Who was the person who put in our first EHR system?

The first home I bought was in Denver.  Built in 1898, it lacked so many amenities that it seemed better suited as a log cabin.  There was not a single closet, perhaps because that was a time when Americans were more focused on hunting than gathering.  Compared to today’s McMansions, it was doll-house sized.

It needed work—things like electricity, water—did I mention closets?  I stripped seven coats of paint from the stairs.  Hand-built a fireplace mantle and a deck.  One day I arrived home only to find my dog had eaten through the lath and plaster wall of the space which served as my foyer/family room/ living room-cum-hallway.  I discovered the plaster and lathe hid a fabulous brick wall.

My choice was to patch the small hole, or remove the rest of the plaster.  I knew nothing of patching holes, but felt pretty confident about my demolition skills.  Within an hour I had purchased man-tools; two mauls, chisels, and a sledge hammer.  I worked through dinner and through the night.  The only scary moment came as the steel chisel I was using connected to the wiring of two sconces which were embedded in the plaster.  On cold nights I can still feel the tingling in my left shoulder.

As the first rays of dawn carved their way through the frosted beveled glass of the front door, I wondered why I never before had noticed that the glass was frosted.  I wiped two fingers along the frost.  A fine coating of white powder came off the glass leaving two parallel tracks resembling a cross-country ski trail.  I surveyed the room only to see that the air made it look like I was standing inside of a cloud.  The fine white powder was everywhere, covering my Salvation Army sofa, a semi-matching machine-loomed Oriental rug from the Far East (of Nebraska), a two-ton Sony television, and a component stereo system that had consumed most of my earnings.

Bachelor living can be entertaining.  One of my climbing buddies moved in with me.  The idea was I’d keep the rent low, and he’d help me by maintaining the house.  He didn’t help.  I made a list of duties; he didn’t help.  I left the vacuum in the middle of the floor, for two weeks and he walked around it.  I made him move out, and advertised for a female roommate—an idea I now wish I’d marketed.  A girl from church came over to see the place.  I turned my back on her to allow her to view the house with a degree of privacy.  When I returned I found her on her hands and knees cleaning the bathroom.  I was in love.  It was like having a big sister and mother.  She even asked if it was okay if since she was doing her laundry if she did mine at the same time.  Life was oh so good.

Sometimes when one approach isn’t working it’s real easy to try something else.  And sometimes the something else gives you a solution in the form of a water-walker.  Healthcare IT and EHR aren’t ever going to be one of those sometimes.  There will be no water-walkers, no easy do-overs.  There won’t be anyone walking your hallways talking about their first wildly unsuccessful EHR implementation.  Nobody gets to wear an EHR 2.0 team hat.  Those who fail will become the detritus of holiday party conversations.  Who will be the topic of future holiday parties?  I’m just guessing, but I’m betting it will be those who failed to develop a viable Healthcare IT plan, whoever selected the EHR without developing an RFP, the persons who decided Patient Experience Management (PEM) was a waste of money.  The good news is that with all of those people leaving your organization there will be more shrimp for everyone else to eat.

I’d better go.  I just noticed somebody left the vacuum in the middle of the floor so I need to get cracking before my wife advertises for a female roommate.

EHR: there’s a difference between finished and done

The phone rang last fall. It was the school nurse asking me if I would come pick up my seven year-old son. When I inquired as to the reason she informed me he exhibited the classic symptoms of the crud; tummy-ache, non-responsive, crying. She’s the nurse, so without better information, who was I to question her diagnosis?

We got into the car and the tears started to come again. “Do you feel like you’re going to be sick?” I asked as I looked at the leather upholstery. He didn’t answer me other than to whimper. He didn’t seem sick at breakfast. I remembered that he was crying last night, but that had nothing to do with his stomach. At first I thought it was related to the thunder. Nope. He was hugging his favorite dog, a five year-old Bichon.

We had learned a few weeks prior that the Bichon is ill and won’t ever be a six year-old Bichon. The person having the most difficulty with it is my youngest. I asked him if that was why he was crying in class and he confirmed that it was. Dads know everything, at least some times.

So, here’s the deal. The school nurse had done all the right things to diagnose my son’s problem, but she stopped short of determining what was wrong. Let’s try a more relevant situation from the perspective of an EHR implementation.  The word implementation sort of suggests that when you reach the point of having implemented that there’s nothing left to do.

