productivity

Spilling Tea–Why Your Business May Be Failing

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Years ago the word Lubyanka was enough to bring normal Russians to their knees in terror.  Lubyanka is known best for being the headquarters of the Soviet secret police, then called the KGB.  The basement of Lubyanka housed a prison which had one hundred and eleven cells, cells that were used to hold and interrogate political prisoners during Russia’s purge.

Two times each day the prisoners were given tea.  A prisoner in each cell would place a teapot outside the cell. Another prisoner, carrying a bucket filled with tea, would pour tea from the bucket into the teapot.

Tea spilled on to the floor.  The prisoner would clean the spilt tea with a rag.

Lubyanka’s prison operated for twenty-seven years.  Tea was served to the one hundred and eleven cells and spilled in front of each cell twice a day, seven hundred and thirty times a year per cell.

Two million one hundred eighty-eight thousand spills during those twenty-seven years.  The same number of cleanups.

Someone somewhere made the decision that it was easier or cheaper to spill and clean the tea 2,188,000 times than it was to use buckets with spouts on them.

What are the buckets in your company?  What dumb, wasteful, redundant activities and processes have been left unchanged?

The most obvious one for most companies is customer care.

It is easier to take 2,188,000 calls each year about a given problem than it is to fix the problem.

And do you know where the fallacy in the argument is?  The fallacy comes from the erroneous belief that by having a call center, by answering calls you are actually providing your customers a service.

You are not.  All you are doing is wiping up spilt tea.

 

Poor Project Planning–Musings of a drive-by mind

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It takes a lot of energy to dislike someone, but sometimes it is worth the effort. It is not easy being a consultant.  One client required me to shout “unclean, unclean” as I passed through the hallways.  Maybe that is why I leave newspapers scattered around the floor of my desk, so nobody can sneak up on me without me being able to hear them.

I have a knack for complicating simple things, but the voices in my head tell me that is better than simplifying complicated things.  Either way, I appreciate those of you who continue to play along.  Just remember, if you choose to dine with the devil it is best to use a long spoon.

You’ve probably figured out that I am never going to be asked to substitute host any of the home improvement shows.  I wasn’t blessed with a mechanical mind, and I have the attention span bordering on the half-life of a gnat.

I’ve noticed that projects involving me and the house have a way of taking on a life of their own.  It’s not the big projects that get me in over my head—that’s why God invented phones, so we can outsource—it’s the little ones, those fifteen minute jobs meant to be accomplished during half-time of a football game, between pizza slices.

Case in point—touch-up painting the trim in your house.  Can, brush, paint can opener tool (screwdriver).  Head to the basement where all the leftover paint is stored.  You know exactly where I mean, yours is probably in the same place.  Directions:  grab the can with the dry white paint stuck to the side, open it, give a quick stir with the screwdriver, apply paint, and affix the lid using the other end of the screwdriver.  Back in the chair before the microwave beeps.

That’s how it should have worked.  It doesn’t, does it?  For some reason, you get extra motivated, figure you’ll go for the bonus points, and take a quick spin around the house, dabbing the trim paint on any damaged surface—window and doorframes, baseboards, stair spindles, and other white “things”.  Those of us who are innovators even go so far as to paint over finger prints, crayon marks, and things which otherwise simply needed a wipe down with 409.

This is when things turn bad, just as you reach for that slice of pizza.  “What are all of those white spots all over the house?”  She asks—you determine who your she is. if you do not have one I can let you borrow mine.  You explain to her that it looks like the way it does simply because the paint is still wet—good response.  To which she tells you the paint is dry—a better response.

“Why is the other paint shiny, and the spots are flat?”

You pause.  I pause, like when I’m trying to come up with a good bluff in Trivial Pursuit.  She knows the look.  She sees my bluff and raises the ante.  Thirty minutes later the game I’m watching is a distant memory.  I’ve returned from the paint store.  I am moving furniture, placing drop cloths, raising ladders, filling paint trays, all under the supervision of my personal chimera.  My fifteen-minute exercise has resulted in a multi-weekend amercement.

