Here is the presentation on whether one should meet Meaningful Use I am giving in May at New England’s HFMA conference. Please let me know what you think. http://ow.ly/4Joet
planning
“Our Lady of Perpetual Implementations”
“There is no use trying,” said Alice;
“one can’t believe impossible things.”
“I dare say you haven’t had much practice,” said the Queen.
“When I was your age, I always did it for half an hour a day.
Why, sometimes I’ve believed as many as
six impossible things before breakfast.”
There are a number of people who would have you believe impossible things. I dare say some already have. Such as?
“My EHR is certifiable.”
“They told me it will pass meaningful use.”
“We’re not responsible for Interoperability; that happens at the Rhio.”
“It doesn’t matter what comes out of the reform effort, this EHR will handle it.”
“We don’t have to worry about our workflow, this system has its own.”
Sometimes it’s best not to follow the crowd—scores of like-thinking individuals following the EHR direction they’ve been given by vendors and Washington. Why did you select that package—because somebody at The Hospital of Perpetual Implementations did?
There is merit in asking, is your organization guilty of drinking the Kool Aid? Please don’t mistake my purpose in writing. There are many benefits available to those who implement an EHR. My point is is that there will be many more benefits to those who select the right system, to those who know what business problems they expect to address, to those who eliminate redundant business functions, and those who implement proper change management controls.
When your ACO gives you lemons—make Lemonade
This weekend the temperature warmed enough to cause the neighborhood children to set up the season’s first lemonade stand. One of the moms suggested the stand be set up in the corner of the cul-de-sac. By definition, a cul-de-sac is roundish, as in no corners. When I laughingly questioned the mom as to which corner of the round cul-de-sac she had in mind, she failed to see my humor.
Each of the children brought different supplies; lemons, paper cups, a table, a hand-painted sign, water, and pre-mixed lemonade.
By closing time they had collected twenty-one dollars and seventeen cents. They met at our house to divide the spoils of their venture, a task that sounded easier than it was. The corner cul-de-sac child felt the money should be divided equally. As her only contribution to the venture had been a tablecloth, her suggestion was met with a robust debate.
I suggested they look at using some of the money to pay back those children according to what their supplies cost—according to the children the supplies did not cost them anything because they took them from their homes.
By now you have figured out where this ACO conversation is going. Without knowing ones’ costs, how can one really allocate profits against those costs? The children knew what they charged, and they knew what they made, but they knew nothing of their costs. The same concept applies when viewing the problem of performing a hip replacement instead of simply selling lemonade.
Perhaps providers should start with opening a lemonade stand to get a better understanding of the business requirements, and then work their way up to the ACO model.
How to handicap selecting your EHR
Several years ago I was invited to go on the ultimate boys’ toys, weekend getaway. A dozen of us flew from Denver to Utah, and then drove to a point somewhere west of Bozeman Montana. It was to be a weekend of sport, a weekend of competition, and a more than occasional libation. To say that the people who organized the trip came from money would be a major understatement. They were in the oil bid’ ness. The father of one of the guys was the CEO of the second or third largest petroleum company in North America. We stayed at his ranch, a 12 bedroom log cabin in the middle of Nowhere, Montana, which is about 20 miles west of Next to Nowhere, Montana.
The weekend’s activities included fly fishing, duck hunting, and Gin Rummy. Each participant was given a handicap rating in each event. The idea behind the rating was that if you are weak in one event, you were paired with an individual who is skilled in that event. In theory, that would level the playing field among the teams. Since I have never fly-fished or hunted I was odd man out. But I was game, and it’s amazing how good one can become at something when one has to fight their way through it.
Let the games begin. We started the competition with a full day of fly-fishing. Our destination was the Madison River, an impressive, fast running, expanse of snow melt. The stretch we would finish was about 150 feet wide, and its average depth was somewhere between waist and chest high. As I would soon learn the bottom was covered with what appeared to be the equivalent of moss covered bowling balls. I was instructed by one of the more experienced fishermen to tie a nymph to the end of the tippet. For those of you who are as novice to the sport as I was, a nymph is an artificial lure which mimics an insect larva. It is designed to lure fish who feed along the bottom, not the nubile young woman referenced in Greek mythology.
