EHR

EHR’s 5 stages of grief

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Being a blogger is not too dissimilar to being a failure’s biographer.  Unless you simply repeat the ideas of your contemporaries, good blogging requires a certain avidity to oppugn those who revel in the notion that theirs was the only good idea.  To me, their Sang-froid calmness has all the appeal of a cold omelet.  Good writing requires that you make intellectual enemies across a range of subjects, and that you have the tenacity to hold on to those enemies.  So let us step off Chekhov’s veranda and bid farewell to the sisters of Prozorova.

The Kübler-Ross model, commonly known as the five stages of grief, was first introduced by Elisabeth Kübler-Ross in her 1969 book, On Death and Dying.  I heard a story about this on NPR, and it made me think about other scenarios where these stages might apply.

My first powered form of transport was a green Suzuki 250cc motorcycle.  My girlfriend knitted me a green scarf to match the bike.  One afternoon my mother walked into the family room, saw me, and burst into tears.  When I asked her what was wrong, she told me that one her way home she saw a green motorcycle lying on the road surrounded by police cars and an ambulance—she thought I had crashed.  I asked her why, if she thought that was me lying on the road, she did not stop.

My girlfriend’s mother, didn’t like my motorcycle—nor did she like me.  Hence, my first car; a 1969 Corvair.  Three hundred and fifty dollars.  Bench seats, AM radio.  Maroon—ish.  It reminded me a lot of Fred Flintstone’s car in that in several places one could view the street through the floor.  Twenty miles per gallon of gas, fifty miles per quart of oil.

Buyer’s remorse.  We’ve all had it.  There is a lot of buyer’s remorse going around with EHR, a lot of the five stages of grief.  I see it something like this:

  • Denial—the inability to grasp that you spent a hundred million dollars or more on EHR the wrong EHR, one that will never meet your needs
  • Anger—the EHR sales person received a six-figure bonus, and you got a commemorative coffee mug.  The vendor’s VP of Ruin MY life, took you off his speed dial, unfriended you in Facebook, and has blocked your Tweets. You phone calls to the vendor executive go unanswered, and are returned by a junior sales rep who thinks the issue may be that you need to purchase additional training.
  • Bargaining—when you have to answer to your boss, likely the same person who told you which system to purchase, as to why productivity is below what it was when the physicians charted in crayon.
  • Depression—you come in at least fifteen minutes late, and use the side door, taking the stairs so you won’t see anyone.  You just stare at your desk; but it looks like you are working. You do that for probably another hour after lunch, too. You estimate that in a given week you probably only do about fifteen minutes of real, actual, work. (Borrowed from the movie, Office Space.)
  • Acceptance—the EHR does not work, it will never work, you won’t be around to see it if it ever does.  Your hospital won’t see a nickel of the ARRA money.  You realize the lake house you were building will never be yours, but the mortgage will be.

The five stages of EHR grief.  Where are you in the grieving process?

True, there are a handful of EHR successes.  Not nearly as many as the vendors would have you believe.  More than half of hospital EHR implementations are considered to have failed.

If you are just starting the process, or are knee-deep in vendor apathy you have two options.  You can bring in the A-team, people who know how to run big ugly projects, or you prepare to grieve.

If it was me, I’d be checking Facebook to see if I was still on my vendor’s list of friends.

What then is EHR?

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An hour and twenty minutes on the train to Washington. The young woman behind me:

“And she was like…”

“And I was like…”

“And they were like…”

“And she was like…”

Ninety long minutes.  She never got off the train, and in a way I feel responsible. I locked her in the bathroom…She kept right on talking…”And she was like…”

The lanky guy seated across the aisle from me was a human tattoo museum.  The matron by the window spent an hour trying to decide which ringtone to use for incoming calls, listening repeatedly to the dozens of options with the phone’s volume set to its highest level.

So went my day.  Arriving home late at night I did the unthinkable, the unforgivable—wiped my hands on the decorative towels in the guest bathroom.  You probably have the same towels.  In fact, you probably have not even cut of the tags.  There they hang.  They have hung in the same spot, undisturbed.  Generations have come and gone, yet the towels stay.  They have become a fixture.

