EHR–“Our Lady of Perpetual Implementations”

“There is no use trying,” said Alice;
“one can’t believe impossible things.”
“I dare say you haven’t had much practice,” said the Queen.
“When I was your age, I always did it for half an hour a day.
Why, sometimes I’ve believed as many as
six impossible things before breakfast.”

There are a number of people who would have you believe impossible things.  I dare say some already have.  Such as?

“My EHR is certifiable.”

“They told me it will pass meaningful use.”

“We’re not responsible for Interoperability; that happens at the RHIO.”

“It doesn’t matter what comes out of the reform effort, this EHR will handle it.”

“We don’t have to worry about our workflow, this system has its own.”

Sometimes it’s best not to follow the crowd—scores of like-thinking individuals following the EHR direction they’ve been given by vendors and Washington.  Why did you select that package—because somebody at The Hospital of Perpetual Implementations did?

There is merit in asking, is your organization guilty of drinking the Kool Aid?  Please don’t mistake my purpose in writing.  There are many benefits available to those who implement an EHR.  My point is is that there will be many more benefits to those who select the right system, to those who know what business problems they expect to address, to those who eliminate redundant business functions, and those who implement proper change management controls.

Your EHR vendor’s biggest secret

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.

Your EHR Works As Designed, And That’s The Problem

This is my newest contribution to

What could we have done differently, is the question I hear from many of the healthcare executives with whom I speak about the productivity loss resulting from their EHR.

My answer, nothing. I am willing to bet that in most cases your EHR was implemented correctly. I am just as willing to bet that the training was executed well. “If we did everything correctly, then why is the EHR performing so poorly?”

Fair question. The EHR is not performing poorly. It is performing exactly as it was written to perform. If that is true, why is there such a dichotomy between how it is working and how we need it to work? That is the perfect question to be asking. Here is why. If you interviewed your EHR vendor and asked them to tell you how the system is supposed to work when a nurse or doctor is with a patient they will tell you something like this:

We wrote the system to mimic what doctors and nurses need to do during an examination. Start with getting a history of the present illness (HPI). Then get vital signs, list of allergies, significant events, medical history, current meds, and lab and test results. Then write any prescriptions, order tests, and end the visit.

Very neat, very orderly. Linear. Move from Task 1, to Task 2. Just the way the EHR was written, just the way doctors were trained to conduct an exam.

Unfortunately, most exams do not follow that flow. Why? Patients. Somebody forgot to tell the patients and the clinicians that, in order for the EHR to work in anything that could be construed to be an effective and efficient manner, the exam must be conducted according to the EHR’s script. In order to minimize the number of screen navigations and clicks, you must complete all of Task 1 before moving on to Task 2. Linear. Front to back.

Exams are not linear. Patients generally dictate much of the order of an exam. They move indiscriminately and randomly from one task to the other. This randomness causes the clinician to hop about the screens in the EHR in an ad-hoc manner. Data entry and screen navigation are neither orderly nor complete. Nor are they front to back. The patient may start the exam with a question about lab result or about a side-effect of a medication.

All of this jumping around adds time, more time than what was allotted for the exam. Imagine that on your desktop you have several programs running; PowerPoint, Word, Excel, and email. Instead of completing what you hoped to accomplish in one program, closing it, and moving on to your next task, you were forced after each minute to stop what you were doing in one program and go work on something different in the next program.

Is there anyone who doubts that it would have taken less time to complete all your tasks if you were allowed to complete one before starting the other?

You EHR was not designed to work efficiently in an non-linear exam. Chances are good that your EHR was never really designed at all. Were designers, professionals with advanced degrees in human factors — cognitive psychology, heuristics, taxonomy, and anthropology — asked to determine how the EHR would need to work? Did they watch users work prior to writing code? Did the EHR firm iteratively build prototypes and then measure how users used it in a research lab that tracked hand and eye movements? If not, that is why I think it is fair to characterize EHRs as having been built, not designed.

The good news is that even at this point, even as you continue to watch productivity drop, you can choose to bring design in to solve the problem. Retraining will not solve the problem. After all, it was trained users who helped bring about the productivity loss.

AP reports national EHR rollout will fail-now what?

I just fell out of the stupid tree and hit every branch on the way down. But lest I get ahead of myself, let us begin at the beginning. It started with homework–not mine–theirs. Among the three children of which I had oversight; coloring, spelling, reading, and exponents. How do parents without a math degree help their children with sixth-grade math?

“My mind is a raging torrent, flooded with rivulets of thought cascading into a waterfall of creative alternatives.” Hedley Lamar (Blazing Saddles). Unfortunately, mine, as I was soon to learn was merely flooded. Homework, answering the phone, running baths, drying hair, stories, prayers. The quality of my efforts seemed to be inversely proportional to the number of efforts undertaken. Eight-thirty–all three children tucked into bed.

