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

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.

“Improved” never sold anything.

(AP) Redmond Washington.  After a much heralded launch, the buzz around Microsoft’s launch of Windows 8.0 is centered on the fact that when the computer crashes that users will no longer see the blue screen of death.  Instead, users will now see a friendly screen requesting that they restart their systems.

“Which is why we have decided to close the company at the start of 2012,” said CMO Droid Nelson.  “I mean when you spend two hundred million dollars just to market 8.0 and the only chatter is about the crash screen, the time has come.  We have not offered anything of interest to early adopters since 1997.  After all, what are we supposed to do?  If we continue on at this rate sooner or later we will hold a news conference for Windows 17.0 and Office 2024 and nobody will care.

How many times can we put a new ribbon around the same old software?  It is not like we can make it run any faster or any easier to navigate.  And Office is still Office.  When was the last time we added anything to that suite?  Most of our customers already cannot use half of the features we built, why should we keep building until we get that figure up to eighty percent?

The innovation train left the station around the time Starbucks came out with their half-caf-decaf with a double shot.  We made ourselves irrelevant.  Hell, I use an iPad and Google Docs.”

Can you name what Microsoft launched the last time you were willing to tailgate to be the first one to own it?  Nobody can.

Can you name the last time your customers were willing to tailgate to be the first one to purchase your firm’s newest offering?  Didn’t think so.

The thing to remember about new and improved is that it isn’t either.  If it was so brand spanking new, you wouldn’t have to tell anyone.

New is not a feature.

Improved is not a feature.

When Apple launched the first iPod their pitch was something along the lines of every song you every wanted to listen to in this little box.

Customers stand in line for innovation.  Is there a line outside your door?

The most relevant EHR/EMR piece you will ever read

According to the New England Journal of Medicine, somewhere north of fifty percent of EHR implementations fails.  Your odds of success are no greater than the flip of a coin.

What if there is a tool whose use can stop the failure of most EMR system implementations?  The purpose of this post is to let you know that there is a definitive solution to help small providers, clinics, IPAs, and hospitals.

What tasks of the EMR process is the primary cause for failure?  They are the tasks that are under budgeted, neglected, haphazardly addressed, or addressed by people who have no earthly idea how to perform them.

They are the same tasks that cause systems projects in other industries to fail.  If you do these tasks wrong, nothing else you do will make any difference—do-overs cost twice as much as your first failure.

The laundry list of those tasks is:

  • Defining your requirements—for physicians, nurses, staff—all of them.
  • Putting those requirements into an operable framework.
  • Ranking the requirements in a way to enable you to pick a good solution.
    • Technology Evaluation
    • Clinical Workflow Evaluation – Analysis of current clinical workflows.
    • Gap Analysis – Comparing current technical capabilities to desired capabilities.
    • EMR/Practice Management needs evaluation
    • ARRA Incentive Estimation
    • Qualified EMR vendor list
    • Vendor competitive bid assessment
    • Hardware requirements

I recently asked a hospital CEO, “What would you have done differently regarding your EHR selection?”

Here is a paraphrase of his response.

  • Invested much more time in understanding what system we should select and how we would use it.
  • My peers assumed someone else had already done all the up-front stuff (see the above list), and they selected their system solely on what others were using.  Alternatively, they picked a system based on a golf course conversation or something they saw at a trade show.

How many of your business and clinical requirements do you need to meet for your EHR selection to have any chance of succeeding?  The best answer is “All of them”.  How many requirements are needed to define your needs; one hundred, two hundred?  Not even close.

Try this exercise.  Search Google for “CRM RFP” or “ERP RFP”.  There are hundreds of useful responses.  Now search Google for “EHR RFP” or “EMR RFP”.  There are no useful responses.  (If you cannot find something on Google, it often means it does not exist.)  The healthcare industry is usually very good at sharing useful information.

I’ve been coaching executives for thirty years about how to get these tasks right.  In doing so, I developed something that made the software selection task winnable.  (This piece is not a Tony Robbins narrative, it is not about me; I am not selling anything.)

Here is what I did.  I built a Request for Proposal (RFP) for CRM and ERP.  I started with 1,000 requirements for each.  I license it to clients and work with them to edit it, to add new requirements, to delete requirements that did not apply to their organization.  They would use the result to select the application best suited to their firm.

This process never failed to benefit my clients.  I would take whatever new requirements they created and add them to my RFP.  My RFP became more robust.  Each time the RFP was issued I collected the responses from each of the vendors and built a database of what their applications could deliver.  I now have a few thousand functional and technical requirements, and up to date responses on what the applications vendors could deliver.

Why did I build this RFP?  The answer is simple.  I needed to create a reason for a firm to hire my firm instead of hiring one of the name-brand multi-national consulting firms.  The RFP served as a cost differentiator.  Instead of spending a million dollars to hire a name-brand firm to develop something from scratch, they could be months ahead, and at a lower cost by using a proven tool.

Therefore, here’s my point.  There is a firm that built a tool similar to mine, a tool to add to the probability of you selecting the best EMR/EHR for your firm.  It will not guarantee your success, but it will significantly reduce the chances of failure.

Clearly, even if you select the right system there are still many opportunities to fail.  The converse is that if you select the wrong EHR, it will fail.  That statement is not an opinion; it is a fact.

I’ve arranged a Go-to-meeting conference call with the CEO of that firm for the week of July 26.  This organization has built what I described; an RFP with more than a thousand unique requirements, an automated way to analyze the vendor responses, and a way to match your prioritized requirements to a short list of EHR vendors.  It will not be a sales pitch.  It is designed to be a question and answer session.  Who should participate?

