The other day a colleague forwarded me an email that has surely made the rounds and probably is in your inbox (or maybe your junk/spam mail). The email contained Mr. HIStalk’s Universal Rules for Big EMR Rollouts (from 2007). Here are the rulesfrom Mr. HIStalk:

1. Your hospital will pledge to make major process changes, vowing to “do it right” unlike all those rube hospitals that preceded you, but the executive-driven urgency to recoup the massive costs means the noble goals will change to just bringing the damn thing up fast, hopefully without killing patients in the process.
2. The project and/or system must be anointed with an incredibly dopey and user-embarrassing name, preferably chosen from user submissions and with the offer of crappy vendor paraphernalia or lame IT junk as a prize, and also preferably made up of a far-fetched phrase whose contrived acronym spells out a medically related word or female name. Instead of inspiring the expected collegial chumminess among users, it will serve as a bitter reminder of the innocent, naive days between RFP and go-live before it got ugly.
3. Doctors won’t use it like you think, if at all, because hospitals are one of few organizations left that doctors can say ‘no’ to.
4. You’ll spend a fortune on mobile devices and carts that will sit parked in a corral due to the short life of their $100 battery and a dysfunctional but not yet fully depreciated wireless network, the keystone arches to the entire project.
5. All the executives who promised undying support to firmly hold the tiller through the inevitable choppy waters and who overrode all the clinician preferences in a frenzy of inflated self esteem will vanish without a trace at the first sign of trouble, like when scarce nurses or pharmacists threaten to leave or when the extent of the vendor’s exaggeration first sees the harsh light of day in some analyst’s cubicle.
6. It will take three times as long and twice the cost of your worst-case estimate.
7. You’ll pay a vendor millions for a software package consisting of standardized business rules, then argue bitterly that all of them need to be rewritten because your hospital is extra-special and has figured out the secrets that have eluded the vendor’s 100 similar customers. The end result, if the vendor capitulates, will be a system that looks exactly like the one you kicked out to buy theirs.
8. You’ll loudly demand that the vendor ship regular software upgrades to fix all the bug issues you submit, but then you’ll refused to apply them because you’re scared of screwing something up with the skeleton maintenance staff you can afford, given that millions were spent on systems with nothing left for additional IT support staff or training.
9. All those metrics you planned to collect to show how quickly the EMR would pay for itself instead show the situation unchanged or getting worse, so factors beyond your control will be blamed (like a ridiculously long implementation time that changed all the assumptions and external conditions) and ROI will not be brought up again in polite company.
10. No matter how unimpressive the final result toward patient care or cost, the EMR will be lauded far and wide as wonderful since the vitality of the HIT industry (vendors, CIOs, consultants, magazines, HIMSS, bloggers) requires an unwavering belief that IT spending alone will directly influence quality, even when nothing else changes

I must confess I have read these before and have wished I could have the insight, the wit and the cynicism to put this list together. When I read them this time, though, something struck me – could Mr. HIStalk have developed a simple set of rules as irrefutable and vexing as Newton’s 17^th century laws of motion??? Given the track record of HIS (please check out this video clip for the early 60’s ) perhaps so, but I would like to think not. So as I ponder this possibility, my engineering background demands that I examine the list and try to refute the irrefutable. So I did and developed my own list - Santa Rosa’s Irrefutable Remedy to the Universal Rules for big EMR Rollouts. Here is that list:

1. Get the project out of the IT department. IT is a supporting player, not the lead. Recruit a series of respected leaders in the clinical community to sponsor and spearhead the project.
2. Establish a strong governance structure with an appropriate set of committees. Remember not all committees design camels (as in a camel was a horse designed by a committee). This committee structure will help mitigate risks in regards to process redesign and budgeting.
3. It is indeed a universal truth that IT projects produce significant cost overruns. Why is that? It is simply a complicated, complex thing. As health care professionals we must learn from our colleagues and the industries errors. Remember, as George Santayana said – “Those who cannot remember the past are condemned to repeat it”. Basically, we know that $2M = $5M, be upfront, budget appropriately and ultimately if your site does not have the money to adequately fund the deployment, perhaps you should consider making do with what you have.
4. Demand documentation from the vendor, but perhaps most importantly the internal IT team. Most issues around upgrades arise not regarding a vendor’s update, rather internally because Billy built a “fix” and he left last year and folks pray it does not break. Simply stated, because the internal IT department does not document their work, the vendor updates are nearly impossible to deploy because the site does not understand their own modifications to the vendor’s standard implementation.
5. In order to mitigate the unfulfilled ROI and potentially downward trending metrics – risk share. Most of the time ROI expectations are initially set by the vendor and over time ownership of these metrics is transferred to the site, i.e., you. Once that happens indeed you are stuck holding the bag for the good and bad. Risk share by documenting specific ROI in the contract – make the vendor pony up by hitting them in their wallet.

So there it is - The Santa Rosa Irrefutable Remedy to the Universal Rules for big EMR Rollouts. In the end, did this disprove Newton or Einstein – no, but absolutely these rules will mitigate the risks of a big (or small) EMR deployment or upgrade.

While I have poked fun at the HIStalk list and tried to lighten up a serious topic, in the world of Meaningful Use, 5010 upgrades and ICD-10 conversions these Santa Rosa rules are huge. The health care IT industry is considered mediocre at best. Health care IT has a consistent trail of failed or marginally successful deployments and it is almost an accepted practice. Across the health care industry there are 10’s of billions being spent in software, hardware and infrastructure acquisition and upgrades – we as professionals must all be stalwart stewards of these precious funds. These Santa Rosa rules will help.

Please contact Santa Rosa Consulting to see how we can help your organization deploy these Santa Rosa rules. We can also help you develop innovative and unique approaches to ensure that you are a solid steward of your care delivery system’s precious dollars.