There are three categories of stuff—wants, needs, and must-haves.  I want a Porsche, I need air, and I must have towels that nobody will ever use.

What then is EHR?  For many hospitals it has become a must-have.  I have always thought nine figures was a lot of money to spend on something that saw no more use than guest-towels.

How to push the EHR into the cloud

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For those wondering if the fact that I have not written recently is a result of me having mellowed or having found the world more to my liking, not true.  I have been busy earning minus points as I tried to get it sorted in those wide open spaces of my mind.  It is difficult for me to find much comfort in sleep when I think all the leftist gremlins are in cahoots—I see two masons shaking hands and I think conspiracy.

Now, before this begins to read like I wandered too far from the republican rest home, I note that some of my best friends actually know democrats; so I am not as close-minded, or perhaps clothes-minded, as I would like to be.

Some are slow to adapt ideas to a changing world, aimlessly swatting new ideas away with a no-pest-strip as though they were plague carrying mosquitos.  Their thoughts, frozen in time, move so slowly they have been overtaken by a skateboard—and that skateboard was under someone’s arm.  These are the same individuals whose ability to play outside of the comfort of their own sandbox has not been seen since the internet was powered by steam.  It is a little like being a dinosaur while those around you are still floundering in the primordial bisque, still trying to wrap their synapses around the cold ideas distilled in the anecdote.

That is not to suggest that others do not think.  I am sure they have dozens of thoughts scribbled on the inside of their head, but those thoughts are erased each time they play with their hair—brains not big enough to swing a cat in without giving it a minor concussion.  There are fomenting alchemies of thought nuggets, but never quite enough to turn base metals into gold.  Sometimes, when the lighting is just right, you can see their curve of illogic thought arching overhead like static electricity.

In normal prose, I tend to be few of words.  I can get through entire days uttering no more than ‘uh-huh,’ a condition to which I attribute having exited the womb not fully-formed.  Writing is different than the spoken word.  For one thing writing is infinitely easier and more pleasingly voyeuristic, for it can be more entertaining to write about venomous ideas, not enough to kill my prey, simply to stun it.

Where then do ideas originate?  They are not like sex in a packet where all you have to do is add water.  The lack of thinking has led us to a tragic age most refuse to take tragically.  Thought patterns are aborted before they germinate, as though the thinker was taking intellectual contraceptives.  But believe it or not, I often find myself hoisted high on the petard of my own self-induced mesanic naivetés.  When a spark of a thought enters my mind, I rarely let it go quietly into that good night.  Instead I tear at it like Henry VIII coming off a forced diet—I know I mixed the metaphor, but I liked it.

I know rarely how my mind moves me from thoughts A to B.  Today proved no different.  Take the Poken.  This device is the newest technological mind-nibblet—a tiny jump-drive device about the size of prune whose purpose in life is to help two individuals sync their personal contacts by pok-in’ their respective Pokens.

You have got to hand it to them, for it sounds like it could be more entertaining than syncing one’s Blackberry.  If I understand correctly the concept, if my Poken pokes your Poken the Pokii mate—Pokii may or may not be the correct form of the plural, but it will have to do for now.  Once the mating process has ended, and before mine finishes its cigarette, I have your contact information and you have mine.

This could be an interesting way to swap business contacts, but as I live in the land of the Jabberwocky my mind does not work that way.  “Then he got an idea, an awful idea. The Grinch got a wonderful, awful idea.”

I jested about the Poken a few days ago, and then I thought about how this device could be made to work in healthcare.  The Poken is a communication device, sending and receiving secure requests to the cloud to permit one to access and update contact information.  Not much of a healthcare offering doing that, but what if?  What if instead of letting me share my contact information with someone I select, it, or something like it, allowed me to share my personal health record with my physician?  What if my physician was able to update my health record using a similar device?

The EMR and PMR applications would be in the cloud.  The Poken would provide the “handshake.”  One fully functional EMR.  The rest is history.  Thanks for playing along.

What EHR users really want

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I just read an article in the Harvard Business Review about the notion of what Henry Ford would have said if he were asked what people wanted.  The oft-quoted response was “Faster horses.”