We fished for several hours. My legs ached from trying to maintain my balance in the strong current. I was about ready to admit defeat when the tip of my rod bent sharply into the water. Standing perpendicular to the current, I could see as the brightly speckled back of a large rainbow trout turned upstream. Naturally, I turned upstream with it and began to try to reel him in. First mistake. It was at that point that I first realized that the height of the water was now about level with my chest waders. Second mistake. The guys on the other part of the river and along the bank were yelling at me. I thought it was words of encouragement. Final mistake. As it turns out, they were trying to convince me not to turn upstream. At the exact moment that I faced stream head on, was the exact moment my feet lost purchase with those moss covered bowling balls of which I wrote. Turning yet again to my physics, I quickly recalled the equation; force equals mass times acceleration. Instantaneously, I was swept downstream, still clutching my fly rod in my right hand.
Wayne Newton’s first law of fluid mechanics took over; waders, no matter how good they are, if positioned in a plane that is horizontal to the river will fill rapidly with water, just as mine did. The choice with which I was faced was do I save myself and lose the fish, or do I try and land the fish? One of the shortcomings of maleness—I was going to use maledom until I Googled it—is that we rarely have actual choices, especially when we are around other males or for that matter, females. Naturally, I opted to land the fish. My reel had become dislocated from my rod. I remember grabbing the reel and stuffing it down my waders, and as I tried to float my body as though it was a raft without a rudder towards the river’s nearest bank, I began to reel in the monofilament with a hand over hand motion. After several minutes I was standing dripping wet and proudly displaying a 19 inch rainbow trout.
We cooked the fish and played Rummy until about three in the morning, awoke at four, grabbed our shotguns and headed out into the darkness without so much as a cup of coffee. Round three of the competition was to be duck hunting. To this day I’m still unclear as to why we had to hunt ducks while it was still dark. Weren’t there any ducks who needed shooting at brunch time, I inquired? Twelve guys, who collectively smelled like a distillery, and who are operating on an hour of sleep, armed with loaded shotguns, trod through a willow thicket as dawn approached. As I neared the river bank, a startled duck shot skyward. I raised my over and under twelve-gauge shotgun, sort of took aim, and fired a volley. The duck seemed to pause in midair, and then fell like a rock into the racing water. I watched helplessly as my quarry floated away from me. I looked downstream and was pleased to see two men fishing from a rowboat. The duck floated right towards them. A man reached down, retrieved my duck, and dropped it in his boat. He then waved to me. Thinking he was being friendly I returned his wave. He then rowed away with my duck.
It was a great three days. Part of what made the weekend fun with not having to excel at each event. It helped knowing that in areas where my skills were not as good, I could count on the skills of others and vice versa. The idea behind this approach was to build competitive and level teams. That approach works well in mano y mano events like those I described. It works much less well in EHR, HIT and healthcare reform in general. I’m trying to recall if I wrote previsouly about a meeting I attended with a former hospital CEO. His take on EHR was the total inability of his peers to have any precience regarding their approach to EHR. According to him, very intelligent people were making very unintelligent decisions, committing their entire institution to strategies made with almost no data. Some people can give a better explanation for why they bought their car than they can for why they selected their EHR. That’s the wrong way to handicap this event.
There are two ways to handicap your EHR. One way is to look at the program from the perspective of risk assessment and assess–handicap–the risks. The other way to to be a detriment to the program’s success. One of these is bad.
EHR Strategy: It’s all about thawing Chicken
Success and failure are often separated by the slimmest of margins. Sometimes you have to be prepared to think on your feet to out think unfavorable circumstances. Sometimes success hinges on how you present your idea. It is possible to force the circumstances via rapid evolution to pass from problem, to possible solution, to believable, to heroic? I believe so.
