and a trainer can be at the elbow of each users. It is a little labor intense, but the clinics come back up to full speed much sooner. We had one ophthalmologist seeing 87 patients a day within one week of go live. His partners that didn’t do the mock clinic took weeks to get back up to full speed.

To what degree provider productivity would be negatively impacted and how that would impact the productivity-based comp plans of physicians and administrators. There’s a reason CIOs have a hard time surviving an EHR implementation, first among them messing with peoples’ pay checks.

How to generate sincere engagement for the implementation with the clinicians and staff as beneficial to their patients and care delivery. And helping all to make the project not just about the billing.

We learned after the CIOs and people allowed in the room had chosen Epic just because, that all non-Epic apps that were to integrate into the EMR had to have a test environment, or else integration was denied. Even apps with fewer than five users. Go-live was pushed back months, there no budget for this, and rebuilding non-Epic apps took time away from learning and building the actual future EMR and getting certified.

Focusing on optimizing physician workflows and making them as efficient as possible is absolutely important, but the same amount of effort must be made for the other roles on the ambulatory clinical care team: nurses (especially nurse triage), medical assistants, in-house laboratory and radiology, as well as all other ancillary services provided by the practice. Ensuring that the physicians are happy should not come at the expense of everyone else in the practice.

What I Wish I’d Known Before … Implementing a Vendor’s Cloud-Based System

You still have to work at the application’s care and feeding – you can’t just “dump it in the cloud” and expect all the problems to go away. Some of them will, but not as many as you think.

The Internet gets slow and breaks more often than you think, especially when vital services are at the other end. Downtime procedures are even more important.

Do the research to figure out what all the pieces you will or might need are. Once you’ve done the big deal, you have very little pricing leverage until you have big money to commit again. Example: a full-copy test environment. With one well-known CRM vendor, those environments are priced as a percentage of total licensed product. That makes sense in a way, because a full copy is just that — a full copy. However, that also means that the cost of the environment goes up when you add more products or add-ons to your list of licensed things.

They seem to track their application only up to the point where it leaves their data center or Cloud Source. Anything else between their address and my user location is left up to me to figure out if there is a problem with the application and my users. We have had to go to other third-party products to get the health of the Internet between the SaaS source and our end users. Yet they (the SaaS source) blame our internal network setup for any end response issues at play. Very tired of hearing “none of our other users are having that problem” when the problem lies in the health of the general Internet and not our last mile.

Was the solution architecture design for the Web and cloud, or was it client-server front-ended by Citrix?

If it’s your first time down this path, your internal HIPAA team or legal may end up having no idea what to do with it based on their standard vetting process. You might have to take additional time in the implementation for back and forth with the vendor to while they jump through whatever hoops are placed in the way to get a green light to implement or even sign a contract.

I’ll have to pay to get my data back.

The importance of not just a DR plan, but a business continuity plan. You are not in control of when down applications will be available, but you still have patients to care for and business functions that must continue. Always have a plan and have it readily available for staff.

You won’t necessarily have full access to the database or software maintenance tools. Ask in advance and put a plan in place on how when data will be accessed / software changes will be completed.

You will spend a lot of time explaining your business operations. Analysts go from those making configuration changes to someone who needs to partner and fully understand business processes and operations. Vendors will not successfully function as your systems analysts.

This was 15 years ago. I wish we had known the true cost of going to the cloud. Verizon charged us a ton to install a redundant pathway to the Internet after questioning why we wanted to do such a silly thing.

Wish I’d required more detail in how my data will be turned over to me at contract termination. Our outgoing ambulatory EMR vendor refuses to hand over our contractually mandated export until the day *after* our account is turned off, giving us zero opportunity for smooth migration to the new vendor.

I wish we better understood and negotiated standard maintenance windows and patch load times for production issues. We sometimes have to wait weeks for patches and get a nine-hour window, any time during which the system could be brought down to install the patch. I also wish we had better prepared ourselves for the challenges of offshore support. They only want to talk via the ticket system and you have to try hard to get them on the phone or a WebEx. It really exposed now poor our internal support was since every issue required going through this painful process with the vendor support.

