Healthcare IT Strategy

January 12, 2012

Will National EHR Work?

Filed under: EHR,healthcare 2.0,Hospital,NHIN,planning,Rants & Musings,Who's Running the Show? — Paul Roemer @ 9:36 am

I’ve never been mistaken as one who is subtle.  Gray is not in my patois.  I am guilty of seeing things as right and left and right and wrong.  Sometimes I stand alone, sometimes with others, but rarely am I undecided, indecisive, or caught straddling the fence.  When I think about the expression, ‘lead, follow, or get out of the way,’ I see three choices, two of which aren’t worth getting me out of bed.

I do it not of arrogance but to stimulate me, to make a point, to force a dialog, or to cause action.  Some prefer dialectic reasoning to try to resolve contradictions, that’s a subtlety I don’t have.  Like the time I left the vacuum in the middle of the living room for two weeks hoping my roommates would get the hint.  That was subtle and a failure.  I hired a housekeeper and billed them for it.

Take healthcare information technology, HIT.  One way or another I have become the polemic poster child of dissent, HIT’s eristical heretic.  I’ve been consulting for quite a while—twenty-five plus years worth of while.  Sometimes I see something that is so different from everything else I’ve seen that it causes me to pause and have a think.  Most times, the ball rattles around in my head like it’s auditioning for River Dance, and when it settles down, the concept which had led to my confusion begins to make sense to me.

This is not most times.  No matter how hard I try, I am not able to convince myself that the national EHR rollout strategy has even the slightest chance of working as designed.  Don’t tell me you haven’t had the same concern—many of you have shared similar thoughts with me.  The question is, what are we going to do about it?

Here’s my take on the matter, no subtlety whatsoever.  Are you familiar with the children’s game Mousetrap?  It’s an overly designed machined designed to perform a simple task.

Were it simply a question of how to view the current national EHR roll out strategy I would label it a Rube Goldberg strategy.  Rube’s the fellow noted for devising complex machines to perform simple tasks.  No matter how I diagram it, the present EHR approach comes out looking like multiple implementations of the same Rube Goldberg strategy.  It is over designed, overly complex.  For it to work the design requires that the national EHR system must complete as many steps as possible, through untold possible permutations, without a single failure.

Have you ever been a part of a successful launch of a national IT system that:

  • required a hundred thousand or so implementations of a parochial system
  • has been designed by 400 vendors
  • has 400 applications based on their own standards
  • has to transport different versions of health records in and out of hundreds of different regional health information networks
  • has to be interoperable
  • may result in someone’s death if it fails

Me either.

Worse yet, for there to be much of a return on investment from the reform effort, the national EHR roll out must work.  If the planning behind the national ERH strategy is indicative of the planning that has gone into reform, we should all have a long think.

I hate when people throw stones without proposing any ideas.  I offer the following—untested and unproven.  Ideas.  Ideas which either are or aren’t worthy of a further look.  I think they may be; you may prove me wrong.

For EHR to interoperate nationally, some things have to be decided.  Somebody has to be the decider.  This feel good, let the market sort this out approach is not working.  As you read these ideas, please focus on the whether the concept could be made to work, and whether doing so would increase the likelihood of a successful national EHR roll out.

  • Government redirects REC funds plus whatever else is needed to quickly mandate, force, cajole, a national set of EHR standards
    • EHR vendors who account for 90%–pick a number of you don’t like mine—use federal funds to adapt their software to the new standard
    • What happens to the other vendors—I have no idea.  Might they go out of business?  Yup.
    • EHR vendors modify their installed base to the standard
  • Some organization or multiple organizations—how many is a tactic so let’s not get caught up in who, how many, or what platform (let’s focus on whether the idea can be tweaked to make sense)—will create, staff, train its employees to roll out an EHR shrink-wrapped SaaS solution for thousands and thousands of small and solo practice
    • What package—needs to be determined
    • What cost—needs to be determined
    • How will specialists and outliers be handled—let’s figure it out
  • Study existing national networks—do not limit to the US—which permit the secure transfer of records up and down a network.  This could include businesses like airline reservations, telecommunications, OnStar, ATM/finance, Amazon, Gmail—feel free to add to the list.  It does no good to reply with why any given network won’t work.  Anyone can come up with reasons why this won’t work or why it will be difficult or costly to build or deploy.  I want to hear from people who are willing to think about how to do it.  The objective of the exercise is to see if something can be cobbled together from an existing network.  Can a national EHR system steal a group of ideas that will allow the secure transport of health records and thereby eliminate all the non-value-added middle steps (HIEs and RHIOs)?  Can a national EHR system piggyback carriage over an existing network?