This is what usually happens when the project plan isn’t tested or isn’t validated.  My plan was to be done by the end of halftime.  Poor planning often results in a lot of rework.  There’s a saying something along the lines of it takes twice as long to do something over as it does to do it right the first time—the DIRT-FIT rule.  And costs twice as much.  Can you really afford either of those outcomes?  Can you really afford to scrimp on the planning part of IT?  If you don’t come out of the gate correctly, it will be impossible.

Back to my project.  Would you believe me if I said I deliberately messed up?  Maybe I did, maybe I didn’t, but the one thing I know with certainty is that I now have half-times all to myself.

EHR’s 5 stages of grief

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Being a blogger is not too dissimilar to being a failure’s biographer.  Unless you simply repeat the ideas of your contemporaries, good blogging requires a certain avidity to oppugn those who revel in the notion that theirs was the only good idea.  To me, their Sang-froid calmness has all the appeal of a cold omelet.  Good writing requires that you make intellectual enemies across a range of subjects, and that you have the tenacity to hold on to those enemies.  So let us step off Chekhov’s veranda and bid farewell to the sisters of Prozorova.

The Kübler-Ross model, commonly known as the five stages of grief, was first introduced by Elisabeth Kübler-Ross in her 1969 book, On Death and Dying.  I heard a story about this on NPR, and it made me think about other scenarios where these stages might apply.

My first powered form of transport was a green Suzuki 250cc motorcycle.  My girlfriend knitted me a green scarf to match the bike.  One afternoon my mother walked into the family room, saw me, and burst into tears.  When I asked her what was wrong, she told me that one her way home she saw a green motorcycle lying on the road surrounded by police cars and an ambulance—she thought I had crashed.  I asked her why, if she thought that was me lying on the road, she did not stop.

My girlfriend’s mother, didn’t like my motorcycle—nor did she like me.  Hence, my first car; a 1969 Corvair.  Three hundred and fifty dollars.  Bench seats, AM radio.  Maroon—ish.  It reminded me a lot of Fred Flintstone’s car in that in several places one could view the street through the floor.  Twenty miles per gallon of gas, fifty miles per quart of oil.

Buyer’s remorse.  We’ve all had it.  There is a lot of buyer’s remorse going around with EHR, a lot of the five stages of grief.  I see it something like this:

  • Denial—the inability to grasp that you spent a hundred million dollars or more on EHR the wrong EHR, one that will never meet your needs
  • Anger—the EHR sales person received a six-figure bonus, and you got a commemorative coffee mug.  The vendor’s VP of Ruin MY life, took you off his speed dial, unfriended you in Facebook, and has blocked your Tweets. You phone calls to the vendor executive go unanswered, and are returned by a junior sales rep who thinks the issue may be that you need to purchase additional training.
  • Bargaining—when you have to answer to your boss, likely the same person who told you which system to purchase, as to why productivity is below what it was when the physicians charted in crayon.
  • Depression—you come in at least fifteen minutes late, and use the side door, taking the stairs so you won’t see anyone.  You just stare at your desk; but it looks like you are working. You do that for probably another hour after lunch, too. You estimate that in a given week you probably only do about fifteen minutes of real, actual, work. (Borrowed from the movie, Office Space.)
  • Acceptance—the EHR does not work, it will never work, you won’t be around to see it if it ever does.  Your hospital won’t see a nickel of the ARRA money.  You realize the lake house you were building will never be yours, but the mortgage will be.

The five stages of EHR grief.  Where are you in the grieving process?

True, there are a handful of EHR successes.  Not nearly as many as the vendors would have you believe.  More than half of hospital EHR implementations are considered to have failed.

If you are just starting the process, or are knee-deep in vendor apathy you have two options.  You can bring in the A-team, people who know how to run big ugly projects, or you prepare to grieve.

If it was me, I’d be checking Facebook to see if I was still on my vendor’s list of friends.