At one point Ford had two-thirds of the market.  A few years later Ford’s share had dropped to fifteen percent.  Those in the know suggest this drop accrued to the fact that the customers did not want faster horses; they wanted better cars.

This is somewhat in line with how the healthcare providers have responded to EHR systems.  The hospitals with whom I have spoken have made a wide range of choices with regard to what they are doing with their EHR.

  • They use it because they have no other choice
  • They continue to do paper charting and use the EHR after the fact
  • They use it as a document management system and continue to dictate
  • They use the monitor as a flashlight to help them see while they write their notes
  • They sign a petition stating they are not going to use the EHR that is being forced upon them
  • They change EHRs believing that anything else has to be better than the system they are using

These are all variations of the faster horse theory of EHR.

What EHR’s users want is a better EHR, one that helps them do their job rather than one that hinders them.

Is Your EHR More Like iPhone Or iTunes?

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Below is my latest post on healthsystemcio.com.  Let me know what you think.

Times are perilous, and they ain’t a-changin.  As Europe focuses its attention on whether the Euro will become a collector’s item, and the Middle East eagerly awaits the chance to lower the amount it pays for air conditioning because of the surplus of electricity that will be available from all of Iran’s nuclear reactors, America is all a-twitter about what Angelina Jolie was wearing at the Oscars.

No wonder the impact of the billions being spent on healthcare IT has taken a back seat.

Ask yourself, how good is your EHR? Does it do what you want it to do? Does it do it in the way you need it to do it? If it was your decision, would you have spent a hundred or two-hundred million dollars for it?

Okay, get the smirk off your face.

I have been writing recently a lot about the difference between user acceptance (UA) and the usability of large business systems like EHR systems. A business system is a lot more than an IT application. It also includes process and people — users.

Achieving high user acceptance is easy. Implement one system and make everyone use it. Check the box. User acceptance only involves the IT application: the EHR. UA does not measure the value of the business system to the users; it simply measures the percentage of users.

Usability is a testament to whether or not the system, in this case the EHR, adds value to the organization, to its users. Does it make them better, more effective, more efficient? The secret sauce towards achieving good usability is the addition of design.

Here is an example of a company with two business systems depicting the difference between UA and usability. The company is Apple, the two business systems are the iPhone and iTunes.

iPhone system:

  • Phone, camera, game player, GPS, email, SMS, MP3 player
  • One button
  • No training required
  • Great usability

iTunes system:

  • Web shopping program for purchasing services to use on Apple products
  • Full keyboard
  • High learning curve
  • Poor usability, poor user experience
  • High UA — users have no other choice

Brothers from different mothers. Their usability is so different that it is difficult to believe both business systems came from the same company.

  • One business system lets you do everything using one button; the other barely lets you do anything using 61 keys.
  • One is intuitive, one is anything but

I am willing to bet your EHR reminds your users more of iTunes than it does the iPhone. You can choose to accept it as is, or you can make it better. The great thing about business systems, unlike products, is you can choose to apply design to a poor business system and gain tremendous value for little investment. Or not.

Healthcare IT’s Black Hole

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Last year scientists turned on the largest machine ever made, the Hadron Collider. It’s a proton accelerator. This all takes place in a donut-shaped underground tube that is 17 miles in circumference.

Fears about the collider centered on two things; black holes and the danger posed by weird hypothetical particles, strangelets, that critics said could transform the Earth almost instantly into a dead, dense lump. Physicists calculated that the chances of this catastrophe were negligible, based on astronomical evidence and assumptions about the physics of the strangelets. One report put the odds of a strangelet disaster at less than one in 50 million, less than a chance of winning some lottery jackpots—what they failed to acknowledge is that someone always wins the lottery, so negligible risk exists only in the mind of the beholder.

If I understand the physics correctly from my Physics for Librarians mail-order course—and that’s always a big if—once these protons accelerate to something close to the speed of light, when they collide, the force of the collision causes the resultant mass to have a density so massive that it creates a gravitational field from which nothing can escape. The two protons become a mini black hole. And so forth and so on. Pascal’s triangle on steroids. Two to the nth power (2ⁿ) forever. Every proton, neutron, electron, car, house, and so on.