There’s finished and then there’s complete.  Finished doesn’t mean the task is over until the system does what it was supposed to do.  Sort of like when W landed on the aircraft carrier.  If you didn’t do a good job of defining it up front you may never know the breadth of what was intended for the EHR.  In the case of EHR, done includes change management, work flow engineering, training, and user acceptance.

The point is, if it looks like you finished the EHR implementation, double check that you have before you take a bow. Technology alone will not an EHR implementation make, it is simply a part of the overall task.

Patient Relationship Management (PRM)-why men can’t boil water

There was a meeting last week of the scions of the Philadelphia business community. The business leaders began to arrive at the suburban enclave at the appointed hour. The industries they represented included medical devices, automotive, retail, pharmaceutical, chemicals, and management consulting. No one at their respective organizations was aware of the clandestine meeting. These men were responsible for managing millions of dollars of assets, overseeing thousands of employees, and the fiduciary responsibility of international conglomerates. Within their ranks they had managed mergers and acquisitions and divestitures. They were group with which to be reckoned and their skills were the envy of many.

They arrived singularly, each bearing gifts. Keenly aware of the etiquette, they removed their shoes and placed them neatly by the door.

The pharmaceutical executive was escorted to the kitchen.

“Did your wife make you bring that?” I asked.

He glanced quickly at the cellophane wrapped cheese ball, and sheepishly nodded. “What are we supposed to do with those?” He asked as he eyeballed the brightly wrapped toothpicks that looked banderillas, the short barbed sticks a matador would use..

“My wife made me put them out,” I replied. “She said we should use these with the hors d’oeuvres.”

He nodded sympathetically; he too had seen it too many times. I went to the front door to admit the next guest. He stood there holding two boxes of wafer thin, whole wheat crackers. Our eyes met, knowingly, as if to say, “Et Tu Brutus”. The gentleman following him was a senior executive in the automotive industry. He carried a plate of freshly baked chocolate chip cookies. And so it went for the next 15 to 20 minutes, industry giants made to look small by the gifts they were forced to carry.

The granite countertop was lined with the accoutrements for the party. “It’s just poker,” I had tried to explain. My explanation had fallen on deaf ears. There is a right way and a wrong way to entertain, I had been informed. Plates, utensils, and napkins were lined up at one end of the counter, followed in quick succession by the crock pot of chili that had been brewing for some eight hours, the cheese tray, a nicely arrayed platter of crackers, assorted fruits, a selection of anti-pastas, cups, ice, and a selection of beverages. In their mind, independent of what we did for a living and the amount of power and responsibility we each wielded, we were incapable of making it through a four hour card game without their intervention.

I deftly stabbed a gherkin with my tooth pick. “Hey,” I hollered “put a coaster under that glass. Are you trying to get us all in trouble? And you,” I said to Pharmacy Boy, “Get a napkin and wipe up the chili you spilled. She’ll be back here in four hours, and we have to have this place looking just as good as when she left.”  I thought I was having the neighborhood guys over for poker; I was wrong. So was each of the other guys. We had been outwitted by our controllers, our spouses. Nothing is ever as simple as it first appears. We didn’t even recognize we were being managed until they made themselves known.

Who’s managing the show at your shop, you or the patients?  The answer to that question depends on who owns the relationship, who controls the dialog.  If most of the conversation about your organization originates with them, the best you are doing is reacting to them as they initiate the social media spin, or try to respond once the phone started ringing.  It’s a pretty ineffective way of managing.  It’s as though they dealt the cards, and they know ahead of time that your holding nothing.

There are times when my manager isn’t home, times when I wear my shoes inside the house—however, I wear little cloth booties over them to make certain I don’t mar the floor.  One time when I decided to push the envelope, I didn’t even separate the darks from the whites when I did the laundry.  We got in an hour of poker before I broke out the mop and vacuum.  One friend tried to light a cigar—he will be out of the cast in a few weeks.

Be afraid. Be very, very afraid.

The EHR wore Prada: Stilleto Change Management

I just returned from the Prada show in Milan. Not really—that was the opening line from a piece on NPR. Apparently this year’s runaway hit on the runways has to do with high heels, with the emphasis on the notion of high.

