Hospital

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

Posted by

1

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

Thanks Sue.  The rest is hers.

The EHR’s New Clothes

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

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

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

And that’s just for one medication order!

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

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

And drops your productivity about 20%.

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

Healthcare IT: Shave the Cat

Posted by

0

As I was going up the stair, I met a man who wasn’t there.

He wasn’t there again today…I think, I think, he’d gone away.

This particular fellow happened to be a CIO.  Now, before you throw tomatoes at your monitor, he was atypical; I hope.

We were talking about the various healthcare initiatives that have his attention as the CIO of a hospital.

EHR—done

Meaningful Use—we will pass it in April

Planning for HIPAA 5010 and ICD-10—starting in July

He did not even blink.  It was almost like he was bemused by the triviality of what he faced.  Listening to him, it sounded like he was reading from a scrap of paper he had pulled from hi pants pocket:

  1. Pick up one gallon of milk
  2. Finish EHR
  3. Drop off dry cleaning
  4. Collect ARRA money
  5. Shave the cat
  6. Convert ten thousand systems to 5010
  7. Walk on water

If there is a difference between being confident and being grounded in reality, he may be the poster child.

EHR–where do you place the emphasis?

Posted by

4

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

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

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

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

Blazing Saddles: the original HIE-NHIN model

Posted by

1

Several have inquired as to why I came down so hard in yesterday’s post regarding the CMS-ONC’s approach to link our physicians and hospitals through the development of HIEs and the N-HIN.  I think, as do others, the goal is worthwhile but, is the current strategy going to work?

I think the current plan is fatally flawed, and is racing ahead like a herd of turtles.  Just because everyone is working hard, and has good intentions, does not necessarily mean the outcome will deliver what is needed.  It seems over engineered to the point that it is like trying to put ten pounds of turnips into a five-pound bag.

Unfortunately, until the leadership of the CMS and the ONC come to that realization the CMS, the ONC, and healthcare providers will continue to spend hundreds of millions of dollars to support an infrastructure that:

  • Unnecessarily complex
  • Is not necessary nor sufficient
  • Cannot be built
  • Will not work

Call me Deep Throat.  The perspective that the HIE-NHIN plan will not work is only spoken of in the bowels of the Watergate Hotel’s parking garage in hushed voices late at night.  Many of you have shared with me that you are of the same opinion but, like vampires you shudder that your voice on this matter would see the light of day.  It would be less antagonistic to open a kosher deli in Tehran than to say the CMS-ONC needs to be rethunk but, sometimes a little antagonism is what is needed.

Do you recall the scene in Blazing Saddles when Harvey Korman’s horde of bad guys is racing through the desert on horseback to get to the town of Rock Ridge only to be halted in the middle of a wide open prairie by a lone toll gate?  Instead of being able to go directly to where they wanted to go they are forced to go through the toll gate, and their progress is stopped entirely because nobody has any spare change.

What makes it nonsensical, and quite funny, is their failure to realize that all they had to do was o ride around the toll gate.  Maybe it is just the way my mind works, but trying to get electronic health records to a national network via several hundred disparate HIEs reminds me of the toll gate.  Why not just go around it?

 

EHR, HIEs & N-HIN; a prophecy of doom

Posted by

1

Whether it’s vendors, RHIOs, HIEs, or the N-HIN, where is a plan that will work?  Is not this what it’s all about?  Perhaps it is time that the rest of the national HIT leaders at CMS and the ONC who devised this plan, and who have lead physicians and hospitals down this ill-fated path promising them riches at the end of the journey should acknowledge their mistake and look for other ways to pass their time; pursue something more achievable, like gardening.

If the plan of of nationalizing healthcare by using HIEs, RHIOs, Meaningful Use, and the N-HIN had any real chance of working, don’t you think we would see a lot more organizations lining up to collect their EHR rebate?

In 1-2 years Meaningful Use will have been replaced by something else or done away with entirely.  In 3-5 years the HIE-NHIN plan will have changed dramatically.  That does not help people who are spending money today chasing ghosts.

As a side note, many hospitals will miss the ICD-10 conversion date.  Not for lack of interest, but because so much of their attention is focused on chasing the banshee known as EHR.

HIEs remind me of hand-to-hand fire bucket brigades.  It’s time we agree to use a truck.

EHR–it’s like herding cats

Posted by

0

Herd of cats? Of course I’ve heard of cats.

