EHR productivity need not be awful

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

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

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

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

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

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

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

Your brand ain’t what it was

Posted by Paul Roemer

Many brands have been redefined by a hospital’s patients through their patients’ use of social media. Your brand is now what their patients—their social mediaphiles—say it is. How’s that for a wakeup call?

Hospitals spend millions of dollars each year marketing to build their internal and external image; to what end? At best, a hospital’s only barometer for how well they are getting their message across is a metric for name recognition. Do more people know your name than they did a year ago?

I bet they do. I would also bet most hospitals would have the same recognition factor if they did not spend a dollar on marketing. Many organizations have no return on their marketing investment. Installing a billboard on a highway a mile away from the hospital depicting a picture of smiling urologists is not bringing new patients or helping you retain current patients.

It may be time to figure out what the market and your employees are saying about your organization. Chances are good that many of their messages are far different from your hospital’s vision statement and mission. Chances are also good that their bandwidth and access to your customer base is significantly higher than yours.

EHR: know when to ask for help

Posted by Paul Roemer

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?

Patient Relationship Management (PRM)

Posted by Paul Roemer

If you watch too much television your brain will fry. Sometimes I feel like mine is in a crepe pan that was left sitting on the stove too long. Two nights ago I’m watching Nova or some comparable show on PBS. The topic of the show was to outline all the events that took place that helped Einstein discover that the energy of an object is equal to its mass times the speed of light squared, better known as E=mc². It was presented to the audience at a level that might best be described as physics for librarians, which was exactly the level at which I needed to hear it. It’s physics at a level that is suitable for conversation at Starbucks or any blog such as this.

So here’s what I think I understood from the show. It tracked the developments of math and physics in 100 years prior to Einstein’s discovery. The dénouement appeared to occur when Einstein and his fiancée were riding in the bow of the small boat. Apparently, he was leaning over the side of the boat and noticed that the waves generated by the front of the boat moved at the same speed as the boat. He then noted that fact only held true for those persons in the boat, who were in fact, traveling at the same rate of speed. However for those persons watching from the shore, that same wave was not only moving slower than the boat it got further behind over time. Some other things occurred, yada, yada, yada, and there you have it. Clearly, the details are in the yada, yadas.

So here’s what happens when you watch too much television. As I’m running this morning somehow my mind takes pieces from that show and staples them together to yield the following. Let’s go back to the equation E=mc². For purposes of this discussion I’ll redefine the variables, so that:
E = the percentage of Patient Complaints/Inquiries.
m = Patient in-bound calls.
c = number of Patients
If this were true–this is an illustration, not an axiom–the percentage of complaints in the call centers of an healthcare provider is equal to the number of in-bound calls times the square of the number of patients. So as the number of calls increases the number of complaints/questions increases and as the number of patients increases the number of complaints increases exponentially. Of course this is made up, but there appears to be a grain of truth to it. As a number of calls increase the percentage of complaints is likely to increase, and as the number of patients increases there will probably be an even greater increase in the percentage of complaints incurred. I think we can agree that a reasonable goal for a healthcare provider is to decrease the percentage of complaints and perhaps to shift a hefty percentage of inquiries to some form of internet self-service vehicle.

I think sometimes the way providers like to assess the issue of Patient Relationship Management (PRM) is by looking at how much money providers throw at the problem. I think some people think that if one provider has 2 call centers, and another provider has 3 call centers, that the provider with 3 must be more interested in taking care of the their patients, and might even be better at PRM. I don’t support that belief. I think it can be demonstrated that the provider with the most call centers, and most Patient Service Representatives, and the most toys deployed probably has the most problems with their patients. I don’t think it’s a chicken and egg argument. If expenditures increase year after year, and resources are deployed continuously to solve the same types of problems, I think it’s a sign that the provider and its patients are growing more and more dysfunctional.

How does this tie to Einstein and his boat? Perhaps the Einsteins are those who work with the provider; those who are moving at the same speed, those in lockstep. From their vantage point, the waves and the boat, like the provider and its patients, are all moving forward at the same speed. Perhaps only the people standing along the shore are able to see what is actually occurring; the waves distance themselves from the boat in much the same way that the patients distance themselves from the provider.

PRM is such an easy way to see large improvements accrue to the provider, especially using social media.

