Sunday, July 25, 2010

Don't Be Strangled By Process-Improvement Black Belts

In ITIL, we healthcare CIOs are acting in predictable fashion by following the “Most Popular Practice” as opposed to the “Best Practice.” Before we pull the trigger on yet another silver bullet savior of process, I urge all of us to look closely at the contribution of burdensome process in the woes of Toyota…and GE…and Motorola. Try though we might to fix the problems of healthcare IT with rigorous process-- most recently ITIL-- we’re only putting lipstick on a pig.

Fat processes like ITIL will only make matters worse for us until we fix the core issues: (1) Stop buying poorly designed software systems and insist on something better from vendors; and (2) Hire and mentor engineers, computer scientists, mathematicians, and musicians into healthcare IT and stop microwaving nurses, doctors, registrars, and technicians into overnight software developers and IT professionals.

Those of you who know me, know that I’ve admired Toyota for many years, particularly their philosophies of leadership, employee relations with management, Lean manufacturing and the Toyota Production System. My faith in Toyota is taking a beating as I watch it struggle with one recall after another, even though, I’m betting, the problems with runaway acceleration will more likely be associated with driver error than faulty design. We’ll see what the Failure Modes and Effects Analysis (FMEA) team at NASA has to say when they release their report in the next few weeks.

Even so, there’s no getting around the fact that Toyota is losing its edge in quality and innovation—they’ve been out-Toyota’d by Hyundai and Kia. In fact, at the rate they’re going, Toyota is going to be out-Toyota’d by Ford. The root cause of Toyota’s problems is, of course, a tangled web of roots, but I see a common thread that crosses the fabric of other companies across 30 years—and the common thread is Process Overkill.

In the Air Force, I was one of Motorola’s biggest customers for their new products, notably spread spectrum and CDMA networking (but many other radio-based systems as well). I was around when Six Sigma was a Motorola baby — that was in the early 1980s when quality and reliability were more important to the military than product agility and innovation. I thought Six Sigma was the coolest thing around. Everyone thought Six Sigma was awesome … including Motorola … they burned Six Sigma into their hiring, organizational structure, and the DNA of the company.

Then they started believing their own press or, as my granddad would say, started drinking their own bathwater. Fast forward to the mid-1990s, when it wasn’t enough to produce reliable products anymore … you had to produce reliable and innovative products, faster than ever before. Mean Time Between Failure (MTBF) was replaced by Mean Time to Improvement (MTTI) (that’s a Sanders Theory and phrase…so don’t bother to Google it). Six Sigma bogged Motorola down like a Mississippi mud walk, and they still can’t get it off their feet. Motorola might be able to produce a fairly reliable product, but you couldn’t possibly describe Motorola as innovative. They’ve been strangled by the Black Belts of Six Sigma.

Jump to the late 1990s and early 2000s … cut and paste the exact same story at Motorola, then do a global replace with “GE” and “DMAIC”. Jack Welch was to GE what Steve Jobs is to Apple, and without either leader the company identity is completely different. Nevertheless, the weight of DMAIC on GE has them stuck in the mud walk of innovation, too — Jack Welch or not. Drive the time machine ahead to 2009 and do the same cut and paste, but this time insert “Toyota” and “Lean” into the story. Lean’s gone Fat at Toyota and their arteries are ready for a CABG.

In love with their own success and thirst for their own bathwater, Toyota over-applied Lean concepts, creating a bureaucratic environment that squeezed innovation to death (only the Chevy Citation was uglier than the current Toyota Camry), and cultured apathy in their design teams and production lines. Toyota might be salvageable, however, because their leadership still exudes humility and accountability. It’s going to be interesting to watch.

Do you believe for one second that Google’s search engine was the product of a DMAIC session? Or Apple uses Six Sigma or Lean Gone Fat in their product development? You could argue that a dose of better process would have prevented the worm in Apple’s recent 4G antenna problems, but the 4G, iPad, and iPod are the most innovative, best quality products to be produced in the US since the Apollo space program. It’s amazing to me that the 4G antenna problem is the only problem they’ve had in a string of pioneering, revolutionary products. Take away Apple and Google, and the only claim to major, society-wide impact and innovation we can claim in the U.S. since the late 1960s are hedge funds and credit debt derivatives.

The best processes are worthless in the hands of the wrong people. Does a good change-control process in the hands of a bonehead make a genius of that bone? No. Even worse, Processes Gone Wild — such as ITIL, Lean, Six Sigma, and DMAIC — are a disaster in the hands of great people. Good people trump everything. EVERYTHING. But the best people … the most innovative people … will not stick around if constantly force-fed ITIL, Lean, Six Sigma, or DMAIC. They’ll go to work for Apple and Google. The force-fed people and organizations left behind will end up as so much foie grais.

Sip from the cup of ITIL Kool-Aid, don’t gulp it.

DARPA for Healthcare: An EMR Shootout

Building on a recent post about Peter Orszag's resignation, and stimulus funding for healthcare IT...As long as we're throwing money around by the billions...