The following comes from the UK Telegraph: The girls looked like rabbits trapped in the headlights; their faces taut and unsmiling, their eyes wide with fear and apprehension. Were they about to undertake a parachute jump? Abseil down a 1,000ft mountain? None of the above. All they were doing was trying to negotiate the catwalk at Prada during this week’s Milan fashion shows in shoes that were virtually impossible to walk in. At least two models tripped and fell on to the concrete floor; others wobbled and stumbled, teetering and tottering, clearly in agony, and all the while their minds were fixated on just one thing: reaching the sanctuary and safety of the backstage area without suffering a similar fate.

According to the NPR reporter, the heels are so high that regular people—women people that is—can’t seem to walk in them without falling. This problem has led to the creation of an entirely new micro-industry. In L.A. and New York, there are classes to teach ladies how to walk in very high heels without hurting themselves. These classes are being offered through dance schools that couldn’t fill their dance classes—they are now booked solid.

Tell me this isn’t the same as trying to walk and chew gum at the same time. Multitasking. Now before I make fun of some thirty year-old that has to relearn how to walk, let us turn our attention back to those dancing—cum—walking schools. From a consultant’s perspective what makes this story interesting is that those businesses saw a need and re-engineered a part of their operation to meet that need, sort of like we’ve been discussing regarding the impact EHR and reform can have on your organization.  With the implementation of EHR, many things will change.  If they don’t require change, you probably wasted your money on the EHR.  What’s important is having a plan to define the change and manage it.  Rework work flows, remove duplicated processes and departments.

Now I’m going to go saw the heels off my wife’s shoes before she hurts herself.


Is it time to rethink your approach?

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 loaves, and place the loaves 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, we’ll talk 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.

Controlling the patient dialog

Remember when there were 200 firms in the Fortune 100?

How long ago was that? I think it was around the same time when people still thought you shouldn’t wear white after Labor Day. Time to drop-kick those white pumps to the back of the closet. What made me think of that bit of nonsense was a meeting I had recently with one of the sharpest people I’ve had the pleasure to meet professionally, and a classmate of mine from grad school. She happens to be the founder and president of one of the country’s go-to firms for dealing with business ethics. Having served as a board member for several publicly-traded firms, as well as chairing their audit committees, when the Andersen and Enron scandals hit she went looking for professionals who could help her help her firms. When she couldn’t find the help, she created it.

That conversation got me thinking and made me wonder why there were no longer 200 firms in the Fortune 100. Was it; is it, a matter of business ethics? How often do unethical practices come up when firms interact with their customers? A couple of takeaways from the meeting—for board members to be able to meet their obligation, they ought to do more than reply on the meeting book pulled together by the firm they serve. Simply relying on the book presumes ethical behavior, a presumption not always supported by fact—how much should one believe if the information is being provided by someone who purchased a $900 shower curtain?

What can they do? Due diligence is being reinvented, and the Social Network is leading the charge. One example is to go to Yahoo Chat to see what’s really being said about your organization. Other things I’ve done to obtain facts and opinions, things which particularly gauge how customers and employees feel about the firm include Google Reader, Facebook, Twitter, and YouTube, to name just a few. You don’t need patient focus groups to learn what’s being said, or to learn how good a job your hospital is doing. The patients already have a laser focus. In many instances the group lacking the focus is the healthcare provider.

Firms should focus on maintaining a strong Reputation Bank, one strong enough to be able to handle withdrawals, because you never know when there might be a run on the bank. Might be a good time to look at your own bank deposit slips.  Deposits can be made easily through the social media network.  You can’t stop patients from talking about you but you can shape what they say.

EHR productivity need not be awful

I wrote this in response to a question I posted on a LinkedIn discussion group.

I have met with CIOs and CMIOs who have spent well over $100 million on name-brand systems-wide EHRs whose productivity in the exam room after more than two years is 20-30% less than it was before they implemented the EHR.  Two of those hospitals are replacing their EHR and expecting different results.

I watch some physicians spend more than half their time with a patient sitting at a keyboard clicking and navigating while the patient sits there.  I watched it happen to me in an exam.  My physician knows what I do and asked me if there was a way to improve his face-time.

That got me thinking about how to do that.  Most hospital EHRs are very broad and complex systems.  They are designed to do a multitude of things that go well beyond the  interactions needed to document what occurs during the exam.  My review of those systems indicates that in many cases their breadth makes it difficult for them to render effective and efficient service during an exam–too many clicks, and difficult navigation.
Most physicians are much more effective writing than typing, selecting options from a slew of drop-down menus, and finding their ways around a maze of screens.