Permit me to illustrate with frozen chicken. Several hours before dinner I threw the frozen chicken breasts into the sink, choosing to thaw them with water instead of the microwave. Some twenty minutes later while checking emails I wondered what we were having for dinner. Not to be outdone by own inadequacies, I remembered we were having chicken. I remembered that we were having chicken because I remembered turning on the hot water. The only thing I couldn’t remember was turning off the hot water.
I raced to the kitchen. My memory was correct. Grabbing every towel I could find, I soaked up the puddles from the hardwood flooring, thinking while mopping about how I might answer to my wife if she happened to return to a kitchen that looked like the Land of Lakes. My first reaction, admittedly poor, was to tell her that I thought the countertop wasn’t level and that the only way to know for sure was to see which direction the water ran. Telling her the truth never entered my mind.
Once the major puddles had been removed, I worked on version two of the story, quickly arriving at a version of the truth that was more palatable—tell her I decided to wash all the towels. Why not get bonus points instead of getting in trouble? Version three looked even better. Since I was wiping the floor with the towels, instead of telling her I washed the towels, why not double the bonus points? I decided to wash the floor, and wash the towels. Husband of the year can’t be far off.
A few hours have passed. The floor is dry—and clean, the towels are neatly folded and back in the linen closet, and the chicken is on the grill. All the bases covered. A difficult and embarrassing situation turned into a positive by quick thinking.
A few of you have asked, let’s say we buy into what you are saying, how do you propose we turn around our EHR approach? All kidding aside, it comes down to presentation. Clearly you can’t walk into a room with a bunch of slides showing that your EHR investment was wasted. The first step involves defining the quantitative returns that can be achieved by changing the focus of EHR away from ARRA money and Washington, and focusing on the business problems EHR will address.
So, how did the dinner turn out? I was feeling confident that I had sidestepped to worst of it. Overconfident, as it turned out. My son hollered from the basement, “Dad, why is all this water down here?”
HIT: The Change Keeps Changing
Hello to those whom I’ve yet to meet. This is rather long, so you may wish to grab a sandwich.
I write to share a few thoughts. I reside in the small place where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s where those who place principle over fees dare to tread.
Where to begin? How to build your provider executive team? (Those who wish to throw cabbages should move closer to their laptops so as not to be denied a decent launching point.)
I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time your project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.
If I were staffing a healthcare organization, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon, external influences—the implications of reform and Stages 2 and 3 of Meaningful Use, and a national roll out of EHR with no viable plan to get there. Staffing only to execute today’s perceived demands will get people shot and will fail to meet the needs of hospital. To succeed we need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications.
Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare implications of reform and IT. They’ve also indicated—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform. I somewhat disagree with that perspective.
Here’s a simplified version of the targets I think most of today’s hospital CIOs are trying to hit.
1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards
There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them. Here’s what I think. You don’t have to accept this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since this is my piece, I used it.
Before we go there, may I share my reasoning? From a business perspective, many would say the business of healthcare must move from a 0.2 to a 2.0 business model. (This is not the same as the healthcare business—the clinical side.) The carrot? The ARRA incentives—an amount that for many providers will prove to be more of a rounding error than a substantive rebate.
Large healthcare providers are being asked to hit complex, undefined, and moving targets, and they are planning on adapting to reform and reforming their own business model while they implement systems which will change how everyone works. Hospitals are making eight and nine figure purchase decisions based in part on solving business problems they have not articulated. If success is measured as being on-time, in-budget, and fully functional and accepted, for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.
Their overriding business driver seems to be that the government told them to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on an EHR system than they would to build a new hospital wing. Many don’t know what the EHR should cost, yet they have a budget. Many don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.
So, where would I staff to help ensure my success—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot. I’d staff with a heavy emphasis on the following subject matter experts:
• PMO
• Planning & Innovation
• Flexibility
• Change Management
• PR & Marketing
Contrary to popular belief, not all of these high-level people need to have great understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime.