If I were Dr. Blumenthal, I’d dangle $500M in front of Amazon, Google, Nintendo, Facebook, salesforce, eBay– or any other capable body– and sponsor a shoot out: Build an inpatient/outpatient EMR and financial management system that will rock our world.

In the rush to incentivize adoption and certification of EMRs, there is a commensurate rush to purchase known and “safe” products– the market leaders with typical solutions–and that will be a disaster. Many of the top EMR vendors themselves will tell you behind closed doors that they are not necessarily proud of their products, but they keep selling, so there is no incentive for them to stop producing.

The current HITECH focus on investment in integration is putting the cart before the horse….we need better horses, first. The measurable and sustainable value provided by HIE’s is the reduction in redundant lab tests. That’s as far as we need to go with HIE’s at the moment, and that’s a relatively simple technical solution that the insurance companies offered to providers many years ago, but providers rarely accept.

We are taking on massive federal debt to invest in a crop of mediocre products. Here’s the ironic scenario that I see: Five years from now, when almost everyone is running on EMR products designed around paper charts; and inflexible client-server, message oriented architectures, there will be a new and better product on the market, probably produced in another country, which is better than anything else on the US market… but no one in the US will have the money or willpower to adopt and adapt it for the US, because they exhausted themselves under the current HITECH strategy of Now, Now, Now. Let’s ensure and accelerate the development of that better product in the US and hold-back some funding to make its adoption possible.

We don’t need more medical informaticists. We need hardcore computer scientists and engineers, like the kind going to work for, Nintendo, Facebook, Amazon, and Google. It’s much faster for the supply chain of labor to teach great healthcare to a computer scientist, than it is to teach great computer science to a physician or nurse. No offense to my many doctor and nurse friends, most of whom would agree.

I’m not saying that we will receive no innovation from HITECH. I’m saying we won’t get as much innovation as we need or could, unless we set aside more funding and manage it properly to stimulate true innovation in healthcare IT.

Peter Orszag’s Resignation: Why CIOs Should Care

Before I levy my criticisms on Orszag and the mess that his philosophies will leave behind for healthcare CIOs, you need to understand that I’m as politically liberal as they come. I voted for Obama and celebrated in Grant Park when he was elected. However, while I’m a spendthrift with my money, I’m a tightwad when it comes to spending other people’s money, and therein resides the problem that Peter Orszag created for healthcare CIOs.

Unless we pause now and deliberately change course, Peter Orszag’s economic policies are going to leave healthcare CIOs with a crop of under-performing, over-priced electronic medical records and surrounding products. While Osrzag leaves his current position at OMB to chalk up another score on his glowing resume, his think-tankish, economic behaviorist policies are going to leave the rest of us with a giant mess and healthcare in the US will suffer.

Orszag is the outgoing Director of the Office of Management and Budget under the White House. He was in that position for a very short period—not even two years–starting in November 2008, but in that time frame, drove the economic policies behind the White House and designed the Obama budget, including HITECH funding. His background is as academic as they come– and I would give my right leg to share—Exeter, Princeton, London School of Economics. Orszag believes that healthcare spending is at the root of the US economic meltdown, which may not be entirely true, but I concur it is to a large extent. He was also a key architect in the bailout of the banks and automotive industry. In a recent interview with John Stewart, the non-academic Stewart asked the highly-academic Orszag to explain why more of the ARRA funding didn’t flow directly to the consumer—why must the money pass through the banks first, in the hope that it would eventually make its way into the hands of the average citizen with a failing mortgage? Orszag replied, “Because you don’t want to create an incentive [in consumers] for defaulting on their home loans.” Stewart’s eyes illuminated at the irony and he howled in laughter. The brainy Orszag was caught with his economic pants down.

There are two extremes of political-economic thought—democratic capitalism advocates think that hands-off, free-enterprise business will eventually benefit the populace and world—less government is better. Socialism believes in cooperative ownership and governance of wealth and business, all for the common good—more government is better. It’s pretty clear to me from empirical evidence that neither extreme works, and that the most successful countries in the world today are a mixture of both, with the socialist-leaning horses leading the race by half a length.

I would assert that Orszag’s $19B in HITECH funding, a cornerstone of his strategy for addressing the ever-increasing costs of healthcare, has gone too-far socialist and will strangle the efficiencies and creativity of free-market capitalism out of the EMR market…unless we pause now to withhold some of those funds and invest them– venture-capital style– to seed development of a new generation of EMRs that reflect a new model for healthcare delivery. There are numerous models in government for successfully funding innovation—DARPA is the best example. DARPA takes advantage of government power and free-market ideas, balancing capitalist and socialist economics extremely well.

Dr. Blumenthal—Return some free-market balance to the healthcare IT economic model. Don’t let Peter Orszag’s economic policies drive healthcare IT into the mud of mediocrity for the next 20 years. Withhold some of that HITECH money and invest it in innovation—create a DARPA for healthcare IT please!!

Russian Nuclear Subs Prowling Again

This article in the Washington Post describes the increased presence of Russian nuclear-armed submarines off the coast of the US, reflectin...