change management

EHR: I may have found a shortcut

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How able are you to conjure up your most brainless moment—don’t worry, we aren’t on the EHR part yet.

As I was running in San Diego I was passed by a harem of seals—Navy Seals.  Some of them were in better shape than me, I couldn’t judge the fitness of the others as they ran by me too fast.  That got me thinking.  For those who having been regular readers, you’ll know this is where I have a tendency to drive myself over a cliff.

Seeing the Seals took me back to my wistful days as a cadet at the US Air Force Academy.  Coincidentally, my hair looked then a lot like it looks now.  One of the many pastimes they tossed our way for their amusement and our survival was orienteering; sort of map reading on steroids.  One night they took us to the foothills of the Colorado Rockies, paired off the doolies, gave us a set of map coordinates, a compass, map, and flashlight.  The way training worked, those who proved to be the fastest at mastering skills fared better than those who weren’t.  Hence, there was plenty of incentive to outperform everyone; including getting yourself to believe you could do things better than you could, sort of a confidence building program.

We were deposited in a large copse—I’ve always liked that word—of trees—I don’t know, but it seems adding trees to the phrase is somewhat redundant.  We had to orient ourselves and then figure out how to get to five consecutive locations.  The sun had long since set as we made our way through the treed canyon and back up a steep ravine.  After some moments of searching we found the marker indicating we were at point Able.  The group started to examine the information that would direct our journey to point Bravo.

While they honed their skills, I was examining the map, taking some bearings with the compass, and trying to judge the terrain via the moonlight.  My roommate, a tall lanky kid from Dothan, Alabama asked why I didn’t appear to be helping.

“Look at this,” I replied.  “Do you see that light over there, just to the right of that bluff?  I think I’ve found us a shortcut.”

“What about it?”  Asked Dothan.

“If my calculations are correct, that light is about here,” I said and showed them on my map.  “It can’t be more than a hundred yards from point Delta.”

“So?”

“So why go from Alpha to Bravo to Charlie to Delta, if we can go right to Delta from here?  That will knock off at least an hour.”  I had to show my calculations a few times to turn them into believers, but one by one they came aboard.  The moon disappeared behind an entire bank of thunderheads.  We were uniformly upbeat as we made our way in the growing blackness through the national forest.  Unlike the way most rains begin, that night the sky seemed to open upon us like a burst paper bag.

“Get our bearing,” I instructed Dothan.  As it was my idea, I was now the de facto leader.  As we were in a gully, getting our bearings required Dothan to climb a large evergreen.

“I don’t see it,” he hollered over the wind-swept rain squalls.  I scurried up, certain that he was either an idiot or blind.

“Do you see the light?”  They asked me.  I looked again.  Checked my map.  Checked my compass.  “It has to be there,” I yelled.

A voice floated up to me.  To me I thought it probably sounded a lot like the voice Moses heard from God as he was building the Ark.  (Just checking to see if you’re paying attention.)  “What if they turned off the light?”

I almost fell out of the tree like an apple testing the laws of gravity.  What if someone had turned off the light?  There was no ‘what if’ to consider.  That is exactly what happened.  Some inconsiderate homeowner had turned off their porch light and left us stranded.

Fast forward.  We were lost, real lost.  We didn’t finish last, but we did earn extra exercise the next day, penalized for being creative.  Who’da thunk it?

Short cuts.  When they work, you’re a headliner.  When they fail, chances are you’re also a headliner—writing the wrong kind of headlines.  I hate being redundant, but with EHR we may be dealing with the single largest expenditure in your organization.  It will cost twice as much to do it over as it will to do it right.  If you haven’t done this before—I won’t embarrass anyone by asking for a show of hands—every extra day you add to the planning process will come back to you several fold.  There may be short cuts you can take, but planning should not be one of them.  How much should we plan?  How long should it take?  Who should participate?  We will look at each of those questions in some detail.  For now, let’s answer those three questions with; more than you think, longer than you’ve planned for it to take, and different skills than you’re currently using.saint

Your EHR: Is it Well & Good?

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There were four of us, each wearing dark suits and sunglasses, walking uniformly down the street, pausing at a cross-walk labeled “consultants only”—I think it’s a trick because a lot of drivers seem to speed up when they see us. We looked like a bad outtake from the movie Reservoir Dogs. We look like that a lot.

Why do you consult, some ask? It beats sitting home listening to Michael Bolton or practicing my moves for So You Think You Can Dance, I tell them.