The collider could do exactly what it was designed to do. Self fulfilling self destruction. Technology run amuck. Let’s personalize it. Instead of a collider, let’s build a national healthcare information network (N-HIN) capable of handling more than 1,000,000 transports a day. What are the rules of engagement?  Turn on the lights and let’s see how it functions.

Let’s say we need to get anybody’s record to anybody’s doctor.  That’s overly simplistic, but if we can’t make sense out of it at this level, the N-HIN is doomed.  The number of possible permutations, although not infinite, is bigger than big.  Can you see what can happen? Strangelets.  The giant sucking sound comes from ARRA and stimulus money as it is pulled in to the black hole.

So what is the present thought leadership proposing to fight the strangelets? Healthcare information exchanges (HIEs)—mini N-HINs.  Regional Exchange Centers (RECs).  A few million, a few billion.  Not only does their plan have them repeating the same flawed approach, they are relying on embedding the same bad idea, and doing it using hundreds of different blueprints.

Einstein defined insanity as doing the same thing over and over and expecting different results.

Stop the craziness. I want to get off.

It’s the end of the world as we know it…and I feel fine. R.E.M.

Redux–What people at HIMSS were afraid to say

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One image of HIMSS that will not escape my mind is the movie Capricorn One—one of OJ’s non-slasher films.  For those who have not seen it, the movie centers on the first manned trip to Mars.  A NASA Mars mission won’t work, and its funding is endangered, so feds decide to fake it just this once. But then they have to keep the secret…

The astronauts are pulled off the ship just before launch by shadowy government types and whisked off to a film studio in the desert.  The space vehicle has a major defect which NASA just daren’t admit. At the studio, over a course of months, the astronauts are forced to act out the journey and the landing to trick the world into believing they have made the trip.

Upon the return trip to Earth, the empty spacecraft unexpectedly burns up due to a faulty heat shield during reentry. The captive astronauts realize that officials can never release them as it would expose the government’s elaborate hoax.

I think much of what I saw at the show was healthcare’s version of Capricorn One.  Nothing deliberately misleading, or meant as a cover-up or a hoax.  Rather more like highlighting a single grain of sand and trying to get others to believe the grain of sand in an entire beach.

The sets for interoperability and HIEs served as the Martian landscape, minus any red dust.  There was a wall behind the stage from where the presentation interoperability was shown.  I was tempted to sneak behind it to see if I could find the Wizard, the one pulling all the nobs and using the smoke and mirrors to such great effect.  It was an attempt to make believers, to make people believe the national healthcare network is coming together, to make us believe it is working today and that it is coming soon to a theater near you.

After all, it must be real; we saw it.  People wearing hats and shirts emblazoned with interoperability were telling us this was so, and they would not lie to you.

The big-wigs, and former big-wigs—kudos to Dr. B. for all his hard work—were at the show for everyone to see, and to add a smidgen of credibility to the message.  They would not say this was going to happen if it were not—Toto, say this ain’t true.

The public relations were perfect, a little too perfect if you asked me.  Everyone was on message.  If you live in Oz and go to bed tonight believing all is right with the world, stop reading now.  If what you wanted from HIMSS was a warm and fuzzy feeling that everything is under control and that someone really has a plan to make everything work you probably loved it.

Here is the truth as this reporter saw it.  This is not for the squeamish, and some of it may be offensive to children under thirteen or C-suiters over forty.  In the general sessions nobody dared speak to the fact that:

  • Most large EHR implementations are failing.
  • Meaningful Use isn’t, and most hospitals will fail to meet it.
  • Hospital productivity is falling faster than are the Cubs chances of winning a pennant.
  • Most hospitals changed their business model to chase the check
  • Most providers will not see a nickel of the ARRA money—the check is not in the mail and it may never be.