EHR: What’s in it for me?

Posted by Paul Roemer

Field of Dreams. Best guy movie of all times? Forgive me, but I don’t usually start my day being PC. (I don’t end it that way either.) Pardon me as I wipe a tear. Want to have a catch Dad? For those of you whose minds don’t immediately shift to the shooting of Old Yellar, you’re on the wrong blog.

First there’s the field. It’s green. The same green God made when he made green. There’s a cross-hatched pattern to the cut, the white lines brilliantly juxtaposed. The air smells of peanuts and dogs.

Baseball, as spoken by James Earl Jones:

“Ray. People will come, Ray. They’ll come to Iowa for reasons they can’t even fathom. They’ll turn into your driveway, not knowing for sure why they’re doing it. They’ll arrive at your door, as innocent as children, longing for the past. Of course, we won’t mind if you look around, you’ll say. It’s only $20 per person. They’ll pass over the money without even thinking about it: for it is money they have and peace they lack…And they’ll walk off to the bleachers and sit in their short sleeves on a perfect afternoon. They’ll find they have reserved seats somewhere along one of the baselines where they sat when they were children, and cheered their heroes. And they’ll watch the game, and it’ll be as if they’d dipped themselves in magic waters. The memories will be so thick, they’ll have to brush them away from their faces… People will come, Ray…The one constant through all the years, Ray, has been baseball. America has rolled by like an army of steamrollers; it has been erased like a blackboard, rebuilt, and erased again. But baseball has marked the time. This field, this game, is a part of our past, Ray. It reminds us of all that once was good, and it could be again. Ohhhh, people will come, Ray. People will most definitely come…”

This is the twelve step nightmare for anyone who had a father. At the end of the movie there is a dialog between Ray Kinsella and Shoeless Joe Jackson:

Ray Kinsella: I did it all. I listened to the voices, I did what they told me, and not once did I ask what’s in it for me.
Shoeless Joe Jackson: What are you saying, Ray?
Ray Kinsella: I’m saying? What’s in it for me?

Amidst all the confusion, amidst all the regulation, where does that leave you? Ask, “What’s in it for me?” What’s in it is whatever you put into it. Drive this process to your benefit. Build an EHR because it benefits you, not because it’s forced upon you.

How does Heisenberg’s Uncertainty Principle affect EHR?

Posted by Paul Roemer

One of the great things about social media is its ability to infer attributes of both the readers and the writer. When you finally meet your virtual pen pal the mind wanders—I thought he sounded taller.

There are those among us who when they picture me writing, see me sitting at my desk, wearing my baby seal-skin slippers, and supping on a bowl of loggerhead turtle soup.

Segue.

According to Heisenberg’s Uncertainty Principle (used in physics) certain pairs of physical properties cannot both be determined simultaneously. That is, the more precisely one property is known, the less precisely the other can be measured. For instance, the next time you are standing by the side of the road, and cars are whizzing by you, try to decipher the speed of the car, and its exact location. If I remember my math correctly, the first derivative is its velocity, the second, its acceleration. To know exactly where the car is at a precise moment in time, the car must be stationary—as in not moving. Thus, to ascertain its position, the position must be fixed. The Heisenberg Uncertainty Principle requires that for someone to determine B, A must cease to be a variable.

The Uncertainty Principle can be represented as something like this:

One can see that as additional properties are tossed into the mix the probability of predicting any particular outcome goes to zero.

Thus follows Roemer’s EHR Uncertainty Principle—if you don’t know where you are going, you arrived a long time ago (A little like Pink Floyd’s, “How can you have any pudding if you don’t eat your meat?”).

The conflicting principles include;

· Implementation date

· Completion date

· Final cost

· Your functional requirements

· The vendor’s capabilities

· Acceptance testing

· What should the EHR do

· How do you know when you are done

· Should you meet Meaningful Use

· Will you receive the ARRA money

Here is the point of the allegory. The chances of a physician group or hospital knowing the answer to all but one of the above principles are zero.

Permit me to throw a wrench into the loggerhead soup and let you know that not having the answers to all but one of the variables is okay. That is the way projects work.

Since most of you implementing EHR have not ‘been-there, done-that’ with respect to implementing EHR, it is reasonable to expect there are more unknowns than knowns (spell-check indicates that it is not a word, but I know you are keeping up with me).