Listening to the BBC World News on NPR whilst driving, there’s one thing I always come away with—they, the British, are always so…so British. No matter the subject—war or recession—I feel like I should sit up straight and having a proper pot of tea and little cucumber sandwiches with the crusts removed; no small feat while navigating the road.

Today’s NPR conversation included a little homily about the Gordian knot with which the company Timberland is wrestling, questioning whether as a company Timberland should do well, or do good. (Alexander the Great attempted to untie such a knot, and discovered the knot had no end (sort of like a Möbius strip, a one-sided piece of paper–pictured above. (For the truly obtuse, among which I count myself, the piece of paper can be given a half twist in two directions; clockwise or counter-clockwise, thereby giving it a handedness, making it chiral—when the narrative gets goofy enough, sooner or later the Word dictionary surrenders as it did with chiral.))) I’m done speaking in parentheses.

Should timberland do well or good? Knowing what little command some have of the English language, NPR’s listeners must have wondered, why ask a redundant question. Why indeed? That’s why I love the English, no matter the circumstances they refuse to stoop to speaking American.

Back to Gordo and his knot. That was the point of the knot. One could not have both—sorry for the homonym. Alexander knew that since the knot had no end, the only way to untie it was to cut it. The Gordian knot is often used as a metaphor for an intractable problem, and the solution is called the “Alexandrian solution”.

To the question; Well or good. Good or evil. Are the two choices mutually exclusive? For an EHR? They need not be, no matter how intractable the EHR. The question raised by the BBC was revenue-focused (doing well) versus community or green-focused (doing good). My question to the reader is what happens if we view EHR with this issue as an implication, a la p→q.Let’s review a truth table:

if P equals if Q equals p→q is
define requirements increase revenues

TRUE
play vendor darts increase revenues

FALSE
ignore change management increase revenues

FALSE
no connectivity increase revenues

FALSE
new EHR software increase revenues

FALSE
change processes increase revenues

TRUE
eliminate waste increase revenues

TRUE
decrease redundancy increase revenues

TRUE
Strong PMO increase revenues

TRUE

From a healthcare provider’s perspective the answers can be surprising; EHR can be well and good, or not well and not good.  The Alexandrian solution for EHR is a Alexandrian PMO.

Have your people call my people–we’ll do lunch.

EHR: The 40-chicken crocodile

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Got a couple hundred million burning a hole in your pocket?  Why not buy an EHR?  Indeed.

Riddle me this Batman, “What is a 40 chicken crocodile?”

It is the number of chickens you have to feed it each day to keep it from eating you. What is the crocodile at your hospital?  Is it your EHR?

Let me recount to you a true story about the details of one of the EHR “success” stories.  A major hospital who selected their EHR from among one of what I like to call the oligopoly EHR Flavor of the Month Club.  You know the suspects.

Permit me to throw a wrench to those clairvoyants who think they know where this is going before I’ve even written it.  Admittedly, I have a tendency to throw metaphorical tomatoes in one direction—that of the vendors.  That’s because, they are often easy targets.  Slow down Pepito.

This hospital, and from what I was told, the vendor, did it right.  I am not sure I would have differed from the approach of either.  The hospital spent a few years in its vendor selection process, and they were very thorough.  They spent two years building their process maps, ensuring the vendor implemented the EHR to meet their needs, not the other way around.  Operations led the nine-figure project.

They implemented many of the support functions and a few of the specialty functions.  Here come the chickens.  After implementation, cash flow dropped by 80 percent for several months due to significant issues they encountered cleaning up the revenue side.  Doctors were instructed to cut their hours by fifty percent to allow them to learn to use the system.  Hours are still down by twenty percent, well more than a year later.  Users use about one-third of the functionality, even after a rigorous training program.

The hospital held off doing most of the clinical implementations for two years.

I asked for some recommendations.  What would you have done differently?  Here’s what I learned.  If you have a research organization you need to spend extra special attention to their workflows.  Managing post-go-live was a big issue to begin to offset productivity losses. Without a continuous process improvement program the EHR would not have been accepted. Do not pick a go-live date at the outset of the project as it causes the organization to be paralyzed simply to hit the date.  Testing was compromised to meet the go-live date. The post go-live issues are still being fought.  Do not let the design or build teams skimp on either reporting or testing, they are still playing catch-up.

So, after doing a pretty bang up job, at least from where I sit, there are still a lot of chickens being fed to the crocodile.  Wonder how many chickens it would have taken had the users not been as involved as they were.  How many had the users not spent two years pre-build defining processes?  A lot.  Now comes the rest of the clinical effort.  See you at the poultry counter.

 

Guest post: EHR would work better if we just got rid of the doctors

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I am pleased to share a guest blog by Sue Kozlowski, the Manager of Performance Improvement at Henry Ford Hospital in Detroit, Michigan. She’s a featured blogger at iSixSigma.com, writing on lean process improvement and change management.  Sue and I were speaking about some of the issues surrounding EHR.  She had an interesting and new perspective, and I asked her to share it with you.  One of my physicians shard something similar with me about the value of the data in their EHR, “The data is great if you are a patient or payer who wants to sue us.”

Thanks Sue.  The rest is hers.

The EHR’s New Clothes

Paul and I were talking the other day about Electronic Health Record systems, and he made an interesting comment. It seems that some hospitals and systems implement their EHR expecting great things, and then they’re somewhat startled to see a big drop in productivity – sometimes on the order of 10 – 30%.

I have a hypothesis about this, related to the way healthcare experts work and the way EHRs are designed. To become a physician, you go through years of school. You learn to develop an intuitive thought process that puts together the patient’s current state, his or her desired future condition, and medical pathway to get there. You were trained to document on a paper chart and when you write assessments or orders, you write them in the chart, sign/date/time it, and then leave the chart for a clerk to transcribe orders and follow through on them.

Now let’s look at this process with an EHR which has a feature called CPOE, Computerized Physician Order Entry. Let’s write a prescription, shall we? (By the way, this scenario is not based on any one system but may be considered a possible experience.)
1. Go to the meds tab
2. Start typing into the field “Tyl”
3. See the drop-down list bring up Tylenol, pick Tylenol
4. Click on the dose field to bring up the drop-down list
5. Scroll down and select 200 mg
6. Click on the route field to bring up the drop-down list
7. Scroll down and look for “oral;” settle for “by mouth”
8. Click on the frequency field to bring up the drop-down list
9. Scroll down and look for PRN; have to select “every 4 hours as needed”
10. Click on the Start Date field to bring up the calendar (can’t just type it in)
11. Select the start date
12. Go to “Electronic Signature” field and type in first three letters of last name
13. Find name in drop-down box
14. Click “Enter”
15. Get warning message, “Medication Alert;” click on alert button to see details
16. Read that Tylenol may have a reaction with another medication the patient is taking; click “Continue”
17. Scroll back down to click on “Enter”

And that’s just for one medication order!

So my point to Paul in this discussion was that so far, we have developed electronic documentation and billing systems that are wonderful for capturing standard documentation information; this is very useful for data-mining and for coding and billing. Features like cross-checking drug interactions, or pre-loading patient care pathways, can also enhance patient safety. These are all good things.

But, it doesn’t do so much for fast-thinking, highly trained, busy caregivers. The cost is in the productivity of the people who are entering the data. From a computer standpoint, everything is codified and the programmers have been careful to provide every possible alternative available in drop-down and radio-button format. We’ve turned the process from a 30-second note (granted, sometimes illegible) into a 3-minute process that is safer, great for reporting, and maximizes appropriate revenue.

And drops your productivity about 20%.

Lest you consider me a Luddite, I’m actually an early adopter of most new technologies and I love the prospect of safer patient care that an electronic medical record can bring. As a process improver, I’m ecstatic about the data mining opportunities. But let’s be realistic when we make these decisions: there is a cost, in addition to money, that must be paid to use these systems in their current state. I hope that in the future, programming can mimic the physician’s thought process and approach. In today’s world, it feels like we are asking our clinicians to meet the needs of the capability of the application, rather than building systems that maximize the value of the clinician’s time.

EHR–where do you place the emphasis?

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You said I stole the money. Sometimes it all depends on what you emphasize. For example, say the sentence aloud to a friend, and each time place the emphasis on a new word. You said I stole the money. Yousaid I stole the money. You said I stole the money. You said I stole the money. You said I stole the money. The meaning changes as you change your emphasis. You said I stole the money? You can even change it so that it reads like a question.

The same is true with providers and the level of success a firm has working with EHR. Where is your emphasis? If you believe there is a correlation between emphasis and spending, I bet we can prove your firm’s is much more closely aligned to technology than it is to process. What does technology address? Let’s list how deploying technology makes your firm better, or does it?  Millions followed by millions more. Redesign the patient portal.  Add EHR. Mine the data—heck, strip mine it.  Show me the ROI. Isn’t that a lot of money to spend without a corresponding business justification?  Then add in the fact that the productivity at many hospitals after implementing EHR is twenty percent below what it was prior to EHR.  That does not not do much for the ROI.

The technology that is tossed at the problem reminds me of the scene from the “Wizard of Oz” when the Wizard instructs Dorothy and the others, “Pay no attention to the man behind the curtain.” When Toto pulls the curtain aside, we see a nibblet—I love that word—of a man standing in front of a technological marvel. What’s he doing? He’s trying to make an impression with smoke and mirrors, and he’s hoping nobody notices that the Great Oz is a phony, that his technology brings nothing to help them complete their mission.

From whose budget do these technology dollars usually come for EHR? IT. From the office of the CIO–the only department in the whole hospital which will not “use” the EHR. What did you get for those millions?  Just asking.
Part of the problem with doing something worth doing on the EHR front is that it requires something you can’t touch, there’s no brochure for it, and you can’t plug it in. It’s process. It requires soft skills and the courage to change your firm’s emphasis. They won’t like doing it, but they will love the results.

EHR-Do not use as a flotation device

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EHR potentially will offer a number of benefits.  It won’t offer much at all if you don’t install it correctly.

However, EHR is not a panacea.  Without having a detaile understading of the business problems you are trying to solve, it may not be of much more value than a Xerox machine.

Can you make color copies with your EHR?

 

What do processes have to do with EHR success?

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As a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR? The reason is simple. The taxonomy of most, if not all EHR systems, is that they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

 

EHR’s Gordian knot

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There were four of us, each wearing dark suits and sunglasses, uniformly walking down the street, pausing at a cross-walk labeled “consultants only”—I think it’s a trick because a lot of drivers seem to speed up when they see us. We looked like a bad outtake from the movie Reservoir Dogs. We look like that a lot.

Why do you consult, some ask? It beats sitting home listening to Michael Bolton or practicing my moves for, So You Think You Can Dance, I tell them.

Listening to the BBC World News on NPR whilst driving, there’s one thing I always come away with—they’re always so…so British. No matter the subject—war or recession—I feel like I should be having a proper pot of tea and little cucumber sandwiches with the crusts removed; no small feat while navigating the road.

Today’s conversation included a little homily about the Gordian knot with which the company Timberland is wrestling, questioning whether as a company Timberland should do well, or do good. (Alexander the Great attempted to untie such a knot, and discovered it had no end (sort of like a Möbius strip, a one-sided piece of paper–pictured above. (For the truly obtuse, among which I count myself, the piece of paper can be given a half twist in two directions; clockwise and counter-clockwise, thereby giving it handedness, making it chiral—when the narrative gets goofy enough, sooner or later the Word dictionary surrenders as it did with chiral.))) I’m done speaking in parentheses.

Should they do well or good? Knowing what little command some people have of the English language, those listeners must have wondered, why ask a redundant question. Why indeed? That’s why I love the English, no matter the circumstances they, they refuse to stoop to speaking American.

Back to Gordo and his knot. That was the point of the knot. One could not have both—sorry for the homonym. Alexander knew that since the knot had no end, the only way to untie it was to cut it. The Gordian knot is often used as a metaphor for an intractable problem, and the solution is called the “Alexandrian solution”.

To the question; Well or good. Good or evil. Are the two choices mutually exclusive? For an EHR? They need not be. The question raised by the BBC was revenue-focused (doing well) versus community or green-focused (doing good). My question to the reader is what happens if we view EHR with this issue as an implication, a la p→q.Let’s review a truth table:

if P equals if Q equals p→q is
define requirements increase revenues TRUE
play vendor darts increase revenues FALSE
ignore change management increase revenues FALSE
no connectivuty increase revenues FALSE
new EHR software increase revenues FALSE
change processes increase revenues TRUE
eliminate waste increase revenues TRUE
decrease redundancy increase revenues TRUE
Strong PMO increase revenues TRUE

From a healthcare provider’s perspective the answers can be surprising; EHR can be well and good, or not well and not good.  The Alexandrian solution for EHR is a Alexandrian PMO.

Have your people call my people–we’ll do lunch.