We have reached the point of lead, follow, or get out of the way, and two of these are no good.

December 21, 2011

EHR: How Important is Due Diligence?

Filed under: EHR,Hospital,informatics,planning,Rants & Musings,Strategy,Who's Running the Show? — Paul Roemer @ 10:30 am

What was your first car?  Mine was a 60’ something Corvair–$300.  Four doors, black vinyl bench seating that required hours of hand-stitching to hide the slash marks made by the serial killer who was the prior owner, an AM and a radio, push-button transmission located on the dash.  Maroon-ish.  Fifty miles to the quart of oil—I carried a case of oil in the trunk.  One bonus feature was the smoke screen it provided to help me elude potential terrorists.

I am far from mechanically inclined.  In high school I failed the ASVAB, Armed Services Vocational Aptitude Battery—the put the round peg in the round hole test.  Just to understand how un-complex the Corvair was, I, who hardly knows how to work the radio in a new car, rebuilt the Corvair’s alternator—must not have had many working parts.  Due the the excessive amount of rusting I could see the street from the driver’s side foot well.

However, it had one thing going for it; turning the key often made it go—at least for the first three or four months.  Serves me right.  The guy selling the car pitched it as a date-mobile, alluding to the bench front seat.  Not wanting to look stupid, I bought it.  Pretty poor due diligence.  An impulse purchase to meet what I felt was a social imperative—a lean, mean, dating machine.

The last time I made a good impulse purchase was an ice cream sandwich on a hundred degree day.  Most of my other impulse decisions could have used some good data.  The lack of good data falls on one person, me.

How good is the data you have for deciding to implement an EHR?  In selecting an EHR?  Did you perform the necessary due diligence?  How do you know?  Gathering good data is tedious, and it can lack intellectual stimulation.  I think it affects the same side of our brain as when our better half asks us to stop and ask someone for directions; we like being impulsive, and have built a career based on having made decisions on good hunches.

The difference between you buying and EHR and me buying a clunker is that when I learned I’d made a poor decision I was able to buy a different car.  You can’t do that with an EHR that has more zeros in the price tag than the national deficit.  Plenty of hospitals are on EHR 2.0–they also happen to be on CIO 2.0. while CIO 1.0 is out shopping for a Corvair.

December 20, 2011

EHR–WWOD (What would Oprah do?)

Filed under: consulting,EHR,informatics,planning,Strategy,Who's Running the Show? — Paul Roemer @ 12:13 pm

So, I’m watching a football game on television and it suddenly strikes me, there are probably a lot of people trying to understand what it is a consultant does that we can’t do for ourselves.

For those who have a life, those who missed the game, Alabama opens the game with several well-scripted opening plays and grabbed an early lead.

Their first ‘n’ offensive plays were brilliant.  They were planned perfectly.

It became apparent they had not planned the however many of the ‘n + 1′ plays.  Their plan failed to go beyond what they’d already accomplished.

How does that apply to what you do, what I do, and why I think I can help you?  It is best described by comparing your brain to a consultant’s brain.  Your work brain functions exactly as it should.  It’s comprised of little boxes of integrated work activities, one for admissions and registration, one for diagnosis, another for care.  There’s probably another box for whatever it is the newsletter stated IT was doing three months ago and how that impacts what you do.  That’s your job.

Your boxes interface in some form or fashion with the boxes of the person next to you in the hospital’s basement cafeteria who is paying for her chicken, broccoli, and rice dish that reminds you of what you ate at crazy Uncle Bob’s wedding reception.  That interface is the glue that makes the hospital work.  It’s also the synapse, the connective tissue—I know it’s a weak metaphor, but it’s a holiday weekend—give me some slack—that tries to keep healthcare functioning in an 0.2 business model.

There are names for the connective tissue, you know it and I know it.  It’s called politics.  It’s derived from antiquated notions like, “this is how we’ve always done it”, “that’s radiology’s problem”, and “nobody asked me”,

At some point over the next week or two the inevitable happens; the need arises for you to add some tidbit of information.  Do you add it to an existing box, put it in an empty box, or ignore it?  This is where you must separate the wheat from the albumen—just checking to see how closely you’re following.

Your personal warehouse of boxes looks like the final scene in Raiders of the Lost Ark—acre after acre of dusty, full boxes, no Dewy-decimal filing system, and no empty box.  There are two rules at the hospital; one, bits of information must go somewhere, and two, nobody can change rule one.

The difference, and it’s a big one, is that consultants have an empty box.  It’s our Al Gore lockbox.  We were born that way.  It’s like having a cleft chin.  We also have no connective tissue to your organization.  No groupthink.  No Stepford Wives. No Invasion of the Body Snatchers to turn us into mindless pods.  Consultants may be the only people who don’t care.  Let me rephrase that.  We don’t care about the politics.  We don’t care that the reason the hospital has four IT departments is because the hospital’s leadership was afraid to tell the siloed docs that they couldn’t buy or build whatever they wanted.

Sometimes it comes down to your WWOD (what would Oprah do) moment.  Not ‘what do they want me to do’, not ‘what would they do’, not ‘what is the least disruptive’, not ‘what goes best with what the other hospital did’.

At some point it comes down to, what is the right thing to do; what should we do.

Big, hairy healthcare IT projects come out of the shoot looking like Alabama did.  The first however many moves are scripted perfectly.  Heck, you can download them off Google.  Worse yet, you can get your EHR vendor to print them for you.

The wheat from the albumen moment comes when you have to come up with an answer to the questions, “What do we do next,” and “Why doesn’t it work like they said it would?”

That’s why consultants have an open box.  You know what we are doing when our brain takes us to the open box?  Thinking.  No company politics to sidetrack us.  Everybody knows the expected answers, but often the expected answer is not the best answer.  Almost everybody knows what comes after A, B, C, and D.

Sometimes…E is not the right answer or the best answer.

December 19, 2011

HIT/EHR: Adult supervision required

Filed under: EHR,Hospital,innovation,planning,Rants & Musings,Strategy,usability,Who's Running the Show? — Paul Roemer @ 9:19 am

Among other things, EHR requires adult supervision–kind of like parenting.

My morning was moving along swimmingly.  The kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—those of you more politically astute would call them evergreens—to make them look snow-covered.  (I just em-dashed an em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  It may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things it can be are things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR, a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctors.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.

December 14, 2011

EHR: read before you buy

Filed under: EHR,informatics,planning,Rants & Musings,Strategy,Who's Running the Show? — Paul Roemer @ 4:05 pm

There is a first time for everything.  Sunday was the first time it occurred to me that there is a difference between being twenty and not being twenty.  A few days ago one of the women at the gym was bemoaning the fact that being forty wasn’t at all like being thirty–puhleeaasse.

My wife would have me point out her admonition of “You are not twenty anymore.”  Women do not understand that to men this phrase goes into our little brains and comes out reshuffled as the phrase “Just you wait and see.”

There are those who would have you believe that there is no single muscle that is connected to every other muscle, a muscle which if pulled will make every other muscle hurt.  I beg to differ.  I think I found it—I call it a my groinal—it’s connected to my adverse and inverse bent-egotudinals, the small transflexors located behind the mind’s eye.  I found the muscle while running back a kickoff during a Saturday morning game of flag football.

Call it an homage to the Kennedys.  Sort of made me fee like one of them—I think it was Ethyl.  Old guys versus new guys—I know it’s a poor word choice but you know what I mean which after all is why we’re both here.  Did I mention that everything aches, so much so that I tried dipping myself in Tylenol?

There are two types of people who play football, those who like to hit people and those who don’t like being hit.  I am clearly a member of the latter camp.  I used to be able to avoid being hit by being faster than the other guy.  This day I avoided getting hit by running away from the other guy.

The weird part is that my mind still pictures my body doing things just like the college kids on the field, and it feels the same, it just isn’t.  Two kids passed me–they were probably on steroids, and my only reaction was the parent in me wanting to ground the two of them.  Half the guys are moving at half the speed of the other guys.  At the end of each play, we find our side doubled over, our hands on our knees, our eyes scanning the sidelines for oxygen and wondering why the ground appears to be swaying.

As the game progresses, instead of running a deep curl pattern, I find myself saying things like, “I’ll take two steps across the line of scrimmage, hit me if I’m open.”  Thirty minutes later I’m trying to cut a deal with their safety, telling him, “I’m not in this play, I didn’t even go to the huddle.”  After that I’m telling the quarterback, “If you throw it to me, I’m not going to catch it, no matter what.”

