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

EHR: What questions remain unanswered?

“We need to talk about your TSP reports.”  Office Space—Possibly the best movie ever made. Ever worked for a boss like Lumbergh? Here’s a smart bit of dialog for your Wednesday.

Peter Gibbons: I work in a small cubicle. I uh, I don’t like my job, and, uh, I don’t think I’m gonna go anymore.

Joanna: You’re just not gonna go?

Peter Gibbons: Yeah.

Joanna: Won’t you get fired?

Peter Gibbons: I don’t know, but I really don’t like it, and, uh, I’m not gonna go.

Joanna: So you’re gonna quit?

Peter Gibbons: Nuh-uh. Not really. Uh… I’m just gonna stop going.

Joanna: When did you decide all that?

Peter Gibbons: About an hour ago.

Joanna: Oh, really? About an hour ago… so you’re gonna get another job?

Peter Gibbons: I don’t think I’d like another job.

Joanna: Well, what are you going to do about money and bills and…

Peter Gibbons: You know, I’ve never really liked paying bills. I don’t think I’m gonna do that, either.

One more tidbit:

Peter Gibbons: Well, I generally come in at least fifteen minutes late, ah, I use the side door – that way

Lumbergh can’t see me, heh heh – and, uh, after that I just sorta space out for about an hour.

Bob Porter: Da-uh? Space out?

Peter Gibbons: Yeah, I just stare at my desk; but it looks like I’m working. I do that for probably another hour after lunch, too. I’d say in a given week I probably only do about fifteen minutes of real, actual, work.

I like to think of Peter as my alter-ego.

When I’m playing me in a parallel universe, I’m reading about a surfer dude cum freelance physicist, Garrett Lisi. Even the title of his theory, “An exceptionally simple theory of everything,” seems oxymoronic. He surfs Hawaii and does physics things—physicates—in Tahoe. (I just invented that word; it’s the verb form of doing physics, physicates.)

Ignoring that I can’t surf, and know very little physics, I like to think that Garrett and I have a lot in common. I already know Peter Gibbons and I do. So, where does this take us?

It may be apparent that I look at EHR from a different perspective than many of others involved in this debate; I’m the guy who doesn’t mind yelling ‘fire’ in a crowded theater. The guy who will never be invited to speak at the HIT convention unless they need a heretic to burn for the evening entertainment. I can live with that.

Like Garrett, I too see an exceptionally simple theory in everything, especially when it comes to improving business. It’s not rocket surgery, but then, it was never meant to be. You’ve seen the people running it, they are definitely not rocket surgeons—before someone writes, I know it should be scientists.

Sometimes I like to look at the problem from a different dementia—Word didn’t have a problem with that usage. I look at the productivity loss brought about by EHR and ask myself three questions:

1. Why do people really believe that retraining the end users will help–training them did nothing good for productivity?

2. Why are many hospitals thinking that scrapping their EHR and putting in a new one will improve productivity?

3. Why are their no major initiatives to recapture the lost productivity?

What do you think?

EHR: How trained users killed productivity

In order to complete today’s lesson you will need one prop, your EHR vendor contract. I will pause for a moment—please let us know when you are ready to proceed.  Ready?

Now, turn to the section with all of the commas and zeroes, that is right, it is probably labeled pricing.  Skim down until you see the line item for training.  Got it?  It is a rather substantial number is it not?  And that number is simply the number your vendor is charging you to train your people.  Your actual training costs are probably double or triple that amount.

Why?  Because there is an opportunity cost for each hour of time one of your employees spends in training to use the EHR.  It is an hour they are not spending doing what they were hired to do.  Now I know some of you are thinking ‘Only Roemer will try to make a big deal out of EHR training.  Goodness knows, he has come down hard on everything else associated with EHR,” and you are probably correct.

Gartner suggests that for an average ERP project firms should budget seventeen percent of the total project cost to training end-users.  Seventeen percent.  I can hear the CFOs gnashing their respective teeth.  Knowing that EHR is at least as disruptive to the organization, and will have more users than ERP, let us agree that a good rule of thumb for training costs for EHR is fifteen percent of the total cost of the EHR project.  When you factor in the opportunity cost of 2X the number starts to get pretty big.

We all can name hospitals whose EHR project cost north of one hundred million dollars.  Who are we trying to kid; we can name hospitals whose cost was way north of that figure.  Looking back at your vendor contract I am willing to bet that nobody budgeted training at or around fifteen percent of the total cost of the project.

Is that a bad thing?  No.  Why?  EHR projects are not failing as a result of hospitals not spending enough on end-user training.  I know that statement flies in the face of conventional IT wisdom, but here is my thinking behind that statement.

Training is designed to get the end-users to use the EHR the way the EHR is intended to be used.  And that is not a good thing.  Whoa big fella.  Don’t believe me?  Just look at your EHR productivity numbers.  Didn’t productivity nose-dive once you required your trained end-users to use the EHR?  Still don’t believe me, ask your physicians and nurses.

Why not train everybody again, wouldn’t that help?  What did Einstein say about the definition of insanity?  Insanity is doing something over and expecting different results.  If the hospital already spent fifteen million dollars to train the end-users on the EHR, and the result was a twenty percent drop in productivity, might it not be time to say enough already?

EHR adage 101: When you are in a hole stop digging.

The EHR project summary for many hospitals reads a little like this:

  • EHR cost               $100,000,000
  • Training cost          $15,000,000
  • Opportunity cost $15,000,000
  • Productivity loss 20%
  • Cost of productivity loss—priceless

Face it; you spent millions of dollars to be worse off than you already were.

Today I spoke with the CFO of a hospital that owned one of those hundred million dollar EHRs.  His question to me was whether or not he should hire the EHR vendor or a large, expensive system integrator to help him recapture the productivity loss.  I told him no.  Why?  All the EHR vendor will do is to retrain your people, and you have already proven that training your people to use the EHR brought about the productivity loss.  After all, it wasn’t untrained users who did it.  Why not hire a systems integrator for tens of millions to reimplement the system?  Because I bet you put the system in correctly in the first place.

If training is not the reason productivity is low and a poor implementation is not the reason, what is?  Productivity is low because the hundred million dollar EHR never included a single dollar of resource to design it around how your physicians and nurses function.  Your expensive EHR was built to answer the question of what needs to be done; it was not designed to deal with the issue of how something is to be done.  At best, the only input the hospital had, if it had even this much, was a list of functional requirements that was handed over to a bunch of coders.  I am willing to bet in most cases even this did not happen because all of the EHR code was already written.  The EHR is not productive because it was never designed for your organization.

It is never too late to incorporate design into a business system, but remember, neither IT nor the EHR vendors are designers, and you have already seen their results.

Help has arrived for your EHR productivity loss

I was thinking about the time I was teaching rappelling in the Rockies during the summer between my two years of graduate school.  The camp was for high school students of varying backgrounds and their counselors.  On more than one occasion, the person on the other end of my rope would freeze and I would have to talk them down safely.

Late in the day, a thunderstorm broke quickly over the mountain, causing the counselor on my rope to panic.  No amount of talking was going to get her to move either up or down, so it was up to me to rescue her.  I may have mentioned in a prior post that my total amount of rappelling experience was probably no more than a few more hours than hers.  Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her.

The sky blackened, and the wind howled, raining bits of rock on us.  I remember that only after I locked her harness to mine did she begin to relax.  She needed to know that she didn’t have to go this alone, and she took comfort knowing someone was willing to help her.

That episode reminds me of a story I heard about a man who fell in a hole—if you know how this turns out, don’t tell the others.  He continues to struggle but can’t find a way out.  A CFO walks by.  When the man pleads for help the CFO writes a check and drops it in the hole.  A while later the vendor walks by—I know this isn’t the real story, but it’s my blog and I’ll tell it any way I want.  Where were we?  The vendor.  The man pleads for help and the vendor pulls out the contract, reads it, circles some obscure item in the fine print, tosses it in the hole, and walks on.

I walk by and see the man in the hole.  “What are you doing there?”  I asked.

“I fell in the hole and don’t know how to get out.”

I felt sorry for the man—I’m naturally empathetic—so I hopped into the hole.  “Why did you do that?  Now we’re both stuck.”

“I’ve been down here before” I said, “And I know the way out.”

I know that’s a little sappy and self-serving.  However, before you decide it’s more comfortable to stay in the hole with your EHR productivity loss and hope nobody notices, why not see if there’s someone who knows the way out?

Merely appointing someone to run your EHR effort doesn’t do anything other than add a name to an org chart.

What does lost EHR productivity cost?

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.