What EHR users really want

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I just read an article in the Harvard Business Review about the notion of what Henry Ford would have said if he were asked what people wanted.  The oft-quoted response was “Faster horses.”

At one point Ford had two-thirds of the market.  A few years later Ford’s share had dropped to fifteen percent.  Those in the know suggest this drop accrued to the fact that the customers did not want faster horses; they wanted better cars.

This is somewhat in line with how the healthcare providers have responded to EHR systems.  The hospitals with whom I have spoken have made a wide range of choices with regard to what they are doing with their EHR.

  • They use it because they have no other choice
  • They continue to do paper charting and use the EHR after the fact
  • They use it as a document management system and continue to dictate
  • They use the monitor as a flashlight to help them see while they write their notes
  • They sign a petition stating they are not going to use the EHR that is being forced upon them
  • They change EHRs believing that anything else has to be better than the system they are using

These are all variations of the faster horse theory of EHR.

What EHR’s users want is a better EHR, one that helps them do their job rather than one that hinders them.

Is Your EHR More Like iPhone Or iTunes?

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Below is my latest post on healthsystemcio.com.  Let me know what you think.

Times are perilous, and they ain’t a-changin.  As Europe focuses its attention on whether the Euro will become a collector’s item, and the Middle East eagerly awaits the chance to lower the amount it pays for air conditioning because of the surplus of electricity that will be available from all of Iran’s nuclear reactors, America is all a-twitter about what Angelina Jolie was wearing at the Oscars.

No wonder the impact of the billions being spent on healthcare IT has taken a back seat.

Ask yourself, how good is your EHR? Does it do what you want it to do? Does it do it in the way you need it to do it? If it was your decision, would you have spent a hundred or two-hundred million dollars for it?

Okay, get the smirk off your face.

I have been writing recently a lot about the difference between user acceptance (UA) and the usability of large business systems like EHR systems. A business system is a lot more than an IT application. It also includes process and people — users.

Achieving high user acceptance is easy. Implement one system and make everyone use it. Check the box. User acceptance only involves the IT application: the EHR. UA does not measure the value of the business system to the users; it simply measures the percentage of users.

Usability is a testament to whether or not the system, in this case the EHR, adds value to the organization, to its users. Does it make them better, more effective, more efficient? The secret sauce towards achieving good usability is the addition of design.

Here is an example of a company with two business systems depicting the difference between UA and usability. The company is Apple, the two business systems are the iPhone and iTunes.

iPhone system:

  • Phone, camera, game player, GPS, email, SMS, MP3 player
  • One button
  • No training required
  • Great usability

iTunes system:

  • Web shopping program for purchasing services to use on Apple products
  • Full keyboard
  • High learning curve
  • Poor usability, poor user experience
  • High UA — users have no other choice

Brothers from different mothers. Their usability is so different that it is difficult to believe both business systems came from the same company.

  • One business system lets you do everything using one button; the other barely lets you do anything using 61 keys.
  • One is intuitive, one is anything but

I am willing to bet your EHR reminds your users more of iTunes than it does the iPhone. You can choose to accept it as is, or you can make it better. The great thing about business systems, unlike products, is you can choose to apply design to a poor business system and gain tremendous value for little investment. Or not.

The True Measure Of Success For HIT Systems

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My newest post in healthsystemcio.com.  Feedback appreciated.

The title of the book on the lap of the person sitting next to me was “Cost Justifying Usability”. My cynicism jumped immediately to Def-Con 4.

Cost Justifying Usability. Did the author get his inspiration for the title at the Shopping-For-New-Ideas store? Now, before you laugh too hard, recall that many inane ideas make gobs of money, such as thePet Rock and Chia Pet. For every book, there must be an audience. I can only believe that the intended audience for this epic must be senior business executives.

Imagine yourself being one of those executives. Someone finds you lying on the floor in the fetal position and suggests you read the book. How should you respond?

  • I assumed usability was the antecedent  for buying that system
  • We just spent $300 million dollars on an enterprise system. Does making it usable cost extra?
  • They told us the drop-dead date is March 21. Drop-dead is the perfect phrase; we only measured cost and speed — nobody thought to measure usability?

