EHR

EHR: How to purchase an EHR

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Are you really going to where that?  Do these pants really make my…

Did you ever have one of those non-halcyon days when you felt the need to ask someone “Did a house fall on your sister?”  Try to stay with me, it will come to you.  Enough about falling houses Toto.

I sought the counsel of a friend before heading down this path, and I’ve decided to choose the road less traveled anyway.

I may have written that I have observed differences between men and women.  You too?  Here are a few examples from my side of the gated compound.

  • We are willing to make mistakes as long as someone else is willing to learn from them
  • A good excuse is almost as good as getting it right
  • Good intuition will often make up for a lack of any facts
  • We refine our personality flaws, for without them we may not have a personality
  • Peter the Great heard the voices too

I regret that I am unable to share my list about women, for I am a coward.

While shopping the other day, I noticed that women shop for clothing differently from men.  For women, shop is a participatory verb—whatever that is—involving all twelve senses, for men it’s something we’d rather do online while watching the game.  From what I’ve observed, in fostering the she-conomy women:

  • Do their homework—what’s in, what’s not, what’s on sale
  • View shopping as a competitive sport, for some, a blood sport
  • Try on things, often more than once
  • Buy something they may need in case they someday find some other thing they may need that may go with it
  • There is no rule about having too many shoes—buy in volume
  • There is no rule about having too many black shoes

So, let’s see if we can segue beyond this jingoistic tractate on one to something more in line with the lofty subscription fee you paid for this site.

Permit me to employ two definitions which help me keep my ideas cogent.

  • IntraEHR—EHR statements that relate mostly to the healthcare provider
  • InterEHR—EHR statements that relate mostly to the movement  or transport of the EHR record from point A to point B

EHR and shopping.  Can one be at one with this duality?  How can one not be?  From having spoken with a number of healthcare providers about their IntraEHR selection, my take on a lot of the process is that more often than not there is no process.  It’s a lot like watching men shop.  It’s over and done with without much reasoned or substantiable—I was afraid I’d have to invent this word but I found it on Google—thought.  Over and done with, now back to the game.

Maybe EHR scholars will one day be able to trace speed buying of IntraEHRs back to that whole Neanderthal hunter gatherer thing in the Pleistocene epoch.  Sort of a think fast on your feet or you’ll be eaten approach to software selection—an awful metaphor, however CNN ran a feature with that title, so it has some legitimacy.  Maybe the hospital’s executive committee will be able to trace the hastily made IntraEHR purchase back to a lack of a plan, the lack of business requirements, and the lack of an adequate request for proposal RFP.  Maybe your successor will figure it out.

For those who haven’t contracted for their IntraEHR, it may be better to approach this like a woman.  To those who are women—you should know who you are—you are probably already approaching it that way.

Now, where did I leave my black pumps?  And no, I am not going to finish my thought about the pants.

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.

Informationweek Healthcare Article on Meaningful Use

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This link takes you to an interesting and well-written article written by Anthony Guerra.  Even if he didn’t quote me in the piece, it would still be worth reading.

http://www.informationweek.com/news/healthcare/leadership/showArticle.jhtml?articleID=227500796

Is a Universal Patient Record a Solution?

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Today is the anniversary of the solving of Fermat’s last theorem.  As a long recovering mathematician, these types of thing interest me so I sought a copy of the proof and began reading.  The mathematics for librarians description of the proof is something like this:

  • The Pythagorean theorem states that for a right triangle the sum of the squares of the sides equals the square of the hypotenuse.
  • Fermat stated that the theorem only holds for a coefficient of 2, squaring, and that no other coefficient will work
  • This went unproven until recently

One might have thought that the solution could be solved by brute force using a computer.  How many numbers are there to be dealt with? If you approach the problem this way you’ve got to do it for infinitely many numbers. So, after you’ve done it for one, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a thousand numbers, how many, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a million, well, there’s still infinitely many left. In fact, you haven’t done very many, have you?  In fact, using this approach, you’ll never finish.  This got me thinking about our EHR system.

I think something has been lost in the confusion about a national EHR system.  After all, that’s the target right, a national system?  We only unleash the power of EHR if we are able to make it work out outside of the provider’s four walls.  Is it possible that perhaps the logic of how we have been viewing developing a solution for the problem is wrong?  I think it is.  Since the outset, the problem has been defined as how do we develop a system that will enable us to get everyone’s health records (let’s call an individual record A) to some arbitrary set of healthcare providers, call them P.  There are some 350 million A’s and for simplicity let’s agree that there are 100,000 P’s.  So now, the system to which everyone is working is the system that will enable all of the A’s to get to any combination of P’s.

See?  Now what happens if we place a few hundred Rhios and health information exchanges (HIEs) in between the A’s and the P’s?  Let’s label them G’s for gatekeepers.  So, in the current framework all the A’s (everybody’s health records) have to pass through all the G’s, make it up to the national network, then back through all the G’s and then sorted through all the P’s to the correct P.

How can we know this design will work for every possibility?  The only way is to test every combination of A’s, G’s and P’s.  It’s a difficult problem.  It becomes more difficult when we acknowledge that there are hundreds of EHR vendors supplying software to all of those P’s.  Many of those P’s will have modified the software, meaning that there are probably thousands of variations of EHR systems.  Oh, and did I mention that all of this is being done without any single set of standards?  That means my stuff will look different from your stuff, and the G’s will have to move different stuff, and from an “IT” perspective the EHRs at the end of the food chain will have to interpret different stuff and then update your stuff with their stuff.  That’s a lot of stuff.