Eight-thirty-one. The eleven-year-old enters the room complaining about his skinned knee. Without a moment’s hesitation, Super Dad springs into action, returning moments later with a band aid and a tube of salve. Thirty seconds later I was beaming–problem solved. At which point he asked me why I put Orajel on his cut. My wife gave me one of her patented “I told you so” smiles, and from the corner of my eye, I happened to see my last viable neuron scamper across the floor.

One must tread carefully as one toys with the upper limits of the Peter Principle. There seems to be another postulate overlooked in the Principia Mathematica, which states that the number of spectators will grow exponentially as one approaches their limit of ineptitude.

Another frequently missed postulate is that committees are capable of accelerating the time required to reach their individual ineptitude limit. They circumvent the planning process to get quickly to doing, forgetting to ask if what they are doing will work. They then compound the problem by ignoring questions of feasibility, questions for which the committee is even less interested in answering. If we were discussing particle theory we would be describing a cataclysmic chain reaction, the breakdown of all matter. Here we are merely describing the breakdown of a national EHR roll out.

What is your point?  Fair question.  How will we get EHR to work?  I know “Duh” is not considered a term of art in any profession, however, it is exactly the word needed.  It appears they  are deciding that this—“this” being the current plan that will enable point-to-point connection of an individual record—will not work, and 2014 may be in jeopardy—not the actual year, interoperability.  Thanks for riding along with us, now return your seat back and tray table to their upright and most uncomfortable position.

Even as those who are they throw away their membership in the flat earth society, those same they’s continue to press forward in Lemming-lock-step as though nothing is wrong.

It is a failed plan.  It can’t be tweaked.  We can’t simply revisit RHIOs and HIEs.  We have reached the do-over moment, not necessarily at the provider level, although marching along without standards will cause a great deal of rework for healthcare providers.  Having reached that moment, let us do something.  Focusing on certification, ARRA, and meaningful use will prove to be nothing more than a smoke screen.

The functionality of most installed EHRs ends at the front door.  We have been discussing that point for a few months. When you reach the fork in the road, take it.  Each dollar spent from this moment forth going down the wrong EHR tine will cost two dollars to overcome.  To those providers who are implementing EHR I recommend in the strongest possible terms that you stop and reconsider your approach.

What does lost EHR productivity cost?

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

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

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

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

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

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

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

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

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

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

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

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

What’s the difference: User Adoption Versus EHR Usability?

Below is my new post in blog is up “User Adoption Versus EMR Usability” comment appreciated.

There is always a great deal of discussion about hospitals controlling costs. Articles on the subject seem to infer that the idea of controlling costs, should one elect to do so, dwell in the rarefied realm of innovation.

Here is a dirty little secret—from the moment your hospital opened its doors the hospital has been controlling costs. It may not have been doing it well, but unless some unknown organization is signing purchase orders and authorizing accounts payable, it is the hospital that is in control of what it spends.

It occurred to me that nobody writes about the need for hospitals to control revenues. When was the last time you saw an article titled “Control Your Revenues?”  Is it because nobody really believes they have any control over revenues?

When I write about controlling revenues, I am not referring to a revenue assurance or ICD-10 project, I am talking about how to make money, not simply collect the money you have already made. In a room of one hundred healthcare managers, for every ninety-nine who know how to control costs only one knows how to control revenues.

The thing with controlling costs and revenues is that control is a two-way street. If revenues go down or costs go up, if you are the person in charge you must take ownership of the revenue loss or the cost increase. Control is all about the resultant direction, up or down, good or bad. We will come back to this point in a minute.

How does this discussion impact IT, and more specifically IT and its role with EHR?  Conventional thinking will lead one to believe that if, at the end of implementation, user acceptance is high, IT will have done its job. Not so fast sparky. User acceptance tends to be a binary measure. User acceptance can be defined as the total user population minus those people who are not using the system.

Total potential EHR users – those not using EHR = user acceptance

As though the potential user population was given a choice! Using the EHR does not imply any degree of liking the EHR, any fondness for the system, or any measure of perceived effectiveness any more than Meaningful Use has anything to do with users. Permit me to repeat that point in that I have yet to read it in any forum—Meaningful Use does not have anything to do with who or how many who’s are using the EHR.

User acceptance and usability are not the same things; they are not even spelled with the same letters. The difference has to do with how we use it because we have toversus we use it because it is usable. Both control costs and revenues, however user acceptance can easily cause costs to increase and revenues to decrease. This is true if the user acceptance causes productivity to crash.

Usability, while not a perfect measure, can be a start in the right direction. If users feel the EHR is highly usable, usability can lead to productivity increases and lower costs.

Here is the summary point of this piece—contrary to popular belief, IT, via EHR, has a direct line of sight to revenues, costs, and productivity. How it chooses to respond to that opportunity is what many people are evaluating.

EHR: I may have found a shortcut

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 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