I spent a summer in Weaverville, North Carolina, just outside of Asheville. (I couldn’t find it on the map either.) That summer, I was the head wrangler at Windy Gap, a summer camp for high school kids. I’m not sure I’d ever seen a horse, much less ridden one, so I guess that’s why they put me in charge. I thought that maybe if I dressed the part that would help. I bought a hat and borrowed a pair of cowboy boots from a friend; the boots were a half size too small, and I spent the better part of the first night stuffing sticks of butter down them trying to get them off my swollen feet.

The ranch’s full-time hand taught us how saddle the horses and little bit about how to ride. In the mornings we had to herd the horses from the fields, bring them into the corral, and saddle them. The other wranglers would ride out to the field to bring in the horses, while I being the least experience of the wranglers would race after them in my running shoes trying to coax them back to the barn. We would take the children for a breakfast ride halfway up a mountain path where we would let them rest and cook them a breakfast of sausage and scrambled eggs. One morning there were a group of 15 high school girls sitting on the fence of the corral. I walked up behind them carrying two saddle bags filled with the breakfast fare. I slung the saddlebags over the top rail of the fence, and hoping to make a good impression I placed one hand on the rail and vaulted myself over. I landed flat on my back smack dab in the middle of the pile of what horses produce when they’re done eating—so much for the good impression.  That earned me the nick-name, “Poop Wrangler.”

I brushed myself off and saddled my horse. The moment I gripped the reins the horse reared, made a dash for the fence and jumped it in one motion. I could tell the high school girls were impressed as I flew by them. Both of my arms were wrapped around the horse’s neck, and I had my hands locked in a death grip. I yelled, “whoa” and stop”, only to learn that the horse didn’t speak English. We raced the 200 yards to the dining hall, stopped on a dime, and raced back to the corral, as the girls continued to cheer. One final leap, and I was back where I started; on the ground, in the corral, looking up at the girls. I took a bow and quickly remounted my steed. The full-time ranch hand came over and instructed me rather loudly, “You can’t let the horse do that. You have to show the horse that you’re in charge.” After that piece of wisdom he grabbed my horse by its bit, pulled its head down, and bit a hole in my horse’s ear. I’m not sure what kind of in an impression it made on my horse. I guarantee you it made an impression on me.

Horses aren’t very intelligent, but they know when you don’t know what you’re doing, when you’re bluffing—dressing like a cowboy didn’t even fool the girls, much less my horse—I guess he hadn’t seen many westerns. Here we go—you had to know where this was headed.

Selecting and implementing an EHR will be the most complex project your hospital will undertake.  If you do it wrong, you may not look any better than I did laying on my back in the corral.  You won’t have girls laughing at you, but you also may be looking for another line of work.

You don’t want to read this, but if your projected spend exceeds ten million dollars, your chances of success, even if you do everything right, is less than fifty percent.  I define success as on time, on budget, functioning at the desired level, and accepted by the users.  That’s reasonable, correct?  We don’t need to talk percentages if you don’t do everything right.

These figures come from the Bull Report—that’s really the name, honest.

The main IT project failure criteria identified by the IT and project managers were:

missed deadlines (75%)
exceeded budget (55%)
poor communications (40%)
inability to meet project requirements (37%).

The main success criteria identified were :

meeting milestones (51%)
maintaining the required quality levels (32%)
meeting the budget (31%)

How is yours matching against these?  Given a choice, sometimes I’d rather be the horse.

 

Nietzsche on HIT Strategy

Posted by

0

The problem with being a consultant is not everyone wants their responses packaged in the same manner I tend to deliver them.  I communicate best visually, pictorially.

Asked what I want for dinner, I respond with a 3-D bar graph.  Forty-five percent of me wants pasta, thirty percent wants roast beef—a year over year increase of seven percent, but not a statistically significant sample size—and one hundred and twelve percent of me wants whatever she is willing to cook—which means I do not have to cook.

There are two kinds of consultants and, I am the other kind.  ‘Nuff said.  On a side note, as I keep telling the police, I am not the person responsible for holding giraffe fights in the linen section of Neiman Marcus.  Nor am I the guy with the collection of taxidermist-stuffed German World War II soldiers in my basement.

When one reviews the value of a healthcare IT strategy—if your organization does not have one click (http://www.disney.com) and you will be taken to a site to make more valuable use of your time—in order for it to be worth more than graffiti on an overpass (plebian) the plan must have a plan.  It also helps if the strategy at least pretends to be strategic.

The stigmata of most strategic plans is they are neither strategic nor plans.

If there is one thing a strategy should be able to address it is to be able to answer why, to be able to answer what benefit the execution of said strategy will deliver.

More than fifty percent of hospitals will not have a written IT strategic plan.

More than half that do have strategic plans will not pass the value test.