So, if that is where things are, what can be done about it?  My take on a solution is that the problem with this model lies with the word in italics, ‘everyone’.  Every possible patient with every possible need getting to every possible provider.  How to solve this or at least simplify the magnitude of the problem?  One possible solution is to build out the EHR system and the network such that one patient’s record can go to one provider and have that record updated.  Would it not make more sense to build it for a single patient, create a universal patient record (UPR) that can handle all instances?  Do it right once.  Prove that it works and then replicate it instead of building millions of different ones and hoping they work?

Is it time to rethink your approach?

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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.

You now know which ERH you should have bought

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This occurred to me while listening to a report on NPR that was comparing the Kindle to the iPad.  The comparison made regarding a study conducted to assess the viability of using the devices in universities as e-Textbooks instead of paper textbooks.  The Kindle was tested for a year; the iPad was tested next.

The traditional textbook prevailed over the Kindle; iPad may have reinvented the textbook.  A winner and a loser for what many consider being the same device in different packages.  Apple did the same thing for MP3 players and the cellular phone.

The conclusion about that Kindle was it was a bad imitation of its paper counterpart, saying it was simply a copy of what was on the paper but not as effective.  To me, this sounds like the conclusion many physicians have made about their EHRs—a poor automation of a poorer set of processes.  This is why user acceptance has been poor and why in many places productivity has fallen off the charts.

The study concluded some of the issues with the Kindle for both the students (think patients, and the professors (the physicians)—the analogous EHR function is noted within the parentheses has the following negatives.  The Kindle:

  • is less interactive than a piece of paper
  • does not follow the layout of a textbook or the flow of the discussion (navigation)
  • cannot easily handle full color illustrations and photographs (imaging)
  • is more difficult to annotate (SOAP notes)
  • takes longer to load the material, input data, and to search for information (clicks and drop downs)
  • the users stopped reading Kindles as scholarly texts and began reading them as novels (how physicians read and chart)
  • the students learned less and required additional time to learn the same amount (productivity)
  • did not maintain pace with the discussion or activity (process)

The textbook winner, the iPad, creates multimedia functionality out of a book.

Just because you search for electronic book readers online, and up pop both the Kindle and the iPad, does not mean they are equal.  You cannot expect a search engine to distinguish between them.

Here’s the punch line.  Just because you Google EHRs and get a list of vendors does not make them equal.  I know you know that.

I think most of EHRs are equal, equally dysfunctional.  Sticking with the analogy of the Kindle and the iPad, most EHRs are Kindles.  Most EHRs—in fact almost all of them; 99% of the 400—are to healthcare what Kindle is to textbooks; not much.  For many, the chart is better.

If you already implemented EHR you learned your EHR, how well is it performing?  I am willing to bet more than half have not met expectations, or expectations have been lowered to meet the performance.  Let us look at the same scorecard we used above.  If your EHR…

  • is less interactive than a piece of paper
  • does not follow the flow of the patient/doctor narrative
  • cannot easily handle full color illustrations and photographs
  • is more difficult to annotate than a paper chart (SOAP notes)
  • takes longer to load the material, input data, and to search for information (clicks and drop downs)
  • does not allow doctors to review notes and images the way they read charts
  • requires additional time to read and document the same amount of information than paper charting (productivity)
  • does not maintain pace with the patient discussion or activity (process)

…you have quite a mess on your hands.  If this makes you a little weak in the knees, what does this type of performance imply about your chances of meeting Meaningful Use?  Having a certified EHR will not make these problems disappear; you will simply have certified problems.

If you disagree with this assessment, please tell me why.  If you agree with the assessment, what are you doing to try to fix it?  I am willing to bet you a bag of licorice that it will not make things better.

Those who have read this far did not need to read this to know your EHR has not done what you needed it to do.  The strange thing is very few know what to do about it.

Those who have yet to complete their EHR or have yet to begin the process will come to the same conclusion unless they find the hidden jewels that make up the one percent of EHRs that actually function better than a paper chart.

EHR productivity need not be awful

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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.

EHR: know when to ask for help

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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.  But before you decide it’s more comfortable to stay in the hole and hope nobody notices, why not see if there’s someone who knows the way out?

Interoperability-this is the problem

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How does one depict the complexity of the mess being presented as the national roll out plan of electronic health records (EHR) via the national health information network (N-HIN) using Health Information Exchanges (HIEs) designed by Regional Health Information Organizations (RHIOs), with the help of regional extension centers (RECs) without Standards (Standards) and with N too many vendors?

Class?  Ideas?  Class?

If this looks dumb, undo-able, unimplementable, uninteroperable–it’s because it is.  your vision is fine.

Remember the idea behind all this is to get your health record from point A to point B, any point B.  It’s that little word ‘any’ that turns the problem into a bit of a bugger.

Find yourself in the picture below, pic a dot, any dot (Point A).  Now, find your doctor, any doctor (Point B).  Now figure out how to get from A to B–it’s okay to use a pen on your monitor the help plot your course.   That was difficult. Now do it for every patient and every doctor in the country.

Now, do you really think the DC RHIO-NHIN plan will work?  If EHR were a Disney park, who’s playing the Mouse?

Avoiding the Binary Trap on EHR

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Here’s my latest post on healthsystemcio.com.

http://healthsystemcio.com/2010/09/02/avoiding-the-binary-trap/