What is the title of the antithetical book—Cost Justifying Unusability or, Cost Justifying Failure?

The statement most in HIT are afraid to utter is that most HIT spend has no ROI. There is no ROI because the usability measure of most of the largest HIT systems (enterprise and EHR) is negative — productivity is showing a net loss instead of a net gain.

Usability is not the same as user acceptance. User acceptance for these unusable systems will approach 100 percent. Why? Because users have no other option. And then there is Meaningful Use — an odd phrase because it has nothing to do with users. An EHR can pass Meaningful Use and have low user acceptance and the usability factor of hammering a nail with a banana.

If the healthcare industry needs to be convinced that a cost justification for usability is required before anyone takes the issue seriously, perhaps a moniker change is in order — HIT to OBIT.

Call me silly, but I think the time has come to do away with how we measure the success of all business systems projects. Was the system usable — did it increase ROI, did it make the organization more effective, and did it enable innovation? Only two approaches to measure need be used.

  1. On time, on budget, high user acceptance, unusable:             failure
  2. Not on time, not within budget, usable:                                        success

No matter what else happens, if the best your business system project does is to give you back performance similar to what you had without the system, a reasoned executive would say the investment in the system was wasted. It then stands to reason that if the new system delivered worse performance than what you had previously, it too is a wasted investment.

When I talk with some seasoned executives in HIT about the success or failure of their EHR system, I pause for a second waiting for someone to say, “Pay no attention to the small man behind the curtain.” Their standard of measure? See above, Approach 1. Some would have you believe it is heretical to say that spending a hundred million dollars on a system whose usability is poor was a waste of money. Most of those who defend the spend are those who did the spending.

Ask the users if they think the money was well spent. These three quotes came from a physician whose hospital spent $400 million on a name-brand EHR.

  1. “Their (the hospital’s) most expensive resource spends a lot of time doing data entry.”
  2. “The data is very good if you are a patient or an insurance company that wants to sue us.”
  3. “My productivity is still down thirty percent.”

Imagine yourself as a hospital executive and answer the following question. Which of these two pieces of information is more valuable: knowing your EHR passed Meaningful Use or, learning from your users that the EHR is unusable? In HIT, there are two rules:

  1. The usability measure of most EHRs is unacceptable.
  2. Paying more for your EHR than the next guy or gal does not change Rule 1.

EHR: How is your EHR vendor performing?

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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

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This is my newest contribution to HealthsystemCIO.com.

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.

How to recover your lost EHR productivity

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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 of having forgotten to turn off the water 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 seemed 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 the results of our EHR implementation? 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. Additionally you cannot hide the fact that your productivity is dropping faster than Congress’ favorability polling.

The first requirement to turn EHR infamy into fame is to halt the slide towards the EHR abyss.  Publically acknowledge that productivity is in the dumpster.  Think of it as an IT 12-step meeting; “Hi, my name is Paul, and my EHR project is killing us.”  See, that was not so difficult.  After all, everyone already knows about the productivity problem.  The only unanswered question is whether or not you are going to man-up and own the problem and own the solution.  If you don’t, they will find somebody who will.

Your EHR implementation broke new ground.  It may be the first time that automating a task has ever made the task take more time rather than less..

And what is the problem that requires fixing?  It is this.  The EHR being used by your doctors and nurses was never designed, it was coded, and that distinction has everything to do with why productivity has dropped.  Not a single business system designer ever researched how your EHR needed to work.  Nobody trained in cognitive psychology or human-computer interaction or content strategists ever watched the doctor-patient-nurse interaction and translated those observations into design specs for your EHR.  Ipso-facto, the amount of time required to complete each patient visit has increased, and since the number of hours in a day remained constant, the number of patients that can be seen in a day has decreased.

The time has come to define a plan to recover the lost productivity.

So, how did my chicken 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?”

 

EHR’s marmalade-and-toast hypothesis

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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.