So, how can you use Heisenberg’s Uncertainty Principle to your advantage? It is actually rather simple. Do not allow your implementation to be guided by the unknowns.

· Do not set an arbitrary budget for something you have never purchased

· Do not set an arbitrary implementation deadline

Do what you must to make sure you implement an ERH that does what you need it to do. Do not let yourself be constrained by principles whose only possible effect will be to derail your project.

If you are willing to take that risk, the other principles become moot (the correct terms is moot, not mute—look it up—sorry about the preposition).

If all else fails, consider getting a pair of the seal-skin slippers.

Paul M. Roemer

Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335

+1 (484) 885-6942

paulroemer@healthcareitstrategy.com

My profiles:

My blog: Healthcare IT Strategy How to Revive a Failed EHR Implementation

How to Revive a Failed EHR Implementation

Posted by Paul Roemer

My latest post on www.healthsystemCIO.com. Here’s an idea I think merits consideration.

http://healthsystemcio.com/2010/07/30/how-to-revive-a-failed-ehr-implementation/

What do you think?

A little IT knowledge can kill you

Posted by Paul Roemer

It almost killed me. Curious? I lived in Colorado for a dozen years, and spent almost every other weekend in the mountains, fly-fishing, skiing, climbing, and painting—any excuse would do. Colorado has 54 peaks above fourteen thousand feet. In my twelve years I climbed most of them. Some solo; some with friends.

I owned almost everything North Face made, including a down sleeping bag with thermal protection which would have made me sweat on the moon and a one-burner propane stove which cranked out enough BTUs to smelt aluminum. Two of my friends and felt we needed a bigger challenge than what Colorado’s peaks offered.

The dot in the photo is me.

We decided on a pair of volcanoes in Mexico, Pico de Orizaba and Popocatépetl—both over 18,000’. We trained hard because we knew that people who didn’t died. We trained with ropes, ice axes, carabineers, and crampons. One day in early May we arrived at the base ofPico de Orizaba. The man who drove us to the mountain made us sign the log book, that way they’d know who they were burying. After a six hour ride from a town with less people than a K-Mart, we were deposited at a cinder-block hut—four walls, tin roof, dirt floor. Base camp.

Before the sun rose we were hiking up ankle-deep volcanic ash; gritty, coarse, black sand. The sand soon turned in to thigh-deep snow. We took turns breaking trail, stopping only long enough to refill our water bottles by hand-pumping glacier melt from the runoff in the bottom of cobalt blue ice caverns carved from solid glacier.

Ice Cave we used to collect drinking water

Throughout the trek we passed crude wooden crosses that were stuck into the ash and snow, serving as grim reminders of those who’d gone before us.

We knew the signs of pulmonary edema, but were reluctant to acknowledge them when we first saw it. It was about one the following morning when we decided to make camp. My roommate was having trouble concentrating, and his speech was slightly slurred. When we asked him if he was ill, he responded much like one would expect an alcoholic would respond when asked if he was okay to drive. “I’m fine.”

We were at about 16,000’. The slope seemed to be at about forty-five degrees. The sheet of ice upon which we stood glistened from what little light the stars emitted. I removed my tent pole from my pack and placed it on the ground—we were going to camp for the night. We watched in awe as the pole gained speed and hurtled down the side of the volcano, quickly lost in the darkness.

Realizing my friend wasn’t doing well, and that I was now feeling somewhat punkish, we made the difficult decision to turn back. The only survival for edema is to lose enough altitude until you reach an altitude where there is enough air pressure to force the oxygen into the blood. Eighteen hours of climbing. Pitch black. And then it started to snow. Any other time the view would have been awesome. We headed down, me carrying my pack and his, he with our friend.

We arrived at the block hut around four that morning. By then I was no longer making any sense. My roommate had recovered, but I had become somewhat delirious—at least that’s what they told me later. Not knowing right from left or wrong, I was determined to keep walking. The two of them took turns laying on me to prevent me from sneaking out during the night.

A little knowledge almost killed us. The scary thing is that we knew what we were doing. We had trained at altitude, had a plan, worked the plan. The plan shifted. Sometimes shift happens.