Here’s why I think this is important. Here’s what I believe will happen. Three to five years for now the government would like us to believe there will be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of RHIOs, and mapped to a N-HIN. Under the proposed model, standardization will not occur if only for the fact that there is no monetary value to those vendors whose standards are not standard.
Interoperability, cost, and the lack of standardization will force a different solution—one which is portable. I think the solution will have to be something along the lines of a single, national, open, browser-based EHR. It will be driven by consumers. Consumers will purchase the next generation of super-smart portable devices that offer a combination of iPad/iPhone functionality.
The Personal Health (PRH) will have evolved to become the EMR. How is this possible? What do smart devices do? They do one thing, billions of times each day, and they do it perfectly—they send and receive ones and zeros. That is what today’s EMR are—ones and zeroes. Those next-gen devices will be EMR-capable. Why? Because there are more than a hundred million customers who will keep buying these devices.
The so-called N-HIN will be the new Super Internet—not some cobbled together network of RHIOs.
Firms like Apple, Google, and Microsoft will drive this change. We already buy everything they offer, in fact, we line up at midnight to do so. By then, those firms will care less about selling the devices than they will about transporting the ones and zeroes that comprise the data. Their current PHRs are their way of introducing themselves to consumers as players in healthcare.
The point I am trying to drive home is that from being able to adapt to change and reform, lean towards staffing the unknown. Staff with leaders, innovators, and people who can turn on a dime. Build your organization like turning on a dime is your number one requirement. Don’t waste time and money worrying about Certification or Meaningful Use. If anyone asks you why, you can blame me.
If you want a real reason, I have two. First, they won’t mean a thing five years from now. Second, if I am the person writing an incentive check, I want to know one and only one thing—will your system connect with the other system for which I am also writing a check? That is the government’s home run.
What if hospital business models weren’t so tribal?
I tend to look at it from the perspective of the business model of many hospitals. How does one transform a 0.2 business model to function in today’s let alone tomorrow’s changing healthcare model?
The clinical side of healthcare, the healthcare business, in juxtaposition to the business of healthcare, would never quarter to the idea of buying millions of dollars of technology without first knowing how they were going to use it.
Plenty can be gained by applying what other industries have done to become more effective. In some respects the inherent structure, cost duplication, and rigid departmental silos remind me a lot of how the various agencies under Homeland Security function, operating in isolation, performing much of the same work, and not sharing information.
Other industries operate with a much less tribal model than healthcare. Hospitals have created tribes and tribal chiefs. In some hospitals the tribes have names like radiology, general surgery, psychiatry, and OBG/YN. Other hospitals have redundant tribes named admissions, human resources, IT, and payroll. Each tribe is run by the tribe’s chief. The chief’s dominant weapon is his or her budget which is lorded over its individual tribe, and a dispute vehicle of the other tribes.
The tribal organization is more a reflection of how the hospital evolved over the years, not a result of an inept business strategy. Nobody set out to build an ineffective and internally competitive model, or one that duplicated support functions. Acquisitions have reinforced and exacerbated the problem, duplicating and increasing costs without yielding a resultant increase in value.
Before the business of healthcare is prepared to cope with the unknowns of the myriad of external influences it will face in the next few years, it must first change how it functions under its current structure. It might begin by revisiting its present structure and making sure that its performance and quality precede the application of technology.
I frown on using the term efficient. To me, efficiency implies speed, and doing bad things faster is no solution. Let us work at improving effectiveness and good things will happen.
HIE: Are two HIEs one too many?
The is my most recent post at healthsystemcio.com
According to Wikipedia, Health information exchange (HIE) is defined as the mobilization of healthcare information electronically across organizations within a region, community or hospital system. HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged.
That seems really straight forward, at least to me. I find it helpful to whittle complex ideas down to a point that enables me to explain them to my parents, without either of us having to reach for the Tylenol.
