Hospital

What does lost EHR productivity cost?

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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?

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Below is my new post in healthsystemcio.com blog is up “User Adoption Versus EMR Usability”ow.ly/770YV 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

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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?”

“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

EHR Usability: Why is it such a disaster

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Do you ever look at the title of a book over and over? You know something is not right about it but you just cannot put your finger on it.

The book in question is titled Cost-Justifying Usability.

I sat.  And I puzzled until my puzzler was sore.

And then it hit me.  Nobody really needs to justify usability.  What needs to be justified is non-usability.  Non-usability must have a fairly substantial justification and ROI because most firms spend millions of dollars creating and maintaining non-usability in their systems and business processes.

Let us take for example one hospital (feel free to insert yours if the shoe fits) which spent more than one hundred million dollars on EHR—actually, they spent WAY more than that figure.

And, what did they get for all of their money?

One thing they did not get was usability.  If we define breakeven on usability to be the same level of productivity after implementing EHR that they had prior to implementing EHR, this hospital did not even breakeven on usability—they lost ground.  In the king’s vernacular this means that had the hospital spent no money on EHR it productivity would exceed its productivity with EHR.  It also begs the question of why, if the hospital spent nine figures and lost ground, heads are not rolling.

I may be guilty of oversimplification, but sometimes over simplifying a complex issue is the only way I know to shed light on something that may be being glossed over, the pay no attention to the man behind the curtain style of management.

How to put lipstick on the pig during your keynote address to the other members of the hospital’s C-Suite, “Our EHR productivity is only down twenty percent, an improvement of thirty-three percent from its prior low.”

Just how much does a point of productivity or a point of usability cost in real dollars in a real hospital?  We are using Roemer math in this example and all of the accounting knowledge I remember from my one accounting class.  Let us assume we are dealing with a hospital whose annual revenues are five hundred million dollars.  Let us also assume said hospital spent two hundred million dollars on its EHR system.  If the hospital’s margins were forty percent, which of course they are not, but if they were, a two hundred million dollar EHR would gobble up every dollar of margin for a year just to pay for itself.

Now in real life we know margins are probably one-tenth of forty percent which means if all of the hospital’s profits went towards paying for the EHR it would take ten years; also unrealistic.  Another rule of thumb regarding large IT systems is that they have a shelf life equal to that of a fruit fly. This means your hospital will be paying for your EHR long after it is dead and buried.

We have just shown that in a perfect world, EHR’s productivity and usability numbers will not have the CFO dancing a jig in the ER.  The great news is this drop in productivity and usability can be solved.  The bad news is that it cannot be solved by your hospital’s IT department or by your EHR vendor.

Design firms specialize in adding a human factor to the EHR interface and really can put the use back into your usability.

What was the name of your project that lost all the productivity

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Since we are already talking about productivity I thought it would be worth spending a few minutes trying to understand why large numbers of hospitals seem to have acquiesced to the notion that operating with a productivity loss is their new steady state.

Imagine for a second that you were to discover that your least costly resource, say the person who answered the phones was spending twenty percent of their day updating their Facebook page.  Were that the case, you would know two things with a high degree of certainty;

  1. The productivity loss had a measurable cost
  2. The productivity loss would be corrected quickly

Now imagine that your hospital spent eight or nine figures on an EHR system.  Imagine that the hospital’s most expensive resources, the doctors, are spending most of their time entering data into the hospital’s expensive EHR system, so much time in fact that they are only able to see eighty-percent of their patients.  Now imagine that you do not have to imagine these because they are real.

Headline:  EHR results in a twenty-percent productivity loss.

Any hospital executive should be able to answer the following two questions:

  1. How much does each percentage of productivity loss cost the hospital?
  2. What is the name of the project to recover the lost productivity?

The project has no name because there is no project, and that is a shame.  The project to create the productivity loss had some stellar name, it had a war room, and it probably even had its own T-shirts.  The project to lose all of that productivity was a massive undertaking.

Should not the project to recover the productivity receive a little attention?

There are those who believe the lost productivity is gone forever.  Productivity is not like energy; it can be created and destroyed.  All kidding aside, there is a way to retrieve the lost productivity, all of it.  If you would like to know let me know.

The Cat in the Hat’s EHR Philosophy

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My mind is a raging torrent, flooded with rivulets of thought cascading into a waterfall of creative alternatives. (Hedley Lamar—that’s Hedley)

Let’s see if we can tie this collection of thoughts into something that won’t waste your time or mine.

The sun did not shine.  It was too wet to play.  So I sat in the house all that cold, cold, wet day.  It was too wet to go out and too cold to play ball, so I sat in the house and did nothing at all. (Dr. Seuss)  It was around that time when my wife decided maybe this whole sitting around thing wasn’t optimizing my time, so she decided “we”—which can also be interpreted to mean “me”—should caulk the master shower.  Personally, I thought that why God invented the Yellow Pages, you know, the whole thing about, “Let your fingers do the walking.”

I notice we just blew through an entire paragraph without accomplishing anything.  Sorry.  I got my designer tool belt, the same one I’ve had for twenty years—still looks the same as the day I bought it.  Today’s Roemer Minute—the less you know about what you’re doing, the more important it is to dress the part.  (This does not seem to work with the people whom I’ve told that I’m studying cardiology.)

Tool belt.  Tools—caulk taker-outer, caulk puter-inner.  Paper towels—the need for these will become clear.  Worse case, this is a ten minute job, but if I finish too quickly, there will be additional assignments coming my way.  The trick with caulking is that the success or failure can all come down to how much of the plastic tip you circumcise (can I say that on TV?).  Too much and caulk is everywhere, not enough and it is nowhere.  I made the incision and started to lay down the first bead.  It was quickly apparent that I should have used clear caulk as the white stuff stared back at me like bleached bones—I try and add a little medical flavor wherever I can.

I’ve watched the same shows as you.  Sometimes people spread the caulk with a tool, others prefer a wet finger.  I am equally unskilled with both, so I went with the finger method, smoothing the caulk into the joint.  I wipe my sticky white finger on the paper towel, place the towel on the limestone tile, and return to work, only to notice that although the caulk looks good, my finger created to parallel lines of caulk on either side of the repair, sort of like a snow plow does.  I grab another piece of paper towel and begin the process of trying to remove the excess caulk, finally tossing the paper towel to the side.

Fast forward twenty minutes.  The caulking is done.  My hands are so white it looks like I am wearing a pair of Mickey’s gloves.  (That’s spelled M-O-U-S-E.)  As I wipe my hands with a used piece of towel—there are no more clean ones—I unknowingly step on one of the pieces.  The piece sticks to my shoe.  I retrieve the other pieces and notice that the caulk which had been on the paper towels is now spread all over the tile like someone had a food fight with smores.

Whatever I touched only exacerbated the problem.  I am immediately reminded of the Dr. Seuss book, “The cat in the hat comes back.”  In the book, the cat goes from good intentions to spreading a pink stain over everything—sort of like me with the caulk.

Sometimes good intentions don’t add up to much.  I’d wager that everyone in the EHR process has good intentions.  Sometimes it’s more important to pair good intentions with good skills.  Let’s call EHR one of those sometimes.  Good intentions are okay up to the point when you’re dealing with two or more commas on the cost side.

Here is today’s thought, the one reason you keep coming back to this site. Why did you implement EHR?  The answer will surprise you.  You did it for one simple reason, to get people, doctors and nurses, to do what you want them to do and to do it in a way you want them to do it.  EHR will modify their behavior.  I am sure yours did, but did it modify it in the way you wanted?

Most times it’s good to call a professional before you start tracking caulk across the floor.

I can fix your EHR productivity

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That is a bold statement and one I can back up. I feel so confident in this claim that if productivity of your EHR does not improve the cost to you is nothing.

EHR potentially will offer a number of benefits.  It won’t offer much at all if you don’t install it right.

However, it’s not a panacea.  Without having a detailed understanding of the business problems you are trying to solve, it may not be of much more value than a Xerox machine.

Do you want make color copies with your EHR?  Probably not.

I picture your office situation is something like this.  The EHR vendor left months ago.  IT keeps coming around to ask how you are doing, to ask how the system is performing.  Not wanting to hurt their feelings you tell them everything is fine, but it is not fine.  It has not been fine since you started using it. Your productivity is down, way down, and it looks like it is not going to get better any time soon.

Does that sound about right?

What is I told you your productivity loss can be fixed?  Stop laughing long enough to read.  The vendor will not be the one to fix it. IT will not be the one to fix it.

All kidding aside, if you want to discuss how you can recoup your productivity, please let me know.

When Good Projects Go Bad

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What are the EHR fail-safe points?  The points of no return, beyond which you can’t recover without exploding the budget and the  schedule?