The future as they see it is not here, and may never be, at least until someone comes up with a viable plan.  Indeed, CMS and the ONC have altered the future, but it ain’t what it used to be.  People speak to the need to disrupt healthcare.  Disrupt it is exactly what they have done.  The question is what will it cost to undo the disruption once reason reenters the equation?  What then is the future for many hospitals?

  • Hospitals on the whole will lose more much more money due to failing to be ready for ICD-10 than they will ever have seen through the ARRA lottery.
  • It make take years to recover the productivity loses from EHR and the recoup those revenues.
  • Hospitals spending money to design their systems to tie them into the mythical HIE/N-HIN beast will spend millions redesigning them to adapt to the real interconnect solution.
  • The real interconnect solution will be built bottom-up, from patients and their primary care physicians.
  • Standardized EMRs will reside in the cloud and patients will use the next generation of smart devices.  And like it or not, the winners will be Apple, Google, and Microsoft, not the ONC and CMS.  Why?  Because that is who real people go to to buy technology and applications.  A doctor still does not know which EHR to buy or how to make it work.  Give that same doctor a chance to buy a solution on a device like an iPad and the line of customers will circle the block.

And when doctors are not seeing patients they can use the device to listen to Celine Dion.  This goes to show you there are flaws with every idea, even some of mine.

(I published this post one year ago, just after the Orlando HIMSS.  It appears to still be valid today. Comments?)

The True Measure Of Success For HIT Systems

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My newest post in healthsystemcio.com.  Feedback appreciated.

The title of the book on the lap of the person sitting next to me was “Cost Justifying Usability”. My cynicism jumped immediately to Def-Con 4.

Cost Justifying Usability. Did the author get his inspiration for the title at the Shopping-For-New-Ideas store? Now, before you laugh too hard, recall that many inane ideas make gobs of money, such as thePet Rock and Chia Pet. For every book, there must be an audience. I can only believe that the intended audience for this epic must be senior business executives.

Imagine yourself being one of those executives. Someone finds you lying on the floor in the fetal position and suggests you read the book. How should you respond?

  • I assumed usability was the antecedent  for buying that system
  • We just spent $300 million dollars on an enterprise system. Does making it usable cost extra?
  • They told us the drop-dead date is March 21. Drop-dead is the perfect phrase; we only measured cost and speed — nobody thought to measure usability?

What is the title of the antithetical book—Cost Justifying Unusability or, Cost Justifying Failure?

The statement most in HIT are afraid to utter is that most HIT spend has no ROI. There is no ROI because the usability measure of most of the largest HIT systems (enterprise and EHR) is negative — productivity is showing a net loss instead of a net gain.

Usability is not the same as user acceptance. User acceptance for these unusable systems will approach 100 percent. Why? Because users have no other option. And then there is Meaningful Use — an odd phrase because it has nothing to do with users. An EHR can pass Meaningful Use and have low user acceptance and the usability factor of hammering a nail with a banana.

If the healthcare industry needs to be convinced that a cost justification for usability is required before anyone takes the issue seriously, perhaps a moniker change is in order — HIT to OBIT.

Call me silly, but I think the time has come to do away with how we measure the success of all business systems projects. Was the system usable — did it increase ROI, did it make the organization more effective, and did it enable innovation? Only two approaches to measure need be used.

  1. On time, on budget, high user acceptance, unusable:             failure
  2. Not on time, not within budget, usable:                                        success

No matter what else happens, if the best your business system project does is to give you back performance similar to what you had without the system, a reasoned executive would say the investment in the system was wasted. It then stands to reason that if the new system delivered worse performance than what you had previously, it too is a wasted investment.

When I talk with some seasoned executives in HIT about the success or failure of their EHR system, I pause for a second waiting for someone to say, “Pay no attention to the small man behind the curtain.” Their standard of measure? See above, Approach 1. Some would have you believe it is heretical to say that spending a hundred million dollars on a system whose usability is poor was a waste of money. Most of those who defend the spend are those who did the spending.

Ask the users if they think the money was well spent. These three quotes came from a physician whose hospital spent $400 million on a name-brand EHR.

  1. “Their (the hospital’s) most expensive resource spends a lot of time doing data entry.”
  2. “The data is very good if you are a patient or an insurance company that wants to sue us.”
  3. “My productivity is still down thirty percent.”