My reference to the term GUI is meant as a placeholder, perhaps I should have called it an ambulatory EMR front-end.  Whatever its label, I believe there are inexpensive solutions that can be implemented alongside large EHRs that can make the doctor more productive.  The fact that nobody is doing this does not mean it cannot be done.

I have seen EHRs that serve ambulatory care providers that are highly effective and do not neutralize the patient-doctor interaction.  I have seen a doctor be fully functional in as little as 30 minutes.  Some physicians use the increased productivity to spend more time with patients, and some use it to see more patients.

I think it is also an important cost and ROI consideration.  If a hospital spends $200 million on an EHR, and their result is a productivity decrease of twenty percent, the total cost of their EHR is substantially higher than $200 million.

Social media isn’t what it never was.

Social media isn’t what it never was.

The term ‘social media’ is too polite to effectively communicate its importance to what it means for healthcare.  To me, Social Media sounds more like a coffee clutch or a discussion that would take place on Oprah or on The View.

Social media (SM) is often a targeted, violent dialogue fraught with vitriol.  There is nothing convivial or social about it.  It is not undertaken with your organization’s permission or its wellbeing in mind.

It may be easier to understand what it is not than to describe what it is.  SM is not B2B Facebook—it is not throngs of people who want to friend your organization and share nice comments about what it does.  SM usually begins with someone who has a bone to pick with your organization.  Their intent is to fan the flames of their discontent and turn it into a digital conflagration.  It need not be fair or honest.  For the most part SM is propaganda, and its purpose is to sway others to the propagandist’s way of thinking.

If your firm is looking at how to participate in SM, it is best to begin with an understanding of the ground rules—you have some, your opponents do not.  Their approach is like guerilla warfare.  Who knows where they will appear next.  Twitter, Youtube, blogging?

Most organizations who are considering enhancing their SM presence look at it as in IT initiative—enhance the web site, put up a Facebook page, maybe even starting to Twitter.  Just so you know, none of the opposition is throwing social jabs at your IT department.  IT can get you a presence.  What the presence consists of belongs to the likes of marketing, operations, and the executives.

If you have a good PR firm, pull them into the conversation.  It will be like taking your firm to a therapist and starting its own twelve-step program.

How to stop throwing away money on charts

I sometimes need to rewrite ideas to help me get a better grasp of them—this is one of those times.  Too many words mean I still have too much chaff blowing around in my wheat.

More often than not I find it helpful instead to reframe the idea into an analogy.  I hope this is one of those times.

The idea I, and I think one which others are struggling, is where should physicians—hospitals, clinics, and practices—be looking to see benefits from their EHR, and I think part of the answer is that we may be looking in the wrong place.

Now, if your practice is running like a well-oiled business, this piece will not add another arrow to your quiver.  But, if your practice is like many I’ve seen, there may be an ah-ha moment forthcoming.  Most practices, rightly or wrongly, have been told to look for EHR benefits in the exam room.  While I think those benefits exist, if the rest of the practice—everything that happens between you and your staff, and your staff and your patients—resembles the chaos of an elementary school cafeteria giving away free ice cream, the clinical benefits may be hidden beneath the detritus of discarded creamsicle wrappers.

What if we look at the issue this way?  I was asked to paint the metal security door which leads from our laundry room to the garage.  The dogs had taken it down to bare metal.  In my small mind this should have been a thirty minute task.  Not so fast Sparky.

I went to the basement where twenty separate buckets of leftover paint are stored.  Found the white paint, grabbed my brush, gave the can a quick shake, and was ready to knock this out before my wife returned home.  In walked my supervisor—I was exactly 29 minutes too late.

“Don’t you need to wash the door before you paint it?  It is all rough where the dogs scratched it.  If you don’t sand it, we will still see the scratches.  You can’t use that paint; that is for wood and it won’t stick as well.  I printed these instructions from Google,” she said as she handed them to me—I was too busy watching my weekend disappear before my eyes.  “It says for painting metal you have to prime use a primer.”

My perspective on doing projects, for what it is worth, you can either tell me to do something, or you can tell me how to do it, but you cannot do both.  As I drove clear across town to the paint store I realized she’s never allowed herself to be distracted by my perspective.

Two hours after I had started the project the door was sanded and washed.  An hour later the primer had dried enough that I could apply the final coat of paint.