Although there are several, my take is that the most important one is the planning process.  Without the right plan, an organization is entering its permanent whitewater moment.

What plan do you have to rigorously evaluate the plan before you step off the EHR cliff?  Are you stepping off with a parachute or a bag of rocks?

My best – Paul

Step away from the computer

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Our middle school child is in the middle of a family consumer science project (home economics) to organize one room in our home.  He has redefined the project so that he reorganizes during commercials, and he is seven hours into a project involving our walk-in closet.

While watching the news it occurred to me that something is missing from my life, I do not belong to a gang, not even a little one.  So, I have decided to start one, a white collar gang of consultants.  A rough and tumbled, manicured group of professionals.

Instead of gang emblem, I am thinking each member of the gang will have their own embossed business card.  We will come up with creative gang nicknames.  For myself I am vacillating between ‘Dr. Knowledge’ and ‘The Voice of Reason.’  Instead of Harleys, we will roll through town to our national rallies on monogrammed Segways, and instead of leathers we will dress in Armani.

Mothers will hide their children from us as we power noiselessly down Main Street at four miles an hour, and their CPA husbands will turn green with envy.  We might not win many fights, but we will have the satisfaction of knowing we are smarter than those who beat us to a bloody pulp.

Sounds too good to be true, doesn’t it?

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 Men.

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.

Certification: Myth or just plain stupid?

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EHR certification inspectors will be dropping in on hospitals like UN inspectors looking for WMDs, only they’ll be slightly less congenial.

Why is this a part of the overall plan?  Is this planned failure?  Do they have reason to believe that a certain percentage of EHRs will fail the inspection?

Of course they do.

Permit me to begin with a C-Suite IQ test. Given the choice would you rather have:

  1. A certified EHR that resulted in a productivity loss of 20%
  2. An uncertified EHR that resulted in a productivity gain
If you picked ‘1’ reading further is useless.

Let’s describe two failure types; certification and Full test.  The certification test, by definition, is necessary.  The Full test is both necessary and sufficient.  It is possible to pass certification without passing the Full test.  Therefore, the Full test is a stricter test.  Build out to pass the Full test, and by default, one should pass the Certification test.

What is the full test?  Same as always.  Fully functional, on time, within budget, and user accepted.  Functional, for purposes of this discussion includes updated workflows, change management, and interoperability, and a slew of other deliverables.

Here’s what can be concluded just based on the facts.

Fact:  One-third to two-thirds of EHRs are listed as having failed—this statistic will get smaller over time.

Opinion:  The reason the failure rate will get smaller is that the failure rate will be artificially diluted by a large number of successful small-sized implementations.  Large implementations, those have far-reaching footprints for their outpatient doctors, Rhios, and other interfaces requiring interoperability will continue to fail if their PMO is driving for certification.  (Feel free to add meaningful use to the narrative, it doesn’t change the result.)

Fact:  Most large, complex, expensive IT projects fail—they just do.  This statistic has remained constant for years, and it is higher than the percentage of EHR projects that have failed.  Even a fairly high percentage of those projects which set out to pass the Full test.

Opinion:  Failure rate for large EHR projects—let’s say those above $10,000,000 (if you don’t like that number, pick your own)—as measured by the Full test, will fail at or above the rate for non-EHR IT projects.)

Bleak?  You bet.  Insurmountable?  Doesn’t have to be.

What can you do to improve your chances of success?  Find, hire, invent a killer PMO executive out of whole cloth who knows the EHR Fail Safe Points.  EHR Fail Safe Points?  The points, which if crossed unsuccessfully, place serious doubt about the project’s ability to pass the Full test.  The points which will cause success factors to be redefined, and cause one or more big requirements—time, budget, functionality—to be sacrificed.

This person need not and perhaps should not be the CMIO, the CIO, or an MD.  They need not have a slew of EHR implementation merit badges.  The people who led the Skunk Works had had zero experience managing the types of planes and rockets they built.  They were leaders, they were idea people, they were people who knew how to choose among many alternatives and would not be trapped between two.

The person need not be extremely conversant in the technical or functional intricacies of EMR.  Those skills are needed—in spades—and you need to budget for them.  The person you are looking for must be able to look you in the eye and convince you that they can do this; that they can lead, that these projects are their raison d’etre.  They will ride heard over the requirements, the selection process, the vendors, the users, and the various teams that comprise the PMO.

A certified EHR is all it never was.

What do you think?