Imagine yourself as a hospital executive and answer the following question. Which of these two pieces of information is more valuable: knowing your EHR passed Meaningful Use or, learning from your users that the EHR is unusable? In HIT, there are two rules:

  1. The usability measure of most EHRs is unacceptable.
  2. Paying more for your EHR than the next guy or gal does not change Rule 1.

Your EHR vendor’s biggest secret

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I am working on a novel, my second.  It involves a serial killer. There is something richly cathartic about killing someone with bits and bytes. If you are in a bad mood, it can be calming. If the killing does not provide the calming effect I had hoped to achieve, rekilling him in a more vengeful manner usually does the trick.

The novel involves the skills of an FBI profiler. If you have read any of the books on profiling you would think it an exact science.  Chapter by chapter the writer extols the successes of profiling—this profile worked, that one worked.  According to how it is spelled out in the book, one would want to ask, if profiling is so successful, why do they not use it on every case?

Perhaps because there are unwritten chapters, chapters that never make it into the profiler’s handbook.  The reason those chapters do not make it to the book is because it sort of defeats the purpose to print cases in which the profiles that were created did not match that of the killer’s—white male in his mid-thirties, wooden leg, drives a Prius, and enjoys watching Dancing with the Stars.

When I thought about it, it occurred to me that business software is pitched a lot like profiling serial killers.  You never hear about the bits that do not work.

Think back to when you and your colleagues watched various processes of your software being demonstrated—add a patient or a customer, schedule an appointment, write a new script.  The functionality was so smooth it brought a tear of hopefulness to the eyes of the prospective users.

In a recent conversation I learned of a patient scheduling system that had more than five-thousand user screens.  That is a five followed by three zeroes; almost enough to have a separate screen for each patient.

Like the author of the book on profiling who only wrote about the cases on which his technique worked, software vendors only show potential buyers those processes that function smoothly. In an EHR system, vendors show how their software works in a real-life setting with only one thing missing, a patient with which it must interact.  A rather critical missing part of the functionality puzzle if you ask me.

The entire situation, that of acquiescing over time to having to use bad software, reminds me of the experiment of the frog and the pot of water; drop a frog in a pot of boiling water and it leaps out, place it in a pot of water and gradually raise the temperature and the frog will remain in the pot until it is cooked to death.

Users of bad software are a lot like frogs in a pot. They never quite get up the moxie needed to jump out of the pot. More often than not they allow their situation to worsen until it is too late.

Can you blame providers if they fail Meaningful Use?

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I don’t wake up each day planning to be at odds with ninety-eight percent—I’m probably being overly generous assuming two percent of the people are as jaded as me—of the HIT community, maybe I just come by it naturally.

The first time I heard of RECs (regional extension centers) the first thing that came to mind was playgrounds, something akin to what the Police Athletic League might find useful.  Five hundred and ninety-eight million dollars.  They tried 597 and determined it wouldn’t be enough and figured 599 would be too much, but 598 million was just right.  Then Goldilocks made her way over to the porridge—sorry for turning left at the fairy tale ramp.

A large part of the success or failure of reform hinges on the success or failure of EHR.  Accordingly, the government made the egregious decision to manage the process of building and rolling out a national EHR down at the molecular level.  They have involved themselves at the front-end, at the vendor level, and at the back-end.  The more anxious they become, the more money they waste, adding another guise to get the healthcare providers to take their eyes off the ball.  Five hundred ninety-eight million “we’re just here to help you” dollars.

This money could be spent to pay the top EHR vendors to create one set of standards and modify their systems to fit those standards.

Meaningful Use.  Don’t get me started.  How can I fault thee; let me count the ways.  Those tested early for Meaningful Use will be examined less rigorously than those tested later.  This is like the IRS saying that if you file your taxes in February, don’t worry about those silly little math errors.  Healthcare will be the only industry whose software quality assurance check occurs after they pass the fail-safe point, the point of no return.

With good leadership providers should know EHR will pass meaningful use before implementing the system. If they fail to pass Meaningful Use, shame on them.