 

Relative (Non) Value Units (RVUs)

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Below is my lastest post in HealthSystemCIO.com.

http://healthsystemcio.com/2010/12/01/relative-non-value-units/

This issue has been troubling me ever since a doctor told me her hospital was implementing it.  It is good to know that there are no patents on bad business ideas—that way everybody gets a chance to use them.  Sometimes bad ideas come with misnomer labels that suggest they are less evil—Meaningful Use is a good example of a misnomer idea, but that is not the topic of today’s discussion.

Permit me to illustrate this idea with an identical policy in another industry, one that I believe will hit home for many.  Think back to the last time a cable television technician came to your home to perform some piece of work; moving or adding an outlet, installing cable or internet.  (Before I started practicing medicine on-line, I spent many years consulting to the cable industry about how to improve their operations using the tools of IT.  I often rode with the technicians to observe how they did their work.)

During these times I noticed jobs when the technician did not have the time needed to complete the work described on the work order.  Rarely did the technician have time to complete any add-on work—work requested by the customer while the tech was at their home.

What really interested me was the answer to my question of ‘why’?  It comes down to the following.  When the technician leaves the service bay in the morning, the tech has a list of work orders that must be completed by the end of the day.  Each work order is worth a fixed number of points, and the technician is evaluated and paid in relation to the number of points earned.

Let’s say the tech is to install a new wall outlet; five points and 30 minutes may be assigned to that work order.  The tech arrives at the home only to learn the outlet is to be installed on an interior wall and the cable will have to by threaded through the wall via the attic; a sixty minute job.  If the tech stays to complete the work, it will only yield five points and delay his entire schedule by thirty minutes.

Either way, the process fails, and the customer is failed.  The tech will return tomorrow at double the cost to the company, but he will now be allocated 60 minutes for the work.  There is always time to do the work over, and never time to do it right.

This business process suggests the next customer is always valued more highly than the present customer.  This is why when you are being helped by a clerk in a store and the phone rings the clerk will stop servicing you—a paying customer—to service someone who merely wants to chat.

The process? Relative Value Units (RVUs), and it’s another misnomer.  An argument can be made to show RVUs have little or no relative value, but entire hospitals run on these, and IT builds systems to assign, track, and report on RVUs.  Is there a way for IT to demonstrate or report the impracticality of running a business in this manner?

 

Taking Care of Patients (TCOP)–the business side

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That’s me in the back row–just kidding. There are approximately 640 muscles in the human body. Yesterday I pulled 639 of them. In anticipation of the onset of winter I’ve been ramping up my workouts, and at the moment am scarcely able to lift a pencil. I came across an article that describes the full body workout used by the University of North Carolina basketball players. It involves a ten-pound medicine ball, and 400 repetitions spread across a handful of exercises. I’m three days into it and giving a lot of thought about investigating what kind of workout the UNC math team may be using. At my son’s basketball practice last night, the parents took on the boys—they are ten. That 640th muscle, the holdout, now hurts as bad as the rest of them.

So, this morning I’m running on the treadmill, because it’s cold and the slate colored clouds look heavy with rain. While I’m running, I am watching the Military History Channel, more specifically a show on the Civil War’s Battle of Bull Run—I learned that that’s what the Yankees called it, they named the battles after the nearest river, the Rebs called it the Battle of Manassas, named after the nearest town. The historian doing the narration spoke to the wholesale slaughter that occurred on both sides. He equated the slaughter to the fact that military technology had outpaced military strategy. The armies lined up close together, elbow to elbow, and marched towards cannon fire that slaughtered them. Had they spread themselves out, the technology would have been much less effective.

Don’t blink or you’ll miss the segue. You had to know this was coming. Does your hospital have one of those designer call centers? You know the ones—wide open spaces, sky lights, sterile. Fabric swatches. The fabric of the chair matches that of the cubicle, which in turn are coordinated with the carpeting. Raised floors. Zillions of dollars of technology purring away underfoot. We have technology that can answer the call, talk to the caller, route the caller, and record the caller for that all important black hole called “purposes of quality.”

The only thing we haven’t been able to do is to find technology to solve the patient’s problems. Taking Care of Patients (TCOP), also known as Patient Experience Management (PEM).  We’ve used it to automate almost everything. If we remove all the overlaying technology, we still face the same business processes that were underfoot ten years ago. Call center technology has outpaced call center strategy. Call center technology hasn’t made call centers more effective, it’s made them more efficient. Call center strategies are geared towards efficiencies. Only when we design call center strategies around being more effective will the strategy begin to maximize the capabilities of the technologies.