Somewhere along the way the word consulting in our field changed. Today consulting is about finding available freelancers on a just in time basis. The “consultant” is nothing more than a recruiter with a billing back office. Some consultants claim they screen the candidates, but there is no way that can be done effectively given the turnaround time to place people.

Furthermore, the consulting firms take very little accountability for the consultants they place. But, how can they when their experience is so varied and there is no standard for good service?

When I hire a consultant, part of what I am looking for is a well defined way of doing various types of work. I want the consulting group reviewing each engagement and revising their approach to work based on the lessons learned from each engagement. If I am going to hire a project manager, I want that person trained in the firm’s project management approach. If I hire someone to assist with a selection, I want that firm to have a clear written means to conduct IT selections. I don’t want someone that might have participated in one of these activities a while back and will try to mimic one the way a child mimics an adult.

Of course that means a large investment in people that develop these methodologies and take the time to train permanent staff. That seems to have gone the way of the dodo bird. Nobody has staff, they have home-based employee people working the phones looking for talent to place.

Update: In re-reading this post I recognize that it is too general. There are a lot of consulting groups that bring intellectual capital to the table. When I am introduced to a new consulting group the first thing I do is categorize them as a traditional firm with an investment in their staff, or a recruiter of free agents with no connection to the people they place.

Update 2: Too frequently someone claiming to represent a consulting firm, is really with a staff augmentation firm. There is a big difference between the two and I wish the staff augmentation firms understood this.

Radiology IT is a more challenging area than other helathcare IT systems. The Radiologists (and cardiologists) rightly want to be very involved in the selection of the systems that they interact with. Many of them sit in front of these computer systems all day and something as nuanced as the placement of a button can have a great impact on their productivity and overall satisfaction. In this regard, trying to select a mutually acceptable Radiology IT system is much like standardization of orthopedic implants or surgical sutures.

On October 4 Apple’s CEO said: “Over 80% of the top hospitals in the US are now testing, or piloting, the iPad.” This statement is a little misleading.

Firstly, he said “testing or piloting.” What is the number of hospitals that are actually buying and deploying iPads to use with their core clinical applications? I bet that number is less than 1%.

What exactly defines a “top hospital in the US?” Are those the ones that answered Apple’s calls? I have an Apple sales executive (Rachelle, who is a super nice woman) that periodically calls on me to keep track of what we are doing. When she last called I toled her we had a pilot taking place to test connecting employee owned devices (including iPads) to our Exchange Server so our employees can get email and appointments.

That’s it, just a pilot. No roll-out. No committment. Furthermore, it is just for Exchange connectivity. Still, I presume this means that our 15 hospitals are in that 80%.

But, the picture behind Cook is two men, with lab coats and stethescopes, staring into an iPad. This might give the world the impression that 80% of the hospitals have doctors and nurses accessing electronic patient records on an iPad.

Not yet.

My organization is not going to deploy the current generation of Windows client applications on iPads, just because they are cool. When core vendors produce native iPad apps (or properly formatted web apps) that will be the right time to look at radical device changes. And don’t talk to me about Citrix. Citrix on the iPad’s relatively tiny screen is a terrible user experience and not worth the cost to make a radical change to our device support model.

I have been writing this blog for 8+ years. This is the first time I recall going completely off topic. I want to talk about baseball. Tonight all of us in Wisconsin are celebrating the Brewers advancing to the National League Championship Series.

There was a play in the top of the 9th inning that drives me crazy. The Diamondbacks had runners at the corners with 2 outs.  The Brewers Betancourt scooped up a slow bouncer and raced to 2nd base, ariving a split second before a sliding Justin Upton.

Why does Upton slide into second base? I would argue that sliding slowed Upton down enough to allow him to be forced out. What if instead, he were to run through 2nd base to avoid the force? Sure he would be tagged out before he could reach 3rd base. But the runner at third would have already crossed the plate before he could be tagged. I am gad that didn’t happen because that run would have likely eliminated the Brewers.

If a runner is forced out for the final out another runner crossing the plate will not score, even if the runner crosses home before the force out. If the runner is tagged out after reaching the base, then it becomes a matter of what happened first – the final out or the runner touching home plate. Because the runner at third usually has a bigger lead, they typically can cross home plate at the same time the force out occurs. Even if Upton were immediately tagged after running through second, the Diamondabacks would have scored the winning run.

Maybe someone will post a comment telling me why I am wrong. Maybe there is a rule that requires the runner to slide. But I think Upton slid because, for over 100 years, every player in the same situation has slid.

Is there something in your IT operation that you do because it has always been done that way? Is there a simple but unconventional change that you can make to get a better results?

Maybe this post wasn’t off topic after all.

Alexander Graham Bell (March 3, 1847 – August 2, 1922)
Thomas Alva Edison (February 11, 1847 – October 18, 1931)
Henry Ford (July 30, 1863 – April 7, 1947)
Steven Jobs (February 24, 1955 – October 5, 2011)

These people radically changed the lives of every American alive in their lifetime. It was awesome for me.

I am all for standards. The more we define and codify the practice of medicine, the better and more interoperable our EHRs become. But a standard, for the sake of a standard, takes us backwards.

I believe the writers of the Final Rule that defined Meaningful Use of an EHR took us backwards when they specified two different standards for coding the problem list (SNOMED and ICD-9). Most organizations appear to be using ICD-9 to code the problem list. I believe that this is because SNOMED is way too complicated and there is no decent implementation reference.