In its simplest form, an HIE is a pipe, a pipe that transports ones and zeroes. Back in the days when I still had hair, one of my clients was the CEO of a large cable television company. He explained his business this way; “We are just like the water department. We put a pipe in the ground, send something through it, and every month people mail me money.”
He also sent ones and zeroes.
Now, there are those around us, apparently thousands of them, who have made it their mission to convince those in the minority that HIEs are far more complex than they really are. Maybe I just do not understand the concept of ones and zeroes.
You probably know that several hundred HIEs are in the process of being built—and they are all being built by people who have little to no experience building HIEs. Now, here is where everything gets a little hairy. Let us look back on the definition of an HIE and let us focus our conversation on building just one HIE. The tricky part about getting the HIE to work is that pesky little word “disparate,” as in disparate health information systems, and the last time I counted EHRs, I hit 300 before giving up.
That is where all that disparate clinical information comes from. However, when push comes to shove, the information from all of those different EHRs is pretty much the same, but the various EHR vendors just line up their ones and zeroes differently, thus enabling them to prevent others from playing in their sandbox.
There is another disparity surrounding HIEs, one that is unspoken. Suppose you and I decide to build an HIE, a good one. After some period of time, we get rid of all the little disparities among the various EHR vendors and are able to zip those little ones and zeroes from one end of the HIE pipe to the other. Let us also suppose we used a very long pipe, so we could use this HIE anywhere. It would work for a hospital, or at an Integrated Delivery Network (IDN), or across a region.
Our HIE is able to move our individual healthcare information from one end of the pipe to the other wherever the other end may be.
I forgot to mention the disparity. The unaddressed HIE disparity is the one created from having hundreds of HIEs, each designed in its own vacuum by people who have little experience filling vacuums. And when those HIEs have been built, what will they do? Exactly. They will move clinical information among disparate healthcare information systems. In laymen’s terms—ones and zeroes from EHR vendors who do not play well together.
The new ones are identical in functionality to the one we just built, only now there are 500 of them.
Now to the meat of the issue. If we build an HIE correctly, and build it to be able to handle any disparity, is there any more need for HIE 2, since in theory HIE 2 will be able to do the same things as HIE 1? Let us extend this same thinking from HIE 1 through HIE 500. At some point—irrespective of certain technical issues—can it be concluded that the total number of HIEs needed to move ones and zeroes is one?
Other than the redundancy and expense of building a few hundred things that each perform the same function, the real problem of having multiple HIEs is that each new HIE greatly increases the complexity of moving a personal health record from point A to point B. If HIE 2 is the same as HIE 1, we do not need HIE 2. If the two HIEs are not alike, when we try to transport a personal health record from a patient in HIE one and move it to a doctor in HIE 2, the disparity created between the two almost requires a new HIE to resolve the problem. We will have infinitely compound the complexity of moving ones and zeroes by deploying 500 HIEs and hundreds of thousands of healthcare providers and a few hundred million patients, and we have designed quite a mess.
And why does the mess exist? It exists to move those same ones and zeroes we were moving quite nicely by the HIE we built. One can argue that scale may create its own design issues, but those issues do not make this idea dead in the water. Issues of scale are solvable; those of compounded complexity are self-imposed due to an overzealous design.
The proposed way to solve the upcoming problem of compounded complexity is to build the National Health Information Network, the NHIN. We need the NHIN to act as a super HIE, to remove the disparities that result from having multiple disparate HIEs.
Adding further unwarranted complexity to the multi-HIE model is the fact that each HIE has resulted in several hundred providers designing and retooling their healthcare IT systems to adapt to these anomalous HIEs.
Sometimes the most difficult solution to envision is the least difficult one to implement.