Let us suppose for a moment a hospital has what they believe to be a real HIT strategic plan.  Does that document contain answers to the following questions?

  • Implement XYZ EHR.  Why?  Why XYZ?  What benefits will the hospital receive?  Few if any will formalize benefits ahead of time because they can be held accountable when those benefits are not delivered.  Is it safer to simply check the box for having “completed” the implementation?
  • Meet Meaningful Use.  Ditto.
  • Accountable Care Organization.  Ditto.
  • ICD-10.  Ditto.
  • Family Experience Management.  Ditto.

Maybe Nietzsche knew more about IT strategy than he has been credited.  “All things are subject to interpretation.  Whichever interpretation prevails at a given time is a function of power, not truth.”

 

EHR Failure Factors–step away from the computer

Posted by

0

There are days when it doesn’t pay to be a  serial malingerer, and when it does, the work is only part time, but I hear the benefits may be improving as I think I heard somebody mention healthcare is being reformed.

I don’t know if you are aware of it, but there are actually people who have taken an Alfred E. Newman, “What, me worry” attitude towards EHR.  For the youngsters in the crowd, Alfred was the poster child for Mad Magazine, not Mad Med.

Just to be contrarian for a moment–as though that’s out of character for me–most providers have no need to fear–does this happen to you?  You are writing aloud, trying to make a point, and the one thing that pops into your mind after, ‘there’s no need to fear’ is “Underdog is here.”

Anyway, since many providers haven’t begun the process, or even begun to understand the process, there is still time for them to lessen the risk of failure from an EHR perspective.  Many don’t want to talk about it, the risk of failure.

Here’s another data set worth a look (The Chaos Report).  They went a little PC on us calling them ‘Impaired” factors.  EHR impairment.  Step away from the computer if you are impaired, and take away your friend’s logon if they are.  These are failure factors.

Project Impaired Factors % of  the Responses
1. Incomplete Requirements 13.1%
2. Lack of User Involvement 12.4%
3. Lack of Resources 10.6%
4. Unrealistic Expectations 9.9%
5. Lack of Executive Support 9.3%
6. Changing Requirements & Specifications 8.7%
7. Lack of Planning 8.1%
8. Didn’t Need It Any Longer 7.5%
9. Lack of IT Management 6.2%
10. Technology Illiteracy 4.3%
11. Other 9.9%

My take on this is with overall “failures” so high, several respondents could have replied to “all of the above.”  Also of note is that these failure reasons differ from the ones listed previously.

Who knows, maybe if we multiply them by minus one we can call them success factors.

 

The Physics of EHR

Posted by

2

To read and complete this post you may use the following tools; graph paper, compass, protractor, slide ruler, a number two pencil, and a bag of Gummy Bears—from which to snack.  The following problem was on the final exam in my eleventh grade physics class.  Let us give this a shot and then see if we can tie it into anything relevant.

A Rhesus monkey is in the branch of a tree thirty-seven feet above the ground.  The monkey weights eight pounds.  You are hunting in Africa, and are three hundred and twenty yards from the monkey.  You have a bolt-action, reverse-bore (spins the shell counter-clockwise as it leaves the gun barrel) Huntington rifle capable of delivering a projectile at 644 feet per second.  The bullet weighs 45 grams.  The humidity is seventy percent, and the temperature in Scotland is twelve degrees Celsius.

At the exact moment the monkey hears the rifle fire it will jump off the branch and begin to fall.  Using this information, exactly where do you have to aim to make sure you hit the monkey?

I used every piece of information available to try to solve this.  I made graphs and ran calculations until there was no more data left to crunch, computing angles and developing new formulas.  I calculated the curvature of the earth, and the effect Pluto’s gravitational pull had on the bullet.

The one thing that never occurred to me was that since the monkey was falling to the ground, so was the bullet—gravity.  The bullet and the monkey both fall at the same rate because gravity acts on both the same way.  So, where to aim to hit the monkey?  Aim at the monkey.

All of the other information was irrelevant, extraneous.  The funny thing about extraneous information is that it causes us to look at it, to focus on it.  We think it must be important, and so we divert attention and resources to it, even when the right answer is staring us in the eye.

Attempting to implement EHR is a lot like hunting monkeys.  We know what we need to do and yet we are distracted by all of this extraneous information that will hamper our chances of being successful with the EHR.  Two of the most obvious distractions are Meaningful Use and Certification.  The overarching goal of EHR is EHR; one that does what you need it to do.  If the EHR does not do that, everything else has no meaning.

 

EHR’s Gordian knot

Posted by

0

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

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

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

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

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

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

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

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

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

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