“What are all those white drops on the wood floor?”  We both knew she was being rhetorical, but waxing on about rhetoric was not the point of here question.  “The directions say you should be using a drop-cloth, and should clean up the paint spatters with a clean cloth and soapy water.”  Now why didn’t I think of that?  The truth is, I did, but each of those steps looked like they would only lengthen the task.

Five hours after beginning the quest for her holy grail, the door was painted, the splatters were no more, the brushes were cleaned, and the paint cans were stored neatly in the basement.  What I realized is that between starting the painting and completing the painting, many other tasks had to be completed that involved much more of my time than the actual process of painting the door.

During the five hours I spent on the project, only 30 minutes of my time was spent applying the finish coat—10 percent of the total time.

It makes the process appear a lot shorter if all one does is focus on one piece of it.  The whole issue of an EHR’s impact on your charting processes looks a lot shorter if one’s only focus is what happens to the chart from the time the physician pulls it from the holder on the back of the door to the time it is replaced.  In some practices more than a dozen people may be involved in getting it to the door and returning it to the file room.  What happens to the chart in the exam room is only a very small fraction of the cost of using paper charts.

It is less expensive to toss $100 bills out of the car than to fund paper charts.

At the end of this piece is a list of some of the chart handling processes I have seen at some of my clients.  In some places, there are many more processes than just the ones listed.  The average handle time (AHT) for a chart begins the moment a chart is requested, and it does not end until the chart is returned to its proper place on the shelf.  Any steps that can be taken to eliminate some or all of these processes, and the cost of the people who perform them, will contribute to the ROI of an EHR implementation.  In many cases, eliminating the majority of these steps will constitute the bulk of the EHR’s ROI.

From the perspective of the business, any time you can get rid of a process whose only contribution to the P&L is a cost, do so.  Having someone carry a chart, insert papers into it, or file it does nothing to improve care, and it does not contribute a dollar to revenue.  Eliminating these processes will make the business function better.  It will enable the business to handle growth.  None of what you’ve just read has anything to do with meeting Meaningful Use or having a certified system.

In the interest of full disclosure, I actually painted the door while my wife was out of town.  It took me thirty minutes, just like it should have—don’t tell her.

Here the list of the manual charting processes that increase AHT, and add no measurable value to your business.  They are workarounds, and should be eliminated.  A similar argument can be made for dealing with in-bound phone calls, but we’ll save that for the next time I have to paint something.

  • Old charts are ordered from archives
  • Loose sheets received daily at chart room from offices
  • Loose sheets are received from labs
  • Loose sheets are sorted by doctor and then either alphabetically or by date
  • Loose sheets distributed to clerk serving the particular doctor
  • Clerk pulls charts that have loose sheets to be filed
  • Clerk inserts chart out card as a place holder
  • Loose sheets will be filed to charts stored in chart room
  • Clerk hole punches loose sheets
  • Clerk returns chart to shelf and removes “out card”
  • Clerk crosses out his/her name
  • Charts arrive from archives storage to the chart room
  • Charts are sent to offices by courier
  • Charts are returned from offices to chart room by courier
  • Charts sent between offices by courier
  • Charts returned to archive by courier
  • Patient schedule is generated
  • New schedule compared to schedule generated yesterday to determine add-ons
  • Clerks determine which patients have no charts at chart room
  • Clerks determine which missing charts are at archive
  • chart room makes temp chart for add-ons; patients who were added to schedule after cut-off
  • Schedules needed are distributed to clerks that serve specific doctors
  • Charts on the schedule are pulled from chart room shelves by clerks
  • Clerk writes their name and date on out card indicating they have the chart
  • Out card is inserted as a placeholder
  • If chart is not found, clerk checks out-card to determine who last had the chart
  • Clerk tries to locate the chart
  • If chart is located, a request is made to send it to the correct office
  • If chart is not located, clerk creates a temp chart
  • Clerk adds note to temp chart explaining why she created a temp chart
  • Clerks match loose sheets against charts, punch and insert them
  • Additional forms may be added by clerk to chart
  • That chart is inserted into the box to be sent to the doctor
  • Boxes of charts returned from offices are distributed to clerks to be re-filed
  • These charts are returned to shelves, out card is removed
  • Clerk crosses off his/her name
  • chart room receives fax requests for charts
  • Those requests are delivered to the assigned clerk
  • Clerk repeats the chart hunt and pull process

Kind Regards,


Paul M. Roemer
Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer