usability

What then is EHR?

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An hour and twenty minutes on the train to Washington. The young woman behind me:

“And she was like…”

“And I was like…”

“And they were like…”

“And she was like…”

Ninety long minutes.  She never got off the train, and in a way I feel responsible. I locked her in the bathroom…She kept right on talking…”And she was like…”

The lanky guy seated across the aisle from me was a human tattoo museum.  The matron by the window spent an hour trying to decide which ringtone to use for incoming calls, listening repeatedly to the dozens of options with the phone’s volume set to its highest level.

So went my day.  Arriving home late at night I did the unthinkable, the unforgivable—wiped my hands on the decorative towels in the guest bathroom.  You probably have the same towels.  In fact, you probably have not even cut of the tags.  There they hang.  They have hung in the same spot, undisturbed.  Generations have come and gone, yet the towels stay.  They have become a fixture.

There are three categories of stuff—wants, needs, and must-haves.  I want a Porsche, I need air, and I must have towels that nobody will ever use.

What then is EHR?  For many hospitals it has become a must-have.  I have always thought nine figures was a lot of money to spend on something that saw no more use than guest-towels.

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.

HIT/EHR: Adult supervision required

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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?

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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.

EHR: How trained users killed productivity

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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

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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?

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One of the most exciting parts of any project is the point when the period of anoesis ends and members of the project team drift back to reality, back to a period of having to come to terms with what they have wrought.  That is the point at which you know things will feel better once they stop hurting.

For those inclined to argue that the project was a success because of the number of people who use it, may we visit that notion a little before we buy in all the way?  Arguing that use is the same as acceptance is a little like arguing the same about our use of gravity—after all, it is not as though we have much of a choice as to whether we are going to use gravity.  Maybe we should allow users to rename user acceptance to grim resignation.

User Acceptance may be a good thing, and it may be better than no user acceptance. Therefore, User Acceptance is a necessary but not sufficient condition of how well you spent the millions.

What could possibly be wrong with having one hundred percent of the user community using the application?  Well, if users have no choice, or if penalties are involved with not using the application, merely using the application does not tell you if the application is any good, it simply tells you it is being used.

Electronic Health Records (EHR) systems are deployed in many hospitals.  In some hospitals, user acceptance is quite high.  In many of those hospitals productivity has dropped, and this productivity drop is being traced directly to using the EHR.  Written in a different way, and with other factors remaining constant, doctors were able to see more patients prior to the implementation of the EHR.  The EHR, more specifically how they use the EHR, has resulted in them being able to see fewer patients.

Many physicians in large service provider environments are reporting that they are only able to see about eighty percent of the number of patients they had been able to see.  Now one school of thought would have you believe that seeing twenty percent less patients is not a problem because sooner or later all of the patients are seen.  This argument does not work.

Let us look at an example of a hundred and forty physician orthopedic practice that before implementing EHR its doctors were seeing four patients an hour over a ten hour day.  So as to not scare anyone, let us also assume that on any given day only half of the doctors were scheduled to see patients.  Since what we are looking at is the productivity delta of pre and post EHR, we are assuming that all other factors are similar.  Before EHR the group saw twenty-eight-hundred patients a day; after EHR they only saw twenty-two-hundred and forty patients.

In this example we see a net loss of five-hundred and sixty patient visits each day.  Seeing those patients tomorrow does not solve the problem.  The problem is that real revenue was lost today, and will be lost again tomorrow and the next day and so forth and so on.

In this example we can put an exact figure on the amount of revenue lost due to an unproductive yet fully user accepted EHR system.  This example also shows that this service provider cannot hope to grow because it cannot even manage its current patient load.  To get back to its old revenues, the provider would have to hire twenty-five percent more doctors.

So, does it make any sense to not deal with the distinction between user acceptance and productivity?  Why would a provider accept having to go from one-hundred-forty physicians to one-hundred-seventy-five physicians just to see the same number of patients?  In theory, they would have to increase the number of physicians by twenty-five percent to attain pre-EHR revenues.  Even if they added thirty-five physicians, although revenues would recover, costs would go way up, and margins would take a pounding.

What exactly does a twenty percent productivity drop look like?  I think some people only think of it in terms of inefficiencies and ineffectiveness and forget that it has real dollars attached to it.  Let us calculate the cost to our orthopedic practice.  Just in round numbers, forgetting labs and scripts and therapy, five hundred and sixty visits a day multiplied by two-hundred and fifty days a year equals one-hundred and forty thousand missed patient visits a year.  Just to keep the math simple, if the average missed visit results in a revenue loss of one hundred dollars, the loss to the business is about fourteen and a half million dollars.

Maybe that is enough incentive to come up with a name for the project whose purpose is to offset the EHR productivity loss.  The good news is you can recapture the lost productivity but you will need to look outside of IT and your EHR vendor to do it.

What’s the difference: User Adoption Versus EHR Usability?

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

There is always a great deal of discussion about hospitals controlling costs. Articles on the subject seem to infer that the idea of controlling costs, should one elect to do so, dwell in the rarefied realm of innovation.

Here is a dirty little secret—from the moment your hospital opened its doors the hospital has been controlling costs. It may not have been doing it well, but unless some unknown organization is signing purchase orders and authorizing accounts payable, it is the hospital that is in control of what it spends.

It occurred to me that nobody writes about the need for hospitals to control revenues. When was the last time you saw an article titled “Control Your Revenues?”  Is it because nobody really believes they have any control over revenues?

When I write about controlling revenues, I am not referring to a revenue assurance or ICD-10 project, I am talking about how to make money, not simply collect the money you have already made. In a room of one hundred healthcare managers, for every ninety-nine who know how to control costs only one knows how to control revenues.

The thing with controlling costs and revenues is that control is a two-way street. If revenues go down or costs go up, if you are the person in charge you must take ownership of the revenue loss or the cost increase. Control is all about the resultant direction, up or down, good or bad. We will come back to this point in a minute.

How does this discussion impact IT, and more specifically IT and its role with EHR?  Conventional thinking will lead one to believe that if, at the end of implementation, user acceptance is high, IT will have done its job. Not so fast sparky. User acceptance tends to be a binary measure. User acceptance can be defined as the total user population minus those people who are not using the system.

Total potential EHR users – those not using EHR = user acceptance

As though the potential user population was given a choice! Using the EHR does not imply any degree of liking the EHR, any fondness for the system, or any measure of perceived effectiveness any more than Meaningful Use has anything to do with users. Permit me to repeat that point in that I have yet to read it in any forum—Meaningful Use does not have anything to do with who or how many who’s are using the EHR.

User acceptance and usability are not the same things; they are not even spelled with the same letters. The difference has to do with how we use it because we have toversus we use it because it is usable. Both control costs and revenues, however user acceptance can easily cause costs to increase and revenues to decrease. This is true if the user acceptance causes productivity to crash.

Usability, while not a perfect measure, can be a start in the right direction. If users feel the EHR is highly usable, usability can lead to productivity increases and lower costs.

Here is the summary point of this piece—contrary to popular belief, IT, via EHR, has a direct line of sight to revenues, costs, and productivity. How it chooses to respond to that opportunity is what many people are evaluating.