All the parts are the same ones I’ve always had, but they aren’t functioning the way they should.  It’s a lot like assembling a gas grill and having a few pieces remaining—I speak from experience.  Unfortunately, implementing complex healthcare information technology systems can often result in things not functioning the way they should, even if you have all the pieces.  It helps to have a plan, have a better one than you thought you needed, have one written by people who plan nasty HIT systems, then have someone manage the plan, someone who can walk into the room and say, “This is what we are going to do on Tuesday, because this is what you should do on Tuesday on big hairy projects.”.

Then, if you pull your groinal muscle implementing EHR, try dipping yourself in Tylenol.

November 7, 2011

EHR’s Kitchen Table Amateurs (KTAs)

Filed under: EHR,Hospital,informatics,planning,Rants & Musings,Strategy,Who's Running the Show? — Paul Roemer @ 9:29 am

So I’m making dinner the other night and I’m reminded of a story I heard a while back on NPR. The narrator and his wife were telling stories about their 50 year marriage, some of the funny memories they shared which helped keep them together. One of the stories the husband related was about his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf. She’d mix the ingredients in a large wooden bowl; 1 pound each of ground beef and ground pork, breadcrumbs, two eggs, some milk, salt, pepper, oregano, and a small can of tomato paste. She’d knead the mixture together, shape into a loaf, and place the loaf into the one-and-a-half pound pan, discarding the leftover mixture. She would then pour a mixture of tomato paste and water, along with diced carrots and onions on top of the two loaf, and then garnish it with strips of bacon.

He went on to say that meatloaf night at home was one of his favorite dinners. His wife always prepared the dish exactly as she had learned from her mother. One day he asked her why she threw away the extra instead of cooking it all. She replied that she was simply following her mother’s recipe.  The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”

Therein lays the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing. Several of you have inquired as to how to incorporate some of the EHR strategy ideas in your organization, how to get out of the trap of continuing to do something the same way it’s been done, simply because that’s the way things are done. It’s difficult to be the iconoclast, someone who attacks the cherished beliefs of the organization. It is especially difficult without a methodology and an approach. Without a decent methodology, and some experience to shake things up, we’re no better off than a kitchen table amateur (KTA). A KTA, no matter how well-intentioned, won’t be able to affect change. The end results would be no better than sacrificing three goats and a chicken.

So, think about how to define the problem, how to find a champion, and how to put together a plan to enable you to move the focus to developing a proper strategy, one that will be flexible enough to adapt to the changing requirements. But keep the goats and the chicken handy just in case this doesn’t work.

October 28, 2011

Help has arrived for your EHR productivity loss

Filed under: EHR,planning,productivity,Strategy,usability,Who's Running the Show? — Paul Roemer @ 11:21 am

I was thinking about the time I was teaching rappelling in the Rockies during the summer between my two years of graduate school.  The camp was for high school students of varying backgrounds and their counselors.  On more than one occasion, the person on the other end of my rope would freeze and I would have to talk them down safely.

Late in the day, a thunderstorm broke quickly over the mountain, causing the counselor on my rope to panic.  No amount of talking was going to get her to move either up or down, so it was up to me to rescue her.  I may have mentioned in a prior post that my total amount of rappelling experience was probably no more than a few more hours than hers.  Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her.

The sky blackened, and the wind howled, raining bits of rock on us.  I remember that only after I locked her harness to mine did she begin to relax.  She needed to know that she didn’t have to go this alone, and she took comfort knowing someone was willing to help her.

That episode reminds me of a story I heard about a man who fell in a hole—if you know how this turns out, don’t tell the others.  He continues to struggle but can’t find a way out.  A CFO walks by.  When the man pleads for help the CFO writes a check and drops it in the hole.  A while later the vendor walks by—I know this isn’t the real story, but it’s my blog and I’ll tell it any way I want.  Where were we?  The vendor.  The man pleads for help and the vendor pulls out the contract, reads it, circles some obscure item in the fine print, tosses it in the hole, and walks on.

I walk by and see the man in the hole.  “What are you doing there?”  I asked.

“I fell in the hole and don’t know how to get out.”

I felt sorry for the man—I’m naturally empathetic—so I hopped into the hole.  “Why did you do that?  Now we’re both stuck.”

“I’ve been down here before” I said, “And I know the way out.”

I know that’s a little sappy and self-serving.  However, before you decide it’s more comfortable to stay in the hole with your EHR productivity loss and hope nobody notices, why not see if there’s someone who knows the way out?

Merely appointing someone to run your EHR effort doesn’t do anything other than add a name to an org chart.

October 25, 2011

What does lost EHR productivity cost?

Filed under: EHR,EMR,Hospital,planning,productivity,Rants & Musings,usability,Who's Running the Show? — Paul Roemer @ 3:22 pm

One of the most exciting parts of any project is the point when the period of anoesis ends and members of the project team drift back to reality, back to a period of having to come to terms with what they have wrought.  That is the point at which you know things will feel better once they stop hurting.

For those inclined to argue that the project was a success because of the number of people who use it, may we visit that notion a little before we buy in all the way?  Arguing that use is the same as acceptance is a little like arguing the same about our use of gravity—after all, it is not as though we have much of a choice as to whether we are going to use gravity.  Maybe we should allow users to rename user acceptance to grim resignation.

User Acceptance may be a good thing, and it may be better than no user acceptance. Therefore, User Acceptance is a necessary but not sufficient condition of how well you spent the millions.

What could possibly be wrong with having one hundred percent of the user community using the application?  Well, if users have no choice, or if penalties are involved with not using the application, merely using the application does not tell you if the application is any good, it simply tells you it is being used.

Electronic Health Records (EHR) systems are deployed in many hospitals.  In some hospitals, user acceptance is quite high.  In many of those hospitals productivity has dropped, and this productivity drop is being traced directly to using the EHR.  Written in a different way, and with other factors remaining constant, doctors were able to see more patients prior to the implementation of the EHR.  The EHR, more specifically how they use the EHR, has resulted in them being able to see fewer patients.

Many physicians in large service provider environments are reporting that they are only able to see about eighty percent of the number of patients they had been able to see.  Now one school of thought would have you believe that seeing twenty percent less patients is not a problem because sooner or later all of the patients are seen.  This argument does not work.

Let us look at an example of a hundred and forty physician orthopedic practice that before implementing EHR its doctors were seeing four patients an hour over a ten hour day.  So as to not scare anyone, let us also assume that on any given day only half of the doctors were scheduled to see patients.  Since what we are looking at is the productivity delta of pre and post EHR, we are assuming that all other factors are similar.  Before EHR the group saw twenty-eight-hundred patients a day; after EHR they only saw twenty-two-hundred and forty patients.

In this example we see a net loss of five-hundred and sixty patient visits each day.  Seeing those patients tomorrow does not solve the problem.  The problem is that real revenue was lost today, and will be lost again tomorrow and the next day and so forth and so on.

In this example we can put an exact figure on the amount of revenue lost due to an unproductive yet fully user accepted EHR system.  This example also shows that this service provider cannot hope to grow because it cannot even manage its current patient load.  To get back to its old revenues, the provider would have to hire twenty-five percent more doctors.

So, does it make any sense to not deal with the distinction between user acceptance and productivity?  Why would a provider accept having to go from one-hundred-forty physicians to one-hundred-seventy-five physicians just to see the same number of patients?  In theory, they would have to increase the number of physicians by twenty-five percent to attain pre-EHR revenues.  Even if they added thirty-five physicians, although revenues would recover, costs would go way up, and margins would take a pounding.

What exactly does a twenty percent productivity drop look like?  I think some people only think of it in terms of inefficiencies and ineffectiveness and forget that it has real dollars attached to it.  Let us calculate the cost to our orthopedic practice.  Just in round numbers, forgetting labs and scripts and therapy, five hundred and sixty visits a day multiplied by two-hundred and fifty days a year equals one-hundred and forty thousand missed patient visits a year.  Just to keep the math simple, if the average missed visit results in a revenue loss of one hundred dollars, the loss to the business is about fourteen and a half million dollars.

Maybe that is enough incentive to come up with a name for the project whose purpose is to offset the EHR productivity loss.  The good news is you can recapture the lost productivity but you will need to look outside of IT and your EHR vendor to do it.

October 18, 2011

What was the name of your project that lost all the productivity

Filed under: EHR,EMR,Hospital,informatics,planning,Rants & Musings,Strategy,Who's Running the Show? — Paul Roemer @ 4:59 pm

Since we are already talking about productivity I thought it would be worth spending a few minutes trying to understand why large numbers of hospitals seem to have acquiesced to the notion that operating with a productivity loss is their new steady state.

Imagine for a second that you were to discover that your least costly resource, say the person who answered the phones was spending twenty percent of their day updating their Facebook page.  Were that the case, you would know two things with a high degree of certainty;

  1. The productivity loss had a measurable cost
  2. The productivity loss would be corrected quickly

Now imagine that your hospital spent eight or nine figures on an EHR system.  Imagine that the hospital’s most expensive resources, the doctors, are spending most of their time entering data into the hospital’s expensive EHR system, so much time in fact that they are only able to see eighty-percent of their patients.  Now imagine that you do not have to imagine these because they are real.

Headline:  EHR results in a twenty-percent productivity loss.

Any hospital executive should be able to answer the following two questions:

  1. How much does each percentage of productivity loss cost the hospital?
  2. What is the name of the project to recover the lost productivity?

The project has no name because there is no project, and that is a shame.  The project to create the productivity loss had some stellar name, it had a war room, and it probably even had its own T-shirts.  The project to lose all of that productivity was a massive undertaking.

Should not the project to recover the productivity receive a little attention?

There are those who believe the lost productivity is gone forever.  Productivity is not like energy; it can be created and destroyed.  All kidding aside, there is a way to retrieve the lost productivity, all of it.  If you would like to know let me know.

October 17, 2011

EHR’s Two Types of Failure at your Hospital

Filed under: EHR,EMR,General HIT,healthcare costs,informatics,planning,PMO,Who's Running the Show? — Paul Roemer @ 1:28 pm

"Kinetic productivity"

I have been rereading John Eldredge’s book Wild at Heart.  It seems his purpose for the book is to help men cope with their feelings of not measuring up to their father’s expectations.  It delivers its punch at much the same level as the last scene in the film Field of Dreams when the father and son have a chance for one last catch.

(I am pausing parenthetically for a moment for the men to wipe their collective eyes.)

Here comes the segue, so hold on to your EHRs.  Let us spend some time dealing with lost opportunity and failure.  What if we define two types of failures; kinetic failure and potential failure?

Kinetic Failure: the failure to achieve the possible

Potential Failure: the failure to achieve the probable

Viewed from the perspective of productivity, let us define X to represent the service provider’s pre-EHR productivity; the distance from P to A represents the productivity loss brought about by the EHR, and the distance from A to K represents the opportunity loss.

P——————————A—————————K

One can argue with some degree of reason that the purchase of an EHR was made with the reasonable assumption that in addition to improving quality and patient safety the EHR would improve productivity to some degree.  In fact, assuming the provider did any sort of cost benefit analysis or return on investment calculation, any ROI, if it exists lives somewhere along the path between A and K.

If productivity is not improved, the service provider incurs an opportunity loss, a kinetic failure. At that point the best a service provider can hope to achieve is to not suffer a productivity loss.

One can also argue that the purchase of an EHR was made with the reasonable assumption that the implementation of EHR would not reduce productivity.

In many service providers EHR has resulted in a double hit to productivity; not only did they not achieve the productivity gains that were possible, they lost productivity.  A lot of people raise complaints when they speak about how much productivity costs.  One thing that is for certain, productivity costs a lot less than lost productivity.

This lost productivity, the kinetic failure, is the elephant in the service provider’s waiting room.  It has been poking its trunk through the door, and the only thing it wants once it gets its trunk through the door is to get all the way in the room.

Well, it is in the room, all the way in.

Part of the confusion facing providers is due to the fact that no matter how bad the productivity loss, a provider can still qualify as a meaningful user. That fact has led many providers to believe that since they can still qualify as such, that perhaps the productivity loss cannot be all bad news.

Let us look at a real example from a client of mine, a hundred and forty physician practice.  This practice had hit a barrier in terms of its ability to add patients, doctors, and staff.  It was running consistently an hour to an hour and a half behind with its patients.

The practice spent millions to implement an EHR.  Several months post implementation the practice was still running an hour behind.  Automating bad practices resulted in only one thing; the bad practices were completed faster.

To have any hope of avoiding kinetic failure and potential failure a healthcare practice must address how it runs its business.  Some business processes are duplicative, some are outdated, and some are wasteful.

Every one of those eats away at possible and probable productivity.  EHR was not designed to be a productivity windfall, but it clearly shines a spotlight on lost productivity.

Fortunately, even if your EHR has led to a productivity loss, all is not lost. Kinetic productivity can be regained, and potential productivity can be captured.  The path to productivity slices right through how the EHR is being used.  User Experience, UX, and usability, can and should be examined, redesigned and deployed.  This is not for the squeamish as it will cut through constraints like ‘We can’t do that’ and ‘We have always done it this way.’

Can’t and always must become productivity’s road kill.

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