It happens more with IT. Much more. Do you know what the chances are of any IT project ‘working’ that costs more than$7-10 million? (Working is defined as having a positive ROI, a project that was delivered on time, withing the budget, and delivered the expected results.) (IT includes workflows, change management, training, etc.) Two in ten. Twenty percent. That’s below the Mendosa Line—non baseball fans may have to look up that one. Remember the last industry conference you attended? Was it about EHR? Pretty scary knowing most of them were planning for a failure.

Put your best efforts, your brightest people on planning the EHR. Make them plan it, then make them plan it again, and then make them defend it, every piece of it. If they don’t convince you they can do it in their sleep, you had better redo it. Do they know what they’re planning to do? Do they know why they’re planning to do it that way? If they haven’t done it before, this may not be the best time for them to practice. EHR is not a good project for stretching someone’s capabilities.

Planning is difficult to defend twice during the life of a large program. First, at the beginning of the program when the C-Suite is in a hurry to see people doing things and signing contracts. The second time planning is difficult to defend is the moment the C-I-Told-You-Sos are calling for your head for having such an inadequate plan.

How would I approach planning an EHR program for a hospital? If we started in September, my goal would be to;

Have a dedicated and qualified PMO in place in four weeks
Begin defining workflows and requirements by October (I’m curious. For those who have done or are doing this piece, how many FTE’s participated? I ask because i think chances are good that your number is far fewer than I think would be needed.)
Issue a requirements document by mid-January.
Be able to recommend a vendor by the end of March.

That seems like a lot of time. There are plenty who will tell you they can do ‘it’ quicker. Good for them. The best factor in your favor right now is time.

Reread this in a year and see where you are…

…See, I told you so. Anyone want to go hiking?

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

How can you solve the EHR puzzle?

Posted by Paul Roemer

Seth Godin wrote about the “Perfect Problem.”

A perfect problem, in its existing state, is unsolvable. The way most of us handle it is to click our heels together three times and hope it goes away. We tend to work on imperfect problems, those that can be solved.

What is the difference between the two? The first step is the ability to understand what makes the perfect problem uniquely unfixable. Perhaps a few examples would help.

The CEO imposed a deadline for the implementation of EHR.
CMS Meaningful Use rules do not fit with our operational strategy.
If we do not implement EHR by this date, we do not get the money.
We must meet Meaningful Use
We do not have enough resources from the EHR users to understand their processes.
We cannot continue to support these low-margin services
We do not have enough time to define our requirements
We cannot afford to spend the time required to assess our processes before we bring in the EHR vendor.

What can be done? The easy answer is to plan for failure and do your best to minimize it.

What is another way to describe the above examples? They are constraints. They can all be rewritten using the word “can’t”. Rewritten, we might say, “We had a chance to succeed, but because of X, Y, and Z we can’t.” If that assessment is correct, you will fail, or at least under-deliver at a level that will be remembered for years to come. That’s a legacy none of us wants.

There are a few solutions to this scenario. You can eliminate the seemingly intractable constraints; the organization can determine to re-implement EHR and hope for different results; or they can simply find someone else to solve the perfect problem.

Experience teaches good leaders really want reasoned advice. They want the members of the C-suite to tell them what must be done to be successful. Good leaders do not accept “can’t”—not on the receiving end, not on the delivering end.

Some will argue, “This is the way our organization works.” Even if that is true one must consider what is needed to make an exception to the constraint. Would you accept this logic from a subordinate? Of course not. You’d demand a viable solution. If you are being constrained in your efforts to solve a perfect problem, perhaps it is time to restate the constraints.

One of my college professors—way back when we still had inkwells on our desks—told me that if you cannot solve the problem the way it is stated, it is to your advantage to restate the problem. Maybe the solution to the perfect problem is to restate it in a manner that makes it imperfect—solvable.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

Why do you think projects fail?

Posted by Paul Roemer

Again on the project failure? Yes. Why? Trying to head it off at the pass. Source, The Bull Report.

Failure_Cause_Survey.264

Fifty-seven percent of failures are due to bad communication. What’s that? Poor grammar? No. Not enough meetings? Doubtful.

It’s about PMO. A hired gun? Perhaps. An advocate who will manage the vendor on your behalf. What’s the rest of the hired gun’s job description? All the blue stuff in the graph..

The good news is that being a bad dresser will not hurt the project.

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy