Monthly Archives: October 2015

Data-Based Client Tracking Services and Outcomes is a Real Challenge for Many Nonprofits

Jake recently wrote a post on the huge challenges faced by primary care provider organizations in meeting EMR Meaningful Use regulations. This got me thinking about other data collection challenges facing nonprofits. Apart from computers and the Internet,* one of few aspects of grant writing that has changed since I started writing proposals when dinosaurs walked the earth is an ever-increasing RFP/funder emphasis on data tracking to demonstrate services delivered and improved “outcomes.”

The scare quotes around “outcomes” expresses how we feel about many of them. While we’re adept at creating plausible data collection strategies in proposals, regardless of what our clients are actually doing in the real world, we know that demonstrating service delivery levels and outcomes is a major issue for certain types of human services providers. These include many faith-based organizations (FBOs)** and ethnic-specific providers, some of which have been operating since the days of Hull House. We’ve worked for several nonprofits that have been providing services for well over 100 years.

It’s not unusual for smaller FBOs and organizations serving immigrant/refugee populations to provide services in what seems, from the outside, to be a chaotic manner. But the service delivery practices are actually well-suited to their mission. A range of services might be provided to a particular individual, like help with an immigration problem, but the agency will end up helping the person’s extended family members with all manner of issues. In many ethnic communities, the concept of “family” is malleable. A nominal “uncle” or “cousin” is actually not related but hails from the same village or clan in their country of origin.

Such services are usually provided on the fly and the harried case worker, who is typically a co-religionist or from the same ethnicity, hops from client problem to problem without time or interest in database entry. Like pulling a thread on sweater, helping one person in a 30-member extended family can result in dozens of “cases” that may not be separated and documented. The family often does not want the problem documented because of cultural/religious taboos and (often justified) fear of government officials. Thus, much service delivery is provided on the down-low.

Everyone knows that New York City has dramatically changed from the bad old Death Wish days of the 1970s to a glittering metropolis of 70-story apartment buildings for the one-percenters and a well-scrubbed, tourist-focussed Times Square. What isn’t generally known is that an amazing 37% of NYC’s population is foreign-born. This percentage is increasing. NYC has more foreign-born residents than the entire City of Chicago has residents! Rapidly growing NYY immigrant groups include Orthodox Jews from the former Soviet Union, Dominicans, Asians, Central Americans, and so on. We work for many nonprofits that serve these immigrant populations; this client type usually only serves their brethren. These nonprofits have great difficulty documenting the often extraordinary services they provide—one of the main reasons they hire us is because of our ability to weave their stories into the complicated responses required by RFPs, including service and outcome metrics. Like the proverbial centipede, these nonprofits walk perfectly, as long as no one asks them how they do it.

The data capture challenge is compounded because few prospective social workers enter grad school with the idea of becoming bean counters. Like the best doctors and teachers/professors, social workers start off with the idealistic notion that they will spend most of their time helping people, not doing data entry and accounting for every minute of their day. When not extruding proposals or writing novels, Jake is a college English professor. He can attest that much of his best teaching doesn’t show up in metrics.

Many of us have had a “hero teacher” at one point and a conversation or a book recommendation might have changed your life, but will not be reflected in grades or academic honors. Similarly, a case worker who gets a tacoria to hire the “nephew” of one of her clients as a busboy to keep him out of juvenile hall might set the young man on a positive life path, even though “job placement” is not part of her official duties and will not appear in the agency’s reports.


* Which have also made the world worse, at least in some respects.

** This this does not refer to industrial-sized FBOs like Catholic Charities or the Salvation Army, which operate with bureaucratic precision.

Meaningful Use Regulations, CMS, HRSA FQHCs and the Stalled Push to Electronic Medical Records (EMRs)

According to Mother Jones, the United States has spent billions on electronic medical records (EMRs)* and we’ve got little to show for it. Digitizing healthcare records was supposed to save time, money, and lives. It hasn’t. That news resonates with us because we’ve written dozens of proposals, mostly for Health Resources and Services Administration (HRSA) and Centers for Medicare & Medicaid Services (CMS) RFPs that either explicitly or implicitly require a discussion of our clients’ use of EMR systems. These clients are usually hospitals, Federally Qualified Health Centers (FQHCs) or other primary care providers. From them we’ve heard numerous heard off-the-record stories about the fiascos that ensued for providers that have implemented EMRs. For example, we worked for a hospital in Southern California that interfaced with a much larger, nationally known hospital that attempted to implement a comprehensive EMR system. The large, famous hospital eventually scrapped a $30 million EMR system because the doctors simply refused to use it.

There seems to be no good solution to the EMR problem. EMRs have been touted for at least the last 15 years as a tech-based way of improving patient outcomes, while reducing healthcare costs or at least bending the cost curve downward (as health policy wonks like to say). EMRs got a got big push with huge amounts of EMR funding included in the 2009 “Stimulus Bill.” The advent of the Affordable Care Act (“ACA,” or, colloquially, “ObamaCare”) escalated the EMR drive. Various Federal and state agencies advocated and then effectively mandated EMRs.

But this well-meaning concept has at best moved sideways. HealthIT.gov promulgates the wonderfully bureaucratically named “Meaningful Use” regulations, which use a combination of incentives (e.g., higher Medicare/Medicaid reimbursements) and threats. The carrots are offered and the threats enforced primarily by CMS. Everyone is supposed to get to Stage 1 of Meaningful Use (data capturing and sharing) on a supposedly smooth trajectory to Stage 3 (improved outcomes). Stage 3 turns out to be like the intergalactic instantaneous travel through spacetime. We’ve yet to find an hospital, FQHC or other client that has reached Stage 3. Most are stuck at Stage 1, with a few bravely claiming Stage 2. We’ve never seen a client hit Stage 3, though they may be out there, perhaps in a galaxy far far away.

The problem is that EMRs are trying to map the extraordinary complexities of the real world into software. The complexity can be seen in the new International Classification of Diseases, ICD-10 Codes, published by our old friend CMS. ICD-10 codes are used by medical providers and billers to track patients and payments, based on the code or codes of the patient’s particular situation. When we talk to FQHCs, they invariably say that coding errors are among their major problems. ICD-10 has an astounding 68,000 individual codes, compared to only 14,000 codes in the previous ICD-9. In recent years, humans have invented or discovered an enormous number of new ways to get hurt. No one can remember more than a few hundred of these mysterious codes, which are easy to mistype into an EHR and/or be misunderstood by harried doctors and mid-level practitioners. The complexity of the codes, combined with human diversity and frailty, inherently generates huge numbers of mistakes.

Folks with too much time on their hands have published various funny ICD-10-CM codes. Some choice ones (we are not making these up) include: “V97.33XD: Sucked into jet engine, subsequent encounter;” Y92.146: “Swimming-pool of prison as the place of occurrence of the external cause” (how many prisons have swimming pools?); and my personal favorite, “R46.1: Bizarre personal appearance.” You can tweet your favorite bizarre ICD-10 codes to @healthcaredive.

Ask your doctor about their EMR system and you’ll likely here a lot of invective. I live with a doctor and so have heard the horror stories from her and her colleagues. Isaac’s primary care physician (PCP) hates EMRs but is more or less forced to use eClincalWorks, an EMR system that is also popular with our FQHC clients. Epic is another popular one. Still, however you feel about whether EMRs is efficacious or horrible or brilliant or whatever, pretty much every healthcare-related proposal has to mention EMRs, statistics, and tracking. That could be as minor as a project that works on childhood obesity or as major as a hospital chain implementing some new facet of EMRs.

Anyway, EMRs are a specialized case of a more general problem described in “Why Software Fails: We waste billions of dollars each year on entirely preventable mistakes.” EMRs, like other forms of software, have numerous moving parts and numerous human users. Anyone working in or around EMRs needs to read “Why Software Fails.” At Seliger + Associates, we expect to keep writing about EMRs for FQHCs and similar clients for years if not decades to come. In the real world, doing EHRs right is simply a Hard Problem—so hard that it deserves capital letters. EMRs are almost impossible to do “right” and yet have to be done right. They’re so hard that we don’t have a solution. “Why Software Fails” explains why a solution may not exist, no matter how badly HRSA or CMS wants one. As the Soviet Union discovered, mandates from above, no matter how strong, do not automatically translate into fixing problems from below.

* EMRs are alternatively referred to as Electronic Health Records (EHRs), particularly in HRSA and CMS RFPs. In ones types “EHR” into Word, or any other word processor, and the autocorrect feature will change it to “HER.” This in annoying, but does result in some unintentionally funny typos. When finished with proposal draft involving EHRs, always do a find and replace for “HER”.

Links: Democracy, academia, standing desks, pre-school / UPK, email, murder, iMacs, and more!

* “American democracy is doomed;” don’t attend too much to the clickbait headline, but this may be the most important thing you read all day, week, or month.

* “I have one of the best jobs in academia. Here’s why I’m walking away.

* “The Future of New York City Transportation: Goodbye Cars, Hello Rails: Young people are driving the city towards a carless future.”

* A review of studies of standing desks; as you know I use a GeekDesk and am standing as I type this. Here’s our 2008 post on tools.

* An excellent piece on Elmore Leonard, one of my favorite writers, ever, and also excellent for anyone working in low-income communities. Start with Get Shorty and Out of Sight, in that order. Like many writers and especially prolific writers his work is uneven, but the best more than excuses the worst. Few of us hit the high notes even once.

* “Preschool Can Be Worse Than the Alternative.” We’ve worked on numerous proposals for New York City’s Universal Pre-Kindergarten (UPK) program, as well as Head Start, and some of that experience has made us… skeptical… of the push for more structured education for everyone, everywhere, all the time. In these discussions about more, more, and still more education, the words “diminishing returns” seemingly never appear.

* “The Real Anti-Facebook Is Good Old Email.” Which I still use more than any other online system, though sometimes I feel out of time for doing so. I do use Dropbox for distributing pictures.

* The Case of Richard Glossip, who is about to be murdered by the state—in and by the United States.

* Parking costs are eating our housing.

* Why aren’t America’s ports automated? Short answer: Unions.

* “How Tasteless Suburbs Become Beloved Urban Neighborhoods.”

* “America: Abandon Your Reverence for the Bachelor’s Degree: Many high-school graduates must choose between two bad options: a four-year program for which they’re not academically or emotionally prepared, or job-specific training that might put a ceiling on their careers.” Again, the phrase “diminishing returns” is important here.

* “In California, Electric Cars Outpace Plugs, and Sparks Fly.” Of course, this is not much of a problem is South Central LA, the Oakland flats and in the 500-mile long Central Valley. What would Tom Wolfe say?

* “Inside the lab: Why Apple still sweats the details on iMac,” a fascinating story; Apple also updated iMacs on October 13. The 5K iMac is an amazing machine. If you order one, make sure you get the Fusion drive upgrade. The 21.5″ iMac is probably the best bargain, as long as you get the Fusion drive.

* Europe’s love affair with diesel cars has been a disaster.

In grant writing, make sure you get to the finish line

Five years ago I wrote a post explaining why applying for grants is not like winning an Olympic Gold Medal. A couple of recent conversations with clients made me re-think this analogy, because these clients seemed to want to give up before we completed the proposal submission package but after most of the work had been done.

The clients had an array of not-mutually-exclusive reasons. They’d been traumatized or paralyzed into inaction by the proposal completion process. They’d experienced difficulty getting support letters. Other members of the management team had lost enthusiasm. Christmas is coming in three months. A sudden opportunity to travel to the Galapagos Islands appeared. And so on. This puts us in the position of a baseball third-base coach waving a runner home, even though Yogi Berra is blocking home, waiting for the bullet outfield throw from Mickey Mantle. In baseball you can’t score if you don’t cross home plate. You can’t win an Olympic Gold Medal in the 100 yard dash unless you break the tape. You also can’t get a grant without submitting the proposal in time to meet the deadline. The closer you get to that deadline, the better off you are completing the proposal so that you can at least have a chance of winning.

In these cases, we do everything we can to get our suddenly reluctant clients to cooperate and meet the deadline, even if the proposal is missing a piece or two or is otherwise less than perfect. While we make every effort to help our clients submit technically correct proposals, we’ve also seen proposals funded that were technically deficient. Grant reviewers sometimes miss the deficiency, either from simple oversight or from the fact that RFPs are often astoundingly complex, contradictory and/or opaque—to reviewers and writers.

We’ve even seen federal grant proposal review comments in which the reviewer clearly confused the proposal we wrote for a proposal submitted by a different applicant in a different part of country. In other words, the proposal we wrote was actually scored entirely incorrectly because someone else’s was mistaken for it. This means the other proposal was also incorrectly scored!

Error is the normal state of human affairs, and decades in the grant business have revealed many errors to us. Keep in mind too that as the deadline looms other would-be applicants are probably feeling as demoralized as you. Force yourself to be disciplined enough to get the proposal in as good shape as you can and hit the grants.gov submit button, even one minute in advance of the deadline. You might be one of a handful of applicants who submits a more or less complete proposal. As we’re written about before, since it’s simply not possible to handicap the chances of any proposal being funded, you might as well submit what you have and hope.

Which brings me back around to Yogi, who left us a few weeks ago to play ball once again, this time on his own Field of Dreams. Yogi was the source of many quotes that apply to the grant preparation process—”It ain’t over till it’s over” and “this is like deja vu all over again” seem apropos.