EHR: How is your EHR vendor performing?

Many organizations have a Program Management Office and a Program Steering Committee to oversee all aspects of the EHR.  Typically these include broad objectives like defining the functional and technical requirements, process redesign, change management, software selection, training, and implementation.  Chances are that neither the PMO or the steering committee has ever selected or implemented an EHR.  As such, it can be difficult to know how well the effort is proceeding.  Simply matching deliverables to milestones may be of little value if the deliverables and milestones are wrong.  The program can quickly take on the look and feel of the scene from the movie City Slickers when the guys on horseback are trying to determine where they are.  One of the riders replies, “We don’t know where we’re going, but we’re making really good time.”

One way to provide oversight is to constantly ask the PMO “why.”  Why did our productivity crash? Why did we miss that date?  Why are we doing it this way?  Tell me again, why did we select that vendor?  Why didn’t we evaluate more options?  As members of the steering committee you are responsible for being able to provide correct answers to those questions, just as the PMO is responsible for being able to provide them to you.  The PMO will either have substantiated answers, or he or she won’t.  If the PMO isn’t forthcoming with those answers, in effect you have your answer to a more important question, “Is the project in trouble?”  If the steering committee is a rubber stamp, everyone loses.  To be of value, the committee should serve as a board of inquiry.  Use your instincts to judge how the PMO responds.  Is the PMO forthcoming?  Does the PMO have command of the material?  Can the PMO explain the status in plain English?

So, how can you tell how the EHR effort is progressing?  Perhaps this is one way to tell.

A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick the cat up. The brother hesitated, then said, “I’m so sorry, but while you were away, the cat died.”

The man was very upset and yelled, “You know, you could have broken the news to me better than that. When I called today, you could have said the cat was on the roof and wouldn’t come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said he had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and won’t come down.”

If you ask the PMO how the project is going and he responds by saying, “The vendor’s on the roof and won’t come down,” it may be time to get a new vendor.

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.

HIT/EHR: Adult supervision required

Among other things, EHR requires adult supervision–kind of like parenting.

My morning was moving along swimmingly.  The kids were almost out the door and I thought I’d get a batch of bread underway before heading out for my run.  I was at the step where you gradually add three cups of flour—I was in a hurry and dumped it all in at once.  This is when the eight-year-old hopped on the counter and turned on the mixer.  He didn’t just turn it on, he turned it ON—power level 10.

If you’ve ever been in a blizzard, you are probably familiar with the term whiteout.   On either side of the mixer sat two of my children, the dog was on the floor.  In an instant the three of them looked like they had been flocked—like the white stuff sprayed on Christmas trees—those of you more politically astute would call them evergreens—to make them look snow-covered.  (I just em-dashed an em-dash, wonder how the AP Style Book likes that.)  So, the point I was going for is that sometimes, adult supervision is required.

What exactly is Health IT, or HIT?  It may be easier asking what HIT isn’t.  One way to look at it is to consider the iPhone.  For the most part the iPhone is a phone, an email client, a camera, a web browser, and an MP3 player.  The other 85,000 things it can be are things that happen to interact with or reside on the device.

In order for us to implement correctly (it sounds better when you spilt the infinitive) HIT and EHR, a little focus on blocking and tackling are in order.  Some write that EHR may be used to help with everything from preventing hip fractures to diagnosing the flu—you know what, so can doctors.  There are probably things EHR can be made to do, but that’s not what they were designed to do, not why you want one, and not why Washington wants you to want one.  No Meaningful Use bonus point will be awarded to providers who get ancillary benefits from their EHR especially if they don’t get it to do what it is supposed to do.

EHR, if done correctly, will be the most difficult, expensive, and far reaching project undertaken by a hospital.  It should prove to be at least as complicated as building a new hospital wing.  If it doesn’t, you’ve done something wrong.

EHR is not one of those efforts where one can apply tidbits of knowledge gleaned from bubblegum wrapper MBA advice like “Mongolian Horde Management” and “Everything I needed to know I learned playing dodge ball”.

There’s an expression in football that says when you pass the ball there are three possible outcomes and only one of them is good—a completion.  EHR sort of works the same, except the range of bad outcomes is much larger.

EHR: What are the voices in your head telling you?

My favorite thing about healthcare is having witnessed it up close and personal both as a cancer patient in the 80’s and as the survivor of a heart attack seven years ago.

I was fortunate enough to have testicular cancer before Lance Armstrong made it seem kind of stylish.  Caught early, it’s one of the most curable cancers.  As those who’ve undergone the chemo will attest, the cure is almost potent enough to kill you.

I self-diagnosed while watching a local news cast in Amarillo where I was stationed on one of my consulting engagements.  As we were having dinner, my fellow consultants voted to change the channel—I however had lost my appetite.  I went to my room, looked in Yellow Pages—see how times have changed—and called the first doctor I found.  This is one of those times when Never Wrong Roemer hated being right.

So, yada, yada, yada; my hair falls out in less time than it took to shower.  A few more rounds of chemo, the cancer’s gone and I start my see America recovery Tour, my wig and I visiting friends throughout the southeast.  If I had it to do over, I would go without the wig, but at twenty-seven the wig was my security blanket.  I don’t think it ever fooled anyone or anything—even my house plants snickered when I wore it around them.

I owned a TR-7 convertible—apparently it never lived up to its billing as the shape of things to come, more like the shape of things that never were.  My wig blew out of the convertible as I made my way through Smokey Mountain National Park.  I spent twenty minutes walking along the highway until I spotted what looked like a squirrel laying lifelessly on the shoulder—my wig.

The last stop on my tour was at a friend’s apartment in Raleigh.  Overheated from the long drive and the August sun, I decided to take a few laps in her pool.  I dove in the shallow end, swam the length of the pool, performed a near-flawless kick-turn and eased in to the Australian Crawl.  As I turned to gasp for air, I noticed I was about to lap my hair.  I also noticed a small boy, his legs dangling in the water, with a look of astonishment on his face.

My ego had reached rock bottom and had started to dig.  Realizing my wig wasn’t fooling anyone but me, I had one of those “know when to hold ‘em, know when to fold ‘em moments” and never again wore the wig after learning it was such a poor swimmer.

Do you get those moments, or get the little voice telling you that your EHR that the users would rather enter patient data on an Etch-A-Sketch?  It’s okay to acknowledge the voices as long as you don’t audibly reply to them during meetings—I Twitter mine.

Sometimes the voices ask why we didn’t include the users in the design of the EHR.  Other times they want to know how that correspondence course in project management is coming along.  It’s okay.  As long as you’re hearing the voices you still have a shot at recovery.  It’s only when they quit talking that you should start to worry.  Either that, or try wearing a wig.

New thoughts on EHR and ARRA money

So, there I was, laying out my plans for 2012.  I had started training to become the first person to cross the English Channel on horseback, but I was having difficulty finding a company to sponsor me.  Given my reputation as a water-walker, several firms indicated they would sponsor me to walk it, but I have never been one to do things the easy way.

Scratch the horse idea.

Then it hit me.  I’ve decided to retrace the footsteps of the Norwegian explorer Thor Heyerdahl in his quest to travel from Peru to Pacific Polynesia on a raft made from natural materials.  His book Kon-Tiki narrates his 101 day journey.

But since balsa wood is scarce, I will need some other readily available material I can lash together to build my vessel.  (Have you figured out where this is headed?)

With so many broken EHRs littering the dustbins, I figured why not?  I bought them for pennies on the million and had them shipped to the seaport of Callao.  I hired a few systems integrators to integrate the various platforms; McKesson and EPIC formed the major components of the hull, and several copies of AllScripts served as decking.

Launch is set for April 1 of this year.  My backup plan in case this fails is to use all of the unclaimed ARRA money, convert it into single dollar bills, and lay it on the water in front of me, bill by bill, for 4,000 miles.  I know this is a bit extravagant, but I hate to see all that money go to waste.

EHR’s marmalade-and-toast hypothesis

Les choses son contre nous—things are against us.  EHR is the marmalade-and-toast hypothesis, that the marmalade-side will land on the carpet when the toast falls from the breakfast plate, played out in bits and bytes.  Resistentialism is the belief that inanimate objects have a natural antipathy towards human beings.  If one were to view the marmalade-toast through the glasses of resistentialism one would conclude that the likelihood of the toast laying marmalade-side down increases with the cost of the carpet. So it is with the EHR.  Your expensive EHR is laying marmalade-side down on a very expensive carpet.

EHR has created an air of technostalgia with users yearning for the bygone days when the technology involved a number two pencil and a pad of paper.  Now that you are using your EHR system, do you ever wonder how different the experience of using it would have been if someone had asked for your input about what the EHR should do?  Would merely asking have solved the EHR myopia that was brought about by those who implemented it, implemented it without involving a single systems designer?

That this problem even exists is demonstrated by the fact that to use the EHR required hours of training.  Users sat there like sock puppets listening to the buzzword-bingo put forth by the trainers.  This should have been the clue that none of what they were about to learn was intuitive or self-evident.  The reason they offer EHR training is to explain “This is how you get the system to do what you need it to do,” because without viewing it that way it will not do anything.

The EHR has turned a lot of normally complacent physicians and nurses into stress puppies.  To understand how far amiss the functioning of the EHR is from what the users had hoped it would be all one has to do is observe it being used.  How many doctors and nurses have apologized to a patient during an exam because of something related to the EHR?  “Sorry this is taking so long…If you will just bear with me while I figure out how to do this…When the nurse returns I will get her to show me how to schedule your next appointment.”

If ever there was a time to have employed defensive pessimism, the implementation of EHR was such a time.  Users went into the project skeptimistic, certain it would go badly.  As niche worriers doctors and nurses imagined all the ways that the EHR would under deliver and would make their jobs more difficult, and they watched their stress portfolios rise.  The forgotten task was that nobody mapped out ways to avert the damage.

That this jump-the-shark problem can and should be corrected by something not much larger than a two-pizza team—a team small enough that it can be fed by two pizzas—seems to have escaped the reason of many.

Many are guilty of treating the productivity drop brought on by EHR as a problem with no solution.  If a problem has no solution it is not a problem, it is a fact.  And if it is a fact it is not to be solved, but coped with over time.  There is way too much coping going on.

The EHR productivity drop can be undone.  It will not be undone by redoing the training.  It will be undone by assessing the human factors and user experiences of those using the EHR, by researching how they users want to use it, and by reconfiguring the user interface.

This is not cheap, but it is much less expensive than the cost of loss productivity.


The Real Reason Your EHR Failed, And What To Do About It

This is the title for my new blog at I would love to read what you think