  • Smaller providers whose only other option is to hire the person who set up their web site to manage their EMR selection
  • IPAs whose members are looking for advice about selecting a system to meet their specialization
  • Hospitals struggling with finding a defensible position for their selection.

If you are involved in the selection of an EMR/EHR, you should find an hour to assess the tool.  If you do not have the resources to make use of the tool, they do.  They can help you help yourselves.  I promise you, this will be the best use of sixty minutes you have had in a long time.  If you know someone who might benefit from this session, please forward this and have them contact me.  If you could benefit, simply respond to me.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

If only doctors were meerly apathetic about EHR

For those who remember the television show M.A.S.H., this brief bit of dialogue was from Henry Blake to Hawkeye after one of Hawkeye’s patients died.

“There’s two rules about war.  Rule 1–in war young men die.  Rule 2–doctors can’t change Rule 1.”

There’s a similar way to apply that logic when it comes to EHR, HIT, and new IT systems.

Rule 1.  If doctors don’t use them, the systems will die.

Rule 2. Simply having an EHR doesn’t change Rule 1.

A survey by Nuance Communications shows that 90% of doctors are concerned about the usability of EHR.  Those results underscore the importance of process and changemanagement and training.

As I wrote previously, it’s not about the EHR, it’s about what you can do with it.

My person struggle with usability–We have a piano in our home even though nobody plays it.  For some reason I’m not permitted to understand, we pay to have it tuned twice a year.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

The User’s Role in EHR–a PowerPoint presentation

This link will take you to a slideshare,net presentation that defines how healthcare providers can take control of the EHR project.  I welcome your comments.


saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

EHR: there’s a difference between finished and done


The phone rang last fall. It was the school nurse asking me if I would come pick up my seven year-old son. When I inquired as to the reason she informed me he exhibited the classic symptoms of the crud; tummy-ache, non-responsive, crying. She’s the nurse, so without better information, who was I to question her diagnosis?

We got into the car and the tears started to come again. “Do you feel like you’re going to be sick?” I asked as I looked at the leather upholstery. He didn’t answer me other than to whimper. He didn’t seem sick at breakfast. I remembered that he was crying last night, but that had nothing to do with his stomach. At first I thought it was related to the thunder. Nope. He was hugging his favorite dog, a five year-old Bichon.

We had learned a few weeks prior that the Bichon is ill and won’t ever be a six year-old Bichon. The person having the most difficulty with it is my youngest. I asked him if that was why he was crying in class and he confirmed that it was. Dads know everything, at least some times.

So, here’s the deal. The school nurse had done all the right things to diagnose my son’s problem, but she stopped short of determining what was wrong. Let’s try a more relevant situation from the perspective of an EHR implementation.  The word implementation sort of suggests that when you reach the point of having implemented that there’s nothing left to do.

There’s finished and then there’s complete.  Finished doesn’t mean the task is over until the system does what it was supposed to do.  If you didn’t do a good job of defining it up front you may never know the breadth of what was intended for the EHR.  In the case of EHR, done includes change management, work flow engineering, training, and user acceptance.
The point is, if it looks like you finished the EHR implementation, double check that you have before you take a bow. Technology alone will not an EHR implementation make, it is simply a part of the overall task.


The ambiguity & apathy of user acceptance


Why write if you can cut and paste.  The comments listed below are extracted directly from a blog titled SmartBlogs Work Force, http://smartblogs.com/workforce/2009/10/05/why-well-miss-ambiguity/#comment-19170.  The blog attacks Generation Why (my term) for being ambiguous in the workforce.  It seems to me that they can just as well be applied to why EHR has a low acceptance level.

  • Animosity between workers and bosses in business will increase. Ambiguity often looks pretty darn black-and-white to the worker who doesn’t see the nuance. And when workers think management is overanalyzing/dragging its feet/fumbling a simple problem, they lose patience with, and lose faith in, management’s ability to perform.
  • Many younger employees will “opt out” of a corporate system they don’t fully understand. This will ultimately prolong their own learning curve as they try to re-create a “better” structure without realizing that a number of the problems with our current structure will exist in any system populated by humans because the problems stem from our human nature, not our system design.
  • Leadership will suffer. Take ambiguity away from leadership, and you take away tough decisions and responsibility. What you’re left with is overpaid administration. That’s the image many young professionals today seem to have of leadership, so that’s what they’ll create.
  • The Applization of design will get more expensive, as companies that try to build simple products with minimal learning curves find they lack employees who can accurately predict real-world user behavior.
  • Individuals will double down on what they are good at, which in this case is solving problems by working HARDER BETTER FASTER SMARTER. This will rob many companies of their “manager class,” as people who stay in the system opt for specialist roles rather than managerial roles that come with more — yep, you guessed it — ambiguity.
  • Career paths will become more fixed. Our ability to process ambiguity extends to our ability to assess other people. Already, resume readers look for specific patterns, jettisoning capable applicants with “non-conforming” histories. This trend will continue to amplify for awhile.
  • Companies will ruthlessly centralize their decision-making functions, concentrating power with a few select people who “get it.”
  • Individuals will become more system dependent, just as people who aren’t good at division become more dependent on their calculators. This will create feelings of frustration and resentment.
  • Stress levels will explode further. If you think it’s bad now, just wait. There is a lot of unresolved fear out there. Mix in a dash of helplessness (which is a often a synonym for “unable to handle ambiguity”) and you’ve got a potent mix.

black saint 2