ICD-10: the true cost of having no experience
The thing I like least about flying has to do with my control issues; someone else controls the plane and there is nothing I can do about it. The pilot’s voice seemed to say “Put yourself in my hands.” Like nails, I thought, like carpentry nails. As a result I find myself creating caricatures of the people seated around me—I can choose do that, or I can choose to rush the cockpit and wind up being a two-minute feature on CNN with the other passengers asking how I got the gun on board.
I get as excited about someone sitting next to me as a dog does about a new flee crawling around on his hind quarters. Picture the woman who sat next to me. I was tempted to ask her how she could dress like that but, I worried she would reply “From years of practice.” She looked like a disaster victim might be expected to look—a tattered, grey wool blanket draped over her shoulders. The only thing missing from the scene was a reporter standing over her asking her how she felt about the plane crash. Her face was strong and equine, with a straight nose that veered slightly leeward. As she gnawed angrily at her gum with her front teeth, her fingers gripped the armrests so tightly I could foresee the need to call a flight surgeon upon landing to amputate her arms at her wrists.
Anyway, that was my flight. Yours? Here’s the segue.
Picture the makeup of the attendees of your last meeting (circle the topic that best describes its purpose; EHR, Meaningful Use, ICD-10). As I look around the conference table, sitting directly across from the bagels is Jackie. Jackie has been a member of the IT team since the invention of punch cards. Bill still prefers to use the “portable” Compaq suitcase PC he was issued during the time the US was playing Reggae hits over loudspeakers trying to coax Manuel Noriega out of Panama. And Mindy has stormy eyes—sorry about that—Mindy has a coffee mug collection acquired at the going away parties for the prior seven CIOs.
Our Lady of Perpetual Billing’s hospital information technology A-team is waiting to see exactly what type of fertilizer is about to be loosed upon the windmill of their little shop of horrors. They run a taught ship; nothing slips by them, and nobody can match their job performance. The last unpaid claim was six years ago, and their efforts have made patient satisfaction so high that the hospital cafeteria’s reservations are booked solid through year end.
It is usually good to have experienced people. People with twenty years of experience. Is it twenty years of experience or twenty in one year’s worth of subject matter? My son has three years of Pokémon experience which makes him an expert on all things Pokémon. This turns out to be a pretty valuable skill as long as the conversation stays on point. Unfortunately, being an expert on Pokémon does not translate as readily as he would like me to believe to other areas requiring his attention, areas like cleaning his room.
So, let’s get back to the issue of Jackie, Bill, and Mindy, and our collection of three IT projects. We can all agree people with their level of experience are very good at what you need them to do, in fact, they are probably irreplaceable. They know what to do from the moment they enter the building until the moment they leave. They are in their comfort zone, even though the hospital may not be in its.
Somebody has to work on EHR, Meaningful Use, and ICD-10. Do you pick people with twenty years of one-year experience? You may not have a choice. Twenty years of one-year experience may be the worst kind of experience to add to your team. It is a given that nobody in your organization is pushing around a wheel barrow full of Meaningful Use or ICD-10 experience.
I spoke with the CIO of a large hospital and listened as he described the hospital’s ICD-10 initiative. I did not have the heart to tell him that the use of the word “initiative” was overly ambitious. The initiative was little more than a meeting of a half-dozen “experienced” people; people from operations, finance, and IT. People who were very good at their jobs—naturally, they had been doing them for…say it with me…twenty years. One of the CIO commemorative coffee mugs sat on the conference table.
These meetings generally begin and end with unblemished legal pads sitting in front of each participant. Why? Let us explore that question for a minute. The group’s charter is to figure out what the hospital needs to do to be HIPAA 5010 ready by the end of 2011, has to be ICD-10 compliant by the end of 2012, and has to determine what it will cost and what resources will be needed.
Suppose that is your charter, or the charter of someone in your hospital. How will those with twenty years of one-year experience help you? What is the first thing you need to do? What is the second? What should the group be doing two weeks from Tuesday?
Maybe the best thing to write is “We do not know how to do this! We need help.”
Guest post: EHR would work better if we just got rid of the doctors
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.
Pale Rhino Consulting 