But ICD-9 coding of problem lists does not make sense. Firstly, this country is in the process of migrating away from ICD-9 codes. Why make that process more laborious by creating one more conversion? Let’s skate to where the puck will be.

More importantly, ICD-9 codes do not describe problems in the hospital. ICD-9 codes are medical billing codes.  Sure, they are based on a disease classification system, but problems are not always analgous with a disease or condition. For example, an important problem to note during a hospital stay is that the patient is “at risk for fall” based on a fall assessment. What is the ICD-9 code for this?

ICD-9 codes collected as part of creating the problem list will not provide any additional data beyond the ICD-9 codes that are already abstracted as part of the billing process. So, this pseudo-standard does not provide any new insights. Furthermore, I don’t believe this codification will do anything to improve the interoperability between providers and systems. In the end this is work for work’s sake. Busy work keeps us from implementing the rest of meaningful use that has true benefit to the patient and those that pay for care.

At least this is the way I see it. Am I missing something?

I think that part of being a productive employee in the 21st century is finding online services and mobile appps to meet your needs that are not met by the IT department’s standard offerings. Since Internet service and a modern browser are typically standard offerings, this opens up a whole world of offerings. Browsing simplespark.com gives you a sense for the IT services that are available.

Using web based services is not the same as asking the IT department to install software on corporate devices. That ultimately creates a support burden on the IT department. People don’t understand why we don’t want to buy and install their $100 application. It isn’t the $100. These are the things that IT managers hate about one-off software installs:

• we need to reinstall that ap every time we upgrade or fix the user’s PC.
• the help desk team members need to have knowledge of the applications when they call the user
• in a short period of time we will get a call telling us the software version is no longer supported and we need to purchase the upgrade, convert the data and train the user

But more importantly, locally installed software is increasingly unneccessary as Software as a Service (SaaS) makes everything accessible from the browser. Our corporate QuickBase account gives our user base a simple but powerful way to meet many of their needs for dabases and basic workflow. This is why our employees have created over 7,000 applications. This is 7,000 times that employees were able to meet their own needs instad of requesting software and services from IT.

One of my favorite web-based services is Toodledo. Toodledo.com is a web based to do list (there are iPhone and iPad apps) to. I like it betther than Outlook tasks. I like the usability and there are some cool features like automatic prioritization based upon due date and prioirty. Mostly I like that I can access it anywhere without launching a Citrix session. This is important becuse I use it to manage my work tasks and my personal life too. I use the paid version because it allows me to store attachments with my tasks. But the free version is impressive.

So this is the second in a series of rants regarding some of the more silly aspects of the Meaningful Use Stage 1 Final Rule. Let’s visit core obective 7 for hospitals (pg 257 Fed Reg):

(7)(i) Objective. Record and chart changes in the following vital signs:
(A) Height.
(B) Weight.
(C) Blood pressure.
(D) Calculate and display body mass index (BMI).
(E) Plot and display growth charts for children 2–20 years, including BMI.

The writers of the Meaningful Use rules were on a good roll there. A through D are totally reasonable. I believe every EHR should capture these things and hospital should be document these vital signs for most inpatient stays.

My best friend’s Dad ran a manufacturing plant. I remember him saying that the way to find the optimal setting on a piece of equipment is to turn the dial until it breaks, then go back one setting. I kind of feel that is what happened with this objective. They should have stopped at (D). Growth charts are great, every pediatric practice should maintain one for each child, and in this day and age they should be computerized. But why would a growth chart be a requirement for a hospital stay? Does that make any sense? I have spoken to a few pediatricians and none of them have stated that there is a medical need for a growth chart in the hospital stay.

This looks like a sloppy cut and paste from the Eligible Provider Objectives to the hospital objectives without thinking through the different environments.

Affinity Medical Group’s EHR pilot went live on GE Centricity EMR this week. It has been a well run project throughout and I had the honor of joining our bright, hard-working team for their end of day huddle. They did a few things that I really liked. This is not exhaustive list. I would love to hear from others on their ideas to run the Live Huddle.

Issues

The primary focus of the Live Huddle is the issues that have been surfaced during the day. The issues are typically categorized something like this:

• Critical infrastructure or application problem that is having a negative impact on business operations (bad)
• Unanticipated issues that need a near term resolution
• Workflow issues
• Suggestions for improvement

As always the documentation of the issues is key: detailed descriptions, good examples and no abbreviations. One day I will blog about what constitutes a good issues list (tip 1: you can’t use Excel to manage issues). A great issues list is one of a handful of key project controls required for project success.

During the AMG huddle today I saw the team was using paper forms so they could jot down issues on the fly. Later they entered them into the project issues tool. Ultimately the live issues need to get into the same tracking tool as the rest of the project issues.

Statistics

During AMG’s huddle they shared some key stats about the day. I really loved this because it made the use of the system more tangible, building on the sense of accomplishment. Here are some stats from today’s huddle:

• refill requests processed: 27
• labs ordered: 64
• phone notes: 125
• visit notes: 129

Mood

The other creative thing that this group did was create a form that gauged everyone’s mood. Everyone was encouraged to complete the VERY SHORT form, including IT, managers and especially users. I think this can serve as a good early warning sign if the project is heading south.

What are your tips for a goo Live Huddle?