What I Wish I’d Known Before … Replacing My Hospital’s Time and Attendance System

That our hospital’s Time and Attendance policies were not being applied throughout the organization equitably in all departments.  We found a lot of departments that were providing extra incentive pay to nurses in order to boost their salaries. Other departments were making up their own on-call pay programs for their personnel.

That employees were getting around showing up late by not punching in and then later stating that the system must not have worked when they “clocked in.”

Anything that directly or indirectly to do with payroll is EXTREMELY sensitive. Expect people to freak about any test results that don’t match the result of the existing system in payroll, down to the penny.

If your facility is non-union, and has been working to stay that way despite onslaughts by SEIU and others, expect to deal with lots of very complex pay premiums. Don’t be surprised if disgruntled employees and/or organizers try to make something sinister out of the system change.

Place time clocks in areas with enough room to hold all the employees standing around waiting to clock in in the morning and clock out in the afternoon.

If your internal sponsor is the HR director, make sure that you reassure that person early and often that the system change won’t accidentally result in pay changes.

Hospital pay rules are more complex than any other industry, sometimes exceeding the capability of non-healthcare specific payroll systems to handle them. It was shocking to find how many departments were running their own unapproved overtime, call time, and bonus programs in direct contradiction to hospital policy. It takes a lot of time and finesse to find these exceptions and then some HR backbone to bring those departments into compliance instead of building rules just for them.

If your implementation involves installation of hardware, allow lots of time to make it happen. Hospital construction can be very tricky from a permitting standpoint.

Plan to run tests through month end and end-to-end with payroll to make sure everything is perfect before you agree to a cutover plan.

Don’t let Procurement sunset the contract with your existing vendor until you are absolutely confident in your cutover dates.

Policy over technology. Users run in the door and swipe at 8:14:59, then get ready for work, and out the door at 4:45:01.

Pay attention to the choice of letting employees clock in by telephone and limit that to in-house phones.

Expect managers to express shock and indignation that it’s their job to review time clock reports against reality. And to look the other way if they’re worried the offending employee might quit over being paid accurately rather than generously.

I wish we had understood the complexities of overtime, the number of salaried employees that are required to clock-in/clock-out even though their pay doesn’t change (and the frequency with which they forget or delay their swipe), and I wish it was understood exactly how much manual overriding would be needed over the first four payroll cycles to make sure employees were appropriately paid. I also wished we had budgeted for all of the overtime required for staff that were perpetually on call to handle these and other issues during the transition period. In short, I wish we knew everything since what we actually knew was nothing, and our vendor was complicit in helping us fail pretty spectacularly during the process.

Will employees be able to access accrued PTO in their current paycheck (leaving a zero PTO balance) or will their pay be docked even though they have PTO remaining? This “feature” has to be manually overridden by our HR personnel with management approval.

How difficult is it for employees to enter multiple days off in a row. Do they have to do every single day as a separate entry or is the multiple-entry feature seamless and user-friendly?

That a focus on staffing workflow impact is equally or more important than the specific technology. That includes integration with upstream and downstream systems.

Don’t underestimate the creative nature of employees clocking in and out. Before we got wise and changed it, some would stop and clock in and or out at our remote locations (30-45 minutes away) and then drive in to the hospital. We noticed a spike in overtime. Also we noticed an incredible number of time sheet edits by non-management folks who had the authority previously. Their role went away and the authority moved to managers (some of whom argued it wasn’t their job?) Every management level now had to sign off for their areas. The number of edits decreased but it took a long time and a lot of oversight.

A story about a payroll system. I don’t recall the name but it was a Mom & Pop vendor (Mom was the CEO and Pop was the techie) selected by the HR division. On January 31 with no other option, we had to mask out the SSNs on a couple hundred (or more) printed W-2s, then run them through the printer as blank sheets with a correctly placed SSN cell from Excel. We moved on to a new vendor and the company was gone the next year.

They were in negotiations to be acquired by a competitor and there equipment would be sunset within the year.

It’s not the system that causes issues. It’s the clock in/out & OT calculation policies & procedures.

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